September is designated in the U.S. as National Suicide Prevention Month, in conjunction with World Suicide Prevention Day, which falls on Monday, September 10 in 2012. Tricare recognizes this important, month-long effort to educate the military community about suicide awareness and prevention. The Navy has established its own suicide awareness page, with information and links to other resources. The Marine Corps website has a section on suicide prevention with resources for Marines and their families. The Army has created a suicide awareness PDF, full of information and resources. The Air Force has a very comprehensive suicide prevention website which, while mainly geared towards active-duty members, provides useful information and links for families, as well.
The issue of suicide among military members and veterans is a very hot topic these days. The current numbers indicate one military member or veteran commits suicide every day. Thankfully, the increased press interest in bringing desperately needed attention to this crisis, and the DOD and VA are responding to the need and to the public outcry. However, another dark number remains hidden in this story: the suicide rate among military family members.
The DOD has made some progress in recent years in reducing the personal and professional stigma attached to military members’ seeking help for mental health issues. We, as rational and compassionate people, understand how living through the horrors of war can cause depression, anxiety and post-traumatic stress. No reasonable person would blame a veteran for having a hard time readjusting or coping with his or her experiences in country. But what about compassion, understanding and reduced stigma for people with very different wartime experiences? What about those who are left at home, consumed with worry and fear for days, weeks and months on end? After all, we’re military spouses! We are notorious for our strength, our support networks, and our ability to manage households, kids, jobs, bills and deployments like superheroes, right?
RIGHT?!?
In 2010, Deborah Mullen, the wife of then Chairman of the Joint Chiefs of Staff, Admiral Michael Mullen, spoke at a national suicide prevention conference. Mrs. Mullen expressed her shock and dismay upon learning that the Army, specifically, reported they had no way to track suicides among military family members. Mrs. Mullen continued to delve into the issue, discovering significant systemic problems in the mental health care available to military family members. Since that time, Blue Star Families conducted a survey of military families that revealed that 10% of military spouses had considered suicide. (This result is thought to be inaccurately low because 10% of those responding to this survey refused to answer this question.)
When our spouses are deployed, we truly become our sisters’ (and brothers’) keeper. We as military spouses are the ones who are most likely to hear or notice that another spouse is struggling. We are the first line of defense in preventing suicide among military spouses and family members. This is a role for which most of us feel woefully unprepared. We take first aid and CPR courses to be prepared to save a life in the event of drowning, heart attack or choking, but who among us has a card in her wallet saying she is trained in psychological first aid? Well, I do, and I am going to share with you some basic, factual and clear information on how to recognize a mental health crisis – in yourself, a family member or a friend – and how to respond.
In my career as a Psychiatric Crisis Clinician, I have evaluated thousands of suicidal patients since 1999. I have fielded hundreds upon hundreds of crisis phone calls from suicidal patients and concerned friends and family members, desperate for information and resources. I have been empowered in three states to involuntarily commit adults and children to the hospital for mandatory psychiatric evaluation. What I have learned about preventing suicide can be boiled down into four key steps I refer to as RACE:
Recognize
Ask
Call/Contain
Explain
RECOGNIZE
Preventing suicide begins with recognizing that someone you know is at risk. It is reasonable to consider every military spouse of a currently or previously deployed military member to be at risk for suicide, simply based on what our spouses do and what that means for us. Does this mean we are all weak, or incompetent or whiny? No! It means we are all human, and we are all vulnerable to having our ability to cope become outstripped by the stressors we face. That is the definition of psychiatric crisis: having one’s ability to cope outstripped by stressors. I often explain coping and stress to my patients using the analogy of a teacup.
The teacup represents your ability to cope with stress. Some of us have big teacups, some have small teacups. Some teacups are missing handles, and some have cracks or chips in them. All of these factors determine how we cope with stress. Now, imagine your teacup filling with water – or stress. You may live your life on a daily basis with your teacup 1/4 full to 1/2 full. A deployment may come around, and your teacup may be averaging around 3/4 full. It doesn’t matter how your teacup gets full. It can fill up one drop at a time over weeks and months, or there can be a sudden downpour that fills your little china cup in a matter of a minute or two. Regardless, once your cup is full, it will begin to overflow, and then you have crisis.
Now, imagine you are in the middle of your spouse’s third deployment in four years. You have a sick kid at home and another one getting into trouble at school for hitting a classmate. You get a phone call from your mother, who has found a lump in her breast. You haven’t made it to yoga class in over a month, and the checkbook is about to start bouncing like a basketball. Your teacup is hovering at 99% full on a daily basis! What would it take to push you into psychological crisis? Not much! These are the times when we find ourselves snapping and losing it at the commissary because they are out of the brand of dish soap you prefer. Or when you’re chatting with your spouse via Skype and become enraged when he or she asks about how you’re managing the finances in a way that sounds a bit too accusatory. When you are living on the edge of your ability to cope, almost anything can push you over and cause your little teacup to pour out all over the floor.
So, now you can look at your teacup and those of your fellow milspouses and gauge how full they are. What are some signs that those teacups are getting kind of full?
Changes in eating habits: eating much more or much less than usual, unintentional noticeable weight loss of weight gain (but especially weight loss)
Changes in sleeping habits: sleeping either much more or much less than usual
Changes in personality: being more irritable, more hostile, less pleasant, more tearful
Changes in social connectedness: not wanting to engage in usual activities, including social activities; not wanting to be with others as usual
Changes in general functioning: not caring for personal appearance as usual; not bathing; not cleaning the house or grocery shopping; not caring for children; not going to work; not paying bills
ASK
You will almost never know for sure whether someone is having suicidal thoughts if you don’t ASK. Noticing any one of the above signs is reason enough to go to this milspouse and check-in with him or her. Have a conversation. You can start off by saying that you’ve been having a hard time lately and just need to talk to someone for a few minutes. (Even if it isn’t true, it gives you a foot in the door that can help that milspouse know that you will be open and nonjudgmental if he or she is also having a hard time.)
If your fellow milspouse doesn’t take the hint and begin talking about his or her own situation, then you can simply ask. “So, how are you doing with all of this going on?” When I see patients, even those brought to me by the police who are accompanied by a written report explaining they were found up on a bridge trying to jump, I nearly always begin the interview by asking the patient, “So, what’s been going on for you today?” People in psychological crisis are desperate to be heard, and sometimes they need to be given permission to talk about their situations. All it takes to open up that conversation is an invitation.
As your friend talks, listen for clues in the conversation, such as, “I am at the end of my rope,” or “I don’t think I can keep doing this.” These statements may be more subtle, such as, “I’m so overwhelmed.” They may be overt, such as, “I wish I could just go to sleep and not have to deal with this deployment anymore.” If you hear any of these hints, it’s time to ask directly: “have you been feeling suicidal?”
People tend to panic a bit at the idea of saying the word suicide to someone, as if the word has some power to cause someone to act. The only power the word suicide has is the power of secrecy! If you don’t ask, you allow the secret to continue and progress, with potentially devastating consequences. Don’t let fear keep you from helping!
If the reply comes back as, “yes,” or “a little,” or “sometimes,” or “not really, but . . .” then it’s time to ask for some TMI! TMI = Thoughts, Method and Intent
Thoughts: Ask more about those thoughts. Are they happening often? Constantly? Now? Are they intrusive so they come up all day long and cannot be pushed away? Are they frightening? Does your friend feel able to resist these urges?
Method: Has the person thought of a method he or she would use to commit suicide? If so, what is it? Does he or she have access to the items needed, such as a gun, ammunition, medication, rope, a hose to hook up to the car’s tailpipe? (When it comes to medication, one of the most easily accessible over-the-counter medications out there is among the most deadly: Acetaminophen. Don’t think your friend is safe just because he or she does not have access to prescription medications.)
Intent: THIS IS KEY! Does your friend WANT to die? Does he or she intend to carry out the plan? Is your friend unable to commit to you that he or she will NOT act on that plan?
So, what do you do with this information now that you have it? It’s time for some hard thinking. Here, in a nutshell, is how I determine level of risk:
Suicidal Thoughts, No Plan, No Intent = Low Risk
Suicidal Thoughts, Has Plan but does not have needed items = Moderate Risk
Suicidal Thoughts, Has Plan and is gathering items = High Risk
Any combination of these factors that includes positive INTENT is URGENT RISK!
Also, a person’s risk for suicide must be always be considered at least moderate if the person has ever attempted suicide in the past or has a relative or friend who has committed suicide. If this person has a plan, the risk is automatically urgent!
You do NOT need to determine the level of risk alone, and I advise that you DO NOT! Now is the time to call a crisis hotline and ask for guidance.
CALL/CONTAIN
Once your friend has revealed suicidal thoughts and any combination of plan or intent, you need professional guidance in deciding how to proceed. Every county in every state has a suicide crisis plan. There may be a local crisis hotline, or that plan may simply consist of calling the local Emergency Room for guidance. If you cannot find your local information, you can always call the National Suicide Prevention Hotline, which can be reached at 1-800-SUICIDE (800-784-2433). Another Suicide Helpline is available at 1-800-273 TALK (800- 273-8255). This hotline has a special option for Veterans and Military Families. (Dial option 1 for the Veterans Crisis Line.) You can explain your friend’s situation and symptoms, and a hotline counselor will guide you in the next steps.
Now, what do you do if your friend is not happy about your wanting to call a hotline, gets angry with you and leaves? What if the Hotline Counselor says your friend needs help NOW, and your friend says, “Thanks, but no thanks” and takes off? Now, you have no alternative: you need the help of law enforcement to ensure your friend’s immediate safety. You must CONTAIN the person. You need to call 911. Your friend may be angry. Your friend may be furious! Better furious than dead. Be prepared to give the dispatch operator a physical description of your friend including what he or she is wearing, when and where you last saw the person and whether he or she has access to any weapons.
EXPLAIN
Your information about your friend’s mental status is going to be essential to whoever ends up evaluating him or her for suicidal risk. That person could be a police officer, an Emergency Room doctor, or a Crisis Clinician at a community mental health center. This person needs to know what specific information you have about your friend’s situation, including:
Current Stressors
Living Situation (especially whether there are minor children in the house. Be
prepared to tell this decision-maker about who is caring for any minor children,
or else the children may be taken into protective care by the Child Protective
Services while the evaluation and any required treatment is conducted.)
Support System
Suicidal thoughts, plan and intent
Psychiatric history, if you know it
Without your input, the decision-maker will have nothing to go on other than your friend’s self-report, which often consists of,”No, I’m fine. My friend was overreacting.” You may need to go to the ER, the police station or mental health center to give this information, but it can usually be provided over the phone. Make sure the police officer or paramedic who picks up your friend gets your name and contact information.
If your friend is hospitalized and his or her spouse is deployed, you should notify your unit’s Ombudsman, Family Readiness Leader, Family Readiness Officer or other support person right away so it can be determined whether an AmCross message can be sent.
In the event your friend is not hospitalized, outpatient care is definitely the place to turn for ongoing support and care. In addition to being your link to obtaining counseling and psychiatric care, Tricare also has excellent informational resources. The Tricare website for your region is a great place to start when you are looking for self-education, suggestions or connections to face-to-face care providers. This link displays a PDF-formatted document with information on accessing mental health care in any Tricare region, including resources and information for those stationed in various OCONUS locations.
Tricare North Region 1-877-874-2273
Tricare South Region 1-800-700-8646
Tricare West Region 1-866-284-3743
(TriWest also has the option for online chat support at this page.)
You may not have a Psychological First Aid card in your wallet, but hopefully with this information, you feel better prepared to respond should the need arise. Remember, these guidelines apply not only to milspouses, but to anyone in crisis. Your concern and intervention may be just what it takes to set your friend or loved one on the road to healing and safety. Together, we can get through anything!