Transcript SUICIDE BRIEF NME JAN.2012

1st SERGEANT’S BRIEFING
Airmen in Distress
Neysa Etienne
Clinical Psychologist
Maxwell Air Force Base
Mental Health Clinic 42nd MDG
Learning objectives

Describe Phenomenon of Suicide
 Model
 Mind

Manage your reactions to Airmen in distress
 Take a collaborative, non-adversarial stance

Manage Suicide Risk in Airmen




Helpful Language and Approach
Reconcile conflicting goals
Plan for how to assist
Awareness of helping agencies
Why The
st
1
Sgt?
 Spends time w/ personnel almost every day
 Is most likely familiar w/ typical behavior
 One of the first to see problems develop
 You are the first line of defense
Being proactive with wellness & safety benefits
people as well as the AF’s mission
SNAPSHOT: MILITARY FAMILIES
2005-2009: > 1,100 members of the Armed Forces took their own lives
2010: ARMY suicide rate among active-duty soldiers decreased slightly
2009: 162
2010: 156
2010: Number of suicides in the Guard and Reserve increased by 55%
2009: 80
2010: 145
2010: More than half of the National Guard members who died by suicide
had not deployed.
* Suicide among veterans accounts for as many as 1 in 5 suicides in U.S.
* No greater risk for service members compared to general population…
“Mostly, I have been impressed by how little value our society
puts on saving the lives of those who are in such despair as to
want to end them. It is a societal illusion that suicide is rare. It is
not.”
--Kay Redfield Jamison
SNAPSHOT: UNITED STATES
- 11th leading cause of death in the US
- 2nd leading cause of death among college students
- 3rd leading cause of death for young people aged 15-24
- 4th leading cause of death among people aged 25-44
- For every suicide event, 6 survivors are left behind
- More than 30,000 Americans Commit suicide every year
- 1 Suicide in the US approximately every 17 minutes
- 650,000 attempted suicides per year
- 2:3 Ratio (HOMICIDE TO SUICIDE) in the U.S.
MYTH OR FACT
1. Suicide Usually Happens with no warning
2. More than 70% of people who kill themselves have previously
considered it seriously?
3. There is most often a note left behind when someone commits suicide.
4. People who are suicidal are intent on dying and feel there is no turning
back?
5. Someone who survives a suicide attempt is really not serious about it.
6. Discussing suicide openly with someone who seems really depressed
does more harm than good.
7. People who attempt suicide once, are unlikely to try it again.
EXPERIENTIAL EXERCISE
1. FIND A PARTNER
2. FACE OFF
3. RELATE
4. DEBRIEF
5. WHY?
MIND & MODEL
 Theoretical Framework
 BIOPSYCHOSOCIAL MODEL
 THE SUICIDE MODE (Rudd, 2009)
 Predispositions to Suicide
 Triggers
 Interaction between:
 Perceptions (thoughts)
 Emotions (feelings)
 Behaviors
 Physiology
BASELINE RISK
 Predispositions
 Male
 Same sex orientation
 Recent discharge from inpatient unit
 Family history of suicide
 History of physical, emotional, or sexual abuse
 Previous suicide attempts
 Impulsivity
 Subjective or Objective
ADDITIONAL RISK
 Additional Risk Factors
 Older
 Caucasian
 Isolated
 Medical issues
 Alcohol use
 Depression
 Panic attacks
PROTECTIVE FACTORS
 Optimism about the future
 Strong social support
 life has purpose and meaning
 Feeling a sense of belonging
 Willingness to seek help
 Willingness to talk about problems
 Effective coping and problem solving skills
 Cultural norms that encourage
KNOW YOURSELF
 Questions to ask self:
 Self-Awareness of personal reactions
 How to Manage Your Reactions
 Unhelpful Attitudes
 Recognize Difference in Goals
 Conflict of interest in accomplishment
 Reconcile differences
 Collaborative approach
Questions to ask self
 Why do people die by suicide?
 What are your beliefs about suicide?
 What have you learned about suicide during
your life?
 What type of person kills themselves?
 Who do you know that has died by suicide?
(Rudd, 2006)
BE MINDFUL OF
REACTIONS
 Fear
 Helplessness: “I can’t do anything to help”
 Hopelessness: “Nothing I do matters”
 Anxiety
 Over-protectiveness: Reduce autonomy
 Under-protectiveness: Casual avoidance
 Anger
 Lack of compassion: Inability to care
 Criticism: Blaming
YOUR REACTION
 Accept that we will have emotional reactions
to the problems our Airmen bring to us
 Take some time to explore our beliefs about
the issues we will commonly face
 Keep in mind that it is not our problem or
perspective that matters, but the Airman’s
 Recognize that you do not have to agree with
an Airman’s beliefs, perspectives, or behavior
in order to help them
ATTITUDES & BELIEFS
 Avoiding or denying that the Airman has a problem
 Doing the bare minimum to help the Airman
 Over-reliance on one’s own opinions and experiences
 Defensiveness
 Believing the Airman is being manipulative
 Undervaluing or overvaluing helping agencies
GOAL CONFLICT
1.
2.
3.
4.
5.
1st Sergeant Goals:
Keep Airman safe
Keep others safe
Mission effectiveness
Protect unit morale
Stay out of trouble
1.
2.
3.
4.
5.
Airman’s goals:
Reduce distress
Reduce pain
Alleviate suffering
Be understood
Stay out of trouble
APPROACH CONFLICT
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1st Sergeant:
Talk with others
Increase healthy behaviors
Access professional help
Distressed Airman:
Alleviate the pain
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Drinking
Drugs
Reckless behaviors
Violence / aggression
Suicidal ideation
Reconciling
Differences
 Understand that the Airman engages in harmful
behaviors because they “make sense” and they
work
 Recognize the functional purpose of the
behaviors
 View the Airman as individual with unique set of
issues and circumstances
 Listen to the Airman’s “story”
"I got very angry when they kept asking me if I
would do it again. They were not interested in my
feelings. Life is not such a matter-of-fact thing and, if
I was honest, I could not say if I would do it again or
not. What was clear to me was that I could not trust
any of these doctors enough to really talk openly
about myself."
COLLOBORATIVE APPROACH
 Managing risk vs “telling” the Airmen what is best for him/her.
 Airmen is the “expert” on his or her behavior
 Airmen feels safe discussing sensitive issues.
 Increase the Airmen’s openness for discussion
 Increase the patient’s help-seeking behaviors in the future
 Improve the effectiveness of the risk assessment
 1st Sgt is the “coach”
 1st Sgt can reinforce any help-seeking behaviors and/or any already
existing coping resources
 Willing to do whatever it takes, however long, at whatever time
 Decreases the 1st Sgt’s emotions (i.e. lessen the unrealistic sense of
responsibility) Can’t work harder than they are willing
 How you communicate matters…
HELPFUL APPROACHES
 LISTEN first before giving advice
 Ask directly about thoughts of suicide
 Take reports of suicidal ideation seriously
 Don’t be judgmental
 Don’t promise anything
 Express genuine caring and hope
HELPFUL LANGUAGE
 I've noticed you're feeling upset.
 What's going on in your life?
 Are you thinking about suicide?
 What do you think might help?
 Where would you like to go for help?
 Why don't we make the call together?
 I'm not going to feel comfortable without
being sure you're going to get some help.
Direct Communication
 HARD communication
 H
 Good Ex: “you look down”
 Bad Ex: avoidance
 A
 Good Ex: “Sometimes people are down”
 Bad Ex: “Airmen don’t kill themselves”
 R
 Good Ex: “Would it be ok if we talk”
 Bad Ex: “get in my office”
 D
 Good Ex: “Are you thinking about killing yourself”
 Bad Ex: “ambiguity” (Your not planning a get-away…)
REDUCING ANXIETY
 Be direct
 “Are you thinking about suicide?”
 “Do you know how you might do it?”
 Notice hesitancy and body language
 “It looks like this is difficult to talk about.”
 Do not accept the first “no”
 Ask in slightly different ways
 Remain relaxed and unhurried
 “I know this can be tough, so take your time.”
RAISING ThE ISSuE…
 Make behavioral observations
 “I’ve noticed…” technique
 Express concern
 Avoid judgmental language
 Stick to the facts
NORMALIZE DISTRESS
 Normalize the Airman’s feelings through
gradual sequencing of questions
 “When people are extremely upset, they often feel
like things will never get any better. Do you feel
that way?”
 “When people feel things will never get any better,
they often think about death. Have you been
thinking about death or not being around?”
 “When people think about death, then sometimes
think about killing themselves. Have you had any
thoughts about suicide?”
ATTENUATE SHAME
 Phrase questions so that positive response do
not feel self-incriminating or accusatory
 “With all this going on, have you been drinking
more often?”
 “You said you were opposed to suicide, but I’m
wondering, with all this stress you’ve been
experiencing, did you have some thoughts about
suicide, even if only a little bit?”
WHAT ARE SOME SIGNS?
-Preoccupation with Death and Dying
-Drastic changes in behavior or personality
-Recent severe loss or threat of loss
-Unexpected preparations for death
-Giving away prized possessions
-Previous attempts
-Uncharacteristic impulsiveness
-Loss of interest in personal appearance
-Increased use or abuse of alcohol
-Sense of hopelessness about the future
SEEK hELP WhEN…
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Persistent stress interfering w/ daily life
Difficulty coping
Difficulty functioning
Accumulating signs of distress
Multiple risk factors
Thoughts about suicide
ACCESS TO LETHAL MEANS
 Suicidal crises are short-term peaks in distress
 Among survivors of life-threatening attempts:
 24% decided within 5 minutes preceding attempt
 70% decided within 60 minutes preceding attempt
 Suicide rates by firearm:
 57x higher in week following purchase
 30x higher in month following purchase
 7x higher in year following purchase
 Routinely ask about methods and access to means multiple times
IMPORTANT TERMS
 Suicide
 Suicide Attempt with injury
 Suicide Attempt without injury
 Non-Suicidal Self Injury
 Suicide threat
 Suicidal ideation
 Morbid ideation
Consult
 Your suspicions are substantiated
 Contact The Mental Health Clinic
 When to Contact Them
 DOCUMENT Your Interaction
Document
 Improve Continued Risk Assessment
 Improve Management Interventions
 Help Develop Long Term Treatment Plans
 Expedite the Transferring of Care
 Very Important Function in the Case of
Morbidity/mortality Reviews
 Important in the case of CDE
 Important in the case of Admin Separation
MH RISK ASSESSMENT
 Suicide Status
 Informed Consent
 Commitment to Treatment
 Crisis Response Plan
 Suicide Tracking
 Stabilization
Item 1: Psychological Pain
 “Psych-ache”: unbearable suffering unique to
the individual
 Suicide risk reduction occurs through 2
processes:
 Increasing tolerance for psychological pain
 Removing / ameliorating root of psychological pain
Item 2: Stress
 Largely external (sometimes internal)
pressures or demands that psychologically
affect the individual
 Relationship conflicts
 Job loss
 Command hallucinations
 Ruminations
 Intimately linked to overwhelming feelings
Item 3: Agitation
 State of being emotionally upset, disturbed,
and disquieted
 Cognitive constriction
 Predisposition for self-harm
 Impulsive desire to do something to change or
alter his or her unbearable state
 Psychological energy / driving force behind
suicidal behaviors
Item 4: Hopelessness
 One’s expectation that a negative situation
will not get better no matter what one does
 Intimately linked to future thinking
 Based largely on work of Aaron Beck
Item 5: Self-hate
 Suicide as escape from unacceptable
perceptions of self
 Suicidal individuals are fundamentally
preoccupied with their unhappiness
 2 essential components of suicidal struggle
:
(Baumeister, 1990)
 Need for escape
 Core importance of self
Item 6: Self-assessment
 Behavioral self-report of risk
 We have the tendency to overestimate suicide
risk when compared to patient self-report

(Joiner, Rudd, & Rajab, 1999)
CONFIDENTIALITY
 Harm to Self
 Harm to Others
 Abuse
 Child
 Spousal
 Elder
 UCMJ
 LPSP (Limited Privilege Suicide Prevention)
 1st Sgt & Commander
 Profile
 Line of Duty
 Duty Impact/Restrictions
 Mobility Restrictions
Commitment to
Treatment

I, ________________, agree to make a commitment to the treatment process. I understand that
this means that I have agreed to be actively involved in all aspects of treatment including:
 (1) attending sessions (or letting my therapist know when I can’t make it)
 (2) setting treatment goals with my therapist
 (3) voicing my opinions, thoughts, and feelings honestly and openly with my therapist
(whether they are negative or positive, but most importantly my negative feelings)
 (4) being actively involved during sessions
 (5) completing homework assignments in between sessions
 (6) taking my medications as prescribed
 (7) trying new behaviors and new ways of doings things
 (8) implementing my crisis response plan when needed

I also understand and acknowledge that, to a large degree, a successful treatment outcome
depends on the amount of energy and effort I make. If I feel like treatment is not working, I
agree to discuss it with my therapist and attempt to come to a shared understanding as to
what the problems are, and to identify potential solutions together. In short, I agree to make a
commitment to treatment, and to living. This agreement will apply for the next ____ months,
at which time it will be reviewed with my therapist and modified as needed.
Crisis Response Plan
 When thinking about suicide, I agree to do the following;
 Use relaxation skills
 Go for a walk or play a video game
 Call a friend; (Earl; XXX-XXX-XXXX)
 REPEAT ALL OF THE ABOVE
 Call provider at Clinic X (Dr.; XXX-XXX-XXXX)
 If unavailable, call Clinic (XXX-XXX-XXXX)
 Call crisis hotline; 1800-273-TALK
 Go to the emergency department
 Call 911
TRACKING
 Levels:
 Stabilization
Back to baseline
 Self-management
Mastery and use of skills
 Utilization
 1st Sgt’s Role
ROLE OF LEADERSHIP
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Good leadership promotes suicide prevention
Build a supportive work environment
Know Your Airman
Know the warning signs
Know the helping resources
Ask the tough questions
Encourage help seeking behaviors
Stay involved until problem is resolved
Recognize when help is needed and get it
Apply Suicide Intervention Skills
ASK CARE ESCORT
A - Ask your wingman

Have the courage to ask the question, but stay calm
 Ask the question directly: "Are you thinking of killing yourself?"
C - Care for your wingman
 Calmly control the situation, do not use force, be safe
 Actively listen to show understanding and produce relief
 Remove any means that could be used for self-injury
E - Escort your wingman
 Never leave alone
 Escort to chain of command, behavioral health professional,
Chaplain, or primary care provider
 Call the National Suicide Prevention Lifeline: 1-800-273-8255(TALK)
URGENT HELP
 Escort the person to the ER or the Mental Health Clinic
 Mental Health Clinic is on call 24/7
 Notify your supervisor or call 911 for help
 Don’t leave the person alone
 Remove means of self harm
 Suicide Prevention Hotlines:
1-800-273-TALK or 1-800-SUICIDE
 1-800-273-TALK can connect you to a counselor who
understands military issues
 By law, only commanders can order Airmen to receive a
mental health evaluation, and only when following
appropriate procedures
Research Direction
 Current Research in the Maxwell Clinic
 Guilt & Shame w/ Suicide Risk
 Aim of this Research study
Tips for managing crises
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Understand your own triggers or hot buttons
Be consistent in how you help Airmen
Avoid coercion
Encourage and model openness and honesty
Recognize positive change might be slow
Pay attention to positive changes
(not just negative changes)
Tips for after the crisis
 Protect privacy
 Normalize stress reactions
 “Who wouldn’t feel this way?”
 Foster a culture of help-seeking
 “Who wouldn’t get help in this situation?”
 Maintain Airman’s level of responsibility
 Avoid stigmatization
 Provide support on group level
 Don’t single out Airmen in distress
Connecting
Airmen to
helping agencies
RESOURCE LIST
Be prepared
 Keep a list of helping agencies nearby
 Familiarize yourself with AF policy
 Discuss with leadership how problems and
issues will be handled in the unit
 Be Wingmen – don’t let your Airmen go alone
Helping Agencies
 Airman & Family Readiness Center: 953-2353

Transition Assistance, Employment Assistance, Volunteer
Resources, Information & Referral, Financial Readiness, Relocation
Assistance, Air Force Aid, Personal & Work Life, Family Readiness,
Family Ser-vices
 Family Advocacy: 953-5055

Family Maltreatment assessment & intervention, Outreach &
Prevention Programs, New Parent Support Program, Family
Resource Library
 Sexual Assault Response Coordinator: 953-4416
 24 hr assault report hotline 953-8676
 Education, Awareness & Protection, Confidential Consultation,
Victim Advocacy & Support
Helping Agencies
 Family Member Support Flight: 953-3524
 Full time child care, School Age Program, Hourly Care, Part Time
Enrichment, Give Parents A Break
 Chaplain Service: 953-2109
 Counseling services for: Premarital/Marriage, Family/ Parenting, Religious
Issues, Work Related Issues, and Grief
 Catholic/Protestant Worship & Religious Education
 Mental Health Clinic: 953-5430

Group Therapy, Individual Therapy, Marriage Counseling, Personal
Problem Assistance, Command Consultation, Evaluations, Psychological
Testing, Relaxation Program, Healthy Thinking, Substance Abuse
Evaluation & Treatment, Special Needs Coordination (SNIAC)
 Health & Wellness Center (HAWC): 953-7117
 Nutrition Assessment & Counseling, Weight, Cholesterol, Hypertension &
Diabetes Management, Exercise Assessment, Body Composition
Assessment, Tobacco Cessation, Relaxation Room, Wellness Library
Helping Agencies
 Educational & Developmental Intervention
Services (EDIS): 953-4415
 Early intervention services for children under three
years of age who have developmental delays of certain
medical conditions
 Behavioral Health Consultant: 953-5430
 Behavioral Health appointments in primary care setting
 Military Family Life Consultant: 334-430-4409
 Free confidential counseling, up to 4 appointments
 Military One Source: 1-800-342-9647
 Free confidential counseling, up to 12
appointments
Final thoughts
"Suicide, I have learned, is not a bizarre and
incomprehensible act of self destruction. Rather,
suicidal people use a particular logic, style of thinking
that brings them to the conclusion that death is the
only solution to their problems. This style can be
readily seen, and there are steps we can take to stop
suicide, if we know where to look".
-- Edwin Shneidman
Final Thoughts