 Hi I am delighted to be here with you this morning and want to thank Chief Wright for giving us the chance to talk to you about a very important topic one that as you know since the start of the year we've had some higher numbers and going to present some information to you give you lots of takeaways I'm actually going to be talking in terms of the suicidal mind and give you some information about how a person actually becomes suicidal I think you can't do good prevention or intervention or postvention unless a person actually understands the the suicidal mind so I'm going to give you some information about that and the focus of the lecture however is on postvention it's a term that some people are not familiar with it is a component of the three components of suicide prevention and you will leave here again with a whole lot of information now when I was when I started lecturing for the Air Force about 10 years ago we didn't do much lecturing on postvention and we weren't making a lot of headway on postvention but we are now and joining me today is Lieutenant Colonel Madison to give you information on trend data as well as the progress that we're making on postvention as we move forward so I want to spend a little time talking about defining the challenge why is this a challenge for chiefs because you're going to have to keep the conversation going about suicide this is not a topic as you know that's going to go away but how are you going to be engaging enough to keep that topic going so people understand it's something that we do need to keep at the forefront and think about in terms of taking better care of people and then again helping you understand the mind and then the postvention so there's a three prong process to suicide prevention we've done pretty good on prevention we've done pretty good on intervention we need to get better on the postvention and we really are now the idea of postvention which I'll define in just a moment is that if you do good postvention work after a suicide it actually becomes very good prevention work so it's important that we get the postvention side of it remembering again that there are three prongs to it and I think for the most part what we did is we got very heavily involved in prevention because when the number started to rise several years ago we needed to get involved in intervention actually first then we took a step back and caught our breath and got very involved in prevention and now again we're moving forward on postvention so what is this thing I talk about when I say postvention it is the things that leaders will do following a suicide that will help make the difference in rebuilding a community following a tragedy of such such a kind of such sort so there are three actual components to three goals for effective postvention this isn't just willy-nilly off the you know off the cuff there are actually primary goals that will make postvention more effective the first is promoting healing promoting healing among those in the community that are suffering because of the loss of an airman the second is to reduce the risk of contagion and what is contagion if you've probably heard the word but let me explain that contagion is a fact that many people are many well many people in the audience or in a squadron or in a unit might have depression might have anxiety and might be thinking about suicide and so the contagion effect is not that you're going to put the idea in someone's head but that the ideas are already there and they may act on their own ideas about suicide following another suicide that they saw occur and then identifying those at risk and making sure that we get them connected well to the resources that they need those are the primary goals of effective postvention your use serve as a role model how you handle the aftermath of a suicide is actually going to model for all the airmen how we move forward and rebuilding the community so part of the challenge I think in suicide especially in the postvention phase is that you need to manage your own emotions and responses regarding suicide but we don't ask ourselves these questions very often we don't ask who do I think dies or kills him or herself by suicide what do I believe about suicide what was I raised to believe about suicide and I can say this because I've been living in the south now for 15 years but if you're born and raised in the south and you were taught that a person who dies by suicide will burn in hell then you have to know that it will affect if you ask questions what questions you ask how you ask them and what you do with the information so it's very important that you do a self-assessment also so that when you have a colleague who is experiencing a suicide and is rolling through the postvention process you know how to better support them because you have your own you've managed your own emotions about suicide itself so understanding suicide again as I mentioned a moment ago it's very important for us to understand the suicidal mind I think this is a miss we we miss the mark on not helping people understand what gets a person to that point so let me explain it just a little bit I know this is a little bit of a busy slide it's probably one of the busiest I have but it is in one slide captures the essence of the suicidal mind so the first thing is that it's primarily a decision made by a person that's experiencing real or perceived pain whether it's real pain in that they've lost a limb they're recovering from some illness or something of that sort or it's perceived that they're going through a divorce after 15 years and they don't know how they're going to recover from it that's perceived pain now there are different theories that actually explain suicide and the theory that we submit to you today is by Thomas Joyner who's one of the leading suicidologists in the nation right now and Thomas Joyner indicates that there are three components that lead a person to think about suicide the first is that they believe they are of some sort of burden that their suicidal thinking or that their lives and their circumstances are a burden to that person and to those that love them and so they feel that they're carrying this burden and they don't want to share it with another person what that leads to oftentimes is a sense of disconnectedness now these are not linear these things do not actually happen in order they happen together so you can actually feel a sense of disconnectedness before you feel a sense of burdensomeness but when you combine them together is when you have that suicidal thinking that might emerge so a person that has no authentic connections is a person that's disconnected from their their spiritual community their family their children their work environment and the more that they feel disconnected the more burdened they often feel the third component that will lead a person to suicide is developing a fearlessness about death they develop a sense of capacity to die by suicide there are certain some professions that have a higher rate for suicide than others and one of the professions that has a higher rate for suicide are veterinarians well this is because they are at death's door all the time day in and day out they are euthanizing animals day in and day out and so they're right there at death's door experiencing it they develop an act they acclimate to the idea of death and so it might become easier for them this puts our military members at a bit of a disadvantage because they are taught to lean into the fear and lean into the danger and lean into the death the possibility that you may be sacrificing your life for your nation so they're they're already predisposed to this sense of potential fearlessness about dying and it's not so far stretched that they're feeling the other things to actually want to die by suicide there is something that a person experiences that's suicidal and it's called psychological pain or psych a have you ever seen a commercial for an antidepressant where a person is like holding their head and they're saying but it hurts it hurts because when you get to a certain point when you're thinking about dying by suicide there's actually a physiological change that occurs in the brain that brings you physical pain and so that physical pain is also another burden that this person might carry i also want to draw your attention to the last billet to remind you that we need to do a paradigm shift in terms of how we're thinking about suicide suicide is not attention seeking suicide is help seeking this is about a 40 year old woman who's going through a divorce perhaps or losing custody of her children or a man who's losing custody of the children going through a bitter battle not knowing how the what their circumstances are going to be like after and is trying to seek help but doesn't have the voice what does a two-year-old do when they don't get what they want they throw a temper tantrum right they don't have the vocabulary to even explain what's frustration they're experiencing inside of themselves this is sometimes what happens for teenagers and adults they don't know how to articulate the psychological pain that they're experiencing and so it is acted out but it's a paradigm shift to move our thinking from attention seeking to help seeking if you think about it in terms of the person seeking help then it's easier to digest and manage your own reactions to it so i wanted to show you for those of you are a bit more visual the visual graft of joiner's theory i simply want to make this point that when we get people to cut to begin a discussion about their suicidal thinking when they're experiencing that psychological ache or that disconnectedness we're more likely to get them to step back from desk door it's when we are looking at it and coming at it from that sense of fearlessness or the acquired capacity to die by suicide that it gets a little harder for us to step them away from that idea of suicide so your role as chiefs and as spouses is to try and engage people in the discussion when they're just initially feeling disconnected if we can engage in those discussions at that point we may not even have to refer someone to mental health but of course we know that referring them to mental health is also the one of the one of the most secure ways to help them reduce their suicidal thinking now i was not able to show this slide um 10 years ago we this is an exciting slide to me because we did not have this information 10 or 15 years ago we didn't know what the components to suicide were and then we not only do we not know the components we didn't know what the solutions were we did not know what the issues were that were leading our airmen to suicide necessarily and we certainly didn't know what the solutions were this slide shows you that not only do we know the components we know what the issues are and we know the answers the challenge with this slide is that you all are the arrows how are you actually going to help a person reduce their access to means if we know that having means is a a likelihood a greater likelihood that they're going to potentially die by suicide if we know and we do that relationships are the number one issue facilitating suicide among our airmen you are the aerial the the arrow how are you going to help that airmen strengthen their connections this is exciting information in terms of understanding suicide information that we didn't have many years ago but it's a challenge it's easy for me to say you're the arrow between this the challenge or the issue and the solution but that's the reality so i want to get you thinking about what are you going to do in terms of reducing those issues getting a person who's having legal and administrative issues leading to their suicidal thinking into the education that they need so let's talk about this thing of postvention following a suicide attempt i'm going to talk about following a suicide attempt and then an actual suicide and how to recover from it so the first thing in terms of following a suicide attempt is not to fear the airmen or the issue now that is also easy for me to say i've been working and studying suicide for 15 years and there's not a person i've met who's suicidal that i don't feel fear because i realize this is a difference between whether or not they live or they die so however it's very important that as you lead the way you show the airmen that you're not afraid of it and that this is a reality sometimes for a person and that we will get through it together there's no stronger message that a chief can send or any senior leader can send than to go into the shop following a person's reintegration and stand beside them because of HIPAA you can't say a whole lot but you send a message to that unit or that squadron or that shop that this stuff happens and we're going to get through it together do you want to set the example for engagement if the person does go into the hospital you want to talk with the support staff to determine whether or not you should go and visit the person in the hospital now one thing that many people don't know is that the highest time of risk for a suicidal person after they've attempted suicide is the 90 days following their discharge from hospitals this is an important message for you to understand because oftentimes what happens is we refer the person to the hospital or we get them admitted into the hospital thinking okay they're in a very safe place and they are but we only refer people to the hospital to medically stabilize them not necessarily to reduce their suicidality however by medically stabilizing them they get the medication that they need to become more stable and actually might have the the added energy that they need to follow through with the suicide so it's very important to understand some research indicates that a person in their first 90 days after their discharge is that a great a more than a 270 percent greater likelihood to die by suicide think about that for a moment they're at a more potential higher rate to die by suicide after their discharge and they're coming back to you highly suicidal because the average stay for suicide is about two and a half to three days and if it's more serious maybe five to two five days to two weeks but that's actually not common so it's important to understand that they're coming back and being reintegrated into the units in a highly suicidal state and so your awareness and intervention in this postvention phase is really critical you want to make sure that you are discussing alcohol and weapons with that person you want to make sure that you can explain that you've had the discussion about weapons weapons reduction this doesn't mean wrestling the gun out of their hand but it does mean that you're making it very clear and showing them that you're not afraid of the topic that if they have access to the guns they're in a greater likelihood again to die by suicide you want to help them reintegrate with their peers and you want to ask the question never underestimate your the question when you're asking them what can i do to be helpful in your recovery process ask that question because sometimes they don't know but in asking the question you begin the dialogue that they need to get help from you to reintegrate better you also want to be alert for and watch for the contagion effect and look for signs that that suicide attempt may have affected frontline supervisors i'm i reflect back on the many stories that i have and i think about the first airman suicide that i experienced was a tech sergeant who was going through a very very bitter divorce battle we were at raf millenhall at the time and it was a young airman that actually came into the hangar and found found his supervisor because he was of course as the younger person charged with going in and very early in the morning making sure that everyone had their coffee but that was his experience so it's very important after an attempt to remember the frontline people and the frontline supervisors that will be helping that airman with the reintegration back into their work process now postvention is a little bit different than other types of loss in our lives we can get our heads around cancer does someone dying by cancer cancer happens we can get our minds around the idea of an accidental death accidents happen but no one is prepared for a suicide no one wakes up when the wind is blowing from the west on a wednesday and says i think that this is the day i might lose my loved one they might be suspect that something might be going on but it's a very complicated process and so in addition to feeling the normal types of grief experiences like denial anger bargaining depression and acceptance they might also experience a myriad of other emotions which i have up here for you to take a look at they might experience tremendous guilt we had and guilt not just with suicide but with other kinds of loss as well the the tricky thing about postvention is that you didn't need to know the decedent the person who died in order to feel affected by it what happens when a suicide occurs is it conjures up the grief and loss that people experience from other kinds of losses like loss of their father or loss of loss of a parent or loss of a sibling or loss of a child so they might end up wanting to talk with you or the first sergeant about those losses but it was the suicide loss that actually triggered it so in addition to feeling guilt and embarrassment they might feel that sense of isolation what happens when a person loses a loved one to cancer in the cul-de-sac someone will probably bake a casserole go to their front door and offer them their condolences and let them know if they need anything just to give them a call what happens when a person loses someone to suicide is not only do they not get the casserole but the neighbors go out the back door because they don't know how to engage in a conversation with them this leads to social isolation and when these emotions are experienced there is a there is a chance that it might actually lead that person to suicide one of the factors one of the risk factors in suicide is actually losing someone to suicide that's why this postvention is so important because if an airman that was beside was very good friends in a unit or in a shop with an airman who died by suicide they might be experiencing their own depression and their tremendous sadness and guilt and isolation it reminds me of a story i responded to a suicide once and it was in an ndi shop and it was a smaller shop there are only about seven people and so they had their benches that they were working on and i went up to the first person and i said how are you how are you doing since the loss of the of the sermon and she said i'm not doing so well ma'am because he was my benchmate and i worked with him for three years and i'm you know profoundly sad about this and i went around and i came to the last came up to the last person i asked him how are you doing and he said i'm pissed i'm really pissed he said because i never liked the guy i wanted the guy out of the shop and this is not how i wanted him out of the shop i wanted him out but i didn't want him to leave us one man down and now we have twice the work to take care of so a wide range of emotions from a person who's experienced this postvention after after an attempt or after a completion all right they might have the intrusive thoughts and images or they might have those changes in social relationships and so these are the things that i want you to be aware of that a person is experiencing after they've lost someone to suicide this is a glimpse of what that experience is like we don't often think about fully what the experience of losing someone to suicide is like can you imagine driving on the road this is everyone's worst nightmare ring ring you pick up your phone this is officer so and so i am at your home there's been an incident please come home as quickly as you can of course you're worried about your loved ones um you know it was your child who's there at that time because it's after school and you're actually driving home to go go home to your child so you drive as fast as you can to get home so you can see what's happened you get to the scene you get to your house and all you want to do is run in and take your child in your arms because you know that that because you've been told that your child is dead and you are told that you cannot enter the house because now it is a crime scene can you imagine that experience we don't think about those things when we think about losing someone to suicide also they may be the person that tried to perform CPR another story i have is it was a an air force member and it was a guard member as a matter of fact he wasn't on guard on guard duty that weekend it was happy to be home and his phone kept ringing and he just he saw it with the caller was a sister and he didn't answer it because he didn't want to be bothered after the fourth time he went to the phone he was picking it up and he said man i'm going to give her a piece of my mind and she was screaming into the phone get over here get over here they lived near each other he hopped in his truck he went to the house he tried to perform CPR and his brother-in-law died and he came to me and he said i'm the reason he died and i said well what do you mean he said if i picked up the phone sooner i may have gotten there sooner he said the problem is that i lost my father five months ago i lost my brother who was my other best friend three months ago and now i've lost my brother-in-law and i now am thinking about suicide so you can see the trigger for suicidality is not about a non-resilient person this person was fairly resilient this is about life circumstances that happened that put us in a place that we never thought we could be in so what are some postvention guidelines what are some things that we need you to consider what are the things the actions that you're going to put into place to help rebuild that community after the suicide and that and for and i'm sure that there there's probably not many of you out there i'm acutely aware that have an experienced suicide in some way so i do want to mention that after this we have our contact information on the last slide which you'll be getting copies of you are more than welcome to contact doctor mad at lieutenant colonel madison or myself if you have any follow-up questions or any reactions to the information but in terms of actions that you can put into place you want to be empathic to the survivors now one of the things on emotional intelligence when we give the when we give an emotional intelligence survey or questionnaire or assessment instrument to people is that they may not feel that they have a lot of empathy this is a time where you're going to dig deep and you're going to tap into that empathy because that's what this person needs it is not the time to debate whether or not suicide is right or wrong you want to make sure that you're using the decedent's name and not the words he and she this is a very personal experience to the person who's lost someone to suicide you want to pay close attention to responders and support staff and the best way for me to emphasize that is to share this story again i had a suicide and we decided since it was overseas to have a memorial service on base at the at the chapel so i went to the service and at that it was actually my client who had died by suicide and i always like to caveat this that since i've been studying and working with suicidal patients for a long long time you can imagine that i've had patients who died by suicide so i'm actually a clinical survivor of suicide i don't want you to get the impression that most of my clients die by suicide okay but this in this case what happened did happen to be my client so i went to the memorial service and i'm sort of surveying people to make sure that i can take care of people as needed and i saw a young woman she could not have been more than 19 or 20 years old probably it was her first term assignment and i see her off in the corner somewhere and i went up to her and i said can you tell me how what brings you here today how did you know the person who died by suicide and she said oh i didn't and i said well what brings you here today and she said i'm the photographer that took pictures of the scene of the crime and i said how are you doing since the incident and she said i'm not well i haven't slept since i took the pictures so it's very critical to remember the first responders casualty affairs first the first responders that are there that might have to do the cleanup another story that i have in terms of postvention and you serving and knowing how to watch out for people is there was a suicide and it was on the side of a highway with a gun and the wife called the chief about three days later and said i need my car back so i can get to where i need to be going they didn't have a second car and so they actually asked some members in the unit to go out and secure the car clean the car up and bring the car back to the spouse well one of they did what they didn't know and this they just couldn't have known this really unless he had said something but one of the young airman that went with the three people as one of the three people actually knew the person in fact was on the phone with the person when he actually died by suicide and he felt so guilty he wanted to be as involved as possible so he went along on the cleanup but afterward he was not doing so well so these are circumstances that you tend not to think about but that i want to encourage you to to consider it uh in postvention guidelines be aware of your own reactions to suicide again i bring you back to the earlier slide of managing your own reactions if you've lost someone to suicide in your own life this is going to conjure up new things for you things that haven't been resolved necessarily i want you to understand what the long-term goals for the survivors are what are their goals because their goals in the long-term survival of this are going to be things that you're going to be helping them with so you want they they need to begin to work on reconciling their anger and their fear and their anger may actually be with the air force and so you might be taking the brunt of that but again it's very important to help them work through this long-term goal it might be to forgive the decedent and others that are perceived for this that person's role in their suicide death you want to help them increase their engagement with social networks to reduce their isolation these are things that the families might be reaching out to you for it's not uncommon for a spouse after they've lost their airman to come into the chief's office and engage in a conversation are you comfortable having that conversation what kinds of questions will you ask in that conversation or how will you listen in that conversation they're working on trying to accept the mysteries of the unknown and your work is to try to help them understand that recognizing that if this isn't necessarily about a spouse that dies by suicide this is about i'm sorry an airman that dies by suicide if it's the airman's spouse or child that dies by suicide these are their long-term goals this is what they're going to need assistance with and you want to help them increase the grieving process with other people that have have similar losses and so in every state there's an american foundation for suicide prevention chapter and almost every chapter in each state has survivors of suicide support groups that you might be able to identify locally you can actually get online look at that national website and identify when where support groups are in your state what are the long-term goals for leadership i think chief right talked a little bit about taking care of yourselves and that's why we wanted to include a slide on taking care of yourself at this time one of the most important things i can ask a leader i was at a conference once and there had been a suicide on a base and then originally there were five people from the base five leaders from the base that were going to be coming they sent only one and i was asked at that at that conference where i was speaking on suicide to talk with that general and i came out from where i was speaking and i asked you know i asked some details we talked about postvention have you messaged the right things um what have you done so far what can you do to help rebuild the community and then i stopped and i said now in the last four minutes that i have with you the most important thing i can ask you is how are you doing and he got tears in his eyes and he said i am not doing well i've known this airman for 20 years of my life this is not the person that i thought would die by suicide i'm not doing so well so it's important for your own self-care you are going to be just you for those of you have experienced a suicide you know that you are discharged to take care of the many many people in the community but it is equally important for you to step back and take a look at again managing your own reactions and how this is impacting you you want to make sure that your presence is there and it's useful you want to make sure that the right leader walks through the unit or the squadron at the right time and sometimes as chiefs you're the ones that have the unfortunate blessing if you will to make to tell someone that they're not the ideal person to walk through the walk through the squadron so you want to make sure that it's someone that's actually understand suicide and is sincere about their their their want their desire for the recovery of the community we actually had a death incident of fatality this weekend at acsc we lost an international officer to a hit and run on the side of a road and it was very interesting to me at nine o'clock last night after everything that we were doing to stabilize the faculty the staff and the students i sent the dean a message because i watched him do something that i think he didn't even know he was doing well he was walking through the halls we have four long hallways and he was circulating between all four hot all four hallways just walking back and forth to be he didn't realize this his visibility was absolutely critical in the post-vention phase now that didn't happen to be a suicide it was a critical incident but he did not understand the the the the impact that that was having so visibility of leaders after an incident of suicide is actually very very important and then recognize that other members and other people recover it in different ways i remember another incident again it was in europe when um we had a series of critical incidents and i'm not lying when i tell you they happened what uh three consecutive wednesdays in a row one wednesday we lost someone to a suicide the very and i was working at then if you remember back it was the family support center 20 some years ago so i was working at the family support center we anticipated because it was a small community that people would be coming into the family support center early so we were we had the the recall roster we all got in but remember the old phones we didn't have texting and everything and we got we all came in an hour early to just open up the doors and be available no one came in one week later on that next wednesday we had an accidental death no again we did the recall roster we opened up the doors early thinking now we've had two sequential deaths so they're probably going to start coming in and one week later we had the death of princess diana we were all in shock as well we didn't think to go in early to open the doors and by the time i arrived there was a line of people trying to get in the family support center all the way around the building that's the kind of strange experience that death and grief conjures up for people you just don't know what the trigger is going to be so the long-term goals for leadership are to taper off your increased visibility get back to mission readiness as you know leadership self-care also engage in and promote your own healthy grieving connect with other other colleagues who have lost members to suicide i i might i'd like to start a list actually i should have started this 10 years ago of all the things that senior leaders have done that worked well in the wake of a suicide and the things that haven't worked well and you're actually going to get some information on resources and i'd like to post it on the new website for the air force so that you have some sort of guidance on what have other people's experiences been but in terms of your own self-care connecting with someone else who has lost someone to suicide can be one of the best things you can do for yourself coordinate with your internal and external resources make sure that you know who the best resources are to handle a critical incident like this use this experience as a teachable moment and make sure that you have a postvention plan in place and i'm actually going to give you a resource that you can use if you pulled out the word worker or employee and plugged in the word airman you'd have actually a pretty solid postvention plan and you want to make sure that you follow those postvention protocols so here are some resources for you to be aware of and again you're going to get this on your slides the first three or four are not they don't have anything to do with the air force but i want to point out that the organization connect that is what they specialize in is postvention work they will actually bring people out of course you have to pay them to come out and do postvention work to help you rebuild the community then i want to draw your attention to the last bullet on this slide which is the new resilience website that i just mentioned this website has a lot of a wide variety of resources available for you now it was just i think it was just uploaded and ready to go in late december early january and lieutenant colonel madison is going to tell you more about that and give you some trend data but i want you to know that the what's exciting about that resource and that website is that never before have we had a component of postvention resources available to senior leaders you will find resources for prevention intervention and postvention on that website on that website so it's a very exciting time for the air force as we move forward with this whole concept of teaching senior leaders about how to take care of people after a suicide with that being said i'm going to turn the microphone over to lieutenant colonel madison who's going to give you some additional information thanks all right can we please hear it for dr barrett mary Bartlett and all the work she's been doing thank you dr Bartlett and thank you for our continued partnership and chief right where's chief right he left he's in the back he said he was going to watch i don't know maybe not um i wanted to thank chief right for this opportunity to be here with you all today um as chiefs and very soon to be chiefs and also to your spouses who i'm told are perhaps watching um this on a live stream um i want to thank you all because your reach and your impact when it comes to the care and feeding of our airmen just grew exponentially and that includes your spouse's influence as well suicide is an incredibly complex phenomenon there is no one single answer on how can we never lose another airman or family member to suicide if it was simple we would have solved this years ago okay but it is preventable but it takes every single one of us it takes every system that we have it takes folks in our community to work together to get after never losing another person to suicide suicide is our leading cause of death of our airmen that is the fact we lost 58 last year and we lost 101 total force airmen last year to suicide we lost over 25 family members to suicide we think that number is higher we're working on a way to capture that better and what i really want you all to know as leaders as citizens as parents it is the second leading cause of death of ages 10 to 34 now in our nation ages 10 to 34 so this is something that we all need to collectively get after and so some of the ways that the air force has historically gotten after this is we have worked with professionals like Dr Bartlett to create some tools to help empower and equip our leaders like yourselves on how to prevent how to intervene and then how to help heal after we have lost an airman or a family member to suicide so we do have some tools that we continue to improve and i want you to know that this has all been done with all of you it's with our line leaders our medical leaders who have unfortunately walked that path of postvention every time this happens we try to learn and do better going forward in fact this past year general wilson challenged us to develop a system similar to a safety investigation board to look at cases where we have lost an airman to suicide and so we put this together at the half level we did at this past june we not only looked at active duty cases for the first time at the half level we looked at guard reserve and civilian cases as well from that i think the most important piece is that we partnered with the decedents unit leaders we brought them in and together we discussed what could the air force have done better to prepare you to help you increase the resilience of your units what could we have done to help improve our intervention with this particular airman what could we have done to help you and your unit and the family heal and recover and mitigate some of that risk that we know occurs when we lose a loved one or a friend or a unit member to suicide from that effort now we have a new reg it's 95,001 integrative resilience so at the madcom levels now it is a requirement for you to hold an annual suicide analysis board is the name that we we have given to this process we have standard operating procedures we're here to help in fact right here right after this i'm flying to help the National Guard with theirs so this will be coming to you all and it is purely a way to improve our prevention efforts it's to look at gaps and seams and how can we do better going forward does it require legislation does it just does it require equipping what does it require what can we do collectively as a community to never lose another airman to suicide that's some of the things that we are doing and just please know that you're you're going to be a part of that i mentioned some of these stats at the beginning but i want to share some trends that we're seeing so these are trends from 2018 so just this past calendar year okay um this is what it looks like for our total force this does not include spouses okay we continue to lose more men in fact about 93 of our suicide deaths last year were men well in our force were about 80 men so that's an over representation given end strength now we know across our nation men do have higher rates of suicide deaths so if you know that maybe this isn't as surprising the men are married 64 percent that we are losing it used to be that we had more single airmen that we are losing to suicide we're seeing a little bit of a shift they're married so the legal status is married it's not legally separated although some of these were experiencing significant relationship issues and maybe were physically separated but not legally separated from their spouses what we're also seeing is there's an age shift it used to be that we were losing more of our very very young airmen it's shifted a little bit now it's our 21 to 30 year olds and along with the age shift is a rank shift and i really want you to please pay attention to this e-fives and e-sixes it's the largest proportion of those that we are losing to suicide it's our e-fives and our e-sixes now i still want you to care about our young airmen who are single living in the dorms but we also need to collectively think about how are we supporting our e-fives and our e-sixes there's something more perhaps we need to be doing for sort of what i consider the heart of our force those frontline mid-line mid-level supervisors that are out there a fsc's this probably looks familiar okay you still have aircraft maintenance we have our our security forces a little new um to these stats of cyberspace support and then we have vehicle maintenance i want to make a point about aircraft maintenance um they're a large a fsc hey we've got they they comprise a large part of our end strength so what we do is we look at the end strength compared to the percentage of our suicide deaths and we determine is this an over representation or an under representation historically aircraft maintenance has been overrepresented even though there's a lot of them they're still overrepresented in suicide deaths but something has happened this past year and i'm working with those the functional leaders in that community to try to figure out is there something we can learn because they have gone down more than half of suicide deaths so even though they're still on this list they're underrepresented given their end strength they had 19 losses the year before and they had eight this past year so we're trying to figure that out and once you know if we there's something we can glean and pass on to the rest of the force we will additionally um folks are still dying um through the use of privately owned firearms in fact we have the highest percentage out of the other services in fact we had zero issued weapons the previous year were used they were all privately on firearms about 70 percent and with the total force it's like 73 percent okay and then um what were the issues they were dealing with okay we know kind of the biggest one that usually emerges relationship issues is chief toberman here in the audience he what i thought he was earlier he's the only one when i asked this question who doesn't have relationship issues he's the only one that's ever jumped up and said i have no no relationship issues whatsoever and i said well maybe that's because you you know i'm going to call your wife and i'm going to let her know what you answered okay a lot of us do have these challenges um and we're not suicidal okay but i'll tell you a lot of these folks who have died by suicide have multiple of these challenges not just one that's why the percentages don't add up so relationship issues continues to be the most represented next we have legal and administrative issues you all know this okay you know to pay special attention to airmen that are within your scope of responsibility who are in some kind of legal trouble or administrative trouble okay they are at higher risk for suicide and then we have workplace issues so these are other issues at the workplace that don't rise to the level of administrative or legal actions then we have this new one that we started assessing and this foot stomps everything dr Bartlett just shared with you about the importance of postvention and the increased risk that we all have when we lose someone to suicide the fourth most common stressor that those we lost to suicide last year is that they were dealing with the suicide death of a family member or a unit member or a friend that is the fourth stressor that emerged finances we used to talk about finances that was way down at the bottom like three percent we're dealing with financial issues far more we're dealing with the suicide death of a friend or family member so mitigating risk that we know increases after a suicide death is so important it is prevention it is prevention here's the thing though none of us should ever walk alone if we have lost someone to suicide because unfortunately many of us have walked it okay i've lost a family member i've lost one of my own troops to suicide how many of you out there could you please raise your hand who has lost a family member or a unit member an airman to suicide look at that more of us have than have not so there is no reason for any one of us to walk this alone no reason whatsoever okay and i want to say while there is no single solution to suicide this morning chief right got it as right as right can get okay and i'm not just saying that because i because i have to all right it is bold courageous and engaging leaders it is you and it is i but we are not born knowing how to be bold courageous and engaging leaders so a part of our air force level initiatives is to equip you all with what that looks like to give you some tools to help you live that behave that way interact that way with your airmen so our initiatives are kind of bucketed in four areas right at the top we have connecting communities we know that that's a very important part of a resilient community where we can drive down negative outcomes this involves our spouses we have a spouse initiative and i'm always looking for spouses the maybe they'll you know they'll write down my email and send me a note let me know they want to be a part of it how can we engage our family members when it comes to recognizing and then knowing what to do to mitigate suicide risk hey we we've got some some modules we're creating and some psa's and some things coming out to equip our spouses and our family members we need connected communities we need protective environments protective environments you all need to know how to have a conversation with someone who's at risk onto how can we safeguard their environment do they own a weapon can we just safely store it temporarily can we can we get leave the levels of medications out of your home because i care about just like i wouldn't let you drive drunk right friends don't let friends drive drunk and you know i care about you if i take your keys or like chief right just shared with me earlier he'll go and he'll he'll be that dd he'll come pick up his airmen who maybe had too much to drink it doesn't have a ride home because he cares it's the same thing with safeguarding environments and just taking some lethal means put out of the equation put them away we've got to make people safer when we know that they are at risk right another one is detection how do we help equip you to truly detect who's struggling out there who's at risk because some people are really darn good at hiding it in fact it's usually our high performers so it's usually folks like yourselves really good at hiding when you're distressed and you're struggling how can we equip ourselves as leaders to better detect the risks that exist with individuals and within our units we're getting after that and equipping is that last one i wholeheartedly ask you to please go to a new website it was developed after our suicide analysis board to help equip leaders with tools so you you're not walking alone right we're walking with you please it's in its infancy go out to www.resilience.af.mil it's leadership tools for prevention for intervention and postvention we're going to grow that to include more of a total force application of tools as well as for our spouses so we're going to grow it it's brand new please go check it out and give us feedback we know it can be better we know it's maybe missing some things we need to tweak some things please partner with us because we want to partner with you to get after never losing another airman or family member to suicide so with that i'm going to bring dr dr Bartlett back out and we have about about 15 minutes for questions now one of the things i've learned whenever i present co-present with lieutenant colonel madison is that most of the questions are directed at her so um because i am a therapist i'm not afraid of feelings and things of that sort so if you have any process oriented questions or concerns related to suicide i'm your i'm your person yes please good morning uh chief guzman headquarters usaff africa just had a quick question about the new afi the 95001 chapter five mentions a checklist or a protocol for first sergeants and commanders to follow for folks on their investigation can you elaborate on that some more is that checklist available yet first of all you just made my day because you actually read the new instruction so that's awesome thank you so much so um if any of you have been in the business of kind of trying to write uh instructions lately number one we got rid of three afis to put it into one because we're supposed to reduce afis number two they have to be succinct number three they don't want you to put um attachments in it so in the old suicide prevention afi we used to have these checklists as attachments now you will find them on www.resilience.af.mil so chief check it out and m-a-t-t-e-s-o-n email me oh right do we do we need to change it up make it better move to the next slide oh oh oh yeah here and here's our email appreciate you thank you thanks chief and again thanks for reading it good morning senior master sergeant kevin hammer uh joint base maguire dicks lakehurst eod flight chief first of all this is uh exceptionally frustrating information to hear and uh partially because we had a suicide in our unit uh about two and a half years ago and uh when we approached our mental health folks about what we do about postvention they had no clue um they came in and they gave us a uh a cbt on suicide prevention so we were kind of left our own devices in and how to care for our own airmen and it wasn't just the fact that he he committed suicide uh it was that there was two prior attempts and there was no training uh given to our folks on on how to reintegrate him or how to help him it was a uh after he had went through inpatient he was delivered back to our unit and it was your problem um which ultimately resulted in committing suicide so i'm not sure about everybody else in this room but this is the first time i've heard this information on a postvention program for the air force and i've been asking for years so it's good to see that the initiative is in the works so what are we doing to pass this information down to who i would consider the subject matter experts or mental health folks that's a great question and i'm so sorry that we weren't where we are today two and a half years ago um so so i uh kind of represent a bridge um the suicide prevention program um when i came on board two summers ago it was still over in the sg and that's where it had been since it stood up in the 90s um we took that program brought it over to the pentagon to the half we are now integrated with what used to just be cbs uh sexual assault hey it's now sexual assault sexual harassment we brought the resilience program in and then suicide prevention and we work um for the line so my director is is general martin and my sea is chief barbie so that was a really important move in my humble opinion because it's where it should be okay it is not just like a mental health phenomenon although mental health is incredibly important um in the cycle of preventing suicide but it's really being led by the line and so it has allowed for many more conversations um to talk about the misses in the past and how do we get better how do we strengthen um the the delivery of prevention to our airmen to include how do we take care of our airmen who have had a non-lethal suicide attempt to perhaps have been impatient how do we take care of them coming out dr bartlett was spot on when we know that that is the time of highest risk is when someone comes out and so how are we working with and partnering with our leaders um who then so so let me just really quickly okay we're working it from both sides we're working to improve the communication that must take place between mental health and our our unit leaders again working it from both sides one of the things that we're doing is we're writing standard operating procedures that require line leadership unit leadership to be present before discharge when the safety planning is taking place for the individual who's going to be discharged so you will be at the seat you will be at the facility you will know every part of that safety plan for the airmen who's going to come out of the hospital because we know that that was a big um gap in communication that came out loud and clear when we did the suicide analysis board and let me also add um that i agree first of all i'm sorry for that loss and i share your frustration i've been foot stomping postvention for the air force for about 10 years and um i am very pleased at the progress that we're making now even though we were slow to get there chief right has done a fantastic job in lieutenant colonel madison i can honestly tell you that in her since she's taken her role in this position has moved postvention forward further than i ever thought we could get in my lifetime so i'm very pleased about that but i think that it's not just about educating the mental health providers which is a key element but it's also about training our key leadership like you and so to that end i've been teaching postvention uh resources and strategies to our leadership here across air university as well as across other major commands so i actually teach all the elements of postvention at the first sergeant's academy at the chief the regular chief's course um ots acsc air war college many of the colleges here but when i get a special request an invitation to go and speak somewhere else i generally it's shifted now 10 years ago my invitations were on prevention and intervention now they're on postvention so we're seeing a shift in the leadership knowing that this is an important issue and topic and bringing us in to do more of the lectures just for this the the front line supervisors as well who need to be equally equipped in it just one one more quick thing with with the um with the creation of a1z integrated resilience there's now a capability that was rolled out to each of your installations and at the madcom levels and that's your violence prevention integrators it's a new capability and we are working on how we train and equip them as well but their job is primary prevention really of all these negative outcomes and so that's something else that the air force has done to try to increase the capacity other questions i'm sorry i don't know if we go back and forth or you put your hand up first in the back so good morning ma'am good morning senior master and david 86 there live weighing ramstein so i was checking out the demographics that you had on the screen and i was curious what research you guys have done into folks with combat experience post traumatic stress disorder um and the reintegration efforts that's a great question so we've looked at it and looked at it and looked at it and the dod has done a tremendous amount to look at like the effect of deployments um and i'll quite frankly it's because congress is asking right media is asking america is asking we're asking um is there a link so this is what i will tell you about mental health and those that we have lost to suicide about half have known mental health um conditions now i say known because perhaps more had mental health um challenges but we just didn't officially know about it yet um for um depression that tends to be the highest kind of diagnosis folks that are dealing with depression um if untreated can get into a suicidal realm a very dangerous realm about 12 percent of those that we lost to suicide the previous year um had known depression um diagnoses about eight percent had known ptsd diagnoses so about eight percent had formal diagnoses of ptsd when we look at deployments about half have had one deployment and maybe uh i think it was about nine percent had more than one deployment so is it a factor are we looking at it we're looking at it it seems to be a small factor um that we see and for reintegration i think the reintegration efforts um again it's wonderful to be at the half um with a1z because we are working collaboratively with other agencies that have parts and and pieces of the reintegration efforts um we are working with the wounded warrior program invisible wounds of war actually you have a briefing the wounded warrior program here coming up next we're working collaboratively together to look at how can we improve existing reintegration um efforts i will tell you a theme that comes out when we look at mental health and suicide and i need your help each and every one of you with this everything we say and do needs to contribute to a culture that supports early help seeking early help seeking the earlier we can get people into the health that they need the better the outcome it's never too late but when something has gone on whether it's ptsd or depression it does get more difficult to turn around it's not impossible but it's more difficult so we are trying to make sure that message is incorporated through all of our reintegration efforts so it's a great question thank you um i'm sorry i was like you're all like it's shadowed so i don't know who was up there first may i'm uh chief spitzka i'm at the pentagon as well um earlier you said you know our um our numbers are increasing this year i know that the american average is also increasing um but you also said i think it's 270 percent greater chance of dying from suicide when when uh coming out of a suicide attempt coming back to the unit um and then you said it was like a an average of a three day oh sit in the hospital why why is it only a three day sit then i mean is there information showing it doesn't really matter you're just delaying it anyway well um there are a lot of fact thank you for that question um there are a lot of factors the reason that a hospital stay for a suicidal person is on an average two and a half to three days is largely due to insurance purposes that there's the the need and there aren't enough beds for there aren't enough psychiatric beds for patients to come in and so they're trying to get people out medically stabilized as quickly as they can and then out again and that's why we wanted to make sure that we brought you that information so that you understand their suicidality is typically not being worked on to any great to any great length um while they're in the hospital and that's why they're coming back to you we need you to know they're coming back to highly suicidal so the reasons that they're not allowed to stay longer typically have to do with insurance purposes um or the fact that the client is indicating within that three days that they are no longer suicidal once the client indicates that they're not suicidal they will not harm themselves they will not kill themselves they have no intention of killing themselves they are then released well i had if i've heard the the air force you know the goal of you know zero suicides for i don't know at least eight years now or so um we're not there obviously so if it's an insurance thing i mean we've got the insurance to here's a complicating factor um legal rights so i with with us in tricare i think maybe for our population maybe the insurance is is not as much of a factor as it is in the civilian sector for us it's more how long can we hold somebody against their will and we have legal limitations um and with dr Bartlett explain if people are saying that they're not in imminent danger of harming themselves um then they're going to be ready to be released which is why we know that it's so important that you insist and you are at the table for the safety planning for that individual and if that individual has a spouse that is and it's a relationship that is supportive the spouse needs to be there needs to know what that safety plan is if there's a roommate whoever this person is going to be going and staying with they need to know what that safety plan is because here's the thing you go to an inpatient psychiatric unit you get stabilized you're released your work has just begun the work has just begun for those individuals and that's why they are still at risk and i know it's frustrating i've been on both sides of this equation like i i shared with you i've lost one of my own staff sergeants to suicide and it was after he was released from an inpatient stay so i've been on both sides i've been a provider and i've been on a leadership position on this on this issue when somebody comes out of a hospital they have a lot of work that they still need to do to really get to a healthy place and i'd like to just also add to that that their likelihood for suicide research shows does go down month by month but the challenge is that it's still likely over 100 percent even after 12 months so that whole first year that they're back at your unit is a time for eyes on you know not that you're going to treat them with kid gloves you still have to do mission first but to be thoughtful of the challenges and the work that they're going to need to do over the course of the next year and sometimes two years we are out of time and so i thank you for these wonderful questions and your engagement our contact information is provided and we hope that we will hear from you again any questions that you have if i don't have the answer and you contact me i will make sure that i get you the information i want to thank you for the work that you're doing and congratulate you for the positions that you're in now really it's humbling for both of us to be able to provide this information to you on this new cons for many of you the concept of postvention was new we were grateful to have the chance to bring it to you thank you very much all right just a couple quick quick announcements before break would all aphsoc personnel come up to the front my left at the beginning of this break and would all the air force reserve please come up to the right at this break please be back in your seats at 10 25