1. Suicide Prevention Gatekeeper Training
Human Services
Resources used for this program:
Substance Abuse and Mental Health Services Administration TIP 50- Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment;;
University of Southern Florida’s Youth Suicide Prevention School-Based Guide;
Harvard School of Public Health Project = Means Matter ; The Trevor Project and The Jed Foundation

2. A Gatekeeper refers to someone who:
Gatekeepers are individuals who by the nature of their job, or in their personal relationships or friendships, are in a position to observe high risk behaviors and take action when necessary. Gatekeepers are not counselors but are individuals who can identify depression and warning signs and refer to the proper resource.
Gatekeeper Training is the process by which individuals acquire basic suicide prevention and intervention skills.
A Gatekeeper refers to someone who:
Knows basic information about suicide.
Believes that suicide can be prevented.
Learns basic suicide intervention skills.
Has the confidence to respond.
Can assist in the aftermath of a suicide.

3. Through Gatekeeper Training Staff Come to Understand
They can:
Recognize warning signs associated with suicide and importance of potential triggers;
Identify at risk individuals;
Communicate with individuals at risk for suicide; and
Make referrals to connect at-risk individuals with skill-building and/or crisis intervention services.
Staff do not:
Need to be mental health professionals to help someone in crisis.
Increase the risk of suicide by asking someone if they have thought about hurting themselves.

4. WHO are some gatekeepers?
Teachers
D&A staff
Senior Center staff
Residential staff
Clergy
Law enforcement
Beauticians
Coaches
Girl/Boy Scout Leaders
Commissioners and MH Program Administrators
EVERYONE!

5. Coaches and other athletics staff are in a unique position to help student-athletes at risk for suicide. Here’s why:
• Coaches can observe signs for suicide risk not obvious to parents or other adults.
• Kids may be prone to talk w/athletics staff before they would a parent or counselor.
• May work with the child for more than one year, so can observe their behaviors over the course of time.
• As a primary care provider, the certified athletic trainer is in an ideal position to detect serious post-injury depression and to determine whether the injured athlete is at risk for suicide.

6. Research shows that during our lifetime:
20% of us will have a suicide within our immediate family.
60% of us will personally know someone who dies by suicide.
Yet………

7. On a 1 to 10 scale, how comfortable you are talking about suicide?
Very Uncomfortable Very Comfortable

8. What We Know About Suicide
There is no typical suicide victim.
There are no all inclusive predictive lists of warning signs.
Suicide is always multi dimensional.
Suicidal individuals want to end their pain and do demonstrate warning signs.
Most suicidal youth confide concerns to peers rather than adults.
As few as 25% of young peer confidants tell an adult.
Means Matter!
An assessment of minimum legal drinking age (MLDA) found that between 1970 and 1990, the suicide rate of 18- to 20-year-old youths living in States with an 18-year MLDA was 8 percent higher than the suicide rate among 18- to 20-year-old youths in States with a 21-year MLDA (Birckmayer & Hemenway, 1999

9. What we KNOW Suicidal crises are temporary conditions.
The intensity and urgency associated with suicidal crises tends to disappear or diminish with time. (but may return).
Most suicide attempts among youth occur in the afternoon or early evening in the teen’s home.
Most youth suicide attempts are preceded by interpersonal conflicts.
And…. 30 percent of deaths by suicide involved alcohol intoxication – At or above legal limit.
90 percent of individuals who die by suicide had a mental
disorder.

10. The physical symptoms of Depression aren’t “all in your head.”
Depression is one of those heavily used terms applied to everything from a fleeting feeling to a serious clinical syndrome.
Individuals who have been depressed for a while are so used to it they may not even recognize it as depression!
When it interrupts your life it is a serious medical illness.
Depression can cause real changes in your body.

11. The following checklists are two tools to understand and identify mood, and physical symptoms.
Emotional Checklist:
A persistent sad, anxious or “down” mood?
Loss of interest or pleasure in activities once enjoyed?
Reduced appetite and weight loss or weight gain?
Sleeping too little or sleeping too much?
Restlessness or irritability?
Persistent physical symptoms that don’t respond to treatment (such as headaches, chronic pain, or constipation and other digestive disorders)?
Fatigue or loss of energy?
Difficulty with concentration, decision-making or memory?
Feeling guilty, hopeless or worthless?
Thoughts of death or suicide?

12. Because these symptoms occur with many conditions, many depressed people never get identified.
Physical Symptoms Checklist:
Headaches. These are fairly common in people with depression.
Back pain. If you already suffer with back pain, it may be worse if depressed.
Muscle aches and joint pain. Depression can make any kind of chronic pain worse.
Chest pain.
Digestive problems. You might feel queasy or nauseous. You might have diarrhea or become chronically constipated.
Exhaustion and fatigue. No matter how much you sleep, you may still feel tired or worn out.
Sleeping problems. Many people with depression can’t sleep well anymore. They wake up too early or can’t fall asleep when they go to bed.
Change in appetite or weight.
Dizziness or lightheadedness.

13. Suicidal crisis vs. suicidal ideation
Suicidal ideation is relatively common and is not necessarily associated with a crisis situation.
Suicidal gestures typically occur in the context of crisis periods, or periods that are associated with overwhelming stress, seemingly unbearable and unendurable emotional and/or physical pain, and which seem to have no possible solution other than suicide.
Suicidal Crisis usually lasts about 48 hours.
The thinking of people who are experiencing a suicidal crisis is typically clouded and negatively biased, intensely self-focused, and highly emotional.

14. Language is Important
Suicide - A self-inflicted death for which there is evidence of intent to die.
Suicidal Ideation - Thoughts in which self-inflicted death is a desired outcome, and which may or may not include a plan, but does involve an explicit attempt.
Nonsuicidal Self-Injury - A self-inflicted, potentially injurious behavior for which there is evidence that the person did not intend to kill him/herself (that is no intent to die).
Please say that an individual has died by suicide – not committed suicide.

15. Youth
● Although suicide rates vary somewhat by geographic location, within a typical high school classroom it is likely that three students (one boy and two girls) have attempted suicide in the past year.
● Not all adolescent attempters admit their intent. Therefore, any deliberate self-harming behaviors are to be considered as serious, and the youth should be evaluated further.
“Youth Suicide Fact Sheet,” Washington, DC: American Association of Suicidology, March 19,  

16. C0LLEGE AGE STUDENTS
Major Life Transitions- leaving home may exacerbate existing physiological difficulties or trigger new ones.
Leaving peer supports to enter an unfamiliar environment can deepen depression or heighten anxiety.
Insurance coverage may not support needs.
Improved management of psychologically challenged adolescents during high school allows them to further their education.
College also eliminates some of the safety nets available to young people living at home.

17. College age
Students 25 years of age and older have a significantly higher risk of suicide than younger students.
Suicide is the second leading cause of death for college students. (auto accidents is the 1st)
Suicide rates tend to be higher in the Spring- not around the holidays.
1 in 10 college students have considered suicide.
18 to 24 year olds think about suicide more often than any other age groups.

18. D & A
Suicide is the leading cause of death among people who abuse alcohol and drugs? (Wilcox, Conner, and Caine 2004)
Individuals who are treated for alcohol abuse or dependence are at about 10 times greater risk to eventually die by suicide compared to the general population, and people who inject drugs are at about 14 Xs greater risk for eventual suicide?
People in treatment are at elevated risk for many reasons, including:
- They enter treatment when they are at a point where their substance abuse is out of control, increasing a variety of risk factors for suicide;
- Mental Health problems(e.g., depression, Post traumatic stress disorder, anxiety disorders, some personality disorders) associated with suicide often co-occur among people who have been treated for substance abuse.
- Crisis like relapsing are known to increase suicide risk sometimes occur during treatment.

19. LGBT Issues
Suicide is the 3rd, 2nd leading cause of death among 15 to 24 year olds. Now from 12 years of age to 24!
LGBTQ youth are up to 4x more likely to attempt suicide than their heterosexual peers because of the ways they are treated in their homes, schools, and various communities
Sources: CDC 2007; Massachusetts Youth Risk Behavior Survey 2009
LGB youth who come from highly rejecting families are more than 8 times as likely to have attempted suicide than LGB peers who reported no or low levels of family rejection
More than 75% LGBTQ youth report verbal abuse while 15% report physical abuse at school. More than 1/3 will lose friends through coming out. Increased victimization and losing friends both predict negative mental health outcomes—including substance use and suicide

20. Older adults Depression is NOT a normal part of aging
Often co-occurs with other serious illnesses
Under-diagnosed and under-treated
Suicide rates in the elderly are the highest of any age group. Higher rates of “minor” depression.
20% of elders have a debilitating level of anxiety with even higher rates among the very old.
Alcohol/drug abuse is a growing problem among older adults.

23. This is why Means Matter
Forty-eight percent of patients treated for a suicide attempt reported that the period between deciding to attempt suicide and the actual attempt was 10 minutes.
Others interviewed reported……
     24% said 5-19 minutes: 23% said 20 minutes to 1 hour: 16% said 2-8 hours: 13% said 1 or more days
It's a myth that without a gun handy, people bent on killing themselves will just find another way. For many, the suicidal crisis is temporary, and 90 percent of those who survive an attempt do not go on to die by suicide. Any obstacle or delay can break the self-destructive trance ... Protecting your family from this risk means getting rid of or locking up your guns.

25. MYTHS of Suicide People who talk about suicide won’t complete it.
Suicide happens without warning.
Suicidal people are intent on dying.
Improvement after an attempt means the risk is over.
A promise to keep a note unopened should always be honored to keep trust.
If you talk to a suicidal person about suicide it will encourage the person to kill themselves.
Self-injury is a strong indicator of suicidal thoughts.
If someone medicates themselves with alcohol, it lessens the stress and the threat of the person acting on it.

26. Myth vs. fact Myth Confronting a person about suicide will only make
them angry and increase the risk of suicide.
Fact Asking someone directly about suicidal intent lowers
anxiety, opens up communication and lowers the risk
of an impulsive act.
Myth Only experts can prevent suicide.
Fact Suicide prevention is everybody’s business, and
anyone can help prevent the tragedy of suicide.

27. More Facts
Youth- 3 out of 4 youth who know about a peer’s intent to suicide will not tell anyone!
All ages- Direct questions about suicidal thoughts actually lessen the anxiety and decrease suicidal attempts.
Older Adults- While depression and sadness might seem to go hand and hand, many depressed seniors claim not to feel sad at all.

28. Suicidal Thinking In a suicidal individual’s mind:
Distress, torment and anxiety are seen as overwhelming.
Coping abilities are inadequate.
Suicide is seen as a way to end the turmoil.
Unable to think about the irreversibility of suicide or the consequences of death on their friends and family.
They believe that their thinking is rational.
Often asking questions allows a suicidal person to let off steam and take steps toward accepting help. Without intervention, suicide may be seen as the only solution to solving the problems.

29. The Suicidal process

31. Warning signs Triggers are IMMEDIATE concerns.
ALL AGES
Triggers are IMMEDIATE concerns.
Talking about hopelessness
Seeking access to a gun. “I want to use it for target practice.”
D&A
“This is my last chance, I can’t go through this again,” “If I relapse I’m going to kill myself.”
D&A and OLDER ADULT
Talking about being a ‘burden’ to someone.

33. Pay attention to triggers!!!!!
  • The break up of a close personal relationship (e.g., engagement or marriage). • The death of a close relative or friend. • Constant physical or emotional pain that goes on for a length of time.
• Something "embarrassing" happens.
• Loss of self-esteem or status (e.g., losing a job, failing at school, being cut from a team,
etc.) or feeling humiliated . • Failing an important exam at school. • Financial loss or incurring major indebtedness. • Rejection (e.g., not getting a job/promotion, not be accepted to a college). • Becoming seriously ill or disabled.
• Facing arrest, trial, prison, or other legal difficulty.
RELAPSE of Substance Use Athletic Injury

34. Triggers for an older adult
Arguments with friends/relatives
Rejection or abandonment
Death or major illness of loved one
Loss of pet
Anniversary of a (-) event
Major medical illness or age-related deterioration
Stressful event at work
Medication Noncompliance
Substance use

35. Athletes Warning Signs  Changes in performance on the team
 Withdrawal from social interaction
 Increase in reckless behavior, substance use
 Irritability, sensitivity to criticism
 Legal problems, difficulty with authority figures, fighting
 Unexplained aches and pains
 Resistance to participating in a full shift of practice
 Irresponsibility, lying
 Decline in performance—athletic, academic
 Neglect of appearance, grooming, hygiene

36. Older adults Signs a disorder is present?
Unexplained or aggravated aches and pains
Feelings of hopelessness or helplessness
Anxiety and worries
Memory problems
Lack of motivation and energy
Slowed movement and speech
Irritability
Loss of interest in socializing and hobbies
Neglecting personal care (skipping meals, forgetting meds, neglecting personal hygiene)

37. Prescription Medications in Older Adults Can be Risk Factors
Medications that can cause or worsen depression include:
Blood pressure medication (clonidine)
Beta-blockers (e.g. Lopressor, Inderal)
Sleeping pills
Tranquilizers (e.g. Valium, Xanax, Halcion)
Calcium-channel blockers
Medication for Parkinson’s disease
Ulcer medication (e.g. Zantac, Tagamet)
Heart drugs containing reserpine
Steroids (e.g. cortisone and prednisone)
High-cholesterol drugs (e.g. Lipitor, Mevacor, Zocor)
Painkillers and arthritis drugs
Estrogens (e.g. Premarin, Prempro)

38. RISK FACTORS

40. Lgbt risk factors
Gender Non-conformity
Coming Out Issues
Rejection when Coming Out
Coming Out at a Young Age
Gay Related Victimization
Unique Developmental Stressors

41. When evaluating risk take these into account
Family history of suicide.
Previous suicide attempt(s).
History of mental disorders, particularly depression.
History of alcohol and substance abuse.
Feelings of hopelessness.
Impulsive or aggressive tendencies.
Local epidemics of suicide (contagion factor).
Isolation, a feeling of being cut off from other people.
Barriers to accessing mental health treatment.
Loss (relational, social, work, or financial).
Physical illness.
Easy access to lethal methods.
Unwillingness to seek help because of the stigma attached to mental health and substance abuse disorders or to suicidal thoughts.
THE MORE FACTORS = THE MORE RISK  

42. Older adults may complain of -
low motivation,
a lack of energy, or
physical problems.
In fact, physical complaints, such as arthritis
pain or worsening headaches are often the
predominant symptom of depression in older
adults.

43. It is vitally important to treat depression in Older adults
- Substantially increases the likelihood of death from physical illnesses
- Increases impairment from a medical disorder and impedes its improvement
- Interferes with a patient's ability to follow the necessary treatment regimen
- Lasts longer in the elderly.

44. Barriers (RISK) to help-seeking for mental health problems reported by athletes:
Stigma - # 1 for all populations
• Difficulty in or not willing to express
emotion
• Lack of problem awareness
• Lack of time
• Denial of problem
• Scared of what might happen
• Worried about affecting ability to play/train
• Not sure who to ask for help
• Believe it would not help
• Not accessible

45. Barriers (RISK) to help-seeking in older adults
Stigma in seeking help
Concern over loss of independence or control over their life
Fear of being placed in a nursing home
Don’t want to be a burden
Fear of dependency
Fear cost of services
Fear they may be exploited financially

46. Look at protective factors

47. Warning, RISK & PROTECTIVE FACTORS
Triggers and Warning Signs bring an individual to our attention
Then….
We look at the Risk Factors to gauge how serious the situation may be, and…..
Protective Factors come into play, but the warning signs are most important.
Still do the intervention!

48. Now what do we do?
If you suspect that someone is at risk for suicidal behavior because you have seen some of the warning signs mentioned above, or because the person has confided suicidal thoughts or plans to you…….
your job is to talk to them and obtain help for them…...
You do not have to conduct a risk assessment or be certain.

49. BASIC INTERVENTION
Show You Care.
Ask About Suicide.
Get Help.

50. TRY TO Stay Calm.
Speak directly to them in a clear and concerned voice. Tell them what has been observed and don’t be hesitant to voice your concerns without any blaming. Ex. “I am really concerned about your isolating yourself lately.”
Buy time. Encourage the person to talk and let them know you are hearing them. Ex. “I can tell something is bothering you, and I would like to help you.”
Inquire about their feelings. Don’t rush or over-react.
Don’t try to talk them out of their feelings, don’t preach or minimize their situation. Let them know that you care. “I really care and see you are getting overwhelmed. I would not want you to make any bad decisions.”
Acknowledge what you are hearing and let them know you are taking their concerns seriously. Say directly, “I want to help.”

51. Ask them directly if they are thinking of harming themselves. Ex
Ask them directly if they are thinking of harming themselves. Ex. “Sometimes, when people are feeling overwhelmed they may think of harming themself. Are you having any thoughts of suicide?” “ I hear you denying that you are thinking of hurting yourself, but I am still feeling concerned.”
Don’t give advise. Don’t ask “Why?” Don’t act shocked. Don’t aggressively question.
Never promise confidentiality. Tell them there is no confidentiality in such a serious issue, but support them and listen to their concerns about telling someone.
Ask about if they have any lethal means (especially guns) available to them. Explain why you are asking and that for now, the safest thing would be to make arrangements to have them removed and stored at a friend’s house. Discuss other precautions such as removing lethal doses or locking up prescriptions. Explain that risk sometimes rapidly escalates - MEANS MATTER!
Offer help and hope that alternatives are available. Tell him/her you are staying with them until they can talk to a professional, connect with supports, or offer to help them with their concerns. They are not in this alone, nor are you.

52. What can you say?
I’ve noticed you’re feeling upset
What’s going on in your life?
Are you thinking about suicide?
What do you think might help?
Where would you like to seek help?
Why don’t we make the call together?

53. Show you care Take ALL talk of suicide seriously
If you are concerned that someone may take their life, trust your judgment!
Listen Carefully
Reflect what you hear
Do not worry about doing or saying exactly the "right" thing. Your genuine interest is what is most important.

54. “Tell me what’s going on.”
What should coaches, athletic trainers, parents and teammates DO for a student-athlete who may be at risk for suicide?
If you think there’s something wrong, or you’re not sure, inquire.
Listen to them—without judgment. Give your total attention. Make eye contact.
Ask open-ended questions:
“Tell me why you’re feeling like this.”
“Tell me what’s going on.”
Explore with them: “How bad does this pain get for you?”
Ask them directly: “Are you having thoughts of suicide?”
Indicate your desire to help. Make an appropriate referral (have resources ready).

55. Keep in mind
You do not need to solve all of the person's problems – You can’t Just engage them.

56. How Not to ask the suicide question:
“You’re not thinking of suicide are you?”
“You’re are not thinking of doing something stupid are you?”
Audience question: Why doesn’t this question work?

57. Helping caretakers How you can be helpful: Avoid judging or blaming.
Provide information and help with referrals.
Ask:
How can I help?
How are you coping?
Who can you talk to? Would it be helpful if I dialed for you (hopefully the parent is there in person)?
I can appreciate how this has turned your world upside down. It has been great the way you are willing to get help.- No one can do this alone.

58. Let’s Revisit This Question……..

59. On a 1 to 10 scale, rank how comfortable you are talking about suicide now?
Very uncomfortable Very comfortable

60. Schools/ Caretakers
A TOOL that therapists do that you can ask for.

62. Society for the Prevention of Teen Suicide - http://www.sptsusa.org
Educator Certified on-line Training
On-line Video for Parents
CALM- Counseling About Lethal Means
WELL AWARE
On-line achieved webinars

63. What is The Trevor Project?
The leading national organization focused on suicide and crisis prevention efforts among lesbian, gay, bisexual, transgender and questioning (LGBTQ) youth
U-Trevor, we are available 24 hours a day, every day of the year.

64. QUESTIONS?