Managing Suicidal Sailors: A Guide for Senior Leadership

1. Managing Suicidal Sailors:A Guide for Senior Leadership LCDR Rob Hines Ship�s Psychologist USS GEORGE H. W. BUSH (CVN 77)

3. What does it mean to be �suicidal�? Typically the term �suicidal� means that an individual is experiencing active thoughts of suicide (suicidal ideations). Being �suicidal� (experiencing suicidal ideations) is not a diagnosis. Suicidal ideations are symptoms.

4. What does it mean to be �suicidal�? Suicidal ideations can be brought on by a wide range of psychological problems. Some of the most frequent causes are: Major Depressive Disorder Borderline Personality Disorder Adjustment Disorders Bipolar Disorder Substance abuse problems Psychosis

5. What does it mean to be �suicidal�? What is a �suicidal gesture�? Typically it refers to an incident in which a person engages in an act of self-harm with a low level of lethality (e.g. taking a small amount of pills, light cutting) and a high chance for rescue (if needed). Often little or no medical assistance is required to prevent death. May be due to a �cry for help�.

6. What does it mean to be �suicidal�? What is a �suicidal attempt�? Typically it refers to an act of self-harm with a high probability of death (e.g. gun shot, hanging) and a low chance for rescue. If no intervention is made these acts will likely end in death.

7. What does it mean to be �suicidal�? What does the term �completed suicide� mean? This term is used for individuals that have committed suicide.

8. What does it mean to be �suicidal�? What causes someone to engage in a suicidal gesture or attempt? This is a very complex question. In a sense it�s like asking: �How do you get to Washington D.C.?� It depends on where you are starting from.

9. What does it mean to be �suicidal�? Some common factors for Sailors that may lead to a suicidal gesture/attempt: New to the USN and feeling overwhelmed with the transition Relationship loss (e.g. divorce, child custody, break-up of a dating relationship) Intense feelings of depression, helplessness, and hopelessness Increase in self-hatred or self-loathing The idea that death may be a way out of terrible psychological pain

10. What does it mean to be �suicidal�? Some common factors for Sailors that may lead to a suicidal gesture/attempt (continued): Overwhelming emotions subsequent to experiences in combat Inability to see alternatives to their present situation The feeling that they are a source of shame Being the victim of a recent humiliation Abuse of alcohol or drugs Pending legal problems and/or currently UA Manipulation / Malingering

11. Who is at an elevated risk for suicide? Who is at an elevated risk for suicide? Let�s start with some fictional examples:

12. Who is at an elevated risk for suicide? Sailor A 18-year-old, male, undesignated SR, six months of active duty. Has a girlfriend back home who is seven-months pregnant. Attached to a ship that is about to deploy for six months. Overheard saying: �The recruiter told me that I�d never have to go to sea!� �I didn�t enlist to become a janitor!� �I can�t take it anymore. I hate this place. I�d rather be dead than finish my time in the Navy!�

13. Who is at an elevated risk for suicide? Sailor B 26-year-old, female, E-5, six years of active duty. Single, no children, pattern of unstable romantic relationships. Recent break-up with boyfriend. Previously seen by a psychologist for thoughts of suicide. No counseling for past few months. Overheard Saying: �I can�t believe this keeps happening to me!� �I don�t even want to be here anymore!� �I just can�t imagine living without him!�

14. Who is at an elevated risk for suicide? Sailor C 35-year-old, female, new chief, 15 years of active duty. Married, two kids, husband also on active duty. Feeling overwhelmed with stress and chronic worry. Struggling to keep up with her work and home responsibilities. Overheard saying: �The stress is driving me crazy!� �I just can�t please anyone!� �Maybe everyone would be better off without me!�

15. Who is at an elevated risk for suicide? Sailor D 60-year-old, male, O-6, department head, 26 years of active duty. Divorced, three kids, no relationships with kids. Under increased stress. His department is having significant problems. His CO recently berated him and told him that he is losing confidence in him. Overheard saying: �Nobody talks to me like that!� (referring to his CO) �I�ve given my whole life to this organization!� �He doesn�t need to fire me, I�ll be long gone before that!�

16. Who is at an elevated risk for suicide? So which of these people are at an elevated risk for completed suicide? a) Sailor A, 18 y.o., male, undesignated SR b) Sailor B, 26 y.o., female, E-5 c) Sailor C, 35 y.o., female, chief d) Sailor D, 60 y.o., male, O-6 e) All of the above

17. Who is at an elevated risk for suicide? The answer is, all of the above. Each of these people are at an increased risk for completed suicide. If anyone starts expressing active thoughts of suicide they are at an increased risk. If they are also experiencing significant emotional difficulties at the same time, their risk goes even higher.

18. Who is at an elevated risk for suicide? Suicide can be an issue for almost anyone. Make sure that you are looking out for all of your Sailors. Don�t just assume that they are going to be fine.

19. How do we manage suicidal Sailors? As a senior leader, what steps can I take to effectively manage suicidal Sailors? Let�s start with some fundamental issues to address:

20. How do we manage suicidal Sailors? Get the Sailor to a doctor. The Sailor needs to be assessed for their risk for suicide. Don�t do the assessment yourself. Get the Sailor involved in counseling (if they are interested).

21. How do we manage suicidal Sailors? Secure any available weapons. If the Sailor is experiencing thoughts of suicide it is important to limit access to weapons. If the Sailor has a gun or rifle at home, you may need to step in and find a safe place to store these items.

22. How do we manage suicidal Sailors? Check for impact on their job or duty. For example: no armed watches, no flight deck duties. For nuclear field workers � it can be disqualifying for duty.

23. How do we manage suicidal Sailors? Ensure that the Sailor has a mentor and/or peer support. Having someone available to these Sailors to help them deal with their issues is very important. Knowing that someone cares about their situation can help fight off feelings of hopelessness and helplessness.

24. How do we manage suicidal Sailors? Check the morale and stress level of the ship and/or department. If suicide has been trending up there might be leadership issues to address (e.g. poor leadership, corrupt leadership, or pushing stress too high). If Sailors are literally jumping off of the ship to get out of the command � there is a problem. Make sure that we are supporting our Sailors as best we can while maintaining the mission.

25. How do we manage suicidal Sailors? Monitor the Sailor�s status over time. If the Sailor stays with the command, make sure that leadership checks in with the Sailor periodically to see how they are doing. Be proactive if problems come up (e.g. if the Sailor goes UA � actively seek them out).

26. How do we manage suicidal Sailors? Some �leadership� styles to avoid

27. How do we manage suicidal Sailors? Challenging or threatening Sailors with regard to thoughts of suicide. �Get back to work and stop complaining about this stuff or else�� �You�ll never do anything to hurt yourself. You�re too chicken.� �You�re just trying to get out of work. I don�t want to hear about this anymore.�

28. How do we manage suicidal Sailors? Retaliation with regard to changes in duty status as a result of issues of suicide. For example: Assigning the Sailor the worst possible job available without the proper resources to get the job done. Assigning them a new job and then setting up conditions that ensures failure.

29. How do we manage suicidal Sailors? Degrade them in public or private. For example: �We thought you had a lot of promise. I�m very disappointed in you.� Asking in front of the department: �Who can take this watch since this Sailor is too screwed up to do it?� Using nicknames or derogative terms to address these Sailors.

30. Issues of suicide and fitness / suitability for duty Issues of suicide and fitness for duty / suitability for duty Who stays and who goes?

31. Issues of suicide and fitness / suitability for duty What conditions can lead to an administrative separation for a suicidal Sailor? Personality Disorders (e.g. Borderline PD, Antisocial PD, Dependent PD) Adjustment Disorders What conditions can lead to a Medical Board? Depressive Disorders Post-Traumatic Stress Disorder Anxiety Disorders Bipolar Disorders Psychotic Disorders

32. Issues of suicide and fitness / suitability for duty What is a recommendation for Expeditious Administrative Separation? If a Sailor has been diagnosed with a Personality Disorder and is currently experiencing active thoughts of suicide, they can be processed for immediate separation. Based on MILPERSMAN 1910-122 A new change: If the Sailor also has a diagnosis of Post-Traumatic Stress Disorder (PTSD) or Traumatic Brain Injury (TBI), they must receive a medical board and cannot be administratively separated.

33. Issues of suicide and fitness / suitability for duty What is a recommendation for a Routine Administrative Separation? It requires a page 13 entry warning and then a subsequent violation of that warning before a Sailor can be processed for separation. If a Sailor has been diagnosed with an Adjustment Disorder or a Personality Disorder (but is not actively suicidal), they require a Routine Administrative Separation. Based on MILPERSMAN 1910-122 (for a Personality Disorder) Based on MILPERSMAN 1910-120 (for an Adjustment Disorder)

34. Issues of suicide and fitness / suitability for duty What is a Medical Board? A Medical Board is a formal fitness for duty and disability determination process. The official name of this process is a Physical Examination Board (PEB). This process is handled by a formal board in Washington D.C.

35. Issues of suicide and fitness / suitability for duty What is the difference between Fitness for Duty and Suitability for Duty? Fitness for duty refers to whether or not a Sailor is physically able to carry out their duties. If not fit for duty � they require a medical board or a period of limited duty Suitability for duty refers to whether or not a Sailor can to function effectively in the Navy environment. If not suitable for duty � they require an administrative separation

36. Issues of suicide and fitness / suitability for duty Frequently asked questions with regard to issues of suicide and the USN

37. Issues of suicide and fitness / suitability for duty My Sailor has had problems with thoughts of suicide in the past. Can I just order my Sailor into counseling so that I can get rid of them? No. Counseling and mental health treatment is completely voluntary. You cannot order anyone to participate in a mental health evaluation unless the command has taken the steps to set up a Command Directed Evaluation.

38. Issues of suicide and fitness / suitability for duty As a senior leader, what do I do with a Sailor I believe is malingering suicide? Document all the observations / evidence that leads you to believe that the Sailor is malingering. Contact the doctor in charge of the Sailor�s treatment and express your concerns. If the doctor concurs and diagnoses the Sailor with malingering � then send them to Captain�s Mast. Occasionally, based on the Sailor�s report alone the doctor will diagnose malingering.

39. Issues of suicide and fitness / suitability for duty If the command starts administratively separating Sailors for suicidal ideation, isn�t that just going to encourage more people to say that they are suicidal? Not usually. Most Sailors don�t want to get fired from their jobs. There are some exceptions (e.g. If morale is extremely low � some Sailors may start expressing more suicidal ideation).

40. Discussion Questions?