A Grandpa's Notebook Part 15

Camouflage is not unusual: suicide preparations may be arranged so that the act will appear as an accident. An ailing individual might suddenly stop taking life-saving medication; or family members, friends, or 'significant others' might goad or exert harsh psychological pressures on an emotionally distraught person so that suicide becomes the only escape. Ironically, 'suicide statistics' do not examine the impact of a suicide on the victim's family and friends, nor do they note the traumatic and often permanent effects of the failed attempt on the victim. Further, they ignore the financial burden of subsequent home or inst.i.tutional and health care for both victim and family as well as paying for precautions against further attempts.

Context.

Before I retired from the federal civil service in 1974 I was the civilian deputy to the Inspector General (IG) at McClellan Air Force Base, a large military installation near Sacramento, California. I was and am a civilian and a non-professional lay person in all mental health disciplines. I attribute my involvement in 'suicide prevention' to circ.u.mstances of the 'Viet Nam' period. At that time, many military mental health professionals and other caregivers were on duty at medical and mental health facilities in Southeast Asia, at way stations along routes for military personnel returning to the U S, and at medical and other facilities in the U. S. where Armed Forces wounded received care. One result was a general shortage of mental health specialists and staff at military installations in the continental U. S. Existing staff, including untrained civilian employees, were often a.s.signed 'additional duties' to fill gaps.

In 1969, the McClellan Air Force Base senior Commander instructed me to represent him on the Sacramento County Mental Health Council. At the time, the Council was considering the establishment of a county Suicide Prevention Service (SPS). The SPS was approved, and I became involved as a volunteer worker. As the SPS functions and workload became clear, I joined its paraprofessional training to certification and when the Service became operational I took my turn on the 'hotline,' especially those related to my McClellan responsibilities. I extended my duties to include SPS liaison with several other military bases in the Sacramento area. At that time, central California and Nevada had military installations where military personnel of all Services were stationed for training and operations, or who were in transit to or from Southeast Asia. In effect, the Sacramento-San Francisco corridor in the late 1960s-early 1970s was filled with military personnel on their way to and from Viet Nam and elsewhere in Southeast Asia. From the outset, as word spread about Sacramento County's SPS hotline, increasing numbers of calls came in from potential and selected draftees and active duty members of the Armed Forces and their families.

One of my Inspector General's office responsibilities was to organize and operate McClellan AFB's support to the Air Force Inspector General Complaints System. The basic principle of the System holds that, as a last resort within their organization, military and civilian personnel and members of military families have the right to address a grievance or appeal to the installation's Inspector General. The installation Inspector General represents the installation's senior Commander in these matters. An appeal to the IG may be for information and explanations concerning status and duties, to describe perceived unreasonable conditions under which the appellant works, to report on inadequate support to themselves or their dependents or, for other reasons to seek relief from what the grievant considers an intolerable and unjustifiable situation.

The IG, or deputy IG, acting for the senior Commander, hears complaints and appeals and conducts such inquiries and investigations that may be required to resolve the matters. In the context of this memoir, when hearing (or reading) a complaint, there were occasions when a complainant hinted at suicide as the only remaining option should he or she not be given what they considered a reasonable resolution of the problem they presented.

A significant number of phone calls was also being received by the County Suicide Prevention Service 'hotline' from active duty military, military veterans and retired military of all Services, and from members of their families. Many, if not most, such calls (to the SPS) required information or actions from a military or other government ent.i.ty.

The SPS policy was to not disclose a caller's ident.i.ty: Protecting a hotline caller's ident.i.ty is (or was at the time) generally practiced by most crisis intervention centers unless the situation was an imminent life-death crisis.

Organized, volunteer-staffed, telephone suicide prevention 'hotline' services were beginning to appear in the larger cities throughout the U. S. in the late '60s; less than a hundred were in operation across the U S at the time. In order that I might better understand the 'suicide' phenomenon and to accomplish my duties in support of the USAF IG Complaints System, I became a regular volunteer at the SPS, attended their ongoing paraprofessional upgrade training, and worked a s.h.i.+ft on the hotline. I served with the SPS Speakers Bureau, Executive Board and other committees and gave talks about the community program at staff, non-commissioned officers', military dependents', and civilian community meetings.

Job-related, I compiled an information kit on suicide myths, and the signs that would generally indicate that a friend or family member might be thinking of suicide. I sent copies of whatever literature I acquired from the SPS and the National Inst.i.tute of Mental Health (NIMH) to my counterparts at other military bases. The USAF Inspector General printed an article about the information kits in the USAF TIG BRIEF (The Inspector General Brief) an IG administrative newsletter distributed to USAF facilities worldwide and to the Hqs of the other Services. The TIG Brief newsletter was also distributed in Viet Nam. The item resulted in more than 150 requests from Southeast Asia for the information packet, which we forwarded.

During talks I gave to military and general audiences I was occasionally asked for examples of what 'hotline' exchanges with military callers were like. Two of the 3 summaries that follow were related to the Viet Nam conflict. The third is a problem all too common, regardless of the times; it happened and continues to happen as often in the civilian world as it does in the military. I've screened my recollections so as to honor my commitments to confidentiality. The narration reflects a tiny sample of the effects of stress that can surface in military life and is not intended to represent major emotional, behavioral, or physical indicators toward suicide ideation. My regular work s.h.i.+ft at the SPS brought me as much of a military-civilian mix of callers as the other hotline workers, so I've seen both sides.

The contacts were all by telephone, and in two of the three cases led to a number of quick follow-on calls to several parties on and off the base. Each caller had the potential for violence, either to self or another. If intervention, at a high point in the interaction failed, the situation might well have deteriorated, possibly with tragic results.

Draftee.

While on the job in the McClellan IG office, a phone call came in from the SPS Director who told me he needed my help right then. A young Army draftee was on the SPS hotline and he was threatening to commit suicide. He was supposed to be on his way to Viet Nam but he had gone AWOL instead. He was far from home and felt lost and confused. He said he had one question before deciding whether to kill himself: 'What'll they do to me if I turn myself in?' He wouldn't identify himself or say where he was.

The SPS Director said that he didn't have the answer. He told the soldier he had a contact at a nearby military base that could check it out. Holding him on one line he called me on another and gave me the facts. I immediately called the Staff Judge Advocate - who was part of my on- base network - and had him phone the SPS Director immediately to review the ramifications of military justice as it might apply. The SPS Director pa.s.sed the information to the soldier and then talked to him for about an hour. The guidance provided by the Staff Judge Advocate gave the soldier options that might reduce potential charges he faced, not ruling out desertion. We never found out what the soldier decided; he never called back.

This call, and how it was handled, demonstrated teamwork between a community suicide prevention resource and military and civil service administrators on a military base. Comparable groundbreaking was going on in other military-civilian communities and contexts.

Family Problem.

The Base Chaplain called me at home late one Sunday night and said he'd had a phone call from a hotline worker at the community SPS. The SPS worker had asked for his help in a call that had come in from an airman's wife. She had phoned the SPS from her home off-base and threatened to kill her husband and then commit suicide.

The caller to the SPS had impulsively terminated the call to the SPS after a few minutes, but in her responses to questions at the outset of the interview, had given her phone number to the crisis worker. After she hung up, the crisis worker judged the woman was more than moderately lethal, and also that she might listen to a military Chaplain. That brought on the call to the Base Chaplain.

After getting the specifics from the crisis worker, the Chaplain phoned the woman and talked to her for about 10 minutes before she hung up on him too. His conclusion, also, was that she was highly lethal for both homicide and suicide. He phoned the Base Security Police and then the Director of Personnel. The Chaplain was leaving that day for Viet Nam; the Director of Personnel suggested he call me.

The Chaplain asked me to follow up. I called the woman. The conversation was heavy, and lasted for more than 2 hours. The problem was in marital relations, finances, and spouse abuse. We finally got around to talking about on-base resources that might ease the load she was carrying: the Staff Judge Advocate, Family Services and Medics. Just listening, and then talking about potential on-base resources helped to lower the pressure. She finally agreed to wait until morning, now only a couple of hours distant, so that the resources we had discussed could be consulted.

First thing that morning, I got the base Family Services people into the act. They moved in fast, took control, got the airman's wife around to talk to the right people, and did a lot themselves. I checked back later. Family Services had her under their wing. She wasn't talking about murder-suicide any more. It was going to be one day at a time for her for a while. She now had somewhere on-base where she felt she could turn, and people in whom she had some confidence.

Why hadn't the woman tried Family Services on her own? I don't know. She chose the civilian community's suicide intervention resource. She had other options, and she might have tried them too. What's my point? Another instance in which military and civilian resources collaborated and made the system work.

Returnee.

At about 11 PM one night, I was working my s.h.i.+ft at the SPS hotline desk. A call came in from the switchboard supervisor at the city's telephone company. The supervisor said she had a man on-line and he was in a fury. She couldn't handle him. Would I take him? I told her to let me have him, and he was on.

It took a while to get him down to where he could speak coherently. He was an enlisted man in from Viet Nam, making his way to the East Coast. His problem wasn't suicide, it was homicide. He was in a barroom, he said, drinking and minding his own business. Shortly before his call, another patron had ridiculed his uniform and his Service. He had a weapon in his bag and had an almost overwhelming urge to use it.

A stranger in town, pa.s.sing through, he felt he'd better divert and talk to someone. Searching for some means to vent his rage other than a.s.sault, he had, on impulse, picked up the barroom phone and dialed the operator. He must have come down real heavy on her and her supervisor; he found himself of a sudden switched to a hotline worker at the local SPS.

We talked for more than three hours. At the outset he was openly hostile, demanded to know who I was, and how the h.e.l.l I had been loaded on to him. When I told him, he said he didn't know what 'suicide prevention' was about and wanted no part of it. But he didn't hang up, and we never hung up on anyone.

In our give-and-take, when he realized he was talking to someone who had more than a pa.s.sing knowledge of the military, who could respond in his jargon and relate to his lifestyle and to his feelings, his hostility eased off. Other feelings began to surface.

He admitted that he had been deeply shaken and enraged by his experiences during border crossings into Cambodia, and he still carried the same, almost overwhelming, anger. Without my bringing it up, he confided that he'd had intense thoughts about self-injury, even suicide, and that the feelings had been strongest before taking off on missions. The rage, and the thoughts of suicide, were still with him and, looking back at them in calmer moments, he said that he was alarmed by their intensity. After a while, he admitted, reluctantly, that he might need help. He said he would think about seeking it out when he got to his permanent station.

At the close, he was much calmer. He phoned back a few hours later and told the hotline worker on duty that he was at the bus depot, and would soon leave for the east. He said to pa.s.s the word to me that he was OK.

Collaboration.

Eventually, it became evident to me from my IG and SPS experiences, that much could be accomplished through a carefully designed system for collaboration between military bases (or other federal agencies) in any given geographic area and the crisis intervention/suicide prevention (ci/sp) resources of adjacent civilian communities. The potential for good was enormous, not only for and within the military community, but national as well. I learned in time that I was not alone; many others, professionals and lay, were thinking and active along similar lines.

I was convinced that the time was long past for both military and civilian managers and supervisors, in both the public and private sectors to acquire basic indoctrination in ci/sp as it pertained to the people that they commanded or supervised. I wrote numerous letters on the issue, recommending specific actions, and continued doing so after I retired in 1974. My appeals went to the Federal Executive, Congress, and the media. I stressed the urgent need for proactive command (or agency)- wide training and motivational programs to confront the suicide phenomenon, and get organized to reduce suicide attempts and deliberate self-destructive behavior among military personnel, members of their families, and DoD and other Departments' employees.

The essence of my appeal was, first, for a set of formal objectives for the federal military and civil services to move them toward collaboration with community resources that were engaged in gra.s.s roots suicide prevention; in essence, collaboration and teamwork between the federal government, as an employer of people, and the communities in which their people lived and worked. If the concept could get a foot in the door at the federal level, then state and county governments might hitch a ride on the system, and ultimately, so would private sector employers. In made no difference which level took the initiative, cross feed and human nature would eventually get the others interested. The suicide trend, the way I read the Public Health Service's statistics of the early and mid-70s, was heading up.

Many government and private sector employers already had in-house programs for stress management. They also had employees who, although lay persons, had been trained and qualified to give emergency CPR and other forms of first aid at the work site. So why not someone in the shop or office who was basically trained in suicide prevention and crisis intervention? As with other on-site emergency services, this person, who would have been trained and qualified to recognize discernible and professionally recognized signs that might precede a suicide attempt, would consult with a supervisor, and exercise his/her judgment in getting the person-in-distress ASAP to professional help.

Community suicide prevention programs (certified SP Centers, informal hotlines, Community Mental Health Centers, etc.) had by that time become a fact of life: they existed, and were part of the system, organized or ad hoc. Proactive 'suicide prevention,' would generate its own force for being: it would not get canceled like an aircraft, s.h.i.+p, or construction program, to the contrary. With oversight by reasonable and conscientious leaders, managers, and supporters, suicide prevention would become ingrained, omnipresent, and a way of life in which everyone would play a vital role. Naive? Maybe, maybe not.

What is vital to sustain 'suicide prevention' is to spread the idea, and make it 'everybody's business.' Making the idea acceptable as 'everybody's business' would be 'everybody's job.' The 'everybody' would include parents and teachers and counselors of children and youth, police officers and rescue workers on the street, and supervisors, staff, and union officials in the workplace. It would be where people played, in their neighborhoods, and go along with each age group to where they would spend their retirement years.

For the elderly (among whom depression and suicide rates are very high) crisis intervention resources, and suicide prevention and risk- reduction depends on leaders and staff of health care inst.i.tutions, administrators and staff in retirement residence and convalescent communities, senior centers, AARP chapters, and anywhere the elderly gather. The reality would also depend on the elderly themselves, individually and collectively, e.g., to get past the long history they inherited of bigotry, superst.i.tion, and ignorance when it comes to mental health, suicide, and helping survivors of suicide. Emphasis on adult education, support group discussions, and motivational training can help to reduce such barriers among middle year's adults (parents of school age children) as well as the elderly.

An article I wrote in 1984 Suicide Prevention Must Be Everybody's Business was published in the January 14, 1985 issue of the Army, Navy and Air Force Times. It advocated an organized suicide prevention program within the military which would include training and involvement of all active duty military, not confined to those in the medical and mental health fields. I posed the questions: 'a. Does your base have a program whereby supervisors and co-workers who might be confronted with suicidal people are trained to recognize the warning signs and refer potential suicides to professionals?

'b. Are any base personnel, especially security police, social actions or family support workers, trained in crisis intervention techniques? Are any of them volunteer workers in the local community's suicide prevention program?

'c. Does your base have any sort of arrangement with local suicide prevention centers or hotlines so that a civilian crisis worker can contact the base for information or a.s.sistance? Do civilian volunteers know exactly whom to call for help when a military person or dependent threatens suicide?

'd. Do your base officials routinely check with local crisis clinics to find out the number and types of distress calls being received from military people? Is this information a.n.a.lyzed to determine trends or patterns?

'e. Do your base mental health workers give talks to active duty and dependents' groups on this subject? Are civilian experts in suicide prevention brought on base to explain their services?'

The following month (February 22, 1985), the Secretary of the Army and the Chief of Staff issued a Memorandum for Major Commands and Staff Agencies which stated in part, 'The Department of the Army has developed a Suicide Prevention Strategy designed to help commanders deal with this problem. Commanders must use this plan and complement it with initiatives tailored to specific needs.' Over the following months the Army issued implementing Departmental, major command, and subordinate level Regulations, programs, and guides.

Later that same year (1985), I secured copies of studies, plans, directives, motivational guides and other doc.u.ments published by NIMH, the American a.s.sociation of Suicidology (AAS), and the Army on their in- house suicide prevention programs and which they provided to me in response to my appeals. I published in book form the material that I received, and marketed it on a not-for-profit basis to cover my printing and related costs. My initial report, printed on Feb 26, 1971 (during Viet Nam) was 'Summary and Commentary on the Inst.i.tute in Suicidology in Los Angeles January 23-27 1971' and had limited distribution within the Air Force, and the next compilation was in June 1985, 'Military-Civilian Teamwork in Suicide Prevention.' A subsequent update was published in 1988 'Suicide Prevention Programs in the Department of Defense', and the last update, in 1994, returned to the original t.i.tle 'Military-Civilian Teamwork in Suicide Prevention.'

My intent, in collecting and disseminating to the general public the suicide prevention programs and practices of the Armed Forces, NIMH, and other contributors was to join the many lay persons like myself who had become involved. Wide distribution might also promote cross feed and disclose conflicting policies and procedures. The process, itself, I felt, would encourage collaboration among professionals, paraprofessionals, and administrators and directors of suicide prevention ent.i.ties in neighboring civilian communities. Further, I hoped that publicizing the Armed Forces' plans and procedures for suicide prevention and crisis intervention would encourage other government ent.i.ties to explore their need for comparable programs, and that potentially beneficial methodologies might spin off to the private sector.

My continuing interest in proactive and organized suicide prevention efforts in the Armed Forces led me to write to then Secretary of Defense Les Aspin, and to Senator Sam Nunn and Congressman Ronald Dellums in their responsibilities as Senate and House chairmen, respectively, of committees charged with the oversight of military affairs. A copy of my letter to and the response from the Office of the Secretary of Defense is attached.

Programs.

A monumental medical and social advance was made in suicide prevention by the original U S Army Suicide Prevention Plan, (Feb 1985) prepared by the Directorate of Human Resources, Office of the Deputy Chief of Staff for Personnel. The Plan called on each U S Army base to develop and publish an installation Suicide Prevention Plan. The plan was to provide for active duty units, Army families, the Army Community, and civilian employees of the Army. Among its many initiatives were several concerned with collaboration with civilian communities and other public and private sector mental health and crisis intervention resources.

The Navy issued its program in 1987, and the Air Force issued formal policy guidance in 1997 on implementing their suicide prevention program. Since the USAF 1997-policy statement follows my dated copies of the Army and Navy programs by about a decade, I a.s.sume that it conforms to more recent DoD medical policies on the subject and perhaps even reviewed and commented upon by the other Services. The following is from the USAF Policy Letter Digest December 1997 (Source: World Wide Web, search t.i.tle: 'Air Force Policy Letter Digest').

QUOTE:.

Building Healthy Communities - Intervention and Prevention The global mission of the Air Force requires airmen who are fit, healthy and ready to deploy on a moment's notice.

To build healthy lifestyles and do it in the most cost-effective manner, the Air Force is investing in capabilities that promote prevention and intervention. Put Prevention into Practice (PPIP) is a strategy developed by the U.S. Department of Health and Human Services, which the Air Force has implemented to organize and guide the preventive medicine efforts of medical providers.

The first step in PPIP is the health enrollment a.s.sessment review (HEAR), which is conducted with each patient as he or she enrolls... and (which is) then is updated annually. Data from the HEAR helps to identify the health status and prevention needs of patients. This data ... is used by major commands and the Air Staff to a.s.sure that resources are available to care for the populations a.s.signed.

The second element of PPIP is the preventive health a.s.sessment (PHA), which in 1996 replaced the periodic physical examination program for all active-duty members. The PHA is a four-stage process that includes a prevention-oriented clinical screening, occupational examination, screening of military-unique medical requirements and counseling. The PHA will help ensure the highest rates of mission and mobility readiness by providing feedback to commanders on the health of their troops.

Air Force leaders.h.i.+p is concerned about the ability of its members to cope with increasing levels of stress in the face of significant increases in operations tempo and force downsizing. As a result, the Air Force established an integrated product team (IPT) to evaluate suicides among active-duty members and to develop strategies for suicide prevention and intervention.

The IPT identified numerous factors as leading causes of suicide service wide. Chief among them were relations.h.i.+p difficulties, members facing adverse actions viewed as 'career ending,' financial difficulties, substance abuse and the perception that seeking help would have a negative impact on the individual's career. After evaluating this information, the team called in consultants from both the Air Force and public sector to develop a comprehensive approach to suicide prevention.

Since the inception of the suicide prevention IPT, the suicide rate for active-duty members has decreased by more than 35 percent. This has been strong senior leaders.h.i.+p, awareness training for all Air Force members, training at all levels of professional military education, and the development of critical incident stress management teams at every installation. The bottom line in successful suicide prevention is self-aid and buddy care. Everyone must lead the culture s.h.i.+ft in the way prevention services are delivered and remove the stigma of seeking help.

The Air Force established policies providing limited confidentiality protection to service members experiencing personal problems and greatly expanded the proactive role of mental health service providers. Various helping agencies in the Air Force - such as family services, chaplains, mental health services, substance abuse and health and wellness centers - now work together to provide comprehensive prevention services that enhance both individual and organizational resilience. In fact, a civilian consultant hired by DoD to evaluate the military services' suicide prevention programs praised the Air Force's program as one that is 'as advanced and enlightened as any I have heard of.'

Commanders, first sergeants, first-line supervisors and co-workers must be aware of danger signs and encourage members to seek help. Leaders should become familiar with Air Force Instruction (AFI) 44-154, 'Suicide Prevention Education and Community Training,' and AFI 44- 153, 'Critical Incident Stress Management.'

Base helping agencies are now working closely together under an integrated delivery system, or IDS. The IDS is designed to link base helping agencies to address risk factors, reduce stress and improve the coping skills and general well- being of individuals and families in the Air Force community. Wing commanders received guidance on implementing this system for their units earlier this year. Commanders at all levels can now work closely with the various agencies to offer a more comprehensive range of prevention services, increase the protective factors and decrease the behavioral risk factors in the community.

As base agencies join ranks, potential problems can be identified earlier and efforts taken more quickly to prevent tragic trends.

AIR FORCE INSTRUCTION 44 -154 1 MARCH 1997.

(text) SUICIDE PREVENTION EDUCATION AND COMMUNITY TRAINING.

This instruction implements AFPD 44 -1, Medical Operations, concerning suicide prevention education and community training. It establishes requirements and procedures for the conduct of general suicide prevention education and community training. This instruction applies to all active duty Air Force, Air National Guard, and Air Force Reserve, as well as Air Force civilian employees, except for t.i.tle 32 U. S. C National Guard Technicians (IAW Technician Personnel Regulation 100 (172)).

1. Community Training Requirements.

1.1. The Secretary of the Air Force will ensure that all Air Force personnel, to include active duty, guard and reserve, as well as civilian employees receive training in general suicide prevention education at least on an annual basis including awareness of basic suicide risk factors and referral procedures for potentially at risk personnel. Training programs will be designed to destigmatize help seeking behavior among Air Force personnel and not destigmatize the act or attempt of suicide itself.

1.2. The Air Force Surgeon General will be the primary Air Force OPR for this training, and will ensure that this training is conducted as detailed throughout each MAJCOM, as well as in the Air National Guard and Air Force Reserve.

1.3. Each MAJCOM will ensure that all squadron commanders receive training in basic suicide risk factor identification and referral procedures for at risk personnel as part of the new squadron commanders course. Additionally, each MAJCOM will ensure that the following training is conducted at each base, with base mental health serving as the primary OPR for this training.

COMPLIANCE WITH THIS PUBLICATION IS MANDATORY.

UNQUOTE.

Mental health experts have come to accept paraprofessional-level suicide intervention and prevention workers as among those in the forefront of primary resources. The view is that their intervention might reduce the lethality of a person contemplating suicide, and even influence someone who has actually initiated an act of suicide. In this regard, some years ago, Dr. Calvin Frederick, a past President of the American a.s.sociation of Suicidology wrote (quoting): (Dealing with suicidal behavior, that is, suicide prevention) differs from more cla.s.sical diagnostic and treatment procedures in the following respects: 1) suicidal behavior covers a broad range of disturbances and personalities and is, therefore, not a unitary concept; 2) it possesses a unique life or death quality; 3) intervention does not utilize traditional therapy methods; 4) the problem is multidimensional and multidisciplinary, often involving social and cultural att.i.tudes, the law, medical intervention, and innovative psychological approaches; 5) the use of indigenous volunteers as stable and sensitive crisis workers is greater than that found in most aspects of therapeutic endeavor. (unquote) The following is quoted from the Inst.i.tute of Medicine's (IOM) Healthy People 2000 Report-Citizens Chart the Course, a separate volume of Healthy People 2000 that records the testimony and suggestions of citizens interviewed by the Public Health Service in the development of year 2000 national health objectives. The quote is from the section: Violent and Abusive Behavior, page 137): 'Meyer (Mike) Moldeven of Del Mar, California, says that volunteer training is an important component of successful suicide intervention for all ages: 'A community's suicide intervention and prevention resources - of which the suicide prevention center, crisis center, and hotline are elements - depend to an enormous degree on local paraprofessionals and trained volunteers.' In the workplace, employers already provide programs for stress management, as well as cardiopulmonary resuscitation and first- aid training. Thus , 'why not a lay worker on the job site who is trained to function in an emergency suicide situation?' asks Moldeven. 'The United States [Armed Forces] have established formal suicide prevention programs, and the groundwork laid can be used to tailor comparable programs for other employers.'

The largest single federal department, formally recognizing suicide as a critical challenge to the good and welfare of their personnel, took a great leap forward by inst.i.tutionalizing suicide prevention. With the foresight and efforts of advocates and caring managers, comparable initiatives, both formal and informal, can be expected from other government ent.i.ties. When top-management directed - and supported - suicide intervention and prevention policies do take root throughout the federal system, as they inevitably will, they will merge or interact with adjacent Regional, State and community programs. The United States Armed Forces' everybody's business approach to crisis intervention and suicide prevention for their military and civilian populations has great potential for the public good.

Public and private sector employers and schools benefit from their awareness of policies, resources, and standard operating procedures for suicide intervention and prevention practiced by inst.i.tutions and other employers in their area. Where such cross feed and mutuality does not prevail, employer-community initiatives can explore them and apply the results for the common good. Such efforts contribute to the well being of employees and their families; parents, teachers, counselors and students, encourage and improve industrial and community safety, and generally enhance esteem and mutual respect among employers and the community of which they are a part.

In order that ci/sp policies, practices, and training can move forward, information that will help the ultimate recipient of crisis intervention services needs to be disseminated to all levels and throughout all functions of the military and civilian communities: the line and the staff and their families; the civil services, academic and business communities, the domain of the elderly, and the general public. Readily accessible in public, inst.i.tutional, and corporate libraries, adapted to and ingrained into the system, the procedures and delineation of who-does-what in crisis intervention/suicide prevention will help to coordinate and improve plans, methods, and collaboration across the board. It would be a true win-win.

The news media and the Internet can alert employers that do not as yet have their own programs, and keep them informed of opportunities to partic.i.p.ate.

Suicide prevention is everybody's business.

Atch (Copy of letter from) Meyer Moldeven April 26, 1993 To: Secretary of Defense The Pentagon Was.h.i.+ngton, DC 20301 Honorable Secretary: [The opening paragraph in the original letter cited a number of suicides in a military organization. Identifying the activities involved is not relevant to the focus of this copy and has been omitted.]

There is one aspect of organizing around (suicide intervention and prevention)-all-services-that deserves review at command level and, if a covering policy or management system exists, that it be publicized throughout the services and in civilian communities adjacent military installations.

Normally, a military person with an intolerable personal problem tries to get relief from within the system of which he or she is part, e.g., a buddy, family support services, chain-of-command, personnel staff, the IG, etc.. Many personal problems are not job related, but because of the victim's inability to cope, spill over and affect "job." When the person is in a suicidal crisis, realizes that help is urgently needed, and wants such help, he or she will not hesitate to contact whomever can provide it, if not from within the system then from outside.

Unless the military administrative system has changed on this point, a suicidal military person, or a suicidal member of his or her family who seeks help from within the system, believes that a record of the contact will be made. The "record" transforms to stigma and a potential threat to present job and future career. "Records," more often than not, compel the person in a suicidal crisis to look elsewhere. Elsewhere includes the adjacent civilian community's crisis intervention resources, specifically, the suicide prevention telephone hotline where callers need not provide identification - they're as safe from being identified as anywhere they can be under their circ.u.mstances. The hotline worker does what can be accomplished quickly to keep the caller from slipping deeper into crisis and acting out a threat to suicide. They listen, offer nonjudgmental feedback, and together with the caller, explore options.

Almost invariably, when a civilian community crisis worker (telephone hotline or face-to-face) needs information on options unique to military life to help a suicidal military member or someone in his or her immediate family, the source is the nearest base's health care, personnel, or other administrative functions. Very often, when contacts with base officials occur and the worker has the name of a suicidal caller, confidentiality is literally vital; being tagged in the base's records as someone who phoned an off-base crisis center carries almost certain exposure to military authority, and might well add the final straw.

If it's accepted that the military base and its adjacent civilian community should cooperate in suicide intervention, then the civilian and military agencies need mutually accepted procedures to do the job. If a community's crisis resource has one set of procedures for cooperation from the Navy, another for the Marine Corps, and still others for the Army and the Air Force, confusion mounts and collaboration suffers. This is especially true when the situation is tight and there isn't much time to keep a suicide threat from becoming an act. To the telephone hotline worker in a suicide prevention center it makes no difference whatsoever if the person on the other end of the line is a soldier, sailor, airman, marine - or civilian. On the other side of the scale, however, is the we-take-care-of-our-own turf, and that, to the suicidal person, is meaningless.

I hoped that, by now, military bases would have been further along in collaborating with adjacent civilian suicide prevention resources and that such teamwork would be reflected in base and community media. How else would a military person or a member of his or her family on the edge of a life-death decision for themselves know where to go or whom to phone, especially where their privacy and confidentiality would be respected - if they decided to take a chance to continue living? Is a city telephone directory listing for the local crisis center enough?

Agreements, procedures and contact points for military-civilian teamwork in suicide prevention deserve to begin on a county, metropolitan, or other regional basis, rather than in single-base to community understandings, especially where the area has bases representing different services. When all the services in an area have maximum understanding among themselves about collaborating with community suicide intervention resources, it will optimize the support that they and their people as individuals can ask for from that resource, and the help that the hotline worker can offer to them. In effect, when a civilian suicide hotline has been appealed to for help by a military member/family member, the crisis worker will have clearly written, mutually agreed upon procedures for communications and actions with each base in the area. All concerned will have been trained, tested, and know to the greatest degree possible who is going to do what. With present computer networking capabilities the resources indices in such guides can be readily maintained current and widely disseminated throughout a region and on and among military installations.

The opinions in this letter are my own, and are based on my experiences as a civilian IG-a.n.a.lyst and suicide prevention hotline volunteer in the late '60s/early 70s (and ha.s.sling the bureaucracy on this issue into the mid-80s.) I am not now a.s.sociated with any mental health profession or military organization-strictly a private citizen. It may be that what I've suggested already exists or, conversely, that it isn't justified; I don't know, but I would be remiss not to present my views for your consideration.

Respectfully, s/Moldeven Reply (Copy) (From) Office of the Secretary of Defense Was.h.i.+ngton D. C. 20301 (Force Management and Personnel) 1 June 1993 (To) Mr. Meyer Moldeven Dear Mr. Moldeven: Thank you for your letter of April 26, 1993 to Mr. Les Aspin, regarding suicide prevention programs in the Department of Defense.

Your letter prompted a review of policy in the Department of Defense on suicide prevention. The Department of Defense does not address suicide prevention in its directive on Health Promotion. That directive was published March 11, 1986, and is in need of revision. The Department is reviewing and revising that directive and a suicide prevention section will be added. We will address in the development of that section the issues you raised in your letter to Mr. Aspin.

Thank you for your interest and continued concern in this important mental health area.

S/Nicolai Timenes, Jr. Princ.i.p.al Director (Military Manpower and Personnel Policy [added, hand-written: 'Thanks!']

Afterword.

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