QPR for Communities
Thank you for your interest in our community suicide risk reduction program.
This article describes one approach to community-based suicide prevention planning that can lead to the implementation of community-wide suicide risk reduction programs and practices. This program is intended to build community competence via a systems approach to gatekeeper training. Links are provided to more than ten downloadable, in-depth, executive and research summaries, surveys, assessment tools, and other informative documents to assist organizations interested in establishing community-based suicide prevention programs.
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The QPR concept grew out of a community-based suicide prevention effort lead by the Spokane County Health Department, Spokane Mental Health, Spokane Police Department, the help of citizens who had lost loved ones to suicide, and with the participation of more than a dozen community-based organizations, including schools, churches, and hospitals. The history of this collaborative process is available on request.
As a community-based multidisciplinary team of professionals, the QPR Institute staff and faculty believe that for suicide attempts and completions to be reduced, a unified community response is required. Ideally, this community effort is supported by local, state and national leadership, including university-based experts. At the community level, both lay citizens and professionals must work together to achieve two common goals:
- A greater sense of shared responsibility for the prevention of suicide
- Enhancement of community competence in preventing suicide and suicide attempts
Our Philosophy and Theoretical Assumptions
We believe that, fundamentally, all communities care about human life and will go to great lengths to prevent and mitigate the human suffering that precipitates suicidal behavior and the agony and pain survivors experience in its aftermath. We define communities as networks of people working in common cause for shared goals. Thus, a small town, a correctional facility, a military unit, a mental hospital, a university, a large corporation, a city, a county or a geographical region may all be defined as “communities.” We also believe that, provided with suicide prevention tools that work, communities can come together to prevent not only self-destructive acts, but the other-directed violence that is too often associated with suicidal behaviors.
We believe that once community leaders, volunteers, first responders and healthcare providers are equipped with specific knowledge and training aimed to reduce suicidal behavior, good will, personal energy, funding and implementation of suicide prevention efforts can and will be successful at the community level. By simultaneously building shared community responsibility and individual and group competence to identify, assess, manage and treat suicidal members of the community, communities can define themselves as caring, confident and competent in the prevention of suicidal behaviors among their members. To declare otherwise is to say of one’s community that it cannot provide for the basic psychological, emotional and spiritual needs of its members.
It is unlikely all sucicides can be prevented. And yet, public health awareness efforts, gatekeeper training, and enhanced skills training across the spectrum of health and human services, correctional workers and other provider organizations can dramatically lower the risk that a community member will attempt or will die by suicide. Research, including that conducted by the Devereux Foundation, Inc. and the United States Air Force, has shown such efforts can be effective. Using a comprehensive program, the U.S. Air Force reduced its suicide rate by 33% over a four-year period (Knox, et.al., 2003), while the Devereux Foundation has had a similar experience with its consumers of clinical services in a variety of behavioral healthcare settings (LeBuff & Soldivera-Kiesling, 2003).
The four cornerstones of the theory upon which our approach is derived are these:
- Those who most need help in a suicidal crisis are
the least likely to ask for it.
- Thus, we must find our at-risk citizens and go to them with help without requiring that they ask for it first
- The person most likely to prevent you from dying by
suicide is someone you already know.
- Thus, those around us must know what to do if we become suicidal
- Prior to making a suicide attempt, those in a suicidal
crisis are likely to send warning signs of their distress and suicidal intent
to those around them.
- Thus, learning these warning signs and taking quick, bold action during these windows of opportunity can save lives
- When we solve the problems people kill themselves
to solve, the reasons for suicide disappear.
- Thus, crisis intervention, problem resolution and treatment save lives>
As members of the human family, and living in communities as we do, each of us is surrounded by others, some of whom care deeply about our personal welfare and whether or not we live or die. By reason of pride, age, gender or culture we may not be able to ask for help when we are suicidal. Yet it is through this intimate, interpersonal knowledge of one another that suicidal communications, behaviors and warning signs can be recognized, interpreted and acted upon in a quick and effective fashion. Without this “gatekeeper” function, this social safety network of educated and vigilant others to observe, interpret and respond to our distress calls, individual suicide will be difficult to prevent.
Suicidal warning signs and pre-attempt communications range from weak and coded to strong and clear, and may be sent to some people and not to others. While much research is needed on this dimension of human interaction, for now we know enough to train ourselves and others to act as gatekeepers for those at risk. (For a PowerPoint file describing how QPR works for an older, isolated woman living in the community click here and wait for program to load (free PowerPoint Viewer software can be downloaded here))
That those around us are the ones most likely to assist us in a crisis of suicidal proportion cannot be overemphasized. This concept lies at the heart of the QPR community-based model and method of suicide prevention. Simply put, even isolated suicidal persons living alone in their communities are in contact with someone who knows them: a family member, a case manager, a pharmacist, someone at church, someone…. This someone must be trained to respond in a helpful fashion when suicide warning signs are detected, otherwise no rescue effort will occur and no life saving interventions and treatment will be initiated. (For a narrative review of how QPR works in a community setting click here)
Once individual suicidal persons are detected by community gatekeepers, they must be referred for assessment and possible care by competent community-based professionals. Unfortunately, many healthcare professionals don’t know what they don’t know about suicide and its prevention. For a community to be competent to assist its suicidal members, community providers must be trained in state-of-the-art assessment, management and evidence-based and effective treatments for persons with suicidal behaviors. For agency-based providers, a complete risk reduction program should be operational in that provider’s agency, and should include the use of comprehensive clinical risk reduction practices and treatments.
A Community Model
To accomplish substantial change at all levels of a community, an innovation-diffusion educational program designed to alter individual and group behavior in the majority of lay and professional community members is recommended. The QPR Institute has designed, built and tested a variety of training programs that, when taken together, constitute a systems approach to reducing suicide risk in individuals and in identified at-risk populations living in their communities. We believe the solutions to reducing the frequency and negative impact of suicidal behaviors any community are to be found in that community.
Experts agree suicide is a preventable form of death (U.S. Surgeon General, 2001), and that lives can be saved with the implementation of comprehensive, evidence-based suicide risk reduction strategies, including public awareness campaigns, and by improving education and training in the identification, referral and treatment of potentially suicidal people. In our view, it is important for communities to also address the prevalence of non-fatal suicidal behaviors and the potential benefits that can be achieved if this much broader range of self-destructive behaviors is addressed through a community-based risk reduction program.
For example, studies conducted by the QPR Institute and Washington State University College of Nursing Education at four hospitals in Spokane County, Washington, found that the cost of non-fatal suicidal behaviors resulting in hospitalization averaged $16,500 per episode of inpatient stay for adults, and $27,500 per episode of care for adolescents. As provided by the Washington State Hospital Commission, these costs figures were exclusive of consultative psychiatric services, additional psychiatric hospitalization costs, or community follow up. In one year (1995), and in only four of our six hospitals, approximately 500 persons were admitted to hospital for medical treatment of self-inflicted injuries. Total costs ran into the millions. Thus, any cost-benefit analysis of a community-based suicide prevention and risk reduction effort should include an analysis of the consequences and impact of all potentially preventable self-destructive behaviors.
Another frequently overlooked cost to communities are those associated with domestic violence, homicide and suicide. Evidence from the U.S. Air Force study cited here showed that exposure to a suicide prevention program also reduced other outcomes, including a 51% reduction in homicide, 18% reduction in accidental death, and significant reductions in measures of family violence. Thus, by reducing the risks associated with suicidal behaviors, a community may also reduce the risks and costs associated with other-directed violence. (For a narrative executive summary on the relationship of domestic violence and suicide click here)
We feel one key to the successful implementation of a community-based program is to ensure that all community leaders fully understand the true cost of self-and-other-destructive behaviors in their community. Without this awareness and understanding, attitudinal support for the required broad community changes necessary to reduce risk factors for suicide, and enhance protective factors, will be difficult.
Lastly, suicide prevention is too important a task to be left to government. Thus, it is critical that businesses, labor unions and professional membership organizations be at the suicide prevention table. Since most American suicides are by men in their middle years (employed males), it is essential that employers become stakeholders in community-based suicide prevention programming, even using the worksite as a suicide prevention training venue. Lastly, it is only through public-private partnerships that a sense of shared community responsibility for preventing suicide can be achieved.
One Proposed Solution:
At the present time, the QPR Institute has tested and successfully implemented a comprehensive and integrated systems approach to suicide risk reduction in several large healthcare organizations in the United States. Another large, federally-funded clinical trial is underway at this writing in a community/school setting. This trial combines elements of our basic gatekeeper training program with more advanced training for school counselors in the assessment of at-risk youth identified by adult gatekeepers in a large school system.
Basically, the one-hour, citizen-oriented QPR gatekeeper training program grew out a successful community-based outreach program for multiply-impaired, home-dwelling, at-risk elders, and has now become a community-based public health suicide prevention gatekeeper training initiative. (For a narrative description of the development history of the QPR concept click here)
By marrying the basic QPR program to a state-of-the-art suicide risk reduction program for professionals and institutions, a combined, integrated and systematic community-based suicide prevention program emerges. This model is designed to:
- Train community gatekeepers to identify and refer individuals at-risk for suicide
- Train at least one adult per family in the basic QPR gatekeeper program
- Train crisis line volunteers in crisis intervention and suicide risk assessment
- Train law enforcement and other first responder professionals in basic suicide risk assessment and referral skills
- Train health and behavioral healthcare professionals in a “best practices” method of suicide risk assessment and management
- Train discretionary decision makers in the criminal and civil court systems in the detection and initial assessment of those at risk for suicide
- Train correctional workers in the management and monitoring of potentially suicidal inmates
- Educate and train a broad range of community participants in better understanding the causes of suicide, how intervention and treatment saves lives, and how to enhance protective factors that help prevent suicide through promoting healthy lifestyles and values
Community Planning, Templates and Tools
We are frequently asked, “What is an ideal community-based program?” While our answer can only be tentative until more evidence of effectiveness is compiled, we have a suggested “best practices” model for communities. For a given neighborhood, county, city or community, the goal would be to train all thought leaders and at least one QPR gatekeeper per family, and all first responders, hotline staff/volunteers and correctional workers, and all health and mental health professionals serving at risk populations (e.g., the elderly) to a level of knowledge and skill commensurate with their roles and duties to at-risk persons in their communities.
We offer here a possible pathway and tools for the development
of a community-based, community-led and community-driven program.
- Formation of a suicide prevention task force and determination of key leadership roles and persons to carry out and support the program
- Review of the Surgeon General’s National Strategy for Suicide Prevention: Goals and Objectives for Action as well as review of a variety of community building kits and models available through the following national organizations: American Foundation for Suicide Prevention, National Organization of People of Color Against Suicide, Suicide Prevention Action Network, Suicide Awareness Voices of Education, and others (web links are provided through our web site)
- Completion of the Community Readiness Questionnaire (click to download/print)
- Data collection and cost-analysis study of costs associated with self-destructive behaviors
- Determination of pathways, organizational agreements, and referral network agreements
- Secure local, state and national continuing education approvals for suicide prevention training to ensure professionals will attend
- Conduct a Professional Training Needs Survey (click to download/print)
- Determination of time frames for pilot and/or program implementation
- Determination of end point and outcome measures (click to download/print)
- Implementation of awareness-raising program to gain community support
- Train all public and private mental health, counseling and select medical staff (see descriptions of training programs on the QPR Institute web site)
- Train all fire, police, correctional workers, clergy, school counselors, select nursing home staff, EMS, social service and juvenile justice staff and others key gatekeepers in the QPR intervention or QPR Suicide Triage intervention (see program descriptions on web site)
- Install a suicide risk reduction program in one or more psychiatric hospitals or medical-surgical hospital with a psychiatric unit (click here to review our Institutional Program)
- Provide books, booklets, cards, brochures, CD-ROMs, videos and access to these and other national suicide prevention resources to all community members, and make these materials readily available to libraries
- Provide public service announcements for local television, news print media and others
- Train at least one adult person per household in the QPR intervention, using school, work, union, church and other community educational venues.
- Complete first year evaluation and report to community leaders.
- Conduct ongoing monitoring of program outcomes and provide annual follow up and report to community leadership.
Highlights of this plan
Unfortunately, many of the key professional gatekeepers in a community are untrained in suicide risk reduction practices and lack specific knowledge about how to assess and manage persons at risk for suicidal behaviors. Some resistance to training from this sector is to be expected.
However, we wish to point out that both the Surgeon General and the Institute of Medicine have targeted these professionals for specific training in suicide risk reduction practices, as the research literature makes clear that more training is needed. This lack of education and training by those professionals who will be receiving referrals from community-based gatekeepers should be a serious concern for any unified community effort. To address this area of potential concern, the QPR Institute, together with the Health Sciences Center of Washington State University, has developed and tested a professional knowledge quiz to help determine the level of need for suicide risk assessment and risk management training among healthcare professionals, including school counselors, substance abuse professionals, physicians and many others. This quiz is hosted on the QPR web site and can be taken free of charge. Participants are asked to supply demographics and, upon completion of the quiz, a Pass/Fail answer is provided. Our national benchmark study finds that without specific training the majority of mental health professionals are unable to pass the quiz at a 75% items correct standard. (Click here to see PowerPoint slides on the pre-post pass-fail data from 1,100 mental health providers (free PowerPoint Viewer software can be downloaded here))
Once a community decides to act, it is often difficult to know what steps to take and in what order. Fundamentally, suicide is a public health problem. Collective action and sustained effort are required to initiate and reduce and hold down suicide rates low. Any reduced suicide rate will be a function of the employment of public health principles: defining the problem, identifying the causes, implementing interventions and evaluating outcomes. Here, we have attempted to provide a sample of how a community might proceed, but ours is not the only approach. We suggest that, whatever steps a community determines to take, that those steps be part of whatever national goals and objectives and have been established for the country in which that community resides.
For the United States, we have provided here a matrix of the goals and objectives listed in the Surgeon General’s National Strategy for Suicide Prevention and how the QPR Institute has addressed these in our research, writing, and publishing of suicide prevention education and training programs. (Click here to download/print this matrix)
As we are particularly concerned with the loss of life to suicide among older persons – and since QPR grew out of a program designed for at-risk elders living in their homes – we have provided a summary of this program for review (click here).
Finally, whatever efforts are undertaken will require not only initial support and commitment, but also mechanisms to sustain prevention programs, including specific, competency-based skills in the identification, assessment and treatment of at-risk persons. Comprehensive and affordable evaluation of effort must be included in any cost calculations.
As selected by community leadership, pilot projects can be useful ways to test the effectiveness and expected outcomes of a suicide risk reduction effort, using either QPR or some other intervention(s). Because of their cost-effectiveness, we encourage using distance learning technologies to train gatekeepers, as well as community-based trainers, who can deliver awareness and educational programs to both public and professional audiences. Data collected from this “saturation training” can be used to enhance local capacity, establish the program among professional groups and provider organizations while securing ongoing support for maintenance of effort over time.
To help prepare provider organizations interested in piloting risk reduction training programs, the QPR Institute provides turn-key quality improvement projects for participating healthcare organizations. These projects can measure the impact of training on staff clinical performance, as well as impacts on the quality of documentation of medical records (request CQI Project document in Word). Quality improvement projects can be provided to correctional facilities to accomplish measurements of enhanced risk assessment and risk management of suicidal inmates.
Once pilot projects are completed and qualified instructors can be made available to train staff in a variety of institutions, broad public gatekeeper training can begin on a massive, population-saturation basis in the larger community.
While the QPR Institute is primarily a practical, hands-on training resource for interested institutions, professionals, universities and communities, the staff and faculty of the QPR are willing and available to consult with and assist in the development of comprehensive, community-based suicide risk reduction programs and practices.
- The National Strategy for Suicide Prevention: Goals and Objectives for Action, 2001, U.S. Department of Health and Human Services
- Rogers E.M. & Shoemaker, E.F., (1971) Communication of innovation, New York, Free Press, 99-134
- Knox, L.K., Litts, D.A., Talcott, W.G., Catalano, F. & Caine, E.D. (2003) Risk of suicide and related adverse outcomes after exposure to a suicide prevention programme in the US Air Force: cohort study. British Medical Journal Volume 327
- World Health Organization, 2003, www.who.org
- LeBuff, P. & Soldivera-Kiesling, S., (2003) Reducing risk in behavioral healthcare. Paper presented at the spring meeting of the American Association of Suicidology, Santa Fe, New Mexico
- Quinnett, P.G., QPR for Suicide Prevention, 1995, QPR Institute Inc., Spokane, Washington