Rural Suicide Prevention

Editor's Note: September is Suicide Prevention Month. While often a difficult topic to discuss, it is one that hits rural America particularly hard. Over the past two decades, suicide rates have been consistently higher in rural America than in urban America, according to the CDC. With that in mind, we are reposting this article on suicide prevention that originally ran in May as part of our special "Mental Health Hope & Help" series. If you or someone you know is having thoughts of suicide, call 988, the national suicide and crisis lifeline.

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When rural North Dakota resident "James" drove by his neighbor "Bob" sitting in his vehicle near a field, something seemed off -- the time and place for Bob to be there were unusual. James immediately turned around and went back to ask Bob if he was all right. A long conversation revealed Bob was dealing with a great deal of stress and struggling emotionally. James persuaded Bob to get help, and thanks to that assistance, Bob's situation improved. Later, Bob admitted to James he probably wouldn't be alive if James hadn't stopped to ask him if he was OK.

This real story is an example of how the simple act of reaching out to someone who is struggling emotionally and having thoughts of suicide can potentially save that person's life, said Katie Henry, a family and community wellness Extension agent with North Dakota State University.

Henry is a certified trainer for a suicide-prevention program called "QPR," which stands for "Question, Persuade, Refer." The program -- and others like it -- teach people how to recognize the signs of mental health distress and empower them to provide lifesaving assistance.

The key message of these training programs is that, like many other health issues, suicide is preventable. Each program teaches a slightly different approach to giving help, but at their core, all focus on the same basic principles: recognizing the warning signs that people may be considering suicide, reaching out to them, and connecting them with the appropriate mental health help.

WATCH FOR WARNING SIGNS

The training program "Talk Saves Lives" teaches that the first step in preventing suicide is to recognize the warning signs that someone is struggling, according to Becky Wiseman, a clinical social worker and family consultant case supervisor for Cornell University's New York FarmNet Program. In a recent Rural Minds webinar on rural suicide awareness and prevention training, Wiseman said suicide warning signs are typically displayed in three ways: through people's talk, behavior and mood.

Examples of things people might say if they're considering suicide are that they're feeling trapped, they have no reason to live, they feel they are a burden to others, they're in unbearable pain, or they're thinking about ending their life, Wiseman said.

Behavioral warning signs may include an increased use of alcohol or drugs, sleeping too little or too much, acting recklessly, withdrawing from activities they normally participate in, isolating from family and friends, looking for a way to kill themselves, or giving away possessions, she said.

Moods that may be warning signs could include depression, apathy, rage, irritability, impulsivity and anxiety. "We all have ups and downs in our moods, but if you notice something that's changed, (and) it's uncharacteristic or concerning, it's really important that you speak to that person about what's happening and what you're noticing," Wiseman said. "And then trust your gut; our gut really tells us what we need to do."

If you're on the fence about whether to reach out to someone, Wiseman stresses you should always assume you are the only one who is going to do it. "In too many instances, people talk about their concerns for someone amongst themselves, but they hesitate to reach out to that person directly."

HOW TO REACH OUT

Often, the hardest thing to do is ask people if they are considering suicide. A common fear many people have is that asking someone whether he is considering suicide could put the thought in that person's head or make him more likely to follow through. That fear is unfounded, mental health experts say.

"We know that asking somebody directly if they're having (thoughts of suicide) actually lowers their anxiety and opens up that critical line of communication between you and that person and gives them an opportunity to ask for help," said Madeleine Smith, an NDSU Extension agent and certified QPR trainer, who participated in a recent QPR training webinar sponsored by NDSU.

Wiseman recommends that if you suspect someone might be suicidal, talk to the person privately. "Listen to their story, express concern and caring, and ask directly. Don't be afraid to ask, 'Are you thinking of ending your life?' 'Are you thinking of suicide?'" she said.

Don't worry about saying the wrong thing when talking to someone about suicide, Wiseman and other experts agree. The fact that you ask the question is more important than how you word it. However, they do caution against minimizing a person's feelings or offering judgment. Avoid a question such as "You aren't considering suicide, are you?" which may come across as judgmental.

Then, the best thing to do is to listen, Wiseman said, without trying to offer solutions to the issues that may have led the person to consider suicide.

GETTING A SUICIDAL PERSON HELP

If you suspect someone has a plan to end his life soon -- especially if it comes up in a conversation -- don't leave the person alone, said Wiseman. Stay with the person and help him connect with professional help. If the person is in immediate danger of harming himself or others, call 911, Wiseman said. If the danger is less immediate, urge the person to call 988, which is the national suicide and crisis lifeline, or offer to call the line with the person. Experts also recommend offering to take the person to someone who can help, such as a mental health professional, a clergy member or someone the person trusts.

If the person doesn't have an immediate plan to end his life and can't get into a mental health professional right away, the next best thing to do is to get a commitment from the person to accept help and then make the arrangements to get that help as soon as possible. Then, follow up with the person soon afterward to make sure he is following through.

REDUCE ACCESS TO LETHAL MEANS

Another potentially lifesaving action people can take is to reduce a suicidal person's access to lethal means, such as firearms or medications, according to mental health professionals.

People who attempt to kill themselves usually choose a means they are familiar with and already have access to, said Tara Haskins, Total Farmer Health director for AgriSafe Network, in a recent Counseling on Access to Lethal Means, or CALM, webinar. CALM is another training program aimed at preventing suicide, primarily through reducing access to lethal means.

Most suicide attempts involve medications, Haskins said. However, 55% of all suicide deaths in the United States involve firearms, she said.

Because the thought of suicide is often spontaneous and brief, putting time and distance between someone who is suicidal and that person's access to lethal means can sometimes allow the suicidal thoughts to pass, Haskins said.

"Individuals usually consider suicide not necessarily because they want to die," Haskins said. "In fact, we know from interviewing individuals that have survived a suicide attempt or that have had suicidal thoughts, they also admit to having thoughts of ambivalence. That's what we're trying to capitalize on are those ambivalent thoughts. It's also important for us to remember that more than 90% of those who attempt suicide and survive do not go on to die by suicide."

Haskins suggests approaching the topic by focusing on the person's safety and the safety of the person's family -- without being judgmental -- and making the person a collaborative partner. Ask questions such as "What do you think we can do to help make you safer?" or "Can we think about steps to keep you safe until things get better?"

If a suicidal person has access to firearms, the best option is to collaborate with the person on temporary off-site storage, such as at a friend's or relative's place, a gun range, a self-storage facility or a pawn shop. The next best option is in-home storage, where firearms are locked and unloaded and stored in a safe or lockbox. Another option could be to add trigger or cable locks to the firearm for added time in gaining access to them. Or the keys or combination to a locking device could be given to a trusted person. Other options could be to remove an essential component of the firearm to make it inoperable, include photos of loved ones or a magnet for 988 in the box with the stored firearm, or freeze the keys to a safe or lockbox in a block of ice.

If a suicidal person has access to medications, CALM training recommends working with the person to limit the amount of medications available to only what the person needs immediately. Some options include safely disposing of any out-of-date, unused or excess medications and over-the-counter remedies; using a lock box to secure any lethal and additional mediations; and asking a pharmacist or the Poison Center to help determine "safe" levels of medication.

It's difficult to reduce access to every form of lethal means, Haskins said, but if a person considering suicide mentions something specific, it's important to take steps to remove, limit or disable it. And then follow up on a plan for safety and assist the person to connect with professional help.

SIMPLE ACTS CAN SAVE LIVES

Chad Reznicek, a behavioral health state specialist with the Colorado AgrAbility Project, is a certified trainer for both QPR and another program called "Changing Our Mental and Emotional Trajectory," or COMET, which teaches people how to intervene when they encounter someone who is in a vulnerable space and help shift the person's mental health trajectory back to a place of wellness instead of proceeding toward a mental health crisis.

In his 20 years as a licensed professional counselor, Reznicek said he has worked in several different settings, from correctional settings to residential treatment and in-home therapy, and has done thousands of suicide assessments. Through his work, he said, he has witnessed firsthand the power of reaching out to people who are struggling.

"Many of the assessments we did (on people who had considered or attempted suicide) would ask questions such as "Had you ever had a plan to complete suicide and something or someone stopped you?" and the number of times that people reported some small, caring gesture, some simple act of human kindness as being the thing that allowed them to hit the brakes on their suicidal intent that day and keep going has given me a tremendous amount of hope and optimism," said Reznicek.

For more advice on how to prevent suicide, visit these sites:

-- 988 Suicide & Crisis Lifeline: https://988lifeline.org/…

-- CDC, "Preventing Suicide": https://www.cdc.gov/…

-- #BeThe1To, "The 5 Steps": https://www.bethe1to.com/…

-- National Alliance on Mental Illness (NAMI), "Risk of Suicide": https://www.nami.org/…

-- healthychildren.org, "Suicide Prevention: 12 Things Parents Can Do": https://www.healthychildren.org/…

-- American Psychological Association, "Talking to teens: Suicide prevention": https://www.apa.org/…

SUICIDE PREVENTION TRAINING PROGRAMS

Several suicide-prevention training programs are available that teach people how to recognize the warning signs that someone may be considering suicide, how to talk to them, and how to connect them with appropriate mental health help.

Here is a list of some of these programs:

-- CALM (Counseling on Access to Lethal Means)

https://www.calmamerica.org/…

This program teaches people how to collaborate with those at risk of suicide to implement safe storage of firearms and dangerous medications.

-- COMET (Changing Our Mental and Emotional Trajectory)

https://medschool.cuanschutz.edu/…

Developed by the High Plains Research Network Community Advisory Council (a grassroots group of ranchers, teachers, small business managers, students, retirees in rural eastern Colorado), rural mental health professionals, and health researchers, COMET teaches people how to intervene when they encounter someone who is in a "vulnerable space" and help shift the person's mental health trajectory back to a place of wellness instead of proceeding toward a mental health crisis.

-- Mental Health Awareness & Suicide Prevention in Rural America online course

https://ecornell.cornell.edu/…

Cornell University's College of Veterinary Medicine and NY FarmNet, in partnership with Rural Minds (https://www.ruralminds.org/…), offer this free online course for veterinary students, veterinarians and agribusiness professionals. The course provides an overview of mental-health challenges, including suicide in rural America, and equips participants with practical support strategies and resources.

-- QPR (Question, Persuade, and Refer)

https://qprinstitute.com/…

Created in 1995 by Paul Quinn, QPR, like CPR, is an emergency intervention for someone experiencing a life-threatening mental health crisis. The program teaches participants to be able to recognize the warning signs of suicide and question, persuade, and refer people at risk for suicide for help.

-- Talk Saves Lives

https://afsp.org/…

This program covers the general scope of suicide, research on prevention, and what people can do to fight suicide.

Anthony Greder can be reached at anthony.greder@dtn.com

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