By Virginia DeRoma, PhD., ABPP
Sep. 22, 2022

U.S. Space Force photo by Airman 1st Class Tiarra Sibley

Each September, National Suicide Prevention Month is an opportunity to highlight our nation's ongoing commitment to suicide prevention services for service members and veterans. Statistics on the rising numbers of deaths by suicide have made providers more aware than ever about how important it is to have open conversations about suicide with patients. Given the challenges inherent in using responses to screening and self-report measures in the prediction of suicidal thoughts and behaviors¹, provider connections with patients that encourage trust and disclosure are critical. The majority of patients who have died by suicide often have a visit with a health professional in the past 90 days², suggesting the value of using patient health care visits to connect with the patient in a way that encourages forthright discussions and disclosures. Within the context of existing, prescribed guidance and protocols for clinical evaluation and comprehensive assessment, consider engaging patients in conversations that are timely, sensitive, and informative, as suggested below:

Preparing for conversations about suicide: As concerns arise, the provider worries that queries about suicide thoughts and behaviors might have negative impacts³. Consider:

• Check unfounded fears - Given that patients often struggle with difficulties with disclosure of suicidal thoughts and stigma⁴, breaking the silence with a nonjudgmental professional could bring relief. Keep in mind, talking about suicide does not prime consideration of it.
• Active awareness - The conversation doesn't always start with help-seeking through self-disclosure. It can also begin with providers opening the conversation following non-disclosure on self-report measures after recognition of the presence of risk factors/warning signs.
• Set the tone for honesty/acceptance - Initiating conversations about suicide supports patient engagement in acceptance (vs. denial)-based coping, which could, in turn, help mitigate risk⁵.

Encouraging motivation to disclose: Perceived risks and benefits of disclosure identified by those with lived experiences of suicide attempts⁶ can be queried in conversations with patients, specifically:

• Explore benefits of disclosure. Examples include: getting immediate help with personal safety in a crisis, getting professional help needed, increased trust in others following disclosure, learning new coping strategies and getting support implementing coping, sense of relief about letting go of secrecy, increased sense of hope and self-acceptance, a sense of strengthened social support, personal empowerment related to recovery, and challenging the notion that suicide ideation is shameful.

• Examine discouragers of disclosure. Examples include: risks that disclosure will be met with unhelpful reactions (e.g., discomfort in others in hearing disclosure, not listening, or overreacting), having to face unwanted attention and treatments (including being hospitalized against wishes), stigma and lost opportunities because of stigma, provoking and re-experiencing difficult emotions, belief that best it's best to manage the topic privately, and doubt that disclosure will lead to help.

Starting the conversation: Although providers may be tempted to tiptoe around questions in order to be respectful or to avoid embarrassing a patient, it's important to begin a conversation about suicidal thoughts and behaviors without hesitation, as hesitation might signal discomfort.

• When reviewing screening measure responses and during interview, invite patient disclosure by approaching questions about suicide directly: (e.g., "You've said everything you're going through is too much to handle and you can't do it anymore. Have you been thinking about suicide?")
• Reassure the patient that disclosure fears related to feeling stigmatized are common⁷; if you are comfortable having these conversations about stigma, this may increase their comfort.
• Engage in meaningful, active, and supportive listening; at a minimum, actively listen for:
  • Recent stressors/triggers that might serve as drivers for suicide thoughts/behaviors
  • How past suicidal crisis began/escalated and if coping strategies used were helpful
  • Reasons death by suicide is being considered as a solution
  • Intentions, plans, or preparations related to suicide
  • Warning signs and indicators of imminent risk/danger that require immediate action
  • Information about modifiable risk factors, including those unique to military life
  • Resilience/protective factors that might be leveraged in treatment
  • References to trusted/supportive others who have helped in the past
  • Degree to which patient expresses confidence about maintaining own safety

Sensitive delivery: Delivery is important in conversations to support patient disclosure⁸. Connect in a way that encourages the patient to engage in conversations and:

• Attune emotionally - Even when reviewing responses on self-report measures, show genuine sensitivity and empathy to the difficulties that a patient is experiencing and discussing.
• Check biases and judgment - Non-judgmental listening has been identified as the most common helpful response to disclosure of suicidal thoughts⁹.
• Adopt a collaborative mindset - Use wording that conveys approaches the involve/empower patients in processes: "We will work closely together to plan for your care and safety."

Conversing about connection: Converse about specific areas of social support with known significant associations to suicide ideation/attempts for past or present military personnel^10,11,2, including the patient's perception of:

• Social connectedness - Ask about any thoughts/feelings that patient might hold about needing to "go-it-alone" and ask about presence of/barriers for support-seeking with family, friends, and their unit. Address benefits of support and ask what support close others might be providing at the current time. The provider and patient can collaboratively identify/invite further involvement needed from those who the patient would feel comfortable turning to when in crisis. The Psychological Health Center for Excellence's clinical support tools include a family resource brochure to help family members recognize important risk factors/warning signs and how they can help a loved one struggling or in crisis.
• Thoughts about being a burden - Check in with patients to identify if they see themselves as a drain or inconvenience to certain or all others or society. Ask about how this affects support-seeking. These conversations can take place in context of reassurance that asking for help is difficult.
• Relationship problems - Ask about any relationships that are not working out recently and what the stresses, difficulties, and complaints are around these relationship struggles.

Conversing about components of care: Talk through how certain aspects in standards of suicide risk care can feel threatening, but are designed to help the patient secure or plan for help when needed:

• Confidentiality - Discuss the conditions under which patient information would need to be shared and why, including command. Describe tracking processes used to ensure that appropriate attention and follow-up care is provided and how these are designed to support.
• Safety planning - Explain the collaborative process of identifying signs of a crisis and protocols for development of a plan ahead of time for what can be done to help. PHCoE's clinical support tool, the safety plan worksheet, can provide step-by-step questions for each of the different components of the safety plan. A digital version of this worksheet is also available, allowing patients to store their plan on mobile devices to enable more convenient access when needed.
• Hospitalization - Introduce any need to intensify level of care to hospitalization as a compassionate decision that provides patients with an optimally safe therapeutic environment.

Conversing about how specialized treatment helps: When referring to therapy, note that a patient may be naïve to what a vital role therapy can play in reducing suicidal thoughts and behaviors and explore:

• Prior experiences with therapy and any ways patient found it to be helpful or unhelpful
• Perceptions of benefits and barriers to engaging in treatment, to include time constraints or stigma
• Likelihood that a patient will go to a therapy appointment; consider discussing:
  • How treatment focused specifically on reducing suicidal thoughts/behaviors can help
  • Available therapies (e.g. medication, brief cognitive-behavioral for suicide prevention) and benefits of each
  • How risk factors unique to a patient could be modified for relief: For example, a patient could learn how to apply skills to seek/maintain support if past attempts were rejected¹²

Conversing in context of lethal means safety counseling: Identification of firearms as the lethal means used in the majority of deaths by suicide in military and veteran populations has led to new firearm safety initiatives¹³. Veterans have reported acceptance of provider initiation of firearm safety in health care settings, provided that the conversations are transparent and respectful of their unique relationship to firearms¹⁴. PHCoE's lethal means counseling fact sheet summarizes key points valuable for collaborative lethal means safety discussions. As referenced, consider the following talking points:

• Ask about accessible lethal means (i.e., medications, poisons) at home, with attention to those associated with ideation; specifically, firearms accessibility
• Explore attitudes/perceptions related to gun ownership and openness to lethal means counseling conversation
• Introduce strategic options for putting time and distance between patient and LM; ask for input
• Collaborate to identify how to involve trusted others to help with a plan to reduce LM access
• Ask to collaborate on steps (locks, removal) to increase reduced access and home safety
• Reassure that restrictions/removal of LM is temporary and based on concerns about risk level
• Ask about how information could be shared to confirm that plans for safety were followed

In combination with effective screening, provider conversations with patients about suicide and suicide prevention can create connections that not only spur disclosure, but also encourage patients to take intentional steps toward safety.

If you have an emergency or are in crisis, please contact the Military Crisis Line or the Suicide & Crisis Lifeline by dialing 988.

Visit these resources for more information on comprehensive risk assessment, recognition of suicide risk factors/warning signs, and how to talk to someone about suicide:

• For guidance on clinical evaluation and comprehensive risk assessment, providers are encouraged to consult the VA/DOD Clinical Practice Guidelines (2019). The assessment and management of patients at risk for suicide provider summary. https://www.healthquality.va.gov/guidelines/MH/srb/VADODSuicideRiskCPGProviderSummaryFinal5088212019.pdf
• MHS Nurse Advice Line: Visit MHSNurseAdviceLine.com for web chat and video chat, or dial 1-800-TRICARE (874-2273), option 1. Support is available 24/7 by phone, web chat, and video chat. Can be accessed to get evidence-based health care advice from a registered nurse, find an urgent care or emergency care facility, receive recommendations for the most appropriate level of care, schedule same or next day appointments when recommended by a registered nurse and enrolled to a military hospital or clinic
• PHCoE Suicide Risk Clinical Support Tools. https://health.mil/Military-Health-Topics/Centers-of-Excellence/Psychological-Health-Center-of-Excellence/PHCoE-Clinician-Resources/Clinical-Support-Tools
• Guidance on Firearms and Means Safety: https://health.mil/Military-Health-Topics/Centers-of-Excellence/Psychological-Health-Center-of-Excellence/PHCoE-Clinician-Resources/Suicide-Risk/Firearm-and-Means-Safety

References

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2. Department of Defense. Annual Suicide Report: Calendar Year 2020. https://www.dspo.mil/Portals/113/Documents/CY20%20Suicide%20Report/CY%202020%20Annual%20Suicide%20Report.pdf?ver=0OwlvDd-PJuA-igow5fBFA%3D%3D
3. Dickens, C., & Guy, S. (2021). How Can We Support Staff to Talk Safely about Suicide?. Preventing and Responding to Student Suicide: A Practical Guide for FE and HE Settings, 194.
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5. Pietrzak RH, Pitts BL, Harpaz-Rotem I, Southwick SM, Whealin JM. Factors protecting against the development of suicidal ideation in military veterans. World Psychiatry. 2017 Oct;16(3):326-327. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5608823/
6. Sheehan L, Oexle N, Armas SA, Wan HT, Bushman M, Glover L, Lewy SA. Benefits and risks of suicide disclosure. Soc Sci Med. 2019 Feb;223:16-23. https://pubmed.ncbi.nlm.nih.gov/30690334/
7. Ammerman BA, Piccirillo ML, O'Loughlin CM, Carter SP, Matarazzo B, May AM. The role of suicide stigma in self-disclosure among civilian and veteran populations. Psychiatry Res. 2022 Mar;309:114408. https://pubmed.ncbi.nlm.nih.gov/35150977/
8. Richards JE, Whiteside U, Ludman EJ, Pabiniak C, Kirlin B, Hidalgo R, Simon G. Understanding Why Patients May Not Report Suicidal Ideation at a Health Care Visit Prior to a Suicide Attempt: A Qualitative Study. Psychiatr Serv. 2019 Jan 1;70(1):40-45. https://pubmed.ncbi.nlm.nih.gov/30453860/
9. Nicholas A, Pirkis J, Reavley N. What responses do people at risk of suicide find most helpful and unhelpful from professionals and non-professionals? J Ment Health. 2022 Aug;31(4):496-505. https://pubmed.ncbi.nlm.nih.gov/32930018/
10. Bell CM, Ridley JA, Overholser JC, Young K, Athey A, Lehmann J, Phillips K. The Role of Perceived Burden and Social Support in Suicide and Depression. Suicide Life Threat Behav. 2018 Feb;48(1):87-94. https://pubmed.ncbi.nlm.nih.gov/28093796/
11. Crowell-Williamson GA, Fruhbauerova M, DeCou CR, Comtois KA. Perceived burdensomeness, bullying, and suicidal ideation in suicidal military personnel. J Clin Psychol. 2019 Dec;75 (12):2147-2159. https://pubmed.ncbi.nlm.nih.gov/31332803/
12. Mournet AM, Kellerman JK, Yeager AL, Rosen RL, Kim JS, Kleiman EM. Daily-level assessment of the contexts under which seeking social support relates to risk of suicidal thinking. Suicide Life Threat Behav. 2022 Aug 16. doi: 10.1111/sltb.12911. Epub ahead of print. https://pubmed.ncbi.nlm.nih.gov/35972392/.
13. The Associated Press. (2021, Nov. 3). Biden announces New Veteran and Military Suicide Prevention Plan. https://www.kwtx.com. Retrieved Sept. 8, 2022, from https://www.kwtx.com/2021/11/04/biden-announces-new-veteran-military-suicide-prevention-plan/
14. Veterans are agreeable to discussions about firearms safety in primary care. Newell S, Kenyon E, Clark KD, Elliott V, Rynerson A, Gerrity MS, Karras E, Simonetti JA, Dobscha SK. J. Am. Board Fam. Med. 2021; 34(2): 338-345. https://pubmed.ncbi.nlm.nih.gov/33833002//a>.

Virginia DeRoma, PhD., ABPP, is a licensed clinical psychologist with specialized training in suicide prevention. Dr. DeRoma works as a technical advisor to the Defense Health Agency Psychological Health of Excellence. Her prior work in VA, Military Treatment Facility, and intensive outpatient care settings reflects a dedication to practices and policies that forward patient safety.