Styles of Suicide InterventionProfessionals’ Responsesand.docx

Styles of Suicide Intervention:
Professionals’ Responses
and Clients’ Preferences
Jill C. Thomas and Larry M. Leitner
Department of Psychology
Miami University, Oxford, OH
As the rates of suicide in America continue to rise, suicide
recently has been declared
to be a national public health concern. The crisis intervention
model, which has dom-
inated the treatment of suicidal individuals in America since the
1950s, is currently
believed to be the most effective model for suicide intervention.
This study examined
this belief by taking a more complex look at professionals’
responses to suicidal cli-
ents both by investigating the existence of different ways in
which professionals in-
terpret the crisis intervention model. In one interpretation (the
“fight” response), the
professional takes power and agency away from the client and
does what is perceived
to be “best” for the client. An alternate interpretation, the
“ideal” response, allows for
a respectful engagement with the client. Professionals also can
act contrary to the
model (i.e., the “flight” response). In addition, based on the
humanistic notion that
clients are the experts of their own experience and that their

voices are a very valu-
able part of evaluating the treatment process, this study
investigated which response
style clients report to be most helpful and most desired. The
results suggest that while
the typical response of mental health professionals to suicidal
clients is most charac-
teristic of the “fight” response style, clients overwhelmingly
report that the contrast-
ing “ideal” response style is most helpful. The findings are
discussed along with im-
plications for practice, research, and training.
The most recent statistics reveal that there are approximately
30,000 suicides in
America every year. There are about 80 suicides and 1,500
attempted suicides in
America each day: one suicide every 18 min and one attempt
each minute. Suicide
is the eleventh leading cause of death in the United States and
the third leading
THE HUMANISTIC PSYCHOLOGIST, 33(2), 145–165
Copyright © 2005, Lawrence Erlbaum Associates, Inc.
Requests for reprints should be sent to Jill C. Thomas,
Department of Psychology, Miami Univer-
sity, Oxford, Ohio 45056. E-mail: [email protected]
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cause of death among American youth ages 15 to 24 (American
Foundation for
Suicide Prevention, n.d.). For every suicide it is estimated that
there are six friends,
family, significant others, or loved ones the suicide has left
behind. Based on this
estimate and the most recent suicide statistics, there are now at
least 4.5 million
American survivors of suicide (Caruso, n.d.).
With these alarming statistics, it is no wonder that the response
in the suicide
prevention movement has historically been an active and
aggressive fight to pre-
vent the spread of this epidemic (U.S. Department of Health and
Human Services,
2001; U.S. Public Health Service, 1999). Today’s approach to
suicide prevention
and intervention is rooted in the theoretical framework
established in 1958 with the
inception of the first suicide prevention center (the Los Angeles
Suicide Preven-
tion Center; Allen, 1984). This framework, known as the crisis
intervention model,
prescribes a standard protocol for responding to the suicidal
client. After quickly
establishing rapport with the client and developing an
understanding of the prob-
lem, the crisis intervention worker must develop options and
take action, using all

measures possible. These measures include: reducing immediate
danger with the
use of no-suicide contracts, helping to make the client’s
environment safe, evaluat-
ing the client’s need for medication, involving family or
significant others in the in-
tervention, linking the client to other community resources,
helping the client to
structure his or her time, and possibly voluntary or involuntary
hospitalization
(Fremouw, de Perczel, & Ellis, 1990).
Although the crisis intervention model explains clearly and
concretely what steps
are to be taken and what actions are needed, it offers little in
the way of prescribing
the manner in which these steps and actions are to be carried
out, thus allowing for
multiple possible interpretations of the model. The typical
interpretation of the
model is one in which the crisis interventionist is assertive,
active, and aggressive.
Leenaars (1994), for example, likens the activity of a crisis
intervention worker to
that of a cardiologist in an emergency unit. This metaphor is
consistent with the be-
lief that the role of the crisis interventionist is to take charge of
the situation and take
over for the person, who is rendered weak and/or helpless in the
face of the crisis, to
fix the problem or repair the person. This metaphor is consistent
with the depiction of
the crisis interventionist in most of the literature and results in
one prototypical pro-
fessional response to suicidal clients (i.e., the following “fight”
response). However,

as stated previously, the crisis intervention framework does
offer room for other pro-
cedural interpretations (i.e., the following “ideal” response).
THIS STUDY
As Maris, Berman, and Silverman (2000) have reported,
“research on treatment ef-
fectiveness [for suicidal people] is both difficult and rare” (p.
527). Methodological
issues in the study of suicide, like confounding variables and
the ethical prohibitions
146 THOMAS AND LEITNER
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to using a control group in testing treatment efficacy (Berman,
2000; Frankish, 1994;
Neimeyer & Pfeiffer, 1994a), make it difficult to empirically
validate the crisis inter-
vention approach. As such there is little empirical evidence for
what works with sui-
cidal clients and almost a total lack of evidence that the crisis

intervention model
(typically operationalized consistent with the cardiologist
interpretation) is the most
effective or is even effective at all (Berman, 2000; Frankish,
1994). Despite the lack
of evidence, the crisis intervention model is currently believed
to be the best option
for the treatment of suicidal individuals, and, as such,
professionals continue to teach
it, and to evaluate the skills of their volunteers based on their
ability to work within it
(Neimeyer & Bonnelle, 1997; Neimeyer & Pfeiffer, 1994a,
1994b).
This two-part study was conducted in an effort to examine the
belief that the cri-
sis intervention model is the ideal treatment model for suicidal
clients. Part I of the
study takes a more complex look at professionals’ responses to
suicidal clients
both by investigating the existence of different interpretations
of the crisis inter-
vention model as well as the existence of ways professionals act
contrary to the
model. This portion of the study attempted to understand these
varying interven-
tion styles through interviews with community mental health
professionals about
the ways they have responded to suicidal clients in the past.
Part II of the study evaluated the belief that the crisis
intervention model is the
ideal treatment model for suicidal clients by examining which
response style sui-
cidal clients report through interviews to be most helpful and
most desired. This

portion of the study was based in the humanistic notion that
clients are the experts
of their own experience and therefore that their voices are a
valuable part of evalu-
ating the treatment process. While acknowledging the
methodological difficulties
inherent in suicide research, this study, by looking at the issue
from the suicidal cli-
ent’s perspective, offers one viable way of understanding the
therapeutic and prac-
tical implications of different response styles.
The data gathered in the two parts of the study were compared
in an effort to an-
swer the main research question: Do the responses that
professionals offer suicidal
clients match with what clients report to be most helpful? Given
the startling sui-
cide statistics and the rising rate of suicide in this country, the
overall study hypoth-
esis was that a mismatch exists between the response styles
professionals are offer-
ing and the type of response that suicidal clients desire or find
most helpful.
Styles of Suicide Intervention
This examination was conducted based on a literature review
that suggested the ex-
istence of two problematic styles of response (“fight” and
“flight”) along with an
alternate more “ideal” style. Those, for example Szasz (1980,
1986), who describe
the problematic response types, launch a harsh attack on many
mental health pro-
fessionals who intervene with suicidal clients. However,

although these arguments
are valuable in pointing out responses that may not be helpful to
the suicidal indi-
STYLES OF SUICIDE INTERVENTION 147
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vidual, they are not presented here as an attack. Most mental
health professionals
respond to suicidal clients in the best way they know how. The
problematic “fight”
and “flight” responses described in the literature are
understandable responses to a
very difficult situation.
“Fight.” The popular “cardiologist” interpretation of the crisis
intervention
model described earlier is consistent with the assertive, active,
and aggressive
“fight” response style, which takes power, agency, and control
from the client
without much forethought or discussion. (Table 1 describes the
“fight” response.)

It is important to make clear that the “fight” is not inherent in
the actions required
by the model but rather is evident in the manner in which the
actions are taken. Due
to the importance of the goal of suicide prevention, the
professional takes the mea-
sures suggested by the crisis intervention model against the
client’s will. In this
case, and even in other less extreme cases, although the
measures themselves are
not inherently “fighty,” they are reflective of the problematic
“fight” response be-
cause they come primarily out of the needs of the professional
without first talking
with, listening to, and considering the needs of the client.
For Szasz (1986), the “fight” style of suicide intervention
results in a rapid
abandonment of the therapeutic alliance and “coercive
intervention” in which any
and all means necessary to prevent the suicide are quickly taken
against the client’s
will. This response can even incorporate the use of fraud and
force and results in a
struggle for power between client and helper (Szasz, 1980). The
client in this
struggle wants control over his or her life. The professional,
although claiming to
want to help this person by the use of involuntary
hospitalization, police involve-
TABLE 1
Description of the “Fight” Response Type

• Incorporates the use of fraud and force (actions against the
client’s will made under the false
pretense that the motivation behind the action is for the client’s
sake).
• May result in a struggle for power between client and helper.
• May use involuntary hospitalization.
• May use police involvement.
• May use forced medication or shock treatments.
• May advance the client’s feelings of hopelessness and despair
and/or aggravate the client’s
problems.
• May point out the immorality of committing suicide.
• May react in a hostile or angry manner toward the suicidal
individual.
• May involve client’s family and/or develop another support
network for the client in the
community, possibly against the client’s wishes.
• May contact the client’s family physician to alert him or her to
the possibility of an overdose on
prescription medications, possibly against the client’s wishes.
• May aid in structuring the client’s time between sessions.
• Actions come out of the needs of the professional without first
talking with, listening to, and
considering the desires of the client.
• Responds in an active and directive way.
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ment, forced medication, or shock treatments, essentially
deprives this person of
basic human liberty as a means of, “gain[ing] control over the
patient’s life to save
himself from having to confront his doubts about the value of
his own life” (Szasz,
1980, p.191). Likewise, Jobes and Maltsberger (1995) state that
this “fight” re-
sponse is due to the “strong countertransference wish to do
something active, pow-
erful, and healing so that the therapist will not have to endure
the empathic pain of
experiencing the patient’s despair” (p. 205). The descriptions
offered by Grollman
(1971) of the “helper as a moralizer” and the “angry helper”
also fit the “fight” re-
sponse type, and he, along with Szasz (1980), asserts that this
response may actu-
ally advance the client’s feelings of hopelessness and despair
and aggravate the cli-
ent’s problems rather than help the situation
“Flight.” Szasz (1980) elaborates the other problematic
response, the “flight”
response, by describing professionals who respond in this way
as those who, when
confronted with the issue of suicide “run for their lives” (p.

191; See Table 2). As
Grollman (1971) states, suicide is
ugly for onlookers, devastating for relationships, and harrowing
even for those pro-
fessionally involved. So the entire subject is often studiously
avoided, even when a
person threatens to take his own life. Some just do not want to
become entangled in
the sordid predicament (p. 87).
Jobes and Maltsberger (1995) explain this type of response as
being due to the thera-
pist’s inability to engage with the client’s intense suffering, and
say that, as a result of
this inability, the therapist remains detached and “professional.”
As such, they may
rush through or avoid the topic of suicide altogether or even
refuse to see the client.
TABLE 2
Description of the “Flight” Response Type
• Those who, when confronted with the issue of suicide, “run
for their lives.”
• May avoid the subject of suicide, even when a person
threatens to take his own life.
• May communicate disinterest to the suicidal client.
• May feel concern about the personal ramifications of
uncovering serious suicidal ideation,
including extra expenditure of time and energy.
• May not inquire about suicide or may wait until the end of the
interview to ask about it.

• May rush through the assessment of suicidal intent, thus not
creating an environment where the
client feels comfortable to share suicidal thoughts or feelings.
• May ask leading questions which invite a negative response
(e.g., “you’re not thinking of hurting
yourself are you?”).
• May take the first “no” for an answer rather than probing
further about suicidal ideation.
• May take a very passive role in suicide intervention, does not
respond in an active and directive
way.
• May divert discussion away from powerful emotion to a more
intellectualized or abstract
exchange.
• May offer superficial reassurance that everything will be okay.
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The “flight” response to suicide is problematic because it
communicates disin-

terest to the suicidal client and confirms for the client his or her
belief that no one
cares. Shea (1998) helps to develop a clearer picture of how this
avoidance might
actually look in the interaction between client and therapist. He
feels that helpers
are often concerned that if they uncover serious suicidal
ideation, they are opening
themselves up to a messy situation that will probably be very
time and energy con-
suming. As a result, he says that, to avoid this mess, some
clinicians may not even
inquire about suicide or may wait until the end of the interview
to ask about it. He
suggests that they may also rush through the assessment of
suicidal intent, thus not
creating an environment in which the client feels comfortable
enough to share sui-
cidal thoughts or feelings. In addition, the clinician may ask
leading questions that
invite a negative response (e.g., “You’re not thinking of hurting
yourself are you?”)
and then will take the first “no” for an answer. Shea (1998)
states, “the clinician
should seldom, if ever, leave the topic after a single denial” (p.
468) because many
suicidal people will often deny these feelings when first asked.
TONY’S TALE
Both the “fight” and “flight” response types are illustrated by
the response a cli-
ent, Tony, described when interviewed by the researcher. Tony,
who says the
worst thing a mental health professional can do when
interacting with a suicidal

client is to “brush him off,” says that is exactly what happened
to him. Tony re-
cently called his therapist because he was feeling really down
and was thinking
of suicide. Tony says that when he was talking to his therapist,
he felt like his
therapist was not concerned about his suicidal thoughts. Tony
says, “I felt like he
thought I was making it up, but I wasn’t. I was thinking about
suicide. All he’s
concerned about is how many clients he can get and making
money.” Tony says
that the therapist told him that suicide was wrong and that, if he
were to go
through with it, his soul would be in danger of “hell and
damnation.” Tony re-
ports that the therapist sounded anxious at times and tried to
rush him off of the
phone by telling him things like, “We’ll talk about it next
session.” Disgusted,
Tony could not believe this response because, as he said, “you
know, he didn’t
know if I was going to commit suicide or not after that!” Tony
also felt very let
down. He now questions if he would call his therapist again if
he were feeling
suicidal. He says he would most likely call someone else.
Tony reported that he also tried to talk to his psychiatrist about
his feelings. He
was shocked and angry when the response he received was, in
his words,
I’m a psychiatrist. I only dispense medicine. Your therapist is
the one you should be
talking to.’ She should not have said that. She’s supposed to be

my doctor. I don’t un-
derstand what that was all about. That was very confusing to
me.
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When reaching out for help in a time of great need, Tony was
confronted with pro-
fessionals who did not seem to want to help him, or believe
him, or hear him. For
whatever reason, consistent with the “flight” response, these
professionals seemed
unavailable to be present for their client in suicidal crisis. Both
professionals com-
municated a disinterest to Tony and a desire to avoid the issue.
Tony was also faced
with a “fight-like” value judgment about the morality of
considering an option like
ending his life when his therapist pointed out the moral–
religious implications of
suicide. In addition, also consistent with the “fight” style, Tony
was confronted with

anger on the part of the professionals working with him, which
he picked up in their
tone of voice and manner of speaking. Tony did not find the
“flighty” or “fighty” as-
pects of these responses to be helpful. Instead, when asked what
he finds to be the
most helpful professional response to a suicidal client, Tony
says that that he wants
someone to, “Hear me out. Let me talk to them. Give me a little
comfort. Not rush me
off the phone … That’s what they’re supposed to be doing,
helping.”
The Alternative “Ideal” Response: Neither
“Fight” Nor “Flight.”
The response Tony described as most helpful more closely
resembles the third re-
sponse style examined in this study. This “ideal” response
stands in contrast to
both of the previously mentioned problematic responses (Table
3). Jobes and
Maltsberger (1995) describe this type of response when they
state that, “suicidal
patients need the therapist’s genuine warmth, interest and
respect … The therapeu-
tic interest we refer to is agape: that unselfish, nonerotic
unexploitative concern
that loyally accepts others and seeks their well-being” (p. 209).
A description of this “ideal” response can also be found in the
Personal Con-
struct Psychology (PCP) literature. When talking about suicide,
Kelly (1961)
states, “instead of treating it as something evil, pathological or
nonsensical, we can

understand it far better if we look at the act itself and what it
accomplishes from the
point of view of the person who performs it” (p. 257). As such,
rather than
pathologizing suicidal behavior (i.e., asserting a Diagnostic and
Statistical Manual
of Mental Disorders [DSM] diagnosis as its cause), PCP
searches for the meaning
in it. At the same time, while taking this nonjudgmental and
empathic stance, Kelly
(1961) does not advocate for ultimate acceptance of the client’s
desire to die.
Rather, he states that the goal of therapy with a suicidal client
is to “restore and ac-
centuate those universal psychological processes that
characteristically make life
an ongoing proposition” (p. 277). Here, the PCP clinician and
the “cardiologist”
crisis interventionist share a common goal and, as such, some of
the actions finally
needed may be the same in both response styles. However, as
the description of the
“ideal” response style shows, the “ideal” responder aims to
meet this goal in a
qualitatively different manner than does the “fighty” or
“flighty” responder.
This way of being with the client leaves the client with no doubt
that the words,
attitudes and actions of the therapist are genuine and based on
caring and concern
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for the client. Thus, if the client and the therapist should reach
an impasse and they
can no longer collaborate on the issue of suicide, and the
therapist feels legally re-
sponsible to take coercive actions to prevent the client’s
suicide, it is more likely
that the client will remember this genuine caring and, once the
goal of the preserva-
tion of life is met, will be able to reapproach the relationship
with an understanding
of the therapist’s actions.
ANN’S EXPERIENCE
Fortunately, not all suicidal clients have negative experiences
when reaching out
for help. Some clients report that they have been able to build
relationships based
on mutual trust and respect that are associated with a different
kind of response
from professionals than the “flighty” and “fighty” ones
described by Tony. Ann,

TABLE 3
Description of the “Ideal” Response Type
• Some of the actions taken may be the same as those seen in
the “fight” response, but the actions
are taken in a different manner, suicidal feelings and thoughts
are explored with the client as a
means to collaborate around actions to be taken, actions are not
taken against the client’s will
unless an impasse has been reached and the situation is such
that the clinician has no other choice.
• The relationship established between the client and the
therapist is described as a powerful,
respectful collaboration.
• Suicide is looked at with the client in terms of what it
accomplishes from the point of view of the
client.
• The decision to commit suicide is understood and empathically
embraced when the therapist is
looking at the world through the client’s eyes.
• Takes a nonjudgmental stance towards suicide.
• Emphasizes the need for an empathic understanding of the
client and the client’s meaning of
suicide.
• The therapist enters the relationship with the client using a
credulous approach, in which the
therapist accepts everything the client says as the “truth” for the
client and resists the urge to
conform the client to the therapist’s world view.

• The invitational mode used is safe and respectful, inviting to
move the discussion in certain
directions, allowing clients to proceed at their own pace.
• Therapist acknowledges that some topics, like suicide, are
painful and overwhelming to deal with.
• Does not view suicide as a mental illness, does not offer a
DSM diagnosis as the cause of suicidal
intent.
• Affirms the client’s feelings but at the same time helps the
client separate these valid feelings from
the link to self-destructive behaviors.
• Therapist empathically resonates with the experiences of the
client but still recognizes the
experiences as belonging to the client, not the therapist.
• Client feels that the words, attitudes and actions of the
therapist are genuine and based on caring
and concern for the client.
Note. DSM = Diagnostic and Statistical Manual of Mental
Disorders.
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for example, described her experience of the interventions she
received as being
very positive and, as such, is used here to illustrate the “ideal”
response type. Re-
cently, Ann called her case manager because she was having
thoughts about want-
ing to kill herself. Her case manager listened to her and told her
that she had made
the right choice to call. She told Ann that it was good to talk to
people about how
she was feeling. The case manager called Ann back later that
day and told her that
she would like Ann to meet with her psychiatrist the next
morning. Ann agreed and
was pleased that her case manager would arrange this for her.
She perceived this as
a very caring and responsive thing to do. Ann expressed that she
has a very good re-
lationship with her doctor. She says that not only does she trust
him but “he trusts
me too.” This seems evident in his response to her. Rather than
make decisions for
her, Ann states that she and her doctor had a discussion about
her feelings and
talked about some options. Her doctor asked for her opinion
about what she
thought would be most helpful. Ann said that she would have
done whatever he
told her she ought to do but she really just needed his attention
and she felt like she
got that.

The response Ann got from her treatment providers was very
consistent with
what Ann says is the best thing a mental health professional can
do for a suicidal
client, “to listen and be there for them… and to see the doctor
as soon as possible.”
Ann wanted to be heard and wanted attention paid to her
suffering by the person
she knew could help and the person she felt most connected to.
Given the context
of this relationship as compared to a relationship in which the
client does not feel
connected to the mental health professional, Ann’s statement
about the worst thing
a professional can do for a suicidal client is telling. Ann says,
Well, I could say, ‘send me to the hospital,’ but if that’s what it
took, you know, it
would have to be his way, not my way… the worst thing? …
Send me home without
giving me anything. And he didn’t send me home with nothing.
He gave me options.
In the context of a mutually respectful and trusting relationship,
Ann can re-
spect and understand the decisions (e.g., hospitalization) that
are ultimately made
to protect her. Rather than feeling angry, let down, frustrated,
discounted and con-
fused, Ann feels respected and cared for, leaving the
relationship with her treat-
ment provider to grow deeper, more powerful, and ultimately
more helpful.
SPECIFIC RESEARCH HYPOTHESES

Based on the literature describing the detrimental effects of two
problematic re-
sponses to suicidal clients (“fight” and “flight” responses), we
predicted that the
response clients describe as being the most therapeutic would be
in direct contrast
to these two modes. Specifically, we hypothesized that the
“ideal” response would
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most closely capture what clients describe, based on their
experiences of being sui-
cidal, as the most preferable mode of response. In contrast,
given the predomi-
nance in the literature and in the field of the “fight-like”
interpretation of the crisis
intervention model, we predicted that a “fight” style would be
most characteristic
of professionals’ responses to suicidal clients. Taken together,
these predictions

underlie the overall study hypothesis that a mismatch exists
between the interven-
tions professionals are offering and the responses that suicidal
clients desire or re-
port to be most helpful.
METHOD
Participants
The participants for this study were mental health professionals
and clients re-
cruited from community mental health agencies serving
primarily metropolitan
and suburban areas. All participants were paid for their
participation. Initially, six
agencies providing a wide range of services (e.g., case
management, day treat-
ment, individual therapy, residential programs, and other
outreach programs) were
contacted regarding participation in the study. Five of the six
agreed to participate.
To qualify for Part I of the study, mental health professional
participants must
have had an adult client, for whom they had primary treatment
responsibility, present
with serious intent to commit suicide within the recent past (6
months was suggested
but not required if memory for the event was good). Serious
intent was defined as in-
cluding situations in which danger was perceived as immediate
as well as situations
in which danger was not perceived as immediate but likely to
occur in the near future.
This definition did not include chronic suicidal ideation lacking

imminent or im-
pending danger. In total, 48 professionals (i.e., case managers,
team leaders, super-
visors, therapists, clinical nurse specialists, diagnosticians, and
licensed psycholo-
gists) volunteered for this study. (See Table 4 for sample
demographics).
For Part II of the study, qualifying client participants were
adults who had ex-
pressed suicidal intent (as defined previously) while in
treatment with a mental
health professional in a community mental health system within
the recent past (6
months was again suggested but not required). These clients, to
receive treatment
within the system, have been given a DSM diagnosis and have
been classified by
the state as “severely mentally disabled.” In all, 23 client
volunteers were obtained.
(See Table 5).
Procedure
After providing informed consent and relevant demographic
information, the pri-
mary researcher conducted semistructured interviews with
professional and client
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155
TABLE 4
Demographics for All Professional Study Participantsa
Demographic Category n % Other Stats
Sex female 35 73
male 13 27
Race Caucasian–White 33 69
African-American–Black 12 25
other 3 6
Licensure unlicensed 32 67
licensed (LPC, LSW) 7 15
independently licensed
(LISW, LPCC, CCDCIII, RN) 7 15
licensed psychologist 2 4
Education high school diploma, GED 1 2
Associate’s, 2-year degree 5 10
Bachelor’s degree 26 54
Master’s degree 15 31
postdoctoral education 1 2
Age M = 34 years

Years in field Range: 22–56 years
Mdn = 5 years
Range: .375–25 years
Note. CCDCIII = Certified Chemical Dependency Counselor III,
GED = General Equivalency
Diploma, LPC = Licensed Professional Counselor, LPCC =
Licensed Prefessional Clinical Counselor,
LISW = Licensed Independent Social Worker, LSW = Licensed
Social Worker, RN = Registered
Nurse.
TABLE 5
Demographics for All Client Study Participantsa
Sex female 18 78
male 5 22
other 1 4
Age M = 42 years
range: 18–59 years
aN = 23
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participants, who were later debriefed and paid for
participation. During inter-
views with professionals, the researcher asked them to describe
their experience of
responding to a suicidal client, including some general
information about the client
and the client’s circumstances, as well as information about the
clinician’s re-
sponse style and actions. The researcher explored in depth with
professionals what
response they chose and, more important, in what manner they
responded (i.e.,
what exactly did the professional say to the client, how did the
client respond, how
was the professional feeling during this interaction). In
addition, the researcher in-
vited professionals to discuss their past and present personal
and professional
views or beliefs about suicide as well as any previous personal
or professional ex-
periences with suicide. During client interviews, the researcher
asked clients to
talk about their experience during a time when they were
suicidal, including the
specific circumstances of the event as well as the response they
received when they
shared their intent with their clinician. The researcher also
asked clients to describe

what, in their experience, are the most and least helpful
responses professionals
can offer suicidal clients.
Once all data for each participant had been collected, three
clinical research as-
sistants, blind to the hypotheses and the other relevant data,
reviewed the interview
data. The research assistants used a literature-based description
of the three re-
sponse types (See Tables 1–3) to rate professional interviews
for each of the re-
sponse types professionals employed and client interviews for
each of the response
types clients indicated as helpful. Because it was supposed that
many factors prob-
ably simultaneously affect the responses of professionals in
different ways, it was
not expected that most professionals would exhibit one response
type to the exclu-
sion of the others. Rather, we thought that each professional’s
overall response to a
suicidal client would represent a mixture of the three response
types (“fight,”
“flight,” and “ideal”). As such, the research assistants were
asked to record the
level of each of the response types in each interview on a scale
from 0 (no response
of this type) to 10 (the strongest possible response of this type).
An option of “Can-
not Determine” was also given if rankings could not be made.
The raters discussed
each interview to come to a consensus on the ratings for each
response type
RESULTS

Information obtained from 39 of the 48 professional participants
was used in the
final analysis. (See Table 6 for demographics of this
subsample). The reduction
in usable data was due to poor tape quality for some interviews
and inability of
raters to reach a consensus in some cases. Information obtained
from 20 of the
23 client participants was used in the final analysis. (See Table
7 for demograph-
ics of this subsample). One of the 23 clients who initially
volunteered for the
study chose to discontinue participation before completing the
interview and one
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157
TABLE 6
Demographics for Subset of Professional Study Participants

Used in Data Analysisa
Sex female 27 69
male 12 31
other 2 5
Licensure unlicensed 24 62
licensed (LPC/LSW) 7 18
independently licensed
(LISW/LPCC/CCDCIII/RN) 6 15
licensed psychologist 2 5
Education high school diploma/GED 1 3
Associate’s, 2-year degree 4 10
Bachelor’s degree 20 51
Master’s degree 13 33
postdoctoral education 1 3
Age M = 34 yrs.
Years in field Mdn = 5 years
range: .375–25 years
Note. CCDCIII = Certified Chemical Dependency Counselor III,
GED = General Equivalency
Diploma, LPC = Licensed Professional Counselor, LPCC =
Licensed Prefessional Clinical Counselor,
LISW = Licensed Independent Social Worker, LSW = Licensed
Social Worker, RN = Registered

Nurse.
an = 39.
TABLE 7
Demographics for Subset of Client Study Participants
Used in Data Analysisa
Demographic Category n Percentage Other Stats
Sex female 16 80
male 4 20
other 1 5
Age M = 42 years
an = 20
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other client completed the interview but did not meet the
qualifications for the
study. In addition, one interview was rated but could not be
used, as raters were
unable to come to a consensus based on the information
provided in the inter-
view. When comparing the data in Table 4 to Table 6 and Table
5 to Table 7, one
can see that the demographics of the subsets used for data
analysis do not differ
substantially from those of the total sample from which they
were taken. This
suggests that the subsets of participants, both professional and
client, are repre-
sentative of the original samples.
Part I: Mental Health Professionals
In support of the hypothesis, the responses of mental health
professionals are con-
sistently characterized by features of the “fight” response. In
the majority of inter-
views, 55%, the “fight” response was rated as most
characteristic of professionals’
responses (vs. “ideal,” 28%, and “flight,” 17%). On a scale from
0 (no response of
this type) to 10 (most extreme possible response of this type),
the average “fight”
rating for professionals’ responses was 5.2, the average “flight”
rating was 1.6, and
the average “ideal” rating was 3.9. Overall, professionals were
significantly more
likely to intervene in a “fight-like” manner than they were to
avoid or flee the threat
of suicide (t = 6.03, p < .001). At the same time, professionals

were also marginally
significantly more likely to respond with “fight” than with a
more “ideal,” cli-
ent-friendly style (t = 1.94, p = .06). Fortunately, however,
professionals overall
tended to be more likely to respond to the client in an “ideal”
way than with
“flight” (t = 3.29, p < .01).
Part II: Clients
As with the data from the professionals, three paired sample t
tests were performed
on the client data obtained in the study. In support of the
hypothesis, the results in-
dicate that clients show a clear preference for the ideal response
type. On a scale
from 0 (desires no response of this type) to 10 (most extreme
possible response of
this type), the average “fight” rating for client preferred
response was 3.05, the av-
erage “flight” rating was 1.1, and the average “ideal” rating was
6.8. In fact, the
ideal response was seen as most characteristic of clients’
reported intervention
preferences in 80% of the interviews. In contrast, “fight-like”
responses were pre-
ferred by only 15% of clients, and “flight-type” responses were
preferred by only
5% of clients in the study.
Results of the t tests show significant differences in all of the
pairwise compari-
sons. Clients prefer the “ideal” response more than twice as
much as the “fight” re-
sponse (t = 4.93, p < .001) and more than six times as much as

the “flight” re-
sponse, which they least prefer (t = 8.14, p < .001). In addition,
the results show
that although neither problematic response type is preferred, of
the two problem-
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atic types, clients would rather professionals be overly
protective (“fight”) than
avoid or deny (“flight”) the issue of suicide (t = 4.03, p = .001).
The majority (12 of
20 clients) did not include any flight-like characteristics in their
descriptions of the
response they feel to be most helpful but many reported a
preferred response that
had at least some flavor of all three response types and all were
characterized at the
least as a mixture of the fight and ideal responses.
DISCUSSION

Taken together, the results of the two parts of this study support
our overall hypoth-
esis that a mismatch exists between interventions that suicidal
clients report to be
most helpful and interventions that professionals tend to
provide. Although clients
clearly find the “ideal” response to be most helpful,
professionals generally re-
spond in a manner characteristic of the “fight” response. Thus,
the answer to the
initial research question is: No. The responses that
professionals offer suicidal cli-
ents generally are inconsistent with what clients report to be
most helpful. Al-
though ultimately the same actions may be taken, the “fight-
like” manner in which
professionals are responding is in many ways the opposite of
the “ideal” style that
clients find to be most helpful. This fundamental mismatch
between the desires of
suicidal clients and the actions of their treatment providers has
implications for
practice, research, and training. However, before turning to a
discussion of the
findings and their implications, limitations to the study will be
discussed.
Limitations of the Study
First, it should be noted that all of the participants, clients, and
professionals, came
from a community mental health setting. As this type of
environment is in some
ways systematically different than other mental health systems
(e.g., private or
group practice, and inpatient treatment), the generalizability of

the findings may
be limited to the community mental health setting. For example,
as can be seen in
Table 4, most (66%) of the professionals sampled from the
community mental
health population had a Bachelor’s level education or less, and
most (67%) were
unlicensed. These proportions are consistent with the way many
community men-
tal health systems are structured, as most of the direct service
providers are those
with less training and education, whereas professionals who
have less direct con-
tact with clients tend to be those with more training and
education. However, in
other types of systems professionals with more training and
education may be
found in much higher proportions. This suggests that the results
of this study may
be specifically more reflective of the responses of community
mental health pro-
fessionals, who typically have less training and education, than
generally represen-
tative of all mental health professionals.
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ly
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In fact, a preliminary correlational analysis conducted on the
data obtained in
this study indicates that one’s level of professional training may
play a role in
one’s response to suicidal clients. Here, higher levels of
licensure tend to be as-
sociated with a more “ideal” (rs = .34, p < .05, n = 41) and less
“flighty” (rs = –
.36, p < .05, n = 41) response but are not associated with the
level of “fight” in
one’s response (rs = –.13, ns, n = 41). This suggests that
licensed professionals
(i.e., those with more education and training), who are perhaps
more readily
found in other mental health settings, tend to respond in a more
“ideal” manner.
A similar study including mental health professionals from
other settings (in-
cluding other geographical locations) would be helpful in
further understanding
the applicability of this study’s findings.
Second, the study was methodologically limited due to the
possibility for some
demand characteristics with the use of the semistructured
interview design. As
mentioned earlier, the crisis intervention model (typically
interpreted using the
“fight-like” cardiologist metaphor) is currently believed to be
the best option for
the treatment of suicidal individuals and is the model from

which professionals are
taught and evaluated. Given the predominance of this model,
there is a chance that
many clinicians reported their actions as being congruent with
the party line (i.e.,
the “fight” response) because they thought this is what the
interviewer wanted to
hear or because they felt motivated to respond in what they
thought would be the
most acceptable and desirable way. Although there is the
possibility that the de-
mand characteristics inherent in the design may have distorted
the findings, the
flexibility of the semistructured interview format allowed for
more in depth and
specific questioning. This enabled the research assistants rating
the interviews to
get a clearer picture of events as well as a sense of when
participants may have
been coloring their responses in a certain way.
Therapeutic Implications of the Mismatch
What are the potential effects of this mismatch on the client, the
clinician, and the
relationship? This is a valuable question to ask when
considering the importance
of this discrepancy in terms of suggestions for future practice.
Some may wish to
dismiss the finding as trivial, as many believe that it is the
clinician, not the client,
who knows best. In this view, it is the clinician’s view of
treatment that is most ap-
propriate and ultimately most effective. Further, as is implicit
in this view, if the
treatment is not effective, the outcome has more to do with the

problematic client
than with the intervention offered by the clinician.
However, professionals operating from theories of person and
psychotherapy
that emphasize the importance of the relationship, therefore
valuing the positions
of both parties in the relationship, may find that these results
warrant further con-
sideration. From this type of theoretical perspective, any
intervention a clinician
makes is not done in isolation. In other words, interventions are
not things that are
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done by clinicians to passive, helpless clients. Rather, clients
play an active role in
the process by having the power to either validate or invalidate
any intervention of-
fered by a clinician (Leitner & Guthrie, 1993). We believe the
statement made by

the collective client voice brought forth in this study represents
an invalidation of
the style of suicide intervention that is most predominantly
used. In this way, cli-
ents are not only making a statement about the pain and injury
they have felt as a
result of such interventions but they are also communicating
their sense of discon-
nection in their relationships with the clinicians making these
interventions.
Rather than operating from a place of optimal therapeutic
distance from the cli-
ent, in which the clinician is able to balance the needs of the
client and the thera-
pist, the disconnection in the relationship represents the stance
of therapeutic
strangers (Leitner, 1995). When operating from this stance,
clinicians are too dis-
tant from the client to experience the client’s needs and desires,
perhaps as a result
of being preoccupied with their own concerns or fears about the
situation, resulting
in interventions that are experienced as inappropriate, mistimed,
and ultimately
unhelpful, if not hurtful, to the client. Rather than serving to
strengthen the rela-
tionship between clinician and client, leading to more
potentially helpful interven-
tions, this stance weakens the alliance, making further effective
interventions more
difficult. As the relationship is weakened, clients, as they often
reported in this
study, are left feeling hurt and fundamentally misunderstood.
Although this therapeutic distance may ultimately be a

protective move for the
therapist, it has the opposite effect for the client, leaving the
client feeling more
vulnerable and unprotected in the relationship. As they
reported, this effect is espe-
cially disconcerting for suicidal clients who are already in a
very difficult place.
The therapeutic relationship is central in many schools of
therapy no matter what
the presenting issue but given the life and death nature of the
particular case of the
suicidal client, the relationship is perhaps even more key, as it
may be one of the
few things helping the client to remain connected to the world
and engaged in the
struggle to live. Due to this possibility, evidence of a potential
disruption in the
connection between the suicidal client and the clinician is
concerning. As such, we
believe the results of this study alert the professional
community to a disconnec-
tion that deserves further exploration.
Areas for Future Research
Further research in this area would be one way to continue to
explore the issues
raised by this study. As our previous discussion about the study
limitations sug-
gests, one line of further research would include replications of
this study sam-
pling clients and professionals from different mental health
settings as well as
from different parts of the country. Other future research may
involve a change
in study design.

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ub
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.
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hi
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y
fo
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p

er
so
na
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se
o
f t
he
in
di
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se
r a
nd
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to
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ss
em
in
at
ed
b
ro
ad
ly
.
For example, the finding that clinicians’ interventions do not
match with what
clients find to be most helpful was based on a comparison of
results obtained from
the two separate parts of this study. The comparison involved
clinicians’ reports of
their own interventions and clients’ reports about what
interventions they find to be
most helpful. However, in addition to discussing the type of
intervention they de-
sired from a professional when they were feeling suicidal,
clients also provided in-
formation about the interventions they actually received. As
such, a future study
could more systematically investigate the issue of disconnection
from the client’s
perspective by comparing what clients report about both the
interventions they
want and the responses they received.

In addition, as it seems to us that an important part of exploring
suicide inter-
vention is understanding clients’ perceptions of those
interventions, it may be fruit-
ful to compare professionals’ views about the responses they are
giving with cli-
ent’s views about those same responses. Anecdotally, the
primary researcher and
research assistants can agree that in general, the interventions
that clients reported
actually receiving matched in large part the style of
interventions that mental
health professional reported giving. However, this issue was not
more formally in-
vestigated by this study. This could be accomplished by further
analysis of this
data (or in study replications) by asking raters to also rate the
client interviews for
the levels of each of the response styles they reported actually
receiving and then
comparing those ratings with the ratings for professionals’
responses. Alterna-
tively, it may be more useful to pair participants and compare
each client’s experi-
ence of the intervention he or she received with that particular
clinician’s experi-
ence of the intervention he or she offered. This may provide
more helpful
information about the connections and disconnections in the
therapeutic relation-
ship around the issue of suicide intervention.
Implications for Training
In addition to suggesting areas for future research, training is

another area in which
the findings of this study may be informative. Many
professionals in this study,
45%, reported having one or fewer courses (10 or less clock hr)
of training in sui-
cide prevention and/or intervention. Several professionals
(16%) reported having
no training in this area at all. Some of the professionals
interviewed had been in the
field for less than a year, and as such may not have had the
opportunity for in-ser-
vice training to that point. However, even some of those who
had been in the field
for such a short time, less than 1 year, reported having already
experienced a client
(or more than one client) attempting suicide. The fact that
clinicians enter the job
immediately faced with very difficult client issues suggests that
clinicians need to
be prepared to deal with these issues before they begin the
work. In our view, sui-
cide prevention and intervention training should occur before
clinicians are faced
with these issues, not as a consequence of having experienced a
client suicide or at-
T
hi
s
do
cu
m

ly
.
tempt. While certainly there is value in on-the-job training in
many areas, this is an
area where it would be more beneficial and less risky for all to
have had exposure
to the issues and education prior to being placed in a position of
having to make
quick, difficult, life and death decisions.
This, of course, does not speak to the other concern, which is
the amount and
content of the training. Even if the timing is more appropriate,
if the amount or
content are not sufficient, clinicians may still be ill prepared to
handle suicidal cri-
ses. The results of this study suggest that the content of training
on suicide inter-
vention may be particularly important. As stated earlier, the
crisis intervention
model most frequently advocated in the literature offers detailed
prescriptions for
action but little on the manner in which the actions should be
taken to be most help-
ful to the client. As illustrated by what clients report to be most
helpful, what is
more important to clients than the actions taken by their
treatment providers in re-
sponse their suicidality is the manner in which the interventions
are given. What
clients report to be most helpful is the respectful, patient, and
inviting stance sug-

gested in the “ideal” response type. Based on this, it seems that
the professional
who is able to implement the practices of the crisis intervention
model within this
“ideal” mode of response will be more likely to be helpful to
the suicidal client
than one who takes the steps outlined by the model in a more
“fighty” manner. As
such, if the crisis intervention model will continue to be used as
it has been for
more than 45 years, training in suicide intervention should
emphasize not only the
steps and actions involved in the model but also the manner in
which the clinician
implements the model.
CONCLUSION
The suicide prevention movement, now led by the Surgeon
General as well as
other national and local suicide prevention organizations, is
focused mainly on
understanding the risk factors involved for suicide and
improving the profes-
sional assessment of those risks as a means of suicide
prevention (U.S. Depart-
ment of Health and Human Services, 2001; U.S. Public Health
Service, 1999).
However, the results of this study serve as a reminder that
suicide intervention is
a very complex venture that involves much more than assessing
risk. Further,
from our view, the client’s voice, as expressed in this study,
reminds us that sui-
cide interventions are not something that professionals do to
passive, helpless

clients. Interventions are done with clients, which means that
clients play an ac-
tive role in determining the effectiveness of the intervention.
Clients in this study
reported that, as opposed to the response most typical of
community mental
health professionals, the “fight” response, they clearly preferred
the “ideal” style
in response to their suicidal presentation. This is fruitful
information for those
T
hi
s
do
cu
m
en
t i
s
co
py
ri
gh
te
d
by

n
ot
to
b
e
di
ss
em
in
at
ed
b
ro
ad
ly
.
interested in improving the efficacy of suicide intervention and
reducing the
alarming rates of suicide in this country.
ACKNOWLEDGMENTS
The authors would like to thank Lori Koelsch, Valerie Loeffler,
and Amberly
Panepinto for their work on this project. We are also grateful to

Art Miller and Carl
Paternite for their contributions to the thesis project on which
this article is based.
We would also like to express our deep appreciation to all of
the study participants
for sharing their time and their stories with us. Participant
names and details have
been falsified to respect the privacy of participants.
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AUTHOR NOTE
Jill C. Thomas received her MA in Clinical Psychology from
Miami University in
2003. She is currently completing her PhD at Miami University.
Her research in-
terests included eating disorders, embodiment, action research,
and other creative
approaches to research and therapy.

Larry M. Leitner received his PhD in Clincal Psychology from
The University
of Nebraska in 1979. He is Professor of Psychology at Miami
University. His re-
search interests involve the application of Personal Construct
Psychology to
psychotherapy, psychopathology, and personal perceptions.
T
hi
s
do
cu
m
en
t i
s
co
py
ri
gh
te
d
by
th

e
A
m
er
ic
an
P
sy
ch
ol
og
ic
al
A
ss
oc
ia
tio
n
or
o
ne
o
f i

ts
a
lli
ed
p
ub
lis
he
rs
.
T
hi
s
ar
tic
le
is
in
te
nd
ed
s
ol
el

y
fo
r t
he
p
er
so
na
l u
se
o
f t
he
in
di
vi
du
al
u
se
r a
nd
is
n

ot
to
b
e
di
ss
em
in
at
ed
b
ro
ad
ly
.
Field Action Report
Project CREST: A New Model for Mental Health Intervention
After a Community Disaster
Through Project CREST, many have receivedpostdisaster
support who otherwise
would not have sought mental health care.
Carol S. orth. MD. MPE. and BartyA. Hong. PhD

Wheti the Mississippi Riverand Its tnhutanes no(»ded St.
Louis, Mo. m the spring and sum-
mer of 1993. 25(1 menial health
professionals stood ready to help
the thousands whose Iies the
floods would aJTcct It turned out.
however, that most ofthe flixKi vic-
tims sought instead the support of
community leaders they kneu and
trusted.
To meet the need for commu-
nity-based disaster suppon. disaster
inter-ention training that had been
offered to mental health profession-
als dunng the summer of 1993 was
adapted to train community re-
source personnel, ranging from
clergy to police. The result was
Project CREST (Community Re-
sources for Education. Support,
and Training).
CREST"s purpose is to maxi-
mize mental health resources
within communities by ciiuipping
community leaders to proide
initial crisis intervention and
emotional relief services after
community-wide disaster> ,̂ when
professional resources arc uften
limited. CREST has also been
adapted to other types of crisis
intervention-

TIiroLigh Project CREST many
people have received crisis inter-
vention who othenvise would not
have sought mental health c:ire.
The CREST training team mcluded
psychologists, psychiatry residents, psychi-
atric nurses and nurse specialists, clinical
social workers, marital and l.imily coun-
selors. actiit therapists, and doctoral can-
didates in psychology and social work Most
were recruited troni Linicrsit incdicjl cen-
ter employees or adanced docttiral students
in social wurk or clinical pschology Fund-
ing Ircni the James S NKDonnell Inunda-
tion supported ihe authors, first, m develop-
ing ihe (.'RtSl curneulum and training the
trainers and, later, in pnn idmg consultation
The curriculum deelopinent and training
oceupied 2 months in late 1443 and early
19 -̂4. the consultation was ongoing through
the summer of 19iJ4 The authors^—a psy-
ehiatnst who had clinical expertise with dis-
aster populations and a pscht>logist cxpen-
enced in training health protessionals and
communit olunteers—also led the 52-
member t RhSl training team.
CRhST partieipants wore recruited
through team outreach to communit .igen-
cies (hat vere known for their tlttod relief
actiMties The outreach was accomplished
via telephone, letters describing the pro-
gram, and ••vord tif mouth" from preious
trainees Participating agencies ineluded po-

lice departments and academies, sehool dis-
tricts, churches, the Red C ross. women's
self-help centers, neighborhood health cen-
Basics of Crisis Intervention
G u i d i n g p r i n c i p l e s ;>.i ; . , . . . . ,
4 Immediate support
4 Stabilize
4 Not therapy
4 Most are not psychiatrically ill—don't "fix"
4 Distress is universal, and we can help with that
4 Refer people you are worried about
Slide used In Project CREST training program. The training
covers the basics of
responding to community disasters, providing social support to
flood victims,
and identifying and referring people who may need professional
help.
July 2000. Vol. 90. No. 7 Amencan Journal of Public Health
1057
Field .ctinn Report
Key Findings

• During disasters, victims seek support from trusted members
oftheir OWTI com-
munities rather than mental health professionals
' Funher training of these community resource persons can
expand the availabil-
ity of mental health sen ices for individuals after community
disasters.
• An educationai curriculum initially designed lor traininc
mental health profes-
sionals was successful!) adapted tor Project CREST to tram
community leaders.
• The same cumcutum proved useful in training elderly
volunteers to support their
peers in home and heallh care settings
Next Steps
Because o f t h e v u l n e r a b i l t y of St.
Louis to Hooding and to earthquakes (the
area rests on the country's largest earth-
quake fault». CREST will probably see fur-
ther action. Other problems that seem at
times to loom larger than disaster—issues
sueh as school and community violence,
the stresses and strains of mental illness,
and coping Mth the AIDS epidemic—will
also likely tap into the CREST model. More
CREST training will be offered whenever
the need occurs. ^
tors, shelters and emergency serviees for
youth and adults. Catholic family senices.
university student centers, assisted living

agencies, state mental health agenetes.
AIDS groups, counseling centers, and other
community organizations
A half-time projeet director contacted
the communitv groups, handled the logis-
tics ofthe training, and served as one ofthe
trainers. To contain costs. Project C REST
paid its trainers an honorarium (SIUU) and
reimbursed them for mileage
The mental health professionals trained
communitv participants in supportive listen-
ing, disaster coping, and triage skills during
a 3-hour workshop ihat covered a broad
spectrum of issues basic to mental health
crisis intervention. Their presentation in-
cluded slides, overhead transparencies, tlip
charts, and wntten handouts.
The CREST presentation was repeated
nearK 300 times for more than 2S(H) trainees
at 90 different sites. The prograni v^as so
vvell reeeived that a 3-hour sequel to the t~irst
presentation vvas held at most sites This sec-
ond seminar otlered site-responsive topics of
choice, sueh as problem-solving and com-
munication skills In addition, a telephone
consultatu>n line with project stafTwas made
available to trainees and other eoinmunitv
individuals; this sometimes led to triage that
resulted in utfice appointments lor tliKxl v ic-
tims with one of Ihe project leaders (B.H.).
These etforts continued throughout the
summer of 1993 as the Mississippi River

mounted 5 distinct flood crests that repeat-
edlv threatened communities and generated
new and continuing needs for menial health
relief The tollowing spring, limited flood-
ing recurred in L-onimunities along the Mis-
sissippi River near St. Louis. The CREST
program was once again called into action.
During this short-lived crisis, the CREST
professionals were the only mental health
workers serving many of these sites.
Other Interventions
Because of CREST's suceess in help-
ing Rtims ofthe W93 and 1944 floods,
several groups requested additional training
in subject areas other than flooding that
were felt to be equal or even more pressing
cnses for them, sueh as school v lolence and
domestic abuse. The CREST workshop ma-
tenals were readilv modified to the alterna-
tive subjects, and these presentations were
also well reeeived.
The suceess of C REST s model for de-
livery of emotional eare led to its use in the
Older Adult Serviee and Information Sys-
tem (OASISt Institute's "Person to Person"
Program in St. Louis. In this pri>gram,
which began m 1996. elderly volunteers
pro ided conversation, communication, and
support lor their peers in home and health
care settings. The CREST training materi-
als and mode! served as the basis for the
program.

The authors are vKith the [>epartment of Psychiatry,
Washington University School of Medicine, St.
Louis. Mo
Requests for repnnts should be sent to Carol S.
North. MD. MPE. Departmenl of Psychiatry. Wash-
ington l_'niersiiy School ot Medicine. 4940 Chil-
dren's Place. St- Louis. MO 63110 (e-mail: [email protected]
psychiatrv'uusti edu)
This report was accepted February 29. 2000.
Contributors
C S North dnd B A Hong jointly designed the proj-
eci. implemented the work, and wrote this report.
Acknowledgments
This work was supponed by a grant trom the James
S. McDonnell Foundation of St. Louis.
Resources
1. Weaver JD Disa.'iters Mental Health Interven-
tions. Sarasota. Fla Professional Resource
Press; 1W5
2 Smith HM. North CS. Post-traumatic stress
disorder in natural disasters and technological
accidents In Wilson .1. Raphael B. eds- Inter-
national Handbook oj Traumatic Stress Syn-
drtmes- New York. NY: Plenum Press; 1993:
52-95.
3. North CS. Nixon SJ. Shariat S. et al. Psychiatric
dlsorde^^ among suriors ofthe Oklahoma

City bombing. J.AMA. 1^^.282755-762.
105H American Journal of Public Health
July 2000, Vol. 90, No. 7
KATRINA
FIVE YEARS AFTER
PROGRESS REPORT ON RECOVERY, REBUILDING AND
RENEWAL OFFICE OF GOVERNOR HALEY BARBOUR
AUGUST 29, 2010
1FIVE YEARS AFTER KATRINA
TABLE OF CONTENTS
Message from Governor Haley Barbour 2
Introduction 4
August 29, 2005 6
Immediate Response and Restoration of Critical Services 7
Federal Assistance 12
Nonprofits and Historic Preservation 17

Housing 25
Public Infrastructure 41
Economy 51
Education 58
Health and Human Services 66
Environmental and Marine Restoration 70
Disaster Preparedness and Hazard Mitigation 76
Governor’s Commission—Five Years Later 81
Conclusion 87
Appendix 88
KATRINA
FIVE YEARS AFTER
PROGRESS REPORT ON RECOVERY, REBUILDING AND
RENEWAL
Cover photograph of the Biloxi Lighthouse by Brian Hilburn,
courtesy of the Mississippi Emergency Management Agency.
2FIVE YEARS AFTER KATRINA 3FIVE YEARS AFTER
KATRINA
Friends,

Five years ago, Hurricane Katrina wiped away what
we knew as the Mississippi Gulf Coast. Our southern
counties witnessed unprecedented destruction. Many
homes were erased, leaving only a foundation as a
marker of what used to be. Other homes and businesses
were reduced to rubble by blasts of wind and a merciless
storm surge. Ultimately, more than 60,000 homes were
destroyed and more than 100,000 of our people were
without homes. Hurricane force winds extended more
than 200 miles inland. As I’ve said many times, it looked
like the hand of God came down and just wiped away
everything.
The one thing Katrina didn’t destroy was the indomitable
Mississippi spirit. Moments after the storm passed,
Mississippians responded with unparalleled courage and
compassion, often leaving their own shattered homes
to check on a friend or neighbor. The howl of the storm
gave way to the buzz of chainsaws, as residents cleared
driveways and roads. The resilient, hard-working people
of Mississippi took a tremendous body blow during the
worst natural disaster in our nation’s history, and then we got
up, hitched up our britches and
went to work.
Believe me when I tell you that people the world over took
notice, and they were impressed. In
the months and years after Katrina, I’ve had business and
political leaders across the country
tell me, “Haley, you’ve got to be proud of your people.” There’s
no doubt the recovery from
Katrina along Mississippi’s Gulf Coast has cast our state in a
new light.
No, we didn’t do it alone. There were waves of volunteers from

all over the country who showed
up to help any way they could, whether they were driving nails
into homes and businesses or
driving trucks with food and supplies; and we welcomed them
with great appreciation. The
federal government allocated an extraordinary amount of money
– more than $24 billion – to
our recovery effort, and they gave us unprecedented discretion
in how to spend it. We have
spent that money wisely, not just to restore what had been, but
to prepare for the future. We
are not simply rebuilding, but we are building back bigger and
better than ever.
An unprecedented disaster demands an unprecedented response,
and we knew all along that
we would have to break new ground along the way. Where we
found problems, we developed
creative solutions, many of which will be indispensable in the
future. Our state is now much
more prepared for disasters, and lessons learned during Katrina
have been applied in more
recent crises.
Similarly, our congressional delegation and the federal
government stepped up to the plate
effectively and generously. Senator Thad Cochran played a vital
role, via his leadership on the
Senate Appropriations Committee. Senator Roger Wicker’s
assistance in getting support for
our State has been crucial as was that of Senator Trent Lott
before him. Our House delegation
put aside party politics and put Mississippians first.
Representative Gene Taylor’s expertise
in maritime and naval issues has, and continues to be, an
invaluable asset to Mississippi.

Representative Bennie Thompson was essential to our effort to
get federal funding for the
survivable interoperable communications system. Both the Bush
and Obama administrations
rose to the call for aid in the aftermath of the worst natural
disaster in American history. To all
of them, I offer my sincere appreciation on behalf of
Mississippi.
We’ve matched monetary aid with hard work, endurance and
perseverance. We’ve replaced
rubble with commerce. We’ve torn away the blue tarps and
replaced them with new roofs.
From homes and schools to places to play and places to pray,
we’re making Mississippi’s Gulf
Coast more than it was; we’re making it what it can be, what it
should be.
Mississippi has been the beneficiary of almost unfathomable
generosity, and we are truly
thankful.
Marsha and I are extremely proud of the progress and
accomplishments the Gulf Coast has
made in coming back from Katrina. We wish God’s grace and
blessings on you and your family
as we continue to build upon Mississippi’s spirit and character.
Sincerely,
Haley Barbour
KATRINA

INTRODUCTION
Five years ago, Hurricane Katrina unleashed
a fury of destruction on South Mississippi
and the Gulf Coast. The damage caused
was literally unprecedented: Hundreds of
thousands of lives were thrown into disarray;
the coastline was practically wiped away.
Entire landscapes of cities and counties were
changed forever.
Even while piles of rubble covered the
landscape, Governor Haley Barbour made
a promise to all Mississippians: the Coast,
drawing on the resiliency and strength of its
people, would not only be rebuilt, but would
come back bigger and better than ever.
The massive recovery effort coordinated by
the Governor has embodied this Mississippi
spirit. At every turn, Mississippi has rebuilt
and restored that which was lost in a way
that was better than before and rethought
processes and programs to better serve the
affected region.
In many instances, this has meant innovative,
first-of-its-kind programs born from creative
collaborative processes:
• The Governor’s Commission on Recovery,
Rebuilding and Renewal combined
ideas from local residents and leaders
with expert knowledge from around

the country to develop a recovery
framework.
• Mississippi rethought disaster housing
and designed the Mississippi Cottage
as a better alternative to FEMA travel
trailers; indeed, these cottages have
proven their utility by providing
temporary housing during subsequent
disasters in the state.
• An enormous disaster housing grant
program, the Homeowner Assistance
Program, was created and benefited
nearly 30,000 households.
• A regional water and wastewater system
will provide more efficient services to
residents who move inland to be safer
from future hurricanes.
• A statewide interoperable
communications system is in operation
to link emergency responders in times of
crisis. Like the cottages, this system has
already been utilized during the recent
oil spill crisis to enhance communications
between state, local, and federal officials,
as well as crisis responders.
Notable successes achieved in the five years
since Katrina draw on the combined efforts
from all governmental sectors, private
industry, and nonprofit assistance. Examples
include:

• Housing has been restored to meet the
needs of coastal residents. Nowhere
is this more evident than the limited
number of FEMA temporary housing
units; from the tens of thousands of
units that housed more than 100,000
Mississippians, fewer than 100 units
remain on the Coast.
• The state has restored its public
infrastructure using $3 billion obligated
by the Federal Emergency Management
Agency (FEMA), strategically aligning
these dollars with other funding streams
where necessary to meet its vision of
rebuilding bigger and better.
• State employment and job training
efforts have resulted in the Coast’s
having some of Mississippi’s lowest
unemployment rates despite the
economic recession, and has bolstered
the workforce to fuel coastal businesses.
• Every Mississippi school except one re-
opened within six weeks after Katrina,
and students did not let the storm keep
them from achieving high performance
results.
• Medical and social services infrastructure
were restored, allowing impacted
families to quickly get back on their feet.
• Important restoration projects for the

coastal environment, beaches, and forest
lands are underway.
These successes have helped restore what
was lost in Katrina in a manner that was
better than before; however, Mississippi’s
work is not
yet complete.
Several important
initiatives
are currently
underway that will
be the foundation
of the Coast’s
long-term vitality.
Jobs are the
most crucial
piece to the
Coast’s long-term
prosperity, and
the restoration
program at the Port of Gulfport will be the
centerpiece of the Governor’s job creation
efforts. The Port of Gulfport restoration is the
biggest economic development project in
the state’s history, and will be an economic
engine, not just for the Coast, but the entire
state.
The restoration of Mississippi’s barrier
islands will protect the coastline from future
hurricanes, while also nurturing natural
habitats. Unfortunately, Congress has not
yet funded the full coastal restoration plan

created after Katrina. The barrier islands are
an important part of that plan, but other
measures are needed to revitalize coastal
marshlands, forests and beaches.
KATRINA
Although Mississippians demonstrated great
resiliency in the face of Hurricane Katrina –
the worst natural disaster in American history
– the state’s success would not be possible
without the outpouring of support received
from our sister states, corporations and the
federal government. A great debt is owed to
those nonprofits and volunteers from around
the country and world who have donated
countless hours and monies to restore lives
after Katrina.
After Katrina, the state has emerged with a
better preparedness for the risk of natural
disasters and has implemented every
recovery program with a mindfulness of
the need to rebuild stronger and smarter.
The state has significantly upgraded its
response capabilities through interoperable
communications and an improved Mississippi
Emergency Management Agency.
While challenges and work remain,
Mississippi and the Coast have achieved a
remarkable comeback. From the period of
utter obliteration, this region has seized

upon the Governor’s vision of rebuilding
bigger and better than ever, which is
demonstrated across the post-Katrina
coastline, ongoing recovery efforts, and the
continued resiliency and character of the
citizens of the Gulf Coast.
AUGUST 29, 2005
Hurricane Katrina began as a tropical
depression over the Bahamas on August
23, 2005. The depression continued to gain
intensity, becoming tropical storm Katrina on
August 24 and officially obtaining hurricane
status on August 25 – a mere two hours
before its center hit Florida’s east coast as
a Category 1 hurricane. Although Katrina
was reduced to a tropical storm as it quickly
moved across southern Florida, it again
became a hurricane when it reached the Gulf
of Mexico.
The storm strengthened to a Category 3
hurricane on August 27 after its inner-wall
deteriorated and a new, stronger outer wall
of the storm formed, raising wind speeds
to approximately 115 miles per hour and
doubling the size of the hurricane’s expanse
to 140 miles from its center. While still in
the Gulf on August 28, Hurricane Katrina
intensified from a Category 3 to a Category
5 hurricane with winds reaching over 170
miles per hour and the area of the hurricane’s
path increasing to a 200-mile radius. The
hurricane’s most destructive winds reached
nearly 30 miles from the storm’s center—

three times the radius of Hurricane Camille’s
maximum winds in 1969.
As a Category 3 hurricane with 120 mph
winds, Katrina arrived at the Louisiana and
Mississippi borders around 9:45 a.m. on
August 29. Katrina’s intensity as it hit the
Mississippi Coast caused the hurricane to
be nearly as strong as it was at its most
powerful and destructive Category 5 stage.
The Mississippi coastline’s low elevation and
shallow waters rendered the area especially
susceptible to destruction from storm surges.
In the case of Katrina, the storm surge topped
30 feet in many places and obliterated 80
miles of the coastline.
Katrina retained its hurricane classification
until well past Meridian, more than 150
miles north of the coast, where it weakened
to a tropical storm around 7:00 p.m. The
storm became a tropical depression on
August 30 near the Tennessee Valley and
dissipated on August 31 over the eastern
Great Lakes.
Because Katrina was literally unprecedented
in strength and retained its power far
inland, nearly all of the state and its citizens
experienced severe effects from its wrath.
Hurricane Katrina took the lives of more
than 230 Mississippians and left
unprecedented devastation in its wake.
Throughout Mississippi, hundreds of
thousands of housing units were damaged

and 80 percent of the state’s citizens
lost electricity.
IMMEDIATE RESPONSE AND
RESTORATION OF CRITICAL
SERVICES
Mississippi’s hurricane preparedness set the
stage for the state’s post-Katrina recovery,
saving lives and serving the immediate
needs of those affected by the storm.
These measures also laid the foundation
for a faster and more successful long-term
recovery after the hurricane. Actions taken
by the Mississippi Emergency Management
Agency (MEMA) in concert with other state
and federal agencies allowed for the safe
evacuation of coastal residents and enabled
their speedy return after the storm so that
they could participate in the rebuilding of
their communities.
Mississippi began emergency preparations
nearly a week before Katrina came ashore,
including the following:
• August 23, 2005 - MEMA began
publishing daily situation reports,
detailing important information on the
hurricane and response efforts planned
and undertaken.
• August 25 - MEMA conducted an
executive planning meeting in
preparation for Katrina.

• August 26 - Governor Barbour signed
a State of Emergency Order and an
Executive Order authorizing the use of
KATRINA
National Guard assets. A briefing was
conducted for all state agencies and
FEMA liaisons. The State Emergency
Operations Center (EOC) was activated
and unified command was established.
MEMA liaisons were deployed to the
six coastal counties and National Guard
liaisons were deployed to the three
coastal counties. To smooth the flow of
evacuations, Mississippi and Louisiana
began contra-flow of Interstates 55 and
59. A MEMA representative was sent to
the Louisiana EOC to help coordinate
evacuations.
• August 28 - The State Emergency
Response Team was deployed to Camp
Shelby, which is approximately 60 miles
from the Gulf Coast, so that it could ride
out the storm safely and respond quickly
after the storm’s passing. More National
Guard troops were sent to Camp Shelby
in preparation for distribution of food,
water and ice to disaster victims.
On August 29, Hurricane Katrina came
ashore as a Category 3 hurricane. Even

before the storm had dissipated, crews from
the Mississippi Department of Transportation
were clearing immense amounts of debris
from the state’s roadways. As a result of
the immediacy of the responders, all roads
that were structurally safe were opened to
emergency crews within six hours of
Katrina’s landfall.
Massive search and response efforts began
without delay. Volunteers at the MEMA EOC
staffed a missing persons hotline that took
more than 11,000 calls from 40 countries
in three days. Teams from state agencies
as well as from Mississippi State University,
the University of Mississippi and Delta State
University converted the missing persons
addresses into coordinates on GIS maps for
use by state and national search and rescue
teams. These teams performed more than
5,000 rescues in Mississippi after the storm.
The Mississippi National Guard began
handing out food, water, and ice at
designated distribution points in every
county. Because the federal pipeline could
not deliver the quantity of supplies needed in
the wake of this unprecedented storm, MEMA
consistently received only 10 to 20 percent
of the daily requested amount. Not until
September 9, 12 days after landfall, did the
supply of these valuable commodities meet
the daily demand.
Mississippi volunteer agencies coordinated
much of the initial relief, but an outpouring
of help came from around the country. The

incredible volunteer force that responded to
the needs of the Gulf Coast helped to pave
the way in the recovery effort.
To match incoming donations with existing
needs, the Mississippi Commission for
Volunteer Services (MCVS) operated a
donations hotline that was staffed by
AmeriCorps team members. The Mississippi
Department of Finance and Administration,
MEMA, and MCVS managed a donations
warehouse that processed all donated goods
coming into the state. Almost 10,000 pallets
of goods were distributed.
Through the Emergency Management
Assistance Compact and the Statewide
Mutual Aid Compact, more than 25,000
people from 46 states and Puerto Rico
assisted Mississippi during the recovery
process. Several states provided direct
assistance to Mississippi, in some cases
dispatching disaster medical assistance teams
or transporting supplies and commodities
straight to response agencies.
The State’s Volunteer Agencies Active in
a Disaster organization coordinated with
agencies such as the Red Cross and Salvation
Army and worked with the Mississippi
Department of Human Services to ensure
that food was available following the
storm. Faith-based organizations played
a tremendous role in recovery efforts,
particularly in feeding hurricane victims

through shelters, where some evacuees
resided until October 2005.
FEMA began taking disaster assistance
applications immediately after the storm,
setting up mobile application centers in
addition to its normal call center operations.
Nearly 520,000 Mississippi families registered
for federal assistance with more than $1.3
billion given to those residents through the
FEMA Individual Assistance program. Those
funds were used to cover disaster expenses,
such as home repair and replacement,
personal property loss, transportation
expenses, and medical and dental expenses.
Because FEMA had travel trailers in stock and
had pre-existing contracts with companies,
temporary housing was organized in record
time. At the height of this program, more
than 500 travel trailers were being set up
each day. In addition to travel trailers, FEMA
satisfied temporary housing needs by
providing rental assistance for vacant rental
properties, paying for stays in hotels and
motels, and utilizing military facilities and
cruise ships.
THE GOVERNOR’S COMMISSION ON
RECOVERY, REBUILDING AND RENEWAL
Seven days after Katrina’s landfall, Governor
Barbour established the Governor’s
Commission on Recovery, Rebuilding and
Renewal (the Commission) and tabbed

Mississippian and former Netscape CEO Jim
Barksdale as its chairman.
The Governor’s directive to the Commission
was threefold: solicit the best ideas for
KATRINA
recovery, rebuilding and renewal from both
public and private sectors; develop a broad
vision for a better Gulf Coast and southern
Mississippi; and involve local citizens and
elected officials in the process of developing
and endorsing these ideas. Specifically,
the Commission was asked to provide
local leaders with ideas and tools to help
them envision what their region could look
like 5, 10, 20, or 30 years from now and to
recommend strategies and tools for achieving
these goals.
The Commission solicited input not only
from experts and industry-leaders in
housing, planning, and other areas, but most
importantly from the citizens of the affected
counties. Issue committees, comprised of
local stakeholders from both the public
and private sector, were formed to evaluate
challenges and identify opportunities within
specific sectors such as infrastructure, finance,
agriculture, tourism, education, health and
human services, and governmental and
nongovernmental organizations. In addition,

over 50 town hall meetings across 33 counties
were held to receive ideas and opinions on
the long-term recovery and renewal of South
Mississippi. Their input was recorded by
county and regional committees.
The committee meetings and forums
produced many valuable conclusions.
The Commission stressed that while the
process of identifying problems and
recommending solutions is important,
implementation and accountability must also
be addressed, especially in light of the failure
to institute many of the recommendations
after Hurricane Camille. Secondly, the
Commission was also guided by the belief
that local governments and citizens should
control their own destiny in rebuilding their
communities. The Commission believed
communities should have the ability to
explore many different options for rebuilding
their affected area and should accept
responsibility for key decisions.
In October 2005, the Commission, in
partnership with the Congress for New
Urbanism, held a six-day large design
charrette, the “Mississippi Renewal Forum.”
The forum is believed to be one of the
biggest charrettes ever held, as more than
200 professionals from Mississippi and around
the world worked to develop plans for more
sustainable living patterns at all income
levels. Architect and planning teams were
formed and assigned to different cities or

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