Take Note: Kim Ruocco on Suicide Prevention and Postvention

Sep 4, 2020

Kim Ruocco is the Vice President of Suicide Prevention and Postvention for the Tragedy Assistance Program for Survivors, better known as TAPS, an organization that provides comfort, care, and resources to those grieving the death of a military loved one. She is the surviving widow of Marine Corps Major John Ruocco, who died by suicide in 2005.

Kim uses her education, personal experience and information gathered from thousands of survivors to help others more fully understand suicide and serves as an advisor to WPSU’s Speaking Grief initiative.

We talked with her about about suicide rates among active duty and veteran populations, the comprehensive, peer-based program she’s spent a decade building for TAPS, and about how her own loss experience inspired this work. 

Resources Kim Cited during this interview:

FULL TRANSCRIPT:

Lindsey Whissel Fenton:Welcome to Take Note. For WPSU from my home studio, I'm Lindsey Whissel Fenton. Kim Ruocco is the vice president of Suicide Prevention and Postvention for the Tragedy Assistance Program for Survivors, better known as TAPS, an organization that provides comfort, care, and resources to all those grieving the death of a military loved one. She is the surviving widow of Marine Corps Major John Ruocco, who died by suicide in 2005. Kim uses her education, personal experience and information gathered from thousands of survivors to help others more fully understand suicide and has developed a comprehensive peer-based program that offers comfort and care to all those grieving the loss of a service member to suicide. Kim also serves as an advisor to WPSU’s Speaking Grief initiative, Kimber Ruocco, thanks for being here. 

Kim Ruocco: Thanks for having me. 

Fenton: TAPS was founded in 1994 in order to provide comfort, care, and resources to people grieving the death of a military loved one. How did TAPS come to address the particular kind of grief that comes with death by suicide?

Ruocco:My husband died by suicide in 2005. He was a Marine Corps aviator and died by suicide three months after serving in Iraq. And I started looking for resources, especially for my children, who were eight and ten years old at the time. So, I found TAPS had a good grief camp for children. And then I found a brochure in a booklet of stuff that the casualty officer brought me, and someone had written on that brochure, “Call TAPS and they'll help you.” So, I attended a first event there, and there was all kinds of losses there. But I was the only suicide loss survivor that I could find it that first event and a lot of things that I was struggling with, I didn't find other survivors of killed in action deaths and other kinds of deaths struggling with. Like, “Why did this happen? Why didn't I see it? Why didn't I know more? What does this mean about my spirituality (inaudible)? How do I talk to my kids? How do I talk to others about it, all those things I was really struggling with and having trouble even grieving because I was so consumed with all those other issues? So, I really felt like there was a gap in services for people like me. So, I went to the founder, and, you know, told her about it. And she said, “Well, let's build it.” So, you know, in 2008, we started really building programming specifically for suicide loss survivors, to help them sort of stabilize those suicides specific issues.

Fenton: And, I want to talk about that that best practice model that taps has developed around suicide prevention and postvention. But first, let's just start with what is postvention? 

Ruocco: Postvention is an intervention following a suicide loss that promotes healing and decreases the risk in all those exposed to the suicide. Because everybody who was exposed to suicide is at increased risk for suicide themselves, mental health disorder reclusiveness, addiction, and other mental health disorders. So, it's a really critical part of prevention and a really critical part of healing.

Fenton: Can you walk us through the TAPS program and the phases involved in your work with prevention and postvention?

Ruocco: Yeah, so we we've, over the last decade, really packaged up everything that we've learned about postvention. From thousands of survivors, we have about 16,000 suicide loss survivors in our database now, and what we've gathered from experts and what we've had with our own lived experience as professionals, and developed a model that really seems to resonate with the field and was really a missing gap in in knowledge, I think, for how we really care for suicide loss survivors. And it's three phase model was each phase having three tasks and it's not really a linear model, like you don't complete a task and then you never go back to it, but it just gives you kind of a roadmap for how to think about suicide loss, how to help and support suicide loss survivors, and where they might be getting stuck. So, you can go back and sort of address those things. So, the first part of the model is really to stabilize. And it has three tasks. The first one is to really figure out whether that's suicide last survivor is suffering from any kind of mental health issues that are now exasperated from the suicide loss, or if they're at risk, so we do a lot of risk assessment, and also mental health questioning to see, you know, do they need some professional care? Do they need further professional assessments and how can we help them in that sort of area? The second piece is trauma. Many, many survivors of suicide loss have experienced severe trauma related to the death. About 76% of suicides in the military happen either in the family home, the barracks or the workplace. So, if you think about how many traumatic events happen with discovering the body or wit Seeing the death. And so, we've got to be asking about trauma because the experience of trauma is very different from grief and needs to be treated separately. So, we asked very directly about trauma. And then the last task within stabilization is really those suicides specific issues. You know, we help them talk to children, we help them understand that suicide is a multi-factored event that doesn't just happen from one thing, it's not because you had a fight or because you said something wrong. You know, it's a multiple factor event. This helps decrease guilt and shame and all those other emotions that a lot of survivors walk around with. We help them with their spirituality, we help them navigate family dynamics, where they're often strained after suicide loss and a lot of other things. So, we kind of work through those three tasks. And when survivors are kind of stabilized in those areas, we move on to intentionally looking at grief work, and so we try to help it first move away from the cause of death. So, get them thinking not about the seconds or minutes that occurred around how they died. But the whole life of their service, their love, their commitment, their sacrifice, as service members and get them reconnecting with that and understanding that and moving away from cause of death. We then help them find what we call a grief rhythm. So many survivors, you will find them trying to avoid grief feelings, and so we teach people to recognize grief, as love, to embrace it, to feel it, to express it, and then to rest and get support. This is helpful in navigating grief because if they know what to expect, if they know just to embrace it and feel it, it can wash over them and be done with within a matter of minutes, versus avoiding it all day long and maybe having anxiety around it. And then lastly, the third task under grief work is to start reconnecting with the deceased in a new way. Friendship, because we know love doesn't die, we know that a relationship doesn't die. And there's all kinds of ways to reconnect with the deceased and reconnect with the love you had for them the experiences you have with them before they were sick before they died. And then finally, the third phase is post traumatic growth. We know that suicide loss survivors are uniquely perched for post traumatic growth because they are really desperate to make some meaning out of a death, it seems so meaningless and so overwhelming. This is especially true of military servicemembers families, because there's so much focus on how one dies in the military. There's medals and honors and bridges and things named after people who die in these heroic deaths. So, there's a fear of military suicide loss survivors, that how they died will be what will be remembered and will replace everything they've done in real life. So, if you give them the opportunity, they're really willing to find some growth and make meaning So the first thing we do is help them tell their story in a more meaningful, positive way. So hopefully their story will have changed from when it first happens, where they're telling themselves, “It’s my fault. I didn't see it. I shouldn't have done it” to “I did the best I could with the information I had at the time. And now I'm going to use the lessons learned on a look back to help others.” We give them opportunities to do prevention work in all different kinds of ways, whether that's to do speeches to do trainings within the prevention realm, and then we encourage them to live their life in a more intentional, connected way. So, appreciate the little things appreciate the relationships that they build, in honor of and in memory of their loved one. So, it's a really interesting model that's really based on the outcome being post traumatic growth.

Fenton: You touched on grief and trauma. Can you speak a little bit more to the different mental processes that are involved in grief and trauma? Because they think a lot of time It might be easy to lump those two things together

Ruocco: And there's a lot of overlap in what you see in people, both grief and trauma. But for people the difference would be that people that have trauma often have very recurring, painful memories that are consuming and are disruptive to their life, sleep issues, issues around being hyper vigilant, whenever they're out anxiety, flashbacks, ruminating about things, maybe avoidance of people, avoidance of talking about their loved one, really issues that interfere with them moving forward in a healthy way, where grief is more about expressing their love and their connection and not really be caught in a cycle of anxiety and ruminating and being triggered by the remember it's and we very often start by asking, you know, survivors, you know, when you lay your head down at night What do you picture? What do you think about with your loved one? And the difference might be somebody who, who is has trauma might say, “I see the day I found him like, I, you know, it keeps me up all night. I have flashbacks of it.” Where a person who's grieving without the trauma might say, “I just miss him. I'm yearning for him. I just miss him. I'm so sad.” You know? So, there's, it's, it takes some skilled clinician kind of conversations to figure out the difference. But you can ask pointed questions, and we have some pointed questions to kind of suggest for clinicians to start or even friends to start asking to see whether they might need to get some help in coping with the trauma or treating the trauma or whether they're just experienced grief.

Fenton: All TAPS’ efforts involve a great deal of peer support, and the TAPS suicide programs are no exception. Why is peer support so effective?

Ruocco: Yeah, I mean, that I think the main thing, especially for suicide while survivors is you don't have to go in there and explain Like you just you meet eyes with people and you just know that, you know, man, they get it, you know, you don't have to justify your loved ones death or say, you know, “He was a good guy” you don't, you know, they know that they were a good guy, you know, and there's a trust and a, I think a transparency that you're willing to, to take a chance on with another law survivor, that you're, you may not be with other people who are not peers from fear, they might judge you or (inaudible) I think the same way or might criticize you. So, there's an immediate I think, trust and safety with peers that helps move that conversation into a deeper place. And so, there's this beauty and connection about it at the same time, that you're feeling the pain that helps balance that pain a little bit. And that's what I love the most. I mean, some of the people that are the most important in my life now are other loss survivors who have connected with around my pain.

Fenton: Moving outside the peer support to more generally, that that feeling of isolation that can come from, especially, stigmatize loss. How can we work to create safer spaces more generally outside of perhaps a peer support group? Like, what are some things that each of us can do if we are responding to someone who has not only faced a loss, but perhaps a stigmatized loss, like suicide?

Ruocco: And that's a good question. I think, you know, one of my biggest mentors is Frank Campbell, Dr. Frank Campbell, who created the (inaudible) but also created this idea of active postvention. So, it's, it's actively reaching out to stigmatized populations, right? So it's not waiting till they come to you because they may not because they have so much shame and guilt and stigma around it so actively outreaching to them and say, saying, I don't I don't know what you've gone through, but I'm here to listen. And I'm here to support and you know, I gotcha. And just being proactive in in really reaching out to them and being and being willing to sit with them and their pain because That's the thing suicide loss. There's, it's so painful and the emotions around it can be so intense that sometimes people can't tolerate that. And survivors can feel that whenever someone can't tolerate that all of our address books changed after we lost a loved one to suicide and some people who didn't expect moving closer, something who we thought were going to be there, move away. And so, I think if you can sit with people's pain, and proactively reach out to them, you're making the first step in really creating a comfortable, safe environment that will decrease risk and help them heal.

Fenton: If you're just joining us. This is Take Note on WPSU. I'm Lindsey Whissel Fenton and our guest is Kim Ruocco, the vice president of Suicide Prevention and Postvention for the Tragedy Assistance Program for Survivors, better known as TAPS. Another thing that sticks in my mind from the first suicide last survivor seminar attended was this graphic illustrating the experience and the support needed along this grief experience looking at the first five years and I think, especially for people who haven't experienced a loss, you hear five years and that can be really surprising because we have this cultural idea that, you know, grief is this finite thing that happens for a few months, maybe a year. What can you speak to about sort of our ideas around this timeline of grief and trauma and the reality?

Ruocco: I mean, gosh, if someone would have told me that grief is a lifetime journey, I would be like, “I can't do it.” But it is. I mean, grief is a lifetime journey, especially when you have a traumatic loss for suicide loss, though in particular. Very often that first year, a lot of people are traumatized, they're in shock, their, their worlds are turned upside down, and they're trying to just survive very often. They're not really doing intense grief work. They're just trying to survive and stabilize. And so we hear from a lot of survivors and this is true in my case, that it wasn't until really the second year that you started even feel that that grief like it It's like, “Oh this is real.” You know?  “It really happened.” I had this is it's been a year and it's really true and you start to have that grief and it wasn't until the third or fourth year that I started to feel like I had my legs about how it was gonna hurt. Not that I was better, but that I now know how to face it. So obviously I just in some ways just starting my grief journey my third year because I kind of got my legs under I got my kids. OK I've, you know, I've talked to them I understand why a little bit more. I figured out the cycle he's OK. We can grieve as a family in this way. And so, the foundation was built and it's a lifetime journey. Grief comes up on sometimes on holidays and anniversaries, but it also sometimes comes totally out of the blue. Just a… it just blindsides you when (inaudible). I think people don't like to hear that. But they also do like to hear that and you know that they can because they if we give them some ways to face it, they know that they can handle anything that comes and that they don't have to avoid it or fear it.

Fenton: Yeah, a little bit of a roadmap and in terms of the road-mapping support people might need and I'm speaking more to less from a clinical perspective and more like friends, neighbors, those of us who want to care for someone, how does the support that someone might need and that we can offer… how do those needs change over time?

Fenton: I mean, that's a good question. I think. I mean, I think in the beginning, it's the basic needs, right? Like, I think people don't even know what they need. And so instead of saying, “Call me if you need something,” like, just notice what they need and just do it, like, if the lawn needs mowed, just mow it, if they're out of food, or just go to get groceries, you know, like, I think that's in the beginning and then there's a grieve it's sitting with them and the pain and being comfortable and letting them breathe. And then in the long term, people don't want to forget their loved one. So continuing to use the loved one’s name, to continue to ask about them to continue to ask about your grief to acknowledge that it might come up on holidays and anniversaries and, and sometimes out of the blue is really supportive and comforting to say, “Oh, they're not forgotten and they don't expect me to be completely over it” really helps long term.

Fenton: Suicide is the leading cause of death referrals to TAPS and the numbers around this issue in general are pretty staggering. US veterans are 1.5 times more likely to die by suicide than people who haven't served and for female veterans, it can be even higher. What kind of systems do we need in place to turn this around?

Ruocco: So, I mean, suicide is so complicated, it's a little bit like whack-a-mole. I mean, you feel like if you focus on just one thing like gatekeeper trainings or me lethal means trainings or, or mental health and like something else is gonna pop up. So, it has to be a public health approach where everybody sort of understands about better about mental health. And we start need to think about mental health differently. And I think that needs to start in our military academies and our boot camps, where we start saying to our young service members expect to have mental health challenges throughout your career, it's part of what's gonna happen because of what we're asking you to do. The same way you might twist an ankle, or you might need, you know, your wisdom teeth out or you might need to have surgery you probably are going to have some mental health challenges. This is what they look like, this is what is available to you, and you get treatment and then you get back into your job. And I think until we start normalizing mental health and expecting them and giving them tools to deal with it when it comes up. I think we're going to continue to have challenges because you can't wait until people are so sick, that they're saying, “I'm suicidal, and I need help,” because by that time servicemembers are very sick. If they're saying that they're thinking about suicide, they're very sick. And very often, when they're that sick, other things in their lives have now become huge risk factors. They might have relationship problems, job problems, they may have had DUIs or addiction problems and, and other things. So, we I think we have to get way ahead of that, that crisis response model to really integrating mental health into their lives in a positive way.

Fenton: And there seems to be an assumption that, that only or primarily service people and veterans who have deployed or were in combat are at risk for suicide, but about half of military service members who die by suicide have never deployed or seen combat.

Ruocco: Yes. And people are always really surprised by that, but I'm really not because actually combat is a protective factor in a lot of ways. They have the sense of connectedness, belongingness sense of purpose and mission. You know, they have each other's back and they feel like they're Doing something important. You know, if you are never deployed to don't go as a service member, often you might feel like, well, I've done this training for what? And so, you know, we've got to look at kind of what we're asking of our service members as well. Many of the traumas and exposures to loss and other things happen in training accidents. That was the case with my husband as well. He lost many of his friends in aviation training accidents, way before he went to combat. So, you know, we're also asking a lot of our service members that don't deploy in training and what we ask him to do as far as frequent moves and long hours and little sleep and a lot of responsibility. So, so there's lots of reasons, but it seems counterintuitive at first, but if you really look at what we're asking of our service members, it makes sense.

Fenton: Talking about this as a public health issue. You've said that everyone needs to know these right questions to ask when it comes to concerns about mental health and assessing suicide risk. And, you've given the example that a marine might not go to their commanding officer with (inaudible), but they might talk with a bartender. So, what are some of those questions that we should all be aware of to pose when there is a concern for someone's wellbeing?

Ruocco: So, the first thing that I think is important for everyone to know is you need to ask directly and clearly, “Are you thinking about suicide?” It's not going to put that that thought into someone's mind. It's not going to make them suicidal, but it may give them an opportunity to talk about something that they were afraid to talk about. It may a lot of attempts, survivors tell us that it actually felt like a relief when somebody asked him about it, because he was like, “Whoa, they see me,” you know, they and they might they're OK to talk about it. They're OK talking about this. So, I think if, first of all, don't be afraid to ask clearly directly, and then second of all, you know, know what the signs are, especially in service members. If they're talking about being a burden, if they're talking about, “Everyone, you'd better off without me.” If they're talking about, they can't do it anymore or they, they are overwhelmed, you know, start asking questions about that. What do you mean by that? What are you going to do about that? And then ask directly about suicide, if you think it is a challenge. And then I think sharing resources like the national crisis line, or, you know, that's for warriors or other places that they can call and give a variety of resources, because one-size-fits-all is not going to be good for military members. You know, there's a lot of people who won't call the crisis line, there's a lot of people who won't go see a professional clinician, there's a lot that would prefer peer support. So, giving a lot of different resources is really helpful.

Fenton: So that was gonna be my next question. Let's say somebody does answer affirmatively that they have thoughts of suicide or that you're noticing some of these signs—certainly, we want to give resources—but what is an average person might be something that somebody could respond, but to acknowledge the pain that someone's in?

Ruocco: So, I would just thank them for sharing that information and for trusting you with it, and then I would not leave them alone, I would say, “Look, I'm really concerned about you. As a friend, I don't want to leave you alone. Can we do this?” And you can give them some options. “Can we call the crisis line together? Can we call your doctor together? Can we go to the ER together? Can we go to your family and talk together with your family?” But see if you can find something that they're willing to do, and you can stay with them and warmly connect them to somebody else who can really assess for suicide risk. There's a really good tool, the Columbia Severity Rating Scale, that is you can get online and it has like six questions for people. Anybody can just ask somebody to really figure out whether you need to send somebody right away to the hospital or whether you can get them to, you know, just with a family member or whether you can just give them resources. So, you can you can give out that as a resource or read it online, and then ask some of those questions if you're if you're not sure how to ask them.

Fenton:Adults are often uncomfortable enough having conversations about suicide with other adults, let alone with children. And I know one of the things TAPS does is address that. What are some general words of guidance that you can offer for talking with kids about suicide? Let's say a suicide has already occurred. How can caregivers approach that conversation with children?

Ruocco: So, first of all, it's important to start with the truth as simply and as clearly as you can. And that's different developmentally for different ages. One of the phrases that I really like for younger kids is that “He made his body stopped working.” So, you can you can describe to them what death is, and what that means with the body and then you can say he made his body stop working and let them ask the questions. For older kids. They might be more interested in the mental health and why people die. suicide, and the multi factors that lead up but the more simply that you can explain it, the more direct you can explain it. And the more you can let the child know that whatever they're feeling is OK, and that you're going to be there for any questions that you may not have all the answers, but you will answer as best you can, the better that child will begin to trust you, and be able to have conversations about it. It really sets being honest, like this, and having these kinds of conversations really sets the tone for the future with those children to address all kinds of other challenges in their life. I mean, that was really worked for me as having two boys that were eight and ten having a discussion about their dad's suicide really set a foundation for everything else that came later. So, talking about sex or drugs or other challenges was nothing. So, I mean, we had set the foundation that was okay to talk about these kinds of things. And that that I would listen that we would, you know, come up with the answers together and they could trust me with that. So, it's important for families to set that foundation and to really be as honest as they can.

Fenton:The mission of TAPS is to support those grieving the death of a service member. But are the resources and information available through taps applicable to other populations?

Ruocco: Yes, they are. The postvention model is applicable for all populations. It's not just a military model. It's used in a lot of different populations. And peer to peer support is valuable, no matter what. So, while we focus on the families of servicemembers and veterans, we're constantly providing, you know, subject matter expertise to other populations who could use it and glad to do so because we've learned I think, a lot to the work that we’ve done.

Fenton: Where can people go to access some of this information?

Ruocco:So, if you just go to TAPS-dot-org, we have a huge website with all kinds of information and valuable resources. We have a TAPS Institute for Hope and Healing, that has free trainings that anybody can take their everything on suicide prevention and postvention and the model to grief and resilience and post traumatic growth. And you can also call 800-959 -8277 are there 24-7, answered by, by peers?

Fenton: What message would you give to someone listening who is grieving the loss of a loved one to suicide?

Ruocco: Well, first I would just say, “I'm so sorry that this has happened to you because it's very painful, but you can survive it. You can make meaning out of it. And you're not alone. You know, where there's, there's lots of us out there if you're not a military survivor. There's other organizations like the American Association of Suicidology, American Foundation for Suicide Prevention, the alliance of hope, which is an online support to the lost teams, there's lots of lots of resources. So, don't be alone in your grief, reach out connect with others who have had similar losses and it will help you.

Fenton: Kim Ruocco, thank you so much for talking with us.

Ruocco: Thank you for having me. 

Fenton: Kim Ruocco is the vice president of Suicide Prevention and Postvention for TAPS and has developed a comprehensive, peer-based program that offers comfort and care to all those grieving the loss of a service member to suicide. She's the surviving widow of Marine Corps Major John Ruocco, who died by suicide in 2005. For more information and resources about suicide loss support, visit WPSU-dot-org-slash-take note. From my home studio, I'm Lindsey Whissel Fenton, WPSU.

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