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Training Summary 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.
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