Support (All Personnel: Buddy Care, Section 1) 6

Lesson Plan Advance Sheet 7

Instructor’s notes 8-12

Screen (All Personnel: Buddy Care, Section 2) 13

Lesson Plan Advance Sheet 14

Instructor’s notes 15-19

Handout 1 20

Spot (Introduction to Gatekeeper training: Buddy Care) 21-22

Gatekeeper Lesson 1 (All personnel, Section 3) 23

Lesson Plan Advance Sheet 23

Instructor’s notes 24-33

Handouts 2-6 34-40

Gatekeeper Lesson 2 (Officers and Non-commissioned Officers)

Lesson Plan Advance Sheet 43

Instructor’s notes 44-49

Handouts 7-8 50-51

Gatekeeper Lesson 3 (Formal Gatekeepers) 41-49

Lesson Plan Advance Sheet 50

Instructor’s notes 51-54

Handout 9 55

Lesson Plan Advance Sheet 56

Instructor’s notes 57-61

Handouts 10-14 62-70

Military and Civilian Suicide Prevention Training Overview 71-77

Critical Incident Stress Debriefing 78-81

References and Resources 82-83

On July 28, 1999, the Surgeon General of the United States, David Satcher, M.D., publicly declared suicide a serious public health threat, launching a national effort entitled a "Call to Action" to develop strategies to prevent suicide and the suffering it causes. This was an historic first, a recognition at the highest levels of government that this country could no longer ignore or deny the significant numbers of Americans who kill and harm themselves each year, and the trauma these events have on surviving loved ones and colleagues.

On average, more than 30,000 Americans die by suicide each year. An unknown and difficult to calculate number of others (some estimate these to be one hundred times as frequent as completions) make nonfatal attempts to suicide, about one-fourth of which require medical and psychological intervention to prevent further suicidal acts and possible death.

Prevention programming is intended to save lives and reduce the impact of self-harm behaviors. The Army Suicide Prevention Program (ASPP) involves the entire military community in a three-tiered approach to achieve the best-coordinated prevention possible. The first level, called primary prevention consists of those command programs designed to anticipate critical junctures in a person's career and make them less stressful. The second level, called secondary prevention includes those command programs of special support and crisis counseling needed when persons encounter times of crisis and may be helped by a caring professional. The third level is called tertiary prevention. When someone needs immediate care for a potentially life threatening crisis, they require care by a mental health professional.

The first aim of the Army Suicide Prevention Program (ASPP) is to prevent individuals from reaching the point where suicide is seriously contemplated. If these first efforts fail then the aim becomes one of early intervention. The ASPP strategy consists of support, screen, spot, and secure, as depicted in table 1. The goals of the support and screen components are primary prevention, that is, to identify and build internal or personal characteristics, and to build and increase awareness of and access to external support systems that can sustain individuals in times of distress. The spot component is secondary prevention and involves increasing the awareness of suicide and risk factors for suicidal behaviors among all levels of personnel and improving the recognition and assessment of suicide risk by military caregivers. The secure component is tertiary prevention, providing guidelines for health care professionals to effectively assess for treatment those believed to be at risk.

Regardless of the level of available support, some individuals will become suicidal, usually due to disorders such as depression, alcohol abuse, and anxiety, or their particular response to stressors. Screen represents another primary prevention technique that attempts to identify individuals who have personal or situational factors that carry increased risk of suicide. Initial screening of recruits at the Military Entrance Processing Service (MEPS) Station can identify suicidal thoughts or previous attempts. Personnel who are currently or chronically suicidal may be denied entrance into the military. Annual well-being screening and subsequent periodic screening, particularly before deployments and during transitions, can identify troubled or at-risk individuals.

Increased risk for suicide may arise in vulnerable individuals for a variety of reasons that will be discussed as risk and precipitating factors. Therefore, the next line of defense is alert and informed personnel who can spot an at-risk individual. This is called secondary suicide prevention because it involves identifying at-risk personnel.

In order to prepare all service members to spot and provide a supportive response for at-risk individuals, Gatekeeper Training must be widely disseminated. Different levels of knowledge and skills are required of individuals ranging from fellow soldiers to mental health professionals as will be described in the spot or gatekeeper section. All service members, including all new service members, should at least know how to refer troubled or at-risk individuals.

Once at-risk individuals have been spotted, there must be clear policies and procedures and accessible, coordinated resources to secure adequate help that will assess, manage, and intervene with suicidal individuals. This is tertiary suicide prevention because it involves assessment for treatment of suicidal behavior.

Each of these approaches will be addressed in detail in the sections that follow this general introduction. They are presented separately for training purposes, but they are interrelated and complementary. For example, familiarity with policies and procedures by all military personnel facilitates their responding to and obtaining help for troubled individuals in a timely and efficient manner. When individuals know what resources are available, how to access them, and how they will respond, this provides part of the structure that is a key element of the support that can prevent suicidal behavior. Also, as previously noted, the Army Structure provides an overarching framework for all suicide prevention efforts.

This manual provides guidelines for promoting protective factors and screening for individual well-being within the context of Army leadership and structure. The aim here is to prevent individuals from reaching the point where suicide is seriously contemplated. In addition, the manual provides lessons and materials that help to prepare Army personnel to respond to, assess, and obtain help for individuals who appear to be troubled, show warning signs for being at risk for suicide, or are making overt suicide threats or attempts.

Every Installation or Community Commander will establish and chair a Suicide Prevention Standing Committee (SPSC). The SPSC is responsible for integrating and coordinating community helping agencies. It administers the program by overseeing training, reporting and maintaining data, and conducting psychological autopsies when there is a confirmed or suspected suicide. The SPSC reports to the Major Command (MACOM) Suicide Prevention Program Manager.

As in other walks of life, there are stressful aspects to Army life. However, in contrast to much of civilian life, the Army provides an overarching structure that can serve as a protective factor. That is, the Army Structure, consisting of Army leadership and a wide array of helping services and programs can serve as an enabling framework within which all aspects of suicide prevention in this manual can take place.

When a soldier, family member or Department of Defense civilian encounters an event that affects their day-to-day well-being, the Army helping agencies may help them through their difficult times. However, Army programs and services are only beneficial when they are available and can be readily accessed when needed. It is the duty of leaders throughout the chain of command to ensure that these programs are well publicized and available. They must afford personnel who encounter troubled times every opportunity to participate in these programs and services.

Primary and secondary suicide prevention programs are often more cost effective, and usually return an individual to a more normal lifestyle more quickly and effectively than tertiary treatment programs. The supportive structure of the Army facilitates primary prevention in ways that other aspects of our society cannot.

This training session provides a framework for Army leadership to carry out its responsibility to promote protective factors and provides information about available helping resources.

Time: 20 minutes

Target Audience: All Army personnel from top commanders to privates. The material in this lesson should be disseminated through the "cascade training" approach. The appropriate and efficient step-down procedure would be developed by the MACOM and passed down through channels to the lowest level of command. The guiding principles would be to convey that a) this message comes from the top commanders of the Army, b) this process is considered critical, c) leaders will be held accountable for the safety of all personnel in regard to the prevention of suicide, and d) leaders will promote a culture in which everyone feels appropriate responsibility for the safety and support of all personnel.

Mission Statement: The Army Suicide Prevention Program is based on trained and ready personnel at all levels. The mission of all personnel is to encourage help-seeking behaviors and to attain proficiency in the Buddy Care principles in this training module (OH 1).

The Levels of Training: The levels of training are based on the level of gatekeeper responsibility (OH 2). A Gatekeeper is a concerned person who is in the position to render "first aid." The levels are peers (Buddies) Officers & NCOs, Installation Gatekeepers (helping personnel such as chaplains or health care givers) and Mental Health Care Providers.

Task: Understand the Army Suicide Prevention Program (ASPP) structure and promote cohesion and mutual support among all personnel.

Participants will be able to:

1. Describe primary, secondary and tertiary suicide prevention
2. Identify personal and environmental protective factors.
3. Know about support resources and programs.
4. Promote cohesion and a sense of belonging.
5. Encourage help seeking behavior.

None

Conference: OH = Overhead, HO = Handout

Instructor Note: Keep in mind that the introduction of a very sensitive topic requires an equally sensitive approach. You must assume that the class will include people who have been touched by a suicide, and some class members who have seriously contemplated or attempted suicide. Care must be given in discussing this topic. Also, you will seek to motivate members of the unit to become concerned for the well-being of friends and neighbors. Another task for the instructor is to encourage an attitude of hope and renewal.

Instructor Note: When a question is asked, take time to field answers from the class before proceeding.

The Army Suicide Prevention Program consists of three stages or tiers of prevention initiatives. The first level is the foundation on which the entire structure rests. This is called primary suicide prevention and it incorporates all personnel (Buddies) cooperating in a command directed community-wide effort to eliminate feelings of helplessness and hopelessness before they begin. Community programs and supportive counseling by chaplains, social workers and other professionals reduce incidents of suicidal thought and behavior by pre-empting potential crises. Secondary suicide prevention takes place when someone identifies a potentially suicidal person and knows how to respond in helpful ways. Again, professional counselors assist in providing supportive counseling and personal, face-to-face risk assessment for potentially suicidal personnel. Tertiary suicide prevention takes place when an individual is actively suicidal and must undergo professional psychiatric treatment to return to their previous healthy lifestyle.

• Primary prevention: anticipating potential times of crisis and structuring pre-emptive support systems
• Secondary prevention: recognizing the obvious signs and symptoms of distress/crisis and potential emotional/mental disorder while providing caring support and needed interventions.
• Tertiary prevention: Recognizing and treating psychiatric disorders that result in acute suicidal behaviors.

At the foundation level, all personnel cooperate with the Commander's program of community support. The second stage employs caring professionals to screen for personnel who are encountering distress. These are primary suicide prevention efforts. Next comes gatekeeper training which enables all personnel to spot those who are exhibiting signs of self-destructive behavior. Then, formal gatekeepers (chaplains, other professional counselors) are trained to individually screen at-risk personnel for further mental health assessment. Finally, mental health professionals are trained in policies and procedures to secure and treat actively suicidal personnel.

• Support
• Screen
• Spot
• Secure

Ultimately the prevention of suicide will best be accomplished by enhancing supports and strengths. Not all risks can be identified or reliably associated with suicide in individual cases. Nor can all stresses be avoided. Research is beginning to identify resilience or protective factors that can moderate the impact of stress or psychological dysfunction. The presence of these factors can prevent a variety of ineffective behaviors including violence, substance abuse, and suicide, even in the presence of stressful events or environments.

There are two categories of protective factors: personal protective factors and environmental protective factors.

• Easy temperament.
• Previous experience with self-mastery, problem solving, crisis resolution.
• Optimistic outlook.
• Social/emotional competence.
• High self esteem, self worth.
• Decision-making, problem solving skills.
• Sense of personal control, self-efficacy.
• Sense of belonging to a group and/or organization.
• High and realistic expectations.
• High spiritual resiliency.

• Strong family relationships.
• Models of healthy coping.
• Encouragement of participation.
• Opportunities to make significant contributions.
• Available social supports.
• Available helping resources.
• Healthy Spiritual/religious affiliation.
• Cultural and religious beliefs against suicide and in support of self-preservation.

Marsha Linehan, a prominent researcher in suicidology, developed a 48-item scale, the Reasons for Living Inventory, (OH 8) which differentiates suicidal from nonsuicidal individuals. As such, the items represent categories of protective factors that may moderate

suicidality during stressful situations. The inventory categories are Survival & Coping Beliefs (e.g., "I believe I can find other solutions to my problems"); Responsibility to Family; Child-Related Concerns; Fear of Suicide; Fear of Social Disapproval; Moral Objections. When assessing for suicidal feelings one should also assess reasons for living. See pg. 69 for reference to this scale.

Spiritual resiliency is another important aspect that strengthens one's resolve to live. Jarred Kass, Ph.D., LMHC and his wife Lynn Kass, M.A., M.A.T., LMHC developed the Spirituality and Resilience Assessment Packet to help people strengthen their inner resources. The packet inventories the strength of the person's positive worldview and their sense of connection with the spirit of life. The presence of a resilient worldview is empowering. It helps people mobilize their energies, relax their body and mind, think for themselves and trust in others and in life itself. This spiritual connectedness, characterized by confidence in life and self offers hope, a key protective factor. See page 69 for references to this scale.

During World War II, Army personnel made significant contributions to the development of the field of crisis intervention and the promotion of effective coping. Among these were the discovery that, more than personal characteristics, an individual’s sense of belonging and integration into his/her particular unit influenced how he (she) would stand up to the stresses of combat. Thus, promoting cohesion and being alert for withdrawal or isolation are important strategies for the prevention of suicide and other destructive behaviors. Whether we are addressing deaths by combat or suicide, the same principle applies: connections save lives (OH 9).

Of course, the development and promotion of many of these personal and environmental protective factors can be recognized as essential elements of effective leadership. Moreover, the goal of Army training is to develop many of these skills and characteristics in order to promote effective functioning under stressful conditions.

(Instructor note) The extent to which these characteristics are selected for or developed is a military decision. There are measures that assess many of these characteristics, such as the BarOn Emotional Quotient Inventory (Eq-I), which is described at the end of this section on Structure.

Army leadership, assisted by a network of helping agencies constitutes primary suicide prevention through effective external supports. The Consideration of Others Program fosters a caring atmosphere for workers to support one another within their work group. Functions performed by the Army Community Services and the Army Chaplaincy provide support during times of transitional stress. Combat Stress Control Teams, Family Support Groups, Community Counseling Centers, Family Life Centers, the Family Advocacy Program, Army Emergency Relief, the Exceptional Family Member Program, and Community Mental Health, provide support in special need situations. Child Development Centers and Morale Welfare and Recreation programs provide relational services for single soldiers as well as family members. Chapel programs offer spiritual, religious and relational support to soldiers and family members. Medical Treatment Facilities, Dental Clinics and Community Health Nurses provide medical support. Reenlistment Counselors, Education Centers and leaders at all levels should assist soldiers to achieve their full potential within the Army system. (Trainer should obtain handouts that contain information about local resources).

From primary through tertiary prevention, the Army Structure affords a network of multidisciplinary agencies and caregivers unequaled in civilian life. It is extremely important for leaders to be aware of and readily share information about the array of programs and services available in the Army.

In addition, it is important to ensure that services are temporally, culturally, and psychologically accessible to troubled individuals. Suicidal thought and behavior is often a symptom of a very treatable mental and/or spiritual illness. However, seeking help for such concerns is often very difficult, particularly for males. The Army leadership must systematically destigmatize mental illness and help-seeking behavior in response to stress, mental illness, and suicidal feelings by modeling and promoting seeking help as a sign of effectively dealing with problems, and of strength rather than weakness (OH 10). The remainder of this training focuses on preparing peers, leaders, and mental health professionals to respond effectively to at-risk individuals. Without systematic efforts to reduce the stigma of turning to them for help, their expertise and preparation may be wasted.

The role of Army leadership in suicide prevention cannot be overemphasized. This strong leadership is the advantage that the military structure affords, and is the reason why protective factors can be more effectively promoted and sustained in the military than in civilian settings. Ever since the first military system was devised, a prominent characteristic of an effective leader has been the ability to protect those under his/her command. A good leader does not expose those under his/her command to unnecessary risk (OH 11). This applies to death by suicide just like it does to other senseless injury or death. Thus, it is the responsibility of Army leadership from the top commander down to platoon and squad leaders to promote the safety of all military personnel. This can be done in the following ways: (OH 12 a-e)

• Promote a norm of mutual "Buddy Care" among all military personnel: "We are our brother’s keepers!"

• Pay attention to warning signs and respond to those who need help. If anyone suspects or knows that a fellow soldier, family member, or anyone else is troubled, provide or get help for them.

• Be aware that heightened stress, relationship problems, and impending holidays can trigger inappropriate coping behaviors in vulnerable individuals. Pay close attention to the personal needs of your people, and be on the lookout for signs of stress.

• Communicate in your words and actions that it is not only acceptable, but a sign of strength, to recognize life problems and get help to deal with them constructively.

• Support and protect to the fullest extent possible those courageous people who seek help early, before a crisis develops.

• Create a responsive, caring, and responsible environment where individuals are motivated to seek help with personal struggles without fear of being singled out.

• Create and promote opportunities for social interactions that are important in defining a unit’s supportive structure. These range from group and battalion/squadron events to private gatherings. Make sure that you foster a social climate in your unit that communicates to everyone, ‘you belong here’.

Efforts to foster a supportive environment and to destigmatize help-seeking may be the most potent form of suicide prevention currently available. However, they take time to develop and cannot be 100% effective in preventing suicidal behavior. Therefore, it is important that the Army has the capability to screen and identify those at-risk for suicide. This is addressed in the next training sessions.

Screening for suicidal ideation (the thoughts and constructs that people who are feeling helpless and hopeless often have) can be harmful if not administered by professionals who are trained to respond to a person who admits suicidal thoughts or intent. Additionally, suicide scales have proved less than successful when used with groups who are not accessible to the screener for more evaluation. Because of these difficulties, screening has not been used successfully in the civilian realm. The military, however, do to its unique structure and support base, is well equipped to effectively screen its personnel for well-being. The Army has caring professionals to administer screening questionnaires and has access to the personnel for future follow-up. Never-the-less, screening that asks questions regarding current suicidal thoughts and past attempts may stigmatize the respondent and hinder subsequent screening and help-seeking behavior. Therefore, the screening presented in this section is gated, that is to say, it does not begin with suicidal ideation, but with well-being. If personnel self-report difficulties in their perceived level of well-being, then subsequent screening is indicated.

Formal gatekeepers may wish to purchase and use one or more of the secondary screening instruments included in this manual. These tools may prove very helpful for the counseling process. However, they are never a substitute for face-to-face interviews using the screening questions provided in the "formal gatekeeper" section of this manual (see pages 50-55).

This section is a brief overview of the possibilities for well-being screening that exist in the Army. Screening procedures are a matter for consideration by the MACOM, Installation and Unit Commanders. This manual presents a review of available resources.

Time: 10 minutes

Target Audience: All Army personnel from top command to privates. Screening by caring professionals for well-being can enhance early detection and lowest level intervention by community counseling professionals to support and assist personnel in times of distress.

Task: Be knowledgeable of and willing to participate in general well-being screening.

Participants will be able to:

1. Understand the benefits of gated screening.
2. Be informed about confidentiality of screening results.
3. Be informed of secondary screening instruments.

None

Conference

*OH = Overhead

HO = Handout

Instructor Note: Keep in mind that the introduction of a very sensitive topic requires an equally sensitive approach. You must assume that the class will include people who have been touched by a suicide, and some class members who have seriously contemplated or attempted suicide. Care must be given in discussing this topic. Also, you will seek to motivate members of the unit to become concerned for the well-being of friends and neighbors. Another task for the instructor is to encourage an attitude of hope and renewal.

Instructor Note: When a question is asked, take time to field answers from the class before proceeding.

The Army structure offers an opportune atmosphere for screening that exists nowhere in the civilian realm. Because the military is a rather closed society, access to personnel is much less limited and therefore, screening for well-being and subsequently for suicidal ideation is a much more viable option.

• The Army structure makes screening viable.
• Screening must be gated.
• The Suicide Prevention Standing Committee (SPSC) collects and reports anonymous data.

The philosophy behind gated screening (screening which begins at a broad level for personal well-being and steps up in levels of specificity) is to afford treatment to the individual at the first sign of distress and save them from multiplied problems stemming from lack of early intervention. Gated screening begins with the small unit. Well-being screening can tell the screener the relative level of well-being of individuals within the unit as well as reveal trends of felt well-being to the commander. The Goldberg Well-being Scale should be offered to the individual as a tool to assess his or her personal well-being. It gives permission to the individual to self refer if they identify areas of distress in their lives. The individual may be asked to provide an anonymous number score from unit level screening for the SPSC to provide a database large enough to insure anonymity for the small unit and protect the accurate flow of information to the database.

This screening does not mention the word "suicide" and is meant to bring those who feel distressed to self-refer to the screener who then screens them further and/or refers them to the appropriate secondary level counselor for further screening and counseling as appropriate. The secondary level counselor can choose to use a more in-depth screening tool or, if time and resources permit, personally screen the individual with the questions printed in this manual in the "gatekeeper" section.

The instruments that follow are resources for the screener to use. The first instrument is included in its entirety and can be used to screen small units for well-being. This instrument is a primary or first level tool. The other three instruments are optional for more intensive follow-up screening and must be locally purchased if used.

David P. Goldberg, M.A., D.M., M.R.C.P. (London & Edinburgh), D.P.M.

Purpose: Monitor Personal Well-being

Administration: Individual or group

Time: 2-5 minutes

The Goldberg Well-being Scale consists of twelve questions, the best of 140 questions from the General Health Questionnaire (GHQ). This tool can be invaluable to the commander to enhance the quality of life in the command and secure early intervention for at-risk personnel for behavioral health problems

The Goldberg Well-being Scale asks questions which will alert counselors at the secondary prevention level (e.g., Social Workers, Family Life Chaplains, as well as unit level chaplains, ACS counselors, Family Advocacy and Community Counseling Center counselors.) They will then be able to address the well-being needs of soldiers, family members and civilians. Well-being screening can help reduce stress and puts counselors in position to further screen personnel for suicidal/homicidal and abusive behaviors/ideation. Early intervention through well-being screening and treatment at a secondary or crisis intervention level reduces the demand for tertiary or professional psychiatric level intervention and treatment.

The Goldberg Scale does not ask direct suicide questions but asks questions that indicate the perceived changes in well-being the respondent feels. The higher the score, the more stable the respondent feels regarding his/her general well-being.

This method of screening at a lower level can reduce false positives at the tertiary or treatment level, thus enhancing counseling at the secondary level and reducing the screening duties of mental health professionals. The use of this low-level screening device allows Community Mental Health to concentrate more on treating those who need high-level interventions.

Goldberg’s instrument is scored by assigning a zero value to the first two responses of "Not at all" and No more than usual" and a value of one to the second two responses of "Rather more than usual" and "Much more than usual," thus making the scale appear to be a Likert Scale, but in reality, a "Yes" or "No" scale. This method of scoring is the author’s method and is named GHQ after the name of the 140-question instrument. The GHQ method is very simple to do, requiring only simple addition and is statistically as accurate as a Likert scale method of scoring.

A secondary prevention level counselor should administer the instrument annually at the small unit level. It will screen the command for any soldier who needs supportive and/or crisis counseling for personal, family and job related situations that may be causing excessive strain on the soldier and unit. Additionally, the instrument can be used prior to deployment and other high-stress events to reduce the incidence of Operational Stress Reactions. (OH 4).

A follow-on screening for those personnel who show a low level of well-being from the Goldberg Scale can give a more comprehensive picture. Standardized instruments are available such as the Multidimensional Health Profile (MHP), which contains a Psychosocial Functioning subscale that covers life stress, coping skills, social resources, and mental health. Following is a description of this scale from the website of Psychological Assessment Resources (www.parinc.com), Inc., as well as a description of another standardized scale available from PAR, Inc., the Life Stressors and Social Resources Inventory.

Linda S. Ruehlman, PhD, Richard I. Lanyon, PhD, Paul Karoly, PhD, and PAR

Staff

Purpose: Assess psychosocial and health risks in primary health care settings

For: Ages 18 to 90 years

Administration: Self-administered; individual or groups

Time: Approximately 15 minutes for each booklet

The MHP is a comprehensive screening instrument designed for general use in

health-related settings:

• Detects areas of clinical concern and targets areas for follow-up evaluation.
• Developed and standardized for use with individuals ages 18 years and older.
• Consists of two 4-page carbonless, hand-scorable test booklets for use together or separately.

This is the first instrument to provide comprehensive information about psychosocial and health functioning. National representative norms based on a sample of 2,411 participants are available by gender for three age groups (18-32 years, 33-50 years, and 51-90 years).

The MHP materials consist of a Professional Manual and two test booklets written at a fourth-grade reading level:

• The MHP-Psychosocial Functioning (MHP-P) booklet contains 58 items that cover four major areas of concern: life stress, coping skills, social resources, and mental health.
• The MHP-Health Functioning (MHP-H) booklet consists of 69 items that provide information in five major areas of concern: response to illness, health habits, adult health history, health care utilization, and health beliefs and attitudes.

Once the respondent has completed the booklet, the health professional peels back the top page to reveal the scoring page. Scale scores are plotted on the profile grid provided in the booklet. The scores are used to interpret the respondent's level of psychosocial and health functioning.

The MHP Professional Manual provides information on the development of the instrument; guidelines for administration, scoring, and interpretation; normative data; and data bearing on the reliability and validity of the scales.

Qualification Level: B

WW-3994-KT MHP Introductory Kit (includes MHP Professional Manual, 25 MHP-P Test Booklets and 25 MHP-H Test Booklets).

Rudolf H. Moos, PhD

Purpose: Monitor ongoing life stressors and social resources

Administration: Individual or group

Time: 30-60 minutes

The LISRES provides a unified framework to measure ongoing life stressors and social resources and their changes over time. Integrating these 2 domains in 1 assessment tool provides a comprehensive picture of an individual's overall life context. This inventory identifies the level of current stressors and their sources as well as the available social resources.

The LISRES-A may be used with healthy adults, psychiatric, substance abuse, or medical patients:

• It covers 8 major areas of life experience: Physical Health, Spouse/Partner, Finances, Work, Home/Neighborhood, Children, Friends & Social Activities, and Extended Family.
• The LISRES can be administered and scored by those with no formal training in clinical or counseling psychology.

The respondent answers the 200 (LISRES-A) items contained in the 8-page reusable item booklet. Responses are marked on the 2-part carbonless answer/profile form.

Qualification Level: B

WVV-2806-KT LISRES-A Introductory Kit (includes Manual, 10 Reusable Item Booklets, and 25 Hand-Scorable Answer/Profile Forms).

Based on seventeen years of research by Dr. Reuven BarOn and tested on over 19,000 individuals worldwide, the BarOn Emotional Quotient Inventory is designed to measure a number of constructs related to emotional intelligence. A growing body of research suggests that emotional intelligence is a better predictor of "success" than the more traditional measures of cognitive intelligence (IQ).

The BarOn EQi consists of 133 items and takes approximately 30 minutes to complete. It gives an overall EQ score as well as scores for the following subscales:

These areas of emotional intelligence are measured with the aid of 4 validity indices and a correction factor.

Available from: MHS Organizational Effectiveness Group, 908 Niagara Falls Blvd. North Tonawanda, NY 14120, 1-800-456-3003.

Question Number: Top Box Only

Question Number: Bottom Box Only

My Answer: No Responses: ___

The goal of this prevention approach is to increase the chance that at-risk individuals will receive help before they engage in self-destructive behavior by enhancing the knowledge and responsiveness of everyone with whom at-risk individuals come in contact.

Everyone does not share the same level of responsibility, thus the knowledge, attitudes, and behaviors necessary for taking appropriate action at different levels are depicted in Table 2, page 22. At the first level, all personnel can report through the chain of command individuals they suspect as being at risk for suicide. Those at each successive level thereafter must know the procedure for reporting at-risk individuals, must be able to recognize these individuals, and know exactly where to take them for help.

Gatekeeper level I (Buddy Care) applies to all service personnel. Everyone should be prepared to more readily identify or spot suicidal individuals through knowledge of warning signs, common precipitants, and symptoms of depression. They should also be familiar with the myths about suicide that prevent taking appropriate action.

Gatekeeper level II or leaders to whom soldiers may come or refer others to for help must be able to inquire about suicide, and obtain formal help for at-risk individuals.

Gatekeeper level III or Formal Gatekeepers should be able to conduct a basic risk assessment and decide whether to refer to psychological/medical personnel.

Personnel at Gatekeeper level IV must be able to conduct risk assessment screening and provide treatment to resolve the suicidal crisis.

The next sections provide lessons to prepare individuals to spot, respond to, and obtain help for at-risk individuals. Referral sources and policies and procedures are covered in a subsequent section of this manual. The Office of the Chief of Chaplains offers train-the-trainer sessions at the Menninger Clinic, Topeka Kansas. There are also established, comprehensive, gatekeeper training programs that the Army can contract or bring in. Overviews and information about these programs, The Menninger Clinic, LivingWorks, and QPR, are located at the end of the Gatekeeper Training section.

Time: 30 minutes

Target Audience: All personnel (OH 1) *

Task: Assist in identifying a suicidal service member and to take appropriate action, and make proper referrals. Encourage positive action.

Participants will be able to:

1. Understand the Suicide Model.

2. Answer general questions about suicide.

3. Identify common precipitants of suicide.

4. Identify symptoms of depression.

5. Identify myths about suicide.

6. Identify warning signs of suicide.

7. Take appropriate action in response to at-risk individuals.

None

Conference

*OH = Overhead

HO = Handout

Instructor Note: Keep in mind that the introduction of a very sensitive topic requires an equally sensitive approach. You must assume that the class will include people who have been touched by a suicide, and some class members who have seriously contemplated or attempted suicide. Care must be given in discussing this topic. Also, you will seek to motivate members of the unit to become concerned for the well-being of friends and neighbors. Another task for the instructor is to encourage an attitude of hope and renewal.

Instructor Note: When a question is asked, take time to field answers from the class before proceeding.

During this block of instruction, we will address the following areas:

• The Suicide Model.
• What is suicide?
• Why should we know about suicide?
• Why do people commit suicide?
• Some stressful situations that can trigger suicidal feelings in the Army.
• Who commits suicide?
• Special problems that can cause suicidal feelings.
• Misconceptions about suicide.
• How can you tell if someone is thinking about committing suicide?
• Common symptoms of depression and hopelessness.
• Referral Procedures.

Suicide is not a pleasant topic. It is the denial of a human being's basic need: self-preservation and contradicts the evaluation of human life that is implicit in our democratic and social ethics. It strikes at the heart of our underlying moral and ethical principles.

People generally feel a certain fear, hostility and revulsion when they think of suicide. Those who end their lives may be thought of as terribly abnormal or deranged. We are conditioned to see suicide as more shocking, more revolting, and more unacceptable than any other cause of death.

One consequence of these reactions is the tendency to ignore suicide threats and behaviors, assuming that the person is "merely trying to manipulate the system." Most suicidal people in the military convey the message that the solution to their problems is to get out of the service. So making a suicidal threat sometimes appears to be a way to manipulate the system and get out of the military. However, it is very difficult to discern whether such a threat is a manipulative statement or a statement of intent. Certain people might label a suicidal person "lazy"; even more specifically, a segment of people might interpret suicidal behavior as violating the soldier’s mission to serve as a warrior. One military view espouses solitary courage in the face of the enemy above all else, even when the enemy is within us.

The helping person must bear in mind that even if the suicidal communication is a manipulation, it may be the last resort in a series of efforts to find a way out of the emotional pain the person has been experiencing.

It becomes absolutely necessary for the helping person to look beyond the possibility of manipulation and try to gain an understanding of the person's struggle to control his circumstances.

In order to understand the responsibilities of a gatekeeper (a concerned person who is in the position to spot suicidal behavior and render "first aid"), a basic orientation to suicidal progression is essential. The previous lesson covered the primary suicide prevention aspects of structure and screen. When Prevention efforts fail to inhibit self-destructive thoughts and behavior, then the gatekeepers' role intensifies. The Army Suicide Model follows the DOD model developed by Dr. David Shaffer of Columbia University. This model helps us understand the progression of suicidal behavior and the critical points of intervention. The sequence of events in this model may progress very rapidly because suicide is often an impulsive act. Any stress event, however small, may "trigger" a mood change resulting in an emotional crisis. This "unable to cope" stage is a critical intervention point. Gatekeeper intervention, community support and the denial of access to a method of suicide are key to avoiding death by suicide. If a gatekeeper can spot the critical mood change and intervene, a mental health care professional can secure the individual and a life will be saved. The following general questions and answers about suicide will help in identifying those critical intervention points.

1. WHAT IS SUICIDE?

We could say that it is the deliberate ending of one's own life. Suicidal behavior includes (OH 5):

• Serious suicidal thoughts or threats.
• Self destructive acts
• Attempts to harm, but not kill oneself.
• Attempts to commit suicide.
• Completed suicide.

2. WHY SHOULD WE KNOW ABOUT SUICIDE?

Anyone may be in a position to stop a person who is considering suicide. Most suicides and suicide attempts are reactions to intense feelings of loneliness, worthlessness, helplessness, and depression. People who threaten or attempt suicide are often trying to express these feelings to communicate and ask for help.

With the help that is available to people who experience these feelings, many suicide attempts can be prevented.

3. WHY DO PEOPLE COMMIT SUICIDE?

Why do people kill themselves? Psychological pain is a basic ingredient of suicide. Suicide is seldom a result of joy or happiness. Rather, negative emotions lead to suicide. Suicidal death, in other words, can often be thought of as an escape from pain.

Psychological pain is the hurt or ache that takes hold in the mind; the pain of excessively felt shame, guilt, fear, anxiety, loneliness, and the pain of growing old or dying badly.

To understand suicide, we must understand suffering and psychological pain. People who complete suicide feel driven to it. They feel that suicide is the only option left.

The primary source of severe psychological pain is frustrated psychological needs. The need to succeed, to achieve, to affiliate, to avoid harm, to be loved and be appreciated; to understand what is going on.

When an individual completes suicide, he or she is often trying to blot out psychological pain that comes from defeated or frustrated psychological needs "vital" to that person. For practical purposes, most suicides tend to fall into one of four categories of thwarted psychological needs. They reflect different kinds of psychological pain, such as defeated love experiences, acceptance and belonging (OH 6a, b).

• Lack of control related to the needs for achievement, order and understanding.
• Problems with self-image related to frustrated needs for affiliation.
• Problems with key relationships related to grief and loss in life.
• Excessive anger, rage, and hostility.

4. WHAT ARE SOME STRESSFUL SITUATIONS (PRECIPITANTS) THAT CAN TRIGGER SUICIDAL BEHAVIOR IN THE MILITARY? (HO 2, page 34)

Certain events have been found to precipitate suicide in vulnerable individuals. These are not causes of suicide. Rather, they are events that occur just before an attempt or completion of suicide. Like straws that break the camel’s back, they are stresses that push someone who is already vulnerable due to a psychiatric condition, personal coping style, or accumulation of stressful events to take self-destructive action. These include:

• A bad evaluation for an enlisted soldier or officer
• The break up of a close relationship.
• Drug or alcohol abuse.
• Renewal of bonding with family on return from long field training or an isolated tour.
• Leaving old friends.
• Being alone with concerns about self and family.
• Financial stressors.
• New military assignments.

• Recent interpersonal losses.
• Loss of self-esteem/status.
• Humiliation.
• Rejection (e.g., job, promotion, boy/girlfriend).
• Disciplinary or legal difficulty.
• Suicide of a friend or family member.
• Discharge from treatment or from service.
• Retirement.

Depression and Hopelessness

Depression may be caused by personal loss, heredity or body chemistry. For the depressed, hopeless person, life may seem unbearable and the person loses interest in all activities and withdraws. Depressed people see things in a very negative way and have a difficult time generating effective ways of dealing with problems. Hopelessness is a spiritual/relational issue. It stems from feeling disconnected from God and/or others. This manual addresses support from others under the section entitled Support. The connection people have with a higher power or God is spiritual in nature and provides a key link in their ability to withstand grief and loss. The presence of faith in an individual creates a resilient worldview and may enable that person to rebound from the most severe disappointments of life. Spirituality may or may not be religious in nature. The key issue is whether or not that spirituality is heartfelt or intrinsic in nature. Religious or spiritual affiliation/ideation without heartfelt experience offers little to personal resiliency, and may even add to the feelings of hopelessness. On the other hand, when spiritually connected, one may relinquish control to a power beyond themselves, bringing perspective and stability to otherwise overwhelming circumstances. There is a close relationship between depression, hopelessness, and suicide, so lets take a look at some of the symptoms of hopelessness and depression.

5. WHAT ARE COMMON SYMPTOMS OF HOPELESSNESS AND DEPRESSION

(HO 3, page 35)

Hopelessness:

1. Believing all resources to be exhausted.

2. Feeling that no one cares.

3. Believing the world would be better off without you.

4. Total loss of control over self and others.

5. Believing death to be the only way out of the pain.

Depression:

1. Difficulty concentrating or remembering. Decreased attention, concentration or ability to think clearly such as indecisiveness.

2. Loss of interest in or enjoyment of usually pleasurable activities.

3. Loss of energy, or chronic fatigue, slow speech and muscle movement.

4. Decreased effectiveness or productivity.

5. Feelings of inadequacy or worthlessness, loss of self-esteem.

6. Change in sleep habits-- the inability to sleep or the desire to sleep all the time.

7. Pessimistic attitude about the future--negative thinking about the past.

8. The inability to respond with apparent pleasure to praise or reward.

9. Tearfulness or crying.

10. Change in weight-- poor appetite with weight loss or weight gain.

11. Recurrent thoughts of death or suicide.

12. Decreased sex drive.

13. Anxiety

6. WHO COMMITS SUICIDE?

More people die from suicide than from homicide in the United States. In 1997, 30,535 Americans took their own lives. In contrast, 19,491 were homicide victims. On average, 84 Americans commit suicide each day, and there have been more suicides than homicides each year since 1950. In 1997, suicide was the eighth leading cause of death in this country. It was the fourth leading cause of death among 25- to 44-year-olds.

Suicide is a serious problem among young people. Between 1980 and 1997, the rate of suicide increased 109% for 10- to 14-year-olds and 11% for 15- to 19-year-olds. Suicide was the third leading cause of death for 15- to 24-year-olds in 1997. That same year, a nationwide survey of high school students found that in the previous year, one-fifth had seriously considered suicide and 1 in 13 had attempted it.

Most suicides are males. In 1997, males accounted for 80% of all suicides in the United States. Among 15- to 19-year-olds, boys were five times as likely as girls to commit suicide; among 20- to 24-year-olds, males were seven times as likely to commit suicide as females. Although more females attempt suicide than males, males are at least four times as likely to die from suicide.

Anyone, at any age, can complete suicide. Recent studies reveal that the suicides in the U.S. Army follow a bi-modal pattern. The first increase is in the 20 – 29 age group. These tend to be impulsive acts stemming from substance abuse, relationship and financial problems, and UCMJ actions. The second group is the 40 – 49 age category. These suicides often stem from relationship failures, substance abuse and mood disorders. (OH 7).

One interesting study shows that the number of U.S. Army Reserve Component and Army National Guard suicides doubled from 1998 to 1999. (OH 8)

It is important to know relevant myths and facts about suicide because these can influence people’s attitudes toward suicidal individuals and toward taking action on their behalf. Specifically, many myths contain rationalizations that can prevent people from taking action when they suspect or are confronted by someone who is at risk for suicidal behavior.

MYTH: Most suicides occur with little or no warning.

Rationalization: If you can't see suicide coming, there's nothing anybody can do.

FACT: Most people communicate warning signs of how they are reacting to or feeling about the events that are drawing them toward suicide. These warning signs--or invitations for others to offer help--come in the form of direct statements, physical signs, emotional reactions, or behavioral cues. They telegraph the possibility that suicide might be considered as a means to escape pain, relieve tension, maintain control, or cope with a loss.

______________________________________________________________________________

MYTH: You shouldn't talk about suicide with someone who you think might be at risk because you may give that person the idea.

Rationalization: It is best just to avoid it altogether.

FACT: Talking about suicide does not create nor increase risk. It reduces the risk. The best way to identify the intention of suicide is to ask directly. Open talk and genuine concern about someone's thoughts of suicide is a source of relief and often one of the key elements in preventing the immediate danger of suicide. Avoiding the subject of suicide can actually contribute to suicide. Avoidance leaves the person at risk feeling more alone and perhaps with even less energy to risk finding someone else to be helpful.

______________________________________________________________________________

MYTH: People who talk about suicide don't do it.

Rationalization: There is no need to get involved with people who talk about suicide.

FACT: People who attempt suicide usually talk about their intentions, directly or indirectly, before they act. Four out of five people who commit suicide talk about it in some way with another person before they die. Failing to take this talk seriously is suspected of being a contributing cause in many deaths by suicide.

MYTH: Non-fatal acts are only attention-getting behaviors.

Rationalization: These behaviors can either be ignored or punished.

FACT: For some people, suicidal behaviors or "gestures" are serious invitations to others to help them live. If help is not forthcoming, there is an all too easy transition between a desperate invitation to receive help and a conclusion that help will never come-- between little or no intent to die and a higher intent to die. Punishing suicidal thoughts or actions as if they were an improper way to invite help from others can be very dangerous. Punishment often has the opposite effect to that which is desired. Help with problems, as well as help in finding other ways to ask for that help, is far more likely to be effective in reducing suicidal behaviors.

______________________________________________________________________________

MYTH: A suicidal person clearly wants to die.

Rationalization: There's no point in helping. They will just keep trying until they complete suicide.

FACT: Most suicidal people are ambivalent about their intentions right up to the point of dying. Very few are absolutely determined or completely decided about ending their life. Most people are open to a helpful intervention, sometimes even a forced one. The vast majority of those who are suicidal at some time in their life find a way to continue living.

______________________________________________________________________________

MYTH: Once a person attempts suicide, he (she) won't do it again.

Rationalization: I don't need to be concerned now; the attempt will be cure enough.

FACT: Although it is true that most people who attempt do not go on to kill themselves, many do attempt again. The rate of suicide for those who have attempted before is 50 times higher than that of the general population: 50 % of completers have attempted before.

______________________________________________________________________________

MYTH: A suicidal person's need is so great that I can't possibly make a difference..

Rationalization: They need more than I can provide, so only a specialist can help.

FACT: There are as many reasons for suicidal behaviors as there are people who engage in them. In terms of finding general rules that apply to all people, suicide is very complex. However, understanding and responding to suicidal behavior in a particular person does not require deep understanding of the motivation or circumstances of the suicidal feelings. All that is required is paying attention to what the person is saying, taking it seriously, offering support, and getting help. Many persons are lost to suicide because this type of emergency first aid and immediate support wasn't offered or available.

______________________________________________________________________________

MYTH: If a person has been depressed (e.g., withdrawn and lacking motivation) and suddenly seems to feel better, the danger of suicide is over.

Rationalization: They're better. I won't have to talk to them about suicide or keep my eye on them.

FACT: The outcome of feeling better can go two ways: 1) full recovery as one would hope, 2) or increased risk because the emotional conflict over living or dying has been resolved in favor of death. Also, a person who is severely depressed may not have the energy to kill him/herself: a lifting depression may provide the needed energy or give clarity to the perceived hopelessness of continuing with life. Or, resources may withdraw prematurely and not provide the support necessary for continued progress. Open and direct discussion of suicide is the only way to determine which of these directions applies.

______________________________________________________________________________

MYTH: Improvement following a suicidal crisis means that the suicidal risk is over.

Rationalization: Again, everyone can relax and not have to deal with the issue of suicide again.

FACT: Many suicides occur following 'improvement'. Suicidal feelings can return. For at least three months following a suicide crisis, be particularly attentive to the individual. Professionals should see patients frequently during this time, and assessment for depression, hopelessness, or anxiety should be made.

______________________________________________________________________________

MYTH: Once suicidal, a person is suicidal forever.

Rationalization: There is no way to help eliminate suicidal feelings or hope the person can return to regular duties after a suicidal episode.

FACT: Most suicidal crises are limited in terms of time, and will pass if help is provided. However, if emotional distress continues without relief, and help is not provided, the risk remains for further suicidal behavior. Professional help should be obtained after which the individual can usually resume normal activities.

How can you tell if someone is thinking about suicide?

Research tells us that most people who complete suicide give clues to their intentions. Be alert for these particular danger signals:

• Previous Attempts - this may mean that the person is at a high risk to try again.

• Threats - these are often followed by suicide attempts. Take all threats seriously.

• Depression and hopelessness- be aware of the symptoms of depression and hopelessness that were presented earlier (HO 3, page 35).

• Changes In Personality or Behavior - such as sleeplessness; lost weight, or a tendency to withdraw.

• Preparations For Death - such as quickly putting affairs in order, giving away personal possessions, acquiring a means to commit suicide such as a gun, rope or knife.

A complete list of warning signs is presented in Handout 4, pages 38-40.

If you suspect that someone is at risk for suicidal behavior because you have seen some of the warning signs mentioned above, or because the person has confided suicidal thoughts or plans to you, your job is to obtain help for them. You do not have to conduct a risk assessment or be certain at this point.

You and/or the suicidal person may be concerned about his/her getting into trouble or having a negative mark on their record. You may be concerned about their being angry with you. But these concerns don’t compare to the consequences of failure to take action when it is called for (i.e. their possible death). It is better to overreact than under react.

If you can, talk about your concerns about his/her possible suicide or self-harm with the person and then get help. If you do not feel that you can confront the person, bring your concerns to the most immediately available proper authority such as the Company Commander, platoon leader, or chaplain.

REFERRAL PROCEDURES (HO 5, page 39)

1. PREPARATION

A. Identify helping resources available on post.

• battalion aid station
• unit Chaplain
• unit headquarters
• military police
• family life center
• post hospital

2. FOLLOW THROUGH

• Stay with the individual or get someone else to stay with them until you can get the person seen by medical personnel.
• Accompany the individual to Community Mental Health or the local MTF Emergency Room. If you can not accompany them, have someone else personally accompany the individual
• Notify the Chain of Command when applicable.
• Notify military or civilian police as appropriate (i.e. in emergency immediate life-threatening situations).

3. WHAT NOT TO DO

• Don't assume the person isn't the suicidal "type".
• Don't keep a deadly secret. Tell someone what you suspect.
• When speaking with them:
• Don't act shocked at what the person tells you.
• Don't argue or try to reason. Don't debate the morality of self-destruction or talk about how it might hurt others. This may induce more guilt.
• Don't analyze the person's motives. "You just feel bad because..."
• Don't try to shock or challenge the person. "Go ahead and do it." (This only works in the movies!)

Instructor Note: It is recommended that the appropriate local referral procedures and explicit contact persons be provided as a handout here. This lesson provides guidelines for the most basic response by a fellow soldier. More detailed guidelines for the next level of service personnel such as officers are provided in the next lesson.

Remember, Your mission is to encourage help-seeking behavior and to understand the Buddy Care principles in this training module, so that you can get help for any person who is in need. We are involved in a "full court press" to minimize suicidal behavior in the Army. (OH 10)

Certain events have been found to precipitate suicide in vulnerable individuals. These are not causes of suicide. Rather, they are events that occur just before an attempt or completion of suicide. Like straws that break the camel’s back, they are stresses that push someone who is already vulnerable due to a psychiatric condition, personal coping style, or accumulation of stressful events to take self-destructive action. These include:

• A bad evaluation for an enlisted soldier or officer.
• The break up of a close relationship.
• Drug or alcohol abuse.
• Renewal of bonding with family on return from long field training or an isolated tour.
• Leaving old friends.
• Being alone with concerns about self and family.
• Financial stressors.
• New military assignments.

• Recent interpersonal losses.
• Loss of self-esteem/status.
• Humiliation.
• Rejection (e.g., job, promotion, boy/girlfriend).
• Disciplinary or legal difficulty.
• Exposure to suicide of friend or family member.
• Discharge from treatment or from service.
• Retirement.

What Are Common Symptoms Of Hopelessness and Depression

1. Believing all resources to be exhausted.

2. Feeling that no one cares.

3. Believing the world would be better off without you.

4. Total loss of control over self and others.

5. Believing death to be the only way out of the pain.

1. Difficulty concentrating or remembering. Decreased attention, concentration or ability to think clearly such as indecisiveness.

2. Loss of interest in or enjoyment of usually pleasurable activities.

3. Loss of energy, or chronic fatigue, slow speech and muscle movement.

4. Decreased effectiveness or productivity.

5. Feelings of inadequacy or worthlessness, loss of self-esteem.

6. Change in sleep habits-- the inability to sleep or the desire to sleep all the time.

7. Pessimistic attitude about the future--negative thinking about the past.

8. The inability to respond with apparent pleasure to praise or reward.

9. Tearfulness or crying.

10. Change in weight--poor appetite with weight loss or weight gain.

11. Recurrent thoughts of death or suicide.

12. Decreased sex drive.

13. Anxiety.

MYTH: Most suicides occur with little or no warning.

Rationalization: If you can't see suicide coming, there's nothing anybody can do.

FACT: Most people communicate warning signs of how they are reacting to or feeling about the events that are drawing them toward suicide. These warning signs-or invitations for others to offer help-come in the form of direct statements, physical signs, emotional reactions, or behavioral cues. They telegraph the possibility that suicide might be considered as a means to escape pain, relieve tension, maintain control, or cope with a loss.

______________________________________________________________________________

MYTH: You shouldn't talk about suicide with someone who you think might be at risk because you may give that person the idea.

Rationalization: It is best just to avoid it altogether.

FACT: Talking about suicide does not create nor increase risk. It reduces the risk. The best way to identify the intention of suicide is to ask directly. Open talk and genuine concern about someone's thoughts of suicide is a source of relief and often one of the key elements in preventing the immediate danger of suicide. Avoiding the subject of suicide can be a contributory cause of suicide. Avoidance leaves the person at risk feeling more alone and perhaps with even less energy to risk finding someone else to be helpful.

______________________________________________________________________________

MYTH: People who talk about suicide don't do it.

Rationalization: There is no need to get involved with people who talk about suicide.

FACT: People who attempt suicide usually talk about their intentions, directly or indirectly, before they act. Four out of five people who commit suicide talk about it in some way with another person before they die. Failing to take this talk seriously is suspected of being a contributing cause in many deaths by suicide.

______________________________________________________________________________

MYTH: Non-fatal acts are only attention-getting behaviors.

Rationalization: These behaviors can either be ignored or punished.

FACT: For some people, suicidal behaviors or "gestures" are serious invitations to others to help them live. If help is not forthcoming, there is an all too easy transition between a desperate invitation to receive help and a conclusion that help will never come-between little or no intent to die and a higher intent to die. Punishing suicidal thoughts or actions as if they were an improper way to invite help from others can be very dangerous. Punishment often has the opposite effect to that which is desired. Help with problems, as well as help in finding other ways to ask for that help, is far more likely to be effective in reducing suicidal behaviors.

______________________________________________________________________________

MYTH: A suicidal person clearly wants to die.

Rationalization: There's no point in helping, they will just keep trying until they complete suicide.

FACT: Most suicidal people are ambivalent about their intentions right up to the point of dying. Very few are absolutely determined or completely decided about ending their life. Most people are open to a helpful intervention, sometimes even a forced one. The vast majority of those who are suicidal at some time in their life find a way to continue living.

______________________________________________________________________________

MYTH: Once a person attempts suicide, he (she) won't do it again.

Rationalization: I don't need to be concerned now; the attempt will be cure enough.

FACT: Although it is true that most people who attempt do not go on to kill themselves, many who attempt do attempt again. The rate of suicide for those who have attempted before is 40 times higher than that of the general population.

______________________________________________________________________________

MYTH: A suicidal person's need is so great that I can't possibly make a difference.

Rationalization: They need more than I can provide, so only a specialist can help.

FACT: There are as many reasons for suicidal behaviors as there are people who engage in them. In terms of finding general rules that apply to all people, suicide is very complex. However, understanding and responding to suicidal behavior in a particular person does not require deep understanding of the motivation or circumstances of the suicidal feelings. All that is required is paying attention to what the person is saying, taking it seriously, offering support, and getting help. Many persons are lost to suicide because this type of emergency first aid and immediate support wasn't offered or available.

MYTH: If a person has been depressed (e.g., withdrawn and lacking motivation) and suddenly seems to feel better, the danger of suicide is over.

Rationalization: They're better. I won't have to talk to them about suicide or keep my eye on them.

FACT: The outcome of feeling better can go two ways: full recovery as one would hope, or increased risk because the emotional conflict over living or dying has been resolved in favor of death. Also, a person who is severely depressed may not have the energy to kill him/herself: a lifting depression may provide the needed energy or give clarity to the perceived hopelessness of continuing with life. Or, resources may withdraw prematurely and not provide the support necessary for continued progress. Open and direct discussion of suicide is the only way to determine which of these directions applies.

______________________________________________________________________________

MYTH: Improvement following a suicidal crisis means that the suicidal risk is over.

Rationalization: Again, everyone can relax and not have to deal with the issue of suicide again.

FACT: Many suicides occur following 'improvement'. Suicidal feelings can return. For at least three months following a suicide crisis, be particularly attentive to the individual. Professionals should see patients frequently during this time, and assessment for depression, hopelessness, or anxiety should be made.

______________________________________________________________________________

MYTH: Once suicidal, a person is suicidal forever.

Rationalization: There is no way to help eliminate suicidal feelings or hope the person can return to regular duties after a suicidal episode.

FACT: Most suicidal crises are limited in terms of time, and will pass if help is provided. However, if emotional distress continues without relief, and help is not provided, the risk remains for further suicidal behavior. Professional help should be obtained after which the individual can often resume normal activities.

Warning signs are observable changes, behaviors, or statements that indicate directly or indirectly that an individual is contemplating suicide. These can be organized using the word, FACT as an acrostic:

Aside from threats, none of these signs is a definite indication that the person is going to attempt or commit suicide. Many people experience depression, losses, or changes in behavior or demeanor without considering suicide. However, these signs do indicate that a person is troubled, and a concerned friend or supervisor should inquire as to what is going on and offer help. If a number of these signs occur, they may be important clues.

1. PREPARATION

A. Identify helping resources available on post.

• battalion aid station
• unit Chaplain
• unit headquarters
• military police
• family life center
• post hospital

2. FOLLOW THROUGH

• Stay with the individual or get someone else to stay with them until you can get the person seen by medical personnel.
• Accompany the individual or have someone else personally accompany the individual to a professional mental health provider.
• Notify the Chain of Command when applicable.
• Notify military or civilian police as appropriate (i.e. in emergency immediate life-threatening situations).

3. WHAT NOT TO DO

• Don't assume the person isn't the suicidal "type".
• Don't keep a deadly secret. Tell someone what you suspect.
• When speaking with them:
• Don't act shocked at what the person tells you.
• Don't argue or try to reason. Don't debate the morality of self-destruction or talk about how it might hurt others. This may induce more guilt.
• Don't analyze the person's motives. "You just feel bad because..."
• Don't try to shock or challenge the person. "Go ahead and do it." (This only works in the movies!)

Time: 1 hour

Target Audience: Officers/NCOs (OH 1)

The Mission: The Army Suicide Prevention Program is based on trained and ready personnel at all levels. Our mission is to encourage help-seeking behavior and to attain proficiency in the principles of this training module. (OH 2) The Officers and NCOs are vital to the success of the Army Suicide Prevention Program. (OH3)

Task: Provide supportive initial response to suicidal individual.

Participants will be able to:

1. Inquire about suicide
2. Respond to phone callers
3. Obtain help for suicidal individuals

Gatekeeper Lesson 1

Conference, role-plays.

Instructor Note: When a question is asked, take time to field answers from the class before proceeding.

The initial response is what a leader (level II in table 2, page 22) can do in response to someone who is either openly threatening or talking about suicide, or to someone who is showing warning signs, or is known to have risk factors or to have experienced precipitating events. It can be thought of as emotional first aid, and does not require expertise beyond knowing the guidelines outlined here and knowing who the person(s) are to whom the at-risk individual should be taken. The most basic goal here is to engage the person, and stay with them until help arrives or until you can hand them off to a professional. Such encounters all start in one of two ways: either they bring up suicide, or you bring it up in response to the distress/warning signs that you are seeing or because someone has brought the individual to your attention.

They bring up suicide: Direct Statements or Threats (OH 5 a-c). If someone is talking directly about suicide:

• Stay calm: look at them directly and speak in a calm but clear and concerned tone.
• If possible, send someone for help. Note: If there is a weapon involved, CALL THE POLICE and let them handle the situation.
• Do not leave the person alone, even to go to the bathroom. Let them know that you are not going anywhere.
• Buy time: encourage the person to talk and let him/her know you are hearing him/her. It almost doesn’t matter what you talk about, because the more the two of you talk, the harder it is for them to maintain the arousal necessary to take action.

• Acknowledge what you are hearing and convey that you are taking it seriously. Acknowledgement always precedes alternatives, directives:

• Listen to what the person is saying and let him/her know that you are hearing him/her by reflecting back what you are hearing.

• Convey that you hear they see suicide as an only option and let them know that you believe with help other possible options can be discovered.

• Secure any weapon or pills: be directive:

• Note the time any pills were taken so you can provide this information to the person(s) you will be handing them over to for help.
• Take action: send for help or take the person to someone or call someone in. A good rule of thumb is to never try to respond to this situation alone.

If you spot warning signs or have some other reason for concern, you may have to share your concerns with the person. If there is time, and you do not wish to talk to the person, you may raise your concerns with the chaplain or a mental health professional. Here is one way to inquire about suicide (OH 6 a, b):

• Review your evidence- what is happening, what is the person doing that causes your concern?

• Inquire about feelings or state what you have seen or heard:

• If you get denial, persist:

• Use the "sometimes" approach:

• Ask directly:

• Get help:

• Convey Concern

If you get denial and do not feel convinced, let them know:

• Don’t leave the person alone or send the person away.
• Don’t overreact-don’t be shocked by anything he (she) says. You don’t have to explore all of the details. Leave that up to the professional. Get enough information to show your care, concern, and willingness to listen non-judgmentally.
• Don’t rush-remember, you are just trying to establish contact and get the person to someone who can help; you are not trying to completely resolve the crisis.

• Don’t discount or make light of the suicidal threat: "You don’t really want to kill yourself".
• Don’t argue whether suicide is right or wrong.
• Don’t preach or moralize-"You have everything to live for." The issue is the problem or bind the person feels he (she) is in, not life and death per se.
• Don’t challenge or get into a power struggle. You will do everything you can to get help right now, but ultimately he (she) has control over his decision.
• Don’t think the person just needs reassurance. You can reassure that you will get help.
• Don’t promise to keep the conversation confidential. There is limited confidentiality in life-threatening situations.
• Remember that all persons who are at risk for suicide need help. It is always better to overreact (in terms of taking action) than to fail to take action. It is better to have someone angry with you or embarrassed than dead.
• Take care of yourself by asking for a debriefing session. Professionals recommend and practice this regularly.

After the initial response, the person should always be seen by a professional who will conduct a formal risk assessment. The guidelines for risk assessment and the initial interview are presented in the next section entitled Secure.

Remember, The Officer/NCO mission is to encourage help-seeking behavior and to be ready to obtain help for any person who is in need. We are involved in a "full court press" to minimize suicidal behavior in the Army. (OH 7)

Take appropriate action when faced with a potential suicide on the phone.

1. Establish a relationship with the person:

• Quickly reinforce the person for having called or confided in you.
• Be accepting, non-judgmental, warm, friendly, and supportive.
• Although you may be feeling nervous, exude confidence and concern.
• Let the person know you are willing to help, that you care for them as a person.

2. Gather information:

• Get as much information as possible and find out specifically where the person is.
• If someone else is there, get him or her to make the other calls. Get an address and call the military or civilian police first.
• Always call the military or civilian police in a situation where danger of suicide is high and the person is not in a controlled situation, such as in the company of friends or loved ones.
• You may be the only person available to help. In order to make other calls to gather and mobilize the suicidal person's resources, you may have to end your conversation with him or her.
• If so, be certain they understand why you need to end the telephone call. Tell them that you will call them back shortly after you have obtained the required assistance.

• You may call a chaplain, clergy person or obtain the help of paramedics, police, military police, or others. Let the person know who you have obtained help from.

NOTE TO INSTRUCTOR: Present the Scenarios and allow time for class discussion. You may choose to record class answers/responses on overhead, blackboard easel. The first scenario has many "red flags" for discussion purposes. Don't expect suicidal behavior to be so easily recognized.

At this time, we are going to look at some situations of people who ha