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Ask A Question,

Save A Life.

QUESTION.

PERSUADE.

REFER.

Paul C. Harris, Ph.D.

harrispc2@vcu.edu

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��

��For many people, talking about suicide is not easy.��Some of us may be loss survivors, or attempt survivors.��Many experience compassion fatigue and may be more susceptible to the impact of suicide.��Please monitor yourself closely and seek help if needed.

© 2022 QPR Institute. Inc.

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Learning Objectives

Identify stigma and understand suicide as a public health issue
Recognize someone at risk for suicide
Question, Persuade and Refer someone who may be suicidal
Access local and national referral resources
Offer hope and potentially save a life

© 2022 QPR Institute. Inc.

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What is the�Purpose of QPR?

QPR is not intended to be a form�of counseling or treatment.�

QPR is intended to offer hope�through positive action.

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Suicide Myths & Facts

Main points:

This can be done in an activity, but need to be done quickly and in rapid succession
If you have questions and conversation about each one, only spend 1-2 minutes on each point, no longer than that
Use a teaching tool such as a “parking lot” to save conversations until the end of training, or you will go over your allotted time
Activity options:

Click through each one, read the statement
Ask participants if it is a myth or fact.
Thumbs up for fact, thumbs down for myth
Stand up for fact, sit down for myth
Walk to the front of the room for fact, walk to the back of the room for myth

There are many more myths and facts about suicide than these. However, these have been chosen as effective in combating many pre-existing false beliefs.
Preventing a suicide attempt is as good an outcome as we can hope for because we don’t know if a suicide attempt will lead to death.
The method or means used in a suicide attempt will have a bearing on whether the outcome is fatal or not.

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Myths and Facts About Preventing Suicide

No one can stop a suicide, it is inevitable.

MYTH 1

FACT 1

If people in a crisis get the help they need, they may never be suicidal again.

© 2022 QPR Institute. Inc.

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Myths and Facts About Preventing Suicide

Asking a person about suicide will only make them angry and increase the risk of suicide.

MYTH 2

FACT 2

Asking someone directly about suicidal intent lowers anxiety, opens up communication and lowers the risk of a suicide attempt.

© 2022 QPR Institute. Inc.

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Myths and Facts About Preventing Suicide

Only experts can prevent suicide.

MYTH 3

FACT 3

Suicide prevention is everybody’s business, and anyone can help prevent the tragedy of suicide.

© 2022 QPR Institute. Inc.

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Myths and Facts About Preventing Suicide

Most people considering suicide communicate their intent sometime during the week of preceding their attempt.

FACT 4

MYTH 4

People considering suicide keep their plans to themselves.

© 2022 QPR Institute. Inc.

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Myths and Facts About Preventing Suicide

People who talk about suicide may try, or even attempt, an act of self-destruction.

FACT 5

MYTH 5

Those who talk about suicide,�do not do it.

© 2022 QPR Institute. Inc.

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Myths and Facts About Preventing Suicide

Once a person decides to die by suicide, there is nothing anyone can do to stop them.

MYTH 6

FACT 6

Suicide is the most preventable kind of death, and almost any positive action may save a life.

© 2022 QPR Institute. Inc.

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Culture Matters

Stigma and judgment prevent people in the Black community from seeking treatment for their mental health condition. Research indicates that the Black community believes that mild depression or anxiety would be considered “crazy” in social circles. Many believe that discussion about mental health wouldn’t be appropriate even among family.

© 2022 QPR Institute. Inc.

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A Growing Crisis for Black Youth

Suicide is the second leading cause of death.

3,000 youth died by suicide in this age group

Are more likely to die by suicide compared to their white peers.

Youth ages 10 - 19

In 2017

Black males 5 - 11

The suicide death rate among Black youth has been found to be increasing faster than any other raical or ethnic group.

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Black youth under 13

Self-reported suicide attempts

Black Adolescents

Are twice as likely to die by suicide than their white counterparts.

Have increased by 73% for Black male and female adolescents over the past 25 years.

Are significantly less likely to receive care for depression.

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Self-reported suicide attempts

“Historically, white males have had the highest suicide rates among people age 10-24. But in Virginia in 2020 and 2021, the suicide rates for Black boys and young men exceeded the rates for corresponding white males.”

South, M. H. W. a. J. (2023, October 31). Suicide rates for young Black boys and men in Virginia is the highest it’s been in at least a decade. WHRO.org. https://whro.org/news/local-news/42400-suicide-rates-for-young-black-boys-and-men-in-virginia-is-the-highest-it-s-been-in-at-least-a-decade

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Trauma & Suicidal Ideation

Trauma, including childhood maltreatment (Physical, emotional, sexual abuse, and neglect) is a significant risk factor for suicidal ideation. (Bahk et al., 2017)

Direct Impact: Childhood sexual abuse is strongly linked to suicidal thoughts (Bahk et al., 2017, p. 38)

Indirect Impact: Physical and emotional abuse increase suicide risk through anxiety, while neglect influences suicidal ideation through reduced social support.

Key Interventions: Addressing anxiety symptoms and improving social support can help decrease suicide risk (Bahk et al., 2017, p. 42).

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Trauma Prevalence in Black Youth & Warning Signs

Prevalence of Trauma in Black Youth

Black youth experience higher exposure to trauma than White youth. With 57% of Black adolescents reporting a recent experience with violence (Pumariega et al.,2022, p. 28).
Black youth are more likely to experience PTSD, depression, and anxiety compared to White youth (Pumariega et al., 2022, p. 286).
Factors increasing trauma risk: Systemic disparities, racism, community violence, and lower access to mental health care (Pumariega et al., 2022, p. 287).

Warning Signs of Experienced Trauma

Complex Clinical Presentations: Re-experiencing the traumatic event, avoidance behaviors, hyperarousal and emotional and behavioral issues (Danese et al., 2020).
Other Common Psychological Symptoms: Anxiety, clinginess, withdrawal, difficulty maintaining attention, disrupted sleep patterns, irritability, and physical symptoms such as stomach aches or headaches.(Danese et al., 2020).

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Suicide Clues and �Warning Signs

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Take All�Signs Seriously.

The more clues and�signs observed,�the greater the risk.

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Direct�Verbal Clues

Indirect Verbal Clues

Behavioral Clues

Situational Clues

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Direct Verbal Clues

“I’ve decided to kill myself.”
“I wish I were dead.”
“I’m going to commit suicide.”
“I’m going to end it all.”
“If (such and such) does not happen, I’ll kill myself.”

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Indirect Verbal Clues

“I’m tired of life, I just can’t go on.”
“My family would be better off without me.”
“Who cares if I’m dead anyway.”
“I just want out.”
“I won’t be around much longer.”
“Pretty soon you won’t have to worry about me.”

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Behavioral Clues

Any previous suicide attempt
Acquiring a gun or stockpiling pills
Co-occurring depression, moodiness, hopelessness
Putting personal affairs in order
Giving away prized possessions
Sudden interest or disinterest in religion
Drug or alcohol abuse, or relapse after a period of recovery
Unexplained anger, aggression and irritability

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Situational Clues

Previous suicide attempt
Being fired or being expelled from school
A recent unwanted move
Loss of any major relationship
Death of a spouse, child, or best friend�—especially if by suicide
Diagnosis of a serious or terminal illness
Sudden unexpected loss of freedom/fear of punishment
Anticipated loss of financial security
Loss of a cherished therapist, counselor�or teacher
Fear of becoming a burden to others

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Q

QUESTION

P

PERSUADE

R

REFER

The QPR Institute offers a 3-step intervention plan.

Approach:�Direct or Indirect
Identifying questions to avoid

How do you persuade someone to stay alive?

How and to whom will you refer the person you just helped?

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Asking The Question

ASK THE QUESTION. SAVE A LIFE.

Q

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Tips for Asking the Question

If in doubt, don’t wait. Ask the Question!

If the person is reluctant, be persistent.

Talk to the person alone in a private setting.

Allow the person to talk freely.

Give yourself plenty of time.

Have your resources handy: the QPR Card,�phone numbers, counselor’s name�and any other information that might help.

1

2

3

4

5

6

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REMEMBER:�How you ask the question is less important than that you ask it.

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Less Direct Approach

�“Have you been unhappy lately?” �

“Have you been very unhappy lately?” �

“Have you been so very unhappy lately that you’ve been thinking about ending your life?”�

“Do you ever wish you could go to sleep and never wake up?”

Q

Main Point: 3 minutes

Less direct approach: Easy way into a tough question.
Direct approach: generally, the best approach (the last point in the direct approach).

(note from Paul Quinnett) The direct approach tends to work well with men

These are just examples. Use your own voice and speak in a way that is comfortable for you.
This will sound different with each situation and relationship.
You can refer to the warning sign that you picked up on when asking the question. Ex. I noticed that (insert warning sign observed) ……. I am wondering if you are thinking about killing yourself?”
Pick a few examples and elaborate if you wish.
Acknowledge fear and anxiety about asking this more difficult question.
The last point in the less direct approach is a way to ask the S question to someone who does not understand what killing yourself or suicide means
Wrap up with “The most important thing is that the S question gets asked.”

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Direct Approach

“You know, when people are as upset as you seem to be, they sometimes wish they were dead.

�“I’m wondering if you’re feeling that way, too?”�

“I am worried about you. I wonder if you’re thinking about suicide?”�

“Are you thinking about killing yourself?”

Q

Main Point: 3 minutes

Less direct approach: Easy way into a tough question.
Direct approach: generally, the best approach (the last point in the direct approach).

(note from Paul Quinnett) The direct approach tends to work well with men

These are just examples. Use your own voice and speak in a way that is comfortable for you.
This will sound different with each situation and relationship.
You can refer to the warning sign that you picked up on when asking the question. Ex. I noticed that (insert warning sign observed) ……. I am wondering if you are thinking about killing yourself?”
Pick a few examples and elaborate if you wish.
Acknowledge fear and anxiety about asking this more difficult question.
The last point in the less direct approach is a way to ask the S question to someone who does not understand what killing yourself or suicide means
Wrap up with “The most important thing is that the S question gets asked.”

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IMPORTANT:

If you cannot ask the question, find someone who can.

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How not to ask the suicide question:

“You’re not thinking of killing yourself, are you?”
“You wouldn’t do anything stupid would you?”
“Suicide is a dumb idea. Surely you are not thinking�about suicide?”

Main Point: 2 minutes

These questions are telling the person in crisis to tell you “no”
We never tell them not to tell us the truth.
We never pass judgment on a person thinking about suicide
Be aware of your non-verbals (body language, tone of voice)

Activity: Take a moment to have the entire group repeat outlowd “are you thinking about killing yourself?”

remind them that these words are never easy to say but the blunter and clear we are, the better
practice makes perfect, and we are in a safe place to try these words on together, as ONE VOICE
Never isolate voices (have one person say the question, individually) This can cause embarrassment
Let them know you will count to 3, and after 3 we will all repeat out loud together “are you thinking about killing yourself?”�Homework… repeat this question to yourself in the mirror, to your pet, the more practice you can get the better.

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P

PERSUADE

Persuading Someone�to Stay Alive

Listen to the problem and give them your full attention.
Remember, suicide is not the problem, only the solution to a perceived insoluble problem.
Do not rush to judgment.
Offer hope in any form.

Main Point: 3 -5 minutes

What are we Persuading the person in crisis to do?

Stay alive in the moment and get professional help

You are talking to someone who may be hopeless, scared, and ambivalent and probably has not spoken to anyone about it.
It is NOT your job to be their therapist.

If they do not want to talk, that is ok, but give them the space to do so
Your job as the QPR gatekeeper is to LISTEN and provide HOPE in any form

If they do not want to open up and talk, that is ok; do not push. Encourage them to stay safe in the moment and move into the “Refer.”
Active listening is a defined skill set.

If people don’t know how to do this, training is available online and elsewhere.
It is the most critical of skills to master to help people in distress.

Research does not support “No Suicide Contracts”; however, there is weight in a promise between two people to stay safe.

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Then, ASK:

“Will you go with me to get help?”
“Will you let me help you get help?”
“What can we do to keep you safe for now?”

EVEN BETTER:

“We can go see the counselor together or I can call them and see if they can come to us. Which option are you more comfortable with?”
“I can call 988 for help or you can call, and I will sit here with you. Which would you like to do?”

Main Point: 3-4 minutes

Be careful not to ask a question or provide an option that the person could answer “no” or refuse

Provide options to choose from that you are ok with either option
Provide two options, both of which are positive
Ex. “We can go see the counselor together, or I can call them and see if they can come to us. Which option are you more comfortable with?”
Ex. “I can call 988 for help and guidance or you can call, and I will sit here with you. Which would you like to do? “

You may run into resistance. It is okay to ask for help; ask the person in crisis if there is anyone else who would like to get involved.

You may not be the person to help, which is ok. That does not mean you did something wrong.

Remeber that every situation is going to be different, and you must rely on your intuition and trust that you know how to handle the individual situation based on context and your relationship with that individual
This is the segway into the referral

Additional notes:

Please note; “Will you promise me not to kill yourself until we have found help?” is NOT a no-suicide contract historically used by health professionals. No-suicide contracts have been found to be ineffective in preventing suicide attempts and deaths by suicide. Friends, co-workers, and family members ask for and make promises to each other routinely to assure a behavioral commitment to some future action. For example, “Will you promise to go to church with me this weekend?” is not a contract to go to church; it is an ask for a pledge of commitment to do something in the future. Contracts have specific duties and obligations specified in the language of the contract. Promises to do. Do we have research to support this position? No. But we all have experiences with making and keeping promises.

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R

REFER

People living with suicidal thoughts often believe they cannot be helped, so you may have to do more.

Main Point: 2-3 minutes

Instructors should provide local referral resources, organizational referral protocol if training at an organization, university or school, and always provide 988 resources.
Suicide is a solution to a perceived insoluble problem. They not only feel hopeless, the feel helpless. If they could have helped themselves, they would have one it by now.
You will encounter individuals who feel that they may not be able to be helped and may be resistant to treatment.
It is our role as QPR Gatekeepers to offer HOPE in any form and provide access to that referral in the form of a warm handoff.
It is not always possible to get a referral to a professional.
There are places in the world where a professional referral is not available, or the person will simply never go to a mental health or other professional. In these cases, you will have to be creative.
In every culture, village, and social system, there are " go-to” people who may be able to help someone in severe distress. Clergy can do wonders here, and they are much more available than mental health professionals.

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Referral Options

The best referral involves�taking the person directly to someone who can help.

The next best referral is getting�a commitment from them to accept help, then making the arrangements to get that help.

The third best referral is to give referral information and try to get a good faith commitment not to attempt or die by suicide.

★★★

★★

★

Main Point: 2 minutes

Instructors teaching in an organization can include the organization’s referral protocol here if nothing: 988
Every situation will be different, depending on the context, relationship, and level of risk
The gatekeeper should always be aware of the level of risk during the interaction with the person in crisis.

If at any time the person in crisis or the gatekeeper becomes at imminent risk (a weapon is present, there is a life-threatening situation, etc.), the gatekeeper needs to do the following:

Remove themselves to a safe distance; if you can keep sight of the suicidal individual, do so, but only if a safe distance can be maintained
Call emergency services and notify them of the situation.
The more information that can be provided to dispatch, the better the care will be provided.

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Local Resources

Richmond Behavioral Health Authority Crisis Hotline: 804-819-4100
Children’s Crisis Stabilization Unit (CSU) 24|7 Call Center 804-874-9119
Crisis Response and Stabilization Team (CReST) Referral Line 1-833-968-1800
National Suicide Prevention Hotline (text): 988

Richmond Behavioral Health Authority Crisis Hotline: 804-819-4100
Children’s Crisis Stabilization Unit (CSU) 24|7 Call Center 804-874-9119

The Children’s CSU is operated in partnership with St. Joseph’s Villa and offers a safe, therapeutic environment designed to assist youth in stabilizing a mental health crisis.

Services include (youth 5-17 years old):

Individual and Family Interventions (including individual, group, and family therapy)
Assessment and Treatment Planning
Medication Management
Links to community resources
Educational Coordination

3. Crisis Response and Stabilization Team (CReST) Referral Line 1-833-968-1800CReST is a resource for children ages 5 - 18 or adults ages 18 & older who are in crisis and need help avoiding psychiatric hospitalization. With quick response and assistance connecting to on-going services, CReST works to reduce the cycles of crises and prevent the need for more intense care.

CReST staff work with individuals to:

Triage and problem solve the crisis at hand
Identify on-going treatment needs
Link to community providers
Provide community based counseling

National Suicide Prevention Hotline (text): 988

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Any willingness to accept help at some time, even if in the future, is a good outcome.

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REMEMBER:�Since almost all efforts to persuade someone to live instead of attempt suicide will be met with agreement and relief, don’t hesitate to get involved or take the lead.

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Pro Tips for Effective QPR

Offer encouragement, such as:

“I want you to live”
“I’m on your side... We’ll get through this.”

Get others involved. Ask the person who else might help.

Family. Friends. Brothers. Sisters. Pastors. Physician. Counselor. Small Group.

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More Pro Tips

Join a team. Offer to work with clergy, therapists, psychiatrists or whomever is going to provide the counseling or treatment.
Follow up with a visit, a phone call or a card, and in whatever way feels comfortable to you.
Let the person know you care about what happens to them. Caring may save a life.

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REMEMBER

When you apply QPR, you plant the seeds of hope.

Hope helps prevent suicide.

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Role-Play

Practice is important!

Role-play exercises create an opportunity to practice listening skills and to ask directly about suicide.

Stigma and fear make it difficult to ask the S question. Practice helps!

© 2022 QPR Institute. Inc.

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Instructions for In-Person Role-Play

Break off into pairs.�
Each person will play both the role of the person in distress and the role of the QPR Gatekeeper. �
You determine who will play which role first.�
Ensure each person in a pair receives a different role-play scenario.�
Your partner will need to “act” as if they are in a crisis and thinking about suicide.

© 2022 QPR Institute. Inc.

Instructor Prep BEFORE Class:

Have selected role plays you would like to use on hand. Be sure to have at least two to three different role plays so each person in the group has a different role play.
Be sure the role play topics are appropriate for the audience you are teaching (ex., Do not use the role plays for law enforcement in a school setting).
Imbed the QR codes for the roleplays that you want to use on slides 5 and 6
Print out paper copies of the chosen role plays in the event that individuals do not have the capability to use a QPR code

Instructor Notes:

As you facilitate the roleplays, staying aware of everyone’s behavior will be important, as this activity can bring up some emotions.
Be supportive and remember that you may need to perform QPR with a participant in your class.
Although not mandatory, having another trainer or support person during this time is helpful.
All participants you train should have an opportunity to be in both the gatekeeper and person in crisis roles.

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In Person Role-Play Instructions

Start the conversation with an open-ended question such as, �“I noticed you have been a little down lately. What’s going on?" �“You seem upset. Do you want to tell me what is bothering you?”

As you begin your conversation, listen for the problems that suicide would solve and listen for a “warning sign.”

When you hear the warning sign, find a way to ask the S question �“You seem very unhappy right now. Are you thinking about suicide?”

Continue to listen and try to persuade them to go with you to get help.

Be sure you complete all the QPR steps. �
Switch roles with your partner

Group Discussion will follow this activity.

© 2022 QPR Institute. Inc.

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Scenario QR Codes: Scan the QR code below

Scenario 1

Scenario 2

NOTE: Only scan the QR code when you are the person in distress. The QPR gatekeeper should not see it.

*6-7 minutes per scenario

© 2022 QPR Institute. Inc.

Have participants break up into groups of two (or three).

Each person will play both the role of the person in distress and the role of the QPR Gatekeeper (and possibly the role of an observer if incorporating a third participant).
Notify participants which groups they are in (verbally or via the chat function)

Have the participant who is playing the role of the distressed person scan the QR code for scenario #1
Have the participant who is playing the role of the distressed person scan the QR code for scenario #2
Instruct the person who will be playing the role of the distressed person FIRST, to read the scenario to their partner up until the section that states “ what your (role of gatekeeper) does not know….”
Tell them when they are finished with their first role play, switch and distressed person two can repeat the process with their scenario.
Let them know that when they have finished, to wait patiently and you will discuss as a group

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Group Discussion

What did you become aware of during this exercise?
How did it feel to ask the suicide question?
Was it uncomfortable to ask the question?
What was the source of this discomfort?
What did you learn from this experience?

© 2022 QPR Institute. Inc.

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Scan me for Survey, Certificate, & Gift Card!

Dr. Renae Mayes: rdmayes@arizona.edu

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Interested in talking more about Black Youth Mental Health in Richmond? Let us know!

Dr. Lauren Mims:

lcm9999@nyu.edu