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Identifying Individuals at Risk
- Risk Factors
- Recognizing Distress in Individuals with Risk Factors
- Protective Factors
- Balancing Protective and Risk Factors
Ways to Respond
- Helpful Approaches When Someone Talks About Suicide
- Unhelpful Approaches When Someone Talks About Suicide
- Intervening When the Person is Suicidal
- Handling Telephone Calls
- Commander Directed Mental Health Evaluations (CDE)
What Leaders Can Expect from Mental Health
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.
Identifying Individuals at Risk
The following factors do not mean a person will be suicidal but do increase the risk:
- Relationship problems
- Current/pending disciplinary or legal action
- Substance abuse
- Financial problems
- Work related problems
- Transitions (retirement, PCS, discharge, etc.)
- A serious medical problem
- Significant loss(es)
- Setbacks (academic, career, or personal)
- Severe, prolonged, and/or perceived unmanageable stress
- A sense of powerlessness, helplessness, and/or hopelessness
- Presence of a weapon in the home
- History of previous suicide attempts
- Family history of suicide
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.
Recognizing Distress in Individuals with Risk Factors
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:
- Substance use
- Impulse control
- Capacity for enjoyment
- Helplessness or hopelessness
- Peer relations
- Work performance
- Military bearing
In addition, be vigilant when your unit member shows:
- An inability to see a future without pain
- A view of themselves as worthless
- An absence of control over their life or life circumstances
- Feeling alone
- Excessive guilt or shame
- An inability to stop negative thinking
- Pessimism and a belief that there is no solution to life's problems
- Obsessing about death, dying, and weapons
- Challenging people in an aggressive manner
- Giving away possessions
- Excessive sorrow for past behaviors
- Sudden, unexpected improved mood following a period of distress
Seek immediate assistance through your local Military Treatment Facility, or Navy Fleet and Family Service Center (FFSC) or chaplain's for any of the following:
- Thoughts of suicide
- A suicide plan
- Access to the method of suicide described
- Stating they intend to complete the plan
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:
- Unit cohesion and camaraderie
- Peer support
- Easy access to helping resources
- Belief that it is okay to ask for help
- Optimistic outlook
- Effective coping and problem-solving skills
- Social and family support
- Sense of belonging to a group or organization
- Physical activity
- Participation and membership in a community
- A measure of personal control of life and its circumstances
- Religious or spiritual connectedness
Balancing Protective and Risk Factors
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.
Helpful Approaches When Someone Talks About Suicide
- First, share your concern for their well-being
- Be honest and direct
- Use open-ended questions such as: “How are things going?” or “How are you dealing with…?”
- Listen and pay attention to their words, actions, and emotions
- Repeat back what they say using their own words
- Express concern about them and a willingness to help. Individuals who survive a suicide attempt are shocked to find out how many people care about them
- Ask directly about thoughts or plans for suicide
- If someone tells you they are suicidal, it is often a plea for help. Tell someone in the chain of command to ensure they get immediate assistance
Unhelpful Approaches When Someone Talks About Suicide
- Not taking the problem seriously
- Minimizing or discounting the situation or their feelings about the situation
- Keeping the problem a secret
- Ignoring the problem
- Delaying a referral
Intervening When the Person is Suicidal
All hands have a responsibility to assist a suicidal person to stay safe and get care by:
- Learning what to observe and the possible meanings of what is observed
- Adopting an attitude that “I can help”
- Understanding what to do
- Knowing where to get professional help
Click on each letter for more information.
Ask. Do not be afraid to ask, “Are you thinking about hurting yourself?” or “Are you thinking about suicide?”
Care. Listen, offer hope. Suicidal feelings are temporary, depression can be treated. Take the person seriously, but don't judge or argue.
Treat. Take action, get assistance, and follow up. Take the person to get help or have someone stay with the person while you call for help. Do not leave the person alone. Make sure someone stays with him or her until appropriate help is available.
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.
- Remove all potential means of self-harm from their area such as firearms, pills, knives, rope, and machinery.
- Involve Security or local law enforcement if necessary to protect the person from harming him or herself. The person may be so intent on suicide that they become dangerous to those attempting to help them.
- Rely on the advice of local medical and/or mental health professionals as to whether you should transport the person or whether an ambulance should be summoned to provide transportation. If the advice is to transport them in your vehicle, each door must have a person assigned to prevent the person from exiting the moving vehicle or otherwise engaging in risky actions.
- Have someone accompany the person to serve as your point of contact during and after any evaluations. Have your POC ensure the mental health provider has your telephone number for feedback following the evaluation.
- During duty hours you should contact the mental health provider. After duty hours contact the Emergency Department (ED) if your base has one. If not, contact your local civilian Emergency Department (ED).
Handling Telephone Calls
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.
- Quickly thank the person for calling.
- Express an interest in the person's welfare.
- State your willingness to help.
Gather information from the person.
- Immediately get the telephone number they are calling from in case you are disconnected.
- Find out specifically where the person is located.
- Get as much information as possible about their plans, access to means of self-harm, and intent.
- Listen--do not give advice.
- Keep the person talking but avoid topics that agitate them (i.e., their unfair supervisor, cheating spouse, etc.).
- If someone else is with you, get him or her to make calls to medical and/or mental health professionals, 911, or the police.
Commander Directed Mental Health Evaluations (CDE)
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).
What Leaders Can Expect from Mental Health
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:
- Working together to develop a means for ongoing monitoring of potential risks
- Consultation about possible responses to a Sailor's disruptive behavior
- Looking for ways to increase support and decrease factors contributing to the individual's suicidal behavior
- Joint provider and leader follow-up with the unit member
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.
- Part of this plan would address a time frame for follow-up
- Referral to base helping agencies for developing improved coping skills
- Ensure immediate supervisor is alert to suicide risk factors
- Foster peer support and individual self-care
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.
Safety and Restriction of Access to Lethal Means
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.
Monitoring After Evaluation or Hospitalization
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:
- The provider responsible for the Sailor’s care will share information about the member’s status that is important for leaders to know.
- The member should be seen regularly by the medical provider. Additional visits with a chaplain or Fleet and Family Support Center (FFSC) staff do not substitute for face-to face contact with a mental health provider.
- Someone in the unit should check in with the Sailor daily as a means of support and to ensure that needs are being met.
- Leaders should share information about the member’s status at work with the all professionals involved in the sailor's treatment and care (e.g., declines in performance, recent disciplinary action, etc.).
Suicide of a Unit Member
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.
- DODINST 6490.1
- SECNAVINST 6320.24
- OPNAV INST 1720.4A
- OPNAV INST 6100.2
- MILPERSMAN 1770.090
- MILPERSMAN 1770.120
Information, resources and contact information for the Navy Suicide Prevention Program can be found: