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The Suicidal Employee

When it’s someone you know…

Most supervisors and employees hope they never find themselves in The position of wondering whether a colleague, subordinate or coworker is at imminent risk for suicide. Disturbing at any time, completed suicides are particularly disturbing to those who are on the frontline and know first hand the traumatic impact of suicide on everyone involved, including the friends and family who are left behind. The effects are devastating, and no matter how hard someone tries to understand death by suicide it never really “makes sense.” But suicide isn’t about “making sense.” It’s about feelings and those feelings are not likely to make sense to anyone other than the person who is feeling them. As we know from research, suicide isn’t so much about the desire for death as it is about the overwhelming need to end perceived pain

Identifying The Risk

“This past year I responded to the suicide of a 22 year old male who was intoxicated and committed suicide with a shotgun to his head. 12 years earlier I had responded to a call at his mother’s house when she reported him being sexually molested by his biological grandfather (her dad). Grandpa got a few years in the pen and was out. Recently the 22 year old had been living with Grandpa. He had never been the same since he and his sister were molested. The night before he committed suicide he and his girlfriend had been smoking marijuana and drinking heavily. He told his girlfriend what his grandfather had done to him and told her he was depressed. She went home about 2 am and tried to call him back at 4 am. His grandmother found him at 7 am when she tried to wake him for work.

 At the time I worked the suicide I didn’t put 2 and 2 together. I knew I was at Grandpa’s house but didn’t recognize who the kid was until the Medical Examiner was there. I thought, “I wish I could go over there and ask Grandpa how he felt when he killed his grandson at 12 years old.” That’s essentially what he did. It just took 10 years for him to finally die. But you can’t do that, you just clear the call, do your paperwork and go on to the next thing.” 

When we are safely cloaked in our “professional gear,” responding to a crime scene or dispatching on 911, we know what is expected of us. This is what we’ve been trained to do, and as one person said to me recently, “Trauma is my life, whether it’s emotional or physical. I admit that I’m a masochist and I’m at my happiest when I’m dealing with other people’s problems. Maybe it’s my way of subconsciously ignoring my own, but it works.”  

Whether it’s the first time or the fifteenth time our predetermined professional role serves to “separate” us from the reality of the traumatic event. In the professional literature this separation is called a functional detachment, otherwise known as denial. Although we may not consciously realize we are detaching ourselves from our feelings this compartmentalization enables most of us to function effectively during a high stress incident.  

“At the time of the incident I didn’t feel anything. My training took over. I did what I was supposed to do.”

But what if the identified imminent risk isn’t “out there” with John or Jane Q Public making suggestive life threatening statements? What if the warning signs we’re reading are inside and much closer to home?

When these same warning signs are demonstrated by people we know and work with the decision to act can be far more challenging. We question our perception of what we hear or see and wonder whether intervention is necessary? What if we’re wrong? What then? 

When It’s Someone You Know. For many of us working in emergency public safety, with already more than enough memories, thoughts, feelings and images left behind by completed suicides or traumatic deaths we’ve witnessed or responded to, the thought of a colleague, subordinate, friend or family member ending their lives in the same manner is extremely disturbing.

Even though we may know that anyone is vulnerable to depression and at-risk behavior, emotionally we struggle to accept this potential in someone we know and care about. Inadvertently, our own feelings and experiences concerning suicide interfere with our ability to perceive the seriousness of the situation.
 
In The Eye of The Storm.
 
As an undergraduate student I worked part time as a research assistant in the university psychology department. One evening I received a phone call at home from a female graduate student who worked there with me. She was distraught over what she described as her failing grades. Although we’d never had a personal conversation before or outside of the University, I was flattered that she would call me, a younger student, to confide in. I was also understandably concerned when she disclosed how depressed she was.

We talked for over an hour during which time she denied her suicidality, (“I would never do something like that”); swore she had not disclosed her feelings to anyone else other then me, (“No one else would understand.”) and thanked me repeatedly for helping her, (“I feel so much better. You’ve helped me more then anyone.”). Then she pleaded with me to keep her secret, (“You can’t tell anyone! I would be so embarrassed if anyone knew."). I agreed. Approximately one month later this young student committed suicide.

As the students and faculty gathered on campus to share our grief we soon learned a startling fact. Inadvertently we had all participated in our young friend’s demise. Each one of us present, senior as well as junior members of the department of psychology, students, Ph.D.s and M.D.s, in addition to the staff of two suicide hotlines and a variety of outpatient therapists, had all been contacted by this young woman at one time or another and each of us had been given the same information yet none of us knew about each other.  
 
Each was told he or she was the only person she had confided in. Each was sworn to secrecy. Each was thanked for being the “only one to help her” and each, out of concern for her and not wishing to jeopardize what they believed was her only outlet, (themselves) agreed to keep her confidence. 

She was a colleague. She was a graduate student in psychology. She wasn’t failing. In fact, she was an honors student. Her feelings made no sense to those whom she confided in and were obviously irrational but because each of us prided ourselves on our ability to understand human behavior, (“we were all in the field, after all,”) and she “trusted” us with her confidence (“Only me.”) we explained away her behavior. We denied the seriousness of her intent because it was so hard for us to accept that someone who lived and worked and studied in the very midst of a psychology department on a prestigious university campus could actually be suicidal without anyone picking up on it.

We all told ourselves versions of the same story: that if she truly were at risk she would say so (she did) and that even if she didn’t say anything, by some fluke of nature, then certainly one of the many, many mental health professionals she was surrounded by everyday would notice and intervene. But no one did. True, she manipulated each of us by the information she shared but we contributed to the problem by allowing our arrogance, complacency and naiveté to get in the way and by not communicating with each other when the “Red Flags” were so clearly there.

 Our feelings interfered with our perceptions of the situation.

The EPS Professional.  

As a psychologist I’ve spent many hours talking with public safety professionals who vehemently denied they would ever commit suicide or consider suicide an option “because I’ve seen what can happen to someone. I’d never do that to my family.” Yet, months later these same individuals would make a suicide attempt after a crisis. “I can’t believe he killed himself. He seemed to be in such a good mood. He seemed happy.”

I’ve also spent equally as many if not more hours talking with public safety professionals who are so “high maintenance” and labor intensive in their needs that in a room of 20, he or she is the only person in the room one can focus on. The classic case of “20% of the people taking 80% of the resources.” While these individuals are effective at alarming everyone in their presence with their provocative behavior and hundreds of potential “Red Flags,” they never actually seem to follow through with what they threaten or imply. So, what do you believe and when is intervention appropriate?  

Organizational Recommendations  
 
The following sections represent some basic suggestions for your organization and for you professionally, as a supervisor, training officer or colleague. We will also cover you, as the human being, who may one day regrettably find yourself in positions you never wished for and hoped you’d never to go to.

Although not every possibility is listed, the following recommendations are those we feel any organization should consider as a baseline minimum for their employees. Modifications can be made according to the specific needs of the organization, based on size, location, personnel available, etc.

Supervisors often protect those personnel experiencing depression and deny the existence of any problems serious enough to warrant intervention by an outside source. However, such acts ultimately are a disservice to the affected personnel by denying them the help they need. 

· Personnel may resist seeking help. Many fear that if help is sought, employment and economic security will be threatened. This myth can be dispelled through department policy and the approach utilized by responding supervisors.  

· Supervisors must be provided with adequate training and resources so that they themselves feel comfortable with approaching personnel who are potentially suicidal. 
· Education on depression and suicide should be implemented for all department personnel. They should be informed that seeking help does not mean the end of their career, but the start of improving a new career. Asking for health signals strength and insight, not weakness and denial, and that must form the foundation of any prevention program.  

· A suicide prevention program can only work if members of the department feel free to take advantage of it. Administrators and supervisors must play a nonpunitive role. They must be sensitive to the possibility that any intervention provided may be experienced by personnel as stressful and threatening. They must communicate to personnel that seeking help will not result in job termination, all information will be kept confidential, that other ways exist for dealing with a situation, no matter how hopeless it seems at the time and that someone is available to help them deal with their problems.

Training, policy and procedure must be set and communicated consistently across every level of department leadership by word and practice every day.  
Integrity of thought and action are vital. If what you say isn’t what you do, either individually or organizationally, then others will know this. Don’t assume that because you’re a “good player” no one will notice. They will. They may not say anything but they will notice that “what’s good for the goose isn’t what’s good for the gander,” and one of the most important factors necessary for making all this work will be missing: trust. Without it, all the policy and procedures in the world will do nothing to stem the tides of disharmony and poor morale. Your “word” and the word of your organization are really all you have. Once you allow that to lapse the road back is very hard to find.
 
When It's Someone You Know 

Sometimes the red flags just keep on coming, and when it's someone you know taking the next step can feel like the longest mile you've ever traveled. While this is by no means an exhaustive list take time to review its contents. Consider the message embedded within: No one has a crystal ball, not even the professionals. Should personal factors come into play, simply be mindful of them, and repeat this key phrase to yourself:  

"When in doubt, refer them out. Consult, consult, consult.”  
You must be abundantly clear and extremely honest with yourself when reviewing this list and looking within. The consequences of denial can be deadly.

List of 16
1.     Do you know this person well? A friend on the job? A close working associate or colleague? A subordinate you've developed a good working relationship with or who may have at one time been your trainee or probationer? 
2. Do you admire, respect or look up to this person? Do you see him or her as your role model, mentor, or perhaps even the consummate leader and professional? Was he or she instrumental in your professional development, or you in theirs? 
3. With this same individual in mind, whether you are peer-to-peer, or subordinate to supervisor, does your professional relationship include on duty or off duty socializing and the exchanges of confidences? 
4. Is this someone whom you ordinarily seek out after particularly difficult calls, runs, or critical incidents? 
5. Whether you have ever confided this information to another living soul or not, if you are really honest with yourself at this moment in time, have you ever felt significantly depressed or despondent to the extent that suicide, or placing yourself in harms way in whatever fashion, has been or is a viable option for you? (Consider the feelings with this one, and not the words you may have said.) Are you feeling this way now? If this is an experience from your past, do you currently harbor feelings of shame, remorse or guilt for that particular time in your life? 
6. Despite the potential for adverse consequences, and maybe even because of it, do you place yourself in high-risk situations? (For example: respond to shots fired without wearing vest; high speed pursuit without being belted in; extreme sports to the detriment of other activities or self-care; multiple affairs while married or in committed relationship; repeated abuse of substances; first on scene without calling for backup.) 
7. If you were the first on scene of a completed suicide, suicide/homicide, did you see the body? Were you debriefed? Was there follow-up? 
8. Were the victim’s family, children, significant other, parents or friends present, and if so were they extremely emotional? Did you interact with them directly? 
9.  Have you ever been or were you routinely tasked with the responsibility of providing death notification (s) on one or more occasions? Of someone you knew to people you know or still know? 
10. Has someone known to you in your division or command committed suicide? 
11. Has a parent, adult caretaker; significant other, child or close family member ever experienced chronic bouts of acute depression, and/or suicidal ideation? Was a suicidal attempt ever made? Did this occur when you were a child or as an adult, and if the answer is both, was it continuous or on more then one occasion? If a suicide attempt was made did you provide intervention? If a completed suicide occurred did you find the body? Was there support provided to you in the aftermath? Do you still think about this event now? 
12. As a child and then later as an adult, did you experience feelings of shame, embarrassment, humiliation, frustration or anger towards someone you were close to because of the circumstances created by his or her depression? Did you ever tell him or her, or anyone else, how you felt about the experience and your subsequent feelings? Were you honest? Were you honest with yourself? If you've never told anyone, why not? 
13. Have you had one of more instances of providing first response or first point of contact to a protracted critical incident, such as a barricaded suspect suicidal, or barricaded suspect with hostages? Bombing? Plane crash? Public display of violence with fatalities (PDVF)? Were children involved? 
14. Have you dispatched on one or more calls in which the caller completed the suicide while talking to you?
15. Did a successful rescue attempt by you ultimately result in negative consequences for one or more victims? (For example, the victims were saved but later succumbed to their injuries in the hospital. Their final days were painful for themselves and their families. You were witness to their pain and grief.) Was there media attention immediately following the rescue to the extent that your actions were highlighted, or portrayed as heroic?  
16. Do you have a strong personal faith or practice a spiritual belief in which suicide is considered an act against God? 
Note how many and which items you have endorsed on the List of 16 then refer to Table 1 for additional guidelines. Also note that additional information pertaining to supervisors, partners, friends and family members directly follows this section.
 
R
    
 
If you've endorsed items 5, 6, 11, 12 or 13 with Plane Crash, Bombing or PDVF with Children consider this an automatic Three to Four Red Flags.  
The average emergency public safety professional is likely to endorse two or more Red Flags during the course of his or her career.  
Consequently, when faced with numerous Red Flags flying around someone you know, and know well, you may not be able to see the forest for the trees. At no fault to you, your perception may be skewed, influenced or biased by your own thoughts, experiences and feelings. This does not mean that you are incapable of acting appropriately or providing a realistic assessment or following your organizations pre-determined protocol for managing such situations.
However, getting to that next step may be the mitigating factor. Given your acknowledgment of one or more of the above, then consider this:
There may be times, circumstances and situations when you may not be the best person for making the critical decision. 

Your reaction or response to a despondent employee, professional friend or colleague may be disproportionate to the actual needs of the individual, or their safety and well being, and that of the responding agency. Despite, and perhaps even because of, your own years of experience with handling people and circumstances like this as a public safety professional, you may not always see as clearly when it comes to someone you know. Your heart may be in the right place, but your mind may not. You may want to do the right thing, but your ordinarily clear vision may be obscured by your own feelings about suicide, and traumatic death as well as your feelings about the person involved.

This in itself does not have to be an obstacle to providing an appropriate response. However, maintaining a conscious awareness of where you are on the continuum of feelings and how and when they may influence your actions is vitally important.
Interviews with suicide survivors tell us the actual window of time during which they are at greatest risk for attempting suicide is extremely small. If appropriate intervention is provided quickly the impulse to suicide fades and may not resume again. Consequently your next step is an important one.
Best rule of thumb, when it comes to someone you know:
 
When in doubt, refer them out. Consult, consult, consult.
 
Don't be alone in making such an important decision. You may think that you are maintaining confidentiality or protecting someone you care about from unnecessary stress by not telling someone else, but the consequences of not acting can be fatal. You will also live for a very long time with the memory of your decision.

Consulting with someone else (a professional, a supervisor, a trusted friend and colleague) is particularly important if you've endorsed two or more on the list above, and the person in question is actively presenting with symptoms and behavior that are of serious concern to you. The closer you feel to that person, the harder it may be to decide what to do, but if the Red Flags are showing up on the horizon, trust your feelings. The Red Flags wouldn't be there if something wasn't going on. Better to err on the side of caution then to risk someone's life.  

Anything you choose to do can be done carefully, and with kindness and respect. 
The intention of your actions should reflect the care that you feel and the integrity of your beliefs. You are acting to preserve the person, and the relationship, not just to follow standard operating procedures. If you're genuine in your intent, most people you are close to, even those in crisis and those you don't know, will feel that and know it. They will try to meet you where you are. If you are not genuine, they will feel that and know that, too. If you are not the best person for the approach, and you may not be, (There's no shame to this.) "When in doubt, refer them out. Consult, consult, consult." No matter how responsible you may feel for your friend and or colleague, you really are not the only person capable of helping. Let someone else try.
 
“You talk about raising the Red Flags and you list 16 things that can and should raise a Red Flag in an employee or coworker. Christ, I answered yes to most of them and I feel I am a well-adjusted person who just happens to deal with death on a regular basis.
 
Our agency regularly offers critical incident debriefings to any employees who have experienced or handled a critical incident. In homicide we have experienced awful human suffering almost daily but we all successfully practice “functional detachment and denial.” We are too busy to think about the tragedy of an incident and there is always a new case that quickly replaces the current investigation. I don’t know how we coped with what we do but we all seem to have developed that “thick skin” to shield ourselves. I suppose the reason is we don’t know most of our victims even though we can relate to some of them.

I have been involved in the investigation of three employees who have committed suicide. In one of the cases I personally spoke by telephone to a deputy just minutes before he shot himself to death. My conversation with him threw up numerous Red Flags and I called for rescue and patrol deputies to respond to his residence immediately. He killed himself in the time it took responding units to arrive.
I believe that because of my experiences I do recognize the danger signs when others will often rationalize. Your motto, “When in doubt, refer them out. Consult, consult, consult,” is something we stress in our agency although I know we have employees who wouldn’t recognize a clue if it hit them in the face.”
 

If, after reading this chapter, you find you would like additional more detailed explanation of the List of 16, please go the section entitled, “Oh Say Can You See, The Red Flags Flying Over Me.”  
 
 Guidelines For Understanding Suicidal Behavior 

Although there are many lists and formats that are available to help you in this process, the following represents a list intended on providing guidelines for understanding suicidal behavior and coping with the aftermath. It is by no means all-inclusive and there may be other methods or aspects that are not covered in this material. This list can also serve as a stand-alone presentation or hand-out during roll call.

If you find information that is more relevant to you, your situation, or even your temperament and personality we encourage you to use it. In fact, we also encourage you to share this material with whomever you can wherever and whenever appropriate. There can never be too much good resource information on hand.
 
What Motivates Someone To Consider Suicide As A Viable Option?
 
v A Cry for Help – feeling helpless and hopeless 
v As a manipulation or means of control, feeling helpless, out of control, trying to get a response from other people, attempting to regain perceived power 
v To end physical and/or emotional pain and suffering, overwhelming feelings of sadness, depression, anxiety, despair
v Anger 
v There appears no other alternative.
 
Indirect Methods or Signs of Suicidal Intent or Suicidal Ideation
 
¨ Excessive risk taking on the job – putting self in harm’s way (not wear flak jacket, not calling for backup when needed, antagonizing an already volatile situation unnecessarily, reckless driving) 
¨ Excessive risk taking elsewhere
¨ High risk behaviors – not perceiving or acknowledging danger where danger exists 
¨ Drinking and drug abuse 
¨ Non-compliance with prescribed treatment or medication 
¨ Provoking confrontations with dangerous individuals 
¨ Reckless driving and car accidents, falls and other “accidents”
 
Direct Methods 
¨ Any lethal method
Possible Early Warning Signs 
¨ Hopeless and helpless statements, “Things will never get better.” 
¨ Suicidal statements: overt and implied, “Maybe I should kill myself”, “My life is over”, “I’m on the edge”, or “I’m losing it” 
¨ Depression and/or excessive crying
¨ Recent loss coupled with a decline in functioning – “I can’t go on because of / or without _________”
¨ Statement of worthlessness, self-hate, and intense guilt, “I was never any good at relationships anyway.” 
¨ Angry statements such as, “If I can’t have him or her, then no one can.” 
¨ Statements that suggest over identifying with someone who committed suicide, “I wish it were me;” “If someone like him could do it then anyone can.” 
¨ Getting affairs in order – giving away personal possessions 
¨ Any evidence of indirect or direct methods of suicidal behavior (“practicing,” storing or “hording medications,” suspicious signs of “cutting” on self or evidence of self-injurious behavior, etc.)
Possible Interventions With Someone Exhibiting Early Warning Signs 
¨ Offer to talk to and be with the person. Listen and don’t feel responsible for being “the problem solver.” You don’t have to “fix it.” You just have to be mindfully genuinely present. Many times that in itself is a gift to the person who is hurting and can do wonders for mitigating the circumstances. 
¨ Ask the person if they are having thoughts of hurting themselves. Many people are extremely anxious about asking this question, as though voicing their concerns will “push the other person over the edge.” Again, as long you are genuine in your intention and respectful and caring in your approach, many times hearing the words out loud from outside of themselves is a tremendous relief to the troubled person. 
¨ Show concern without trying to take control. Control might be something you are used to having given your professional role and responsibilities, but this is one situation where you do not “hold the ace in the hole.” 
¨ Involve significant others. 
¨ Refer the individual to a mental health professional or crisis intervention facility. 
¨ Call 911. 
¨ Involve the supervisor. Tell someone if you have any doubts. It’s better to be safe than sorry.
 
Normal Reactions to Someone Exhibiting Suicidal Behavior or Intent 

Different people have different reactions to the suicidal behavior and suicide of another person, depending on their relationship with that person and their own life circumstances. However, some normal reactions to this kind of event can be expected. 
Emotional
¨ Concern, surprise, disbelief
¨ Numbness, detachment
¨ Overwhelmed, lost, vulnerable
¨ Feeling abandoned, alienated, disenchanted, disillusioned
¨ Generalized anxiety
¨ Identifying with the person
¨ Helplessness, feeling like a failure
¨ Fear, guilt
¨ Anger, wanting to blame, irritability
¨ Uncertainty of feelings, confusion
¨ Spaced out, lost
Cognitive
¨ Self-doubt, replaying old conversations and thinking, “I should have seen it coming”, or “What did I miss?” or “If only I had…”
¨ Preoccupation with the person and the situation; can’t stop thinking about them.
¨ Taking on the characteristics and concerns of the suicidal person; becoming over responsive or responsible for their feelings or behavior.
¨ Increased or decreased awareness of the surroundings.
¨ Heightened or lowered alertness.
¨ Preoccupation with vulnerability or death.
¨ Poor concentration, flashbacks, distressing dreams.
¨ Memory problems, calculation difficulties, losing things.
¨ Difficulties with decision-making.
¨ Spiritual crisis; a questioning of religious or spiritual beliefs.
¨ Confusion, lowered attention span.
¨ Suicidal ideation without action or intent.
Behavioral
¨ Change in activity level, withdrawal, or clingy behavior.
¨ Less or more communicative than usual.
¨ Change in interactions with others, excessive gallows or morbid humor.
¨ Increased or decreased food intake, increased smoking, increased spending.
¨ Overly vigilant to environment.
¨ Increased alcohol intake without awareness of consequences or with the intention of exacerbating circumstances.
¨ Avoidance behavior.
¨ Acting out, antisocial acts, angry outbursts
¨ Suspiciousness 
Physical
¨ Nausea, upset stomach, diarrhea
¨ Muscle aches, feeling uncoordinated, shakes, tremors
¨ Fatigue, sleep disturbance
¨ Profuse sweating, chills, rapid heart rate
¨ Headaches, vision problems, dry mouth
¨ More frequent visits to the physician for nonspecific complaints
 
Grief and Bereavement Process Following A Completed Suicide or Serious Attempt With Injury 

· Denial- "This can't be happening!"
· Anger- "How could something like this happen!"
· Bargaining- "If only...!"
· Depression- "This is sad."
· Acceptance- "Sometimes bad things happen to good people."
· Not everyone goes through all the stages in order, or according to a set time frame in which feelings will be resolved. Allow yourself, or others, the time needed to work through it. When you’re ready to move on, you’ll know.  

Coping Strategies

1. Talk about thoughts and feelings with people you trust and feel safe with. In fact, we recommend that you talk “until you’re blue in the face.” In most cases, there is no such thing as talking too much. 
2. Connect with others. Don’t set yourself apart or convince yourself that this is something you have to do on your own. Don’t suffer alone. 
3. Get rest but avoid boredom. Maintaining a normal activity level with positive interests and distractions and resting when fatigued is instrumental to healing healthily. 
4. Eat well. This means eat foods that will replenish your life and vitality and give you the energy you need to cope effective. Limit your intake of “empty calories”, foods you know offer nothing beneficial to you beyond satisfying a need to eat or do something with your time and feelings. Limit caffeine, sugar, fat, salt. 
5. Drink more fluids (water and fruit juices are best); eat complex carbohydrates, low-fat and nonfat foods.  
6. Avoid excessive alcohol or over dependence on over the counter substances. If you are unable to sleep, or are experiencing excessive behavioral or physical symptoms beyond a reasonable amount of time see your family practitioner or alternative health care provider. Err on the side of caution. Emotional experiences can manifest in very real physical symptoms that may require professional evaluation and intervention. 
7. Should this event receive media attention, limit your direct exposure and the direct exposure of those involved to the most common forms of media, such as television, cable, newspapers and radio, for at least the first few days.  
If you or any first responder member of your work unit are asked to report on the event through media interviews include someone from your organization, such as press and media relations, to act as support and run interference. Unsupported or overexposure to the impact of a potentially relentless media, either directly or indirectly, can retraumatize the individual unnecessarily.  Use caution. If this cannot be avoided then make certain those involved receive follow-up support services. 
8. Engaging in physical exertion, and exercise as soon as possible after demobilization is extremely helpful. However, keep in mind that the goal of working out is facilitating the body’s normal process of elimination of potentially damaging stress chemicals. Keep the work out to a level of moderate intensity.  
9. Try to restore normality to your daily routine as soon as possible and, when you are ready.  Maintaining normal routines, no matter how small have a “grounding effect” on most people, and will help you reclaim a life you may feel has been shaken by the event. However, also give yourself permission to change things up a little when needed, such as letting go of task you might ordinarily do so as to spend time with a supportive friend or family member. 
10. Maintain working, if possible. The daily structure and routine will help normalize the situation and provide a grounding element that may be needed and welcome. 
11. Allow yourself time to grieve and heal. There’s no time schedule.
12. View your reactions as normal reactions to trauma. Let yourself “off the hook.” Being a professional in emergency public safety does not mean that you “should” not have feelings or that you should get over them sooner and more readily then someone else. . In fact, all to the contrary, it may mean that the successful resolution of your feelings and reaction may be more complex because of your experience and background. Give yourself the room to be human. It’s not a bad thing. Honest. 
13. Allow yourself the freedom to talk about your reactions to what happened with non-judgmental listeners. Choose carefully, however. A judgmental critical listener may reinforce your fear that it’s not safe to express your true feelings. This is not a good thing and is counterintuitive to the healing you will need.
14. Seek peer, clergy, or professional assistance as necessary. While not everyone has experience with emergency public safety professionals, there are many wonderful, supportive and competent professionals who are more then willing and able to help you or our colleagues. Use them; that’s what they are there for. If you have a spiritual practice, even if long gone and neglected, this is the time to resurrect it.  
15.  Don’t be afraid or embarrassed to draw comfort from any resource or avenue potentially available to you, no matter how many years it’s been since you’ve been to church, confession, the temple or wherever.  
16. Work on accepting that anyone in your situation would have responded similarly. When it comes to someone who is close to you, professional or personal, no one can be certain how he or she will respond to a critical event until the moment is upon us. Again give yourself room to be human. You are. Don’t become another statistic. 
17. Be gentle with yourself. Move away from beating yourself up. No one has a “crystal ball.” No matter what you think you knew or didn’t know, no one has the ability to predict someone else’s behavior with 100% accuracy. If someone tells you they do, they’re wrong. If you think you do, you’re wrong. Give it up. Let this one go. Resistance is futile. Holding on to it is only finding a way to punish yourself further. You don’t need it. 
18. Consider using this crisis as an opportunity for growth, healing and positive change. Refocus your goals and energy on what is really important to you. Hug your kids. Love your friends and family members. Remember to be affectionate with your spouse or significant other. Be kind to yourself.
19. Allow yourself to be cared for by others. Let them get close enough to love you, or at least express caring feelings. Stoicism is not always the best defense. Sometimes the best defense is no defense. “The walls that keep you safe, also keep you isolated and lonely.” This doesn’t mean give an open door policy to everyone in your division, but if you’re too busy defending yourself against potential intruders, you also sever any potential opportunities for support. Be discreet and selective. Try giving yourself the opportunity to be known by someone who truly cares for you. It can help. 
20. Attend and participate in a debriefing. If none is offered by your department seek one out on your own. Remember to follow up with additional contacts if one session feels inadequate. You may have to ask for this or actively seek out services on your own. You may have to be persistent. Do it. You are worth it.
21. Debriefings don't work for everyone. If you or someone else are one of those for whom this is true, please keep the above mentioned items in mind, even for you. Being honest with oneself about ones needs and feelings is one of the hardest things we can ever do. Most of us are not early as honest with ourselves as we think we are. Make sure.

When to seek additional assistance or help:
¨ Persistent intense feelings of discomfort. Unusually intense family conflicts that are out of the ordinary for your family or relationships.
¨ Significant symptoms that persist longer than four to six weeks (emotional, behavioral, physical). Unable to use traditional methods for self-soothing.
¨ Persistent suicidal thoughts and/or suicidal planning.
¨ Feel as though you are losing control of your impulses or losing conscious awareness of your behaviors or actions.  
¨ Other self-destructive acting-out that is atypical for you or intensified, (sexual, financial, aggressive, or substance). 
¨ Extreme behavioral changes such as increased inhibition, social isolation, cutting off of most normal contacts, behaviors or friendships. 
¨ Persistently checking in with yourself or others to see if you're "normal."

Where To Seek Assistance
Licensed psychologist or other health care provider in your local area. Employee Assistance Program or Peer Counseling Program
A peer who has been through a similar situation, and with whom you feel comfortable. A mental health worker or counselor through your health plan.  Clergy member of your church, temple or other organized religion or spiritual faith.   
Special Notes 
Supervisors A 13 Year Old Boy Named Jack Family Members, Partners, Friends, Parents of EPSP A Young Couple Love An EPS Professional “Oh Say Can You See, The Red Flags Flying Over Sergeant North Organizations, Books, Articles, Websites and Other Resources  
 
Supervisors 
 
Being a good supervisor can be a tough job on any day of the week, but it’s particularly challenging when navigating the proper channels for managing certain types of emotionally laden situations such as suicide.

No one expects you to “have eyes in the back of your head,” but should you know first hand that a subordinate has had a family member, child, spouse, friend, partner or loved one suicide in the past, taking a few extra minutes to check in with him or her when he or she is the first responder or first point of contact in a suicide can go a long way towards preserving the quality of life for someone and reducing the potential for stress related problems in the future.

This is particularly important if the suicide victim is a child or someone known to the individual, such as a partner or friend.  

Many supervisors feel pressed for time in a schedule that is already significantly overextended. Given their daily pressure cooker of commitments many supervisors I’ve spoken to are reluctant to say anything at all, either because of their own anxiety or discomfort about the topic in general and their lack of available time, or privacy issues when it comes to someone they know. They don’t want to say the wrong thing so they don’t say anything at all. They assume that if this individual needed something from the division, or the supervisor, that he or she would say so.
 
First line of approach: Don’t make assumptions.
 
Showing genuine concern for the well being of an employee or subordinate is worth its weight in gold. You don’t have to write a speech or block out a massive chunk of time in your schedule. It can be as simple as saying a few words, “I heard you were the first responder on the suicide of that 13 year old last night. I just wanted to check in with you to see how you’re doing,” and wait to hear and listen to the answer.
 You don’t have to fix anything. You don’t even have to comment on what they say, just listen and then wish them well, let them know you’re available and go on with your day. Most people are not going to tell you the “whole story,” their life’s history and then how they felt when they rolled out to the crime scene last night, but they will appreciate your awareness of the potential impact it might have had on them and they will remember this.

If you show someone genuine concern you communicate by your actions and behavior that you value that person as a human being. This will go a long way towards maintaining the morale of that person, and of your division.
 
A 13 Year Old Boy Named Jack
 
One of the most significant calls I ever rolled out on was the suicide by hanging of a 13 year old boy. His mother had died the year before. That evening he had dinner with his father, brother and friend, played a game of Nintendo, and then went up to his bedroom. Minutes later his friend found him in his father’s bedroom. He had taken several of his father’s neckties and hung himself from a hook on the closet door. The family called 911 and both emergency medical and police were dispatched on the call. The responding officers were in the neighborhood at the time the call was broadcast and arrived within minutes. The boy was still alive. The responding officers joined in with the paramedics to assist in saving this young boys life. Unfortunately they were unsuccessful and he coded on scene.

I was called out to respond to the division and I was there when the 4 officers returned from the hospital. You may wonder if requesting that a psychologist respond to a division following a suicide is standard operating procedure. It is not. In a city as large as Los Angeles if I had to respond every time patrol responded to a suicide, sadly, I might as well live at the division. There are far too many for this type of direct response, but there were several factors about this call that made it a particularly significant one.

First significant factor: the age of the victim. As I heard repeatedly that night, from each officer, “What does a 13 year old have going on in his life that’s so bad that he kills himself? I didn’t think about things like suicide when I was 13! How could a kid this young feel so hopeless?”

Second significant factor, four out of four officers had young children in their lives and in their homes, (sons and daughters, nieces and nephews). All four officers were experienced tenured officers and yet this suicide rocked them back in their seats. They openly cried during their individual debriefings as they talked about their feelings. Why? Because when they arrived on scene the boy was still alive and as they worked with paramedics to keep him alive they were reminded of the children they had at home. They saw their own sons and daughters in the face of this young boy, and they witnessed their own anguish and grief in the eyes of his father. The boy’s suicide was so unexpected, and ultimately unpreventable. The officers were reminded that no one is invulnerable to unforeseen events.

 Third significant factor, one of the responding officers had a teenage daughter who attempted suicide the year before. While his daughter had been in treatment and was reportedly stable, witnessing the death of this young boy brought up many of the feelings he had when his own child had attempted suicide. He had been the one to find her unconscious body. Fortunately, in his case, his daughter survived. Yet, as any parent or person who has ever had a family member attempt suicide knows, sometimes ones grasp on reality can be fragile and fleeting. No parent ever expects their child to die before them, especially in a suicide. If it happened once, could it happen again?

As can almost be expected when working with emergency public safety professionals, not one of the officers confided in the other about their feelings, but they openly shared their feelings with me. The Watch Commander, a female Sergeant with 18 years on the job, didn’t wait for them to come to her. She knew the circumstances of the death, made a reasonable prediction about the impact the death would have on her officers, and knowing a little bit about the circumstances concerning Officer “Smith’s” daughter made the decision to call me in.
She didn’t have to do anything, if she didn’t want to, but she decided to work proactively and preventatively. She took the extra step. Later, she also checked in with her officers individually when they returned on their next duty day. No big song and dance, no standing on soapboxes for an oratory speech, no lengthy extended appointment to discuss deep-seated psychological problems. Just a few words said at the right time and at the right place, “Just checking in with you. How’s it going?”
A simple act of genuine concern towards an individual can do so much to preserve the integrity and safety of a professional relationship and working environment. Ultimately, everyone benefits, including the organization.  

Family Members, Partners, Friends, Parents of EPSP 
 
“Unless you’re one of us you can’t possibly understand what it’s like to be one of us. The things we see and experience every day… how can we even begin to explain them to you?” 
A common explanation, and inarguably the truth: How does one assess the severity of the circumstances surrounding the needs of the person you love? With diligence, perseverance and patience. There is a fine line, at times, between what you need to know and what you want to know. Certainly there are some circumstances that your partner (family member, friend, etc) in EPSP can not share with you that are duty related, however, the feelings associated with their experiences can always be shared. Are you ready to listen?
 
A Young Couple
 
The other month I was with a young couple, married for five years, and an officer for six.

The officer was a first responder on a “jumper” (a suicide by jumping off a 14 story building). It had been his first time responding to a completed suicide in which the injuries were so catastrophic. He was extremely upset but maintained throughout the call.

Once the coroner had removed the body he’d returned to the division to complete his paperwork on the incident, and called his wife. His wife wanted to listen to him, but when he began to describe the details of the injuries his wife stopped him. Later, she was angry with him for telling her such terrible things. He stopped talking to her about most things related to work.

Two years later, I saw them in marital counseling. In session with me she complained that he never talked to her about anything anymore. She felt disregarded and detached. He complained that he never knew what was safe and what wasn’t safe to talk about. Rather then upset her because he did love her, he simply “sucked it up” and stopped talking.

“I didn’t feel comfortable talking in a group with my peers so I didn’t. I tried to talk to my wife about it but she couldn’t listen. I talked to a couple female co-workers about it but that only made it worse, so I continued to repress my feelings. I had flashbacks and nightmares on and off for almost two years. I told no one.” 

Finding and seeing the body at the scene is the single strongest predictor of grief severity. In Predictors and Correlates of Grief and Suicide researcher Jay Callahan recommends that support groups need to pay attention to the trauma of suicide as well as the grief reactions, including helping people talk about and cope with traumatic images.

Those of you who are emotionally involved with someone in emergency public safety are in a tenuous position. Like the woman I just described to you, you may not want to hear the gory details about what your partner sees or listens to every day, but you don’t have to hear the gory details to be emotionally present for someone you care about. All you really have to do is be there and show up for the experience. What you will then be privileged to listen to is some very important information about someone you care deeply about. 

People working in emergency public safety are repeatedly exposed to suicide and death. It is, unfortunately, a routine part of their job. Some EPS professionals can become exceedingly proficient at denying the presence of their own feelings, yet they are still impacted by their experiences everyday. There is no hard and fast rule as to when and what will tip the barrel and open the floodgates for any one individual. Everyone is different and their tolerance level, history and personal experiences will influence their response and reactions to any single or series of events, but if Red Flags are coming up on the horizon for you concerning the person you love, don’t ignore them. The Red Flags are there for a reason.

You may also be inclined to believe that because your loved one is not on the front line, he or she is a 911 dispatcher; you don’t have to be concerned. Wrong. I know few dispatchers who do not feel they are first on scene when responding to a call. In fact, the vast majority of dispatchers I’ve worked with feel that as a First Point of Contact they are as much on scene of an event as a First Responder. Unfortunately dispatchers receive about half the recognition or validation as First Responders do while experiencing relatively equivalent levels of stress and trauma related to the calls they handle. Ultimately it has an impact.

“I took a 911 call from a woman whose husband was having a difficult time breathing. Easy enough, I thought, or maybe the word is “routine.” We started going through E.M.D. and some prearrivals. The call progressively got worse. The man stopped breathing and I instructed the woman to do CPR. As she was performing CPR she was relaying the fact that her husband had lung cancer. He didn’t make it.
The rescue squad that arrived on scene relayed the information to me later on. I wished I had never been told.

The Fire Chief was the first to arrive on scene. He found the entryway, where the man had collapsed, completely covered in blood. He said he had never in his entire career seen anything like it. He slipped in the blood on the floor. The patient was covered in it. The wife was covered from head to foot in blood, the walls, etc. I think you get the picture. Basically, his lungs and most of his blood were in the entryway or covering his wife.

I was very insistent with her that we do CPR and that she not stop until the rescue squad arrived. I feel responsible for the last moments she spent with her husband; the last memory she will have of him, and the fact that she was left with all that blood and tissue to clean up off of herself and her clothing.

This call never seems to go away.”
 
Love An EPS Professional?
Then Next Time You Sit Down To Talk, Remember The Nitty Gritty 
·
Take the time to ask.  
Be willing to hear the answer.
Be open with your concerns.
Share your own feelings.
Let them know how much you value him or her.
Be available to talk about it again later.
Don’t judge.
Don’t criticize.
Don’t humiliate or induce guilt.
It’s not about you.
It isn’t personal.

 
If , after talking with him or her, you’re still not sure of what you’ve heard, or you are unable to feel satisfied, calmed or comfortable with the responses provided (be excruciatingly honest with yourself here), take the next step. Talk to someone outside the relationship, either to a trusted friend or family member, clergy or to a professional, either alone or with your partner in tow. I call it, “Getting a reality check.” Your partner may become angry or irritated by your actions, but consider the alternative.

I have rolled out to far too many suicides of emergency public safety professionals and in almost every case the individual gave signs of his or her intent in the weeks preceding the suicide.

You may not want to hear it, you may not want to see it but if you’re feeling it and seeing a behavioral and emotional change, it’s there. Trust the feeling. It may not be as bad or as serious as you are fearful of, but if you don’t ask; if you don’t look to see what’s really going on you may not find out until it’s too late. Like Mark Twain said, “Da-nile ain’t just a river in Egypt.” 

 
“Oh Say Can You See, The Red Flags Flying Over Me.” 
 
For those of you who want, or need, more. 
 
 
You’re reading this section because you endorsed one or more of the following sections on the List of 16: 5, 6, 11, 12 or 13 with Plane Crash, Bombing or PDVF with Children, giving you an automatic Four Red Flags. You may wonder why we are weighing these experiences so heavily, particularly if you believe that you have come a long way from those early experiences, perhaps occurring during childhood, and now as an adult you’ve “put all that behind you and moved on.” This may be true.
Other experiences may be more recent and are ones that may have occurred to you as an adult or on the job. As an emergency public safety professional it is hard not to have come into direct contact with any number of extraordinary circumstances, some of which, if you work for a large urban organization, become almost standard fare to the EPS professional. Suicides, homicides, child abuse, and domestic violence all come with the territory, and we almost become “numb” to them. We handled them a hundred times before and we’ll handle them a hundred times again before our career comes to a close.

Then, there are some of you who were reluctant to endorse any items because you already knew the list was far longer then you really wanted to acknowledge. Like many good men and women I’ve met in my practice, and in my life, when I ask you how long you’ve been depressed, you answer, “I don’t know. Seems like I’ve always felt this way.”

My intention in flagging these items is not to dispute the quality of your mental health or the prowess by which you have healed and moved on from painful experiences in your life. My intention is to highlight that there are some experiences that occur in our lives that undeniably change who we are as people, and because of those experiences we will never look at the world the same again.

Like many things, this in itself does not have to be an obstacle to living your life or doing your job, as long as you have an awareness of what belongs to you and your history and feelings, and what belongs to the other person and or situation. This is particularly important when working and making decisions in your capacity as an EPS professional.
 
Sergeant North 

I met Sergeant North after he transferred to a new division of a large metropolitan police department. Tall, strikingly handsome, well respected and admired for his work as a professional Sgt. North was said to be on the fast track to success and promotion on the department. Yet, there was a side to Sgt North that few people saw, on or off the job. His personal life was a shambles.

I met him after the dissolution of yet another relationship with a beautiful woman whom he characterized as chaotic, destructive and “high drama.” On several occasions the conflicts in his relationships escalated to the point of violence, with injuries, and on one occasion an outside agency was called to intervene.

It was with great hesitancy and shame Sgt. North admitted that he was the repeated victim of domestic violence. He never fought back. He was depressed and had been depressed for as long as he could remember. The only period of time in his life that he could remember feeling happy was his first year with the department, while in the academy. Shortly after graduating and while still on his probation, his troubles began with his first girlfriend. His personal life had yet to turn around. 

One of four children Sgt North left home at the age of 16 to move in with friends and finish high school. His dream was to become a police officer. His father was a physically abusive tyrant who was both drug and alcohol addicted. His mother was a passive, emotionally fragile woman who eventually broke under the strain of the physical abuse she endured from his father.

Sgt North’s home as a child was frequently the scene of loud dramatic fighting, and horrific and unpredictable violence. On more than one occasion the police were called to respond to reports of domestic violence that many times led to the arrest and incarceration of his father, a former Viet Nam Veteran.

Sgt North left home as soon as he was old enough and at his first legal opportunity. He went on to graduate high school and then immediately applied to a law enforcement agency out of state. He was accepted into the Police Academy. It was his dreams come true. After graduating he went on to become a highly decorated police officer and eventually promoted.

On the job he was a stellar performer. Off the job he was depressed, disillusioned, often despondent and frequently suicidal. He was resigned to live a life that he believed would never match up to what he had once hoped for. He never told anyone on the job how he actually felt and believed that it had no impact whatsoever on his work performance.

“Why,” he asked, “do I always seem to end up with women who are hell bent on destroying me? I do everything for them. I support them. I give them anything they want. I never argue. I don’t drink. I don’t smoke. I don’t cheat. I’m reasonably good looking. When they hit me I never even fight back. I swore I’d never be like my father. But, in the end nothing seems to matter. They still leave me, and they blame me for the problems!” 

How does an attractive bright police officer with all the ear markings for success end up the depressed despondent victim of domestic violence? As a law enforcement officer he’d successfully responded to countless incidents of domestic violence and prided himself on his ability to resolve issues without force. As a supervisor and Sergeant he’d counseled numerous trainees and probationers on marital and relationship issues, and had even become a peer counselor to improve his skills. Yet, in his own personal life he was unable to function.

Is this just one person out of a million? No, in fact the disparity between home life and personal is far more common then you would think. I have met countless good men and women who are consummate professionals and yet, in their personal lives there are huge gaps.

On more then one occasion I a client, “Does your family background and history have any impact on who you are as a professional or how you do business?” In most instances the answer is a resounding, “No.” Some will say, “It’s because of what I went through as a child that I became a police officer,” or dispatcher, or EMT, but few will admit that personal experiences they’ve had either on the job or off have profoundly influenced them professionally.

Sgt North may want to believe that his family history, or his history with women and failed relationships, does not impact how he does business as a police officer and supervisor, but he would be wrong.

No one lives in a vacuum. In his case he learned early on that his “job,” so to speak, was about tolerating and enduring abusive relationships. His threshold for tolerating dysfunctional behavior was much higher then many of his colleagues.

In some cases this proved to be an advantage in that he was more willing to hang in there with a problematic probationer who was “higher maintenance” than other probationers because he believed that in the end he or she could still make a great officer. However in other cases for Sgt North, it was a potential liability. That same ability to tolerate highly dysfunctional behavior also made him vulnerable to not seeing certain types of warning signs or Red Flags concerning particular types of probationers, or other officers. Often times it was not until the problem behavior became so flagrant that it was undeniable. He became forced by circumstances to respond. This left him, at times, in a perilous position, and he did not always make the best choice.

This same process played out in his personal life as well. Every time he picked someone new he believed he was picking someone who was nothing like the last woman he was involved with. Yet, each time the relationship ultimately bore a striking similarity to the last and with it all of the same resultant problems. In each case, it was also not until the relationship became a high stakes high drama that the women in his life were able to get his attention, but by then it was usually too late.

He always seemed to be the last one to know, on each occasion, that this would happen.

So, what does this mean in the final analysis? 

It means that Sgt North has certain vulnerabilities that are derived from his life experiences. In his case, starting with his childhood that became further complicated by his experiences as an adult and as a police officer. As long as Sgt North continues to live with a certain amount of denial he will feed those vulnerabilities, and he will probably continue to be surprised when the next woman he picks turns out to be just like the last woman he picked, again.  

For most of us who are relatively high functioning the work place is usually the last place that is affected. The manifestation of his vulnerability at work may not be as dramatic as it was with his past lovers, but eventually it will manifest in his professional life. It only takes one time to miss something important in public safety and inadvertently place someone at risk.

Is there no hope for Sgt North? Of course there’s hope. There’s always hope if you are willing to look with both eyes open.

Life is unavoidable. The good and the bad, everything about who you are and what you have experienced has gone into who you are as an adult, and as a professional. Even your experiences as a child, as the caretaker of your woefully neglectful parent, have contributed to the adult you grew up to be. It was all part of your path, and whether you are consciously aware of this or not, it has contributed to why you chose a helping profession to begin with.

As a psychologist I have to be aware of what belongs to me and what belongs to other people. It’s my job. If I am unable to distinguish the difference and I over identify with a client then I’m in trouble and ultimately the therapy is in trouble. My job is to be aware of where the lines are.

As a supervisor, training officer, Watch Commander, Shift Supervisor, police officer, EMT, dispatcher, we are all inherently tasked with knowing where the lines are. Few of us come from perfect backgrounds or have lives that haven’t in some way been touched by tragic or painful circumstances, but that does not in itself have to become an obstacle to living our lives unless we choose it to be that way. Sgt North didn’t intend on becoming a victim in his life. He looked like anything but a victim on the surface, but many of his choices have pulled him down that path. Until now, he has not wanted to take responsibility for what is his life.
 
I didn’t have an idyllic childhood. I’ve had experiences that at times have separated me from those of others, and I haven’t always wanted to see the part I’ve played in creating the problems or maintaining the dysfunctional behavior, but there came a point when I decided I’d had enough.

As a psychologist I’ve believed it was also my professional obligation to be willing to look at what is mine and to do the work needed to become healthier. I have come to understand, accept and take responsibility for what is my life. I’ve learned how to use these experiences to inform me about what is really important to me and what choices I need to make. I’m not always right. I still make mistakes, but that’s OK. I’m human and as long as I’m willing to be abundantly clear and painfully honest with myself, when I need to be, and sometimes even when I don’t want to be, it works out. I have a good life and I am able to do my job, and do it well.

I’ve come to accept that I cannot treat every person who comes to me for help, no matter how much they may want me to, and that I may not always be the best fit for every situation I am asked to handle. I know now I don’t have to. My responsibility is knowing when to say “No,” and when to refer out.

Everything about my life, my experiences in my family, my friends, the way kids used to tease me in elementary school for being “too tall and having curly hair,” the day my mother died, the year we lost our house, the first time a boy ever kissed me, (His name was Mike and we were standing in the stationhouse of the Long Island Rail Road in Kings Park. I was in eighth grade. My mother drove up just as his lips touched mine.), to my experiences as an adult, the first suicide I ever witnessed, the first time my heart was broken, the first moment I saw the lifeless body of the bank robber at my feet at the scene of the North Hollywood Bank Robbery of 1997, all of these experiences and feelings have gone into who I am and have made me the adult, the person and the clinician that I am.

This is neither good nor bad. It’s just what it is, my life as I know it, the same as yours is for you.

 We all have Red Flags. The challenge is being honest with ourselves. If you’re not the person for the situation, if you’re too close to the person you’re concerned about, if your own feelings are getting in the way and clouding your judgment, there’s no shame to this as long as you are aware of your potential vulnerabilities or Red Flags. With awareness we have choices. With denial we have only reactions and sometimes the decisions are made for us. When that happens, sometimes there’s no going back again.

Organizations, Books, Articles, Websites and Other Resources
 
Psychosocial Approaches to Suicide Prevention: Applications to Patients with Bipolar Disorders, Gray SM, Otto MW; Journal of Clinical Psychiatry 2001; 62 Suppl 25: 56-64 
Pharmacologic Interventions in Suicide Prevention, Tondo L, Ghiani C, Albert M; Journal of Clinical Psychiatry 2001; 62 Suppl 25: 51-55 
Childhood abuse, household dysfunction and risk of attempted suicide throughout the life span: findings from Adverse Childhood Experiences study, Dube SR, Anda RF, Felitti VS, Chapman DP, Williamson DF, Gibs WH; Journal of American Medical Association 2001 Dec 26; 286 (24) 3126-3127 
Coping, meaning in life, and suicidal manifestations: examining gender differences, Edwards MJ, Holden RR; Journal of Clinical Psychology 2001 Dec; 57 (12) 1517-1534
The National Strategy for Suicide Prevention Krulewitch CJ; Journal of Midwifery Womens Health 2001 Sep-Oct, 46 (5) 304 
Training Program in suicide prevention for psychiatric nursing personnel enhance attitudes to attempted suicide patients, Samuelsson M, Asbey M,; International Journal of Nursing Studies, Vol 39, Issue 1 Jan 2002 115-121 
What would you say to the person on the roof? A Suicide Prevention Text, Elitzur AC, Omer H; Suicide Life Threat Behavior 2001 Summer, 31 (2) 129-139 
Recognizing and Responding to a Suicide Crisis, Hendin H, Maltzberger JT, Lipschitz A, Haas AP, Kyle J; Ann N.Y. Acad Sci 2001 Apr, 932: 169-186 
Therapists’ Reactions to Patients’ Suicides American Journal of Psychiatry 2000 Dec, 157 (12): 2022-2027 
A New Suicide, Bhalerao S; Journal of Family Practice 2001 June; 50 (6): 551 
Developing a comprehensive school suicide prevention program, King KA; Journal of School Health 2001 Apr; 71 (4) 132-137 
Suicide Prevention. Holding On Laurent C; Health Services Journal 2000 Oct 5; 110 (5725): Suppl 6-7 
Preventing Suicide and Premature Death by Education and Treatment, Rutz W; Journal of Affective Disorders 2001 Jan; 62 (1-2) 123-129 
From the Centers for Disease Control and Prevention: Suicide Prevention Among Active Duty Air Force Personnel--United States 1990-1999; Journal of the American Medical Association 2000 Jan 12; 283 (2): 193-194 
A Review of the Literature On Prevention of Suicide Through Interventions in Accident and Emergency Departments, Repper J; Journal of Clinical Nursing 1999 Jan; 8 (1): 3-12 
Suicide Prevention Protocol, Robie D, Edgemon-Hill EJ, Phelps B, Schmitz C, Laughlin JA; American Journal of Nursing 99 Dec; 99 (12): 53-55, 57 
A Suicide Prevention Advisory Group at an Academic Medical Center, Hough D, Lewis P; Military Medicine 2000 Feb; 165 (2): 97-100 
Adolescent Victimization and Associated Suicidal and Violent Behavior Cleary SD; Adolescence 2000 Winter; 35 (140): 671-682