Effectiveness of Question, Persuade, Refer (QPR)

Suicide Prevention Gatekeeper Training in a College Setting

Introduction

Suicide is a significant concern among college students in the United States. According to the Centers for Disease Control and Prevention (CDC), in 2017, suicide was the second leading cause of death among Americans ages 15 to 24 (National Institute of Mental Health, 2019). Data suggests that “suicide occurs at a rate between 6.5 and 7.5 per 100,000 among college students” (Western Michigan University, p. 2). Furthermore, it was discovered that a large percentage of students struggling with mental health issues do not seek professional help. According to a study conducted by Pasco, Wallack, Sartin, and Dayton (2012), “approximately 80% of those college students who die by suicide are unknown to campus mental health professional and the vast majority (85%) of moderately severe to severely depressed students or students currently thinking about suicide (84%) do not receive treatment” (p. 134). A 2009 study reported that “18% of undergraduate and 15% of graduate students have seriously considered attempting suicide in their lifetimes. Between 40% and 50% of these same students report multiple episodes of serious suicidal thoughts” (Western Michigan University, p. 2). It is also important to note that “studies suggest that female graduate students are at a greater risk for suicide than male graduate students” (Western Michigan University, p. 3).

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Recognition of the prevalence of successful suicides, suicide attempts, and suicidal ideation among college students has resulted in the development of evidence-based suicide prevention programs. The American Foundation for Suicide Prevention, the Jed Foundation, and the Suicide Prevention Resource Center are three of the leading experts in suicide prevention. These foundations believe in the importance of early identification of students at-risk, as well as a campus atmosphere that encourages students to seek professional help. These experts recommend the training of gatekeepers “who can identify signs of psychological distress and direct vulnerable students to appropriate resources” (Mitchell, Kader, Darrow, Haggerty, and Keating, 2013, p. 139-140). Gatekeeper training increases a gatekeeper’s knowledge about the warning signs of suicide and informs them of successful intervention strategies with a suicidal individual. Studies report that gatekeeper training has a positive impact on the staff and students of secondary schools (Pasco, Wallack, Sartin, and Dayton, 2012, p. 135).

The purpose of this study is to evaluate the effectiveness of the Question, Persuade, Refer (QPR) suicide prevention gatekeeper training program on a college campus. Gatekeepers on campus could include but are not limited to faculty, residence life staff, academic advisors, and health center staff. The results of this study will add to the knowledge regarding the efficacy of such programs. It is anticipated that there will be an increase in gatekeepers’ knowledge, attitudes, efficacy, and skills for suicide and suicide prevention. The independent variable being assessed is the QPR gatekeeper training program. The dependent variables being examined are gatekeeper knowledge, attitudes, efficacy, and skills. 

Mental health professionals on a college campus may include social workers, counselors, and psychologists. A school-based social worker “might be responsible for any or all aspects of suicide prevention, intervention, and postvention” (Singer, 2018, p. 30). A core value of the social work profession is competence. The NASW Code of Ethics describes competence as “social workers continually striving to increase their professional knowledge and skills and apply them to practice” (NASW Delegate Assembly, 2017). An important aspect of social work competence is the use of evidence-based practice. This study is relevant to social work practice because it adds to the knowledge on the efficacy of gatekeeper training on college campuses. In turn, this knowledge will assist school-based social workers in “making decisions on how to help clients based on the best available evidence” (DeCarlo, 2018, p. 22).

The primary purpose of social work is to help people solve their problems and cope with their situations. Pasco, Wallack, Sartin, and Dayton (2012) describe a core aspect of gatekeeper training as “enhancing participants’ knowledge, attitude, and skills in identifying individuals at risk and referring them to appropriate services” (p. 134). Appropriate services may include the counseling center, a social worker, psychologist, or a social service agency. Therefore, an increased number of gatekeepers on campus results in an increased number of suicidal students being provided with the resources needed to solve their problems and cope with their situations.

One theory supporting suicide prevention gatekeeper training is the humanistic theory. Hutchison (2013) states that the humanistic theory “includes humanistic psychology and existential psychology, both of which emphasize freedom of action and search for meaning” (p. 65). This theory stresses the value of each person and emphasizes the qualities of warmth, empathy, and genuineness. A program created specifically to prevent people from taking their lives inherently assumes an appreciation for the value of life and each living person. Experts in suicide prevention also highlight the importance of creating a campus that encourages students to seek help (Mitchell, Kader, Darrow, Haggerty, and Keating, 2013, p. 139). Warmth, empathy, and genuineness are excellent factors to promote such an environment.

Systems theory also supports this intervention. Hutchison (2013) explains that the systems theory “sees human behavior as the outcome of reciprocal interactions of persons operating within linked social systems” and that those interactions “produce both stability and change” (p. 39). Suicide prevention gatekeeper training aims to create a social support system for suicidal students on campus. A key goal of this training is to enhance gatekeepers’ abilities to recognize the warning signs and behaviors of at-risk students and refer them to appropriate resources. These interactions potentially lead to students receiving the help they need to regain stability or make necessary changes. In addition to the aforementioned theories, the following literature review provides further evidence to substantiate this researcher’s hypothesis.

Literature Review

This literature review will be organized chronologically. The research observed in the following five studies supports the intervention selected for this study. Two specific suicide prevention gatekeeper training programs were evaluated: Question, Persuade, Refer (QPR) and Campus Connect. Common variables analyzed in most of the research included gatekeepers’ knowledge, attitudes, efficacy, and skills for suicide and suicide prevention. The following literature review will be used to support this author’s hypothesis.

 A study by Tompkins, Witt, and Abraibesh (2010) examined the effectiveness of QPR gatekeeper training in a school setting. One hundred and six school personnel were recruited from a small, rural school district in the Pacific Northwest. Participants were predominantly Caucasian, middle-aged females. A non-equivalent control group design was used. During an in-service training, 78 school personnel participated in the one-hour QPR gatekeeper training program. Participants were asked to complete pre-, post-test, and follow-up surveys. Five scales were used to test for the changes targeted by gatekeeper training: attitudes toward suicide and suicide prevention; knowledge about prevention; likelihood to question a suicidal individual; likelihood to intervene; and participants’ comfort, competence, and confidence to help a suicidal individual. Findings indicate significant gains for attitudes, knowledge, and beliefs about suicide and suicide prevention from pre- to post-test. A limited number of participants (23%) completed the follow-up surveys which restricted the conclusions that could be drawn. Another limitation that should be noted is the timing of the follow-up responses. Several responses were received during the summer and “were not directly comparable to post-test responses that focused on experiences and behaviors occurring during the academic school year” (Tompkins, Witt, and Abraibesh, 2010, p. 514).

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 Pasco, Wallack, Sartin, and Dayton’s 2012 study evaluated the effectiveness of an experiential-based gatekeeper training program called Campus Connect. Campus Connect is “a three-hour gatekeeper training program that emphasizes enhanced communication skills and relational connection between campus gatekeepers and students” (Pasco, Wallack, Sartin, and Dayton, 2012, p. 138). Eighty-five college student resident advisors (RAs) participated in the training program. A majority of the participants were sophomores with a mean age of 19. A total of 65 participants completed the pre-, mid-, and post-test evaluations of skills (SIRI-2) and self-efficacy (SITA). Campus Connect training resulted in substantial improvements in self-efficacy across all 14 items of the SITA measure (Pasco, Wallack, Sartin, and Dayton, 2012, p. 138). Gains included improved comfort in asking about suicide, as well as increased abilities to help students access resources. The SIRA-2 scores also indicated that participants experienced improvement in their crisis response skills. Due to their sample, the researchers did report a limited ability to generalize their results.

 In 2013, Mitchell, Kader, Darrow, Haggerty, and Keating examined QPR suicide prevention training in a college setting. Participants were campus community members recruited from a large, Northeastern, public university. A total of 273 participants completed the pre-, post-test, and follow-up surveys. Participants were given a test prior to the training presentation, a post-test immediately after the presentation, and a follow-up survey three to six months later. The QPR Institute developed the survey for gatekeeper training participants and it was modified for a college setting. This survey is not an empirically validated instrument. Participants were asked to rate their knowledge about suicide prevention, warning signs, how to ask someone about suicide, how to persuade someone to get help, how to get someone help, and local resources. In addition, they were asked to rate their likelihood to engage in suicide prevention behaviors, such as calling a crisis line or going with a suicidal person to get help. Analysis of pre-, post-test, and follow-up measures indicate significantly increased short- and long-term knowledge about suicide prevention, attitudes, and skills. One key limitation to note is the questionnaire used was not an empirically validated instrument.

 In their 2018 study, Litteken and Sale investigated the long-term effectiveness of QPR suicide prevention training in Missouri. A total of 2,988 adults received QPR gatekeeper training between July of 2010 and September of 2011. Measurements were taken immediately prior to and following each training and two years post-training. The instrument used was adapted from the gatekeeper training survey developed by the QPR Institute. Results show an overall increase in self-efficacy as well as a significant increase in the amount of adults who were able to help youth. Additionally, there were also large increases in the number of adults who sought advice from a mental health professional, referred youth to a hotline or mental health professional, or told the youth’s parent or caregiver. The QPR gatekeeper training program lead to both immediate and long-term positive effects on suicide prevention knowledge, self-efficacy, and help-giving behaviors. Analysis also indicated the training program was effective in dispelling suicide prevention myths and training participants about warning signs. Due to the use of a convenience sample, the researchers did report limited generalizability of their findings.

 Mo, Ko, and Xin (2018) provided a systematic review of the effectiveness of school-based gatekeeper training. Using extensive inclusion and exclusion criteria, fourteen studies were selected for analysis. The most common outcomes reported were improvements in gatekeepers’ knowledge, attitudes, efficacy, and skills, and likelihood to intervene. Outcomes included in the review were knowledge about adolescent suicide, self-efficacy, likelihood to intervene, and gatekeepers’ behaviors. Thirteen studies evaluated the outcome of gatekeeper knowledge and showed benefits of increased knowledge. Three of the studies assessed the outcome of gatekeeper skills and all three revealed significant positive effects. Nine of the studies evaluated for change in self-efficacy and all reported positive effects. Two studies assessed the outcome to intervene and both reported positive effects. Three of the studies evaluated effects on gatekeeper behaviors and found positive effects on specific behaviors (Mo, Ko, and Xin, 2018, p. 3-21).

Summary

 This study benefited from many components gathered during the literature review. First, this researcher chose to specifically examine the QPR gatekeeper training program. QPR was chosen based on Mitchell, Kader, Darrow, Haggerty, and Keating’s study which stated that according to a national survey “QPR is the most commonly used suicide prevention program on college campuses” (Mitchell, Kader, Darrow, Haggerty, and Keating, 2013, p. 140). This author also chose to use the same one-hour QPR gatekeeper training program included by Tompkins, Witt, and Abraibesh in their 2010 study. The one-hour program is led by a QPR certified trainer who discusses the prevalence of suicide, risk factors, and the appropriate steps to take when intervening with and referring a suicidal individual.

Additional tools/data/information obtained during review included the instruments used to measure changes in gatekeepers’ knowledge, attitudes, efficacy, and skills for suicide and suicide prevention. The QPR gatekeeper training survey developed by the QPR Institute was used in two of the aforementioned studies. The survey measures key elements of QPR training such as suicide prevention knowledge, self-efficacy, and help-giving behaviors. This researcher chose the version of the survey included in Mitchell, Kader, Darrow, Haggerty, and Keating’s 2013 study because it had already been modified for a college setting. In addition to the QPR survey, this author also selected the SIRI-2 and SITA scales used by Pasco, Wallack, Sartin, and Dayton (2012). SIRA-2 is a self-report questionnaire used to assess counselors’ ability to recognize appropriate responses to suicidal individuals. SITA is a self-report measure created to measure participants’ self-efficacy for suicide- and crisis-related knowledge and skills. Due to the QPR survey not being an empirically validated instrument, this researcher opted to use multiple scales in order to gain maximum evidence-based results.

Transition to the next section.

References

• DeCarlo, M. (2018). Scientific Inquiry in Social Work. Roanoke, VA: Open Social Work Education.
• Hutchison, E. D. (2013). Essentials of Human Behavior. Thousand Oaks, CA: SAGE Publications.
• Litteken, C., & Sale, E. (2018). Long-term effectiveness of the question, persuade, refer (QPR) suicide prevention gatekeeper training program: Lessons from Missouri. Community Mental Health Journal, 282–292.
• Mitchell, S. L., Kader, M., Darrow, S. A., Haggerty, M. Z., & Keating, N. L. (2013). Evaluating question, persuade, refer (QPR) suicide prevention training in a college setting. Journal of College Student Psychotherapy, 138-148.
• Mo, P. K., Ko, T. T., & Xin, Q. M. (2018). School-based gatekeeper training programmes in enhancing gatekeepers' cognitions and behaviours for adolescent suicide prevention: A systematic review. Child & Adolescent Psychiatry & Mental Health, 1-24.
• NASW Delegate Assembly. (2017). NASW Code of Ethics. Retrieved October 08, 2019, from National Association of Social Workers: https://www.socialworkers.org/About/Ethics/Code-of-Ethics/Code-of-Ethics-English
• National Institute of Mental Health. (2019, April). Suicide statistics. Retrieved from National Institute of Mental Health: https://www.nimh.nih.gov/health/statistics/suicide.shtml
• Pasco, S., Wallack, C., Sartin, R. M., & Dayton, R. (2012). The impact of experiential exercises on communication and relational skills in a suicide prevention gatekeeper- Training program for college resident advisors. Journal of American College Health, 134-140.
• Singer, J. B. (2018, October 1). Suicide risk in schools: What social workers need To know. The New Social Worker, pp. 29-31.
• Tompkins, T. L., Witt, J., & Abraibesh, N. (2010). Does a gatekeeper suicide prevention program work in a school setting? Evaluating training outcomes and moderators of effectiveness. Suicide & Life-Threatening Behavior, 506–515.
• Western Michigan University. (n.d.). Facts about suicide. Retrieved from Suicide Prevention Program: https://wmich.edu/suicideprevention/basics/facts