The Department of Defense has stakes in both managing suicidality to reduce risk, and treating suicidality to resolve risk in its service members because both aim to reduce suicide deaths. This blog will examine some established fundamental values of suicide care, briefly review key research findings about suicide treatments, and discuss the differences between managing and treating suicidality in service members.
Fundamental values of suicide care
Most suicide prevention campaigns emphasize that suicidal individuals and their families should take action and get help from their doctor or mental health services. We hope that when they seek help, suicidal individuals are met with services that are consistent with the following values:
Foster hope among service members and help them find meaning and purpose in their activities
Preserve the dignity of our service members and counter stigma, shame, and discrimination around seeking help
Connect service members to peer supports
Promote community connectedness
Engage and support family and friends
Respect and support cultural, ethnic, and/or spiritual beliefs and traditions
Promote choice and collaboration in care
Provide timely access to care and support
These are the values expressed by those who have lived through a suicide attempt or seriously considered ending their life as documented in The Way Forward: Pathways to Hope, Recovery, and Wellness with Insights from Lived Experience, a national consensus document from the Action Alliance to Prevention Suicide. Their Recommendation 3.9 stipulates that “Protocols for addressing safety and crisis planning should be based on principles of informed and collaborative care.” Unfortunately, this recommendation was created because, over the history of mental health treatment in the United States, many suicidal individuals were sent to involuntary, or coerced, inpatient care when they could have benefited from alternative treatments and treatment settings. While treating suicidal individuals can be a complex and challenging process from the health care provider’s point of view, the values proposed above are consistent with the values of health care and it is our goal to find a way to achieve them.
Key findings from suicide prevention research
Several meta-analyses that integrate the data from multiple randomized clinical trials of suicide prevention have been published in recent years. They found that no biological treatment, including antidepressants, lithium, and electroconvulsive therapy (ECT), prevents suicide deaths, suicide attempts or self-harm and neither do partial hospitalization treatment nor case management services. Psychosocial treatments, on the other hand, did show promise in reducing suicide deaths, suicide attempts, and self-harm. Promising interventions include psychotherapies that range in length from three to 100 sessions, as well as brief outreach including Caring Contacts, which involves sending non-demanding caring letters or text messages to suicidal individuals over the course of a year or more.
Managing suicidality to reduce risk
While this is great for the research world, how do these findings relate to the military? We have to start by thinking about managing versus treating suicidality. When therapists manage suicidality, they engage in interventions that seek to reduce risk by modifying risk factors related to suicide. Management in this sense is optimally, but not necessarily, collaborative. Managing therapy includes increasing social connection with and for the service member, treating psychiatric diagnoses, incorporating means safety strategies, and engaging the service member in safety planning so they can survive their darkest moments.
An important objective when managing suicidality is to avoid revolving doors. To do this, mental health clinicians should make referrals for specific, feasible goals rather than to hand off responsibility for the service member to another provider. Referring for goals that are infeasible does not help, frequently drags out the management process through multiple evaluations, and may lead the service member and family to lose hope and give up on treatment. For instance, unlike casting a broken arm or prescribing flu medications, most emergency rooms (ERs) do not initiate psychiatric treatment, provide counseling, or prescribe or refill medications. For behavioral health issues, ERs serve as gatekeepers for more intensive services such as inpatient care or as a brief stabilization before returning to outpatient care. So clinicians should think carefully about when to send a patient to the ER versus managing the crisis in an outpatient setting with a recommendation to contact the Military and Veterans Crisis Line.
Treating suicidality to resolve risk
Responsibly treating suicidal service members also involves orienting them and their loved ones to the crisis management strategies you use. As part of informed consent, therapists should be up front about their practices related to suicide (e.g., when will they refer to a hospital) and their approach to working through a crisis. Additionally, good clinical practice dictates that regardless of a therapist’s choices on how to approach crisis situations, the service member should be fully informed about the potential benefits as well as the implications of disclosing suicidal thoughts, plans, or intent.
Treating suicidality, in contrast to managing suicide risk, involves the therapist and service member engaging in a collaborative relationship to resolve risk by targeting internal as well as external factors that are unique and intrinsic to the service member’s suicide risk. Treatment is necessarily collaborative. The therapist collaborates with the service member in a reflective and consultative role to assist the service member in understanding what drives their desire for death and what to do about it. Through reflection and problem-focused therapeutic strategies, the service member grows in confidence and responsibility in self-management of suicide risk. Resources are available for helping therapists learn how to treat suicidality including Center for Deployment Psychology: Cognitive Therapy for Suicidal Patients and Zero Suicide: Treat Suicidal Thoughts and Behaviors Directly.
To treat suicidal service members successfully, therapists must get past their fears of working with acutely suicidal patients. They need to be able to focus on creating a trusting relationship in which the service member is open about why suicide makes sense to them and able to change their experience of life and reasons for dying. Some reasons that service members are suicidal include interpersonal loss and conflict, inability to recover after trauma, depression, and lack of purpose in life. These are areas military clinicians are quite familiar with and typically only require clinical common sense and well-known interventions. The trick for clinicians is to manage their own anxiety as well as the acute risk so they can stay connected with the service member and the service member can benefit from their clinical wisdom and treatment strategies.
Another recommendation from the Way Forward guide is, “…appropriate interventions seek to understand the individual, his or her unique circumstances and how that individual’s personal preferences and goals be maximally incorporated… .” into treatment. One of the best ways clinicians can help themselves understand is to hear the service member’s suicide narrative – the story of how they came to be suicidal or attempt to take their own life. This is the foundation of the Aeschi Model of collaborative treatment for suicidality. Through the telling of the narrative, the therapist and service member come to a shared understanding of the suicidality, which forms the basis of the treatment approach and objectives.
Final thoughts on the therapeutic relationship and self-care
Though the procedures above seem straightforward and simple, we know that working with suicidal service members can be quite challenging and taxing. Some service members will be so disconnected from other individuals, and themselves, that they require a period of supportive care and understanding before the therapeutic relationship is established. Others require persistent and explicit displays of caring and interest from the therapist before they are willing or able to connect interpersonally. Therapists must be consistent in providing positive reinforcement to support and encourage service member growth. Most difficult of all, therapists must be emotionally available to the service member – get right up next to them and give it all they’ve got, because sitting back and dispensing advice isn’t going to work. Finally, therapists treating suicidality need a clinical team at the ready for support and consultation. Ask yourself, “If you are holding the client up, who is holding you up?”
Comtois is the director of the Dissemination and Implementation Core at the Military Suicide Research Consortium, which focuses on the dissemination of innovative, evidence-based suicide prevention interventions in military settings. She is also a professor in the Department of Psychiatry and Behavioral Sciences and an adjunct professor in the Department of Psychology at the University of Washington. Her research focuses on health services, treatment development, and clinical trials to prevent suicide.
The views expressed in Clinician's Corner blogs are solely those of the author and do not necessarily reflect the opinion of the Psychological Health Center of Excellence or Department of Defense.