Suicide And Homicide Risk Management (Page 13 of 18) in pdf

Suicide and Homicide Risk Management

TABLE 26-2

MANAGING SUICIDE AND HOMICIDE RISK DURING DEPLOYMENT

Full Combat

Basic Precautions

24-Hour Watch (or admit

Evacuation to Combat Sup-

Duty

port Hospital

patient to hold)

Least restrictive 

Most restrictive

Actions

Soldier verbally

1. Secure bolt from weapon

1. Secure weapons and

Enact evacuation procedures

contracts for

until further notice

medications

safety

2. No off-FOB duties until

2. Soldier is under direct

further notice

observation 24 h/day

Examples

Suicidal

1. Primary indication is

1. Military-specific SI/

1. Suicide or homicide risk

thoughts, few

military-specific SI/HI

HI but risk not high

high enough to warrant

risk factors,

2. Psychiatric disorder with

enough to warrant

hospitalization

able to contract

SI/HI but risk not high

hospitalization

2. Medically serious suicide

for safety

enough to warrant unit

2. Psychiatric disorder

attempt (overdose, lacera-

watch

with SI/HI but risk not

tions requiring sutures)

3. Step down from unit

high enough to warrant

3. Suicide/homicide risk not

watch

hospitalization

diminishing after (no more

than) 5 days despite treat-

ment while on unit watch

Advantages

1. RTD

1. Much less stigma than

1. High level of safety

Highest level of safety pre-

2. No stigma

unit watch

precautions

cautions

2. Some level of safety pre-

2. High likelihood of RTD

cautions

3. Consistent with PIES

Dis-

No safety pre-

Fewer safety precautions vs

1. Stigma

Low likelihood of RTD,

advantages

cautions

unit watch

2. “Sick role” with patient

stigma, violates PIES un-

hold

less clearly indicated

FOB: forward operating base; HI: homicidal ideation; PIES: proximity, immediacy, expectancy, and simplicity; RTD: return to duty;

SI: suicidal ideation

suicidal and would kill himself if he wasn’t allowed to leave.

24-hour watch he spent time talking to his escorts about his

During the initial evaluation, he didn’t describe a defined

problems. During this time period, he continued his usual

plan for carrying out his suicide and reported never before

work schedule and came to the clinic every other day for a

experiencing suicidal thoughts. He denied any previous

brief assessment and supportive therapy. Within 2 weeks,

mental health history, had no medical illness, and was not

he had come to terms with his pending divorce, realizing that

using alcohol, street drugs, or medications. A 24-hour watch

his presence at home would probably not have affected his

was recommended to the commander, along with frequent

wife’s plans. He also noted that his distress over the loss of

mental health treatment to help him cope with his emotional

his marriage wouldn’t resolve by throwing away his life or

crisis. On meeting to discuss a safety plan for the soldier,

military career. The 24-hour watch was discontinued at that

the command team reported that he had recently been

point. His bolt, ammunition, and knives were returned to him

serving well in his role as a member of a logistics team.

and, though his wife did leave him, he was able to continue

During the meeting the soldier’s first sergeant reminded

with the mission and complete the deployment. His emotional

the soldier how proud the battalion commander was of the

state had returned to near baseline approximately 1 month

soldier’s proficiency in a recent task. He then expressed

after his initial presentation. After several months of monthly

how the command team valued the soldier, not just as a

follow-up, he required no further treatment for the remainder

“number” but as a person and team member. The command

of the deployment.

team agreed to provide 24-hour supervision for the soldier

in a nonstigmatizing manner by removing the bolt from his

The soldier in this case presented with suicidal

weapon and removing his ammunition and knives from his

ideation in acute emotional crisis after learning of his

possession, as well as allowing him to remain on base where

wife’s plan to divorce him. His access to a weapon and

he would probably not need his weapons. He was allowed to

his primary stressor of interpersonal loss placed him at

choose the soldiers who would be assigned to monitor him,

significant risk for a suicide attempt. However, he did

selecting those with whom he felt the closest connection.

not have a formulated plan for suicide, a significant

He was then returned to duty with mental health follow-up

medical or mental health history, or a substance-use

planned in 2 days. He reported that during the day while on

435

Suicide And Homicide Risk Management Page 13

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