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The Stress Continuum Model
Leadership sets the stage in support of building lives worth living, community connections, and the acceptability of seeking support during difficult times. Day to day unit activities that support quality of life, builds resilience, and reduces risky behaviors, ultimately saves lives.
Navy commands and installations have designated Suicide Prevention Coordinators who can assist leaders in ensuring training and Crisis Response Plans are in place and that information about local resources is readily available for all hands. Your local Fleet and Family Service Center, Chaplain, or Medical Treatment Facility can help you match the great variety of available family, educational, and support resources with the needs of your Sailors. Early intervention and self referral for support greatly improves long term outcomes of health, family, performance, and career as compared to delaying help until after damage occurs in these areas.
The following factors do not mean a person will be suicidal but do increase the risk:
Our Sailors lost to suicide often had a number of life stressors and were in a time of transition and/or a drop in their normal social support. Many also had temporary factors that impaired judgment (alcohol, anger, sleep deficit).
People who attempt or die by suicide may face problems they feel cannot be resolved. Normally, there are alternatives to these problems, but someone who is suicidal is not thinking clearly and often cannot see other possible positive solutions.
Sailors or Marines who are at an increased risk for suicide present a unique challenge for leaders. Effective suicide prevention requires everyone in the command to be alert to the risk factors and warning signs for suicide, know how to respond, and be ready to take action. Any individual who reports suicidal thoughts or behaviors must always be taken seriously and treated with respect.
It is also important to proactively ask about possible thoughts of suicide when command members are dealing with significant life difficulties. Don't assume that merely because someone has not told you they are feeling suicidal, that they are safe. Be especially vigilant with individuals facing multiple stressors.
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Distress in some Sailors can lead to unhealthy behaviors to include withdrawal from social support and ineffective problem solving. These behaviors may intensify the potential risk of suicide. The people an individual sees every day (coworkers, family, and friends) are in the best position to recognize changes stemming from distress and to provide support. Any substantial or observable change in behavior warrants further discussion with the individual. Changes may be exhibited in one or many of the following:
Protective factors are those things that commands can reinforce in order to reduce the probability that difficulties will develop into serious behavioral or physical health problems. Examples include:
Every person is at risk for experiencing difficulties based on their balance of protective and risk factors. The key to suicide prevention is to increase the protective factors and to decrease the risk factors. We are not just focusing on eliminating negative factors, but also on increasing positive factors that will improve the quality of life for Navy members. As a Navy leader you can contribute to the presence of these factors.
All hands have a responsibility to assist a suicidal person to stay safe and get care by:
Click on each letter for more information.
If someone says they are suicidal and has a plan to carry out their wish to die, do not leave them alone for any reason. If you must step away, assign a capable Sailor or two to stay with the person until assistance arrives. If they must retrieve something from their car, or home, have someone else retrieve the item to reduce the risk of fleeing.
Although it is best for professionals to assess and manage suicidal individuals, there may be times when unit leaders or peers find themselves on the phone with a suicidal person. The following guidance may help you provide support and get the individual the appropriate help as soon as possible. It is important to be sure the Command Crisis Response plan in your duty office includes information on handling a distressed caller along with how to contact emergency responders. Establish a relationship with the person.
Gather information from the person.
If a Sailor is a current danger to themselves or others, an emergency mental health evaluation is appropriate. Refer to the local Military Treatment Facility during normal duty hours or the base or civilian Emergency Department (ED) after normal duty hours. If the person is not currently a danger to themselves or others, but is in need of assistance and there is a question about fitness for duty, the Commanding Officer can direct the person for a CDE (for detailed information, see the section of this guide). Only the Commanding Officer can direct the person for a CDE.
This process ensures Sailors and Marines get the help they need while respecting the rights of referred individuals. These rights include legal counsel, protection from reprisal, appropriate use of the evaluation (not a tool for punishment), and two-duty days written notice of the evaluation (except in emergencies where the person is in immediate danger to self or others).
Mental health providers and staff are the primary resource within the base community regarding mental health issues. Sailors can be evaluated on a voluntary basis or can be referred by commands through the Command Directed Evaluation (CDE) process. Mental Health providers can also serve as consultants to leaders regarding the management of personnel at risk for suicide, even if clinical care is not indicated or desired by the service member. Although it is impossible to accurately predict whether or not a person is going to attempt or complete a suicidal act, mental health providers can provide a comprehensive assessment to estimate level of risk. These assessments are based on known risk factors and allow providers to make recommendations for appropriately responding to that risk.
Suicide risk assessment is best accomplished as a collaborative effort between the Sailor, a qualified mental health professional and others who know the individual and have observed him or her in their daily activities. Commanding Officers, Department Heads, Division Officers, Chiefs, and LPOs can provide valuable information to the evaluating provider that might otherwise be unavailable when assessments are being accomplished. Leaders are encouraged to contribute by sharing observations related to the member's functioning in a duty status.
Commands can expect to be informed promptly when dangerousness issues arise in the course of an evaluation or treatment. If the person was referred for a formal CDE, both oral and written feedback will be given to the command that addresses the specific issues raised by the command.
When members are suicidal, hospitalization is indicated. In such cases, the evaluating mental health provider will facilitate appropriate care. Commands will be kept informed of the member's status. Prompt re-evaluation following discharge is essential and leaders will be notified as to the time of this appointment. Leaders can help ensure that the Sailor attends the post-discharge appointment.
Sometimes Sailors will have thoughts or feelings of suicide but will not meet criteria for admission to a hospital. In this situation, outpatient treatment will be offered to address the suicidal thoughts and behavior, as well as any mental health disorders. Often, outpatient treatment is preferable to hospitalization when risk of self-harm is not imminent. Commands will be notified of any increase in dangerousness or recommendations regarding duty status.
There also may be times when members are not imminently dangerous, but display some suicidal symptoms at the evaluation and refuse to return for ongoing care. These situations are challenging since a Sailor who is not at imminent risk for self-harm cannot be mandated to receive medical or mental health treatment. It is essential that leaders and providers collaborate to maximize the Sailor's safety.
Examples of collaboration between providers and leaders include:
There may be times when a comprehensive dangerousness assessment indicates that risk for harm is low. In these situations, leaders and providers should collaborate to develop an appropriate plan for monitoring, follow-up, and reintegration back into the command.
Mental health evaluations must be conducted in a location where medical support and security are available. This will generally be in a medical setting and not at the member’s home or unit. The Military Treatment Facility (MTF's) Emergency Department will likely be the safest and most appropriate venue for conducting after-hours suicide risk assessments. If there is no Emergency Department, the MTF will generally handle suicide risk assessments similarly to other medical emergencies using community resources.
When any provider believes that a service member is at increased risk for suicide, the commander will be notified. The provider may recommend duty restrictions such as removal from positions of increased responsibility, weapon-bearing duties and temporary change in flying status. Commanding officers can also help ensure that the individual’s duties do not involve significant time alone during which there would be opportunity for dwelling on problems and potentially attempting suicide.
Commands may also be directly advised to take steps to reduce access to weapons at the individual’s home. While it is impossible to limit a person’s access to all potential suicidal means, it is important to take reasonable steps to ensure safety when possible. Firearms pose the greatest risk as a readily available means of self-harm and should always be removed from a suicidal individual’s home. Counseling the person, and his or her family or friends, about the possible dangers of keeping a firearm available can achieve this. When necessary, commands should take definitive steps to restrict the member's access to weapons. Security will generally secure personal firearms in the armory.
Sailors who have recently been evaluated or discharged from a psychiatric hospital should be monitored by the command as well as a medical provider to ensure that safety is maintained and that any relapse is recognized early. Leaders should consider the following to ensure appropriate monitoring and support:
Sometimes in spite of everyone's best efforts, a Sailor takes his life. Suicide of a Shipmate can present one of the greatest challenges to the entire command leadership team. Sailors and family members will try to rationalize something that is just not rational in the context of clear thinking. People especially close to the individual or in the direct chain of command will tend to question themselves about why they did not see a problem or were unable to prevent the death. No one is immune to the feelings. It is important for commands to understand that the negative impact on many people will not go away just because the memorial service is over and duty calls again. Conscious efforts are needed to identify those individuals that may be at higher risk of difficulties following a suicide and ensure each of these people is monitored and offered all appropriate available assistance.
Although every situation is unique, leaders may expect that those first on the scene must initiate emergency medical care as appropriate. A second priority will often be to secure the scene and call Security. Ensure command members who found the individual and those who were close to the individual are located and receive any needed emotional support, both immediately following the event and sometimes for months afterwards.
A critical incident intervention team or Special Psychiatric Rapid Intervention Team (SPRINT) team may be called to respond to the unit's needs. Commands can access intervention teams through their local FFSCs, chaplains office or MTF.
These teams can provide resources and assistance required to avoid further problems within a command that has experienced the trauma of a co-worker's suicide. The team can provide individual counseling, a group debrief or advice to the command leadership in the aftermath of a local suicide.
Local military leadership shall coordinate information dissemination to large audiences and news media with public affairs. Public Affairs Officers have access to guidelines for responsible coverage of suicide that include avoiding detailed coverage of methods, location, and other details that have been shown in research to increase copy cat risk. The contributory factors to a suicide are always complex, even when there is some recent stressor that was the final precipitating event, so leaders should avoid disseminating a simplistic explanation. When leaders disseminate information to the command, they may want to seek guidance from a Chaplain or other resource in finding a balance between avoiding dramatization or glorification of the cause of death while respecting the individual's life and allowing those who knew them to work through grief.
The Department of the Defense Suicide Event Report (DODSER) is required for active duty and Selective Reserve member suicide deaths and undetermined deaths in which suicide has not been excluded by the medical examiner. The USN or USMC Suicide Prevention Program Manager will initiate the report process by coordinating the identification of a point of contact (POC), usually at the decedent's command, to complete the DODSER. Navy commands shall retain records until contacted by OPNAV N135 Behavioral Health Program (901) 874-6613 regarding completion of the DODSER. Its expeditious completion requires access to the decedent's medical and service records. The DODSER is a secure web based report. An Instructional video is available on the DODSER site.
A DODSER report is also required for active duty and Selected Reserve members who make a suicide attempt as verified by medical authority. The Military Treatment Facility responsible for the evaluation or referral completes the suicide attempt DODSER reports.
OPNAV shall use analysis of this data for the explicit purpose of improving suicide prevention among Military Services personnel. Thorough and carefully completed reports are essential in order for accurate conclusions to be drawn from the data.
In accordance with OPNAVINST 3100.6J, a UNIT SITREP or OPREP message is required for suicide related behaviors that come to the attention of the command.
Also, a Personnel Casualty Report (PCR) is required for all deaths, serious injury and evacuation from theater. The PCR is the mechanism that facilitates assignment of Casualty Assistance Calls Officers and next of kin notification or bedside travel as warranted.
Information, resources and contact information for the Navy Suicide Prevention Program can be found:
Bureau of Medicine and Surgery
7700 Arlington Blvd. Ste. 5113 Falls Church, VA 22042-5113
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