Suicidal Behaviors
Suicide prevention is the responsibility of the entire community. Each of us is responsible for creating a culture that encourages help seeking and suicide prevention. Suicide is prevented by addressing quality of life concerns on a daily basis.
The following information is designed to inform you of available resources and means to help your members be healthy, resilient, as successful as possible, and to help prevent suicide. By raising the health and resilience of your members, you decrease the likelihood of suicide within your agency.
Reducing the suicide rate through prevention efforts translates into saving the lives of fathers, mothers, brothers, sisters, husbands, wives, sons, daughters, friends, lovers, supervisors, supervisees, etc.
A. Identifying Individuals at Risk
Risk factors are those things that increase the probability that difficulties will result in the development of serious behavioral or physical health problems. The presence of these factors does not automatically mean someone will become suicidal, but the presence of these factors raises that risk. Many of these risk factors can be modified, reduced, or eliminated.
The following risk factors have been associated with suicidal behavior:
- Current/pending disciplinary or legal action.
- Relationship problems.
- Substance abuse.
- Financial problems.
- Work related problems.
- Transitions (retirement, moves)
- A serious medical problem.
- Significant loss.
- Setbacks (academic, career, or personal).
- Severe, prolonged, and/or perceived unmanageable stress.
- A sense of powerlessness, helplessness, and/or hopelessness.
- Presence of a weapon in the home.
- History of previous suicide attempts.
individuals who commit or attempt suicide may face problems they feel cannot be resolved. Normally, there are alternatives to these problems. However, someone who is suicidal may not be thinking clearly and cannot see the other possible positive solutions.
Members who are at an increased risk for suicide present a unique challenge for leaders. Effective suicide prevention requires everyone on the job to be alert to the risk factors for suicide and know how to respond. Commanders, watch commanders, training officers and supervisors must lead the way. Any individual who reports suicidal thoughts or behaviors must always be taken seriously.
It is also important to proactively ask about possible thoughts of suicide when members are dealing with significant life difficulties. Don’t assume that merely because someone has not told you they are feeling suicidal, that they are safe. Be especially vigilant with individuals facing multiple stressors. Such individuals have historically been at a higher risk for suicide.
Recognizing Distress in Individuals with Risk Factors
Distress in some individuals can lead to the development of unhealthy behaviors including withdrawal from social support and ineffective problem-solving. These behaviors may intensify the potential risk of suicide. The people an individual sees every day (coworkers, family, friends) are in the best position to recognize changes stemming from distress and to provide support. Any substantial and observable change in behavior warrants further discussion with the individual. Changes may be exhibited in one or many of the following:
- Mood.
- Concentration.
- Sleep.
- Energy.
- Appetite.
- Substance use.
- Impulse control.
- Recreation.
- Capacity for enjoyment.
- Helplessness or hopelessness.
- Peer relations.
- Work performance.
- Professional bearing.
In addition, be vigilant when your member shows:
- An inability to see a future without pain.
- A view of themselves as worthless.
- An absence of control over their life or life circumstances.
- Feeling alone.
- Excessive guilt or shame.
- An inability to stop negative thinking.
- Pessimism and a belief that there is no solution to life's problems.
- Obsessing about death, dying, and weapons.
- Challenging people in an aggressive manner.
- Giving away possessions.
- Excessive sorrow for past behaviors.
Seek immediate assistance for any of the following:
- Thoughts of suicide.
- A suicide plan.
- Access to the method of suicide described.
- Stating they intend to complete the plan.
Protective factors are those things that reduce the probability that difficulties will result in the development of serious behavioral or physical health problems. Examples include:
- Work unit cohesion and camaraderie.
- Peer support.
- Easy access to helping resources.
- Belief that it is okay to ask for help.
- Optimistic outlook.
- Effective coping and problem-solving skills.
- Social and family support.
- Sense of belonging to a group or organization.
- Marriage.
- Physical activity.
- Participation and membership in a community.
- A measure of personal control of life and its circumstances.
- Religious or spiritual connectedness.
Balancing Protective and Risk Factors
Every person is at risk for experiencing difficulties based on their balance of protective and risk factors. The key to suicide prevention is to increase the protective factors and to decrease the risk factors. We are not just focusing on eliminating negative factors, but also on increasing positive factors that will improve the quality of life for all members. As a leader, you can contribute to the presence of these factors.
Helpful Approaches When Someone Talks About Suicide
- First, share your concern for their well-being.
- Be honest and direct.
- Use open-ended questions such as: "How are things going?" or "How are you dealing with…?"
- Listen and pay attention to both their words and emotions.
- Repeat back what they say using their own words.
- Express concern about them and a willingness to help. People who survive a suicide attempt are shocked to find out how many people care about them.
- Ask directly about thoughts or plans for suicide.
- If someone tells you they are suicidal, it is often a plea for help. Tell someone in the chain of command to ensure they get immediate assistance.
Unhelpful Approaches When Someone Talks About Suicide
- Not taking the problem seriously.
- Keeping the problem a secret.
- Ignoring the problem.
- Delaying a referral.
Helping Agencies
It is essential that leaders know the agencies and resources available to help when someone comes to them with a problem. All of us, especially leaders, have a responsibility to match the needs of our members with available resources. Each organization has access to resources available to help. Working collaboratively with each other we can better identify the needs of the organization and coordinate the delivery of services to meet these needs. Services may vary, but typical offerings by individual agencies include:
Financial counseling.
Employment assistance.
Couples groups.
Parenting groups.
Respite Care.
Infant and toddler play groups.
Life skills groups (stress management, depression, anxiety, anger, etc.).
Workshops (conflict resolution, dealing with difficult people, supervising, etc).
Maintain a listing of the services available, the point of contact (POC), and their telephone number.
Investigative Interview Hand-Offs
The individual’s unit and command are in the best position to determine how this person is coping and whether referral to mental health is appropriate following an interview by Internal Affairs, Inspector General, law enforcement, and Equal Employment Opportunity.
Commander Directed Mental Health Evaluations
If an individual is a current danger to themselves or others, an emergency mental health evaluation is appropriate. Refer to the Emergency Department (ED) or contracted EAP for evaluation.
If the person is not currently a danger to themselves or others, but is in need of assistance and there is a question about fitness for duty, the commander can direct the person to agency mental health or contracted EAP for evaluation. The following represent recommendations. Consult local policy and organizational directives for specific guide lines.
Commander consults with legal office to review the facts and the law, if necessary.
Commander submits written memorandum's to the member being evaluated and to the authorized evaluating authority.
Mental health provider evaluates member's dangerousness to self and others, fitness for duty, and suitability for duty.
The provider delivers feedback to commander.
This process ensures members get the help they need and respects the rights of referred individuals. These rights include legal counsel, protection from reprisal, appropriate use of the evaluation (not a tool for punishment), and sufficient written notice (except in emergencies where the person is in immediate danger to self or others).
What Prevents People from Seeking Help
Suicide prevention must go beyond responding appropriately when suicidal signs and symptoms are evident. Prevention occurs by establishing a culture in which seeking help for problems is not only acceptable but also expected.
Individuals may be reluctant to pursue assistance because of fears that such help will negatively impact their careers. Unfortunately, this often means the person in their distressed state delays seeking help and instead engages in behaviors that create a long paper trail of Letters of Counseling, Letters of Reprimand, and other administrative punishments that damage their careers.
As leaders you must combat the myth that help seeking damages careers. Research reveals that 97% of people who are self-referred to treatment receive no negative carrier impact (termination, change in special duty status, weapon bearing status, etc.). Career impact is minimal when early assistance is obtained. By delaying helping-seeking, an individual is more prone to suffer impairment in duty performance and this has potential to damage careers.
Another fear members have is that the commander will have complete access to their mental health records. Data indicates of those who are self-referred 93 % of cases confidentiality was maintained. In those cases where information was released, the cases either involved mandatory reporting or the leadership was solicited to be a resource for the member.
C. Intervening When Immediate Help is Required
Intervening When the Person is Suicidal
If someone says they are suicidal and has a plan to carry out their wish to die, do not leave them alone for any reason. If you must step away, assign a capable person to stay with the person until assistance arrives. If they must retrieve something from their car, have someone else go to the car and remove the item to reduce the risk of fleeing.
Remove all potential means of self-harm from their area such as firearms, pills, knives, rope, and machinery.
Involve law enforcement if necessary to protect the person from harming himself or herself. The person may be so intent on suicide that they become dangerous to those attempting to help them.
Rely on the ED as to whether you should transport the person or whether an ambulance should provide transportation to an evaluation. If the advice is to transport them in your vehicle, each door must have a person assigned to prevent the person from killing themselves by exiting the moving vehicle.
Have someone accompany the person to serve as your POC during and after any evaluations. Have your POC ensure the mental health provider has your telephone number for feedback following the evaluation.
During duty hours you should contact mental health, or contracted EAP. After duty hours contact the ED.
Although it is best for helping professionals to assess and manage suicidal individuals, there may be times when section leaders or peers find themselves on the phone with a suicidal person. The following guidance may help you provide support and get the individual the appropriate help as soon as possible.
- Establish a relationship with
the person.
- Quickly thank the person for calling.
- Express an interest in the person’s welfare.
- State your willingness to help.
- Gather information from the
person.
- Immediately get the telephone number they are calling from in case you are disconnected.
- Find out specifically where the person is located.
- Get as much information as possible about their plans, access to means of self-harm, and intent.
- Listen, do not give advice.
- Keep the person talking but avoid topics that agitate them (i.e., their unfair supervisor, cheating spouse, etc.).
- If someone else is with you, get him or her to make calls to mental health, ED, or the police.
D. What Leaders Can Expect from Mental Health
Agency mental health providers and EAP staff are a primary resource regarding mental health issues. Members can be evaluated on a voluntary basis or can be referred by commanders through the established local policy and process. Mental health providers can also serve as consultants to leaders regarding the management of personnel at risk for suicide, even if clinical care is not indicated or desired by the member. Although it is impossible to accurately predict whether or not a person is going to attempt or complete a suicidal act, mental health providers can provide a comprehensive assessment to estimate level of risk. These assessments are based on known risk factors and allow providers to make recommendations for appropriately responding to that risk.
Suicide risk assessment is best accomplished as a collaborative effort between the member, a qualified mental health professional and others who know the individual and have observed him or her in their daily activities. Commanders, sergeants, and supervisors can provide valuable information to the evaluating provider when assessments are being accomplished that might otherwise be unavailable to the evaluating provider. Leaders are encouraged to contribute by sharing observations related to the member’s functioning in the duty section.
When members are suicidal, hospitalization is indicated. In such cases, the evaluating mental health provider will facilitate appropriate care. Commanders will be kept informed of the member’s status. Prompt re-evaluation by agency mental health representatives following discharge is essential and leaders will be notified as to the time of this appointment. Leaders can help ensure that the member attends the post-discharge appointment.
Sometimes members will have thoughts or feelings of suicide but will not meet criteria for admission to a hospital. In this situation, outpatient treatment will be offered to address the suicidal thoughts and behavior, as well as any mental health disorders. Often, outpatient treatment is preferable to hospitalization when risk of self-harm is not imminent. Commanders will be notified of any increase in dangerousness or recommendations regarding duty status.
There also may be times when members are not imminently dangerous, but display some suicidal symptoms at the evaluation and refuse to return to counseling for ongoing care. These situations are challenging since a member who is not at imminent risk for self-harm cannot be mandated to receive medical or mental health treatment. It is essential that leaders and providers collaborate to maximize the member’s safety. Examples of collaboration between providers and leaders include:
- Working together to develop a means for ongoing monitoring of potential risks.
- Consultation about possible responses to a person’s disruptive behavior.
- Regular discussions between providers and the sergeant or supervisor to discuss the individual’s behavior.
- Looking for ways to increase support and decrease factors contributing to the individual’s suicidal behavior.
- Leader follow-up with the member.
There may be times when a comprehensive dangerousness assessment indicates that risk for harm is low. In these situations, leaders and providers should collaborate to develop an appropriate plan for monitoring and follow-up.
- Part of this plan would address a time-frame for follow-up.
- Referral to helping agencies for development of improved coping skills.
- Ensure immediate supervisor is alert to suicide risk factors.
- Foster peer support and individual self-care.
Mental health evaluations must be conducted in a location where medical support and security are available. This will generally be in a medical setting and not at the member’s home or job site. A community ED will likely be the safest and most appropriate venue for conducting after-hours suicide risk assessments.
Safety and Restriction of Access to Lethal Means
When any provider believes that a member is at increased risk for suicide, the commander will be notified. The provider may recommend duty restrictions such as removal from weapon-bearing duties and temporary change in duty status. Commanders can also help ensure that the individual’s duties do not involve significant time alone during which there would be opportunity for dwelling on problems and potentially attempting suicide.
Commanders may also be directly advised to take steps to reduce access to weapons at the individual’s home. While it is impossible to limit a person’s access to all potential suicidal means, it is important to take reasonable steps to ensure safety when possible. Firearms pose the greatest risk as a readily available means of self-harm and should always be removed from a suicidal individual’s home. This can be done by counseling the person, and his or her family or friends, about the possible dangers of keeping a firearm available. When necessary, commanders should take definitive steps to restrict the member's access to weapons.
Monitoring After Evaluation or Hospitalization
Members who have recently been evaluated or discharged from a psychiatric hospital should be monitored by the unit as well as the mental health providers to ensure that safety is maintained and that any relapse is recognized early. Unit leaders should consider the following to ensure appropriate monitoring and support:
- The provider responsible for the member’s care will share information about the member’s status that is important for leaders to know.
- The member should be seen regularly by a mental health provider. Additional visits with a chaplain, peer counselor do not substitute for face-to face contact with a mental health provider.
- Someone in the unit should check in with the member daily as a means of support and to ensure safety (e.g., declines in performance, recent disciplinary action, etc.).
If in spite of everyone’s best efforts a member takes their life, the Critical Incident Stress Management (CISM) team should be called to respond to the unit’s needs. Please see section Critical Incidents/Death of a Service Member for additional details.
National Institute of Heath (NIH) Suicide website
www.nimh.nih.gov/research/suicidefaq.cfm
Crisis hotlines provide telephone counseling for people with suicidal thoughts or feelings. Due to the anonymity involved in these services, many people are willing to contact a crisis hotline before they are willing to seek care in person. It is therefore helpful to provide hotline numbers to individuals at increased risk for suicide. Check for crisis hotline numbers in your local area. The National Suicide Hotline number is 1 (800) SUICIDE.
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