Institute of Research, the Office of the Armed Forces Medical Examiner, and the Air Force Office of Special Investigations.

As a result of work done by the IPT, we have a clear view of the problem as well as clear direction on what we can do to improve upon our existing programs. Briefly, the IPT made 11 recommendations for improvements. We are well on the way to implementing many of them and in the process of coordinating the rest. The recommendations are summarized below.

1. Continue senior leadership promotion of help-seeking behavior among Air Force members. It is worth noting that both the Chief of Staff and the Vice Chief of Staff have sent subordinate commanders a number of strong messages and letters which encourage policies that promote getting help. This recommendation included another suggested message and a briefing that offers commanders clear guidance on when and how to use mental health help.

2. Write an Air Force Instruction (AFI) for community training based on CDC recommendations, incorporating metrics.

3. Upgrade professional military education (PME) curricula. The Air Force offers three levels of PME for enlisted personnel and three levels of PME for officers. All levels already offered some training on suicide management. Changes will be made that integrate all levels of training so that information is emphasized that is most relevant for the student's current rank and level of responsibility. Additionally, new training will be included in the Air Force courses for wing, group, and squadron commanders as well as the course for new first sergeants.

4. Integrate delivery of preventive services from all helping agencies to serve the Total Force. We believe we can better integrate and coordinate overlapping services already being delivered by helping agencies on base. As a result, we should be able to better meet the needs of Air Force personnel and their families. We are in the process of drafting guidance for this recommendation.

5. Improve risk assessment and monitoring. This recommendation involves drafting AFIs and memoranda of understanding that will lead to centralized collection of standardized data on completions, attempts, and other risk indicators. These data will allow us to evaluate the effectiveness of our programs and identify areas for improvement.

6. Deploy unit survey tools for risk identification. We plan to continue development and validation of unit survey tools that will provide commanders feedback on their units strengths and needs.

7. Improve social support for members facing legal charges. Personnel who are being investigated or prosecuted are in special need of support. We will draft policy mandating face-to-face interaction with members after high stress legal incidents to ensure appropriate referrals to helping agencies are made.

8. Pursue limited privilege for members using mental health services. This represents a fundamental change for the Air Force and, consequently, needs careful review and coordination. Nevertheless, some arrangements for limited privileged communication represents a real opportunity to reduce the risk of suicide in the Air Force.

9. Provide community-based delivery of preventative mental health services. This will require reworking the standards used to determine mental health staffing levels but can be done within the medical community. 10. Standardize Air Force critical incident stress debriefing teams. A new AFI is being written to standardize the care provided in the aftermath of suicides and attempts as well as other traumatic events in the community. 11. Market the findings of the IPT. Possibly the most important recommendation is to get the word out. We want to change the cultural fiber of the Air Force. We want to strengthen our social commitments to one another, even in the face of the civilianizing influence around us. We want to reach the Total Force, and their families.

We appreciate the outstanding efforts of all IPT members. In addition, we benefited a great deal from the sound advice we received from the Centers for Disease Control, the Walter Reed Army Institute of Research, and the Office of the Armed Forces Medical Examiner. We look forward to continuing to work with these agencies as we review the results of the improvements we are making.

To summarize, suicide prevention is everyone's responsibility, and we are seeking to better educate our people, from the most junior airman to our senior leadership, on their role in this crucial effort. The IPT's review of the Air Force's suicide risk

reduction programs indicated that we have some model programs. However, we have also identified some areas where we can make important improvements. We believe that many of the interventions will be of benefit to the Air Force more generally than simply reducing the number of suicides. While we will never eradicate suicide completely, it is our expectation that the recommendations we are now pursuing will positively impact the mental health and well-being of many people across the Air Force--we'll never know how many lives we've actually saved. This is but one vital way we are seeking to fulfill our mission of building healthy communities. To the members of this committee, I thank you for your support in this extremely important endeavor.

PREPARED STATEMENT SUBMITTED BY VICE ADM. F.L. BOWMAN, USN, CHIEF OF

NAVAL PERSONNEL

I. INTRODUCTION

Mr. Chairman, members of the committee, thank you for this opportunity to describe the Navy's suicide prevention program.

Our Nation struggles to address the tragedy of suicide. The latest information available from the National Center for Health Statistics reports that in 1993 over 31,000 Americans took their own lives. Nationally, suicide is ranked the ninth leading cause of death while homicide is tenth. For youth ages 15-24, suicide is the third leading cause of death. The overall, national annual suicide rate through 1993 has remained fairly constant at 12.1 per 100,000. At the same time, the annual rate for males has risen to 19.9 per 100,000.

During this same period, the Navy's annual suicide rate has remained at 11.4 per 100,000, below both the overall national rate and the rate for males. Suicide is second only to accidents as the leading cause of death in the Navy. Tragically, as in the general American population, too many Sailors die at their own hand.

Although this overview of national and Navy suicide data provides a perspective, numbers are not the focus of Navy suicide prevention. The loss of even one Sailor to suicide is a tragedy for the entire Navy family. The goal of the Navy suicide prevention program is to provide Sailors with the skills, information and support to weather whatever trials and challenges they face. Prevention also recognizes that individuals in distress often do not seek help. Therefore, ensuring that leaders, shipmates, family and friends know when and how to intervene is paramount. An aggressive, comprehensive program of prevention elements, delivered by knowledgeable and caring individuals, has been the Navy's means of successfully reducing the incidence of suicide.

II. PROGRAM OVERVIEW

The Navy Model

The various components of the Navy comprehensive suicide prevention model are represented in Appendix A. This model is an adaptation of the suicide intervention spectrum model described in "Suicide Prevention: Toward The Year 2000" by Silverman and Maris. This model includes all of the elements currently found essential in suicide prevention.

Focus on the individual, with his or her support network of command, family and friends, is at the heart of suicide prevention. Navy's program components are divided into the areas of prevention, early identification and treatment, postvention and maintenance. The program is monitored through the collection of data to determine effectiveness. Policy improvement is then based on analysis of the information gathered.

Prevention and the Individual

From arrival at recruit or officer training, everyone receives suicide prevention information. All recruits are screened for potential suicide risk within the first 3 days of training. Those without significant risk factors continue training. Those found to have greater risk indicators are interviewed by mental health staff for appropriate assistance and to determine their suitability to continue training.

This month the Chief of Naval Education and Training completed a new video targeted at recruits entitled "The Days Will Drag But The Weeks Will Fly." To be shown repeatedly in the first 4 weeks of training, it describes the coping techniques used by recently graduated recruits to successfully complete training. This new video is a method to pass on the "tools of success" from one group of successful recruits to the next at a stressful time when the new recruits need it most.

Once they leave accession training, Sailors receive specific suicide prevention refresher training as part of their orientation at each new duty station. In addition, every Navy command is required to conduct suicide prevention refresher training at least annually. Commands are encouraged (and sometimes directed) to conduct additional suicide prevention training and information campaigns at other times. Suicide prevention is routinely part of health fairs, safety stand-downs and pre- and postdeployment briefs.

Navy media is used to get the suicide prevention message out throughout the Navy. Navy and Marine Corps News, "All Hands" magazine, and the Master Chief Petty Officer of the Navy's newsletter "Direct Line" are some of the internal media used to keep this vital topic in the forefront.

Sailors in distress have access to three categories of direct assistance if they are suicidal. They may seek help directly from a medical provider, a chaplain or a Family Service Center (FSC) counselor. All three receive specific training on how to identify and refer individuals at risk for further evaluation and treatment.

Sailors benefit from Navy programs that address factors known to contribute to suicide risk. FSC programs that assist in anger management, interpersonal communication, or financial responsibility can prevent the development of even bigger problems. Alcohol abuse prevention and treatment programs are also essential to reducing suicidal risk since approximately 50 percent of Navy suicides have involved the use of alcohol. The hopelessness that results from losing one's spiritual compass can be resolved through a variety of chaplain programs. Though these programs are not designed specifically to prevent suicides, their success in resolving distress early clearly contributes to the total prevention effort.

Early Identification

Most individuals who are suicidal do not typically seek help on their own. These individuals often display signs and symptoms that they are at risk of hurting or killing themselves. Those around an individual "at-risk" are referred to as "gatekeepers," recognizing that they can assist the at-risk individual through a gate for help.

Navy recognizes two categories of "gatekeepers" and has specific programs to train them in early suicide identification and referral. One category is professional or positional. This includes supervisors, medical providers, chaplains, FSC staff and anyone else who may need to be aware of risk factors as part of their duties in the Navy. The second category is social gatekeepers. This includes shipmates, family and friends who need to know risk factors and how to respond to assist someone with whom they have a personal relationship.

Suicide risk factor identification and appropriate follow-up actions are now part of the professional training of all Navy petty officers, chief petty officers and officers. Special programs are incorporated for medical staff at all levels. The Chaplain's Supervisory Course, Senior Enlisted Academy and the Senior Shore Command Seminar have detailed training on suicide prevention, and Ombudsmen receive training along with FSC staff and command program managers.

Since 1994, Navy has used the latest in distance learning technology to train over 1,900 command personnel in how to conduct suicide prevention training at their specific location. Regularly reaching 12 fleet concentration sites in CONUS and Hawaii, the system recently has been expanded to reach Navy units in more remote sites, such as Keesler AFB, Goodfellow AFB, and Wallops Island. The system has the potential to serve a majority of commands, and a one-time recent training effort for Yokosuka, Japan verified potential for worldwide application.

A worldwide network of medical providers, chaplains and FSC staffs also supports commands by conducting on-site suicide prevention training. The challenge is to keep them all current in the latest Navy program information and data. Beyond using distance learning technology, the Bureau of Naval Personnel (BUPERS) provides these counselors with information via electronic distribution. Current Navy suicide training materials are available 24 hours-a-day, 365 days-a-year on both the Family Service Center and Chief of Chaplains electronic networks. These materials are updated quarterly, and any command with Internet capability may download or request materials. Requests have been filled to Antarctica, to the Seventh Fleet Flagship, USS BLUE RIDGE, while underway, and to Guam, to name a few. Navy is using every technological solution possible to ensure those needing support to conduct suicide prevention receive what they need quickly.

FSC staffs, chaplains and medical providers all keep up-to-date on current suicide prevention issues. For example, the June 1996 edition of the FSC newsletter "Update" carried a lead story on how training may be impacted by the suicide of Chief of Naval Operations, Admiral Mike Boorda, so that trainers would be prepared to respond to questions from their audiences (Appendix B).

Social gatekeepers are the main focus of command level suicide prevention training. Specifically, training of Sailors by berthing area or barracks has been emphasized, as prevention information delivered to peer groups rather than the command structure has proven to be effective in teaching shipmates how to help each other. Families are also receiving information along with the Sailor. This has been an important shift in emphasis based on Navy data that indicates that in 90 percent of suicides, a family member, friend or shipmate previously knew of one or more significant risk factors. At the same time, only a third of the suicides had presented a risk factor to a professional gatekeeper within 90 days of date of death.

Navy's training video "The Choice" portrays the successful intervention in two suicides by shipmates. This is the message that we will continue to convey: Anyone can intervene to prevent a suicide by getting a shipmate into the Navy support network.

Treatment

Navy policy is clear that the evaluation of suicide risk is the responsibility of mental health professionals only. The complete range of treatment options is available from inpatient care through outpatient follow-up.

Navy does not discharge individuals solely based on suicidal acts. If the conditions that contributed to the distress are treatable, the Sailor may be returned to full duty. This is an important concept in support of prevention. Sailors are reassured that if they need help they will receive it and that their career is not automatically in jeopardy. Again, the Navy training video "The Choice" portrays two individuals being returned to duty after their suicidal crisis and successful treatment.

Two safeguards are designed into Navy policy to protect the career potential of those Sailors receiving treatment. First, mental health evaluations cannot be used as reprisal by the command. Sailors' rights are protected, even under conditions of suicide risk. Second, the evaluation, disposition and treatment for suicidal acts are only documented in medical records. Medical treatment cannot be part of any evaluations or documents used to select individuals for advancement or promotion, or decide whether one should be retained in the Navy.

The importance of establishing a climate where individuals will seek support without fear of negative career impacts was the focus of the most recent (August 1996) Navy-wide message on suicide prevention (Appendix C).

Postvention

Postvention is the ability to respond to the needs of those who survive following the suicide of someone they knew. This includes the surviving family as well as friends and command members. Navy is especially sensitive to the needs of families following the death of a loved one.

The most direct support to families following any death comes from a Navy representative who serves as Casualty Assistance Calls Officer, or CACO. The CACO, typically accompanied by a Navy chaplain, accomplishes official notification to the family in a forthright and compassionate manner. From that moment, he or she provides continuous support during the difficult period immediately following any death of a Sailor, including suicide. During the initial call on the family, the CACO advises them of any investigations to be conducted by the Navy into the circumstances surrounding their loved one's death, and of their legal entitlement to copies of the completed investigation reports. He or she also offers to assist the family in requesting and obtaining copies of those reports. During subsequent visits with the family, the CACO assists them with arranging for burial with military honors, and with preparing necessary documentation to receive survivor benefits to which they may be entitled.

CACO's receive training on their roles and responsibilities through regional Casualty Assistance Coordinators who are available to provide guidance and assistance in the performance of their duties. Immediately following a death, the dedicated staff of the Casualty Assistance Branch at BUPERS also maintains frequent contact with the CACO and acts as Navy's central point of contact for all survivor benefit issues and information. The Office of Medical and Dental Affairs in Great Lakes, Illinois, hosts Navy's Mortuary Affairs Program and are our in-house experts for all mortuary and burial matters. In cases where the designated primary and secondary next of kin reside in different geographic localities, a CACO may be assigned to each. In such cases, both CACOS work in harmony to ensure the family members receive consistent and accurate information in a timely and compassionate manner. CACOs are especially trained to be aware of family stressors, which are intensified whenever there is a suicide or there exists the possibility that the death may have been a suicide. When suicide is suspected, the CACO does not speculate, but stresses to family members the importance of awaiting the results of the thorough

and sometimes lengthy investigative process. Navy does not establish a cause of death while such an investigation is in progress. Annually, in about 15 percent of cases initially reported as apparent suicides, subsequent investigation has found the death resulted from causes other than suicide.

Although natural to desire immediate determination of the cause of death, the family must be informed in a delicate fashion that the complexity of circumstances surrounding the death may result in a determination of cause of death only after an extended period of time. With most suicides being unattended deaths, meaning that there are no witnesses, the investigation must be particularly thorough and pursue every other reasonable option. During this period, the CACO provides the family with confirmed information as it is made available and reassures them that, while the possibility of suicide exists, this has not been established as fact. When the cause of death has been firmly established, the family is notified by the CACO and, in some cases, also by a representative of the investigating agency. Besides CACO and FSC support, and the pastoral care provided by the chaplain, the family may receive additional assistance from medical providers and other Navy and civilian support facilities.

Once a surviving family receives copies of the completed death investigations, if they do not agree with the findings, they are advised of the procedures for requesting a review of the investigation by the Department of Defense Inspector General (DODIG) under Section 1185 of the National Defense Authorization Act of 1994.

In the Navy, particularly complex or tragic situations are subject to another type of review. The Flag Officer Casualty Action Board (FOCAB), chaired by the Deputy Chief of Naval Personnel, a two-star admiral, is composed of flag- and SES-level representatives from various Navy agencies which provide assistance to families of deceased Sailors. These flag-level representatives include public affairs officials, investigative officers, doctors and mental health officials from BUMED, lawyers, chaplains, family service representatives, and pay/entitlement experts. The focus of the FOCAB is to anticipate and preempt potential problems a family may experience in the aftermath of their loved one's death, and to intervene on their behalf to resolve any difficulties or delays they may experience. As a result of lessons learned from the FOCAB experience, policy and procedural changes to casualty assistance, medical, and investigative efforts may be recommended or directed, as appropriate. This ensures continuous improvement in our family support processes. The FOCAB demonstrates Navy's commitment, at the highest levels, to ensuring that surviving family members are treated with the utmost care and compassion.

In light of Admiral Boorda's recent suicide, Navy is uniquely sensitive to the impact that such tragic news can have on shipmates left behind. Assistance to address the impact of a suicide is available to commands from a variety of personnel trained in crisis response. When large numbers of personnel are potentially affected, the Navy will deploy one of its three Special Psychiatric Rapid Intervention Teams (SPRINT). These multidisciplinary, mobilization teams, composed of mental health professionals, chaplains, social workers, and others, can provide much-needed support on short notice for any casualty situation or natural disaster. When smaller total numbers are involved, local mental health providers, chaplains and Family Service Center staff trained in crisis response may be used. These assets, along with paying tribute through area wide memorial services, widely sharing the results of the death investigations, and conducting comprehensive debriefings, are all critical components of successful postvention. They provide opportunities for Sailors and their families to resolve the intense issues and responses a suicide often brings out in the surviving shipmates, friends, and family.

Beyond providing individual support, a goal of postvention is to reduce the likelihood of suicide contagion in a community. Navy data shows that there have been no episodes of contagion following a suicide at any location.

How information about suicides is released to the public is recognized as an important part of preventing contagion. The January 1996 DODIG "Report on the DOD Policies and Procedures for Death Investigations" cited the need for improving DOD procedures for releasing death information to the public. The standards for releasing such information are contained in the Center for Disease Control (CDC) report "Suicide Contagion and the Reporting of Suicide: Recommendations from a National Workshop” (April 1994). When information about a suicide, either suspected or confirmed, is released by Navy sources, every effort is made to comply with these standards.

The release of suicide information requires us to be particularly sensitive to the needs of surviving family and shipmates. Our goal is to ensure that the family is always informed of any official information prior to its release to the public. When agencies or organizations outside the Navy release speculative or sensational information, the support personnel assisting the family unite around them as quickly as