john kennedy toole: recognizing the person at risk of suicide

John Kennedy Toole:Recognizing the Person

At Risk Of Suicide34th Annual I&R Training and

Education ConferenceNew Orleans, Louisiana Monday, May 21, 2012

3:15pm - 4:45pm

John Plonski – FacilitatorDirector of Online Supervisors

IMAlive National Hopeline [email protected]

Paper-free Workshop

Opening questions …

What is your agency’s policy addressing the issue of suicide?

Should we talk about suicide?

Should we ask about suicide?

Can we help the person at risk?

How many people do you know whose lives have been by pandemic

flu? Suicide?

In 2008 the population of the United States was 303,597,646. Of that number it is safe to say that the majority of the population…

Likes Sports!

Reported deaths from suicide in 2008 was 36,035

For comparison the capacity of the new Marlins Park is 36,742

It is estimated that deaths from unreported suicides is

5% (37,837) to 25% (45,044)higher

Boston’s Fenway Park seats 37,493Oriole Park at Camden Yards seats 45,971

Reported suicides + Unreported Suicides = 81,078 (estimated)

(By comparison the Mercedes-Benz Superdome seats 76,468)

It is estimated that, at any given time, 5% of the population

(15,179,882 People) have thoughts of suicide placing them at risk.

From 2008 through 2011, 15,772,600 Race Fans attended NASCAR Sprint Cup Races

These numbers tell us that it is

very possible we may interact

with a person at risk of death by

suicide.

They also tell us

something else.

The numbers not only tell us that the chances are great that we may encounter a person at risk of suicide but that there may be some of us whose lives have been affected by the suicide of another or we ourselves may have been at risk.

With that in mind realize that there is help out there for us. The same skills we will talk about today are the same skills that a person can use to help any of us through the events that may place us at risk. Don’t keep a deadly secret. Please, be good to yourselves and reach out.

In 1999 the Surgeon General issued The Call to Action to Prevent Suicide. The Call to Action recommended:

• Suicide be viewed in epidemiological terms as a major preventable cause of death, affecting gender, age, and ethnic groups in different ways.

• Suggested the same preventive approach public health officials take to address disease and mental disorders.

• Enhanced public awareness of risk factors for suicide.

• Expanded mental health and drug rehabilitation services for those at risk.

• The scientific study of suicide prevention.

• Death resulting from suicide is preventable through appropriate and timely intervention.

• A suicidal person like any person in crisis is faced with an intolerable life issue for which they are seeking a solution.

• The suicidal activity is not, in itself, a crisis. In essence it is a maladaptive coping response.

Some general observations about persons at risk of suicide:

Additional observations when working with the person at risk

of suicide:

• Suicidal activity is both a means for resolving a situation and a method of communicating the intense feelings of hopelessness, helplessness and pain surrounding it . . . A cry for help

• If you suspect a person is considering suicide, ask them in a direct manner.

• The person at risk of suicide will seldom self identify. However they will offer hints or clues about their intention through their Thoughts, Feelings, and Behaviors.

It can be difficult to identify the person at risk of suicide.

As a society we are generally suicide denying.

• We see suicide as something a person shouldn’t do. • Some may see the act as a weakness. • Some may cite religious or legal reasons forbidding the act.

In any case there exists a societal taboo and stigma making it difficult for the person at risk to state their intention openly.

This means the we will need to be aware of

clues a person may be at risk.

Nearly everyone at some time in their lives thinks about suicide.

• Most decide to live because they come to realize that the situation is temporary but death isn’t.

• Some will openly state their wish to die.

• However, most offer hints and clues as to their intent hoping the listener will hear and interpret them, listen and provide help.

• “I just can’t take it anymore”,

• “I want to escape”,

• “I want to go to sleep forever”,

• “They’ll be sorry when I’m gone.”

• “I can’t stand this pain anymore.”

• “Nothing will ever get better,”

• “My family would be better off if I were not around”

Direct Hints can be clues.

• Escape/No escape

• No future

• Guilt

• Loneliness

• Being damaged

• Helplessness

• Preoccupation with talk of suicide/death

• Planning for suicide

People will send hints by their Thoughts.

People at risk Feel they can’t...

• Stop the pain

• Make decisions

• See any way out

• Sleep, eat, or work

• Get out of the depression

• Make the sadness go away

• See a future without pain

• See themselves as worthwhile

• Seem to get control

People will send hints by through their Feelings.

• Desperation

• Anger

• Sadness

• Shame

• Worthlessness

• Loneliness

• Disconnection

• Hopelessness

• Unbearable Pain

The intensity or long duration of painful feelings raise the volume of the hint.

• Crying

• Emotional outbursts• Alcohol/drug misuse• Recklessness• Fighting/law breaking• Withdrawal• Dropping out• Prior suicidal behavior• Putting affairs in order• Recent suicide attempt• Inability to think clearly

Behaviors can be hints or clues

• Trouble eating or sleeping

• Withdrawal from friends and/or social activities

• Loss of interest in hobbies, work, school, etc.

• Writing a will and making final arrangements

• Giving away prized possessions

• Preoccupation with death and dying

• Loss interest in personal appearance

• Increase use of alcohol or drugs

• Unnecessary risk taking

More Behavioral Clues

People will send clues by discussing their situations.

• Losses – actual, perceived, or threatened

• Relationship problems

• Work problems/Failing grades

• Trouble with the law

• Family disruptions

• Sexual or physical abuse

• Recently publicized suicide/violence

Some other situations which serve as hints.

• Death of a significant other (this can include an idol, role model, or a pet),

• Breakup of a relationship, divorce or separation,

• Loss of a job or housing.

• Onset of illness for either the person or a significant other

Some more situational clues.

• Anniversary of a loss

• Move to a new area

• Situation where a guardian is absent

• Onset of physical or emotional disabilities

• Successful resolution of past difficulties

• Serious planning?

• Active preparations?

• Earlier self-harm?

• What is stopping them?

The person’s discussion of Risk can be a clue.

• Lack of interest/pleasure in all things

• Lack of physical energy

• Disturbed sleep

• Loss of sexual interest

• Loss of appetite

• Increase in minor illnesses

Physical Changes can also be an Invitation.

• Very soft or loud voice

• A voice that sounds weak or drained of energy

• Long pauses between words or thoughts

• Deep sighs

• Depressed sounding voice

• Speaking in an agitated manner

The person’s manner of presentation can be a hint.

Our goal in working with the person at risk of suicide is

twofold:

1. To assist them in focusing on the issue thus enabling them to communicate their feelings verbally instead of behaviorally;

2. To explore more adaptive resolutions to the precipitating issue presented.

There are 3 tasks involved in assisting the person at risk:

1. Establishing a relationship (Connecting/Questioning)

2. Evaluating the suicidal potential (Understanding/Persuading)

3. Formulating a plan and mobilizing Resources (Assisting/Referring)

Comparing the 5 Step I&R Process to Suicide Intervention

ContactInvolves establishing an initial rapport or trust with the client.

AssessmentInvolves understanding the nature and extent of a client's situation.

ClarificationEnsures the worker has an accurate understanding of a problem in order to identify an appropriate solution.

Providing Appropriate Information and/or Referrals

Once assessment and clarification have been completed, it is time to provide the requested information and/or referral.

Closure

Provides an opportunity to summarize and restate to the client what has occurred during the I&R process and urge them to action.

Formulating a plan and mobilizing Resources (Assisting/Referring)

I&R Process Suicide InterventionEstablishing a relationship (Connecting/Questioning)

Evaluating the suicidal potential (Understanding/Persuading)

Establishing A Relationship

• Bring the issue of suicide up for open discussion.

• If the person shares anything that gives you the impression they are suicidal ask them, “Are you feeling suicidal?”

• Be accepting, respectful, and empathic.

• Present yourself as being patient, interested, self-assured, and knowledgeable.

• Stay calm and sound confident

Connecting/Questioning

Evaluation of Suicide Potential

• Listen for, indicate, and supportany messages from the person at risk that reflects a reluctance to die (ambivalence).

• The Worker needs to make an evaluation of the seriousness of the person at risk’s suicidal intent.

• This evaluation will determine the best plan of intervention: Calling an ambulance; Engaging significant others; A referral to a mental health agency, etc.

Understanding/Persuading

Evaluation of Suicide Potential

A person’s degree of risk can be accurately determined reviewing the person at risk’s Risk Factors:

• Current Plan• Pain• Resources• Prior Suicidal Behavior• Psychiatric History

Let’s look at each assessment criterion individually.


Current Suicide Plan

• The inherent lethality of the proposed method; “How do you plan to kill yourself?”

• The availability of the means; “Where is the weapon, drugs or other implement that you plan to use?”

• The specificity of the plan; “What have you done to prepare to die?”

• The time frame of the plan; “When do you plan to die?”


Assessing Pain

Suicide is a maladaptive coping mechanism intended to relieve the pain of the hopelessness and helplessness precipitated by crisis.

To assess that pain we need to ask;“Do you have pain that at time feels unbearable?”


Assessing Resources

• Internal; “What have you done to change things before you decided to attempt suicide? Do you think any of those things may work now?”

• External; “Who have you talked to about what is going on for you? Is there anybody else you might consider?”

• Communication with their external resources; “Have you been able to talk with people who have helped you in the past?” Or “How do you get along with people who have helped you in the past?”


Prior Suicidal Behavior

• Have there been previous attempts; “Have you attempted suicide before?”

• The previous method; “What were your previous attempts?”

• History of attempts by significant others; “Has anybody you know attempted suicide?”

• Response and treatment; “Following your previous attempts did you get help? How did that work out for you?”


Psychiatric History

A mental health history can be a contributing factor in a person at risks suicidal ideation.

“Are you receiving or have you received mental health care?”


Formulating a Plan and Mobilizing Resources

All Safeplans include:

• Keep Safe

• Safety Contacts

• Addressing safe use of alcohol or drugs

• Link to resources

Anytime a person says they are thinking about suicide, regardless of the level of risk, the worker will develop a

Safeplan with the client.

Assisting/Referring

Risk Specific Safeplans

Current Suicide Plan: Disable the plan

Pain: Ease the pain

Resources: Link to resources

Prior Suicidal Behavior: Protect against the current danger and support past survival skills

Psychiatric History: Link to mental health worker

Assisting/Referring

When working with the person at risk.

s

• Don’t go it alone!

• Don’t take responsibility for Don’t take responsibility for “saving“saving” the caller.” the caller.

• Don’t debate whether suicide is right or wrong.

• Don’t moralize or judge the person’s feelings or situation.

• Don’t allow yourself to be sworn to secrecy.

• Don’t minimize the person’s pain or situation.

• Don’t avoid talking about suicide.

More things to remember when working with the

person at risk.

• Avoid statements such as , “It could be worse”, “Don’t worry, things will get better.”

• Don’t give advice

• If you suspect a person is at risk ask them directly, “Are you feeling suicidal?”

• Keep in mind that now is NOT the time to solve all of their problems. Now is the time to do something that allows the person at risk to keep safe.

Suicide: General thoughts

• In interacting with the suicidal person we operate under the assumption that the person at risk is ambivalent about their decision to die. This bestows upon us the moral right and responsibility to attempt to intervene.

• Make contact at a feeling level.

• Be patient and listen carefully.

• Listen for hints or clues to discuss suicide.

• Identify and reflect the person at risk’s feelings.

Suicide: General thoughts• Let the person tell their story in their own words and time. Be patient.

• Simply note any factual information about possible resources that the person may share. You can clarify the particulars once openness and trust are established.

• Control your personal feelings of stress and anxiety by reflecting them to the person at risk (Parallel Process).

• Avoid any sermons about suicide or policy.

John Kennedy Toole (December 17, 1937 – March 26, 1969)

• Thelma Toole, mother, was a cultured, controlling woman involved her her son’s affairs for most of his life. She picked his friends and interests. Thelma has been described as a ostentatious, shrill, loud voiced, bossy, bragging woman

• John Toole, father, was less involved in his son’s life and frequently complained about his lack of influence in his son’s life.


• Excellent student.

• Worked on school newspaper and was in the debate club.

• Well received locally as a stage performer.

• Enjoyed the French Quarter, albeit secretly as his mother viewed it as a place for low life individuals.


• Received a full scholarship to Tulane at age 17 and graduated in 1958

• Woodrow Wilson Fellowship to Columbia University – Completed Masters in English Literature in one year.

• In 1959 Assistant Professor of English at University of Southwestern Louisiana.


• During this time friends noticed he became sullen and withdrawn when his Mother would visit.

• Began to frequent country bars and drink beer.

• 1960 offered a 3-year fellowship to the University of Washington – Seattle for a Ph.D. in Renaissance Literature which he left to teach at Hunter College and study at Columbia.


• Developed apprehension about regarding the liberal views of his students.

• Drafted into the Army in 1961 teaching English to Spanish speaking recruits in Puerto Rico.

• Began to drink excessively.

• A Marilyn Monroe fan devastated by her suicide


• Became withdrawn following the death by suicide of fellow instructor who was gay.

• Began working on what would become A Confederacy of Dunces.

• Hardship discharge in 1963 to care for his father suffering from dementia


• Begins teaching at Dominican College.

• Several love relationships over the years end in rejection

• Becomes severely depressed following the Kennedy assassination in 1963

• February 1964 completes A Confederacy of Dunces.


• Dunces rejected several times by several publishers over the intervening years.

• Becomes angry with Mother over her insistence he continue to see the book published.

• Beginning in 1967 friends notice increased paranoiac behavior.


• Personality becomes acerbic.

• Begins to have frequent and intense headaches.

• Deeply affected by the 1968 Kennedy and King assassinations.

• Begins to appear in public unshaved and unkempt.


• Argument on 1/19/69 with Mother regarding the loss of his professorship at Dominican

• 1/20/69 picks up some possessions, withdraws $1,500 savings, and leaves home.

• 3/26/69 dies from suicide in Biloxi, Mississippi

• Dunces published in 1980. Wins Pulitzer Prize in 1981

Opportunities for Training

• ASIST (Applied Suicide Intervention Skills Training) is a two-day intensive, interactive and practice-dominated course designed to help caregivers recognize and review risk, and intervene to prevent the immediate risk of suicide.

• safeTALK is a two-and-a-half to three-hour training that prepares anyone over the age of 15 to identify persons with thoughts of suicide and connect them to suicide first aid resources.

• suicideTALK is a 60- to 90-minute exploration in suicide awareness. It is intended for all members of a community ages 15 and up. Organized around the question, "Should we talk about suicide?"

http://www.LivingWorks.net/

Opportunities for Training

CONNECT: Postvention is Prevention

CONNECT is a 1 – 4 hour postvention training for various professions who might be involved in suicide response. CONNECT helps communities prepare for suicide deaths and to mobilize to prevent suicide clusters.

http://www.theconnectproject.org/postvention

QPR: Question, Persuade, Refer

QPR is is a Gatekeeper training program and can be learned in in as little as one hour. QPR also has an Online Counseling and Suicide Intervention Specialist Training (OCSIS) program. Training available on-site or on-line.

http://www.qprinstitute.com

Any questions?

For more information go to:

http://www.suicidepreventionlifeline.org/

http://www.livingworks.net/

http://www.qprinstitute.com/

If you need help call 1-800-273-TALK

or 1-800-SUICIDE

Or any additional information - [email protected]

john kennedy toole: recognizing the person at risk of suicide

Documents

issue of suicide

thoughts of suicide

risk of death

suicidal person

suicidal activity

oriole park

general observations

mental health