1. SAMPLE DIAGRAM T he Role of Gatekeepers in Preventing Late Life Suicide in an Older Woman Brief text describing why an older female at risk for suicide does not call for help…

2. Reasons for resistance to help seeking in older persons… Pervasive feelings of shame (I can’t take care of myself). Pervasive feelings of shame (I can’t take care of myself). Suspicion of do-gooders (who put you in nursing homes). Suspicion of do-gooders (who put you in nursing homes). Fear of hospitalization and loss of personal control of one’s life. Fear of hospitalization and loss of personal control of one’s life. Failing memory or failing mobility Failing memory or failing mobility Fear of becoming a burden on others Fear of becoming a burden on others Onset of clinical depression Onset of clinical depression

3. Who is in contact with at-risk elders and can be a gatekeeper for home-dwelling elders? Consider training: Property appraisers, apartment and mobile home managers, telephone company personnel, police and sheriff’s officers, ambulance companies, fire fighters, utilities personnel, postal carriers, pharmacists, trust and bank officers, meter readers, power company billing staff, fuel oil dealers, ministers, farm equipment dealers, telephone company staff – anyone with frequent contact with at-risk elders can be a gatekeeper!

4. What did we teach gatekeepers? Problems with personal appearance (unshaven, dirty clothes, body odors, unkempt hair, etc.) Problems with personal appearance (unshaven, dirty clothes, body odors, unkempt hair, etc.) Conditions of the home (poor repair, calendar on wrong month, little or no food, strong odors, too many cats, garbage, walks covered with snow, etc.) Conditions of the home (poor repair, calendar on wrong month, little or no food, strong odors, too many cats, garbage, walks covered with snow, etc.) Mental and emotional - confusion, disorientation, inappropriate responses, forgetfulness, repetitiveness, distrust, fear of strangers Mental and emotional - confusion, disorientation, inappropriate responses, forgetfulness, repetitiveness, distrust, fear of strangers

5. What more did we teach them to observe and look for? Complaints of not eating Complaints of not eating Problems in sleeping Problems in sleeping Evidence of alcohol use (bottles piling up) Evidence of alcohol use (bottles piling up) Anger, irritability, hostility Anger, irritability, hostility Appears sad or blue, talking of loss Appears sad or blue, talking of loss Physical losses? Compliant of hearing loss? Physical losses? Compliant of hearing loss? Mobility losses? Now homebound? Mobility losses? Now homebound?

6. What else did we teach them to look for and observe? Personality changes? Isolated, withdrawn, suspicions, angry? Is this different from earlier contact? Personality changes? Isolated, withdrawn, suspicions, angry? Is this different from earlier contact? Economic problems? Can’t pay bills? Overpays or tries to? Economic problems? Can’t pay bills? Overpays or tries to? The warning signs of suicide…. Multiple losses? Suicidal communications (e.g., giving away personal possessions?) The warning signs of suicide…. Multiple losses? Suicidal communications (e.g., giving away personal possessions?)

7. What did we ask gatekeepers to do? One thing… To call us… with only this: NAME,LOCATION and CONCERNS … we would take it from there…. The following diagram describes a real scenario, who was trained in how to recognize coded suicide warning signs, and how a trained gatekeepers helped save a life…. The following diagram describes a real scenario, who was trained in how to recognize coded suicide warning signs, and how a trained gatekeepers helped save a life….

8. Strong verbal hints Traditional Detection Network Scenario: clinically depressed, 73- year-old widowed female, living alone. Health is failing. She is isolated and has few friends. Only son recently died by suicide and she has saved up a lethal dose of her heart medication. Pastor Church Volunteer Driver Elderly Lady in Crisis Doctor Visiting Nurse Power company billing dept. Pharmacist Neighbor No Clues Coded Clues Self-referral unlikely Hotline call unlikely Intervention unlikely No Clues Coded Clues Relationship? Behavioral Clues Source: Paul Quinnett, Ph.D., QPR for Suicide Prevention Diagram 1

9. Clear Verbal Threats Gatekeeper Detection Network Pastor trained Church volunteer driver Lady in in crisis Doctor Visiting Nurse Power company trained Pharmacist trained Neighbor Trained Non-trained No Clues Coded Clues Self-referral unlikely Hotline call unlikely Intervention now likely Coded Clues Gatekeeper referral Stops payment Source: Paul Quinnett, Ph.D., QPR for Suicide Prevention Gatekeeper Enhanced Opportunities: Pastor Visiting nurse Power company staff Pharmacist Diagram 2 Elderly

10. QPR Gatekeeper Network Lady out of Crisis Power company notifies nurse Doctor supports Meal on Wheels Home repair Home health Pastor supports Volunteer supports Pharmacist Gatekeeper trained Additional Resources Result of gatekeeper action? Problems solved Suicide attempt averted Social, emotional, medical and spiritual supports now in place Referral Gatekeeper Intervention Source: Paul Quinnett, Ph.D., QPR for Suicide Prevention Diagram 3

11. In summary, effective gatekeepers: - Know that suicide is preventable - Understand means restriction - Know how to ask about suicide - Know how to listen, persuade and refer - Know community resources - Are supported by provider agencies - Know something about the involuntary treatment laws and understand the link between mental illness, substance abuse and suicide

12. Changing individuals is not enough, we must change cultures, and we change them one community at a time… (close program to return to text)