Although suicide is a rare behavior, suicide prevention is a key priority for the Military Health System (MHS) and many other health care systems because when a suicide occurs it results in an absolutely catastrophic, and absolutely preventable, outcome. Because the stakes are so very high, experts are working hard to identify and understand the paths that lead to suicide, and how, where and when intervention should occur.
Creating time and space
While many questions remain about how and why suicidal behavior occurs, there’s an almost universal understanding that putting time and space between the individual experiencing suicidal thoughts and the means with which they plan to carry out the lethal behavior is a critical step in the process of ensuring that individual’s safety. This is often referred to as ‘means restriction’ or ‘means safety,’ and it is an integral part of any comprehensive suicide prevention plan. By working together to decrease the access to – or availability of – lethal means, a ‘critical window of time’ is created during which the patient can reconsider engaging in suicidal behavior, utilize strategies discussed in treatment, reach out for help, or simply have an opportunity to recognize ‘reasons for living.’ A discussion and plan about removing lethal means can be very validating for the patient because it communicates that you care enough to take that extra step toward ensuring his or her safety.
Let me give you an example of this critical window of time. The Department of Defense collects extensive data on every suicide-related death that occurs among U.S. service members, and each year publishes a publically available Department of Defense Suicide Event Report (DoDSER) which addresses risk factors associated with military suicides. One of the most consistent and striking findings is that handguns are used in roughly two-thirds of cases that result in suicide, whereas drug overdose is the most common manner of suicide attempt that does not result in death. Both behaviors are lethal, but why is there a differential pattern of fatality? One possible explanation is that firearms result in an immediate consequence whereas drugs typically require a small amount of time to enter an individual’s bloodstream before taking effect. This window of time is important because it gives individuals an opportunity to ‘change their mind,’ reach out for help, or seek and receive medical attention, resulting in a lower occurrence of fatal overdose.
I recently had the opportunity to hear Kevin Hines, a nationally recognized advocate for mental health and suicide prevention, speak about his own history of suicidal thoughts, feelings and actions. Kevin speaks publically about surviving what is typically a very lethal suicidal behavior. He describes an instant feeling of regret and an overwhelming survival instinct that ‘kicked-in’ immediately after he engaged in this suicidal behavior, but at that point it was too late; he no longer had control over his own survival. I’ve heard similar anecdotes from individuals I’ve worked with clinically following suicide attempts. Given these insights, the recognition of an individual’s suffering and the subsequent restriction and removal of lethal means before a crisis occurs, when the patient still has the ability to make changes, becomes increasingly important.
Take steps to restrict means
Oftentimes ‘means restriction’ can be perceived by patients as a negative, controlling response or a loss of personal property or liberties. It’s important to communicate that means restriction is about safety, not punishment. It’s about keeping someone safe who, in that moment, is vulnerable. To me, it’s very similar to taking someone’s keys away if they have been consuming alcohol and intend to operate a vehicle. Many times that individual may protest and attempt to convince you that they’re sober, but you still remove the keys as a safety precaution. Further, restricted access to their car/keys only lasts as long as the individual is impaired. Once the situation has passed and safety can be ensured, there’s no need for further limitation. The same is true with means restriction as it relates to suicide, and having a plan for returning the patient’s property or freedoms is an important aspect of safety planning that is often overlooked.
Means restriction can take many forms, and doesn’t have to be complex. Steps like physically removing or relocating the lethal item(s) from the individual’s environment can reduce risk dramatically. Other examples include:
- Ensuring that firearms are unloaded, locked-up, or temporarily turned in for secure storage and that any firearm ammunition is stored separately from the firearm. For details on how to do this, please see this blog by Navy Lt. Marcus VanSickle.
- Removing extra bottles of prescription and over-the-counter medications or other substances. If you’re a provider who is prescribing medications, ask the pharmacy to limit the amount of doses available at any given time or to package them in blister packs. Old or outdated prescriptions should be disposed of or turned into a pharmacy.
- Removing alcohol is important because alcohol consumption lowers inhibition, increases impulsivity, and can have dangerous interactions with medications.
Take whatever steps are necessary to keep the individual safe. One small act, such as those described above, could save a life. And remember that safety planning and means restriction starts early. Don’t wait for a crisis to develop before taking these steps – do it before a crisis begins.
Talk to your patients about means safety
The 2015 DoDSER shows that 64 percent of service members who died by suicide had made contact with the MHS in the 90 days before their deaths, and 30.8 percent had made contact with MHS behavioral health services – either inpatient (4.5 percent) or outpatient (26.3 percent). Don’t miss those opportunities to talk with your patients; assessment of suicidal thoughts and feelings should be routine and so should safety planning. Consider these tips when starting conversations about safety planning and means restriction:
Communicate, genuinely, that your motivation centers on safeguarding their wellbeing and that simple changes can go a long way in keeping them safe.
Plan out, plainly and concretely, what actions patients should take, for how long, and how they will know when and if it’s time to retire their means safety plan. Write this plan out in an easy to reference form for them to use as a guide once they leave the office, and keep a copy in their record so that you can revisit the plan with them in the future.
Encourage patients to enlist family members and friends who they trust to help secure or remove firearms, medications, or other lethal means, and provide your patients with ideas and resources about safety practices that you would recommend.
Suicide is the result of an extremely complex and highly individual set of thoughts, feelings, behavior and circumstances. Sometimes it’s the smallest things that provide the most hope. Be willing to have those tough conversations. Ask about suicide. That question might just save a life.
If you are a service member or veteran experiencing thoughts of suicide, reach out for help immediately:
- Dial 800-273-8255 and press 1 to talk to a qualified VA responder.
- Start a confidential online chat session at www.veteranscrisisline.net/chat.
- Send a text message to 838255 to connect to a VA responder.
If you are deaf or hard of hearing, you can connect through chat, text, or TTY.
Dr. Larry Pruitt is a licensed clinical psychologist and the program supervisor for the DoD Suicide Event Report (DoDSER) program at the National Center for Telehealth & Technology (T2).
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.