Suicide Prevention Efforts in Idaho
Suicide and
What Can Make a Difference
Kim Kane, MPA
Program Director, Idaho Lives Project
Former Executive Director, SPAN Idaho
Member, Idaho Governor’s Council on Suicide Prevention
Certified QPR Suicide Prevention Trainer
A 501(c)(3) non-profit
Vision : Idahoans choose to live
A Resource
www.spanidaho.org
208-860-1703
BOARD OF DIRECTORS
13 Volunteers
STAFF
Executive Director
Resource Specialist
REGIONAL CHAPTERS
8 Chapters
Volunteer chairperson(s)
Volunteer participants
www.spanidaho.org
8
Driggs
(new)
Stats
US 2011
ID 2011
ID 2012
ID 2013
Total Deaths 39,518 24 299
308
Deaths/week 760 5.5 6
6
Suicide Rate 12.7 17.9 18.7 19.1
Wyoming
Idaho
U.S.
D.C.
6.0
12.7
23.3
9
24
15
1.
Wyoming
1.
Montana
3.
New Mexico
4.
Alaska
5.
Vermont
6.
Nevada
7.
Oklahoma
8.
Arizona
9.
Colorado
9.
Utah
11.
Idaho
We are not unlike our neighbors
Top Eleven States, 2011
1.
Wyoming
2.
Alaska
3.
Montana
4.
Nevada
5.
New Mexico
6.
Idaho
7.
Oregon
8.
Colorado
9.
South Dakota
10.
Utah
11.
Arizona
We are not unlike our neighbors
Top Eleven States:
Lack of Access
Easy Access
Stigma/Rugged
individualist culture
2
nd
leading cause of death among Idaho’s youth.
29%
Idaho high school students, 2013 YRBS shows
1 in 13 have
attempted
suicide
1 in 8 actually
have a
suicide
plan
1 in 7 have
considered
suicide
Idaho has lost
83 school-aged children
to suicide in the last 5 years.
(2008-20012)
16
of those children were age
14 or younger
Suicide is the leading cause of death in
American jails.
Suicide rates in prison are higher than
the general population, but higher still
are rate in smaller facilities
Suicide rates in local jails are
4 - 9x
than the national rate.
The Suicidal Mind
Those who enact murder-suicide, including
school shooters are
first suicidal
.
Suicide is primary; murder is secondary.
“To understand the primary
source code of violence –
the suicidal mind – we must first
understand that persistent
suicidal thoughts and feelings
are markers of unremitting, unendurable psychological
pain and suffering.”
~ Paul Quinnett, PhD
Distinguished Research Professor and The
Bright-Burton Professor in the Department of
Psychology at Florida State University
Author of over 400 peer-reviewed publications
Editor-in-Chief of the journal
Suicide & Life-Threatening
Behavior
Author of “
Why People Die by
Suicide,” “Myths About Suicide”
and “Lonely at the Top.”
Perceived
Burdensomeness
Thwarted
Belongingness
Those Who Are Capable of Suicide
Fearlessness about
Pain, Injury & Death
Acquired Ability for Self-Harm
Serious Attempt or Death by Suicide
Those Who Desire Suicide
Derived from Sketch of a Theory
Power Point presentation, 2013
Thomas Joiner, PhD
D
i
s
t
a
l
F
a
c
t
o
r
s
Why People Die by
Suicide
Suicide:
Fact vs. Fiction
1.
Asking someone about suicide might “plant the
seed” or increase risk.
2.
More females attempt suicide than males.
3.
Suicides increase over the winter holidays.
4.
Very young children complete suicide.
5.
Most suicidal people are ambivalent about it.
6.
Suicide is often done on whim, especially among
youth.
7.
Restricting access to lethal means is a critical
prevention method.
People routinely survive deep depression and
suicidal thoughts and behaviors.
The basic instinct to survive is
ever-present.
Suicidal people survive because someone
identifies what’s happening and gets help.
90% of those who complete suicide had a mental
health or substance about disorder.
THESE DISORDERS ARE TREATABLE!
SUICIDE IS
COMPLEX
Suicide is multi-facetted
There is never just one thing that leads to
suicide
There can, however, be a triggering event:
•
Arrest itself
•
Fear of transfer to more secure facility or
undesirable placement
•
Failure in the program
•
Suicide of a peer/contagion
•
Threat of/failure to visit
•
Death in the family
•
Loss of relationship
•
Ridicule from peers
90% of those who die by suicide had a
mental health and/or substance use
disorder.
55%-75% of those in jail or prison have a
mental health disorder, including
depression.
Three quarters of those have a co-occurring
substance use disorder.
What does this tell us
about the potential for prevention?
Unhelpful
Helpful
Suicide is inevitable
Suicide is preventable
Suicide is selfish
Suicidal youth irrationally
believe they are a burden
S/He only wants attention
Threats and attempts are
two of the most significant
precipitating factors for
suicide
Labeling suicidal thoughts Such labels increase stigma
or behavior as irrational or and can cause youth to shut
“crazy”
down/not seek out or accept
help
What to Look For
The more signs,
the greater the risk.
Warning signs are especially important if the
person has attempted suicide in the past
.
One sign alone may not indicate suicidality
but
all signs are reason for concern
and
several signs may indicate suicidality,
and
any one of
three signs
alone is cause for
immediate action
.
Previous suicide attempts
Talking about, making a plan or threatening to
complete suicide
Isolation, withdrawal from friends, family or society
Agitation, especially when combined with
sleeplessness
Nightmares
“I’ve decided to kill myself.”
“I wish I were dead.”
“I’m going to commit suicide.”
“I’m going to end it all.”
“If _______ doesn’t happen, I’ll kill myself.”
QPR Institute
“I’m tired of life; I just can’t go on.”
“My family would be better off without me”
“Who cares if I’m dead anyway.”
“I just want out.”
“Pretty soon you won’t have to worry about
me.”
QPR Institute
Changed eating habits or sleeping patterns
Giving away prized possessions,
making final arrangements,
putting affairs in order
Themes of death or depression in conversation,
writing, reading or art
Recent loss of a friend or family member through
death, suicide or divorce
Sudden dramatic decline or improvement in the
program
Feeling hopeless or trapped
Use or increased use of drugs and/or alcohol
Chronic headaches and stomach
aches, fatigue
Major mood swings or abrupt
personality changes
Neglect of personal appearance
Taking unnecessary risks or acting reckless
No longer interested in favorite activities or
hobbies.
Room Confinement
Withdrawal from Alcohol or Drugs
Court or other Legal Hearing
Significant Date to the Offender
Receipt of Bad News
Impending Release/Transfer
Family Threat of/Failure to Visit
Failure/Lack of Progress in the Program
Ridicule from Peers
Severe Guilt or Shame about Offense
Sexual/Physical Assault
Talking about wanting to die
or to kill oneself
Looking for a way to kill oneself
Talking about feeling hopeless
or having no reason to live
What to Do
Any suspicion that the person may be
suicidal must be acted upon.
Any report of such suspicions by the
person’s family or other inmates (if
incarcerated) should also be taken
seriously.
Yes, some may use the threat of suicide or a
feigned suicide attempt to manipulate the
system or get attention.
Attention-getting tells us something.
Challenging to tell the difference
Attempt habituation can lead to
underestimation of lethality.
TAKE ALL THREATS SERIOUSLY
Connect with the person
Avoid discussing personal info that may
be embarrassing in front of others
Reduce stress of the unknown
Monitor emotions before and after
visitation or calls
Assist the person in managing
conflict
Encourage discussion and
role play re: court or PO visit, etc.
Can be challenging – be persistent
Talk in semi-private location if possible
Avoid trying to identify with the
person
Avoid trying to argue him/her
out of it
Understand, listen and refer
Try to understand how the person may see
him/herself: Rigid thinking, overgeneralizing,
catastrophizing, attachment, trauma
Listening is Powerful!
•
Explore suicidality – level of intent
•
Listen non-judgmentally
•
Use reflective listening
•
Reasons for dying
•
Refrain from offering advice/solutions or
interrupting with your experience
•
Reasons for living
•
Offer hope, support, willingness to help/get help
Get a commitment to accept help and make
arrangements and contact family/friends
Ensure person is not left alone
Notify family
If person is deemed to be at high risk,
also contact mental health agency where
the person can go for further help.
1-800-273-TALK (8255)
Call police if person is in possession of a weapon
Follow up with person/family and mental health
agency
Debrief staff involved – self care
Document everything!
Clinical Prevention
Not about curing mental illness
Reduce stigma associated with mental health
problems
Reduce stigma associated with help-seeking
•
Being in treatment and using crisis services
Remove barriers to getting help
Building Hope
•
Symptom reduction
•
Identity change
Resolving hopelessness
•
Relationships that last
•
Finding a life worth living
From M. David Rudd, PhD
Suicidality is fluid
Tad Friend. Jumpers. The New Yorker (2003)
On the bridge, Baldwin counted to ten and stayed frozen. He counted to ten again,
then vaulted over.
“
I still see my hands coming off the railing,
”
he said. As he crossed
the chord in flight, Baldwin recalls,
“
I instantly realized that everything in my life that
I
’
d thought was unfixable was totally fixable—except for having just jumped.
”
Willingness to act (motivation to die)
•
People talk about reasons for dying
Preparation to act (preparation and rehearsal
behaviors)
•
People prepare for their death
Will, letters, finances, research
Capability to act
•
Builds over time with exposure
•
Ordinarily people engage in the behavior for some time prior to
death
High Risk Behavior
Self-mutilation
Suicide Attempts
Barriers to act (reasons for living)
•
People will discuss their ambivalence about death
•
Relationships critical
From M. David Rudd
The role of shame and guilt
•
Influence on the assessment dynamic
Recognize the fluid nature of intent
Identify and reinforce individual
ambivalence
•
Reasons for dying are readily accessible to
those in crisis
•
Reasons for living are often
unrecognized and
inaccessible
From M. David Rudd, PhD
N=1,671 CT, ME, UT, WI, Allegheny County, San Francisco County
2001 Data
Impulsivity
•
Hospital Discharge – THE warning sign
•
Capability
•
Loss of connectedness
•
Burdensomeness
•
Shame/Embarrassment
•
Non-Compliance with treatment
•
~37% of suicides are by those in treatment
•
Represents persistence of hopelessness and
intent
•
Issue of personal responsibility for care
•
Potential implicit messages
•
Treatment doesn’t work
•
Treatment is hopeless
From M. David Rudd, PhD
1.
Easy to understand treatment model
•
Identify early skill development/deficiencies related to current
functioning
•
Target
Thoughts (core beliefs) – motivation for dying
Feelings (physiological/emotional)
Behavior (increasing adaptive)
2.
A Focus on Treatment Compliance
•
Specific interventions to target poor adherence
•
Clear directions about what to do in non-adherence emerges
From M. David Rudd, PhD
3.
Focus on Skills-Building
•
Identify skill deficits with opportunity for skills building practice
Emotion regulation
Interpersonal
•
Clear understanding of “what is wrong” and “what to do about it”
•
Separate from identity
4.
Taking personal responsibility
•
Emphasis on self-reliance and self-management (commitment to
treatment statement, safety plan - PRACTICE)
•
Patients assume high level of responsibility for their care,
including crisis management
5.
Easy access to treatment and crisis services
From M. David Rudd, PhD
Items that generate productive, hopeful
thoughts and feelings
Always review items individually
Practice use (review; describe; ask what
are you thinking & feeling? Are you more
hopeful?)
From M. David Rudd, PhD
Survivor Support
Simply be there
Be a friend, family, neighbor, church
community
After 2 weeks – Reach out
Anniversaries
Suicide Survivor Packets: contact SPAN
Support groups
•
Boise Area
Facilitators
:
Kirby and Susan Orme
Where
:
First United Methodist Church Cathedral of the Rockies
11th and Hays Streets, Boise
Olivet Room, enter through glass doors on 11th Street
When
:
Second Friday of each month from 7:00 to 9:00 p.m.
•
Meridian Area
Facilitator: Cynthia Mauzerall
Where: Holy Apostles Church, 6300 N Meridian Rd., Meridian
When: Fourth Monday of each month from 7:00 to 8:30 p.m.
•
www.spanidaho.org, click Survivor Support
Books
•
No Time to Say Goodbye
, Carla Fine
•
Night Falls Fast
, Kay Redfield Jameson
Facilities
Written policies for prevention,
intervention, responding to attempts and
postvention
All staff trained on when and how to
implement these policies/plans
Protocols must include:
•
Assessing suicide risk and imminent suicide risk
Beyond intake because suicidality is fluid
•
Effective communication about suicide risk
Risk status and history can get lost in the shuffle
Staff must be vigilant
Information that must follow the inmate: suicide threat
made, behavior indicating depression, history of
psychiatric care and meds, status of protective custody
Should be part of admission process
Should NOT be a one-time occurrence
Mental health staff: formal assessment
Non-mental health staff may need to do
an informal assessment
•
Ask the question --- more than once if necessary
•
How to ask, how not to ask
•
If they keep denying, is everything okay?
AGAIN
AGAIN
AGAIN
Use of isolation cells
•
Increases risk of suicide
•
If an inmate at risk requires isolation ensure cell is suicide-
resistant
Consider all anchors and ligatures
Training for staff
•
Recognizing and responding to suicide risk
•
CRP and first aid
•
Rescue tools
Availability of first aid safety equipment
•
Latex gloves
•
Resuscitation breathing masks
•
Defibrillators
•
Tools to open jammed cell doors
•
Cutting tools for ligatures
Anchors: Any tie-off point
Ligature: Anything used to hang oneself; any
material which can be tied around the
neck and withstand body weight or strangle
(clothing hooks, shower knobs, cell doors, sinks,
toilets, ventilation grates, windows, smoke detectors)
WHY?
Majority of inmate death are by hanging
Result in death in 5-6 min.; brain death in 4 min.
Reporting:
•
Notify all appropriate staff, family, appropriate outside authorities
•
All staff in contact with the deceased prior to incident should submit a statement
as to their full knowledge of the youth and incident
Mortality Review
Minimize Contagion
•
Share facts to prevent rumors
•
Do not simplify, glamorize or romanticize the person or his/her death
•
Emphasize that suicide is rare and is not a common response to problems with
which other young adults may identify
•
Monitor young adults and most vulnerable and refer those struggling with the
death
SPAN Idaho Postvention Guidelines
Liability - “Deliberate indifference” & Not intervening does not
equal protection from liability
Self Care
Suicide Prevention Resource Center
www.sprc.org
SPAN Idaho
208-860-1703
info@spanidaho.org
www.spanidaho.org
National Center on Institutions and
Alternatives
www.ncianet.org
Kim Kane
Program Director
Idaho Lives Project
208-861-2727
kkane@idaholives.org
Explore the impactful work of Kim Kane, MPA, and the Idaho Lives Project in suicide prevention. Gain insights into the statistics, challenges, and regional efforts aimed at reducing suicide rates in Idaho. Discover the valuable resources provided by SPAN Idaho to support individuals in crisis and promote mental well-being.
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Presentation Transcript
Suicide and What Can Make a Difference Kim Kane, MPA Program Director, Idaho Lives Project Former Executive Director, SPAN Idaho Member, Idaho Governor s Council on Suicide Prevention Certified QPR Suicide Prevention Trainer
SPAN IDAHO WHY? STATS SAVE A LIFE CLINICAL PREVENTION SURVIVOR SUPPORT FACILITIES
A 501(c)(3) non-profit Vision : Idahoans choose to live A Resource www.spanidaho.org 208-860-1703
BOARD OF DIRECTORS 13 Volunteers STAFF Executive Director Resource Specialist REGIONAL CHAPTERS 8 Chapters Volunteer chairperson(s) Volunteer participants www.spanidaho.org 8 8 Driggs Driggs (new) (new)
US 2011 ID 2011 ID 2012 ID 2013 Total Deaths 39,518 24 299 308 Deaths/week 760 5.5 6 6 Suicide Rate 12.7 17.9 18.7 19.1
Sun. Mon. Tues. Wed. Thurs. Fri. Sat. 1 2 3 4 5 X X X X 6 7 8 9 10 11 12 X X X X X X 13 14 15 16 17 18 19 X X X X X X 20 21 22 23 24 25 26 X X X X X 27 28 29 30 31 X X X X X
23.3 17.9 12.7 6.0 15 24 9 U.S. D.C. Wyoming Idaho
We are not unlike our neighbors Top Eleven States, 2011 Wyoming Oklahoma Arizona Colorado 1. 1. Montana 3. New Mexico 4. Alaska 5. Vermont 6. Nevada 7. 8. 9. 9. Utah 11. Idaho
We are not unlike our neighbors Top Eleven States: 1. Wyoming 2. Alaska 3. Montana 4. Nevada 5. New Mexico 6. Idaho 7. Oregon 8. Colorado 9. South Dakota 10. Utah 11. Arizona
Lack of Access Easy Access Boot straps Stigma/Rugged individualist culture
2ndleading cause of death among Idahos youth. 29% Idaho Teen (age 14-19) Mortality Idaho Bureau of Vitial Records and Health Statistics, 2010 1% 8% 3% Accidents 3% Suicide 3% Cerebrovacular 5% Malignancies 48% Heart diseases Congenative Malform Pneumonitis 29% Other
Idaho high school students, 2013 YRBS shows 1 in 7 have considered suicide 1 in 13 have attempted suicide 1 in 8 actually have a suicide plan
Idaho has lost 83 school-aged children to suicide in the last 5 years. (2008-20012) 16 of those children were age 14 or younger
Suicide is the leading cause of death in American jails. Suicide rates in prison are higher than the general population, but higher still are rate in smaller facilities Suicide rates in local jails are 4 - 9x than the national rate.
Those who enact murder-suicide, including school shooters are first suicidal. Suicide is primary; murder is secondary. To understand the primary source code of violence the suicidal mind we must first understand that persistent suicidal thoughts and feelings are markers of unremitting, unendurable psychological pain and suffering. ~ Paul Quinnett, PhD
Distinguished Research Professor and The Bright-Burton Professor in the Department of Psychology at Florida State University Author of over 400 peer-reviewed publications Editor-in-Chief of the journal Suicide & Life-Threatening Behavior Author of Why People Die by Suicide, Myths About Suicide and Lonely at the Top.
Why People Die by Suicide Those Who Desire Suicide Those Who Are Capable of Suicide D i s t a l F a c t o r s Perceived Burdensomeness Fearlessness about Pain, Injury & Death Acquired Ability for Self-Harm Thwarted Belongingness Serious Attempt or Death by Suicide Derived from Sketch of a Theory Power Point presentation, 2013 Thomas Joiner, PhD
Suicide: Fact vs. Fiction
1.Asking someone about suicide might plant the seed or increase risk. 2.More females attempt suicide than males. 3.Suicides increase over the winter holidays. 4.Very young children complete suicide. 5.Most suicidal people are ambivalent about it. 6.Suicide is often done on whim, especially among youth. 7.Restricting access to lethal means is a critical prevention method.
People routinely survive deep depression and suicidal thoughts and behaviors. The basic instinct to survive is ever-present. Suicidal people survive because someone identifies what s happening and gets help. 90% of those who complete suicide had a mental health or substance about disorder. THESE DISORDERS ARE TREATABLE!
SUICIDE IS COMPLEX Mental Illness Substance Abuse Family History Lack of Support Abuse Previous Attempt Hopelessness
Suicide is multi-facetted There is never just one thing that leads to suicide There can, however, be a triggering event: Arrest itself Fear of transfer to more secure facility or undesirable placement Failure in the program Suicide of a peer/contagion Threat of/failure to visit Death in the family Loss of relationship Ridicule from peers
90% of those who die by suicide had a mental health and/or substance use disorder. 55%-75% of those in jail or prison have a mental health disorder, including depression. Three quarters of those have a co-occurring substance use disorder. What does this tell us about the potential for prevention?
Unhelpful Suicide is inevitable Suicide is selfish S/He only wants attention Threats and attempts are two of the most significant precipitating factors for suicide Labeling suicidal thoughts Such labels increase stigma or behavior as irrational or and can cause youth to shut crazy down/not seek out or accept help Suicide is preventable Suicidal youth irrationally believe they are a burden Helpful
The more signs, the greater the risk. R I S K 1. 2. 3. 4. 5. 6. Warning signs are especially important if the person has attempted suicide in the past. One sign alone may not indicate suicidality butall signs are reason for concern and several signs may indicate suicidality, and any one of three signs alone is cause for immediate action.
Previous suicide attempts Talking about, making a plan or threatening to complete suicide Isolation, withdrawal from friends, family or society Agitation, especially when combined with sleeplessness Nightmares
Ive decided to kill myself. I wish I were dead. I m going to commit suicide. I m going to end it all. If _______ doesn t happen, I ll kill myself. QPR Institute
Im tired of life; I just cant go on. My family would be better off without me Who cares if I m dead anyway. I just want out. Pretty soon you won t have to worry about me. QPR Institute
Changed eating habits or sleeping patterns Giving away prized possessions, making final arrangements, putting affairs in order Themes of death or depression in conversation, writing, reading or art Recent loss of a friend or family member through death, suicide or divorce Sudden dramatic decline or improvement in the program
Feeling hopeless or trapped Use or increased use of drugs and/or alcohol Chronic headaches and stomach aches, fatigue Major mood swings or abrupt personality changes Neglect of personal appearance Taking unnecessary risks or acting reckless No longer interested in favorite activities or hobbies.
Room Confinement Withdrawal from Alcohol or Drugs Court or other Legal Hearing Significant Date to the Offender Receipt of Bad News Impending Release/Transfer Family Threat of/Failure to Visit Failure/Lack of Progress in the Program Ridicule from Peers Severe Guilt or Shame about Offense Sexual/Physical Assault
Talking about wanting to die or to kill oneself Looking for a way to kill oneself Talking about feeling hopeless or having no reason to live
Any suspicion that the person may be suicidal must be acted upon. Any report of such suspicions by the person s family or other inmates (if incarcerated) should also be taken seriously.
Yes, some may use the threat of suicide or a feigned suicide attempt to manipulate the system or get attention. Attention-getting tells us something. Challenging to tell the difference Attempt habituation can lead to underestimation of lethality. TAKE ALL THREATS SERIOUSLY
Connect with the person Avoid discussing personal info that may be embarrassing in front of others Reduce stress of the unknown Monitor emotions before and after visitation or calls Assist the person in managing conflict Encourage discussion and role play re: court or PO visit, etc.
Can be challenging be persistent Talk in semi-private location if possible Avoid trying to identify with the person Avoid trying to argue him/her out of it Understand, listen and refer Try to understand how the person may see him/herself: Rigid thinking, overgeneralizing, catastrophizing, attachment, trauma
Listening is Powerful! Explore suicidality level of intent Listen non-judgmentally Use reflective listening Reasons for dying Refrain from offering advice/solutions or interrupting with your experience Reasons for living Offer hope, support, willingness to help/get help
Get a commitment to accept help and make arrangements and contact family/friends Ensure person is not left alone Notify family If person is deemed to be at high risk, also contact mental health agency where the person can go for further help. 1-800-273-TALK (8255) Call police if person is in possession of a weapon Follow up with person/family and mental health agency Debrief staff involved self care Document everything!
Not about curing mental illness Reduce stigma associated with mental health problems Reduce stigma associated with help-seeking Being in treatment and using crisis services Remove barriers to getting help Building Hope Symptom reduction Identity change Resolving hopelessness Relationships that last Finding a life worth living From M. David Rudd, PhD
Suicidality is fluid On the bridge, Baldwin counted to ten and stayed frozen. He counted to ten again, then vaulted over. I still see my hands coming off the railing, he said. As he crossed the chord in flight, Baldwin recalls, I instantly realized that everything in my life that I d thought was unfixable was totally fixable except for having just jumped. Tad Friend. Jumpers. The New Yorker (2003)
Willingness to act (motivation to die) People talk about reasons for dying Preparation to act (preparation and rehearsal behaviors) People prepare for their death Will, letters, finances, research Capability to act Builds over time with exposure Ordinarily people engage in the behavior for some time prior to death High Risk Behavior Self-mutilation Suicide Attempts Barriers to act (reasons for living) People will discuss their ambivalence about death Relationships critical From M. David Rudd
The role of shame and guilt Influence on the assessment dynamic Recognize the fluid nature of intent Identify and reinforce individual ambivalence Reasons for dying are readily accessible to those in crisis Reasons for living are often unrecognized and inaccessible From M. David Rudd, PhD
Impulsivity 33 2001 Data 21 20 % 13 6 0-17 18-24 25-44 45-64 65+ Age group N=1,671 CT, ME, UT, WI, Allegheny County, San Francisco County
Hospital Discharge THE warning sign Capability Loss of connectedness Burdensomeness Shame/Embarrassment Non-Compliance with treatment ~37% of suicides are by those in treatment Represents persistence of hopelessness and intent Issue of personal responsibility for care Potential implicit messages Treatment doesn t work Treatment is hopeless From M. David Rudd, PhD
