FORT HOOD, Texas - Faced with an imminent move to a nursing home, Norma's elderly mother told her daughter the move wouldn't be necessary. She was going to die in her beloved home. When probed, Norma finally asked the question: "Mother, are you thinking of killing yourself?"
Although Norma is Norma Jenkins, a Warrior Transition Brigade occupational therapist, her mother is a character created during a role-playing exercise for a recent WTB-hosted Applied Suicide Intervention Skills Training workshop.
Sponsored by Living Works Education Inc., the two-day workshop, which was adopted by the Army in 2009, is designed to give community caregivers and gatekeepers the practical knowledge and hands-on intervention training in assisting someone contemplating suicide. The ASIST model, which has been taught worldwide in prisons, schools, Parent-Teacher Associations and municipalities, validates that the more people within the community who are trained as first-aid caregivers, the safer the community will be from suicide.
Unlike the Army's ACE (Ask, Care, Escort) model built for soldier to soldier, ASIST trains the gatekeeper who has direct responsibility for the day-to-day care of soldiers and serves as a "Band-Aid" in emergency situations where no professional help is available. It's required training for every soldier and civilian staff member assigned to the WTB.
"I think it's a incredible program for the WTB to have because our soldiers are dealing with psychological trauma, chronic physical pain and myriad other stressors like change of life situations, career and family," said Janique Parnell, WTB's social work supervisor and ASIST trainer. "To have a program where everybody who touches that soldier can say 'I've got a tool to use, if I can identify that this is a person at risk,' that's a fantastic thing."
The beauty of ASIST in an Army environment said WTB chaplain, Maj. Kyle Welch, is that it's community based and incorporates civilians.
"When you go off post, you're in a civilian environment, so you not only have soldiers, but family members providing care," Welch said. "ASIST is a great aid to supplement what the Army is already doing."
Talking reduces sigma
The biggest misconception of suicide, Parnell said, is people are afraid to talk about it. Because of this taboo, there are really no accurate suicide statistics because unreported suicides are usually the unsuccessful attempts.
"Suicide is a much larger issue than most people realize," she said. "We tend to think it's just a couple of people having a really horrible day, but when you look at the true number--on any given time that 15 million people had thoughts of suicide whether it was passive or looking at the barrel of a weapon -- that's a lot of people."
Being able to call suicide what it is, reduces the stigma and opens the door for that individual to be more willing to reach out for help, according to Parnell who said the ASIST model stresses that no one is immune from suicide.
"That's a big decision to end your life by your own hands," she said. "It's not something that people typically wake up to and say 'I think I'll kill myself today.' If you have an open dialogue about it, it doesn't keep it a secret and in the dark."
The foundation of ASIST is putting suicide in the room said Welch.
"When you break out into groups during the role-playing exercises, which is key to the intervention training, you realize how many people in the room have been affected by suicide either directly or indirectly," Welch said. "So on the basis of that experience and the practical exercises, ASIST gives you the skills so that you feel more comfortable if you do have to do an intervention."
Staff Sgt. Andrea Brewer, a WTB ASIST trainer and chaplain's assistant, said that before ASIST, she thought she could talk to someone with suicide ideations.
"Before I went through the class, I always thought I could talk to someone who is thinking about suicide, but actually, you'd be surprised at how much you have to learn to be comfortable in doing so," Brewer said. "This class, especially the role-playing exercises, gives you the knowledge of what to do in those situations and keeps you calm."
The ASIST model teaches caregivers to explore invitations such as changes in behaviors when they suspect someone is having suicide ideations.
"There may be certain events happening in their life that puts them at risk," said Parnell. "So you, as a caregiver, explore that," adding, for example, a loss of a personal relationship for one person might be a good thing for another."
Intervening
The next step, she said, is something most people fail to do: asking that person if they are thinking about killing themselves, and if so, if they have a plan.
"We are so afraid of offending that person by asking," she said, "because we are emotionally uncomfortable. We don't want that person to say 'are you crazy?' And if I--as that caregiver--feel so bad about what's going on in my head, we may never get out that the issue on the table is suicide."
Parnell said asking someone if they are planning on hurting themselves isn't the same message as asking them about suicide.
"If they are planning on committing suicide, especially if they already have a plan, they don't consider that as hurting themselves," she said. "In one of our scenarios, a man was going to end his life with a gunshot. He didn't consider that as hurting himself because he was going to be dead and out of pain."
Before the class, Sgt. 1st Class Alfredo Cerda, a transportation specialist with F Company, said he would never have asked someone if they were going to commit suicide.
"I always thought I'd be planting the idea of suicide in their head," he said, which instructors assured him there's no evidence to support that belief. "But the class helped me to understand that once you ask the question out loud, it makes the person think about it. You just can't beat around the bush because the sooner we know what's wrong with the soldier, the sooner we can get him/her help."
Cerda said the role-playing really opened his eyes because it forced the class to come up with solutions for situations that most had never experienced.
"It could be anything that could trigger that emotion," he said, adding that in his group a soldier was reduced in rank and wanted to take his life. "You wouldn't think that would be a big change or situation for suicide, but it really is."
Unlike Cerda, Staff Sgt. Jennifer Adams-Ward, who is assigned to WTB's 1st Battalion operations department, said she didn't think it would be hard to ask someone in an intervention situation.
"They're either going to tell you or not tell you," she said. "They may not know what to call it, but calling it what it is helps them put a finger on it."
Asking why
Parnell said in the 25 plus ASIST classes she has taught, the hardest part of the ASIST model is asking that person to share his/her reasons for dying while listening for their reasons for living.
"The key tenet in ASIST is that if there is any bit of life to that person, it's going to win out," Parnell said.
"Most of the time when a person decides to take their life, it may not be that they want to die, but that they don't want to live the way they are living. If you listen for awhile, you will find people oftentimes will give you the same reasons they gave you for dying as the same reasons for living. So when you are talking with them, you are listening for that place where they are straddling the fence. When you can grab hold of that, you've got something positive to be able to move forward into that risk review."
During the risk review, Parnell said, you help educate them on the part of that person who isn't really ready to die.
"The part of you that would like to have a family, that part of you that would like to have another job opportunity, is at risk of dying if you kill yourself," she said. "By them acknowledging that they really are at risk, gets you to the next step: a contract and safety plan.
"Let's figure out how we're going to keep that part of you that is not wanting to die right now safe until we can get you some additional support and help," she added. "Once they can do that and repeat their plan, they are engaged. The model's success is being able to use the intervention again because that means they are still living."
No one is expected to be an expert after ASIST, Parnell said, but it's better to be prepared to deal with it than not.
Jenkins said she agreed. "I feel more prepared and will draw on the tools I've learned."
"We have lost so many service men and women," Parnell said. "Suicide is a much bigger issue than most people realize, especially when it hits closer to home."
Parnell praises the Army for pouring so much money and effort into resources like ASIST and ACE to combat the war on suicide, however, she said she wonders why the numbers are still so high.
"But the other question to ask," she said, "is how high might our numbers have been without all the efforts?"