Why QPR teaches situational clues to suicide
Paul Quinnett, PhD
Some years ago, I began a paper called “Crushing Hope.” I was concerned about a question that still deserves our attention: What is a person facing that makes the future seem unbearable? What circumstances seem so painful and so completely inescapable that the person can see no way through them? In the early suicide prevention literature, we spoke of a blocked exit.
Why we teach situational clues
In basic QPR training, we teach people to recognize verbal, behavioral, and situational clues to suicide, including rejection, unwanted separation or divorce, bereavement, terminal illness, impending arrest, and anticipated loss of financial security. These situations belong in the training because someone may be in serious distress before telling us they are thinking about suicide. The question is not simply what the person says or does, but what the person is facing and what that situation means to them (Quinnett, n.d.).
Biblical accounts of suicide include people facing what they regard as an unacceptable immediate future. Saul fears capture and abuse by his enemies (1 Samuel 31:4). When watching films, I find myself analyzing the circumstances leading up to a character’s suicide. The character comes face to face with disgrace, rejection, or the apparent loss of purpose, meaning, and connection. The scriptwriter makes the future look impossible.
In An Officer and a Gentleman (Hackford, 1982), Sid Worley, played by David Keith, dies by suicide after leaving officer training and being rejected by the woman he hoped to marry. His friend Zack Mayo is played by Richard Gere. The story illustrates a collapsed future.
The hazard is something that has not happened yet. A court appearance. The expected end of a marriage. An eviction into homelessness. A medical procedure the person dreads. An impending loss of work, independence, or reputation. An injury ending an athletic career. A student about to be expelled from school. In the person’s mind, something intolerable and unequivocally unavoidable is headed straight at them at the speed of a freight train. They can see no escape.
A world in which I cannot live
The word suicidogenic fits. Applied to situations, it describes circumstances that produce suicidal thoughts. When someone can see no tolerable way forward, suicide is an escape. A feared event does not have to occur before it begins to hurt. Someone awaiting a diagnosis may already be imagining dependence, disability, or leaving a spouse without support. Someone facing prosecution may be living through an imagined future of exposure, public humiliation, and imprisonment. “Anticipatory anxiety” is too mild a phrase for the terror the person is experiencing. Perhaps the only thing worse than pain is the anticipation of it.
For several years in my private practice this was the focus of my work. I was referred many people in crisis facing, for them, unimaginably painful consequences. Other people thought they might attempt suicide and so they sent them to me. I was privileged to learn something some therapists never learn – often out of their own fear to query about suicidal thoughts. What does the landscape of the suicidal mind look like? What do human beings most fear? Why is that fear so terrifying? Is there something about to happen that brings a final curtain down on who you are?
A senior Air Force officer’s anticipated promotion was derailed after an affair with an enlisted woman became known. He died by suicide within days of learning his career path was blocked, before any formal hearing took place. To my knowledge he never saw a therapist. And how could he? He would have to ask for help. And that wouldn't do. Another officer under his command came to my private office carrying cash and asking for an after dark appointment. She wanted no witnesses and no records; such was her fear of the Air Force’s anticipated response to help seeking. He died, she lived. She cried uncle; he did not.
I remember a pastor who came close to making a suicide attempt after an arrest for soliciting a prostitute. Fortunately, the police brought him to me rather than to a lockup. I was the consulting psychologist for the Spokane Police Department at the time and the officers knew me. I was often referred men in prominent positions who faced a terrible fall from grace following misconduct or an accusation of it. A cardiac surgeon. A police chief. A judge. They may never have uttered verbal suicide warning signs, but their circumstances so frightened their friends and colleagues that they realized a death by suicide might be in the offing.
A threatened loss can already be shaping a person’s sense of the future. Recognizing the situation gives us a reason to ask rather than wait for a statement about suicide. We don't have to wait till people cry uncle before we can help them. I have often said that if the word suicide crosses your mind on behalf of someone you know or care about it may well have crossed their mind, and probably has.
A useful example
A recent email from one of our Michigan master trainers brought this unfinished paper back to mind. In conversations with staff at his local pharmacy, he learned that statements were often made over the telephone that raised concerns. Staff described worry about pain medication being discontinued. The fear of oncoming unavoidable, unmitigated pain can crush hope.
The callers making concerning statements were already giving a verbal warning. But their circumstances suggest an earlier opportunity: when someone learns that a medication will be stopped, what do they fear will happen next? Perhaps the worst they imagine is something you and I have not begun to understand.
There is a documented safety concern here. In 2019, the FDA reported serious harms following abrupt discontinuation or rapid reduction of opioid pain medicines in physically dependent patients, including withdrawal, uncontrolled pain, psychological distress, and suicide. It called for individualized tapering and monitoring (U.S. Food and Drug Administration, 2019). This finding concerns opioids; it should not be generalized to every scheduled medication.
For pharmacy staff, recognizing distress in anticipation of discontinuation should lead to a caring response and prompt coordination with the prescriber and appropriate clinical support. The anticipated loss of relief deserves attention before a frightened caller has to announce an intention to die. We should not wait until people cry uncle to help them.
When we are flying into turbulence, the crew tells us to buckle up. They are anticipating danger and taking steps to reduce the risk of injury. In suicide prevention, knowing that a person faces a frightening future should prompt us to turn on our Spidey senses, listen for warning signs, but go ahead and lean into their pain and offer support early and often.
What the evidence supports
The research collected in my early draft of the crushing hope paper included a longitudinal study linking negative events with subsequent suicide attempts in a clinical sample (Yen et al., 2005). Those findings support attention to life circumstances. They do not establish that anticipating an event predicts an individual suicide, and they should not be generalized uncritically beyond that sample.
Clinical guidance also recognizes the importance of looking ahead. NICE guidance for psychosocial assessment after self-harm explicitly includes future circumstances and upcoming events among the matters to be explored.
For any therapist reading this blog, here is a useful question: “Is there something coming up that you are afraid you cannot get through?”
The next questions are practical. When is it expected? What is most frightening about it? What is the worst that can happen? Who can help before, during, and afterward? How can we figure a way around this?
Sometimes assistance can change the event itself. Sometimes it can change the conditions under which the person faces it: legal advice, safer treatment transition, housing assistance, transportation, or someone who stays connected. In my own practice I worked with patients to put off acting on suicidal thoughts while we explored alternatives, including an old dream or a career they had never pursued when they were younger. Working collaboratively, we found our way through many a life-threatening bramble and came out on the other side. Life is full of second chances but sometimes it takes someone else to show them to you.
My point is that getting through rough patches in life should not become so painful that we have to cry uncle and ask for help before someone offers it to us. We ought to be smart and caring enough to see that something bad is about to happen to someone we care about. We ought to be able to up our game and improve our timing to intervene when the window is open, and before the person at risk has begun to isolate and close all doors of potential rescue. We should not require them to cry uncle before we try to help.
Dr. Paul
References
Hackford, T. (Director). (1982). An officer and a gentleman [Film]. Lorimar Productions. Read source
National Institute for Health and Care Excellence. (2022). Self-harm: Assessment, management and preventing recurrence (NG225), recommendations 1.5.10 and 1.6.1–1.6.3. Read source
Quinnett, P. (n.d.). QPR: Ask a question, save a life [Gatekeeper training booklet]. QPR Institute. See “Situational Clues.”
The Holy Bible, New International Version. (2011). 1 Samuel 31:4. Zondervan. (Original work published 1978) Read source
U.S. Food and Drug Administration. (2019, April 9). FDA identifies harm reported from sudden discontinuation of opioid pain medicines and requires label changes to guide prescribers on gradual, individualized tapering. Read source
Yen, S., Pagano, M. E., Shea, M. T., Grilo, C. M., Gunderson, J. G., Skodol, A. E., McGlashan, T. H., Sanislow, C. A., Bender, D. S., & Zanarini, M. C. (2005). Recent life events preceding suicide attempts in a personality disorder sample: Findings from the Collaborative Longitudinal Personality Disorders Study. Journal of Consulting and Clinical Psychology, 73(1), 99–105. Read source
AI Disclosure
The ideas, opinions, clinical experience, and occasional provocations are mine. Quigley helps me get them onto the page, and I review what we produce before it goes out into the world.
