1 st SERGEANT’S BRIEFING Airmen in Distress

1. 1st SERGEANT’S BRIEFINGAirmen in Distress Neysa Etienne Clinical Psychologist Maxwell Air Force Base Mental Health Clinic 42nd MDG

2. 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

3. 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

5. 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…

6. “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

7. 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.

8. 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. Discussing suicide openly with someone who seems really depressed does more harm than good. People who attempt suicide once, are unlikely to try it again.

9. FIND A PARTNER • FACE OFF • RELATE • DEBRIEF • WHY? EXPERIENTIAL EXERCISE

10. MIND & MODEL • Theoretical Framework • BIOPSYCHOSOCIAL MODEL • THE SUICIDE MODE (Rudd, 2009) • Predispositions to Suicide • Triggers • Interaction between: • Perceptions (thoughts) • Emotions (feelings) • Behaviors • Physiology

12. 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

13. ADDITIONALRISK • Additional Risk Factors • Older • Caucasian • Isolated • Medical issues • Alcohol use • Depression • Panic attacks

14. 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

15. 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

16. 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)

17. 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

18. 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

19. 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

20. GOAL CONFLICT 1st Sergeant Goals: 1. Keep Airman safe 2. Keep others safe 3. Mission effectiveness 4. Protect unit morale 5. Stay out of trouble Airman’s goals: 1. Reduce distress 2. Reduce pain 3. Alleviate suffering 4. Be understood 5. Stay out of trouble

21. APPROACH CONFLICT 1st Sergeant: Talk with others Increase healthy behaviors Access professional help Distressed Airman: Alleviate the pain Drinking Drugs Reckless behaviors Violence / aggression Suicidal ideation

22. 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”

23. "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."

24. 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…

25. 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

26. 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.

27. 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”

28. 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.”

29. Raising the issue… Make behavioral observations “I’ve noticed…” technique Express concern Avoid judgmental language Stick to the facts

30. 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?”

31. 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?”

32. 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

33. SEEK HELP WHEN… • Persistent stress interfering w/ daily life • Difficulty coping • Difficulty functioning • Accumulating signs of distress • Multiple risk factors • Thoughts about suicide

34. 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

35. IMPORTANT TERMS • Suicide • Suicide Attempt with injury • Suicide Attempt without injury • Instrumental suicide-related behavior • Suicide threat • Suicidal ideation • Morbid ideation

36. Consult • Your suspicions are substantiated • Contact The Mental Health Clinic • When to Contact Them • DOCUMENT Your Interaction

37. 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

38. MH RISK ASSESSMENT • Suicide Status • Informed Consent • Commitment to Treatment • Crisis Response Plan • Suicide Tracking • Stabilization

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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)

46. 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

47. 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.

48. 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

49. TRACKING • Levels: • Stabilization • Back to baseline • Self-management • Mastered and uses skills • Utilization • 1st Sgt’s Role

50. · 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 ROLE OF LEADERSHIP