THE IMPACT OF SUICIDE : A Workshop for First Responders

1. THE IMPACT OF SUICIDE:A Workshop for First Responders John R. Jordan, Ph.D. Pawtucket, RI Wellesley, MA Jjordan50@aol.com

2. Presentation Overview • Suicide “101” • Overview of Risk Factors • Warning Signs • Prevention - Organizational • Intervention - “How Can I Help?” • Postvention – “If the Worst Happens”

3. Suicide 101 • 10th Leading Cause of Death • 38,000 / year in U.S. • 800,000 attempts/ year in U.S. • Rates Rise with Age • Males Complete about 4 Times as Often as Females • 90% Have Diagnosable Psychiatric Disorder • Co-morbidity • Elderly Caucasian Males Generally have the Highest Rates • Middle-aged Men have the Highest Numbers

4. Suicide as the “Perfect Storm” • Genetic Factors • Biological Factors • Personality • Past Experience • Life Stressors • Isolation • Social Issues • Opportunity/ Access to Means

5. Overview of General Risk Factors • Previous Attempts • Especially multiple attempts • Presence of Psychiatric Disorder • Depression • Bipolar disorder • PTSD • Substance abuse • Also • Anxiety disorders, schizophrenia, eating disorders, possibly complicated grief

6. Overview of General Risk Factors • Presence of Psychiatric Disorder • What is Depression? • Depressed mood – “Black mood & black thoughts” • Sleep disorder • Loss of appetite, energy, libido • Irritability • Trouble concentrating, making decisions • Anhedonia • Irrational guilt, thoughts of suicide & death • Withdrawal & isolation

7. Overview of General Risk Factors • What is Trauma Response & PTSD? • Exposure to a threatening traumatic event • Elicitation of the “emergency” (fight, flight, freeze) response • Rage – (fight) • Panic/avoidance – (flight) • Numbness/shut-down – (freeze) • Intrusive reliving • Avoidance • Autonomic arousal - Hyper-arousal, hyper-focusing, hyper-vigilance • “Altered state of consciousness” • Hopelessness

8. Overview of General Risk Factors • Exposure to Suicide • Esp. family hx. • Isolation • Trauma History • Substance Abuse • Alcohol a “suicidogenic” drug?

9. Overview of General Risk FactorsInterpersonal Model - Joiner • Perceived Burdensomeness • Perceived Lack Of Belonging • Access to Means

10. Warning Signs of Imminent Risk • Suicidal Ideation • Frequency, intensity, duration • Resolved Plans • Plan – lethality, specificity, practicality (access to means) • Enactment of the plan - rehearsal • Dysregulation • Sleep, eating, weight-loss, lack of self-care • “3 A’s” - Agitation/ Anxiety/ Anger • Intoxication • Leave-taking • Closing one’s business • Saying goodbye

11. Warning Signs of Imminent Risk – Thinking Associated with Suicidal Ideation • Unlovability/ Worthlessness • “I don’t belong” & “I don’t deserve to live” • Helplessness • “I cannot solve this” • Distress Tolerance Limit • “I cannot stand the pain anymore” • Perceived Burdensomeness • “They will be better off without me” • Core Issue = Hopelessness – “Hopelessness Kills!”

12. Warning Signs of Imminent Risk • Preparation & Rehearsal (Taking Action) • Seeking access to means • Reckless behavior • Rehearsing self-injury behavior • Direct Communication of Wish to Die/ Intent to End One’s Life • Wish to die – to be dead • Fore-shortened future • Overt suicide threat

13. Warning Signs of Imminent Risk: A Mnemonic • IS PATH WARM • Ideation • Substance Abuse • Purposelessness • Anxiety • Trapped • Hopelessness • Withdrawing • Anger • Recklessness • Mood Changes

14. Prevention - Organizational

15. Prevention - Social & Cultural Barriers to Prevention • Failure to recognize depression, PTSD • Fear and ignorance about psychiatric disorder and suicidality • Taboo about asking about suicide • “John Wayne” – Not asking for help • “Why is physical self-care is for real men, but psychological self-care for wimps?” • Lack of services

16. U.S. Air Force Program • Goals: • Promoting awareness of the range of risk factors related to suicide • Educating the community regarding available mental-health services • Reducing the stigma related to help-seeking behavior

17. U.S. Air Force Program - Method • Community Education • Intensive education of commanders & enlisted personnel about risk factors, warning signs, and referral procedures • Risk Reduction • CISM after traumatic events (including suicide) • Assessment of personnel in legal trouble • “Buddy care” system and training

18. U.S. Air Force Program - Method • Improvement of delivery system • Coordination across programs and providers • Promote help-seeking behavior • Increase confidentiality after seeking help

19. U.S. Air Force Program - Results

20. U.S. Air Force Program - Results

21. SUMMARY - General Principles of Prevention Programs • Buy-in Of Key Leadership in the Community • Destigmatization Of Psychiatric Disorder & Suicide • Raising Awareness Of Risk And Warning Signs • Prescribing Appropriate Response to Risk • Screening, Detection, and Outreach to At-risk Individuals • Facilitating Help-seeking & Access to Services • Appropriate Follow-through With Services • Lowering General Risk Factors And Increasing Protective Factors (e.g. - Social Connection)

22. Intervention

23. Intervention – “How Can I Help” • Know the Warning Signs • When in Doubt - ASK! • “How bad are you feeling?” • “Do you wish you were dead?” • “Are you thinking about killing yourself/ suicide?” • “How strong are those thoughts/feelings?” • “Do you think about a plan?” • “Have you done anything to put that plan into effect?” • “Have you tried to kill yourself before? • “Let’s get you some help?”

24. Intervention – “How Can I Help” • Express Concern & Support • Don’t challenge • Encourage and Facilitate Getting Help • Follow-Up

25. National Suicide Prevention Hotline • For suicidal individuals • For family & friends who are concerned • 1-800-273-TALK (1-800-273-8255)

26. Postvention

27. Grief After Suicide: Prominent Themes For Survivors • WHY? - Making Sense of the Death • RESPONSIBILITY - Guilt & Blame • SOCIAL DISRUPTION - Isolation • SHAME - Stigma • ANGER - Rejection & Abandonment

28. Grief After Suicide: Prominent Themes For Survivors • TRAUMA - Shock & Horror • RELIEF - The End Of Suffering • SUICIDALITY – Why Go On? • SORROW – Grief & Yearning

29. In the Immediate Aftermath:Helping New Survivors • Express Condolences • Support • Listen • EMPATHIZE - don’t judge, offer explanations, or platitudes • Take Your Time • Explain • What you going to do (and why) • What you are doing • What you have done • Watch Your Non-verbal Communication • Tone of voice – anger, disapproval, icy detachment • Recognize Shock/Trauma in New Survivors • Fight, Flight, or Freeze • Cognitive Processing Offline – Confusion

30. In the Immediate Aftermath:Helping New Survivors • Offer Help • Help person think of “next steps” • Make calls • Make Referrals - Samaritans Grief Support Services • Boston - 877-870-4673 • Merrimack Valley - 866-912-4673 • Pay Attention to People Who Appear to Be at Risk • Unable to contain themselves • Threats against self or others • Using substances • People who are distraught and without good support

31. Postvention Advice for Yourself After a Suicide • Practice Self-Care • Check on Each Other • Set your grudges aside • Ask how you can help • Talk About It, Call It What It Is • Educate Yourself About Psychiatric Disorder, Suicide, & Grief • Remember the “Perfect Storm” • Accept the limitations on what we can do • You accept that for medical incidents – accept that for psychiatric disorders and suicide – not all can be prevented

32. Wrap-Up • Questions? • Comments? • Discussion?