www.qprinstitute.com/joomla Sign up for an account using the special code given to you to access the materials. To access the course materials click “learning paths” You get to this page by clicking “Learning Paths” www.qprinstitute.com “QPR Instructor Resources”, password: “listen” www.qprinstitute.com “QPR Instructor Resources”, password: “listen” EMS Instructor Materials next slide EMS Instructor Materials WELCOME COLORADO EMS SUICIDE PREVENTION SPECIALIST TRAINING Before we get started I want you to check out the 3 people sitting nearest to you. Introduction Depending on your relationship with those being trained, I would recommend a brief introduction of yourself. I like to answer the questions; “Who is the person standing up there training me?” “Why should I believe him/her?” “What does he/she have to teach me and where did they acquire this information?” Take Out Your Packets Just Like It’s Your Birthday! Taking Care of Yourself. Suicide is personal Many of you may be survivors Some may be attempt survivors This training can be difficult Take care of yourself during this training. Raise your hand if… Wait until all questions asked Have you ever thought about suicide? Do you know someone who has? Do you know anyone who has made a suicide attempt? or even died by suicide? Are you worried, right now, that someone you know is thinking about suicide? Prerequisite online learning QPR Gatekeeper for Suicide Prevention Certificate Understand suicide as a major public health problem Name major suicide prevention organizations and access their web sites Recognize someone at risk of suicide Recognize at least three suicide warning signs Demonstrate increased knowledge, skill and selfefficacy in the application of QPR Know how to engage and assist a suicidal colleague or co-worker Understand the common myths and facts surrounding suicidal behavior Describe and name multiple local or state referral resources Understand means restriction and how to immediately reduce risk Recognize and identify at least three risk factors for suicide Recognize and identify at least three protective factors against suicide Understand the nature of suicide Engage in an interactive and helpful conversation with someone who has attempted suicide Engage in an interactive and helpful conversation with the loved ones or family members of someone who has died by suicide Classroom learning goals Understand risk factors and warning signs associated with suicide Understand the nature of suicide Recognize risk factors associated with exposure to trauma Understand the need for and identify various strategies for self-care Respond to suicide attempt survivors Help suicide survivors (family members left behind) Help fellow EMS providers who may be having suicidal thoughts Identifying local and national suicide prevention resources Clump Up Why you are here What has your experience taught you Share what you learned from the online material What do you still want to know About suicide About teaching this material Training others to be EMS Suicide Prevention Specialists (EMS SPS) The minimum training required to be awarded an EMS SPS certificate is five (5) hours The course can be taught entirely by the Instructor using the materials and audio visual aids, provided the EMS SPI is also a QPR Certified Gatekeeper Instructor. If not a QPR Certified Instructor, those earning a certificate as an EMS Suicide Prevention Specialist must complete Minimum of two (2) hours of online training Minimum of three (3) hours of classroom training Pass all online and classroom quizzes and exams as determined by the EMS SPI Participate in role-plays and exercises See sample training schedule in packet QPR Institute Training for Everyone To create safer communities means training at all levels: - QPR Citizen Gatekeeper Training and Instructor Certification Course - QPR Suicide Triage Training and Instructor Training Course for 1st responders (e.g., QPR for EMS) - QPRT Suicide Risk Assessment training for health care professionals - QPRT for physicians and nurses QPR Colorado EMS SPS Classroom Training Classroom Material Schedule Introduction and overview Brief review of QPR and online materials Suicide in Colorado Understanding Suicide Local Resources Role-plays Self care Suicide in Colorado 34,598 suicide in United States in 2007 Or 94.8 a day for a rate of 11.5 940 suicides in Colorado in 2009 Or 2.6 a day for a rate of 18.4 Colorado ranked 6th in 2007 Up from a ranking of 9th in 2006 In Colorado in 2009 940 people died by suicide 190 people died by homicide; 8 by legal intervention 15 children age 4 or younger were a victim of homicide 7 people died of unintentional firearm injuries Suicide is the second leading cause of death and homicide is the third leading cause of death for young Coloradans ages 15-34. Health Statistics Section, Colorado Department of Public Health and Environment Colorado Suicide 2005 - 2009 Health Statistics Section, Colorado Department of Public Health and Environment UNDERSTANDING SUICIDE Provide a leading theory to better understand suicide Teach the three necessary conditions for a suicide event to occur Demystify and de-stigmatize suicide by bringing the behavior into the range of understandable human behavior Underlying Principles Suicide is not the great mystery that it has been made out to be. The basic components of suicide are knowable. When we understand these components we can act with more confidence. Informed interventions save lives. Suicidal Behavior Means someone is in extreme pain and suffering Means complex feelings and behavior Involves many reasons and factors Means coming at it from many directions This training is just one those directions Nature of suicide and Joiner’s new theory… Psychic suffering (Psyche-ache) Hopelessness Unbearable mental anguish Cognitive constriction Grossly impaired problem solving ability Feeling a burden to others Thwarted belongingness Acquired capacity for self-injury and habituation to pain T. Joiner, Why People Die by Suicide, 2006 Understanding Suicide Based on the work of Thomas Joiner, PhD and his book Why People Die by Suicide Underlying Principles Suicide is not the great mystery that it has been made out to be The basic components of suicide are knowable When we understand these components we can act with more confidence Informed interventions save lives It’s what we don’t know that we don’t do, and what we don’t do costs us lives unnecessarily lost. Basics of Suicide and Serious Attempts Two major components associated with suicide and serious attempts The desire to die and the capacity for self harm Two elements within the desire to die Perceived burdensomeness A sense of thwarted or low belongingness Sketch of the Theory Those Who Desire Suicide Those Who Are Capable of Suicide Serious Attempt or Death by Suicide Acquired Capacity for Suicide Suicidal behavior is not just about the desire to die It requires the capacity to inflict self injury The Acquired Capability to Enact Lethal Self-Injury This capacity is acquired over time Accrues with repeated and escalating experiences involving pain and provocation, such as Past suicidal behavior, but not only that… Repeated injuries Repeated witnessing of pain, violence, or injury (i.e.. physicians, EMS, ED nurses, and law enforcement personnel) Any repeated exposure to pain and provocation. The Acquired Capability to Enact Lethal Self-Injury According to Joiner, with repeated exposure, one habituates – the “taboo” and prohibited quality of suicidal behavior diminishes, and so may the fear and pain associated with selfharm What do tattoos mean? Tattoos and Suicide In a case-controlled study comparing accidental deaths to suicides, people who died by suicide were more likely to have tattoos (Dhossche, Snell, & Larder, 2000). Could it be that the eventual suicide victims obtained increased capacity for suicide partly via painful and provocative experiences, such as tattooing, piercing, etc.? Deliberate self-harm and suicide Evidence: - People who have experienced or witnessed violence or injury have higher rates of suicide – prostitutes, self-injecting drug abusers, people living in high-crime areas, physicians - Those with a history of suicide attempt have higher pain tolerance than others Components of the Desire for Death Perceived Burdensomeness Thwarted Belongingness Perceived Burdensomeness Feeling ineffective to the degree that others are burdened is among the strongest sources of all for the desire for suicide Suicide lightens the load the rest of us carry…. Research: Brown, Comtois, & Linehan (2000) reported that genuine suicide attempts were often characterized by a desire to make others better off, whereas non-suicidal self-injury was often characterized by desires to express anger or punish oneself … Thwarted or Low Belongingness The need to belong to valued groups or relationships is a powerful, fundamental, and extremely pervasive human motivation When this need is thwarted, numerous negative effects on health, adjustment, and well-being have been documented Thwarted Belongingness The need to belong is so powerful that, when satisfied, it can prevent suicide -even when perceived burdensomeness and the acquired ability to enact lethal self-injury are present… By the same token, when the need is thwarted, risk for suicide is increased Thwarted Belongingness: Empirical Evidence Hoyer and Lund (1993) studied nearly a million women in Norway; over the course of a 15-year follow-up, over 1,000 died by suicide They reported that women with six or more children had one-fifth the risk of death by suicide as compared to other women Those Who Desire Suicide Perceived Burdensomeness Those Who Are Capable of Suicide Thwarted Belongingness Serious Attempt or Death by Suicide Prevention/Treatment Implications The model’s logic is that prevention of “acquired ability” OR of “burdensomeness” OR of “thwarted belongingness” will prevent serious suicidality Increasing belongingness may be the protective factor one can influence the most and quickest Example PSA: “Keep your old friends and make new ones – it’s powerful medicine” Questions and discussion? RESPONDING TO SUICIDAL PEOPLE AND THEIR LOVED ONES The following structured interactive discussion session is intended to assist you by reviewing the training received online in this area. Through role-plays you can practice and share strategies for dealing with those who have attempted suicide and the families and loved ones of both attempt survivors and those who complete suicide Finally this section is to minimize your experience of secondary trauma in responding to suicide events. Review Being emotionally present Accurate empathy Genuineness Unconditional positive regard (NO Judgment!) Active listening Reflecting Open ended questions Problem solving Plan of Action The definition of few terms Survivors of suicide: Committed suicide He took his own life She ended her own life She died by suicide First responders may face any of the three following scenarios: A person who may be suicidal and have recognized warning signs A person who has just attempted suicide or attempted in recent past Family, friends of someone who has attempted suicide or dies by suicide On the way to the ED Distressed person after a suicide attempt: “I just can’t take it anymore. My father is cold and distant and never listens to me when I’m upset. It’s like he can’t stand to be around me when I express my feelings.” You: “It sounds like your dad doesn’t listen to you when you say what you feel.” Distressed person: “Right. You got that right!” Distressed person: “Now that you how hard it is for me to ever talk to my dad, maybe you can see why we can’t spend any time together. If I get the least bit upset, he’s going to blow up.” You: “So anytime you get upset, or show your feelings, your dad seems to withdraw or shut you down. Does he sometimes just leave the scene?” What do you say to the family? Discuss Boot camp “In your experience” Scenarios students have experienced? Thoughts what would you add to what others have said? Building consensus - we’re learning how to do this together Suicidal Language Putting it in context Without understanding the context, it is difficult to understand the message… Which of the following is a suicide warning sign? “I’m going to blow my brains out.” “I just can’t stand it anymore.” If either is a suicide warning sign, which statement requires immediate and urgent intervention? Content vs. Context “I’m going to blow my brains out!” Is sitting in your office in a psychiatric hospital “I just can’t stand it anymore.” Is standing well out of arm’s reach on the edge of 10story building Now… which person needed immediate and aggressive intervention? Help reduce confusion… Risk Factor? Protective Factor? Warning sign? Clue? Threat? Suicidal Communication? Clear statement, coded or hidden? What are these? “I’m going to kill myself!” Buying a gun. Pointing a loaded gun at your head. Giving away prized possessions. Heavy drinking when you are clinically depressed. Telling your friends what kind of music you want at your funeral when are apparently healthy. Saying goodbye, a kiss and hug from a teenaged boy. “If a person kills himself, does he go to hell?” Steven Pinker – The Stuff of Thought The need for indirect speech – the speaker says something he/she doesn’t mean literally knowing the hearer will interpret what was intended and correctly interpret what was meant. All humans know how to “read between the lines” See, Politeness Theory (Politeness: Some Universals in Language Use – Brown & Levinson, 1987) Context is everything…. We are all very nice… When lost and we need to ask a stranger for directions, “Excuse me…” “Would you like to come and see my etchings? “Would you like to come up for coffee?” “Polite indirect speech can use any hint that cannot be pinned down as a request by its literal content, but that can lead an intelligent hearer to infer its intended meaning…” SP, 2006. Our job? To make hearers of suicidal communications, polite requests for rescue, or for help from one’s community or significant others understood so that positive actions can follow. Plausible deniability: “Can you pass the salt?” vs. “The chowder is pretty bland.” Or, “They never have enough salt in this restaurant.” Forms of communications: Off record requests in context… Hints “Lions could hide in the lawn.” Understatements “You got a real nice store here. It would be too bad if something happened to it.” Idle generalizations “It’s too dark to read in here.” Rhetorical questions “It looks like someone has had too much to drink?” Examples from real cases… Parishioner to Pastor, “Do people who kill themselves go to hell?” Catholic woman to best friend, “It’ll be fine, I’ve seen the virgin.” Patient to pharmacist, “Are you sure this is enough medicine to cause death?” Patient to doctor, “You’ve been a wonderful doctor. Thanks for everything.” Last words from real cases Depressed farmer to inpatient nurse on discharge, “Don’t worry about me, I’ll be six feet under by Friday.” Depressed boy to mother, “Do you think God has a place in heaven for a boy like me?” Father to son, “I’m going home soon.” WWII vet to social worker, “Don’t worry, when the going gets tough the tough know what to do.” Suicidal Communications - If you were suicidal, who would you tell? - How would you tell them? - How many times would you tell them? - What would you do if people did not respond? - How would you change your message if ignored? QPR ROLE PLAY PRACTICE SESSION AND Q&A QUESTIONS FOR THOSE WHO WERE “SUICIDAL” “What did you become aware of during the course of this exercise? QUESTIONS FOR THOSE WHO PRACTICED QPR “What did it feel like for you ask about suicide risk?” “How comfortable were you?” FIRST RESPONDER SELF CARE Provide a structured interactive discussion session in which students can recognize and discuss the stressful nature of their jobs In small group discussion, review their personal coping skills and stress management strategies and brainstorm additional ones Help students identify where they can go to gain additional skills What your peers said It works if you work it Having someone to talk too about the stress and the feelings that build up inside so they don’t just one day explode Being around friends and family and just hanging out Sitting by the fire with a few friends, telling stories, watching for the first star of the night and poking the fire with a stick Taking walks, playing ball or other forms of exercise to clear out the tension Going fishing, panning for gold, or other activities in order to spend some valuable time with yourself and clear your head Meditation, prayer, yoga, and other spiritual or religious practices that can help provide a sense of peace and perhaps some perspective Positive Coping Methods Number 1 at 35% Number 2 at 30% Peer and family support talking it out Physical activities, hunting, fishing, outdoors, exercise Other methods included Faith/prayer/reflection Some not so positive coping 7% just walk away/move on to next call 5% drugs and alcohol Other comments included Detach emotionally Inadequate Internalization Irrelevant Getting help for yourself questions How do I know if help is warranted? How bad do I have to feel before I ask for help? Isn't it better to "tough it out" with emotional problems? How do I pick a professional? Which kind? More questions What's the difference between a social worker, psychologist, psychiatrist, and counselor? Whets a CD counselor? If I did make an appointment, what questions should I ask? Will my insurance pay for the help I may need? Once in the office questions: What will happen on my first visit? Are things I should ask to get off to a good start? Is it OK to get a second opinion if I don't like what I hear? How will I know what I need? More questions Do I have to like the professional, and what if I don't? What should I do if I'm disappointed? Should I ask about the risks and benefits of the treatment proposed? Last to recognize it How far do you push a friend, family Who can you go to, to protect confidentiality Particularly in small towns THANKS!