Feature Article
Formulating a plan
When Lt. Gen. Charles “Chip” Roadman II convened a diverse team of military and civilian experts in summer 1996 to consider how to reduce skyrocketing suicide rates in the U.S. Air Force, he never imagined the program they would develop could have such prominent and far-reaching effects.
With that program - the first of its kind to suggest that suicide is a preventable public health problem - in place service-wide, USAF rates plummeted to just 2.2/100,000 in the first eight months of 1999. Quite a decrease from a high of 16.4/100,000 in 1994.
David Litts, O.D., colonel, USAF, was a member of the team and remembers well June and July of 1996 when he and about 75 others gathered to consider how best to attack soaring suicide rates in the Air Force.
“We assembled all that was known about Air Force suicide victims,” recalls Litts. “Then each team member presented his or her view of the ‘problem’ and the ‘solution.’ From this three themes resonated with team members - all centering in the community aspect of the Air Force and the undermining effects that stigma toward accessing mental health services had to that community spirit.”
The three themes among USAF suicide victims that were uncovered by team members were:
1. STIGMA - Airmen feared losing their jobs and avoided seeking professional help because of the stigma associated with mental health problems and their treatment.
2. BELIEFS - Many airmen perceived that commanders and supervisors routinely viewed mental health records, which reinforced barriers to treatment due to perceived stigma.
3. CULTURAL NORMS - The Air Force was losing one if its defining qualities - a supportive interconnectedness best captured in the old Air Force adage, “The Air Force takes care of its own.”
The team then identified the risk factors for suicide and made an astute observation: All of these risk factors, with the exception of previous attempts, were modifiable.
In addition the team identified protective factors that could potentially stave off suicide.
Amazingly, these protective factors were modifiable as well, just as were most risk factors.
“The next six weeks were filled with briefings, discussions, emails and multiple drafts and redrafts,” recalls Litts. During that time certain assumptions emerged that would underlie the remainder of the team's work:
First and foremost, that many, if not most, suicides are preventable.
These assumptions also became apparent:
- Suicide is not a medical problem but a community-wide problem
- Suicide does not exist in a vacuum; it is the “tip of the iceberg” of psychosocial problems. So a responsible prevention program must address the entire “iceberg” of problems and afflictions experienced by individuals, their families and communities.
- An all-encompassing community-based approach to prevention would require committed partnerships among many disparate providers and groups.
- The full endorsement and ongoing support by senior Air Force leadership - starting with the USAF chief of staff and four-star generals - were critical to achieving cultural transformations that could curb suicide rates.
To develop a solid program grounded in these assumptions, team members looked to the research. But because no established suicide prevention methods existed in the literature, the team was guided by 1992 recommendations from the Centers for Disease Control and Prevention (CDC) for youth suicide prevention 1; and 1996 recommendations made by the United Nations and World Health Organization to nations in developing suicide prevention strategies 2. Team members felt these recommendations held the most promise for formulating a sound prevention strategy. The resulting USAF Suicide Prevention Program is comprised of 11 initiatives).
1 CDC. Youth suicide prevention programs: a resource guide. Atlanta, Georgia: U.S. Department of Health and Human Services, Public Health Service, CDC, 1992.
2 United Nations. Prevention of suicide: guidelines for the formation and implementation of national strategies. New York: United Nations, 1996. United Nations publication ST/ESA/245.
Eleven key initiatives
These 11 initiatives comprise the U.S. Air Force Suicide Prevention Program:
- Leadership Involvement - Proactive, rapid and ongoing information through the chain of command.
- Professional Military Education - Community training and professional military education on how to effectively intervene with a suicidal individual.
- Guidelines for Commanders on Use of Mental Health Services - To counter confusion and offer clear guidance on how and when best to access mental health services.
- Community Preventive Services - Mental health staff in the community to serve in prevention/non-clinical roles, a first step to removing stigma.
- Community Education and Training - Coined the LINK program (Look, Inquire, Note, Know), a preventive web of individuals around those at risk.
- Investigative Interview Policy - To assist individuals under investigation with their emotional and psychological needs.
- Critical Incident Stress Management - To address needs of airmen as survivors when a suicide does occur.
- Integrated Delivery System for Human Services Prevention - A major recommendation, this initiative created a coordinated delivery system for USAF health and human services.
- Limited Patient Privilege - A psychotherapist-patient privilege to enhance confidentiality so members would more willingly seek mental health services.
- Behavioral Health Survey - A tool to assess behavioral health aspects of a unit and members of a unit. Developed in cooperation with the Johnson Institute (now Hazelden) of Minneapolis (a civilian contractor), this 196-item questionnaire considers five main behavioral health factors: alcohol use frequency, emotional distress, lack of cooperation with partner, psychological stress and job dissatisfaction.
- Epidemiological Database and Surveillance System - This centralized database for all fatal and nonfatal self-injuries tracks not only events but uncovers potential risk factors for a suicide attempt through its Suicide Event Surveillance System (SESS), which collects broad data including psychological, social, behavioral, relationship and economic status of airmen.
