Suicide Prevention and Intervention Guide for CAF Leadership

Table of Contents

• Introduction
• Leadership and suicide prevention
• Understanding suicide risk
• Individual risk factors for suicide
• Warning signs for suicide
• Suicide intervention: ASK, CARE, ESCORT (ACE)
• Self-care for leaders
• Resources
• Annex 1: Accronyms
• Quick reference guide

Introduction

Suicide prevention is a major public health priority for the Government of Canada. The Joint Suicide Prevention Strategy (JSPS) was implemented as part of the Strong, Secure, Engaged Defence Policy of 2017. The JSPS addresses the unique stressors on members and their families created by military service, both during and after their years of active service using a framework focused on preventing suicide across the entire military and Veteran community. Due to the unique nature of each organization, both the Canadian Armed Forces (CAF) and Veterans Affairs Canada (VAC) created independent Action Plans to address suicide prevention. The CAF Suicide Prevention Action Plan (SPAP) is the CAF specific plan.

Suicide prevention is complex. Command Teams and leaders at all levels may struggle with difficult situations involving CAF members at risk for suicide where there are no easy answers or solutions. Providing guidance to CAF leadership on Suicide Prevention, Intervention and Postvention is a priority for SPAP. This document will provide guidance to all CAF members, with an emphasis on leadership, on issues of Prevention and Intervention. Guidance on Postvention (the response after a suicide) is available in the Postvention Guide for CAF Leadership.

Leadership and Suicide Prevention

Suicide prevention is complex and requires action on a wide range of fronts to build resilience, facilitate treatment of mental and physical illness, open lines of communication and support wellbeing.

Leaders, at all levels, must promote and support an inclusive culture in which all Defence Team members feel respected, valued, and accepted. This will contribute to a psychologically safe and diverse work environment in which personnel thrive.

All leaders are responsible for creating a respectful and inclusive culture that encourages stigma reduction, help-seeking and healthy coping skills. It is the responsibility of all CAF members and DND employees to actively participate in suicide prevention within their work environment.

Leadership actions that generally foster a healthy work environment and strong unit cohesion and morale are important for suicide prevention. The CAF Competency Model outlines many such actions, especially within the Social Capacities and Change Capacities meta-competencies. The Aide-Memoire on Inclusive Behaviours and the CAF Competency Dictionary provides examples of such behaviours.

Leaders can play a role in suicide prevention through actions that are already routinely taken by effective leaders:

• Know your troops (this may help you notice changes in behaviour or attitude).
• Connect and communicate with subordinates regularly, this will make it easier to ask hard questions.
• Create a climate that builds trust and encourages asking for help.
• Encourage unit members to watch out for each other.
• Help people who appear to be isolated, are new to the unit, and/or are finding it hard to fit in.
• Create a sense of belonging.
• Assist and follow up with subordinates in dealing with their work and personal stress.

Leadership actions to support mental wellbeing may also prevent suicide and should be adapted to meet the subordinate’s needs. The mental health continuum model is a useful tool to help determine those needs. The graphic below provides leader actions for “Shield” (when a member is in the green or yellow), “Sense” (when a member is in the yellow or orange) and “Support” (when a member is in the orange or red). See the Road to Mental Readiness Aide Memoire for additional information.

Some people who die by suicide exhibit warning signs that may represent an opportunity to support the member through a challenging time. Leaders need to know the risk factors and warning signs for suicide and be prepared to ask directly about suicide if they notice these warning signs.

Leadership and Stigma Reduction

Understanding of mental illness has come a long way in the last century but stigma about mental illness and suicide is still prevalent in Canadian society and in the CAF today. Stigma is an obstacle to suicide prevention efforts because it is a barrier to help-seeking.

Stigma about mental illness has the potential to show up in a unit in a number of ways such as discrimination or scapegoating, gossip, anger at the member, avoidance of the member, jokes, teasing or verbal abuse. Leaders sometimes over-react or under-react to behaviours of a member suffering from mental illness.

As a Leader, you can help reduce stigma by:

• Respecting privacy and confidentiality – leaders are legally mandated to respect and protect the privacy of anyone dealing with a mental illness; use the ‘need to know’ approach. Leaders need to use a high degree of discretion when addressing groups so no one individual is identifiable and feels called out.
• Knowing the facts. Educate yourself about the basics of mental illness. Taking the Mental Fitness and Suicide Awareness course is a great start.
• Being aware of your attitudes and behaviour and those within your unit/team. We all have preconceived ideas and exercise occasional judgmental thinking, but we can challenge these and change the way we think. Create a space where all feel comfortable respectfully challenging others (even superiors) regarding harmful language.
• Choosing your words carefully. Use inclusive and non-judgmental language. Read Language Matters: Safe Communication for Suicide Prevention to educate yourself on safe communication about suicide.
• Educating others. Allow time and resources for education about mental health and suicide awareness. Find opportunities to share and discuss facts and to challenge myths and stereotypes. Educate members on CAF policies about mental health.
• Supporting people. Cultivate a supportive climate; treat people with mental health challenges with dignity and respect.
• Including everyone. An example of inclusion might be inviting someone on sick leave to a social event or reinforcing the power of the buddy system as one form of support in times of crisis.
• Modeling asking for help as a sign of strength. Asking for help will enable members to remain operationally fit.
• Increasing access to health care. Decrease stigma by making it easier for subordinates to access health care; make appropriate referrals as necessary.
• Respecting Medical Employment Limitations (MELs). Once a member has sought treatment, support their desire to get well by respecting their MELs.
• Manage your team’s workload. Stigma can increase when a team member’s sick leave, modified work schedule or frequent medical appointments increases the burden on others within the team. Resources may need to be reallocated or only the most critical tasks prioritized.
• Asking members how they want to be supported. Always include the individual in discussions on how best to support them. Ask them if you or a colleague can call just to check in.
• Not tolerating behaviours that perpetuate stigma. Enforce a zero-tolerance policy toward bullying, hazing, belittling, discrimination, and other behaviours that adversely impact good order and discipline.

Understanding Suicide Risk

Suicide is complex and multi-factorial. There are usually multiple causes, events and factors that lead up to a suicide. Suicides can be impulsive. Precipitating circumstances for suicide can include stressors such as relationship, family, financial or legal problems, or the death of a loved one. Suicide may also be linked to a mental illness, to an alcohol or substance use disorder or to a physical health problem.

Suicide rates in the CAF are not statistically different from the rates in the Canadian General Population. Information about suicide rates in the CAF can be found in the Report on Suicide Mortality which is published yearly.

According to the Public Health Agency of Canada, about 4500 people die by suicide each year in Canada. Suicide is the second leading cause of death among 15 to 34 years olds. For each death there are an estimated 20 to 25 suicide attempts. Thoughts of suicide are reported by 12% of Canadians at some point in their lives and by 2.6% of Canadians in the past year. Four percent of Canadians report having made a suicide plan in their lifetime and 3.1% report having made an attempt.

Suicide Risk in the CAF

Although CAF members have similar suicide rates to the Canadian general population, they may experience unique risk factors for suicide such as:

• Easy access to lethal means such as weapons;
• High stress workplace;
• Inconsistent work schedule and/or workplace location (such as postings, training, deployments) which can cause a disruption of family routine; inconsistent sleep patterns and/or other challenges;
• Potential for less-inclusive culture in some units that may marginalise some people on the basis of gender or other identity factors; and
• Exposure to violence and training in the act of killing.

However, there are also some protective factors for suicide risk associated with being in the CAF:

• Support system, camaraderie, buddy system;
• Access to care;
• Stable income, job security;
• Programs and resources such as Road to Mental Readiness (R2MR), Sentinels, Strengthening the Forces, the Sexual Misconduct Support and Resource Centre (SMSRC), Military Family Resource Centres (MFRC) etc.; and
• An organisation that is striving for equity, diversity, and inclusion.

Suicide risk in CAF members can also be influenced by pre-enrollment factors (who chooses to join the CAF). For example, studies show that CAF members are more likely to have experienced adverse childhood events (such as physical or sexual abuse as a child) than the Canadian general population. Adverse childhood events are associated with an increased risk of suicide.

Suicide Risk and Deployment in the CAF

When thinking about suicide in the military, it is common to attribute a link with deployment history. We know that operational stress injuries (OSIs) such as posttraumatic stress disorder, like other mental illnesses such as depression and substance use disorders, are a significant risk factor for suicide. Even without an OSI, deployments are a major stressor for CAF members and their families. However, when we compare suicide rates in CAF members who have deployed to suicide rates in CAF members who have never deployed, we don’t find a statistically significant difference.

While it is important for leaders to be aware of the mental health risks associated with deployment, it is also important to understand that CAF members who have never deployed are equally at risk of suicide.

A careful analysis of the reviews conducted after CAF suicides reveals that, just like suicides in the Canadian general population, CAF suicides are caused by a number of complex factors that include psychological (e.g. mental illness), interpersonal (e.g. relationship problems) and socio-economic (e.g. legal or financial problems) factors rather than a single risk factor.

Suicide Risk Based on Sex and Gender

Each person’s situation is unique, and often there are numerous contribution factors. However, research has shown that middle-aged males, between the ages of 40 and 60, comprise the group that is the most at risk of death by suicide. Males are also three times more likely to die by suicide than females. Males are less likely to seek help before reaching a suicidal crisis due to the gender norms prevalent in society that expect men to be “tough” and stoic. Males are at increased risk for suicide if they abuse drugs and alcohol and are socially isolated. Males can also be at increased risk because they can be more impulsive and more likely to take risks.

Males die by suicide more than females, but females attempt suicide more often than males. This can be because males often use more lethal means of suicide. Females are at increased risk for suicide if they experience postpartum depression, eating disorders, intimate partner violence or sexual assault or abuse.

Research is ongoing on the relationship of gender identity and suicide risk, but it appears that transgender and the spectrum of gender diverse people are at increased risk of suicidal ideation and attempt compared with their cisgender peers (see more below).

Suicide Risk in Indigenous Peoples of Canada

Suicide rates have consistently been shown to be higher among First Nations people, Métis and Inuit in Canada than the rate among non-Indigenous people; however, suicide rates vary by community, Indigenous group, age group and sex. According to Statistics Canada, Suicide rates among First Nations people is three times higher than the rate among non-Indigenous people. Among First Nations people living on reserve, the rate is about twice as high as that among those living off reserve. However, suicide rates vary by First Nations band, with just over 60% of bands having a zero-suicide rate. The rate among Métis is approximately twice as high as the rate among non-Indigenous people. Among Inuit, the rate is approximately nine times higher than the non-Indigenous rate. Suicide rates and disparities are highest in youth and young adults (15 to 24 years) among First Nations males and Inuit males and females. Socioeconomic factors, including household income, labour status, level of education, marital status, and geographical factors accounted for 78% of the excess suicide risk among First Nations adults 25 and older, 37% for Metis adults, and 40% for Inuit adults.

Suicide Risk in the 2SLGBTQI+ Population

According to the Center for Suicide Prevention, Canadian lesbian, gay and bisexual youth are at a higher risk for suicide than their heterosexual peers. Youth who identify as lesbian, gay, or bisexual are five times more likely than non-lesbian, gay, or bisexual youth to consider suicide and seven times more likely to attempt suicide. One in 3 transgender youth have attempted suicide in the past year. Transgender people are 2 times more likely than lesbian, gay and bisexual people to attempt suicide. This heightened risk is primarily because transgender people face unique stressors, including stress from being part of a minority group, as well as distress related to not identifying with the sex they were assigned at birth. The decision to medically transition to the gender with which one identifies can be stressful and may place someone at increased risk for suicide. However, studies show that gender-affirming care, social supports and an inclusive environment improve mental health outcomes and decrease the risk of suicide.

Suicide Risk in Veterans

Although CAF members have a similar suicide rate to the Canadian general population, Canadian veterans are at increased risk for suicide.

According to Veterans Affairs Canada, for male veterans, the risk of suicide is highest in the youngest group of veterans: those aged less than 25 years are at 2.5 times higher risk of suicide compared to the male Canadian general population. A statistically significant higher risk of suicide persists until 54 years of age. For female veterans, the risk of suicide does not change with age.

The risk is consistently elevated (1.9 times higher risk) in all age groups, compared to the Canadian general population. The longstanding increased risk of suicide for veterans (both male and female) compared to the Canadian general population underscores the importance of the Canadian Armed Forces and Veterans Affairs Canada Joint Suicide Prevention Strategy.

Individual Risk Factors for Suicide

Risk factors are characteristics that may put people at greater risk of considering, attempting, or dying by suicide. They do not cause suicide and do not always result in suicide. Most people have some risk factors in their lives, but most do not consider, attempt or die by suicide. Sometimes risk factors build up over time or they may just hit a person at a particularly vulnerable time.

Some risk factors, like having a history of depression or a family member who died by suicide, are outside our control. Other risk factors can be controlled.

When leaders become aware of risk factors in a subordinate’s life, they should increase vigilance.

Non modifiable risk factors:

• Family history of suicide or suicide attempts;
• Previous suicide attempts; and
• History of mental illness.

Modifiable risk factors (stressors):

• Social isolation;
• Inter-personal issues;
• Symptoms of mental illness;
• Addiction such as drug, alcohol or gambling;
• Serious medical problems or chronic pain;
• Work-related problems;
• Being away from loved ones or from one’s support network (for example due to postings, training, or operations)
• Severe, prolonged and/or perceived unmanageable stress; and
• Setback (academic, career or personal).

Precipitating risk factors:

• Failed intimate relationship or relationship strain;
• Death of a loved one;
• An arrest, investigation or other legal or disciplinary problems;
• Serious financial problems or bankruptcy;
• Impulsivity; and
• Access to lethal means such as firearms.

Protective Factors

Protective factors are characteristics that make it less likely that individuals will consider, attempt, or die by suicide. They enhance a person’s resilience (the ability to bounce back and recover from adversity) and may counterbalance risk factors. People with strong protective factors have sources of support, connection with others, and reduced stress during difficult times.

Major protective factors for suicide include:

• Access to care (physical, mental and spiritual health);
• Help seeking behaviours;
• Strong relationships with family and/or close friends;
• Connectedness (unit, community, social groups);
• Responsibilities and duties to others;
• Cultural, religious or spiritual beliefs that discourage suicide;
• Impulse control and emotional regulation; and
• Strong coping skills and problem-solving skills.

Warning Signs for Suicide

Warning signs indicate that a person may be thinking about or planning suicide. Warning signs give us an idea about the level of distress and the current or immediate risk. The majority of people who are having suicidal thoughts exhibit warning signs, but these can be difficult to notice and to interpret.

Warning signs are different from the risk factors described in the previous section because they indicate a more pressing concern. For example, high blood pressure is a risk factor for heart attacks, but chest pain is a warning sign for a heart attack.

When warning signs are noticed, leaders should proceed with Ask, Care, Escort (ACE).

Signs of distress:

• Changes to eating patterns or sleeping habits (too much or not enough);
• Neglect of personal hygiene/appearance;
• Increase in hopelessness, anger, anxiety, sadness, helplessness;
• Withdrawal and/or isolation from friends and family;
• Increase in alcohol or drug intake;
• Increase in reckless and/or risky behaviour;
• General malaise;
• Reduced job performance or academic results;
• Difficulty making decisions, lack of focus/ concentration;
• Acting more aggressive or stressed out than usual (e.g. lashing out at people);
• Commenting on being tired all the time, being noticeably fatigued;
• Not being as productive as usual, being unmotivated;
• Reduced capacity for enjoyment;
• Ineffective problem solving;
• Excessive guilt or shame;
• Feeling alone; and
• Excessive regret for past behaviours.

Warning signs for suicide:

• Inability to see a future without pain. Pessimism and a belief that there is no solution to life’s problems;
• Inability to stop negative thinking;
• Preoccupation with thoughts of death, talking about death;
• Giving away possessions;
• Making a will; putting affairs in order;
• Writing poetry or stories about suicide or death;
• Talking about death or suicide, statements such as “I want to die”, “I can’t go on” or “I don’t see a way out;”
• Being very happy after a period of depression (people who have been struggling with thoughts of suicide can experience a sense of calm and relief after making the decision to end their life); and
• Commenting about being worthless or a burden to others (e.g. “Everyone would be better off if I wasn’t here”).

Suicide Intervention: Ask, Care, Escort (ACE)

Ask, Care, Escort (ACE) is the suicide intervention training model used in the CAF. It was first developed for the United States’ military and is now widely used. ACE is currently taught as part of the R2MR curriculum and in the Mental Fitness and Suicide Awareness course.

The Suicide intervention Flowchart can be used to guide leaders through the use of the ACE model.

Ask

When warning signs for suicide are noticed, leaders must proceed with ACE beginning with asking the member about suicide. There are many reasons why people often hesitate to do this. It can be difficult and awkward to ask such questions, or you may worry about what you will need to do if the answer is “yes”. In addition, many people worry that asking a depressed person about suicide will give them the idea to harm themselves or somehow give them the permission to do so. This is a myth. In reality, someone struggling with suicidality will likely be relieved to have the opportunity to share their struggles with someone. They need social connection with someone who can listen and help them feel heard and understood. If the answer is “no”, they will simply let you know that this isn’t a concern for them, but they will likely appreciate the fact that you cared enough to ask.

When asking a member about suicide, leaders need to be clear and direct. This helps to identify you as someone they can open up to and gives them permission to talk about their feelings. Leaders can use the sample script to ask about suicide. Ensure this is done in a quiet private setting that is free from interruption.

Care

After receiving an affirmative response to a question about suicide, leaders need to be able to respond with care and sensitivity to a member who is likely experiencing a great deal of pain. It is a natural inclination to want to “fix the problem” that is in front of us and to find immediate solutions for the member. Leaders must resist the urge to immediately enter problem solving mode.

“Care” is a crucial part of any suicide intervention and is done through active listening and asking open questions. It is essential because this initial intervention:

• Builds trust;
• Begins to bring relief to the member;
• Will help you gather information; and
• Will help you better understand the situation.

In “Care”, leaders will use active listening and open questions to help the member share their “story” about suicide. Opening up and talking about this difficult subject and feeling heard and understood can often ease the member’s pain.

When listening, pay particular attention to information about the member’s potential plan for suicide. If possible, find out about what, where, when, and how. Pay attention to any lethal means that may be required for this plan (e.g. pills or weapons). Having a fully developed plan greatly increases suicide risk.

In the event that the member reveals that they have had a recent suicide attempt, please refer to the Leadership Actions Following a Suicide Attempt section of the Postvention Guide for CAF Leadership.

Active Listening Skills

Active listening is a way of listening and responding to another person that improves mutual understanding. All leaders should use active listening skills whenever having difficult conversations. These skills are essential to suicide interventions but can be useful in all spheres of our lives. Remember, this conversation is about them, not you:

• Talk to them alone in a private setting;
• Stop what you are doing, look them in the eyes;
• Express sincere interest;
• Allow them to talk freely;
• Restate or reflect what you have heard;
• Ask clarification questions;
• Be aware of your own feelings and strong opinions;
• Give them and yourself plenty of time;
• Stay calm and objective;
• Don’t criticize or argue with their thoughts or feelings; don’t insert your own;
• Listen not merely to the words, but to the feeling content; and
• Respect silences.

Asking Questions

Reflecting emotion

• Sounds like this has made you very anxious.
• Sounds like you are experiencing a lot of pain.

Open ended questions

• Tell me more about that.
• How did that make you feel?

Clarifying questions

• So, what I’m understanding from what you are telling me is…
• If I understand correctly…

Questions about safety and the suicide plan

• Have you been thinking about how/ where/when you might do this?
• Have you worked out the details of what you would do?
• Have you taken any steps towards this plan?
• Can I hold on to those pills for you?
• What can we do with your hunting weapons for the next few days?

Questions that lead into Escort

• So, what do you think we can do about that?
• Who should we go see together? (Chaplain, Health Services, Hospital)

Escort

It is imperative that no leader handles a suicidal crisis on their own. This is crucial to the member’s safety as well as to the leader’s own wellbeing.

It is not your responsibility to assess the member’s actual suicide risk, this needs to be done by a qualified health care provider. Your job is to ensure that the member is not left alone until they have been assessed by a qualified professional.

Once you have determined that the person is at risk, it is time to escort them to get help. This should be a collaborative process. Outcomes will be much better if the member is given choices and some control over the next steps. Of course, if the member is unwilling to collaborate with you, safety must come first, and the only options left may be to call the military police or 911 (see Privacy for further details).

There are several factors which will influence the decision of where to escort a member:

• Member’s preference;
• Whether the member is already under medical care for these issues;
• Time of day, day of the week;
• Your location and proximity to military and civilian health care resources; and
• Availability of specialized local resources.

It can be difficult to determine what the best course of action is, especially if you are uncertain about the member’s risk level or unfamiliar with local resources. In many situations, escorting someone to a local civilian emergency department could involve long hours in a waiting room and the member ultimately not being admitted to hospital. Enlist key players to help you and the member decide where to go. Key players could include others within the Chain of Command (CoC), a Chaplain, the member’s Next of Kin (NOK) or other loved ones, the member’s Care Delivery Unit (CDU) or other professionals familiar with the member.

Determining What Services are Already in Place

Leadership actions for Escort will differ for a suicidal crisis that is new, which a member has never disclosed to anyone, in contrast to a more chronic situation for which the member is already receiving care. You will likely have some information about this from listening to the member during “care”, but it may be helpful to further inquire about the member’s current care and treatment plan.

Once the above information has been gathered, leaders can refer to the Escort Flow Chart to determine the best course of action. When in doubt, seek assistance from the General Duty Medical Officer (GDMO) on duty and if unavailable, escort the member to the nearest hospital with an emergency department.

Suicide Intervention and Remote or Virtual Work

Remote work can have many advantages, but it can sometimes increase loneliness and isolation. It can also decrease the boundaries between work and home life. Leaders should be mindful of these potential risks, especially with their subordinates who only work remotely or virtually.

Suicide intervention is best done in person but when this is not possible, leaders should:

• Remember that it is much more difficult to notice risk factors and warning signs for suicide remotely. Extra efforts are needed to ensure good communication and connection with subordinates.
• Communication is best when it includes visual cues such as through Teams. If this is not possible, the phone can be used. It is not appropriate to use email or chat for ACE.
• If a member is identified as being at risk for suicide and needs to be escorted to a safe place, work with the member to determine who can physically escort them. Once someone is identified, ensure that this person clearly understands their role. If no one can be identified to escort the member, consider contacting the local duty chaplain or military police for help.

Leadership Actions Following ACE

Leadership responsibilities for suicide intervention do not end after the member has been escorted and handed off to a caring professional. Key players (such as the Commanding Officer and Sergeant Major) need to be made aware of the situation and coordinate the unit response. They will need to select the right leaders within the unit to help navigate the situation. This person may not always be the member’s immediate supervisor.

It is important that the unit’s response be carried out with the utmost respect and discretion. Maintaining trust with the member will also require keeping open and honest lines of communication in order to build trust. If promises to follow-up are made, it is crucial to follow through. Remember that trust is fragile and broken promises are a surefire way to erode that trust.

Ensure that there is a plan for follow-up:

• Check-in with the member after they have been seen/assessed:
  • Ask them how and when they would like you to follow up. Ask them if they would prefer someone else follow-up with them and ensure this is done.
  • Ensure their family’s needs or other dependant’s needs are addressed.
  • Ask them how you or another member of the leadership team can help if they experience an escalation in distress. Ask them if they would be willing to share parts of their Safety Plan.
  • Offer to assist with lethal means safety (for example, ask if they need somewhere to store their weapons).
  • Review MELs with them and contact their CDU for clarification if needed.
• Ensure key players are made aware of the situation and coordinate efforts to care for the member.
• Debrief. Conduct an Ad Hoc Incident Review (AIR) with everyone involved in the intervention as needed. (Refer to R2MR Aide-Memoire the for guidance about AIRs).
• Pay attention to self-care and maintain personal boundaries.
• Maintain awareness until the crisis is fully resolved.

Supporting a CAF Member with Chronic Suicide Risk

The reality of suicide intervention is that it is incredibly complex and there are often no solutions that can be easily implemented through the use of simple guidelines and flowcharts. Leaders are most likely to struggle in situations when a member has already been assessed by Health Services or by the local Emergency Department, is known to be at risk of suicide but is not admitted to hospital. Leaders can often be left feeling worried, frustrated, and helpless. The key to navigating such situations is communication and teamwork.

• Enlist the help of key supports (others within the CoC, Chaplain, sentinel, member’s family and/or friends).
• Communicate with Health Services: 
  • With the member’s consent, get advice from their mental health clinicians about how to best support them.
  • With the member’s consent, request that a case conference be organized. In such meetings, key players (the member, their care providers, their loved one and unit leadership) can discuss challenges and potential solutions.
  • Remember that even without the member’s consent, you can share some information and concerns about the member to Health Services.

Intervention in cases of chronic suicide risk typically involves a diverse array of caring individuals, resources and organizations. These can often end up working in silos, but the best care plans will be developed through cooperation and consultation with everyone involved. Sharing the responsibility and working as a team will also provide opportunities for debriefing and self-care in these difficult situations.

Self-Care for Leaders

Hearing that someone is thinking about suicide can be shocking. It is normal to experience feelings of helplessness, anger, sadness, or a whole range of other emotions unique to your own experience. These emotions can be heightened when this is someone for whom you are responsible.

Supporting someone who feels suicidal can be emotionally draining. It can also be triggering for someone who has previously experienced suicidality or who has been impacted by suicide loss in the past. It is important to recognize these feelings and look after yourself. This can be particularly difficult for leaders who may feel isolated despite being surrounded by people. Remember that your unit chaplain is available to support you.

Self-Care Following ACE

No matter how well prepared you are to respond to a suicidal crisis, it remains challenging. Even when you know that you have done everything possible to support someone, it’s natural to feel an unsettling sense of preoccupation and responsibility.

When it comes to having conversations about suicide, it is easy to dwell on what you ‘could’ or ‘should’ have said or done long after the moment has passed. While it is natural to think about what you could have done differently, it can also cause anxiety and stress. Focus on what you did do, how you sensitively responded to someone in need. Regardless of how you responded, remember that you were there in that moment to support them, and you said and did whatever you could to help.

Having an encounter with a person at risk for suicide is a big event in anyone’s life. Thinking that it shouldn’t bother us, or that we should just be able to ‘get on with it’ is unrealistic. It is normal to feel emotionally drained. It’s a sign that you care! Give yourself permission to feel this way. If you invest too much energy in trying to push difficult feelings away, you’re only going to wear yourself out and end up feeling worse.

• Focus on what you did do, not what you didn’t;
• Remember that it’s okay to feel upset; it’s a sign that you care;
• Talk to others about how you’re feeling; don’t bottle it up; and
• Remember not to shoulder all the responsibility for keeping the member safe.

Sometimes the worst happens despite our best efforts. People can die by suicide even when highly trained and qualified professionals intervene. It is not realistic to expect that leaders will be able to prevent every suicide. If you lose a member to suicide, the Postvention Guide for CAF Leadership can assist in helping you and your team to address this loss.

Self-Care When Dealing With a Chronic Situation

Supporting someone who has suicidal thoughts and behaviour takes a lot of time and emotional energy. You may find yourself worried and preoccupied about them and this can be physically and emotionally exhausting.

You may feel a responsibility to keep them safe, which may seem like a significant burden. You may feel guilty for not being able to help them feel better or perhaps angry and frustrated at them for causing you so much worry. These are all natural responses to a difficult situation.

It is very important that you do not try to deal with this situation by yourself. Leadership can often be lonely but working as a team is essential when caring for someone dealing with suicidality. This will not only lessen your own stress and help to avoid exhaustion but can also strengthen the support network of people who can look out for the member.

A vital part of looking after yourself is having people to talk to about the situation and how it is affecting you. This may be to someone who is also concerned about the member and understands the situation or someone completely outside the situation who can offer their time, objective support and advice. You can share your thoughts and feelings about the situation while maintaining the member’s confidentiality. Leaders are encouraged to assess where they are on the Mental Health Continuum. Signs that it is time to seek help include negative feelings that persist over an extended period of time, decreased enjoyment, changes in performance, ongoing sleep problems, physical symptoms of stress, and problems that are negatively impacting relationships in your life.

It is important to take appropriate action if you are experiencing symptoms but remember that maintaining mental fitness requires work even when you are healthy. This can include reaching out and seeking social support, setting boundaries, making time for family and friends, taking time to relax and exercise, focusing on healthy sleep and eating, and focusing on your spiritual needs. Seek professional help if you are in the orange or red zone on the Mental Health Continuum Model.

Supporting a member experiencing suicidality can also affect one’s spiritual health. Leaders are encouraged to use the Spiritual Health and Well-Being Continuum to help determine if they are experiencing changes to their sense of meaning, hope, and forgiveness. Seek help from a Chaplain, a faith leader and/or from Mental Health Services if you are in the orange or red zone on the Spiritual Health and Well-Being Continuum Model. Civilian leaders can get support through their family physician or by contacting the Employee Assistance Program.

Resources

9-8-8: This 3-digit phone number enables mental health crisis and suicide prevention services access by call or text, 24/7, from anywhere in Canada for free. Callers will be directed to the appropriate resource for their area. The 9-8-8 website is also a great source of information about suicide and includes a list of local community resources throughout Canada.

CAF Mental Health Services: Contact your local CAF medical clinic to access psychosocial or mental health services.

Royal Canadian Chaplain Services: CAF Chaplains can meet your needs by providing spiritual and/or religious care, guidance, and counselling, by providing an active, personal and supportive presence, and by assisting in understanding and clarifying one’s theological, moral, and ethical views.

Mental Fitness and Suicide Awareness: The Mental Fitness and Suicide Awareness course is offered through the Strengthening the Forces program and prepares CAF supervisors to be aware of suicide and to practice suicide intervention. This course prepares supervisors to use the ACE intervention.

Postvention Guide for CAF Leadership: This document provides guidance for CAF leaders at all levels for suicide postvention (actions taken following a suicide or suicide attempt).

Road to Mental Readiness Aide Memoire: The aim of this guide is to provide military leaders with information and practical strategies for dealing with stress and the provision of psychological support. The goal is to enhance personal and unit effectiveness in modern military operations, whether at home or on deployment.

Canadian Forces Member Assistance Program (CFMAP): The Member and Family Assistance services is a 24 hour, 7 days a week bilingual telephone and face to face counselling service that is voluntary, confidential, and available to CAF members and their families. CFMAP offers short term counselling to assist with resolving many of today’s stresses at home and in the workplace. The CFMAP should not be regarded as treatment for mental illness or addictions.

The Employee Assistance Program: supports DND employee’s health, well-being, and productivity. Employees and their dependents who are experiencing personal or work-related issues can benefit from a variety of services including crisis and short term counselling by phone or chat.

Hope for Wellness: The Hope for Wellness helpline is available to all Indigenous people across Canada. Experienced and culturally competent counsellors are reachable by telephone and online chat 24 hours a day, 7 days a week.

Trans Lifeline: The Trans Lifeline Hotline is a 24/7 peer support phone service run by trans people for trans and questioning people. Services are available in English or Spanish.

Kids Help Phone: Kids Help Phone offers 24/7 e-mental health services to kids, teens, and young adults across Canada. They offer crisis support through chat with trained volunteers and professional counselling through chat or phone.

The Canadian Association for Suicide Prevention is a great source of information and resources on suicide prevention.

The Lifeline App is a free suicide prevention and awareness mobile application. It provides easy access to crisis centers across the country and includes educational material and prevention strategies as well as support for those grieving following a suicide.

Annex 1: Accronyms

• 2SLGBTQI+: Two-Spirit, Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Plus
• ACE: Ask, Care, Escort
• AIR: Ad Hoc Incident Review
• CAF: Canadian Armed Forces
• CDU: Care Delivery Unit
• CF H Svcs: Canadian Forces Health Services
• CFMAP: Canadian Forces Member Assistance Program
• CoC: Chain of Command
• DAOD: Defence Administrative Orders and Directives
• DND: Department of National Defence
• FIL: Family Information Line
• GDMO: General Duty Medical Officer
• JSPS: Joint Suicide Prevention Strategy
• MEL: Medical Employment Limitation
• MFRC: Military Family Resource Centre
• MH: Mental Health
• NOK: Next of Kin
• OSI: Operational Stress Injury
• PI: Personal Information
• R2MR: Road to Mental Readiness
• SMSRC: Sexual Misconduct Support and Resource Centre
• SPAP: Suicide Prevention Action Plan
• VAC: Veterans Affairs Canada