USA ARMOR CENTER SUICIDE PREVENTION LEADERS CHAIN TEACH

USA ARMOR CENTER SUICIDE PREVENTION LEADERS CHAIN TEACH 1 HOME OF MOUNTED WARFARE

USA ARMOR CENTER “It is our responsibility to help our soldiers and civilians understand how to identify at-risk individuals, recognize warning signs and know how to take direct action. ” General Eric K. Shinseki Army Chief of Staff HOME OF MOUNTED WARFARE 2

USA ARMOR CENTER “One of the greatest challenges commanders and leaders face is that of suicide prevention. Soldiers who need our help must get it. We need to erase the stigma attached to seeking mental health care. Seeking help is not a career stopping action - it is a potentially life-saving one. Every soldier must be able to recognize the warning signs, both in themselves and in their fellow soldiers. ” General John N. Abrams TRADOC Commander HOME OF MOUNTED WARFARE 3

USA ARMOR CENTER SUICIDE PREVENTION OVERVIEW • HOW BIG A PROBLEM IS SUICIDE IN THE ARMY? • CAN SUICIDE BE PREVENTED? • WHO IS RESPONSIBLE FOR PREVENTING SUICIDE? • WHO IS AT RISK FOR SUICIDE? • CHARACTERISTICS OF SUICIDAL THINKING. • HOW DO WE RECOGNIZE SOLDIERS AT RISK? • HOW DO WE HELP SOLDIERS AT RISK? • SUICIDE MYTHS. 4 HOME OF MOUNTED WARFARE

HOW BIG IS THE PROBLEM? USA ARMOR CENTER • 12 -16 SUICIDES PER 100, 000 SOLDIERS EACH YEAR, OR 50 -70 DEATHS PER YEAR. • 40 SUICIDES AT FORT KNOX SINCE 1988, ABOUT 3 PER YEAR. • ARMY INCIDENCE MAY BE INCREASING OVER PAST 2 YEARS AFTER HAVING DECREASED THE PRECEEDING 4 YEARS. • SECOND LEADING CAUSE OF DEATH IN ARMY AFTER ACCIDENTS. • SUICIDES IN THE ARMY ARE ALMOST ALL MALES. • ARMY SUICIDES USUALLY BY HIGHLY LEATHAL/VIOLENT MEANS: – FIREARMS: 66% – HANGING: 18% – CARBON MONOXIDE: 3% – OTHER: 13% 5 HOME OF MOUNTED WARFARE

USA ARMOR CENTER HOW BIG IS THE PROBLEM? • ONE SUICIDE IS ONE TOO MANY. 6 HOME OF MOUNTED WARFARE

CAN SUICIDE BE PREVENTED? USA ARMOR CENTER • IN RETROSPECT, 80% OF PEOPLE WHO KILL THEMSELVES GAVE CLEAR WARNING SIGNS. • ALL OF THOSE 80% COULD HAVE BEEN PREVENTED, IF SOMEONE HAD RECOGNIZED THE WARNING SIGNS AND ACTED ON THEM. • MANY SUICIDES IN THE ARMY ARE PREVENTED DUE TO COMMAND EMPHASIS AND A STRUCTURED SUICIDE PREVENTION PROGRAM. MOST CIVILIANS DO NOT RECEIVE SUICIDE PREVENTION TRAINING. – SUICIDE INCIDENCE, U. S. MALES AGES 18 -40: • US ARMY: 14/100, 000 • CIVILIAN: 24/100, 000 7 HOME OF MOUNTED WARFARE

CAN SUICIDE BE PREVENTED? USA ARMOR CENTER • PROBLEM: Soldiers who complete suicide: – Rarely seek help through the chain of command, Chaplaincy or Mental Health. – Often don’t show “classic” warning signs of suicide in the unit. – Frequently choose very lethal means and act privately, precluding rescue. • WHY? – Army culture - “No Fear”, “Suck it Up!”, “Bite the Bullet!” – Stigma of going to Mental Health. – Impulsivity and distorted thinking in crisis (“No one can help”, “It’s hopeless”). – Lack of awareness of available help. 8 HOME OF MOUNTED WARFARE

USA ARMOR CENTER WHO IS RESPONSIBLE FOR SUICIDE PREVENTION? • Remember what GEN Shinseki and GEN Abrams said. . . – – – Each soldier is responsible for him/herself. Battle Buddy, associates, friends, family members. First line supervisors. NCO chain. Command chain. Chaplaincy. Mental Health. Community Agencies. Garrison/Installation Commanders. MACOM DA… HOME OF MOUNTED WARFARE 9

USA ARMOR CENTER WHO IS RESPONSIBLE FOR SUICIDE PREVENTION? • Suicide prevention is everyone’s responsibility. • It will be successful in direct proportion to the extent that the entire community is committed to identifying and helping those at risk. 10 HOME OF MOUNTED WARFARE

WHO’S AT RISK FOR SUICIDE? USA ARMOR CENTER • Almost everyone has thought about suicide at some time. • Stress alone is not a key factor in suicide. • Psychiatric disturbance combined with various stressors, especially significant loss or the threat of loss, appears to be the major precipitant of suicidal thinking and behavior. • More than 1 in 4 Americans suffer from emotional problems severe enough to significantly affect their social and occupational functioning. • Since we all experience stress, it could be said that: – More than 25% of Americans are at risk for suicide. – Take-home message: Under right conditions, ANY SOLDIER COULD BE AT RISK FOR SUICIDE. 11 HOME OF MOUNTED WARFARE

CHARACTERISTICS OF SUICIDAL THINKING USA ARMOR CENTER • Unmet needs in people who are stressed and emotionally vulnerable causes intolerable psychological pain with guilt, worthlessness, shame or aloneness. – The stressors and the pain may appear trivial to observers. • Distorted, constricted thinking and tunnel vision results: – Range of behavioral options becomes limited to either magical solutions or escape (dichotomous thinking). • Goal of suicidal thinking is to escape the pain, not necessarily to die. • Risk of serious suicide attempt and death is highest when: – The person sees no way out and fears things may get worse. – The predominant emotion is hopelessness and helplessness. – Thinking is constricted and dichotomous. – Lethal means are available. • Behavior can be impulsive (acute emotional reaction), planned (chronic condition), or communicative (does not want to die but incapable, unworthy or ignored when attempts to communicate in other ways). HOME OF MOUNTED WARFARE 12

USA ARMOR CENTER How Do We Recognize Suicide Risk? Risk Factors - Psychiatric Disturbance/Vulnerability • Prior suicide gestures or attempts. • Psychiatric disorders: – Depression (47% of suicides). – Anxiety Disorders (e. g. PTSD). – Personality Disorders (9% of suicides). • Substance abuse: – Alcohol Abuse (26% of suicides). • Family history of suicide. • Hopelessness/helplessness. • Impulsivity. • Real or perceived sense of isolation. HOME OF MOUNTED WARFARE 13

USA ARMOR CENTER How Do We Recognize Suicide Risk? Risk Factors - Life Stressors/Other Factors • Recent or threatened loss of: – Love Relationship (up to 70% of suicides). – Social support systems. – Financial or social status. • Disciplinary Problems/UCMJ/Imprisonment. • Work Problems. • Barriers to Treatment including stigma and military culture. • Physical Illness. • Access to lethal means. • Influence of other suicides/media. HOME OF MOUNTED WARFARE 14

USA ARMOR CENTER How Do We Recognize Suicide Risk? Suicide Indicators • • • Suicide gestures or verbal threats. Giving away possessions (rare), putting affairs in order, making a will. Talking or writing about death and suicide. Verbalizations about leaving, “If I’m still around then, ”It’s no use, ” etc. Personality changes or sudden unexplained mood elevation. Symptoms of depression: – sadness, tearfulness, social isolation/withdrawal. – changes in sleep, appetite, sex drive, concentration, hygiene. – feelings of guilt, hopelessness/helplessness, loss of interest in usual activities. Increased alcohol/drug use. Deteriorating work performance. Frequent physical complaints and medical appointments. Stopping medications or saving a lethal supply. Purchasing weapons. HOME OF MOUNTED WARFARE 15

How Do We Recognize Suicide Risk? USA ARMOR CENTER Summary • Understand be alert for suicide risk factors (psychiatric vulnerabilities and life stressors) and suicide indicators. This is essential but not enough. • Remember that many soldiers who commit suicide have risk factors but don’t show them in the unit. • Since they don’t jump out at you- must actively look for them with thermal sights, magnification, and whatever other sensors you have. • There are no unique predictors of suicide; we can only attempt to detect and reduce risk. • Any soldier with significant life issues is at potential risk. . . • …So don’t forget the high speed/low drag good soldier who is cheerful, effective, motivated and good-to-go but may have some marital or financial problems to resolve. They need your attention too. • Need to “connect the dots” to see the big picture, even in the absence of classic risk factors and indications of suicidality. This is just plain old taking care of soldiers. HOME OF MOUNTED WARFARE 16

How Do We Recognize Suicide Risk? USA ARMOR CENTER Risk Assessment • Explore in depth, help develop solutions, provide support and reality check. • If a soldier needs time off to go deal with a problem: – assess soldier’s emotional stability. – review his/her plan and options. – assess support system in area to which soldier is going. – consider contingency and “failure” plans--ask about suicide potential. – ensure soldier can reach you or someone in unit who cares 24/7. – instruct soldier to report telephonically at reasonable periods. – ensure you have a reliable POC where the soldier is going. • If you perform this risk assessment and are uneasy, do not let the soldier go: – keep the soldier with you, explain reasons, stay supportive. – elevate the issue up the chain. – get Chaplain or Mental Health consultation. HOME OF MOUNTED WARFARE 17

USA ARMOR CENTER • • How Do We Help? Command Message Everyone is important to the unit, even soldiers in trouble. Everyone needs outside help sometimes. Responsible people seek help early. I support and protect in any way possible soldiers who seek help responsibly. 18 HOME OF MOUNTED WARFARE

USA ARMOR CENTER How Do We Help? Leader Roles • Recognize problem. • Understand what to do. • Empower leaders and individuals. – destigmatize seeking help. – destigmatize mental health. • Enable soldiers to seek help. – provide time. – educate regarding resources. – mobilize/utilize all community resources. 19 HOME OF MOUNTED WARFARE

USA ARMOR CENTER How Do We Help? Destigmatize Seeking Help • • • Emphasize similarity of mental illness to physical illness. Focus on treatability to encourage self-referral. Use metaphor of “PMCS for soldiers. ” Publicize fact that mental health referrals rarely result in separation. Let soldiers know that, with rare exceptions, they now have privileged communications with counselors. Increase visibility of Chaplains and Mental Health professionals in unit activities. 20 HOME OF MOUNTED WARFARE

USA ARMOR CENTER How Do We Help? Specific Leader Actions • Keep doing what you do best--training, leading, and taking care of soldiers. • Ensure annual suicide prevention training in unit. • Minimize unit stressors within your control--then focus on soldier responses to stress. • Know suicide risk factors and indicators--but don’t rely on them to exclusion of your knowing your soldiers. • Do risk assessment on all soldiers with problems, especially your best soldiers! • Destigmatize seeking help--lead by example! 21 HOME OF MOUNTED WARFARE

USA ARMOR CENTER How Do We Help? Specific Leader Actions • Request Unit Climate and Behavioral Health Surveys. • Request Critical Event Debriefings after traumatic events affecting the unit. • Make sure bad news and adverse actions aren’t given on Fridays or prior to holidays. • Do not condone or minimize alcohol misuse. Refer to ADAPCP. • Refer soldiers to Army Community Service for financial counseling and other vital life skills training. • Emphasize importance of Battle Buddies in suicide prevention. 22 HOME OF MOUNTED WARFARE

USA ARMOR CENTER How Do We Help? General Measures - Do’s • Take all threats, risk factors and indicators seriously. • Take whatever steps are available to help decrease psychological pain often that’s all that’s necessary. • Answer obvious cries for help. • Be a good listener, let the person talk. • Ask questions. • Encourage person to see Chaplain or Mental Health professional. 23 HOME OF MOUNTED WARFARE

USA ARMOR CENTER How Do We Help? General Measures - Questions • • • What do you feel you have to solve or get out of? What would you like to happen? Have you been thinking about harming yourself? How would you harm yourself? What would it take to keep you alive? Have you ever been in a situation like this before, what did you do, how was it resolved? • Have your ever attempted suicide? When? • Why now? 24 HOME OF MOUNTED WARFARE

USA ARMOR CENTER How Do We Help? General Measures - Dont’s • • • Panic. Ignore it or cooperate in hiding it. Act shocked. Debate the morality of suicide. Minimize their problem. Challenge person to do it. 25 HOME OF MOUNTED WARFARE

USA ARMOR CENTER How Do We Help? The Acutely Suicidal Soldier • Stay with soldier. • Remove weapons and dangerous items. • Treat with dignity and respect, restraining only if no other option. • Arrange immediate evaluation by Mental Health professional. 26 HOME OF MOUNTED WARFARE

USA ARMOR CENTER The only thing that will save a human life is a human relationship. HOME OF MOUNTED WARFARE 27

USA ARMOR CENTER Myths About Suicide • People who commit suicide are crazy. • Good circumstances prevent suicide. • People who talk about suicide will not commit suicide. • People who threaten suicide, cut their wrists, or do not succeed with other attempts, are not at risk for suicide (10% will succeed if no changes). HOME OF MOUNTED WARFARE 28

USA ARMOR CENTER Myths About Suicide • Talking about suicide to people who are upset will put the idea into their heads. • People who are deeply depressed do not have the energy to commit suicide. • People often commit suicide without warning. HOME OF MOUNTED WARFARE 29

USA ARMOR CENTER • • • COMMUNITY RESOURCES Behavioral Medicine Clinic 624 -9960 Social Work/Family Advocacy Program 624 -9523 ADAPCP 624 -0321 On Call Chaplain 624 -4481/21 Suicide Prevention Hot Line (24 Hour) 624 -HELP Army Community Service 624 -6291 HOME OF MOUNTED WARFARE 30