Behavioral Health Playbook - AMSUS · Behavioral Health Playbook CDR Julie A Chodacki, MPH, PsyD, ABPP ... “Medically Ready Force…Ready Medical Force” 2 ∎The views expressed

UNCLASSIFIEDUNCLASSIFIED “Medically Ready Force…Ready Medical Force” 1

AMSUS The Society of Federal Health Professionals Annual MeetingNational Harbor, MD | November 26-30, 2018

Behavioral Health Playbook

CDR Julie A Chodacki, MPH, PsyD, ABPP

Branch Chief, Clinical Care

Psychological Health Center of Excellence

Disclosure

“Medically Ready Force…Ready Medical Force” 2

∎ The views expressed in this presentation are those of the author and do not necessarily reflect the official policy or position of the Department of Defense, nor the U.S. Government

∎ CDR Chodacki and the Psychological Health Center of Excellence (PHCoE) staff have no financial interest to disclose. Commercial support was not received for this activity

UNCLASSIFIED

Agenda

∎ Behavioral Health Playbook

• Initial plan

• Built-in adaptability

∎ Courses

• Customer-driven

• Discussion/scenario-based

• Culturally curious

“Medically Ready Force…Ready Medical Force” 3UNCLASSIFIED


I. Psychological First Aid: Prevention and Early Intervention Principles

Behavioral health capability

III. Combat Operational Stress Control (COSC)

II. Military Mental Health Framework

Behavioral Health EngagementYe

ar

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Behavioral Health SMEE Course Overview


Behavioral Health Risk Prevention, Assessment and Mitigation SMEE

Task: To conduct a “Behavioral Health Risk Prevention, Assessment, and Mitigation” Subject Matter Expert

Exchange (SMEE)

Purpose: To exchange information and ideas with attendees in order to build U.S. and partner nation (PN) capacity

to mitigate behavioral health risks associated with experience of severe stressors or trauma.

Description: This exchange leverages didactic, structured, scenario-based practical exercises, facilitated

discussions, and clinical and operational case presentation to cover: psychological first aid, the military mental

health framework, and combat operational stress control. The SMEE is designed to develop and enhance clinical

and non-clinical skills to enable participants to gain expertise in how to scan the environment to prevent or identify

potential stressors or traumatic events, recognize signs and symptoms of stress and mental disorders, and to be

able to appropriate intervene or refer individuals who need assistance with stress or behavioral health concerns.

Participants in the course will be able to provide commanders, planners and decision-makers with realistic and

practical risk prevention and mitigation recommendations to reduce behavioral health risks within troop

operations.

Learning objectives for U.S. participants:

1) Compare and contrast fundamental behavioral health knowledge, practices, and services provided to

troop operations used by PN and U.S. militaries

2) Describe the PN’s local, national, and/or regional behavioral health prevention and care standards and

regulations

3) Describe the perspective towards behavioral health in the PN, and whether there are behavioral health

disorders of concern in PN

End-state outcomes for U.S. military:

1) Increased readiness to perform behavioral health prevention and intervention mission

2) Increased interoperability and professional relationships with the PN

Learning objectives for PN participants:

1) Apply the basic principles of Psychological First Aid and COSC

2) Identify, assess, mitigate, signs and symptoms of stress and mental health concerns; be able to expertly

communicate these concepts to troops at all levels of leadership

3) Develop a behavioral health program to mitigate risk for troops at all levels

End-state outcomes for the PN military:

1) Trained clinicians and non-clinicians capable of training others to execute behavioral health program

2) Increased Force Health Protection and increased military readiness

Lesson Plan (two separate modules for each main building block, for clinicians and for non-clinicians)

A: Psychological First Aid

Section I: Chapter 1: Overview

Chapter 2: Preparing to Deliver Psychological First Aid

Chapter 3: Core Actions

B: Military Mental Health Framework

Section I: Intro to Basic Psychological Health/Substance Misuse Concepts

Section II. Behavioral Health Operational Readiness

Section III. Intro to Military Mental Health Policies and Procedures

Section IV. Behavioral Health Clinical Practice Guidelines

C: Combat Operational Stress Control

Section I: Psychological Health Effects of Deployment

Section II: Deployment-Related Exposures

Section III: Deployment Resources

Section IV: Health Assessment Programs

Handouts

1) Draft behavioral health program workbook

2) Scoring case scenario worksheets

3) Assessment checklist

4) Concepts summary handout

Culminating Activity

1) Review of draft behavioral health program, facility walk through if available

2) Clinical and operational case scenarios scored

3) Command Brief

Potential topics for the PN to exchange with the U.S. military

1) Behavioral health prevention or intervention plans and policies

2) Local, military, regional, or national behavioral health care standards


Capability None Minimal Moderate Significant End State

Doctrine No doctrine of any kind

No local, state, national standards,

SOP’s

Developing standards and doctrine

(SOP) 25%


(SOP) 50%

Specific documented standards

(SOP) 75%

Compliance with local, state and national

standards WHO standards

SOPs100% implemented

Organization Organization is not familiar with

mental health literacy or not

interested

No structure to address

psychological threat

Limited Command interest in mental

health literacy

Limited development of prevention and

early intervention structure

Command interest in mental health

developing

Development of action towards enhancing

protective factors and minimizing risk factors

Command interest in mental health

literacy

Developed structure & services focusing on

primary prevention and early intervention

Command interest in mental health literacy

as a core function

Fully functional primary prevention programs

Early intervention/referral

processes/procedures in place

Training No psych first aid, prevention, and early

intervention training program

No standardized training programs

for leaders, service members, and

families. Minimal trainers

Developing standardized training

programs

Developing trainers

Have a standardized training program

Have qualified trainers

Training program at regional level with cadre of

trainers

Program in place to sustain “bench” of trainers

Material No functional documentation

No PT privacy standards

No ability to respond to R & R needs

Minimal documentation process

Minimal member and family support

materials

Documentation under development

Developing information guides for members

and families

Fully implemented documentation

Fully implemented information dissemination

Fully implemented support system

Planning and budgeting to anticipate support of

psychological health of members and families,

including information systems

Leadership &

Education

No education for leadership

Leadership unequipped to address

mental health literacy issues

No psychological first aid

Programs and actions to develop mental

health literacy in units 25% implemented

Programs and actions in place develop

mental health literacy in units 50%

implemented

Programs and actions in place to develop

mental health literacy in units 75%

implemented

Programs and actions in place to develop mental

health literacy in units 100% implemented.

Self-sustaining/self-generating

PersonnelPersonnel is over-worked, sleep

deprived, malnourished

No trained personnel

25% of personnel is performing

optimally, recovering optimally,

eating, sleeping, exercising for

energy enhancement

50 % of personnel is performing optimally,

recovering optimally, eating, sleeping,

exercising for energy enhancement

75% of personnel is performing optimally,



100% of personnel is performing optimally,



Facilities No facilities to promote primary

prevention, rest, exercise, and

positive coping

Very few facilities are allocated to

promote primary prevention, rest,

exercise, and positive coping

Some facilities are allocated to promote

primary prevention, exercise, rest, and

positive coping

Most members and families have access

to facilities that promote primary

prevention, rest, exercise, and positive

coping

100% of members and families have access to

facilities that promote primary prevention, rest,

exercise, and positive coping

Psychological First Aid: Prevention and Early Intervention Principles




Doctrine No behavioral health (BH) doctrine of any

kind

No local, state, national Standards,

SOP’s


(SOP) 25%

Developing standards and doctrine (SOP)

50%

Specific documented standards (SOP) 75% SOPs in place, monitored

Compliance with local, state, national, and

WHO standards

Clinical Practice Guidelines (CPGs) are

evidence based

Organization Organization unaware of BH

problems/issues or not interested

No BH structure, or liaison services to

address BH threat

Limited Command interest in BH

minimal

Limited development of BH structure,

liaison services to address BH threat

Command interest in BH developing

Partial development of BH command structure,

liaison services on BH threat

BH screen prior to service

Command interest in BH developed

Developed BH structure & liaison services

to address BH threat

Standardize BH fitness/suitability for duty

processing

Command interest in BH as a core

leadership function

Fully functional BH team

BH liaison services avail able to address

needs of community

Training No training program for BH staff or support

personnel

No training cadre

No standardized training programs

for BH

Limited BH trainers

Developing standardized BH training

programs

Developing BH trainers

Standardized BH training program

developed

Qualified BH trainer cadre 100%

Training program standardized at regional

level, easily accessible Trainers available

for consultation

Material No functional medical record (MR)

documentation

No patient privacy standards

Minimal MR documentation process

Minimal patient privacy

MR documentation not shared

Developing Electronic Health Record (EHR)

system

Privacy standards developed

Fully implemented MR documentation

process/EHR system developing 75%

Privacy standards developed and monitored

EHR fully implemented/utilized

Privacy Standards (HIPPA) in place and

monitored 100%

Leadership &

Education

No leadership BH education

Leadership doesn’t know how to

handle/identify BH problems

No BH promotion of educational

services for patients

Programs and actions in place to

prevent, identify, and manage adverse

Behavioral Health issues in units 25%

implemented

Leadership aware of BH problems

Programs and actions in place to prevent,

identify, and manage adverse Behavioral

Health issues in units 50% implemented

Leadership trained in BH issues




Leadership proactive about BH issues




Educational services/specific briefs for all

personnel In AO 100%

Leadership vocal, supportive of BH

PersonnelBH workforce unable to support

population

BH staff report high work stress and

poor work/life balance (WLB)

BH workforce staffing is able to

support the

BH staff report high work stress and

WLB difficulties

BH workforce staffing is able to support the

population -50%

BH staff report moderate stress and

moderate WLB difficulties

BH workforce staffing is able to support

the population -75%

BH staff report some work stress and

some WLB difficulties

BH workforce staffing is able to support

the population-100%

BH staff report minimal to no work

stress and minimal to no WLB difficulties

Facilities No inpatient & residential facilities.

No outpatient clinical or embedded

services that allow BH assessment,

engagement, treatment

25% fully capable medical facilities to

handle all BH needs In primary care,

embedded, and in/out patient care


handle all BH needs


handle all BH needs


handle all BH needs


Military Mental Health Framework



Doctrine No standardized

framework

No SOP’s

No COSC doctrine

No stress continuum model

SOP’s being developed

Stress continuum model developing

SOP’s developed 50%

COSC doctrine being dev.

Stress continuum model developing 50%

Specific COSC doctrine &

SOP’s and stress continuum model 100%

Ability to create & preserve ready

force, long term MH promotion

developing

SOP’s & COSC doctrine 100%

implemented

Stress continuum model 100%

implemented

Ready force, long term mental health

promotion developed, fully implemented

Organization No systematic efforts to preserve

a psychologically ready force, or

long term mental health

promotion

No concept of operations

Limited development of CONOPS for

COSC

Develop organic COSC team 25%

Partial development of CONOPS for

COSC 50%

Organic COSC team 50%

Partial development CONOPS for COSC

75%

Organic COSC team 75%

100% developed and implemented COSC

CONOPS

Developed and integrated organic COSC

team

Training No training program focused

on COSC

COSC training program 25% COSC training program 50% to include train

the trainer

COSC training program 100% to include train

the trainer

Training cadre recruited and 50% trained

Training program implemented at regional

level with training providers

Material No medical information system Medical information (MI) system

access developing 25%

COSC specific FMs under

development

Access to MI systems50%

COSC specific FMscomplete

Access to MI systems 100%

EHR’s, computer networking, equipment to

function in field environment fully deployable

Leadership &

Education

No COSC course No leaders

creating climate of ethical &

moral behavior and resilience

No stress prevention or

resilience courses

25% COSC leadership course

completion

No leadership training program


completion

Leadership training program in

development


completion

Leadership training program 50%

implemented

100% COSC course delivered

Leaders create climate of ethical & moral

behavior and resilience

Leadership training courses fully

implemented

Personnel No COSC

Multidisciplinary & support

personnel in unit

COSC Multi-D workforce staffing is able

to support the theater population-25%





COSC Multidisciplinary personnel in unit

staffing is able to support the theater

population-100% (Deployable)

Facilities No clinical mental health services

avail. in theater & Garrison

Companies vs detachment Co-Locate

with CSH?

Aligned by region at 25%

COSC facilities aligned by region.

Able to provide services 50%

COSC facilities aligned by region, able to

provide services 75%.

Clinical mental health services avail. in

theater & Garrison- aligned by region-

100%


Combat Operational Stress Control


Sample Psychological First Aid: Prevention

and Early Intervention Courses.v2


Psychological First Aid

Suicide Prevention

Technology in Care Mobile Apps

Stigma of MH in Military

Evidence Continuum of Practice

Post-Traumatic Growth


Behavioral Health Content


Content for three BH SMEE building blocks were developed by:

• Leveraging existing PHCoE, Services, National Center for PTSD, and CDP materials

• Identifying various courses/modules taught online or in person; include webinars, apps, other available resources for host nations

• Developing standardized SMEE curriculum, and create new courses to bridge existing gaps where they are identified

A: Psychological First Aid – Prevention and

Early Intervention


C: CoSC

BH SMEE Building Blocks


Behavioral Health Resources Available


Capability Definition: A fully capable military Behavioral Health system ensures that individuals exposed to trauma receive appropriate care to minimize post traumatic disorders; it includes a basic framework for understanding and delivering mental health prevention and response services including leadership support for psych health; and it aims toward effective Combat and Operational Stress Control.

Potential partner organizations:-Psychological Health Center of Excellencehttp://www.pdhealth.mil-DIMO http://www.dimo.af.mil/-USU/CDP http://deploymentpsych.org/about-National Center for PTSD https://www.ptsd.va.gov/professional/manuals/psych-first-aid.asp-Peace Corps http://files.peacecorps.gov/multimedia/pdf/library/T0087_culturematters.pdfhttp://files.eric.ed.gov/fulltext/ED059937.pdf-Directors of Psychological Health: Army, Navy, AF, and Marine Corps- US State Department

IMET Courses:•Mental (Behavioral) Health Specialist Course: 302-68X10•Aeromedical Psychology Training (Officers) Course: 6H-F27•Psychiatric / Mental Health Nursing Course: 6F-66C•Management of Combat Stress Casualties Course: 6H-300/A0620 References:AFM4-02 Army Health SystemATP 4-02.55 Army Health System Support Planning ATP 4-02.3 Army Health System Support to Maneuver Forces Dr. Smith, David, FEB15, Global Health Engagement: Smart Power in Defense

Online courses, webinars, mobile apps, websites: www.realwarriors.net; www.t2health.dcoe.mil;

http://pdhealth.mil/

http://www.dimo.af.mil/

http://deploymentpsych.org/about

https://www.ptsd.va.gov/professional/manuals/psych-first-aid.asp

http://files.peacecorps.gov/multimedia/pdf/library/T0087_culturematters.pdf

http://files.eric.ed.gov/fulltext/ED059937.pdf

http://www.realwarriors.net/

http://www.t2heatlh.dcoe.mil/


Behavioral Health Content Organization


Early Intervention


C: CoSC


Each section contains Chapters with multiple topics, for example:

Section I: Psychological First Aid

Chapter 1Introduction and Overview (Evidence-informed curriculum for non-providers)

Chapter 2 Preparing to Deliver Psychological First Aid

Chapter 3 Core Actions

- Topic 1 Contact and Engagement

- Topic 2 Safety and Comfort

- Topic 3 Stabilization

- Topic 4 Information Gathering: Current Needs and Concerns

- Topic 5 Practical Assistance

- Topic 6 Connection with Social Supports

- Topic 7 Information on Coping

- Topic 8 Linkage with Collaborative Services



Early Intervention


C: CoSC


Each building block contains sections, for example:

Military Mental Health Framework: Sections 1-4

(Two tracks for each section: clinical/non-clinical)

I. Intro to Basic Psychological Health/Substance Misuse Concepts

II. Behavioral Health Operational Readiness

III. Intro to Military Mental Health Policies and Procedures

IV. Behavioral Health Clinical Practice Guidelines

Behavioral Health Content Organization

UNCLASSIFIED Slide 14

Behavioral Health

Subject Matter Expert Exchange

Suicide Prevention


Disclaimer

The views expressed in this presentation are those of the presenter and do not reflect the official policy of the Department of Defense (DoD) or the U.S. Government.

The presenter has no relevant financial relationships to disclose.


Agenda

Perspectives on Suicide in the United States (US)

Suicide in the US Department of Defense (DoD) Historical Importance Suicide Prevention Approach Service Specific Programs

Clinical Practice Guideline (CPG) CPG Development Processes and Evidence Considerations Identification of Individuals at Risk for Suicidal Behaviors

Risk and Protective Factors Warning Signs and Groups at High Risk Levels of Risk and Recommended Interventions

Recommended Treatments for Suicidal Behaviors

Resources and Tools for Suicide Prevention

Suicide Prevention Scenario

Feedback and Questions


Suicide in the US Military


US Common Beliefs about Suicide

Suicide ideation is perceived as cognitive error

Suicide is a preventable tragedy

Suicide deaths are unwelcome and can and should be prevented


What are the prevalent beliefs about suicide in your culture?

How do these beliefs affect individuals’ or organizational behaviors?


Suicide in the US DoD: History

Prior to 2005, US military service appeared to confer a “healthy warrior effect” on its Service members, who had lower rates of suicide than the US general population

Between 2005 and 2009, DoD’s suicide rates doubled

In 2008, suicide rates in DoD surpassed rates for age- and sex-matched cohorts from the US general population

Suicide rates in DoD peaked in 2009

DoD’s rates stabilized in 2012 and have not decreased since


Suicide in the US DoD: Approach

Strategic: DoD Strategy for Suicide Prevention – serves as the “foundation and strategic point of reference for suicide prevention programs in the Department”

Research-Oriented: DoD Military Suicide Research Consortium – for research funding and oversight

Coordinated: Defense Suicide Prevention Office – for advocacy, policy, and oversight of suicide prevention programs

Monitored: DoD Suicide Event Report – for real-time, standardized surveillance data

Collaborative: Partnerships with Department of Veterans Affairs (VA) as well as many Non-Governmental Organizations


Suicide in the US DoD: Programs

Air Force: Air Force Suicide Prevention Program Wingman culture

Interpersonal connection

Army: Ask, Care, Escort (ACE) & ENGAGE Resiliency

Strategic communications

Navy: Sailor Assistance, Intercept for Life (SAIL) Suicide screening tool

Regular follow-up

Marine Corps: Marine Intercept Program (MIP) Follow-up contact

Health care coordination


What suicide prevention strategies

or programs are in place in your

community?


VA/DoD Clinical Practice Guideline:

Assessment and Management of

Patients at Risk for Suicide


VA/DoD CPG

VA/DoD CPG

Summary

Clinical Practice Guideline (CPG)


CPG Development Process (1/2)

Systematic Review of Literature by senior subject matter experts in VA and DoD

Literature reviewed every five years and CPGs updated

Explicit, reproducible methods to develop recommendations

CPG Work Group Evidence Chaperone - ensures conformity to standards

Grade Quality of Studies - GRADE


Strict approach to conflicts of interest

Multidisciplinary development teams

Identification of key questions

Evidence review for key questions

Groups review evidence, apply evidence grading

Development of recommendations and treatment algorithms

Review from trained external & internal subject matter experts

Final CPG reviewed and approved by VA/DoD Evidence-Based Practice Work Group

CPG is disseminated to the field

CPG Development Process (2/2)


CPG Evidence Hierarchy

Recommendations are explicitly linked to the supporting evidenceand graded according to the strength of that evidence


Example of Evidence Hierarchy - Therapy

Source: Council of Medical Specialty Societies (2011). Principles for the Development of Trustworthy Specialty Society Guidelines.


Quality of the Evidence


GRADE: Rating the Quality of Evidence

Source: GRADE Working Group, 2012. See, e.g.: Balshsem H, et al. GRADE guidelines: 3. Rating the quality of evidence. J Clin Epidemiol2011(64), 401-6.


CPG: Summary

In 2013, the VA and DoD collaborated on the development of the CPG for Assessment and Management of Patients at Risk for Suicide

The CPG summarized the latest evidence-based findings on: Risk and protective factors

Warning signs

Psychotherapeutic treatments

Pharmacologic treatments

Discharge planning

The CPG is currently undergoing a revision, with suicide experts compiling and reviewing all available research results in order to update the CPG’s recommendations


CPG: Identification of Individuals at Risk

for Suicidal Behaviors (1/5)

Chronic Risk Factors Acute Risk FactorsMental disorders Loss of employment

Medical conditions Loss of a relationship

History of a past suicide attempt Loss of housing

Financial difficulties Onset of psychiatric symptoms

Relationship difficulties Loss of status or rank

Legal problems Interpersonal assault

Adverse childhood experiences Suicide death of a relative or peer

Risk FactorsSome common risk factors for suicide-related thoughts and behaviors:

Protective FactorsSome common protective factors against suicide-related thoughts and behaviors:

Protective FactorsEmploymentResponsibilities to othersStrong interpersonal bondsResilienceSense of belonging and identityAccess to health careOptimistic outlook




Warning SignsCommon warning signs of suicidal behavior (i.e., signals of intention to engage in suicidal behaviors):

Warning SignsTalking about wanting to die

Threatening to hurt or kill oneself

Planning or preparing for a suicide attempt (e.g., buying a gun)

Making financial and other arrangements for dependents

Social withdrawal

Substance abuse




Groups at higher than average risk for suicide include those with histories of the following:

Previous suicide attempt(s)

Non-suicidal self-injury

Psychiatric diagnoses

Traumatic brain injuries

Military service (i.e., veterans)

In addition to the above groups, clinicians should consider the level of suicide risk for Service members who are or have:

Lesbian, gay, bisexual, and/or transgender (LGBT)1

Exposure to suicide2,3,4,5,6

Traumatic experiences during childhood7,8,9

Recently discharged from a hospital10,11

Other than honorable discharge from the military12




The VA/DoD CPG defines the levels of risk as follows:

Level of Risk for Suicide General CharacterizationHigh Acute Risk Serious thoughts of suicide

Suicidal intent and/or plan

Warning signs

A recent suicide attempt

Symptoms of agitation, impulsivity, and/or psychosis

Acute precipitating events

Low levels of protective factors

Intermediate Acute Risk Suicidal thoughts and/or a plan

No suicidal intent or preparatory behavior

Generally able to control suicidal urges

Limited protective factors

Low Acute Risk Suicidal thoughts

No specific suicide plan or intent

No history of suicidal behavior

Some protective factors

Limited risk factors

Not at Elevated Risk No current suicidal thoughts, intent, or plan




Recommended interventions in VA/DoD Suicide CPG are as follows:

Level of Risk for Suicide Recommended InterventionsHigh Acute Risk Immediate referral for a specialty evaluation

Direct observation by healthcare professional

Limit access to lethal means

Health care professional should remain with the individual until

he/she is safely escorted to an urgent/emergent care setting for

hospitalization

Intermediate Acute Risk Referral to a behavioral health professional for a comprehensive

evaluation

If necessary, consult a behavioral health professional to determine the

urgency of the evaluation

Limit access to lethal means

Low Acute Risk Consider for referral to a behavioral health professional

If necessary, consult a behavioral health professional to determine

appropriateness of referral

Address safety issues

Follow up with suicide risk reassessments

Not at Elevated Risk Routine care

Periodic suicide risk assessments


Suicide-focused psychotherapies

Cognitive therapy for suicide prevention

Problem-solving therapy

Medications

Lithium for bipolar disorder

Antidepressants for mood disorder

During discharge planning - safety planning

*All interventions recommended in the 2013 VA/DoD CPG for Suicide

CPG: Recommended Interventions* for

Suicidal Behaviors


Resources and Tools


Family brochure

Warning signs for suicide

Treatment settings

Websites and phone numbers

Suicide Prevention Guide for Families

Resources and Tools for Suicide

Prevention – for Family Members


Overcoming Suicidal Thoughts and Feelings

Patient brochure

Warning signs

Protective factors and coping strategies

Treatments and crisis numbers


Prevention – for Patients


Safety Plan Worksheet

Patient handout

Collaboratively completed by patient and provider

Used by patients when in crisis

Contains coping strategies to maintain safety


Prevention – for Patients



Prevention – for Clinicians

Safety Plan Treatment Manual

Written by clinicians

Step-by-step instructions

Evidence based

Webinars available online


VA/DoD Suicide CPG: Pocket Guide for Providers

12-page provider guide

Comprehensive summary of CPG

Assessment, risk levels, treatment

Flowcharts guiding assessment and management decisions


Prevention – for Clinicians


Pocket Guide for Clinicians


Military Crisis Line For suicide prevention for all US Military Service Members

Option to link callers to US Veteran

Veterans Crisis Line For suicide prevention for all US Military Veterans

Option to link callers with US Veteran

DSTRESS Line For suicide prevention and other stressors for US Marines and their

family members

Links callers with Marine Veterans, family members, and specialists trained in Marine Corps culture

Be There Peer Support Line For non-urgent stressors and problems for all US Military Service

Members and Veterans

Links callers with peer specialists in areas of financial counseling, parenting support, transition assistance, substance abuse, etc.


Prevention – 24/7 Crisis Lines


Suicide Prevention Scenario


[Please populate the next 7 slides with a culturally sensitive scenario. The current example is adapted from the US Suicide Prevention Training Scenarios PowerPoint.]

A 23 year old, active duty Specialist has been deployed to combat for eight months. He is going home on Rest & Relaxation and wants to surprise his family and girlfriend. In fact, he hopes to propose marriage to his girlfriend of four years. Upon arrival, he learns that his girlfriend is no longer interested in him. He is devastated.

You are a friend of this Service Member (SM).

You do not know:1. This SM is very depressed.2. This SM is abusing alcohol.3. He feels as though there is nothing else to live for.4. He has purchased a weapon.

During the conversation, this SM states, “While deployed to combat, thinking about her helped me to cope. I can’t see myself living without her.”

Suicide Prevention Training Scenario (1/4)


STRATEGIC QUESTIONS:1. As a Commander establishing a suicide prevention program, to what degree do you

consider generational differences, such as “baby-boomers” versus “generation X”?

2. What more can we, as an organization, do to help support unmarried Service members?

3. The military recruits mostly from a pool of young, unskilled individuals who also tend to be socially unskilled. Are there ways we can accelerate the social maturity of such individuals, or do we have to wait for development to take its time? Does the military currently have any mechanism to increase the social skills and maturity of new Service members? If so, what are these mechanisms? What additional measures can the military take to increase the resilience and social maturity of these individuals?

4. How does a Commander promote help-seeking behaviors within his/her organization?

5. How does a Commander monitor his/her unit for possible suicidal intent?




TACTICAL QUESTIONS:

1. Peers of Service members are the first line of defense in the military’s suicide prevention program. How do you prepare yourself for this role? What behaviors must you master in order to fulfill this role?

2. How much training in suicide prevention is enough? How much can realistically fit into your training schedule? How frequently should such training be given? How should new arrivals to your unit be included in this process? When can one stop training in suicide prevention?

3. Is suicide a medical or Command problem, or both? How can behavioral health specialists and unit Commanders best work together to reduce the frequency of suicidal behaviors?

4. As a unit commander, do you think someone who has been hospitalized for suicidal behaviors can ever be successfully reintegrated into the unit?

5. What kind(s) of training do you think is necessary to “harden up” Service members, make them more resilient, and make them less vulnerable to suicidal impulses?


OPERATIONAL QUESTIONS:

1. What risk factors are present to suggest that this individual may act impulsively to harm himself?

2. Since you do not know about these risk factors, how are you going to make a determination regarding this Service member’s needs?

3. Once your friend conveys possible suicidal ideation to you, do you have a moral, ethical, or legal obligation to him?

4. How does one know when the acute danger of suicide has passed?



Feedback & Questions


Web Links

Suicide-related handouts and toolshttps://www.pdhealth.mil/clinical-guidance/clinical-practice-guidelines-and-clinical-support-tools/suicide

VA/DoD CPG on Suicidehttps://www.healthquality.va.gov/guidelines/mh/srb/

Safety Planning Manual and Presentationhttps://www.mentalhealth.va.gov/docs/va_safety_planning_manual.pdf

http://www.dcoe.mil/files/2012SPC-Stanley-Brown-Holloway-Brenner-Safety_Planning.pdf

https://www.pdhealth.mil/clinical-guidance/clinical-practice-guidelines-and-clinical-support-tools/suicide

https://www.healthquality.va.gov/guidelines/mh/srb/

https://www.mentalhealth.va.gov/docs/va_safety_planning_manual.pdf

http://www.dcoe.mil/files/2012SPC-Stanley-Brown-Holloway-Brenner-Safety_Planning.pdf


References (1/3)

1 Matarazzo, B. B., Barnes, S. M., Pease, J. L., Russell, L. M., Hanson, J. E., Soberay, K. A., & Gutierrez, P. M. (2014). Suicide risk among lesbian, gay, bisexual, and transgender military personnel and veterans: What does the literature tell us?. Suicide and Life-Threatening Behavior, 44(2), 200-217.

2 Hom, M. A., Stanley, I. H., Gutierrez, P. M., & Joiner, T. E. (2017). Exploring the association between exposure to suicide and suicide risk among military service members and veterans. Journal of Affective Disorders, 207, 327-335.

3 Bryan, C. J., Cerel, J., & Bryan, A. O. (2017). Exposure to suicide is associated with increased risk for suicidal thoughts and behaviors among National Guard military personnel. Comprehensive Psychiatry, 77, 12-19.

4 Hom, M. A., Stanley, I. H., Gutierrez, P. M., & Joiner, T. E. (2017). Exploring the association between exposure to suicide and suicide risk among military service members and veterans. Journal of Affective Disorders, 207, 327-335.


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5 Bryan, C. J., Cerel, J., & Bryan, A. O. (2017). Exposure to suicide is associated with increased risk for suicidal thoughts and behaviors among National Guard military personnel. Comprehensive Psychiatry, 77, 12-19.

6 U.S. Department of Health and Human Services (HHS) Office of the Surgeon General and National Action Alliance for Suicide Prevention. 2012 National strategy for suicide prevention: Goals and objectives for action. Washington, DC: HHS, September 2012.

7 Blosnich, J. R., Dichter, M. E., Cerulli, C., Batten, S. V., & Bossarte, R. M. (2014). Disparities in adverse childhood experiences among individuals with a history of military service. JAMA Psychiatry, 71(9), 1041-1048.

8 Dube, S. R., Anda, R. F., Felitti, V. J., Chapman, D. P., Williamson, D. F., & Giles, W. H. (2001) Childhood abuse, household dysfunction, and the risk of attempted suicide throughout the life span: findings from the Adverse Childhood Experiences Study. JAMA, 286(24), 3089-3096.


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9 Bryan, C. J., Griffith, J. E., Pace, B. T., Hinkson, K., Bryan, A. O., Clemans, T. A., & Imel, Z. E. (2015). Combat exposure and risk for suicidal thoughts and behaviors among military personnel and veterans: A systematic review and meta‐analysis. Suicide and Life-Threatening Behavior, 45(5), 633-649.

10 Kessler, R. C., Warner, C. H., Ivany, C., Petukhova, M. V., Rose, S., Bromet, E. J., ... & Fullerton, C. S. (2015). Predicting suicides after psychiatric hospitalization in US Army soldiers: the Army Study to Assess Risk and Resilience in Service members (Army STARRS). JAMA Psychiatry, 72(1), 49-57.

11 Valenstein, M., Kim, H. M., Ganoczy, D., McCarthy, J. F., Zivin, K., Austin, K. L., ... & Olfson, M. (2009). Higher-risk periods for suicide among VA patients receiving depression treatment: prioritizing suicide prevention efforts. Journal of Affective Disorders, 112(1), 50-58.

12 Reger, M. A., Smolenski, D. J., Skopp, N. A., Metzger-Abamukang, M. J., Kang, H. K., Bullman, T. A., ... & Gahm, G. A. (2015). Risk of suicide among US military service members following Operation Enduring Freedom or Operation Iraqi Freedom deployment and separation from the US military. JAMA Psychiatry, 72(6), 561-569.

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