Suicide Prevention and QPR (Question, Persuade, Refer)
Suicide Prevention? Far from my mind. It’s Meet the Teacher night. We have staff development this morning. Then we are supposed to take a cheesy picture in our school shirts. I am not concerned because I have some papers to fill out while our principal talks about operating procedures for tonight.
I walk into the room and the cold air hits me like usual. It’s always freezing. This is my tenth year teaching. I’m a vet now, I suppose. I’ve brought a jacket. I’ve brought something to keep my mind busy. A Diet Coke to sip when I’m bored. I prepared. But I’m really not.
Everyone else is already quiet and waiting for our principal to start.
“I have some news,” she says. Then she stops. She visibly swallows. Her hesitancy sharpens my interest. She is always bubbling over with enthusiasm the first day; this is odd. The room seems to hold its breath as she continues. “One of our upcoming sixth graders killed himself last night. He died at 4:06 this morning. We have people with his family at the hospital.” She goes on to say his name and how we will have local counselors available to us throughout the day to help us work through our grief.
Oh, I was so wrong. I am not prepared at all.
And there it is. It took ten years, but I have finally whispered to myself through tears, “We failed him. We failed that baby.”
He was eleven years old.
These words are real. This is no made-up story to tug at your heartstrings. That boy would have sat in my class. I had a desk picked out for him. He was coming to me because I have a specialist degree in Emotional and Behavioral Disorders.
We failed that child. And we thought we were doing everything right. He was getting counseling outside of school. They pulled him out of class to meet with him. His parents worried over him and loved him. He had friends. He played a team sport. But we could have done so much more.
The Warning Signs
Before we move on, let us clear up what suicide is and what it is not. Suicide is defined by the National Institute of Mental Health as “death caused by self-directed injurious behavior with intent to die as a result of the behavior.” A suicide attempt is not fatal, but the attempt to die is present. Suicide ideation is the planning or thinking about suicide. All of these are dangerous stages. Do not dismiss any of them lightly. However, for my purposes, I will only be addressing suicide.
It always gets real for teachers when we look at the data, so let’s look at it very simply. The Center for Disease Control reports that in 2017, there were 3.3 deaths per 100,000 children aged 10-14 and 22.7 deaths per 100,000 young adults aged 15-24.
Let these numbers sink into you: In 2017, we lost a combined total of 517 from the fourth, fifth, sixth, and seventh grades. In our high school population, 17% of students have considered suicide, and 7% have actually attempted it. In 2017, over six thousand of those attempts led to death.
And suicide is believed to be one of the most underreported statistics of all gathered data.
Isn’t that terrifying?
Who the Numbers Represent
Think of your students. Bring their faces to your mind. In my case, it’s my sixth graders. My kids who think I’m the craziest teacher they’ve ever had, who are still required to walk single-file to the library with me, who complain because they can’t have gum on campus, and who love to tell me their dreams of the future. But every year, there’s at least one of my kids who starts setting off warning bells. Because every year, there is at least one who displays the behaviors that the Youth Behavioral Risk Factor Surveillance has flagged as the signals we need to notice. Over eighty percent of suicide deaths are preceded by suicidal threats, fascination with death, depression, and final arrangements.
Did you know that our children with Attention Deficit Hyperactivity Disorder account for over 60% of adolescent suicides, making it the most common mental health problem associated in childhood suicide? Also, only 30% of these children actually experience depression, so sometimes we do not see “typical” indicators that we see in adults. I think that is the scariest part to me–that sometimes we do not have obvious signs. All is not lost though, as we can look at other factors. Children who commit suicide before the age of 14 were more likely to have family relationship problems; whereas, romantic relationship problems is the primary cause for adolescent suicides. Furthermore, a full thirty percent of these children who died actually reported their intent to someone!
These are a lot of numbers I just threw at you, but I hope you saw the important point of this: Too many of our children think that there is no life for them beyond that one moment in time. They give up because they can’t find any other way past their current set of obstacles. They think there is no future.
It Always Come Back to Relationships
The American Academy of Pediatrics reviewed all of this data also, and researchers suggested the following: “Because interpersonal problems were found to be a precipitating factor in both child and early adolescent suicide, targeting interpersonal problem-solving skill development and building positive emotional and interpersonal skills have strong potential to reduce youth suicide rates.” No matter if students are having family or romantic problems, we can help them learn how to deal with it. The United Health Foundation concurs, adding, “Prevention efforts should be aimed at all levels of influence: Individual, relationship, community and societal.” We spend more waking hours with these children than their parents do!
Thus, we must act. It’s time for us to be the ones to prevent tragedy. We work so hard to build relationships with our children. We do not deserve to be slapped in the face with such devastating news at a faculty meeting.
What Did We Miss?
I know a lot about this child who will never sit in my classroom. Let’s call him Chad, although I’m sure you know that is a pseudonym. I had already reviewed his cumulative folder and spoken to his previous teachers since I saw he was receiving counseling services. The worst part is, I knew before he walked into my room what issues I would need to address.
There is one issue though, that we could have–SHOULD have–addressed long before he came to me. Chad had a history of giving up whenever times got hard. His Individualized Education Plan was only for behavior. He locked his academic abilities behind this insecurity. We always look for the antecedent in behavior analysis, and when I looked through the data collected for his Behavior Intervention Plan, I could tell that his antecedents were problems he didn’t know how to deal with. I cannot go into the specifics without jeopardizing Chad’s right to privacy, but know this: Chad had an A in one of his core academic classes by his own merits in 4th grade, but a 21–yes, a 21, in that very same subject in fifth grade. Littered among the data was the repeated entry of, “Does not complete work” and “Puts head down when asked to work.”
Wow. Just wow. This should have set off a major cascade of questions, but it did not. The one interview on file with Chad states that he didn’t understand the work, so he gave up.
He gave up.
He needed a Gatekeeper in his life. Because instead of digging deeper, others labeled him as “defiant”. A Gatekeeper is someone who is familiar with the Question-Persuade-Refer suicide prevention strategy, and would have noticed Chad’s shutdown for what it was.
He didn’t know how to persevere and resolve his issues. This–the “defiance”–was his plea for help.
And yes, my initial reaction to the Chad’s death stands: We failed him by not having the training we needed. We work with young adults, and this special population comes with their own unique set of problems.
When is the Right Time?
Dr. Peter Wyman notes in his research that “childhood and adolescence are key suicide prevention window periods.” He then goes on to discuss how we cannot definatively identify children before they will committ suicide, and so we must infiltrate their daily social systems, such as schools. He encourages an “upstream” approach in which we address the factors that are most likely to make a student suicidal:
Upstream interventions delivered through social systems in childhood and early adolescence have the potential for reducing population-level suicide rates by decreasing the number of adolescents with mental emotional and behavioral problems, as well as creating social environments that expose adolescents to positive coping norms.
In fact, one 2019 study went on to bolster Dr. Wyman’s theory: “Upstream suicide prevention approaches that foster resilience and attenuate the emergence of mental health problems and suicidality are also considered universal-level strategies.”
Anyone can apply them! It does not take an expert; it only takes the evidence-based strategies.
Anyone can apply them!
In other words, if trash keeps floating downstream to your favorite fishing spot, you don’t just keep fishing out the trash in hopes that it will one day stop. It’s a threat to the health of all the environment around you. You go upstream to the source and prevent that trash from floating downstream in the first place. You take action. Our children are the same. They do not deserve to be polluted by the idea of defeat. You, the possible Gatekeeper, can start the process of prevention with just one Question: “Are you thinking about suicide or wanting to kill yourself?” Don’t shy away. The QPR training will teach you that phrasing the question this way leaves no room for misinterpretation.
Dr. Wyman mentioned those “positive coping norms” that we need to incorporate through our previously-established positive relationships. Students need adults in their lives who understand how to build up their accomplishments and overcome their challenges. You could be that adult. Step Two of QPR is to Persuade the student to let you get him the help he needs, and that is going to take every single bit of the positive relationship that you have built with your student.
One Missing Piece
You may not know how to do this though. Chad went to a great school. His teachers cared about him. They are also amazing at producing academic results and are some of the top experts in their field. However, they lack training to handle the real problem.
He gave up. Even though he had a few positive relationships with his teachers, they did not directly address his issues. Not one of them knew how to respond to his shutdown in class. They kept sending him to the principal’s office for punishment.
They could not surrender the “One-Up” relationship that teachers often have, and therefore, Chad was given the label of “defiant.” Instead, they needed to get to the root of the problem, which is that he had no intrinsic motivation; there was nothing driving him to keep going through the hardest parts of his day. Punitive measures such as taking away his recess were only fraying the tattered threads of his relationships at school.
But I want you to know: Chad’s teachers are absolutely not to blame! Just because I am pointing out their lack of training does not mean I think they had anything to do with his death. We do not receive this kind of training in our teacher certification classes, even at the best American institutions. Extrinsic rewards like suckers and stickers (or punishment in some cases) can only last for so long. These children need something that is going to carry them through when no one else is there to help them.
You’ve got to make sure you understand how to avoid this “One-Up” relationship and meet kids like Chad on their own playing field of respect and empowerment. Because the third step in the QPR process is “Referral.” That does not mean you hand the child a list of suicide prevention resources; that means the child trusts you enought to let you physically escort him or her to a health care professional. And once again, I cannot stress enough that if you have failed to nurture the adaptive relationship it takes to get these children to trust you as someone who cares, you will not be able to use a clinically-proven suicide prevention method. Even if you can save one life, you will have succeeded.
Get the Training
Stop waiting for it to happen. Own your ignorance and do something about it. We attend professional development all the time, and admit it, most of the time you’re thinking, “This could have been sent in an email.” This is different. This is practical and applicable each and every day in a culture where our students are coming to us without the life skills it takes to be successful. They need us.
We do NOT give up.
Get the training. Read the research. Do whatever it takes.
Because when it happens to you, you will not feel like a veteran teacher or administrator. You will feel like a failure, sitting there staring at an empty desk and wondering where the future went. You will feel raw inside because that student needed you and all you could feel was helplessness and frustration.
Trust me, I know. I will do my best to never let this happen to another one of our children. Will you?
Health of Women and Children, & United Health Foundation. (2019). Public Health Impact: Teen Suicide. Retrieved from https://www.americashealthrankings.org/explore/health-of-women-and-children/measure/teen_suicide/state/ALL.
Int. J. Environ. Res. Public Health 2019, 16(12), 2165; https://doi.org/10.3390/ijerph16122165
U.S. Department of Health and Human Services, & The National Institute of Mental Health. (2019, April). Suicide. Retrieved from https://www.nimh.nih.gov/health/statistics/suicide.shtml.
Sheftall, A. H., Asti, L., Horowitz, L. M., Felts, A., Fontanella, C. A., Campo, J. V., & Bridge, J. A. (2016). Suicide in Elementary School-Aged Children and Early Adolescents. Pediatrics, 138(4), e20160436. doi:10.1542/peds.2016-0436
Wyman P. A. (2014). Developmental approach to prevent adolescent suicides: research pathways to effective upstream preventive interventions. American journal of preventive medicine, 47(3 Suppl 2), S251–S256. doi:10.1016/j.amepre.2014.05.039