Following Up with Suicidal Patients in the Military: Preparation is Key

Following Up with Suicidal Patients in the Military: Preparation is Key
DHCC graphic
By Jennifer Tucker, Ph.D. and Army Maj. Aimee Ruscio, Ph.D.
September 25, 2017

In the Clinician’s Corner blogs this month, we’ve discussed chaplains and confidentiality, how to assess for suicide risk, and how to discuss means safety. Following risk assessment and means safety, a third crucial responsibility of clinicians working with suicidal individuals is to follow up with their patients after they leave the office, hospital or other clinical setting. Clinicians who follow up with patients at risk for suicide communicate hope and help their patients feel valued. Communicating with patients after discharge also helps patients remain engaged with treatment and access the resources they need should a crisis occur.

This week’s post stems from a personal experience I (Dr. Tucker) had as a therapist working with service members hospitalized for a suicidal crisis. I had a history of approximately two years of non-eventful follow-up telephone contacts with patients who had recently discharged from the hospital. The eventful call occurred when I was least expecting it, with a patient who had made great progress in therapy and had discharged with a solid safety plan and several reasons for living.

When I phoned this individual, he clearly stated that he was feeling suicidal, was not sure he could refrain from engaging in his plan, and did not particularly want to keep himself safe. I was immediately on high alert as he was demonstrating suicidal ideation, a plan and intent, in addition to having a history of suicide attempts.

As I continued to talk with this individual, at times imploring him to stay on the phone with me, I signaled to my in-office team that we needed to initiate our crisis action plan. The team members quickly organized themselves and carried out the plan. Thanks to our preparations, the team was able to direct emergency services to the patient’s home while I continued to engage him on the phone. He was safely transported and admitted to a nearby hospital for a suicidal crisis.

While engaging emergency services could have led to difficulties in the therapeutic relationship, this patient was thankful that we helped to keep him safe and he fully re-engaged with outpatient therapy upon his discharge.

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While events such as the above are infrequent, we can’t afford not to be ready. Thus, in order to preempt problems which may be associated with safety risks in military patients, we suggest that you make the following preparations:

Set up channels of communication with your patients 

  • Discuss with your patient his/her preferred modes of communication and, if phone calls are selected, preferences for voicemails.
    • Record the patient’s preferred modes in his/her file.
    • Also record the patient’s preferences for voicemail messages (yes/no) and whether to speak to or leave messages with an individual who is not the patient.
  • For service members, review your clinic’s policy for notifying command should an at-risk service member not show for a scheduled appointment. Review the intent of the policy, which is to maximize the service member’s safety. It is not intended to be punishment or coercion to attend treatment. 
  • Be sure that you have at least one familial contact (e.g., mother, spouse) and one daily contact (e.g., friend, roommate) in the patient’s file.
    • Ask the patient to sign emergency contact and/or release of information forms for the individuals on his/her contact list. 
  • For service members, be sure that you have contact information for their first line supervisor, unit leadership (e.g. company commander, commander and/or senior enlisted), and the duty desk (a phone line that the unit monitors 24 hours a day). If a unit leader does not answer his or her phone, a provider can delegate the task of locating that leader to the duty desk, freeing the provider to continue with crisis management. 
  • Verify the patient’s address in the electronic health record, paying particular attention to whether the patient lives on or off post/base.

Organize a clinic crisis team 

  • Identify clinical colleagues, nurse case managers, behavioral health technicians, and/or front desk staff who are available in the case of an emergency. 
  • Discuss and document the procedures you will use as a team when there are concerns that a patient is at significant risk of suicide or is experiencing other potentially dangerous mental health symptoms.

Upon contact, ask three critical questions

If the patient answers the phone/text, start the conversation with the patient by gathering three pieces of information:

  1. Patient’s current location
  2. Whether the patient is alone or with others
  3. A back-up mode of communication (such as an alternate phone number) in case you get disconnected This information will help to direct emergency personnel should a crisis arise. After you have this basic information recorded, continue talking with the patient as normal. If the patient appears to be in a suicidal crisis that is urgent or dangerous, give the crisis signal to your team members so they can assist you while you remain connected with the patient.

If the patient is actively suicidal, have your team contact:

  1. Emergency services
  2. Patient’s emergency contact
  3. Command (for service members)

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Although initial implementation of these procedures takes time, the prep time is significantly reduced once your team has developed a routine. By adopting this teamwork approach to contacting patients at risk for suicide, you ensure that you and your clinicians have help and support available should a crisis arise.

Crisis Resources:

National Suicide Prevention Lifeline – 800-273-8255

Military Crisis Line – 800-273-8255, Press 1

Dr. Jennifer Tucker is a suicide prevention subject matter expert at Deployment Health Clinical Center. She has a master’s and doctorate in clinical psychology and has worked with service members hospitalized for suicidality as part of a large randomized controlled trial for cognitive behavioral therapy for suicide prevention.

Army Maj. (Dr.) Aimee Ruscio is a clinical psychologist at Deployment Health Clinical Center. She has a master’s and doctorate in clinical psychology and has worked with suicidal service members in deployed and non-deployed outpatient settings.


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.


Comments

  • I am wondering if anyone has any studies on Cognitive Behavior Therapy and it's reduction in suicide. I would like to know if it really helps patients and what the stats are if using CBT is increasing or decreasing suicidal patients.
    Thank you.

    • Hi Debby.  Thanks for posting your question.

      The seminal study of CBT for suicide prevention in an outpatient setting was conducted by Gregory Brown of the University of Pennsylvania, along with his mentor Aaron Beck. The trial results indicated that suicidal patients who received cognitive therapy were 50% less likely to reattempt suicide in the 18-month follow-up period than suicidal patients who received usual care. Here is a link to a full text version of their publication: https://jamanetwork.com/journals/jama/fullarticle/201330

      Please note that the 2018 revision of the VA/DoD Clinical Practice Guideline for the Assessment and Management of Patients at Risk for Suicide is expected to be published in early 2019. The 2013 version of the guideline and associated clinical support tools are located here: http://www.pdhealth.mil/clinical-guidance/clinical-practice-guidelines-and-clinical-support-tools/suicide. This guideline outlines the latest evidence for suicide-related treatments, including CBT, in order to provide invaluable guidance to clinicians working with suicidal patients in military, veteran, and civilian populations.

      -- Dr. Jennifer Tucker

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