1 st SERGEANT’S BRIEFING Airmen in Distress

1st SERGEANT’S BRIEFINGAirmen in Distress

Neysa EtienneClinical 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 1st 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 FAMILIES2005-2009: > 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 FACT1. 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.

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

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

KNOW YOURSELF

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 CONFLICT1st Sergeant Goals:

1. Keep Airman safe2. Keep others safe3. Mission effectiveness4. Protect unit morale5. Stay out of trouble

Airman’s goals:1. Reduce distress2. Reduce pain3. Alleviate suffering4. Be understood5. Stay out of trouble

APPROACH CONFLICT1st Sergeant:

Talk with others Increase healthy behaviors Access professional help

Distressed Airman: Alleviate the pain

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."

Collaborative 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”

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… 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 Instrumental suicide-related behavior 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 ASSESSMENTSuicide Status

Informed ConsentCommitment to TreatmentCrisis Response PlanSuicide 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 baselineSelf-management

Mastered and uses skillsUtilization1st Sgt’s Role

· 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 ESCORTA - 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

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

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

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

Helping Agencies

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