This video is comprised of two sessions from Captain Adam Dell’s suicide prevention seminar in 2017 at Keesler Air Force Base.
Transcript
Okay, I want to start with this story. Some of the best teachers I’ve had a chance to learn from told stories, and so I want to tell a few stories because I think those tend to stick with us a lot longer than facts or figures or that kind of thing. I grew up about an hour or so outside of Philadelphia in Pennsylvania. Philly’s a big city. I grew up in Lancaster County, Pennsylvania, where my nearest neighbors were Amish, and so Philadelphia was like going to a different planet as far as we were concerned. And when I turned 16 and a couple of guys I played football with turned 16, we thought we were pretty bad when we got our licenses and we could drive up to the mean streets of Philly for a day trip. We thought that was a pretty big deal. We went up there, and it was the first place I had ever been other than like hunting where you’d hear gunshots, you know, and you were in fairly close proximity. It was the first place I’d ever seen a drug deal happen on the street, first place I’d ever seen prostitution just right out there in the open. We kept gravitating to the more and more nefarious parts of the city. Now, this was 20-some years ago. I was born in 19-none-of-your-business, so. (audience laughs) Kensington, Philadelphia might be a beautiful place now, but back then, it was not a very nice place. So, anyhow. We kept going up to this Kensington area, and the more often we went up there, the more we kept hearing about these two brothers who were only a few years older than us, both in their early 20s, and they seemed to be at the heart of just about every nefarious thing that was happening in that part of the city. If it had to do with gangs, prostitution, drugs, violence, it seemed like these guys were responsible or played a role in it. And what blew our minds was that it seemed like everyone in the streets knew that, it seemed like even the police officers knew that, and these guys were kind of above the law. So anyway, my senior year of high school, the older brother gets shot to death in the streets. And so, this is a true story. Younger brother goes to the largest religious venue in that part of the city, which happened to be this massive Catholic cathedral. He goes in and he talks to the priest, schedules an appointment and says, “Listen, priest. “My brother and my family are known across the city. “We’re anticipating hundreds if not thousands of people “to come to this funeral. “This is the largest venue for us to do it, “very beautiful stained glass here. “We’d really like to do it here, “and in fact, I’ll give you $50,000 in cash right now “if you agree to have it here.” Now, in my discipline, we talk about experiencing two opposite emotions at the same time as ambivalence. And I would imagine that priest looking at this guy, knowing about who he was and who his brother was, and also knowing that they weren’t even Catholic, was probably experiencing a lot of ambivalence as he thought about $50,000 in cash. The younger brother says, “Okay, listen. “I’ll give you $50,000 in cash today. “I’ll give you another $50,000 in cash day of the funeral. “Here’s the only caveat: You have the funeral here, “you eulogize my brother, “and during the eulogy you refer to him as a saint.” So, the priest thought about it for a little bit and said, “Okay, we’ll do it.” So, day of the funeral, police cordoned off the entire city block. There were so many people inside that when the fire department arrived, they deemed that it was a fire hazard, so people started spilling out of the building. And back then, they wheeled out these massive box televisions, these hundreds of pounds TVs, out into the streets so that you could see with big speakers and hear what was going on down front. That’s where I happened to be in the street. I had never been to a Catholic service before. I don’t know if this is representative. There was some music that was playing. A priest comes out in priestly garments and big hat. The crowd starts to quiet. Priest walks down front. This guy was probably five-five. He points at the casket, and he says, “The man you see lying in the casket today was a wicked man. “He was a liar and a cheat, and there are rumors “that he was involved in gang activity and violence. “He lived a debauched and duplicitous lifestyle, “but compared to his brother, he was a saint.” (audience laughs) That’s exactly what happened that day. At first I thought, “There’s going to be a second funeral here today.” (audience laughs) And people chuckle. Here’s why I want to lead with that story, particularly when it comes to a topic like suicide awareness and prevention. ‘Cause look, I know I’m working from a disadvantaged position right now. You have all come here with previous exposure to suicide training, CBT and face-to-face. Some of it has probably been sub-optimal or not the highlight of your Air Force career. It’s a difficult topic to discuss, and so I know I’m already working with a couple of strikes against me to talk about a topic like this. But here’s what I also know. We are all very, very poor at coming up with accurate reflections about who we really are and who other people are. There is mountains of social psychology data to suggest that when we try to size other people up, our biases, and prejudices, and stereotypes often get in the way. And when we think about ourselves, we’re often still plagued by those biases and prejudices. And so, for many of you, when you came here today, you thought, “I know this isn’t mandatory, “but somebody encouraged me to come. “And so, I’m gonna come hear “what this bald guy has to say, I suppose, “but this isn’t for me. “This is for maybe a box of very strange people “that might deal with thoughts “of wanting to kill themselves, “or particularly weak people.” Or we have ideas in our head about why certain people die by suicide. We oftentimes don’t come to these trainings saying, “There’s something here for me.” And so, I’m gonna put it to you in a number of ways this morning that we are all saints compared to somebody else, like the story, but that doesn’t mean that we’re necessarily doing that great. Now, let me be real careful to say, I’m not here to glamorize suicide or to talk like that’s a good thing at all. And I’m also not suggesting that all of us are at risk of leaving this auditorium and stepping in front of traffic, that our risk for suicide is imminent. But I am suggesting that as leaders in this enterprise, in the United States Air Force, who shape the culture, we must be mindful to lead ourselves first because we will only lead others as far as we’ve been willing to lead ourselves. We’re gonna look at some really fascinating research about suicide, and I’m going to try to make it as applicable as possible to us first so that we get ourselves squared away and then we can turn and start doing some powerful things for the folks that we’re privileged to serve. So, we’re all saints compared to somebody else, and I believe that this stuff is for everyone here in the room. So, we’re gonna start out with some facts and figures pretty broad, and then we’re gonna narrow it in. Basically, close to 41,000 Americans kill themselves intentionally every year. Now, to put it on a bigger scale, there’s a million suicides in the globe every year. Does anyone have a wager of what percentage Americans comprise of the global population? – 6%. – 5% or 6%? – Yeah, it’s about 4 1/2%. So, 41,000 out of a million is right in that 4% range. There’s some interesting statistics related to Americans. So, we comprise 4 1/2%, 5% of the world population. We have 25% of incarcerated human beings. We are 4% to 5% of the population. We consume 50% of the pharmaceutical drugs. So, we are a highly over-medicated and incarcerated bunch, right? But when it comes to suicide, our suicide rate is representative for the world population and our piece of that. Now, those who die by suicide are that number, 41,000. The attempts are much, much higher. Somebody that attempts to harm to themselves with intent to kill themselves but it’s not lethal. Men are much more likely to die by suicide. Women are much more likely to attempt it. The variable that explains that is firearms. So, men are much more likely, and that’s kind of ubiquitous. Of people who kill themselves across the world, the most commonly used method would be a firearm, which is one of the reasons why, even though it does not prevent a person from going and purchasing another one, one of our first knee-jerk reactions to reduce risk is to remove firearms from a home. So, three to four times as many men actually die by suicide, but three times as many women are actually attempting it. Now, the suicide rate when you look at age ranges, across the globe and certainly within America, the population age wise with the highest rates of suicide are actually the elderly population. And we’re gonna talk very specifically about some factors as to who actually dies by suicide in this brief, and hopefully by the end, you’ll be able to say, “Oh, yeah, that makes a lot of sense.” So, suicide is a ubiquitous problem. It does not discriminate against age, economic, social, ethnic boundaries, and firearms are the most utilized method. Next slide, please. This is just something by the WHO, the World Health Organization. Anytime that they’re reporting on any kind of disease or health related phenomenon, they report it as how many times does this occur in a population per 100,000, which is exactly how the DOD reports on these things. So, we could spend a lot of time looking at this. I know that the words are very small. Basically, the lighter shade of the country, the lower the prevalence rates for suicide. The dark shade of the country, the higher the prevalence rates. And there’s probably some surprises for all of us as we look up there just based on what we would have guessed. One of the things that’s pretty fascinating to me is that there are parts of the world where privilege is not nearly as prevalent, where even like clean water and regular food is not as prevalent, and yet suicide rates are much lower there compared to other parts of the world that might be a little bit more affluent, where we might think there’s more protective factors. Next slide. Okay, so let’s just talk briefly about the Air Force. Air Force has tracked suicides of airmen since the 1980s. In 1996, there was sort of an observed spike in the early 90s, and they established this integrated problem team to address the public health problem of suicide. And there’s a view of the task force report on the prevention of suicide there from 2010. Six years after that, they came up with the Air Force’s guide for managing suicidal behavior which really drives a lot of what myself and my colleagues will do as far as decision making and how we coordinate with commanders and things like that. Next slide. Suicide is still a major public health problem. For those of you who have so much more experience in the Air Force, you know that we are sort of in a bind. On the one hand, suicide is ubiquitous, and it’s probably not realistic to think that we’ll have zero suicides for any prolonged period of time in any population that you’re looking at across the globe. On the other hand, one suicide always seems like it’s way too many and it’s really a big deal. So anyhow, over the past decade, there’s been several spikes in Air Force suicide rates, but we would expect some variability that’s not really statistically significant in anything that we were tracking. Despite this though, there’s actually some good news, and this is not something that we hear a lot, I don’t think, as part of suicide training. I think it’s important for leaders to recognize that number one, the Air Force has the lowest rates of suicide compared to all the other sister services. The Marine Corps actually has the highest rates, and the Army has the most deaths by suicide, but the Army is a beast. When you’re looking at just prevalence rates in a population, the Marine Corps, and there’s probably a lot of variables to help explain that, leads the DOD in suicide rates. The Air Force has the lowest. Furthermore, if you take what makes the Air Force characteristic, so if you take the gender disparities, male to female, if you take married and single, if you take income levels, if you take all those things and you match it to an American civilian representative sample, airmen are killing themselves at half the rate of that representative civilian sample. So, that suggests to me, once again there’s going to be room for us to grow, there’s probably some suicides we can prevent, but there’s something about this organization or something about people who volunteer to be part of the organization that is quite protective. I think it has a lot to do with burdensomeness and belongingness, and we’re gonna talk a little bit more about that as this unfolds. Next slide. Okay, so that was kind of the most pedantic part of this with the busiest slides. Now, I’d like to transition. Some of the best professors that I’ve had in school would start to define a very complex construct like suicide by first saying what it is not because many of us in the room here have wrong ideas about the kinds of people who die by suicide or why people die by suicide in general. In fact, I would be willing to bet that some of you, if you’ve not only though them, you’ve actually said some things the aren’t actually very accurate about suicide out loud. I certainly have. This is the part of the presentation where it’s gonna become a little bit more personal and hopefully a little bit more emotionally engaging because I’m gonna try to elaborate some of these things. I’ll also say, I have stolen all of this from people way brighter than me. So, Thomas Joiner is suicide researcher at Florida State University, but we will not hold that against him. He is one of the preeminent researchers. Bryan and Rudd are oftentimes quoted along with Joiner in a lot of the stuff that the Air Force is publishing as far as Air Force guides for suicide management. This next slide is gonna cover myths, and Joiner has literally written a book called “Myths about Suicide.” So, if you don’t mind, just click one time. The first one is that suicide is committed by weak people. Now, this is something that I’ve actually, I have heard, not from an Air Force commander, but oftentimes when there’s a suicide, whether you’re deployed or at home, very soon Disaster Mental Health gets contacted, and they show up and the commander has to get up. And there’s public affairs guidance for commanders as far as what you should and shouldn’t say and a checklist that you need to adhere to, and hopefully your Disaster Mental Health Team Chief will be able to get that to you if you have to go through that process. But I have literally been in a commander’s hall where the commander was going to address his or her attachment, unit, whatever, to talk about the fact that they lost a member to suicide and the opening remarks were like, “This person wasn’t really one of us. “We’re not the kinds of people that give up. “I don’t expect that this is ever going to happen again,” this kind of thing which may be well intentioned, but I think misses the mark in a lot of ways. And so, I just want to give you some counter examples to this idea that suicide is committed by characterologically weak people. Never in modern recorded human history were suicide rates as high as they were within concentration camps in World War II. And you don’t have to have a PhD or read a book about suicide to kind of put those pieces together as to why that might be. If you saw your entire family get exterminated and you were facing total annihilation, and you felt very, very hopeless, suicide may seem like something that would be a reasonable course of action. What was fascinating, though, is one year, five years, 10 years, 15 years after people were liberated from those camps, so survivors, their suicide rates were still astronomically high compared to peers who were never in a concentration camp. Now, we could probably hypothesize why that might be, but I don’t think there’d be many men or women in this room that would say, “You know, when I think about weak people, “I would think about people who survived Auschwitz.” Similar and unusual statistics, like if you’ve ever won the Tour de France, you’re like 300 times more likely to die by suicide than if you never rode in that event. Now, I don’t know much about the Tour de France other than it’s a bike ride up a mountain for like a month, but that sounds truly awful. I would imagine it would take an enormous amount of discipline and strength, both emotional and physical, to even train yourself for something like that. And I don’t think we would characterize those sorts of individuals necessarily as weak. I’m gonna suggest to you that, and again, this is not in any way meant to glamorize suicide. The moment someone kills themself, they meet criteria for at least one very serious mental illness, so I’m not suggesting that this is a glamorous thing. But rather than weakness, there’s actually something very, very fearsome about an individual who can stare down his or her life instinct and not flinch in that last moment. There’s something fearsome about it. Mentally ill and wrongheaded, but I wouldn’t characterize it as weakness. Next slide. Suicide is taking the easy way out of a temporary problem. Suicide is actually, as I just alluded to, it’s a fearsome thing to stare down your life instinct. I have had patients of mine who have survived gunshot wounds to the head. I have had a patient who drank 12 ounces of toilet bowl cleaner. Now, just the taste of it and actually swallowing that down would be, I think, in many ways unimaginable, but having the hydrochloric acid start to tear holes in your organs, I think too, would just be unimaginable. There are two men in Atlanta in 2009 who owned their own business but it went bankrupt and they become very hopeless. And at least one if not both of them had lost their wife and kids over this deal. They were literally living in the business that they were running because they couldn’t afford to go anywhere else. And then, eventually they were gonna be evicted even from that space. And so, in a very unusual move, they both decided to die by suicide. And so, they wrote a note saying goodbye and to let people know “We’re going out to the woods behind here “and we’re gonna kill ourselves.” They went out into the woods, and their plan was they were gonna saw their arms off with a large saw, not a hand-held saw. And so, this is a true story. Guy number one put his arm out. Guy number two sawed both of his arms off and he passed out. Then the guy turned the saw on himself. And that sounds like a really unusual and disgusting thing. I’ve had patients in Indiana who survived saw wounds to the throat, to the arm. So anyway, he sawed one of his arms off. Lost enough blood that he passed out. Both of those guys are alive today. Suicide is probably a very, very difficult thing to think about ever getting to that point, staring down your life instinct, but stories like that remind me that we are biologically wired to survive, and even when we’re unconscious, even when we’re laying in the forest bleeding out, our body is furiously trying to clot blood and keep us to survive. So, sometimes you hear like, “Oh, that’s just taking the easy way out,” or “That’s just a permanent solution to a temporary problem. “Anybody could do that.” But actually, it’s a fearsome thing. Next slide. This one is one that I think is the most ubiquitous, and it’s this idea that suicide is a very selfish thing, that people who commit suicide clearly were only thinking of themselves and not thinking about their family. And listen, this is something I’ve thought about quite a bit. Several years ago, we had someone commit suicide in base housing, a gunshot wound to the chest. Within an hour or two of that, I was in another home, a model home, because we weren’t allowed to be part of the crime scene, with that individual’s wife trying to console her. And several hours after that, I was sitting on the floor in this model home with a four and a seven-year-old girl, who because of the situation, there was rising up in them university-level questions and I was trying to give them some sort of grade-school or elementary answer about the whys. Why does something like this happen? About morality, and meaning, and destiny. And I remember thinking sitting on that floor, bereft of any kind of words that I think could’ve meant very much, thinking, “How could this guy do this to these little ones?” I thought, “This is so selfish.” And I would imagine many of you have thought that. I don’t know if any of you are familiar, entire states have dealt with the issue of Death with Dignity. I used to work in a psychiatric hospital where people with serious mental illness or advanced dementia would come, sometimes for a prolonged period of time. And if any of you have had family members or colleagues who have gotten into the latter stage of Alzheimer’s disease, you will know that … So basically, the reason why none of you remember what outfit you were wearing your first birthday or what food you ate at your second birthday is because memory is so related to language. That’s how we encode things, with symbols and language. It’s why many of us have childhood amnesia. We don’t remember much before our fifth or sixth birthday, and if you think you do, you’re probably just kidding yourself because you heard a story about yourself or you’ve seen a cute little picture. But you don’t really remember what your mom tended to wear when you were one or what your favorite toy was when you were two necessarily unless there’s a story that’s been kept along with it. Towards the end stages of Alzheimer’s, the ability to consolidate memories gets so degraded that language is even lost. And so, many people in those latter stages before they succumb to the disease will experience fits of rage, unintelligible screaming. And the people that pay the price are the family members. So, unsurprisingly, people that are diagnosed with Alzheimer’s tend to have higher rates of suicide than people that aren’t. And this whole idea of killing yourself to prevent pain to others or the Death with Dignity Act, I’m not here, I studied philosophy in undergrad and I’m not hear to argue the moral tenets of any of that, but I would suggest this. Actually, let me tell you one more story. The night that my grandmother died, my grandfather had been dependent on her for years for just about everything. So, the night that she died, it had been years since my grandfather had driven a vehicle, had gone out and procured his own food, had made his own food, had paid bills. I mean, come to think of it, my grandfather had a pretty good life. My grandma was doing a lot. What’s typical, especially in male-female relationships, as they enter their elderly years is that the male will decompensate at a much faster rate, both cognitively and physically. And that was true for them. My grandfather had been a farmer for most of his life, had just worn himself down. Now, that disparity, if my wife were here, she would probably argue that that disparity exists all the time. (audience laughs) But it’s certainly a little more pronounced maybe in elderly populations. So, the night that my grandmother died, my grandfather had been so reliant on her for so long. What’s fascinating about my grandfather is that he had a son who was diagnosed with bipolar disorder. I never met him. He killed himself when he was 21. Now, if you ever have a member diagnosed with bipolar disorder, that psychiatric diagnosis has the highest prevalence rates for suicide compared to even those with depression. My grandfather was this very conservative, very religious man who just, just condemned that, that his son ever killed himself. So anyhow, my grandmother passed away. Within a matter of weeks, my grandfather penned a note to the family. And a lot of people who kill themselves leave some kind of goodbye. These days, you’re probably as likely to find it on Facebook as you are as a handwritten letter. My grandfather basically wrote this. He said, “I am no longer able to care for myself. “I don’t have any children that live nearby, “and I refuse to become a burden to them. “I only have a little bit of savings left, “and it will all vanquish if I check myself “into some residential facility. “And so, I’d like to leave some kind of inheritance “for my family, and I don’t want to be a burden to them.” And he shot himself, a man who condemned that, could barely speak about it without trembling rage regarding his own son. In the moment that someone commits suicide, I just want to let you know based on solid research from people like Joiner, clinical experience, and personal experience that I’ve had, people who die by suicide almost never intend to harm their loved ones as a result of that behavior. In many ways, wrongheaded as it is, they honestly believe it’s the most loving thing that they could do for family. And obviously, I mean, if my grandfather had vocalized those things to anyone who cared for him, I think they would have put their arms around him and said, “John, that’s just not the case. “We’re happy to do this, and you’re not a burden. “We love you.” So, it’s wrongheaded, but it’s like a perverted virtue. But it’s oftentimes not a selfish thing, as hard as it is for us to understand that. Next slide. Suicide’s an impulsive decision, decided upon a whim. This is kind of interesting. I don’t know if any of you have Netflix accounts. If you do, there’s a documentary on Netflix called “The Bridge.” It is about the Golden Gate Bridge, where thousands of people have jumped to their death. Something like at least once a week, I believe, someone jumps from that bridge to their death. There’s a Bay Bridge, which is pretty close, just a high, and almost no one jumps off of that. There’s sort of memorials across our country, like the Grand Canyon or the Golden Gate Bridge. Certainly throughout China, but anyhow. To say this, if you watched that video, basically this bare-budget crew filmed the Golden Gate Bridge for months, and you literally will see people jump off. And if you’re able to get over the barricade and all the signs that say, “If you need help, call this number,” if you throw yourself off of the Golden Gate Bridge, you’re traveling about 80 miles an hour by the time you hit the water. And when a body hits the water at that rate of speed, the body stops, the organs continue to move inside. Ribs are almost always broken, and 97% of the time, people die. 3% of the people actually live, though. So, if there’s 1,000 people that jump, you’d have 30 that actually survived the jump. And what’s fascinating about this documentary is some of these people you watch walk straight off that bridge, and if that was the only thing you ever saw related to suicide, you would think, “Oh, my God. “That person was just walking straight down the bridge, “took a right, and just didn’t even hesitate.” And you’d think, “That just looks so impulsive.” What’s fascinating about the documentary too is they actually interview at least one person who survived the jump. It’s a really, really interesting look into the mindset of a person that was willing to do something that lethal after the fact and having survived it. But anyhow, it looks very impulsive. What is actually true though is that people oftentimes get to the point where they end their life by suicide after weeks, months, or even years of planning it, which is why a lot of times mental health professionals will try to get that kind of information, recognizing that it’s self-report, which is not always entirely accurate. We want to know how long have you been planning this kind of thing? Do you have any specifics laid out? It is not an impulsive decision that’s decided on a whim. Next slide. Alcohol and drugs make people kill themselves. Close to 75% of people who get autopsies after a suicide have no alcohol or drugs in their system. Of the remaining 25%, half of those have the equivalent of like one standard drink. The idea that maybe somebody just needed one drink to steady themselves to kind of see the deed through. But alcohol and drugs actually do not play a very prominent role for suicide. People who will commit suicide don’t make future plans. This actually makes a lot of us very, very confused if we have colleagues or family members who die by suicide. It’s extremely common if you sit down with a member who is maybe close to someone who died by suicide for them to just be bewildered to think this must have been a murder or something because this person just told me the other day that they’re gonna come play rec basketball with me on Saturday. Or we just saw Grandpa, and he was like, “I can’t wait to see you guys for the Fourth of July.” Once again, I think this hinges upon the idea that suicide is not done to harm loved ones, and it’s certainly not intended to be a selfish thing. People who die by suicide are not intending to wound other people by suggesting, “I don’t want to be a part of your life anymore,” which is why those mixed messages come out. People who talk about suicide are less likely to die by suicide. I deployed last year. In my first or second week, I had several soldiers come into my clinic, one of whom overdosed on an entire bottle of Tylenol and two others who said, “I’m gonna kill myself. “Our leadership is toxic. “I gotta get out of here.” So, being a fairly naive Air Force psychologist who’s mostly worked with Air Force commanders, I called up the company commanders and said, “Hey, I got serious concerns about these individuals. “They need to get removed from the AOR. “These guys are really, really high risk, “and we cannot manage this in a deployed setting. “There’s too much strain from the mission. “We just can’t do it.” And the feedback that I got from some of the commanders were, “Ah, this is total BS. “The people who talk about it “aren’t the ones that I’m concerned about. “It’s the quiet guy in the back that never says anything. “That’s the guy I’m really concerned about.” One commander even went so far as to say, “Oh, they’re just saying this “’cause they just want to go home or whatever. “If they’re so suicidal, make ’em earn it.” (audience murmuring) Within a matter of hours, I was on the phone with a four-star general from RSEN. And for a few days, I thought I was gonna get sent home. It got kind of dicey there for a little bit. Luckily, we got all those people out of there, but that idea that people who are threatening it or talking about it are at a low risk or are unlikely, that is really bizarre. When I’m speaking to a medical community, I always try to think about if somebody comes in and they say, “I literally am thinking of taking my life,” I would treat that with the severity and seriousness and the weightiness of somebody going to an ER and saying like, “I have unimaginable chest pain.” And could you imagine if an ER doc, or nurse, or tech said, “Well, come back in a week “after you’ve earned it” kind of thing. The liability that we would incur as a result of that. Anytime someone makes a threat like that or discloses that, it always needs to be taken very, very seriously regardless of what any kind of ulterior motive is. If they say something like that, they’ve put themselves in a category of risk that is very, very high. Next slide, please. People who die by suicide have no desire to live. This reminds me again of that documentary “The Bridge.” There was an individual who jumped and survived the jump and was later interviewed, and they asked him like, “What was going through your mind “the moment that you threw yourself off of the bridge?” And kind of tongue-in-cheek he said, “You know, the moment I stepped off “and I felt the weightlessness of my body falling, “I had this really profound moment of clarity “where I realized that all of the problems “that I had in my life were solvable “except for the problem “that I just jumped off of the Golden Gate Bridge.” This is part of the reason why people will oftentimes leave a patch of rubber before they drive their vehicle off of a high cliff or why there’s hesitation wounds all over a chest cavity before someone stabs themself in the heart. Our desire to, I’m sorry. Our need to live oftentimes supersedes our desire to die. This is one of the reasons why almost no one drowns themself in a shallow body of water. People don’t commit suicide in four inches of water in their bathtub. They might unintentionally die like that because they really drunk or something. But eventually, your need, biologically wired need to survive and need for air is gonna trump any desire to die. People who die by suicide need to punish loved ones. Hopefully, we’ve dispelled that. Next one, please. Only humans die by suicide or self-sacrifice. This could probably be its own 60-minute briefing. Some of you might even find it more interesting. Joiner has done a lot of work and has written a lot about this. Cutting to the chase, from insects to fish to birds to lions, all across the spectrum of living things, there are examples of self-sacrifice. Now, oftentimes for more sophisticated species it appears to be for what’s best for the herd kind of idea, but this is not a uniquely human phenomenon. I believe in some ways, we’re all creatures, and animals tend to engage in self-sacrificial behaviors in a spiked time, late spring and early summer, and that is exactly that suicide across the world spikes for human beings as well. So, it’s not a uniquely human problem. However, as humans, we’re a little bit more complicated, and so there’s a little bit more for us to say. Next one. Okay, so this is really the rest of the lecture here. I was in college for 10 years, like consecutively full-time. And don’t anyone be impressed by that ’cause what I found was the longer you stay in school, the more narrow your focus becomes. So, like I started out learning about philosophy, and biology, and things like that. And then, the Master’s degree was like only psychology. And then, I eventually wrote this dissertation about something so small. Like, if you stay in school long enough, you eventually know everything there is to know about almost nothing. So, it’s really not that impressive, and I always felt like an imposter there. So, if I had seen something like this in grad school even, I probably would’ve been intimidated by it. There’s different colors. (audience laughs) There’s words that I don’t know. But actually, personally, it’s one of the most simple models to explain why certain people die by suicide. It’s called an inter-personal theory of suicide, meaning between persons. In my discipline, where the malady is oftentimes where you’ll find the cure as well. So, if there are between persons stuff that can lead someone to have a desire to die by suicide or set the stage for that, then this would suggest to us as leaders across the enterprise that there’s probably between persons stuff that we could engage in that could be very protective. And so, that’s the lens through which we’re gonna look at this. If you don’t mind just going to the next slide. You’ll have to click twice. Here’s what’s Joiner’s basic hypothesis is with this. People die by suicide because they develop the capability to kill themself, which is represented by that purple pill-shaped thing, and the desire to kill themself, which is this kind of ugly yellow thing. And where those overlap, there’s a really, really high risk for suicide completion. So, we’re just gonna break these down, each one of them. We’re gonna talk about them individually, and hopefully this model will make some sense. So, the first one we’ll talk about is this purple pill. It’s this idea that there’s a certain capability that people possess to actually stare down their life instinct and not flinch. Some of you are probably familiar with retired Lieutenant Colonel, oh, I just lost his name, Grossman, who’s written books called “On Combat” and “On Killing.” In those books, they’re fascinating, he looks at the psychological consequences of taking another life. And what’s really, really interesting is from the Civil War to Fallujah, he’s got examples of enemy combatants who were within lethal range of one another who fired round after round after round for minute after minute after minute and nobody fell over. In fact, circumstances in war where if somebody had been blindfolded and was just haphazardly firing their weapon, other people would have been harmed, and nobody was. And he talks about how even for folks who are trained to take another life, in the moment that they’re called to do it, oftentimes it’s very, very difficult. And so, I think individuals like Joiner advance that even farther to say, “Man, if it’s that difficult “for people who are trained to do it “against somebody who’s also trained to kill them, “imagine how difficult it would be to take your own life.” This is one of the reasons why autopsies and folks who examine bodies after people have plunged something sharp through their heart or through vital organs, in almost every single case there’s hesitation wounds all over the body, meaning somebody stuck the knife in a quarter of an inch and then pulled it out, and then put it in a slightly different place maybe an eighth of an inch and pulled it out until they worked up the resolved to send it home. Each time they attempted to do that, Joiner would argue they’re actually building their own capability. Here’s kind of a strange thought, and I hope that no one misunderstands this, but each one of you has a different capability to kill yourself right now. No one in this room has none, and probably no one in this room has maximum capability. But Joiner says capability is developed through direct and indirect habituation. Habituation is just a big word to explain a simple phenomenon. I kind of think of it as if I jump into a cold pool in the summertime, at first that really kind of freaks me out and takes my breath away. But as long as it’s not like Titanic cold, I eventually habituate to it. I don’t notice it anymore. Habituation is sort of you kind of bump something up, and then you kind of get used to it. Joiner says there’s direct habituation, and that is why when a soldier comes and says, “No, seriously, I took two bottles of Tylenol,” which actually is a pretty dangerous thing to do. Tylenol will fry your liver. But if somebody has actually attempted suicide in the past, their capability has bumped up, and if they didn’t die by it, then they’re likely to try something even more lethal. That’s why the people that have the hesitation wounds eventually work up the capability to do it. Prior suicide attempts drastically increase the likelihood that somebody will die by suicide. But Joiner also talks about something kind of interesting called indirect habituation. And here’s what he means by that. He explains some things that are very confusing to most of the world. So, for example, every organization has alphas, right? I learned pretty quickly while I was deployed that an O3 psychologist was not very alpha. (audience laughs) The F22 pilots were pretty alpha. The F15 pilots were pretty alpha. I was somewhere else in the pecking order. Within the medical community, largely speaking, surgeons are the most alpha. They go to school for the longest. They get paid the most. They tend to drive the nicest cars, live in the nicest neighborhoods, have the prettiest wives or most handsome husbands. They have really, really good schedules if they’re the right kinds of surgeons. And they have tons of respect. These are men and women that have other people’s lives and death in their hands all the time. And yet, surgeons kill themselves at really, really high rates. And it’s like, these people are well-respected, have all kinds of money, have all kinds of education. Why would they do that kind of thing? Joiner would say that there are certain life events that we can accumulate, and I think within a military population this is a fascinating thing to think about, where we actually deepen or advance our capability to take our own lives as a result of being involved with certain things. And Joiner argues that a surgeon comes to work everyday and has other people’s lives in their hands, cutting into bodies. They’re seeing dead bodies all the time. They’re doing grotesque things. And so, therefore, when they kill themselves in really grotesque ways, it’s not that much of a leap because if you can have other people’s lives and death in your hands, then if you develop a lot of desire to die by suicide, your capability might actually be pretty high. This is probably another reason why psychiatrists die by suicide at such high rates. Nobody’s coming to see a psychiatrist ’cause they’re having a good day. They just listen to these stories all day long and nobody ever pays attention to their own story, and they end up dying by suicide at higher rates than what would be expected. This idea of indirect habituation. If you have had a family member that you’ve lost to suicide, you’ve had a close colleague, once again, you could have all the capability in the world and never kill yourself. As a result of the work that you do, you could have huge capability and never even for a day be very much at risk for suicide. But capability is the difference. Okay, next one. Here’s the next one. So, that was the purple pill. Now, we’re just gonna talk about this circle here, and the top part of that is perceived burdensomeness. This is really key to people having a desire to die by suicide. And this is the idea, I always think about with this slide my grandfather, this idea that your death would actually be worth more to your family than your life, that you have somehow become a real burden to your unit or to your family and suicide is a way to eradicate that burden. This is interestingly probably also a real primary motive for suicide terrorists who have become convinced that they need it for themselves or for their family either in this world or in the next, that killing themselves by suicide terrorism is actually gonna be what’s best for their loved ones. This is a very, very common theme for a lot of women who die by suicide. This is a suicide note, a real one, which basically just reads, “The girls need two happy people, “not a sick, mixed up mother. “There’ll be a little money to help with the extras, “and it had better go that way “than for more pills and more doctor bills. “Try to forgive me, girls, for what I’ve done. “Your father will be so much better for you. “It’ll be harder for you for a while, “but so much easier in the long run. “I’m getting you all mixed up.” I think as leaders it’s important for us to be thinking about as we’re hammering people with discipline, they may begin to start to perceive themselves as to be quite a burden, or if they’re facing getting booted out of the Air Force and all that that will mean for their family and dependents. Once again, we have a job to execute, and we should never … Every commander who ever asks me, “Oh, this person has mental health issues. “Should I hold them accountable?” Absolutely, absolutely you should. You should never make special exceptions ’cause that will eventually come back and really bite you depending on the diagnosis. But, these are important things for us to think about, I think, at a higher level. How do we address this burdensomeness issue for the whole unit and maybe for some of the ones that are quite problematic? Go to the next one. The next one has to do with thwarted belongingness and it’s exactly what it sounds like. Speaking of burdensomeness and belongingness, I not too long ago had a case that I was working on, somebody that had been in the Air Force for longer than a decade who had had an affair with a woman a decade ago that his wife found out about. And so, there was all kinds of burdensomeness stuff back then, right, ’cause that’s an almost incalculable damage that you can try to work through in a marriage. But anyhow, he had convinced his wife over the next 10 years that that relationship was off, but it never was off. So, he went TDY, and he took his iPad, or no, I’m sorry, he took his iPhone, and he started taking pictures of his penis to send to his girlfriend, sexting. What he didn’t realize though was before he went on this extended TDY his teenage daughter had synced her iPad to his iPhone so they could share pictures with one another. So, in the middle of the night one night, he’s firing off pictures of his scrotum to his teenage daughter, who’s waking up and is probably never gonna forget that night, right? And so, very soon after that, this person was in my office, and they were saying, “Look, I’ve done irreparable damage to my family. “I’ve become just an embarrassment and a burden to them. “I don’t think I’m ever going to repair those bridges, “and I know the Air Force is still gonna pay out “that 400k on SJY if I kill myself, “so that’s what I’m gonna do.” Now, that’s kind of a drastic example, but it really highlights this idea that there are certain life choices we can make that place us in the category of feeling like we’re a real burden to people who love us or that belongingness has been really thwarted. Belongingness in general is a fundamental human need. My wife and I were foster parents in the state of Indiana. We have been foster parents here in the state of Mississippi. I can tell you unequivocally that there is profound developmental delays and problems that occur in young lives when they are neglected, when belongingness is thwarted in some way. Literally, they don’t grow at a normal rate. The brain doesn’t develop at a normal rate. Their capacity to have belongingness with other people really for prolonged periods of time after the fact is just forever changed. Belongingness is so central to who we are that it’s actually a part of our development before we’re even consciously aware of it. So, there’s studies out of other countries, orphanages that are overrun with infants where there’s not enough workers to be able to provide appropriate belongingness. Now, in these places, they’re oftentimes warm and dry, and they’re given ample nutrition, but a pretty prevalent phenomenon occurs in those populations of infants called failure to thrive, meaning that this baby had everything that it needed to survive, but it just stopped growing and started to die. That’s how central belongingness is, touch and being connected to others. When belongingness is thwarted, there’s negative mental and physical health outcomes. This is why mothers that have lots of children and lots people need them and a place where they belong have much lower rates of suicide compared with mothers with no children. Identical twins have much lower rates of suicide compared to others, and plausibly, it’s because no matter what’s going on in my life, there’s one other person who looks just like me and is pretty much exactly like me, and I at least belong with him or her, right? And suicide rates actually tend to go down during holidays, which is another myth. A lot of times people think, “Oh, my gosh. “It’s the holidays. “It’s gonna be a crazy time.” I mean, people go nuts with their families, but most of us have a place where we belong. It’s after the holidays there’s usually a higher risk. I’m gonna tell you a story, one of the most profound stories, and this slide will transition to a couple of leadership-specific slides, and then we’re all done. I really appreciate your attention. I read thousands of pages about this stuff last year while I was deployed ’cause I didn’t really have anything else to do. And so, I read a ton of stories about people who ended their life, and this is one that really stuck with me maybe even more profoundly than clinical experiences that I’ve had. And it’s very simple. It’s a story about a young man in his early 20s who jumped off of the Golden Gate Bridge to his death. And forensic examiners went to the apartment where this young man had lived to do an investigation. It’s pretty similar to what OSI would do if there’s a suicide on the installation. They’re gonna rule out the possibility that it was a murder or anything else. Suicide is a conclusion of exclusion. It’s oftentimes arrived at as a last resort. They go to this kid’s, young man’s dwelling place, and he left a note on the dresser which said, “I’m gonna walk to the bridge today, “and if a single person smiles at me on the way, “I will not jump.” I remember reading that and thinking, now, I’m not suggesting we should walk around the installation with goofy grins on our faces trying to save people from themselves. And who knows what happened on that day. Maybe a dozen people smiled at him, and he still jumped. I don’t know. But as a leader, as a young leader in our organization, striving so hard to be the leader that my people deserve, I walk away from that story and I think we should never underestimate the power of even a simple act of kindness toward someone who’s walking to a bridge that we know nothing about. And so, when I’ve had a chance to go out and talk to flights, or squadrons, or groups about this kind of stuff, particularly leaders, I try to emphasize, man, you can never underestimate the power of even a simple act of kindness toward someone who’s walking to a bridge that you don’t know anything about. Next slide, please. And that’s it. No, I’m kidding. Perfect. Murder-suicides comprise only 2% to 3% of annual suicides in America. Joiner wrote a book called “Perversion of Virtue” if that’s something that you’d be more interested in. There’s been one of these since I’ve been here over the last three years. Next, thanks. Okay, so our role as leaders. Go ahead. So, the first thing I’d just like to talk, this is kind of like the so what portion of this. Now, I feel like in some ways I should probably be seated and I should be hearing from any of you men and women about how to be a good leader in the Air Force. I just, please, this is just from a psychologist’s perspective, applying some behavioral science about what I think would be helpful. I want to also emphasize that I do not put the super in supervisor. These are some things that we’ve tried over the last six months within our mental health flight of 40-some people, and how you would address things like burdensomeness and belongingness in your units and how you would empower the people under you, your under-shepherds to do that, I would defer to your expertise. I just want to throw out some ideas about things that we’ve done to say, “Okay, those are great ideas, belongingness, burdensomeness. “How do we address those in a tangible way?” The first one as far as belongingness goes, I want to let you in on an old psychologist trick. I see a lot of people during the week, and all of them have problems, and a lot of them look the same. They’re wearing uniforms, and they have similar haircuts, and their stories are even quite similar. There’s no way that I could remember every detail that someone shares with me. And so, I’m very intentional, whether it’s with my people or with my patients, to be, I actually have this kind of creepy book probably. If anyone ever found it, they’d probably be really creeped out. But I keep this little book of details about just about everybody that I know, so if somebody tells me, “My daughter’s name is Bailey.” Captain Hughes told me that a long time ago. When his daughter was in a car accident, I actually didn’t need it in this case even, but if I had, I could’ve found his page in that book. I could’ve said, “His daughter’s name is Bailey,” and I could’ve called him and said, “Man, I’m concerned about Bailey. “How is she doing?” Or if somebody gives me an anniversary or they talk to me about something, I try to put it in there. This is one of the reasons why within our flight we celebrate everybody’s birthdays because we want to try to increase belongingness in an intentional way. And if you’re able to pull a detail out and give that to somebody down they road, they are going to feel like they have been so well-understood by you, and it will leave a permanent mark that’s hopefully positive. Here’s another thing. So, the making lists, to-dos, keep a creepy book. I don’t know how you would do that, and you probably have more examples of that than I could come up with at my point in my career. Here’s one though that’s really important to me. I am a white male, and I work in a mostly white, male Air Force. And being a white male, I fully recognize, I can’t fully understand it, but I fully recognize that my life has had privileges in it that I continue to experience and enjoy that I oftentimes have been totally clueless about. You know, like if I’m driving down 110 on my way home today, and a police officer pulls me over and kind of aggressively pulls over and hops out of the vehicle, I’m gonna sit in my car and think, “Oh, well this is a nice friendly policeman “who’s here to help me” kind of thing. I’m not going to think for a moment, “Today could be the day that I lose my life “if I move my hand too quickly.” When I go to the mall, no one pulls their children away from me. When I walk through a parking lot, people aren’t locking their doors. I would like to think that everything that I have achieved has been solely my responsibility, but the fact of the matter is the tallest oak in a forest not only came from a really good acorn, but it also grew to be the tallest because it was in a place where there weren’t other little oaks growing up to block it out from sunlight, where the fertile was particularly soil, where it rained quite a bit, and where there weren’t little rodents come and chewing all the bark off. Our environment determines a lot of who we are and the privileges and the opportunities that we have. Now, I realize as a white male, and listen, I’ve given this kind of brief specific to diversity and sensitivity in a lot of settings, and almost every time, white people come up afterwards and they’re very mad at me, so if some of you are mad at me right now, you can … The weirdest one was when a lieutenant colonel turned to me, and we were both at the urinal, and he started talking to me about how upset he was about it. But if you would like to talk to me about it, I will be gone as of 1400 today, but I will keep my global, and I just signed up for four more years in the world’s best air force, so you can fire me an email if you disagree. There’s mountains of data though and research which suggests that you’re wrong if you’re thinking, “Well, there’s no such thing as that.” But here’s what I know. As a white male in a diverse flight, where we have different genders, sexual orientations, religions, all sorts of things like that, as a white guy, if I’m not intentional about paying attention to that stuff and celebrating it, I’m just gonna wander through and never even notice. And so, we sat down as a leadership team within the flight and thought about how do we celebrate and appreciate the diversity within the flight? How do we do that without it being cheesy and horrible? And so, here’s what the research suggests. It’s one thing to have like, “Hey, we’re gonna celebrate this this month.” That’s fine, but what the research suggests is if you want to get at prejudices and stereotypes, you bring different kinds of people together from different backgrounds. You make them work on something and help them to be successful together, and in the process, it will shatter their stereotypes and prejudices that they had about others. And so, in our flight, when it was African American history month, we had airmen, NCOs and officers come together, all different folks. They planned a Lunch and Learn. We shut our clinic down for an hour and a half. We invited our squadron leadership to come and they came. It was wildly successful, and it gave us an opportunity to not only celebrate for that lunch, but to bring those different kinds of people together to be successful with something. We’ve done that for women’s history month. We’ve done that for storytellers. We’ve done that where we sit down just with NCOs and lunch with the flight commander to try to get at what’s it like to be in this flight and how could it be improved? That’s some of the ways that we’ve tried to do it. I don’t know if that sparks something, like, “Oh, maybe we could try this or that,” but that’s certainly something that we could do. You know, another thing, and it might even be a little ostentatious for some of you, I am woefully unprepared to be any kind of interim flight commander for a flight the size of Keesler Air Force Base. Please don’t (speaking indistinctly), but usually that billet is filled by a lieutenant colonel with like a decade more of experience than I have, so I knew I did not have to work very hard at humility before I stepped into that role. One of the things that I did the moment I found about it, when I got back from deployment and Colonel Harris said, “You’re gonna do this,” I ordered these coins which say “Presented by the flight commander for excellence, “81 Medical Operations Squadron, “Keesler Air Force Base, Captain Dell.” It’s got an Air Force logo on the front, and also on the back. I think they came from China. They were very cheap, (audience laughs) and hopefully not made of toxic materials like some of these spinner things. But anyway, that was one thing that I wanted to bring to the flight to enhance belongingness. And here’s how that worked. So, for you in this room, you think a captain who’s an interim flight commander is giving out a coin. I wouldn’t even use that as a paperweight on my desk, right? But you should see the way that airmen in my flight, even NCOs, just lit up when they found out you don’t just get a piece of paper anymore for being a good performer in the flight for the month. You gonna get a coin. Really, really big deal. When it comes to belongingness, what I’ve learned is it’s sort of like the love languages if you’re familiar with that book. All of us kind of seek those things differently. Some people do love to accolades, the awards, the coins. Other people like words of affirmation or praise. Other people just like to be appreciated for who they are. You’ve got to figure that out, I think, as leaders. How do I do that across the enterprise? Okay. Oh, one other thing here. So, therapy recollections. I just want to share something with you. I mentioned I was on the floor with these young kids and I didn’t know what to say. I actually live about 50% of my professional life in that very position. Maybe not on the floor with children, but totally clueless as to really what to say. And you as commanders and leaders, you as husbands, wives, brothers, sisters, you are gonna eventually be approached someday with some sort of unimaginable human suffering that other people are going through that impacts you both directly and indirectly, and you’re gonna think, “What in the world do I say?” And so, it’s really interesting. In therapy, people come in and they talk about very vulnerable things. In fact, I have had people tell me, “I would have been more comfortable coming in here “and taking off all of my clothes “and just sitting in here naked “than coming in here and emotionally undressing like this. “This is truly awful.” And so, as therapists, we spend weeks, months, even up to a year with a person kind of learning more about them in a very privileged and very vulnerable place. So, one of the practices that I started to do early on in my career was when I was knowing it was the last session with a person, especially someone I had journeyed for a while with, I would oftentimes ask them, “What will you take away from our time together? “In order to help me with people in the future, “what was most impactful? “What was so helpful? “Or what wasn’t?” And what was just remarkable to me early on, it actually hurt my feelings a lot, was that most people didn’t really remember much of anything that occurred. Recently, I asked a guy the same question. He looked at me. He got kind of serious. He was like a tough guy. And we had talked about all kinds of stuff, and we had gone through books together. I thought surely this guy is gonna pull something out. He goes, “You know, Captain, I just remember “when I would come in here, you would say, “‘If at first I don’t succeed, try, try again.'” And I never said that! (audience laughs) That’s from like a children’s book. That’s like “The Little Engine That Could.” I’ve never said that. I promise I don’t do that. That’s what he’s walking away from. Here’s what I’ve noticed. If you want someone to learn something, you have to make it a little emotionally salient. Where our emotions are stored in our brain is right where our memory network is. So, if you want people to know something … It’s part of the reason why this lecture has so many stories in it. I want to evoke some kind of emotion that you might walk away from this and remember it. But if emotions get too high, memory consolidation gets all wonky. It’s sort of the basis of PTSD in some ways. But when people are going through something horrendously awful, in the funeral line, or in the wake of some sort of horrible suicide, what you say is not gonna matter as much as who you are and just your presence there. And that is the best advice that I could ever give to you. People will not remember specific things that you say, so the pressure is off, but they will be able to sniff out your sincerity. So, being present and your presence is probably more important than any words that you could ever offer. There’s that quote again, just this idea that we should never underestimate how even a simple act of kindness toward someone who’s walking to a bridge that we don’t know anything about. Being as good at recognizing our people for what they do well as what they do wrong. I think that is, in general, a principle that’s easier said than done, but it’s something, I think, that could enhance belongingness in an idiosyncratic way in your own sphere of responsibility. Here’s an important piece. I believe very firmly you will never lead your people farther than you’ve been able to lead yourself. Man, I just think that’s so true. And so, in as much as this stuff is for us as much as it is for our people, I think it’s really important for us to bear in mind that we also need to have belongingness. Now, for most people, that is both a vertical with a higher power, and also a horizontal with other people. But man, I have had so many leaders in this organization show up in my office completely burned out and frazzled because they have no belongingness, and they have been shouldering the burdens of everybody else for so long, and they just can’t do it anymore. So, this is also, interestingly, women are diagnosed with depression or anxiety three times more often than men. Now, that is not because women are three to four times more neurotic than men. First of all, it’s because women are much more brave and emotionally intelligent. They actually come in for treatment, whereas men say, “I got problems, but I’d rather talk to Jack Daniels.” So, men have much higher rates of substance use problems and women are diagnosed more with depression and anxiety. But here’s another reason which I think helps explain this. It’s that women oftentimes, stereotypically, are called upon to take care of everybody and everything. They’re the primary caretaker for the home, for the kids, for aging, or elderly, or sick relatives. They’re the ones that take care of the spouse. They’re the ones that go out and get food and make the food. They just take care of everything, and eventually even the best of men and women are just men and women at best. And so, being intentional about our belongingness, vertically and horizontally, is so important as leaders. Burdensomeness, this is a quote from Friedrich Nietzsche. I don’t quote Friedrich Nietzsche a lot. I don’t agree with much of what that guy wrote. He had a great mustache. When Hitler met Stalin and Mussolini, he handed them little handbook readers of Nietzsche. But, even a broken clock is right twice a day, and at one point Nietzsche wrote, “A person who has a why can bear almost any how.” I think what he meant by that is if I have meaning or purpose, I can trudge through miles of crap and even be glad to do it, but the moment that I lose some kind of meaning or purpose, and carry the analogy further, then just everything just really is crap. Everything just stinks. It’s this idea that if I have a why, I can go through tremendous periods of adversity and even be stronger on the other side as a result of it. This is one of the reasons, honestly … There’s a certain sense of belongingness within our organization. We do wear the same uniforms. We’re brothers and sisters in the profession of arms. We deploy together and have these shared suffering experiences. We commission, or go through BMT, or whatever. But I think the Air Force uniquely addresses some burdensome stuff as well because hopefully from the food line to the flight line people across the enterprise feel directly connected to something bigger than themselves. And that’s really the task I think. This is a little bit more challenging, I think, to think very practically about without just saying it, but ensuring that your people know you are essential to the mission. When I took over as flight commander, I read a lot of books about leadership as fast as I could. One of the things that really stuck out to me is that a leader should be most concerned about the opinions about him or her from the folks with the least amount of power in the organization, the folks with one or two stripes, because the people that are right behind you are probably just gonna lie to you anyway or they’re just gonna try to take your job someday or something like that. But how you’re perceived by the A1Cs is really, really important. And so, we were very intentional, I’ve got a great flight chief, about being very intentional with them, the youngest people in our flight, saying, “You are just as important and just as valuable “in the execution of our mission.” And so, what is your why? Simon Sinek’s a pretty bright guy, and he’s sort of a consultant to the Air Force. I had a chance to hear him speak at Squadron Officer School last year. He’s written a book called “Start with Why,” which is pretty big. He’s got another leadership book out. It’s actually like a children’s book with illustrations called “Together is Better,” which is a great little thing to just keep on your desk. And then, he’s got a book called “Leaders Eat Last,” which I think is actually in some ways better than “Start with Why.” If you’re interested and you’re not much of a reader, the “Start with Why” is like a 15-minute lecture TED-series talk, which is really, really good. I don’t know what your why is, but I am totally and unequivocally sure that even the best of men and women in here are just men and women at best. And if we’re not intentional about maintaining belongingness and connection to our why, we are gonna burn out. Okay. This is one of the last slides. I just want to give a couple of more tidbits for you to think about as leader. Suicide in some cases is preventable, and we should never underestimate our role to promote belongingness and value through the organization. Okay, I cannot stress enough how important it is, and many of you I recognize, and I’ve been so privileged to work with you. I can’t stress how important it is for you to shift some of the liability off of yourself and onto mental health personnel at whatever base you’re working at for them to help you make the best decisions as a consultant. Our jobs are consultants, and quite frankly as a medical officer, the only thing the Air Force pays me to do is to help you execute your mission. That’s it. And so, I can say, “Hey, as a consultant, “I would recommend this.” You have the final call. I’ve heard a lot of leaders in the Air Force say, “I have an open-door policy.” I would just encourage you … Let me tell you a quick story. So, I went to school for, experience or if you can put yourself in that spot, what is one of the first things that you would ask or say to the person that says, “I’ve just this and this and this and this. “I’m gonna kill myself”? They’re sitting right in front of you. Maybe you haven’t thought a lot about what you would say. Let me spare you from making the mistake that I have. One of the first questions I always ask is, “Have you done something already today to harm yourself?” Because I have had numerous occasions where somebody is sitting in my office, and they’re telling me, “I’m thinking of hurting myself,” and 20 minutes later they face plant on the floor because they had overdosed on like an enormous amount of pills or done something totally dangerous and risky and I never asked about it. So, one of the first questions I ask is, “I’m so sorry to hear that. “Have you done anything in the last 24 hours “to actually harm yourself?” And even if they say no, I don’t believe them, and I get them straight to the emergency room, right? I say, “We’ve got to go “because I don’t want to take that at face value. “You’re gonna get labs drawn, “and I’m gonna make sure that you’re doing okay.” So, here’s another thing. What if a colleague of yours calls you, says he has a weapon, and he’s planning on shooting himself? What advice, what would you do in that situation? I have given this briefing to first sergeants and other types of senior NCOs, people that are great leaders, many of whom will say, “I’m letting that guy know I’m coming straight over there.” There was a professor who taught at the school that I got my doctoral degree from who had had a patient for years in the psychology clinic at the university. And one day that patient, who had always been fairly calm, and clearly had issues and had kind of been like a test case for a long time. He showed up at the library with a rifle and kind of barricaded himself inside there with an unknown number of students and started firing the rifle. There were no windows, nobody could tell what was going on. This is rural Indiana, where there’s not a very nearby hostage negotiator. So, this professor went to law enforcement there as literally rounds are being fired in there and nobody knows if he’s executing people in there, if he shot himself, what has gone on. He signs some waiver and convinces the police, “I have good rapport with this guy. “I really think if I just kind of stand in the door “and let him know that I’m here, “I’m gonna be able to talk him down, “and get this weapon, and make sure people don’t get hurt. “Oh, by the way, I’ve been his psychologist for X number of years, and blah, blah, blah.” And he walked in there and got killed. He just got shot. So, I don’t think any of us have the kind of expertise to know definitively that we’d be able to talk somebody out of handing that weapon. And if someone is totally convinced that their death is worth more than their life to people that love them, then you don’t know what they might do if you’re standing in the way of that. So, I would just always encourage you, if you’ve got somebody on the phone who says they have a weapon, the best thing in the world that you could do as leaders or advice that you could give to your under-shepherds of your flock would be keep that person on the phone for as long as you can. Get somebody else to figure out where this person’s calling from. Figure out where they’re calling from, and get somebody else to call the police out there, people that have protection and training to kind of deal with that kind of thing. You should never be on an island in kind of responding to something like that. So, if you’re sitting with somebody and they’re willing to go to the emergency room with you, and they’re ambulatory and can do it, I would say escort them directly. If you’re aware of an airman in your sphere of influence who’s refusing to go, then you can call up mental health and talk about a CDE, commander directed evaluation, the only time you can force somebody to come talk to mental health. Same rules though. So, I mean, you would want to keep somebody with them unless the had a weapon. Okay, next slide. All right, here’s just a conclusion slide. Suicide is a major U.S. Air Force priority. It’s ubiquitous. Three times as many men as compared to women die by suicide, but women are much more likely to attempt it. Promoting belongingness and value and meaning to dispel burdensomeness is probably one of the most meaningful things from a research perspective that we can do for prevention efforts, which is hard. Consultation with mental health team, as I mentioned. Actually, Captain Hoffman and I are both leaving in the next couple of weeks, but Captain Hughes is gonna be here. He is your guy to contact if you’d like pieces of this briefing again, if you’d just like to consult about any particular case. He will be the guy or he’ll know who to put you in touch with. And then, CDEs are always at your disposal. They are so much simpler than they used to be. Man, commanders used to have to write all this stuff up and get all these signatures. It’s just a phone call to mental health now. You don’t have to create and complete any memorandums anymore, which is really, really nice. These are just some of the references. So, Air Force ones up top. These are three books that Joiner has written, Thomas Joiner, where a lot of this material came from. It’s a huge privilege for me to have your time and attention, so thank you so much. And if there are no other questions, then I’ll just let you go.