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Archive for February, 2013

The previous three posts have dealt with the critical necessity of questioning a depressed (and possibly suicidal) person about whether he or she is considering suicide. It is, I think, the most formidable aspect of the Question, Persuade, Refer strategy for suicide prevention offered by Paul Quinnett on behalf of the National Alliance on Mental Illness (NAMI). It is challenging, for example, to overcome the denial that someone with whom you’re talking could actually be considering suicide. Also, it’s difficult to believe that asking that person directly about suicide is the right thing to do. Still, it remains the vitally important thing to do.

Quinnett’s second step is to Persuade the person to get help. “Ask the following questions: ‘Will you go with me to see a counselor (priest, minister, nurse)? Will you let me help you make an appointment with . . . Will you promise me?”

If the person resists getting help, a no-suicide contract should be proposed. That’s a promise that the person will not hurt him or herself until help is received. “Because making a promise appeals to our honor,” writes Quinnett, “and agreeing to stay safe relieves our suffering, the answer is almost always ‘yes’.” (If the answer is ‘no’, the person is to be considered a danger to himself and/or others and should be involuntarily committed for professional help.)

Other elements of persuasion involve reminding the person that there are better alternatives than suicide, focusing on those alternatives, accepting the reality of the person’s pain, and offering hope in whatever way one can possibly offer it.

At the same time, cautions Quinnett, the helping person should remove firearms, medications, car keys, and “other instruments which may be used to commit suicide.”

Finally, Referral is about getting the person to seek professional help and accompanying him or her, if possible, to the appointment. Someone helping a suicidal person need not be concerned with showing disloyalty or breaking a confidence–not when life is at risk, that is. (Paul Quinnett, PhD., “QPR: Ask a question. Save a life.” NAMI Family-to-Family Education Program: 2012).

Quinnett likens QPR to cardiopulmonary resuscitation (CPR) or the Heimlich maneuver: learn these techniques because you never know when you might be called upon to save a life.

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The first step to preventing suicide is questioning a depressed person about whether he or she is considering suicide, advises Paul Quinnett in his Question, Persuade, Refer strategy. “Giving a ‘yes’ answer to this question is often a release for the individual. It makes him or her feel better, not worse.”

Once the suicide question is under discussion, the questioner has a moral obligation to listen. “Listening is the greatest gift one human can give another,” writes Quinnett. “Advice tends to be easy, quick, cheap and wrong. Listening takes time, patience, and courage, but is always right. Give your full attention and don’t interrupt . . . judge or condemn. Listen for the problems death by suicide would solve” (Paul Quinnett, Ph.D, “QPR: Ask a Question. Save a life.” National Alliance on Mental Illness, Family-to-Family Education Program: 2012).

On the day before my daughter Mary’s suicide, I was questioning her, all right, but not about the one topic that might have saved her life. She had just come home from school that afternoon, and we talked for at least an hour about her school day, the weather, my sister’s upcoming birthday, the proper way to use a make-up brush, her skill as a math tutor to her younger sister, and other pleasant and lamentably pointless subjects. But I felt it was exactly the kind of positive, bonding conversation we needed on a day when Mary seemed to be recovering from major depression, and I think most mothers would have acted similarly.

I’m not dredging up that squandered opportunity to make myself feel bad seventeen years later. Mine was not a failure of love but, rather, a failure of knowledge. In other words, Quinnett’s Question, Persuade, Refer strategy is counterintuitive. It isn’t a process a mother (or anyone else) would instinctively figure out on the spot and put to use. It cuts against logic to bring up the word “suicide” with someone who is struggling with depression. That’s why grasping the system before it might be needed is vital and possibly life-saving. There is one last post to be offered on the subject.

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For the better part of two decades, I’ve wondered about the few minutes preceding my daughter Mary’s suicide. Just what sort of inner resolve did she summon in order to begin swallowing several dozen pills she knew to be lethal?

Well, now I know. Mary had to “pass a psychological barrier” before swallowing her pills and did so, it turns out, by way of champagne. “[A] final wall of resistance is what keeps many seriously suicidal people alive,” writes Paul Quinnett. “Alcohol dissolves the wall and is found in the blood of most completed suicides.” On behalf of the National Alliance on Mental Illness (NAMI), Quinnett adds, “If someone is contemplating suicide, keep them sober.”

Quinnett’s Question, Persuade, Refer system of suicide prevention can and must then begin. “Get the person alone or in a private setting and ask the person if he/she is contemplating suicide. Ask questions that acknowledge the individual’s distress. Questions like, Have you been unhappy lately? . . . Or you can ask directly, Do you want to stop living?” (Paul Quinnett, Ph.D, “QPR: Ask a question. Save a life.” NAMI Family-to-Family Education Program, 2012).

At this point, a dangerous fallacy must be exposed. It’s one I subscribed to, perhaps unconsciously, in relating to my daughter in the last days of her life. The fallacy is this: using the word “suicide” around a seriously depressed person will give him or her the idea of suicide that was not in their thinking before.

“Raising the issue of suicide with those who are severely depressed . . .. can open the door to therapeutic intervention,” writes Carol Anne Milton. “Allowing a person to talk through their worst fears . . . could provide them a lifeline that makes all the difference between choosing life and choosing to die. People already have the idea of suicide; it is in the media constantly. If we ask a person, ‘Do you have thoughts of suicide?’ we are showing that we understand the depth of their pain, that we care and that we take them seriously . . .” (The Coldest Night: A Family’s Experience of Suicide. Dublin: Veritas, 2009, p. 83)

The following post will continue with Quinnett’s plan of rescue for the beloved suicidal among us.

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“It is a myth that suicide can’t be prevented,” writes Paul Quinnett. “It can. QPR is one technique that can help. QPR stands for Question, Persuade, Refer.

Quinnett speaks to those for whom suicide isn’t merely an abstraction occurring “out there.” On behalf of the National Alliance on Mental Illness (NAMI), he educates people whose family members live with certain brain disorders (mental illnesses) that can make them particularly susceptible to suicide. The threat of suicide lurking within those families is what, I think, drives Quinnett’s no-nonsense advice.

Overcoming denial is an important first step for the person who is trying to help someone considering suicide. “Sometimes, because the thought of death is so frightening,” writes Quinnett, “we deny the person may be suicidal.” But someone on the verge of suicide usually provides warning signs that must be taken seriously. (See November 1, 2012 post: “Warning Signs for Suicide.”)

One surprising warning sign is sudden happiness, for no apparent reason, in someone who is depressed. “Since depression saps energy and purpose, sometimes the depressed person is ‘too tired’ to carry out a suicide plan,” says Quinnett. “However, as the depression finally begins to lift, the person may suddenly feel ‘well enough’ to act. As strange as it sounds, once someone decides to end his or her suffering by suicide, the hours before death are often filled with a blissful calm” (Paul Quinnett, Ph.D, “QPR: Ask a question. Save a life.” NAMI Family-to-Family Education Program, 2012).

On the weekend of her suicide in 1995, my daughter Mary went to a video store with her father and sister on Friday night, offered to go to the grocery store Saturday afternoon after I sprained my ankle, helped clean up the kitchen following supper that evening, and then later ate ice cream and watched a television program, probably “Saturday Night Live.” As her mother, I was relieved at this normal-appearing behavior in a daughter who seemed to be recovering from depression. What I didn’t know, of course, is that she was also penning her suicide note that Saturday in between all the normal-appearing activities.

Any one of a hundred moments would have been the moment to ask Mary if she was thinking about suicide and, yes, the question likely could have saved her life. But it wasn’t going to be asked on a day when I was seeing improvement and hoping for the best.

There’s still more to say about Quinnett’s “Question, Persuade, Refer” system.

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