TRAINING SUMMARY

QPR SUICIDE TRIAGE TRAINING FOR POLICE OFFICERS

The key element in any successful intervention is to establish a positive relationship with the person in distress. You no doubt know this, but it is helpful to underscore that your willingness to listen and to be empathetic sends a message of hope, and hope is crucial if the triage interview is to be effective. From experience, we know that without a working alliance with a distressed and suicidal person, inadequate or incomplete risk data will be collected and your decision about next steps will be difficult. Our decision making and assessment of potential risk for suicide hinge on the following:

• What we know

• How much we learn from the person

• The context in which suicide is being considered

• Warning signs

• Risk factors (including the presence of means of suicide, e.g., belt, shoelaces, sharp)

• Protective factors

• What the suicidal person is willing to do to help us save his or her life

NECESSARY PAPERWORK (If applicable).

The QPR Suicide Triage document requires filling in some boxes and collecting some data. This may not be a task required of you. However, if you complete the triage document, please understand that during the interview it is important that you not come across as if you are “just filling in the boxes on some form.” The person will likely detect this sterile, cold approach, and the success of the intervention may be compromised. As we have said, an empathic, understanding relationship is crucial to the success of the information gathering process.

The QPR Suicide Triage interview and document are guides to successful interviewing, not a substitute for all the questions that you may need to ask to carry out a successful suicide prevention interview. When it comes to helping a suicidal person, always sacrifice paperwork first.

HOW QPR TRIAGE WORKS

The QPR Triage interview is a strategic interview designed to: • Detect and assess immediate risk for suicide • Reduce that risk if present (including removing the means of suicide, increasing observation status or monitoring, etc.) • Get the suicidal person to a professional for further assessment or treatment

JOB 1: SUICIDE RISK DETECTION

To assess suicide risk, it must first be detected. The QPR Triage interview begins with asking the S (suicide) question.

Points to consider: • Asking the S Question can be difficult. • Staff discomfort with the topic of suicide may inhibit timely action. • Failure to elicit key information may impact immediate suicide risk. • Asking about suicidal thoughts, feelings, history is mission critical. • Asking about suicide may reduce the person’s distress, open up communications and lower the risk of a suicide attempt.

People die to solve problems they can’t solve by themselves; help them solve the problem and you can save a life.

HOW TO ASK THE SUICIDE QUESTION: The QPR Triage interview is both natural and developmental. The question you open with will be determined by the circumstances. If the person is sitting on the edge of the roof of a tall building high structure, you can skip some of the earlier questions. Where it is not clear the person is suicidal, you can begin with any of the following questions:

Sample: • “Has anyone in your family been depressed or seen a psychiatrist or counselor?” • “Has anyone in your family ever threatened, made an attempt or completed a suicide?” • “Have you ever experienced thoughts of death or suicide?”

More Samples: • “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?” • “You seem very unhappy. Have you had any thoughts of death or suicide?” • “Suicidal thoughts are a common symptom of depression; have you had been depressed lately?” • “With all you’re going through, have you experienced thoughts of harming or even killing yourself?” • “Have you been suicidal or have you been thinking about suicide?” • “Are you considering ending your life?” • “Have you ever wished you were dead?” • “Are you thinking about killing yourself?”

There is only one way not to ask this important question: “You’re not thinking of suicide, are you?”

The frame of this question demands a negative reply and may close off any opportunity for the suicidal person to experience the relief that someone is able to listen to his or her distress. Asking for a negative will generally produce a denial of suicidal thinking or planning. In other words, if you (the interviewer) are afraid to learn the truth, the suicidal person may “protect” you from what he or she is really planning to do.

IF YOU GET A “YES” A yes answer to the S Question opens the interview for the guided portions of the QPR Triage interview (see Triage Document).

IF YOU GET A “NO” A “no” to the S Question leads closes the assessment interview (see exceptions below).

Three Important Facts to Remember: 1. We recommend questioning persons more thoroughly if presenting with considerable distress, expressions of hopelessness or if there are external stresses that make you suspicious. 2. We recommend asking about suicidal history (personal and family) even if the person denies current suicidal thoughts or feelings. A person may not be suicidal today, but may have a history of one or more suicide attempts by history and, therefore, at elevated risk for future suicidal behaviors tomorrow. 3. No single question can expose a competent liar who wishes to conceal current suicidal thoughts, plans or feelings— so you can only do your best and let God take care of the rest. If you feel fear for the safety of someone you think might be suicidal, trust it! Keep up the interview, even gently pestering the person if necessary. Do not talk yourself out of your fear – because your “gut” sometimes knows more than your brain.

If the person responds “Yes” to the S Question

An affirmative answer to the S Question opens the QPR Triage protocol to these seven key questions:

What is wrong? This question elicits the person’s: • personal story about how bad things are and the nature of the problem(s) • personal construction of reasons for suicide • personal measure of psychological pain and suffering

Sample questions: • “Okay John, why don’t you tell what’s wrong with your life right now?” • “Audrey, what made you decide to call for help?” • “We’ve got a few minutes to talk, I’d very much like to hear your version of what’s wrong right now.”

Common answers by theme: • Feels hopeless and depressed (clinical depression is the most common cause of suicide) • Feels isolated and alone • Has lost job or major relationship • Feels overwhelmed, angry and upset • Feels like a burden on others • Financial problems • Has problems at work

Note: Be especially aware that even the most severe psychological pain and suffering may not be detectable by interview, especially if the person is being consciously evasive to avoid a negative consequence. Also, in some cases, the person may have insufficient psychological insight to accurately report on his/her inner state of distress, despair or pain. The author’s again recommend that staff trust their own “gut” fear for the person’s safety and act accordingly, including, if necessary, conducting or requesting an assessment for psychiatric hospitalization.

KEY POINTS: • Most suicidal people need to “tell their story.” Telling it often produces relief. • Active listening without interjecting judgements or opinions at this phase of the interview is critical. • Telling one’s story to a caring third party may help restore the person’s ability to think more clearly and cope more successfully.

Why now? This question elicits: • elements of the current crisis, and what may have started the crisis • history of real or imagined losses or rejections • any sudden and unacceptable change in life circumstances, e.g., the person just received a serious or terminal diagnosis, is facing a long jail term, etc. • onset of possible psychiatric symptoms, e.g., sleeplessness, loss of appetite, anxiety, etc.

Sample questions: • “Robin, what has changed such that you are considering suicide now?” • “It sounds as though this relationship has been difficult for a long time; what’s different for you now?” • “Joe, it sounds like you’ve been unhappy for months and hadn’t contemplated suicide before. Why are things so unbearable now?”

Common answers by theme: • recent loss, rejection or anticipated unacceptable event about to happen • exhausted, can’t sleep • anxious, worried and sees “no way out” • losing emotional control and feels helpless • reports life is not worthwhile

KEY POINTS: • The suicidal person may have been struggling with similar issues for a very long time, but some recent event has increased psychological pain to intolerable levels. • Causing an officer or staff come to the inmates cell may be an attempt to find relief from distress or emotional pain. • Suicidal persons are almost always ambivalent about living or dying. • A necessary condition (e.g., presence of a psychiatric disorder) plus a precipitating event may overwhelm the person’s ability to cope.

With what? This question elicits: • the means of suicide under consideration • access to the means selected • whether more than one method is under consideration

Sample questions: • Have you thought about how you would kill yourself? If the person responds with a “yes,” follow up with:

• “Can you tell me the way in which you’ve considered ending your life?” • “How would you kill yourself?”

Common methods under consideration (either now, in jail, or later): • no plan formulated (most suicidal people have not determined what means to use in an attempt) • motor vehicle crash • firearm • hanging, OD on prescription medications or over-the-counter drugs • alcohol and drug overdose • jumping from a high structure • cutting and bleeding to death • death by attacking an armed police officer

Redundant Planning Some suicidal people plan multiple ways to kill themselves, and therefore it is necessary to inquire if the person has more than one suicide plan. After documenting the initial method of suicide being considered, then ask: • “Have you had any other thoughts of how you might kill yourself?”

Sample questions to determine availability of means: • “Do you have immediate access to (medications, a gun, a razor blade, etc.)?” • “Where is the gun (rope, razor, etc.)” • “Where would you get the medications (gun, rope, razor, etc.)?”

Where and when?

This question elicits: • possible location and timing of a suicide attempt • degree of planning • possible anniversary phenomena

Sample questions? • “Have thought about where you might try to kill yourself?” • “Have you decided when?”

Common locations (when is often determined by an important anniversary or if something does happens; e.g., divorce goes through, sentencing hearing is scheduled, etc). • has not chosen place or time • soon, today, tomorrow, next week • on the weekend when fewer staff are around • at night • when cell mate is not present • after ? occurs or before ? occurs

KEY POINTS REGARDING LETHAL PLANNING (With what? Where? When?): • Many suicide attempts are impulsive and little or no planning will be evident. • Generally, the more detailed the planning, the greater the risk. • It should never be suggested that the method of suicide under consideration is insufficient, e.g., “You can’t take enough of those pills to kill yourself.” • The more methods of suicide under consideration, the greater the risk. • Suicide risk increases dramatically with access to means. • Specificity of time and place for a suicide attempt equals greater risk. • Determination of “anniversary phenomena” is important to risk assessment. • Suicide plans that include an effort to avoid rescue suggest higher risk. • Suicide plans that are contingent on the actions of a third party are especially dangerous (see note below).

NOTE: Some suicide plans involve a necessary contingent event before the attempt is made. A very common example would be a depressed and suicidal man who states, “I’ll kill myself if she doesn’t come home tonight.” Or, in the case of an incarcerated person, “If she doesn’t come to visit me, it’s over.”

One of the most common dynamics for suicide in America is as follows: woman leaves man, man leaves planet. Sometimes he kills her first, and then himself. He’s usually depressed, not in treatment, drinking and has access to a firearm when not in jail. There is often a long history of domestic violence or relationship conflict. Suicide risk can be high among these men when they are being rejected, divorced or otherwise abandoned by the woman they love and depend upon. Men can take a lot punishment, but being left by the woman they love is not one of them.

Suicide prevention is violence prevention.

When and with what in the past? This question elicits: • past history of suicidal behavior • past history of intense suicidal ideation and/or planning • whether rescue was avoided • timing of past attempts • social response to past attempt(s) • potential protective factors • comparison of current method vs. old method

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 Pat responds “yes,” then ask: • “When was that?

After learning when a previous suicide crisis occurred, follow up with the question: “Did you make an attempt at that time?”

After again being told “yes,” inquire as to the method used. For example, • “How did you attempt to kill yourself?” • “What method did you try?”

If the person has been suicidal before, but did not make a suicide attempt, the reasons they did not make an attempt may help to identify coping strategies that may have been helpful in the past. Discovering what and who was helpful in the past may help the person build upon past successes and provide a sense of hope in the current situation.

Example: • “So, you had thoughts of suicide two years ago as well. What were some of the things that helped you to make it through that difficult time?”

If the person has been suicidal in the past and did make an attempt, then gathering as much information as possible about that crisis is important. Identifying precipitating events preceding that attempt (are they similar or different to the crisis now being faced?), the specific method or means of attempt (including how lethal, any injury, the likelihood of being rescued, etc.), and what the person experienced following the attempt are all important elements to understanding the current crisis.

Once this historical information has been gathered, you are advised to go back and inquire if there have been any other attempts in the past, repeating this cycle of information gathering until the caller states that they made no other attempts.

PLEASE NOTE: An added benefit to the suicidal person asked to detail past suicidal crises is that he or she may develop some insight into the types of stresses that precipitate such crises. Armed with new insight, the suicidal person may be able to develop protective strategies to deal not only with the current crisis, but future ones as well.

It is also important to know if the means of suicide under consideration now is a different method than the one(s) tried previously. If different, and especially if a more lethal method is planned (used a knife in the past, but now has a gun), current risk increases dramatically.

KEY POINTS: • Past suicidal behavior is a good predictor of future suicidal behavior. • Past protective factors may be marshaled to reduce current risk. • Intense suicidal thinking and planning in the past is an important aspect of risk assessment. • The “social response” to one’s past suicide attempt may provide insights into the current crisis and its resolution. • If the person avoided or attempted to avoid rescue in an earlier suicide attempt, risk is higher. • Detailing past suicidal history may provide insight into how to deal with future stresses.

Who’s involved? This question elicits: • others who may know or be involved • persons who may or not be helpful to managing the person • names of potentially helpful third parties • possible presence of a suicide pact or murder-suicide plan

Sample questions: • “Who are the people or the activities that are important to you?” • “Who else knows you are in this much pain?” • “Who is your main support during times like these?” • “Who could help you right now?” • “Is there a friend who needs to know that you’re hurting this bad?” • “Have you told your pastor (priest, rabbi, chaplain or spiritual advisor) about how had you’ve been feeling?”

Common answers by theme: • no one • spouse, lover or partner • parents, family, spouse, children, brother, sister • friends, coworkers, healthcare provider

KEY POINTS: • Most suicidal crises involve at least two people (e.g., a couple in conflict). • Suicide threats may have already been made to significant others without producing any relief. • The social and psychological setting in which a suicide crisis is developing may or may not be supportive of seeking help or treatment. • Social isolation increases risk. • Suicidal people may also be planning violence toward others (e.g., domestic violence, murder-suicide, other students at school, co-workers, etc.) or be involved in a suicide pact.

Why not now? This question should elicit: • one or more protective factors (reasons for living) • spiritual or religious prohibitions • duties to others or pets • residual tasks to be completed before the attempt, e.g., making out a will

Sample questions: • “Give me some reasons why you may want to live?” • “You’ve shared some reasons why you are considering suicide. What are some reasons that you should not kill yourself?”

Common answers by theme: • don’t want to hurt others, especially children • has not taken care of “final details” • suicide is morally not acceptable/against religion • has pets to care for or duties to others • has things to live for • afraid of not dying in the attempt

KEY POINTS: • The more protective factors present, the lower the risk. • Few or no protective factors suggest greater risk. • The possibility of treatment and relief from suffering is a powerful protective factor. Offering to get the person to a doctor can save a life. • Protective factors vary by individual, but often include spiritual prohibitions, sobriety, family support, job stability, responsibility for others (including pets), limited access to the means of suicide, good health, and being active in a faith community. • Low risk does not equal zero risk.

PLEASE NOTE: For a variety of reasons, seriously depressed persons may be unable to identify protective factors obvious to anyone else or those around them. Even though there are reasons to live, the depressed mind cannot see them.

***

This ends the description and rationale of the formal QPR Triage questions. Practice them a few times, and they will become second hand.

THE RISK FACTOR CHECKLIST During the course of this interview, many additional risk factors may have been mentioned by the person or learned about through follow-up questions. To aid the documentation process, we have included several potential risk factors in a checklist format. These risk factors were developed and based through a review of the most current medical and research literature.

USE OF RISK FACTORS CHECKLIST While it is desirable to learn if multiple risk factors are present, it is not recommended that the you pursue this data in detail. Generally, the greater the number of risk factors present and checked off, the greater the present risk. Also, it is important to treat all risk factors seriously. However, when many risk factors are present, our judgment about what level of intervention may be required is better informed.

Please note, also, that this list of risk factors is not all encompassing. Highly individual risk factors may not appear. For example, a professional guitar player who just lost two fingers in an accident is an example of a highly individual risk factor. A religious leader arrested on sex abuse charges is another. Again, regardless of the number of risk factors present, it is important to be mindful of your personal “gut reaction” or “felt fear” for the person’s safety during your interactions with him or her. The greater your fear, the greater the risk for a suicide attempt may be.

If in a hostage negotiating situation, or where more time is available, you may elect to use the following additional risk assessment questions.

ADDITIONAL RISK ASSESSMENT QUESTIONS

Who else knows? May provide names of others who can help.

Why in the past? May provide more depth history and insights into current crisis.

Why not in the past? May provide protective factors that can be brought to bear in the current crisis.

Who else in the past? This question is designed to find out who has served as a possible role model for suicide. A parent? A sibling? A lover? An admired celebrity? It is important for you to help the person differentiate his or her problems from those of the role model. Such differentiation helps lower risk.

What will happen after you are dead? This question will elicit death fantasies, including the desire to join deceased loved ones, find peace with God, be reincarnated or see one’s friends gathered around a beautiful funeral.

What type of reactions do you expect from your suicide, and what would you like them to do? This will also elicit the social network of people around the person and may help explain the present dynamics of the crisis, as well as the person’s motives.

Who will find you if you kill yourself? The answer to this question often yields the name of the person with whom the person is in conflict. In domestic violence situations, the “victim” is often the abused spouse. It is not rare that angry, suicidal persons may, with their death, attempt to carry out an act of revenge. Any suicide plan that includes having one’s body discovered by the person the person is angry with may fit this description.

Certainly, there are more questions that can be asked of someone experiencing suicidal thoughts and feelings. The QPR Triage questions are not meant to be exhaustive. However, answers to the questions listed above, in the context of an empathic interview, will not only determine how much risk is present, but should reduce psychological pain and distress.

Persuading the Person to Accept Help

The goal of persuasion is to form a positive relationship and confirm that the person is willing to accept help and find life-affirming solutions. Anticipate resistance in some persons, especially when a detailed suicide plan has been made and protective factors are absent. When few or no reasons for living are expressed, persuading the person to accept a referral or treatment can save a life. However, when you given the distressed person your full attention and gotten answers to the questions we recommend, you have already demonstrated your compassion and interest in what happens to them.

Caring saves lives!

KEY POINTS: • Expressed anger at you may mean greater risk. • Refusal to accept help equals greater risk. • An abrupt or angry withdrawal from the interview may mean greater risk. • Unwillingness to remove the means of suicide equals greater risk. • Reassessment of risk may be indicated if help is refused. • Emergency intervention, consultation and/or supervisory input should be readily available.

Referral

The QPR Triage referral and safety plan is self-explanatory (see document).

Suicide risk is low to moderate when the person agrees to: • remain clean and sober • seek help • see to the removal of the means of suicide • not harm or kill self accidentally or on purpose • seek help in case of crisis • accept treatment or a referral for treatment. • give a verbal affirmation to abide by the safety plan

Suicide risk is high when the person: • has not been cooperative • has said little or nothing about his or her problems • has been distant, evasive and aloof • refuses to go along or agree to the referral and safety plan

To help determine what we call “resistance risk,” (resistance to getting help or treatment) it is recommended that the interviewer review each item in the referral/risk management plan with the inmate. By checking off each item with suicidal persons you will quickly find out how willing they are to, in fact, save their own life. If the suicidal person begins to stall, argue and disagree with what are reasonable steps to immediately reduce suicide risk and accept help, then the inmate should probably be placed on observation status and be seen as soon as possible by mental health professional.

COMPLETING THE DOCUMENT (if applicable)

The QPR TRIAGE document is complete when answers to the six protocol questions are answered and the person’s safety statement is noted in quotation marks. The document may or may not signed by the staff person (this is a policy decision by your employer).