Question. Persuade. Refer.

School students, staff taught how to recognize whether someone is in crisis
Kevin Passon

The Tigerton School District is the first Shawano County school district to offer QPR suicide prevention training to all middle and high school students, as well as staff.

“Being located in an underserved area means that giving students, staff, and community impactful training is all the more vital,” said Megan Suehring, 4-H positive youth development educator for University of Wisconsin-Madison Division of Extension Shawano County.

QPR stands for Question, Persuade, Refer. It is a suicide prevention training that intends for participants to be able to recognize the warning signs of suicide and question, persuade, and refer people at risk for suicide for help. Mental health advocates created QPR, which uses evidence-based training to teach the everyday person how to recognize whether someone is in crisis.

“That strong evidence base is one of the reasons that we can facilitate this training as part of Extension,” Suehring said.

Tigerton school counselor Tori Hoffa said the QPR training was accepted well among the middle school and high school students.

“Some students had a hard time understanding the seriousness of the information being presented, and some students had a hard time emotionally handling the information,” she said. “As we see our mental health needs grow, especially in our youth, I think that the QPR program should be implemented in the majority of school districts, as hopefully having the training will lead our youth to make positive mental health choices more often.”

Extra help for rural areas

Suehring has worked with a variety of school districts in Shawano County, especially on the western end. Often, that area is not prioritized for services as it is rural, compared to Shawano, the county seat.

“We have an opportunity to connect rural residents with services and education,” Suehring said. “The embodiment of Extension is to take education to people who need it the most, and that means delivering programs in villages and towns throughout our 893 square miles.”

Low-income families and those living in poverty have higher risks of poor mental health than financially stable households. Food insecurity is closely intertwined, with clear impacts on children’s mental health.

“Among Wisconsin high school students who are food insecure, six in 10 report anxiety and depression, and four in 10 self-harm,” Suehring said. “Tigerton School District has a 56% free or reduced lunch rate. This is not indicative of mental health per se, but if we know that this is a potential indicator, why wouldn’t we look to give youths and their families more tools?”

Beyond the lack of mental health resources in Wisconsin as a whole, people living in rural areas face unique lifestyle barriers that play a role in determining whether they get the mental health care they need.

“Stigma, that mark of ‘disgrace’ associated with a particular diagnosis, sign or symptom, often keeps people from asking for the help they may need,” Suehring said. “Folks often fear negative judgement from family, friends and members of their communities. As members of small, close-knit communities, many rural people also worry about being able to maintain confidentiality concerning a mental illness.”

Other rural challenges to mental health include too few mental health care providers close to home, lack of adequate insurance to cover the costs of mental health care costs and solitary lifestyles.

“There are nearly 37 million rural Americans — more than half of rural residents — who live in mental health professional shortage areas,” Suehring said. “All of Shawano County is considered a mental health professional shortage area.”

In addition to a lack of adequate insurance coverage, there may be a lack of understanding of treatment types, costs and accessibility. It can be intimidating to say “yes” to counseling or therapy services without knowing how long a person might be seeking services.

For a youth who needs a parent to drive him or her an hour in each direction for mental health care, that parent will need to miss work for up to three hours for each session, possible for months at a time.

“It can be difficult to find an employer that is going to be supportive of someone leaving for half a day, weekly, for a quarter of the year even if a person has the vacation or sick time to utilize,” Suehring said.

Rural residents often have limited access to affordable, reliable broadband internet, with nearly 30% of rural Americans lacking internet in their homes. This means that telehealth appointments are not an option.

“Internet connectivity and capacity is indeed a problem in Tigerton and outlying areas of the district,” Suehring said. “Tigerton School District has been offering a space for telehealth appointments.”

Hoffa said she doesn’t expect to see big changes overnight.

“I am hoping we will see the benefits of this program in the long run with the mental health of our students at Tigerton and in the community.,” she said. “Our telehealth program is a great resource for our students and it is an efficient way to have our students connect with someone on a more consistent basis.”

Children not too young to learn

The QPR training is aimed at middle school and high school students, and Suehring said that age range is not too young. She shared these numbers:

• The median number of years a child experiences symptoms of emotional distress before receiving treatment is 11. Fifty percent of mental health problems are established by age 14 and 75% by age 24.

• Youths are experiencing the signs and symptoms of mental health challenges. (Adults are too. The rate is about one in five.) Often, people (especially adolescents) lack the knowledge of how to describe what they’re experiencing.

“We want youths to know what those signs, symptoms and phrases might sound or look like so that if they hear a friend share something concerning, they have the confidence to connect to a caring and competent adult,” Suehring said.

• Between 22% and 38% of adolescents have thought about suicide at some point in their lives, with between 12% and 26% reporting that within the last year. More than 20 years of school-based prevention programs have failed to document any cases of stimulating suicidal behavior through the discussion of the topic.

Pebbles Peterson, principal in the Tigerton School District, said the QPR training is only the beginning of its newly established Mental Health Task Force, a collaborative effort with UW-Extension.

“In the upcoming months, we have a Youth Mental Health First Aid program scheduled for both students and staff,” she said. “This strategic initiative aims to equip our school community with the essential skills needed to address mental health challenges effectively. Further enhancing our commitment, a dedicated team of teachers is actively coaching the Source of Strength program tailored to meet the complex needs of our students.”

Training program to expand

Suehring said the QPR training isn’t limited to Tigerton.

She has shared mental health education with several schools in the county the past few years. This year, Bowler School District also provided QPR training to staff, and teen Mental Health First Aid to the sophomore class. Working with the College of Menominee Nation, Suehring and others have provided training for college staff and the Boys and Girls Club staff.

“I have taken this type of education into local organizations, from the staff of Shawano County Jail Staff to SAM25,” Suehring said.

Suehring said the QPR training can be completed in about an hour and should be repeated about every two years.

“The goal with QPR training is to get as many people as possible well-versed in the signs and know how to take actionable steps,” Suehring said. “Suicide prevention is everybody’s business, and the QPR Gatekeeper Training works to make everyone feel confident that they can help out during a crisis.” Suehring believes your brain is just as important as your heart.

“We likely wouldn’t bat an eye if a friend experienced a heart attack and now had to seek some sort of therapy, medication, medical appointments, lifestyle changes or nutrition guidance,” she said. “Why should we treat our brains any differently? Everyone needs to be able to talk about their mental health just as easily as their physical health.”


• If you or someone you know needs support now, call or text 988 or chat 988 connects you with a trained crisis counselor who can help.

• Office on Children’s Mental Health:

• Mental Health First Aid:

• Extension specifics on how to support youths:

• QPR: