Prevention, Intervention and
Postvention
Elizabeth K. White, Ph.D.
Prevention, Intervention and
Postvention
Introduction to Suicide
Prevention
Intervention
Postvention
In Conclusion
Prevention, Intervention and
Postvention
Introduction to Suicide
Prevention, Intervention and
Postvention
Introduction to Suicide
Suicide in General
Law Enforcement Suicide
Suicide and Sexual Orientation
Introduction to Suicide
Suicide in General
One suicide every 16.7 minutes
11th ranking cause of death in
USA
~787,000 annual attempts
31,484 completed suicides in
2003
Each suicide significantly
impacts six other people!
Introduction to Suicide
Law Enforcement Suicide
Is Law Enforcement
Suicide an
“Epidemic” or a
Terrible Tragedy?
Introduction to Suicide
Law Enforcement Suicide
Confounding Variables
• Sworn peace
Who is a
officers
member of
• Custody
law
enforcement? officers
• Reserve
officers?
• Parole officers?
• Retired
Introduction to Suicide
Law Enforcement Suicide
Law
Enforcement
Suicide
Concerns
of Police
Survivors (COPS) sent out
a survey 4to 14,000
agencies
regarding
RESPONDED!
surviving family members
of peace officers who had
committed suicide
Introduction to Suicide
Law Enforcement Suicide
Confounding Variables
17 % of Police Suicides Missclassified
25
20
15
10
5
0
5
1
20
12
Law Enforcement
Original Suicides
Violanti, 1996
Municipal Workers
Reclassified Suicides
Introduction to Suicide
Law
Enforcement Suicide
Estimated Law
Enforcement
Rates
Aamodt & Stalknaker (2001)
– 18.1 / 100,000
Loo (2003) – 22.99 / 100,000
Compion (2001) – 18.1 /
100,000
Introduction to Suicide
Law Enforcement Suicide
Suicide Rate Comparison?
Suicide Rate per 100,000 People
25
18.1
20
15
10.8
10
5
0
National Rate
CDC WISQARS Data 2003
Law Enforcement
Introduction to Suicide
Law Enforcement Suicide
Suicide Rate Comparison
Suicide Rate per 100,000 People
2003
25
17.6
20
15
19.5
10.8
18.1
11.1
10
Law
Enforcement
Military
White Males
Males
0
National
Rate
5
Introduction to Suicide
Law Enforcement Suicide
Military Suicide Rates 1990-2004
30
Rates/100K
25
20
15
10
5
0
CY91
92
Navy
93
94
95
96
Marine Corps
97
98
Air Force
99
00
Army
01
02
03
Coast Guard
04
Introduction to Suicide
Law Enforcement Suicide
White Black
Hisp
Asian
LASD 84% 16%
52%
10%
32%
4.2%
LAPD 81% 19%
42%
13%
37%
6%
2006
Male Femal
e
Introduction to Suicide
Law Enforcement Suicide
“A peace officer is twice
as likely to die by his or
her own hand than by the
hand of a suspect!”
Introduction to Suicide
Law Enforcement Suicide
Suicide/Homicide Ratio
General Population Males, Aged 21-65
20000
19114
15000
3.6:1
10493
Suicides
Homicides
10000
5000
0
Suicides
CDC WISQARS Data 2003
Homicides
1.8:1
Introduction to Suicide
Law Enforcement Suicide
Confounding Variables
Having a firearm in the
home increases
your risk for suicide
five fold!
Roggenbaum & Lazear, 2003
Introduction to Suicide
Law Enforcement Suicide
Confounding Variables
Firearm suicide attempts
result in death in
approximately 85% of
cases.
Introduction to Suicide
Law Enforcement Suicide
Confounding Variables
LAW ENFORCEMENT SUICIDE BY FIREARM
95% 94%94%
100%
80%
79%
100%
86%
70%
54%
60%
40%
General
Population
LE
Average
Wyoming
Canada
NYPD
Ireland
Chicago
0%
Australia
20%
Introduction to Suicide
Law Enforcement Suicide
Confounding Variables
The risk of suicide in
alcoholics is 50-70%
higher than the general
population.
Introduction to Suicide
Law Enforcement Suicide
Confounding Variables
ALCOHOL AND LAW ENFORCEMENT
80% 78%
40%
42%
LAPD
NYPD
Detroit
Australia
Ireland
Quebec
0%
17%
16%
20%
Chicago
51% 50%
60%
60%
Canada
60%
Percentages of law enforcement suicides involving alcohol
Introduction to Suicide
Law Enforcement Suicide
Confounding Variables
Suicide by State per 100,000
CDC WISQARS Data 2003
New York
Massachusetts
California
USA
Florida
Nevada
Wyoming
25 21.8
19.4
20
13.5
15
10.8 9.6
10
6.7 6.1
5
0
Introduction to Suicide
Law Enforcement Suicide
Confounding Variables
Health Problems and Law Enforcement
Suicide
3000
2615
2500
2000
Law Enforcement
Retired
1500
1000
500
0
Gaska, 1980
Retired Municipal
White Males
334.7
33.5
Law Enforcement
Retired with
Disability
Introduction to Suicide
Suicide & Sexual Orientation
 Research Difficulties
 Youth Studies
 Adult Studies
Introduction to Suicide
Suicide and Sexual Orientation
Research Difficulties
Are you GLBTI?
After the Fact
Attempts vs. Completions
Compared to What?
Is it Because I am GLBTI?
Introduction to Suicide
Suicide and Sexual Orientation
Youth Suicide Attempts
Bell & Weinberg, 1978
to age 20
11.8%
10.5%
9.4%
8%
6%
6%
7%
2%
Black
Females
Black
Males
1%
White
Male
4%
2%
0%
9.2%
Heterosexual
Gay & Lesbian
White
Females
12%
10%
Attempts:Completion ratio estimated at 100:1
Male:Female Attempt ratio estimated at 1:3
Introduction to Suicide
Suicide and Sexual Orientation
Suicide Completions
2003 CDC Data
Per 100,000
20 19.5
15
8.8
10
4.70
5
5.5
Asian/PI
Hispanic
Black
1.80
White
0
5.0
Males
Females
Both
Introduction to Suicide
Suicide and Sexual Orientation
GLB Youth Suicide
52
Robin et al 2003
Both
Sexes
8%
6%
19
%
32
%
27
%
44
%
Serious Attempt
Same
Sex
17
%
Opp
Sex
5%
12
%
60%
50%
40%
30%
20%
10%
0%
%
GLB Massachusetts/Vermont Attempts 1995/1997
Introduction to Suicide
Suicide and Sexual Orientation
GLB Youth Suicide Attempts
33%
36%
31%
Bradford/Caitland
1988
Garofalo 1998
Massachusetts
2001
24%
D'Augelli, et al
2005
Youth 9-14%
30%
GM Remafedi
1991
40%
35%
30%
25%
20%
15%
10%
5%
0%
Introduction to Suicide
Suicide and Sexual Orientation
GLB Youth Suicide
Contributing Reason
Remafedi, et al 1991
44%
33%
30%
22%
15%
Romance
Substance
Abuse
Peer
Conflict
Depression
Sex
Orientation
11%
Family
Problems
50%
40%
30%
20%
10%
0%
Introduction to Suicide
Suicide and Sexual Orientation
Adult Suicide Attempts
GLB Adults Reporting Suicide Attempt
19%
20%
14%
15%
10%
10%
6%
Attempts:Completion ratio estimated at
Bagley/Tremblay
1997
Ploderl/Fartacek
2005
Cocran/May
2000
0%
Bell/Weinberg
1978
5%
Introduction to Suicide
Suicide and Sexual Orientation
Special Populations
50%
47%
37%
40%
30%
20%
Transgender
0%
Gender
Nonconforming
Males
10%
Prevention, Intervention and
Postvention
Prevention
Prevention, Intervention and
Postvention
Prevention
Designing a Prevention
Program
Obtaining “Buy In”
Prevention
Designing a Prevention Program
 Screening
 Education
 Tracking “at risk”
personnel
 Critical incident
intervention
 Resources/Referral
Prevention
Designing a Prevention Program
Screening
Pre-employment
Psychological
Screening
High Risk Assignment
Screening
– Special Weapons
– Undercover
– Arson/Explosives
Prevention
Designing a Prevention Program
Preventative Education
Academy
Supervisors
Field Training Officers
AOT
Prevention
Designing a Prevention Program
Tracking “At Risk” Personnel
Divorced/Separated
Bereaved
Injured/Ill
Under Investigation
Substance Use Problem
Approaching Retirement
Prevention
Designing a Prevention Program
Critical Incident Intervention
Officer Involved Shootings
Serious Threat to Life
Secondary Traumatization
Incidents
Prevention
Designing a Prevention Program
Available Resources
Law Enforcement Mental
Health Professionals (MHP)
Peer Support Program
Chaplains’ Program
Self-Help Programs
Peace Officer’s Fellowship
Prevention
Designing a Prevention Program
Referral Systems
Supervisor Referrals
Settlement Agreements
Prevention
Obtaining “Buy In”
 “Top Down”
backing
 Saturation
outreach
 Making it stick
Prevention
Obtaining “Buy In”
“Top Down” Backing
Backing of upper managers
- Initial materials cost
- Training time coverage
- Non-punitive/help orientation
“Personal touch” roll out to
middle managers
Prevention
Obtaining “Buy In”
“Saturation” Outreach
Preview presentation/training to
peer support personnel &
chaplains
Availability of materials through
computer as well as
briefing/training
Incorporation of video into all
existing trainings - where
Prevention
Obtaining “Buy In”
Making it Stick
Easy to understand
Easy to remember
Remove impediments
Prevention
Obtaining “Buy In”
“Rolling Backup”

Prevention, Intervention and
Postvention
Intervention
Prevention, Intervention and
Postvention
Intervention
Dynamics of Suicide
Law Enforcement
Complications
So What Do I Do?
Intervention
Dynamics of Suicide
 Myths & Reality
 Risk Factors
 Precipitants
Intervention
Dynamics of Suicide - Myth
Suicidal people
want to die!
Intervention
Dynamics of Suicide- Reality
Suicidal people want a
way out of intolerable
pain.
Some part of them wants
to live if you can help
them find a way to do it!
Intervention
Dynamics of Suicide - Reality
Do People Communicate
Suicidal Intent?
20%
80%
Warning
McCafferty et.al. (1992)
No Warning
Intervention
Dynamics of Suicide - Myth
If someone really
wants to die, you
can’t talk them
out of it.
Intervention
Dynamics of Suicide- Reality
Suicidal feelings
are often
impulsive and
temporary!
Intervention
Dynamics of Suicide - Myth
Asking somebody if
they are suicidal
will push them over
the edge – or they
will lie anyway.
Intervention
Dynamics of Suicide- Reality
You CANNOT give
somebody the idea of
committing suicide.
Many people want help and
will be relieved to tell you
the truth!
Intervention
Dynamics of Suicide - Myth
Any person who
is suicidal will
never fully
recover!
Intervention
Dynamics of Suicide- Reality
Peace officers are
resilient. Once
they get help, they
often recover and
go on with their
lives!
Intervention
Dynamics of Suicide - Myth
Any cop who feels
suicidal can kiss
his or her career
goodbye!
Intervention
Dynamics of Suicide- Reality
NECESSARY AND
SUFFICIENT
INTERVENTION
Intervention
Dynamics of Suicide - Reality
Necessary and Sufficient
Intervention
Involuntary
Hospitalization
Voluntary
Hospitalization
Medication
Counseling
Peer/Family
Support
Intervention
Law Enforcement Complications
 “Real cops” don’t feel
 “Real cops” solve their own
problems
 I am not a “ding”
 Only Crazy People Go to
Psychologists
 Only Really Crazy People Take
“Meds”
 What about my career?
Intervention
So What Do I Do?
 What Should I Know?
 Signs & Symptoms
 Asking the Questions
 SAFER Model
 Pushing on the Scale
 Some Do’s & Don’t
Intervention
So What Should I Know?
Understand the dynamics of
suicide
Know the myths vs. realities
Know the signs & symptoms
Know what to do if you suspect
somebody may be suicidal
Know about available resources
Make a commitment to “Roll
Backup”
Intervention
Signs & Symptoms
Risk Factors
• Sex (male)
• Age (15-34) (also 65+)
• Depression
•
•
•
•
•
•
•
Previous exposure to suicide
Ethanol/alcohol/drug abuse
Rational thinking loss
Social support system lacking
Organized plan
No spouse or significant other
Sickness/Injury
Patterson, W., et al, 1983
Intervention
Signs & Symptoms
Precipitating Events
•
•
•
•
•
•
•
•
•
•
Witness to violence
Victim of crime
Sexuality concerns
Failed
promotion/specialty
assignment
Work
problems/discipline
Financial problems
Substance abuse
Physical abuse
Sexual abuse/assault
Legal problems/arrest
Courtesy of Daniel Clark,Ph.D.
•
•
•
•
•
•
•
Suicide of loved one
Death of loved one
Serious family illness
Loss of health
Divorce/separation
Loss of employment
Loss of cherished
possessions
• Retirement
Intervention
Signs & Symptoms- Direct Verbal Clues
I’m going to kill myself
I wish I were dead
You’d be better off without me
I might as well be dead
If …doesn’t happen, I’m going to end it
I’m going to commit suicide
Courtesy of Daniel Clark,Ph.D.
Intervention
Signs & Symptoms- Indirect Verbal Clues
I can’t go on any longer
I’m taking the plunge
We all have to say goodbye sometime
Nobody needs me anymore
I’m tired of life
You won’t be seeing me any more
Life has lost meaning for me
I can’t take it any more
You’d be better off without me
I can’t take the pain
Eat my gun
You’re going to regret how you treated me
Cash in my chips
Courtesy of Daniel Clark,Ph.D.
Fold my hand
Intervention
Signs & Symptoms- Behavioral Clues
Buying a weapon
Giving away possessions
Making a will
Taking unusual risks
Changes in personality
The “practice run”
Sudden religious
interest/disinterest
Substance abuse relapse
Courtesy of Daniel Clark,Ph.D.
Intervention
Signs & Symptoms- Behavioral Clues
HIGH risk clues
History of a suicide attempt (40%)*
Family/friend suicide attempts/
completions
Substance use
Plan is specific and well defined
Plan is viable
Lethality of method
Rubenowitz et al. 2001
Intervention
Signs & Symptoms - Precipitating factors
Law Enforcement Rationale for Suicide
R
ela
tio
ns
hi
p
U
nk
no
Ps
w
yc
n
ho
lo
gi
ca
W
l
or
k
st
re
ss
Fi
na
C
rit
nc
ica
ia
l
lI
nc
id
A
lco
en
t
ho
lA
bu
se
35% 32%
30%
23%
25%
20%
12%
15%
10%
10%
7% 5% 5%
5%
0%
Aamodt 2001
Intervention
Signs & Symptoms - Precipitating factors
NYPD 1985-1999 Rationale for Suicide
O’Neill 2001
8%
2%
1%
St
Te
re
rm
ss
in
al
Ill
ne
A
ss
lco
ho
lA
bu
se
R
ela
tio
ns
hi
p
U
nk
no
w
n
D
ep
re
ss
io
n
70% 61%
60%
50%
40%
20%
30%
20%
8%
10%
0%
Intervention
Signs & Symptoms - Precipitating factors
Increase in Risk for
Suicide Attempt
50
40
30
20
21.7x
10
0
4.8x
Janik & Kravitz 1994
6.7x
Marital Problem
Suspension
Both
Intervention
Asking THE Question
Have you been thinking
of hurting
or killing yourself?
Intervention
Any other questions?
Have you been thinking of hurting or
killing yourself?
 When did you last think about suicide?
 How would you kill yourself?
 Do you have the means available?
 Have you ever attempted suicide?
 Has anyone in your family
attempted/completed suicide?
 What are the odds that you will kill yourself?
 What has been keeping you alive so far?
Courtesy of Daniel Clark,Ph.D.
Intervention
SAFER Revised Model
Stabilize the Situation
- Mitigate affective escalation.
- Remove from provocative stressors.
- May use a diversion (i.e. walk, coffee, etc.).
Acknowledge the Crisis
- What happened?
- Establish rapport and a sense of safety.
- Provide for cathartic ventilation.
Facilitate Understanding
- Explain the symptoms.
- Normalize reactions.
Courtesy of Daniel Clark,Ph.D.
Intervention
SAFER Revised Model
Encourage Effective Coping
Techniques
- Teach basic stress survival skills.
- Improve immediate and short term
coping.
- Develop a plan for immediate use.
Recovery or Referral
- Assess current adaptive functioning.
- Assess need for further assistance.
- If needed, identify appropriate referral.
Courtesy of Daniel Clark,Ph.D.
Intervention
Pushing on the Scale – Factors
Towards
Suicide
#4
#3
#2
#1
0
20
40
Pain
60
Hopelessness
80
Alcohol
100
Plan
Precipitant
120
140
Intervention
Pushing on the Scale – Factors
Against
Suicide
Time
Sleep
Social
Supports/Obligations
Spirituality*
Sobriety
Dervic et al, 2004
Intervention
Pushing on the Scale – Final Equation
#4
•Time/Sleep
#3
•Social Support
•Spirituality
#2
•Sobriety
•Counseling
#1
0
20
40
Pain
60
Hopelessness
80
Alcohol
100
Plan
Precipitant
120
140
Intervention
“Do List”
Remain calm
Take all suicidal
comments/behaviors seriously
Listen, listen, listen
Help define the problem
Rephrase thoughts/feelings
Intervention
“Do List”
Focus on central issue/
prioritize
Identify preventative forces
Capitalize on old strengths
Identify options
Explore resources
Intervention
“Don’t List”
 Don’t sound shocked
 Don’t deny/minimize the
threat
 Don’t offer empty promises
 Don’t debate morality
 Don’t leave the person alone
 Don’t be the only person
helping
Prevention, Intervention and
Postvention
Postvention
Prevention, Intervention and
Postvention
Postvention
Survivors
How Can I Help?
Impact on Your Agency
Postvention
Suicide Survivors
Friends, family and colleagues
who survive following the
death of a loved one by suicide
31,484 suicides per year
6 survivors per suicide
188,904 suicide survivors per
year
Postvention
Suicide Survivors - How
is suicide
different?
Often compromises usual mourning rituals
Typically not pathological but often
complicated:
–
–
–
–
Leaves “unfinished business”
Often leaves a violent death scene
Scene is a “crime scene”
Media involvement
Expect a 4-7 year recovery period
Disrupts normal functioning for an
extended period of time
Postvention
Suicide Survivors - How
is suicide
different?
Survivor Reactions
Denial of the death as a suicide
Preoccupation with “why”
Guilt/Responsibility
Religious concerns
Extreme anger, abandonment feelings
Complications from others:
–
–
–
–
Blaming the survivor
Condemning the loved one
Awkwardness from social support
Social isolation
Postvention
How Can I Help?
Understand that…
Grief is a process not an event
Each person grieves at a different
rate and in a different way
You do not “get over” grief, but
you can be “in recovery”
Repetition is part of recovery
Postvention
How Can I Help?
Help by…
Listening, listening, listening
Non-judgmental
Don’t answer questions you don’t
know the answer to!
Normalize feelings–even negative
ones
Share the memories
Postvention
How Can I Help?
As time goes by…
Memorials
Special dates
Keeping in contact
Self-help/support groups
Grief counseling
Be aware of follow up suicides
Postvention
Helpful phrases
 I’m sorry for your
loss…
 How can I help?
 Is there anyone I can
call for you?
 What is the most
difficult part for you?
 When you are ready, I
would like to share my
memories of
_________
 You don’t have to deal
with everything right
Courtesy ofaway.
Daniel Clark,Ph.D.
How Can I Help?
Phrases to avoid
 How can you bear that
________ went to
hell…
 You are young enough
to find somebody new.
 Get over it.
 Didn’t you see this
coming?
 At least he is no longer
suffering.
 Don’t think bad of her.
 I know how you feel.
 Time heals all wounds
Postvention
How Can I Help?
Support is out there…
Survivors of Suicide
http://www.survivorsofsuicide.com
Concerns of Police Survivors
http://www.nationalcops.org
Compassionate Friends (children)
http://www.compassionatefriends.org
Survivors of Law Enforcement Suicide
http://www.tearsofacop.com
Family & Friends of Suicide
http://www.friendsandfamiliesofsuicide.com
Postvention
How Can I Help?
“Effective postvention for
suicidally bereaved
families may be one of
the most important forms
of multigenerational
prevention available to
mental health
professionals.”
Jordan, 2001
Courtesy of Daniel Clark,Ph.D.
Postvention
 Impact on Your Agency
 “Postvention Team”
 Target Group
Interventions
 Funeral Considerations
 Agency Actions That
Help
Postvention
Helping Your Agency Recover- Impact
Who is
impacte
d…?
• Work friends
Based
on law
• Work
colleagues
enforcement
• Immediate
supervisors
suicide
rates, an
•agency
Unit commanders
the size of
the LASD can
• First responders
expect to have 1-2
• Homicide
suicides
a
year
investigators
• Personnel
Department
Postvention
Helping Your Agency Recover- Impact
Greater impact on law enforcement…
Increased sense of responsibility
Increased cohesion increases
loss
Increased sense of personal
identification
Increased media attention due to
profession of law enforcement
May have had to handle the scene
Postvention
Helping Your Agency Recover- Impact
Some of the ways this impact
appears…
Attendance problems
Decreased work quality and quantity
Increased alcohol consumption
Increased number of injuries/accidents
Negative impact on interactions
between supervisor, coworkers,
citizens and inmates
Reminders will reactivate grief
Postvention
How Can I Help?
Suicide Policy?
All suicides are not
created equal!
Jordan, 2001
Courtesy of Daniel Clark,Ph.D.
Postvention
Helping Your Agency Recover
A Postvention Team consists of…
Unit commander/Chief
Human resources representative
Psychologist (preferably who rolled)
Family representative
Peer support/CISM leader
Chaplain (preferably who rolled)
Risk management/Legal
representative
Line staff representative
Postvention
Helping Your Agency Recover
Team responsibilities…
Death notification
Internal announcements
Media statement
Cleaning out the locker
Cleaning the scene
Funeral/memorial planning
CISM
Monitor for ongoing/delayed
reactions
Postvention
Helping Your Agency Recover
Target Group Interventions - Family…
On scene (or hospital) crisis
intervention
Death notification
Chaplain assistance
Funeral assistance
Peer support
Grief counseling
Referrals
Postvention
Helping Your Agency Recover
Target Group Interventions – Line
Staff…
On scene (or hospital) crisis
intervention
Death notifications
Chaplain assistance
Individual/group CISM
Peer support
Grief counseling
Referrals
Postvention
Helping Your Agency Recover
Target Group InterventionsSupervisors…
On scene (or hospital) crisis
intervention
Chaplain assistance
Individual/group CISM
Peer support
Grief counseling
Referrals
Follow up training
Postvention
Helping Your Agency Recover
The FORGOTTEN Ones…
Medical assistance providers
Transportation providers
Dispatchers
Crime scene personnel
Homicide investigators
Partners/Former partners
Training officers
Crisis negotiators
Postvention
Helping Your Agency Recover
Funeral Considerations…
Flag ceremony
21 gun salute
Bagpipes
Honor guard
“Brass” attendance
Attendance (off duty, on duty,
assisted)
Uniform/Non-uniform
Official/organized assistance to
family
Official/organized financial
Postvention
Helping Your Agency Recover
Agency Actions That Aid in Postvention…
Confidential counseling available to all
 Employees’ aware of resources
 Decrease stigma of seeking help
Postvention Team
Policy/procedure in place
Emergency activation system in place
Personnel, and their roles, identified
Prevention, Intervention and
Postvention
In Conclusion
Prevention, Intervention and
Postvention
In Conclusion
Summary
Additional Resources
Questions
In Conclusion
Summary
Make a personal
commitment to
“Roll Backup”
In Summary
Additional Resources
American Foundation of Suicide Prevention
http://www.afsp.org
American Association of Suicidology
http://www.suicidology.org
Daniel Clark, Ph.D.
http://www.criticalconcepts.org
SAMHSA Suicide Prevention
http://www.mentalhealth.samhsa.gov
Center for Disease Control
http://www.cdc.gov
In Conclusion
Questions???
In Conclusion
Elizabeth K. White, Ph.D.
LASD-ESSB
4700 Ramona Blvd.
Monterey Park, CA 91754-2169
ekwhite@lasd.org
(661) 272-8880