Suicide Awareness and Intervention: The Role of the Gatekeepers

1. Suicide Awareness and Intervention:The Role of the Gatekeepers Florence-Carlton Elementary and Middle School Guidance and Counseling Department Chrissy Hulla & Joy Jones

2. The most common response to a statement of suicidal intent is silence. “Oh God. What do I do.”

3. The Purpose of Suicide “The common purpose of suicide is to seek a solution. Suicide is not a random act. It is never done pointlessly or purposelessly. It is a way out of a problem, a dilemma, a bind, a crisis, an unbearable situation. It has an inexorable logic and impetus of its own… Every suicide makes this statement: ‘This far, and no further.’” Edwin Scheidman, Ph.D.

4. 10 Commonalities of Suicide Edwin Scheidman, Ph.D.

5. Common Purpose • To seek a solution to one or more problems • Seemingly insolvable problems • Bad grades • Failed relationship • Not getting accepted to college • A personally humiliating exposure • No suicide is a random act; all have purpose and meaning • Solve the problem and suicide loses it appeal

6. Common Stimulus • Unendurable Psychic pain. • When mental/emotional pain becomes unendurable; you can’t stand to be there. • “psychache” • There is no suicide without pain.

7. Common Stressor • Frustrated psychological needs • Loss of love • Loss of identity • Loss of belief system • Physical pain adds to risk, but it is our psychological, social and emotional needs that are frustrated in a suicide crisis.

8. Common Emotions • Helplessness • “I can’t do anything to fix what is wrong.” • Hopelessness • The utter belief that nothing will ever be right or well or bright again forever and ever. • “Hope deferred maketh the heart sick.” • A lack of hope has been shown to contribute to: • Higher rates of disease, suicide, productivity, etc. • 2 cc’s of hope a administered 3x/day.

9. Many more men commit suicide than women. • “Men don’t get depressed. They get angry, homicidal, suicidal, but not depressed.”

10. Common Internal Attitude • Ambivalence • “To be or not to be.” Shakespeare • The only interesting question is whether or not to kill yourself • There are lots of pro-suicide groups on the internet—people with web cams committing suicide together • Questioning each other, “You don’t look sleepy enough. Did you take enough pills?” • These sites are largely unrestricted.

11. Common Cognitive State • Depression is a cognitive disease • Depressed individuals: • Do poorly on decision making tests • Have trouble thinking creatively • Constriction of thought • Depressed people practice revisionism—they turn every positive situation into a negative.

12. Common Cognitive State---Continued • Slowed thinking • Tunnel vision (cognitive restriction) • Russian revisionism (recall only negative stuff) • Capacity to draw hasty, negative conclusions • Impaired problem solving • Poor logic, thus suicide makes “sense” • Inability to name reasons for living • Stuck in the now of suffering Suicide is a hasty, negative conclusion to what are usually the ordinary problems of living

13. Common Action • Escape • Suicide provides a way out when none is otherwise perceived. • For humans, there is always a well lighted exit sign over the door to death.

14. Common Interpersonal Act • Communicate the wish to die to others • When we are in pain, we want to tell someone. • If you are going to get a root canal, you tell someone • Often suicidal individuals will tell someone what they are thinking • Not typically a health provider • This is our window to save lives.

15. Common Patterns • A lifelong pattern of failing to cope • Relationship ending • Poor grades • Job loss

16. Common Goal • The cessation of consciousness • Being aware is the great burden • Death removes awareness and obliterates all consciousness

17. How do we know what we know? Assessment is based on: • How much we learn from the person • The context in which suicide is being considered • Recognition of warning signs • Presence of risk factors • Presence of protective factors • What the suicidal person is willing to do to help us save his or her life

18. Gatekeepers People who regularly come into contact with people in distress

19. Teachers Counselors Bus Drivers Custodians Cafeteria Workers Paraprofessionals Parents Peers Administrators Secretaries Coaches Nurses Who Are Gatekeepers?

20. Community Shared Responsibility

21. Relationship is Everything! • How much we learn depends on how much they like us, and how much we like them. • We didn’t call them, so they want help. • Don’t let them make you mad to prove they can’t be helped. • Find something to like. • Buy time. • Keep ‘em talking.

22. Listen, Listen, Listen • Listening is the greatest gift one human being can give to another. • Listening to someone suicidal can save a life. • Listening means taming your own fear so you don’t rush to judgments. • Listening means sharing the burden of another’s pain. • Listen means paying perfect attention while the other person finds his or her own solution to life’s problems.

23. Listen! • “Tell me more” inspires hope. • Your ears receive, your heart understands. • Listen not to just what the person is saying, but what he or she is trying to say. • Confirm you hunches about what’s wrong with questions; getting yeses saves lives. Remember: It is very hard to kill yourself when another human being truly understands you.

24. Do’s and Don'ts • Do listen for the problem or problems suicide would solve; help them with this and they will choose to live. • Do keep your voice low, calm and well-modulated; nothing so upsets the person in crisis as believing everyone is as out of control as they feel. • Don’t say you understand when you don’t. • Do believe the person will live!

25. Trust your fear! • Felt fear is valuable • Goose bumps and standing hair matter! • The fearless died young • It’s okay to say you’re afraid for someone • They’re scared, too

26. Dealing with Resistance • Don’t take the bait or step in the trap • Stay Calm • Don’t condemn/suicide as interesting option • Normalize feelings • Avoid platitudes • Say you don’t understand when you don’t • Lt. Colombo has the moves

27. S QuestionsNot sure? Ask! SAMPLES • Have you had thoughts of killing yourself? • Are you considering suicide? • Are you contemplating ending your life? • Have you had any personal thoughts of death or suicide?

28. QPR • Q for Question the person about suicide • P for Persuade the person to get help • R for Referring the person to someone who can help Three things you’ve already done a million times

29. Q QUESTION TO ASSESS RISK What is wrong? Elicits the person’s narrative explanation or “story.” • person’s perspective • Value in story telling/emotional release • Don’t but in, except to clarify or understand • Your opinion doesn’t count, or matter • Definition of rapport: Shut up and Listen

30. Sample Questions • Okay John, why don’t you tell me a little bit about what’s happening in your life right now? • Audrey, what made you decide to call this evening? I’d very much like to hear your version of what’s wrong right now.’ • “You know, when people are as upset as you seem to be, they often think about suicide. I wonder if you’re thinking about suicide now?”

31. HOW NOT TO ASK THE S QUESTION “You’re not thinking about killing yourself are you?” Other examples?

32. WHY NOW? Elicits the precipitating event or events • Current crisis? • Hopeless a long time • Magnitude of change event doesn’t matter • No reserves left • Hair trigger condition • Final straw “I just can’t take it anymore.”

33. Why Now Questions • Things have been bad for a long time, what’s happened recently? • What’s changed so much that you’re now thinking about suicide? • Why now? Why are you thinking about killing yourself today?

34. WITH WHAT? Elicits methods of suicide under consideration • Only so many ways to die • How? (name them) • Access to means? • More than one method? • Degree of lethal planning? • Backup plan?

35. With What Sample Questions • Have you thought about how you would kill yourself? • Can you tell me the way in which you’ve considered ending your life? • How would you kill yourself? • How else might you kill yourself? • What method of suicide are you thinking about?

36. Where and When?Elicits possible location and timing of a suicide attempt • Lethal planning (less is good) • Soon? Next week? Next year? • Anniversary date? (“Why that day?) • Uncontrolled contingency, e.g., “If she leaves.” ” • Home? Work? MVA? • Chance of rescue?

37. When and With What in the Past?Elicits important suicide history • Past attempts? • Past suicidal ideation? • Rescue sought or avoided? • Timing of attempt? • Social response to attempt? • What saved them? • New method vs. old method?

38. Sample Questions • “Pat, you’ve been struggling with a lot of different feelings lately and tell me you’ve been considering suicide. Have you ever had thoughts of suicide in the past?” • If ‘yes’ then, “When was that?” • “How did you attempt to kill yourself?” • “What method did you try?” • “What helped you get through that crisis?”

39. Who’s Involved Sample Questions • “Who’s important to you?” • “Who else knows you’re in this much pain?” • “Who is your main support?” • “Who could help right now?” • “Who needs to know about your troubles?” • “Who have you told about your suicidal thinking?”

40. Why Not Now?Elicits protective factors • Reasons for living? • Spiritual or religious prohibitions? • Duties to others/pets? • Tidying up or ‘to list’ before dying? • Fear of death? • More reasons is good, none is bad • Low risk does not equal no risk

41. Sample Why Not Now Questions • “Give me some reasons why you may want to live?” • “You given me reasons why you want to die, can you tell me why you still want to live?” • “Give me three reasons to keep on going?”

42. Additional Useful Questions • “Who else knows?” • “Why in the past?” • “Why not in the past?” • “Who else in the past?” • “What will happen after you’re dead?” • “How will people react?” • “Who will find your body?”

43. P Persuading Someone to Get Help • Your active listening and questions may have already won the battle • Find life-affirming solutions • Refusal to seek help = greater risk • Angry hang up = greater risk • Unwillingness to give up means = greater risk • Help refused? Reassess risk • Send in the Marines?

44. R Referral • Referral is an art and a sales job. • You’re going to feel better, trust me. • Resources ready? • ‘How to’ instructions matter! • Can you personalize the endorsement? • Culture/ethnic/profession/color sensitive? • Got a clinical buddy? Find one.

45. Safety Planning Suicide risk is determined, in large part, by the person’s willingness to assume personal responsibility for his or her own safety.

46. Suicide risk is low to moderate when the person agrees to: • Remain clean and sober • Seek help/accept referral • Remove the means of suicide • Not harm or kill self • Seek help in case situation worsens (involve others) • Makes verbal agreement to safety plan

47. Suicide risk is high when the person: • Has not been cooperative. Not making sense? Psychotic? Agitated? Unable to care for self? • Cannot regain emotional control, e.g., can’t stop crying. • Is distant, evasive, aloof or paranoid • Is in the act of overdosing, has pistol in hand, is bleeding or calling from a 19th floor window • Refuses to accept responsibility for self or safety plan, e.g., give up the means to suicide

48. Suicide risk is high when: • Past treatment has failed • There is a risk of personal humiliation, e.g., fear of pending arrest • There has been recent heavy drinking • There are repeated statements of hopelessness • There is no perceived exit • You’re ticked off Motto, Clark & Faucett

49. Who are the Marines? • As a teacher, counselor, staff member, etc. What do you do if it is an emergency, life or death, situation: • If possible, call the parents, inform them of what is going on, and take the student to the Emergency Room. The ER will do a complete evaluation: • Physician evaluation • Mental Health Evaluation (Emergency #:532-9710) • Admit to the hospital or refer to services in the Community

50. SEMANTICS ARE IMPORTANT • Don’t settle for ambiguity. • “I guess I’ll be okay,” is vague. • “I’ll call somebody if things get bad” lacks specificity. What is “bad?” Who is “somebody?” • If you don’t understand, say so! • Assume nothing!