Leaders Guide - Suicidal Behavior - Marine Seems Suicidal

A Marine may seem suicidal to you if they exhibit suicidal behavior, if they seem very depressed or agitated, or if their behavior changes in a way that suggests to you that they might feel so hopeless that they might consider taking their own life. If a Marine seems suicidal to you or someone else, the time to find out and take action is now. The risk and liability are too high to wait. Once a Marine has decided to commit suicide, they may act very quickly and without further warning. Because those who are truly suicidal often keep their suicidal thoughts to themselves, effective suicide prevention requires everyone in the unit to be aware of the risk factors for suicide and know how to respond. Commanders, SNCOs, and supervisors must lead the way. Any individual who reports suicidal thoughts or displays behaviors suggesting suicidal thoughts must always be taken seriously.

If you are at all concerned, and even if your Marine may not actually be suicidal, at least investigate with the Marine to see what might be wrong before it is too late. It is also important to proactively ask about possible thoughts of suicide when unit members are dealing with significant life difficulties. Don't assume that merely because someone has not told you they are feeling suicidal, that they are safe. Be especially vigilant with Marines facing multiple stressors. They are typically at higher risk for suicide.

What to Look For

Distress in some individuals can lead to the development of unhealthy behaviors including withdrawal from social support and ineffective problem solving. These behaviors may intensify the potential risk of suicide. The people a Marine sees every day (fellow Marines, co-workers, family, friends) are in the best position to recognize changes stemming from distress and to provide support. Any substantial or observable change in behavior warrants further discussion with the individual.

Look For:

Comments that suggest thoughts or plan of suicide.
Acquiring a method for suicide (e.g., buying a handgun).
Rehearsing suicidal acts.
Giving away possessions.
Obsessing about death, dying, etc.
Making amends or challenging people in an aggressive manner.
Uncharacteristic behaviors (e.g., reckless driving, excessive drinking, stealing, UA).
Significant change in workplace performance.
Appearing overwhelmed by recent stressor(s).
Displaying significant change in mood.
Seeing situation as hopeless.
Displaying poor impulse control.

Any one of these signs by itself may or may not indicate that a Marine is suicidal. Clearly, the more serious signs must be addressed with more urgency. But research show that because the suicidal person may keep up a good front, even the less serious signs may be all you will see. If you are concerned, follow up and nip any problems in the bud before suicidal thoughts even start.

What to Do

By Phone:
Although it is best for mental health or medical professionals to assess and manage suicidal Marines, there may be times when unit leaders or peers find themselves on the phone with a suicidal Marine. If a Marine calls and expresses a wish to die or threatens suicide, this is most serious. You may have very limited time and only one chance to find them and intervene. Here is what to do:

Establish a helping relationship with the Marine on the phone (get your foot in the door).
Quickly express that you are glad they called you about this.
Express an interest in the person's welfare.
State your willingness to help.
Gather information from the person.
Immediately get the telephone number they are calling from in case you are disconnected.
Find out specifically where the person is located.
Get as much information as possible about their plans, access to means of self-harm, and intent.
If someone else is with you, get their attention without alarming or ignoring the caller and get them to make calls to Security or the civilian police to immediately pick up and have the Marine evaluated for suicide risk at the nearest ER.
Listen and do not give advice.
Keep the person talking as long as possible until help can reach them, but avoid topics that agitate them (i.e., their unfair supervisor, cheating spouse, etc.)
Follow up and ensure the Marine was found and taken for an evaluation.

In Person:
The most important thing to do if you are concerned is take action. If suicidal, you may not get a second chance to save your Marine's life. Even if the Marine is not suicidal, then at least you can open the door to assistance and get your Marine back on track toward full personal readiness. Either way, taking action will help both the distressed Marine and the unit. Here is a set of actions you might take if the Marine is available in person:

First, find out what is going on with the Marine.
Share your concern for their well-being.
Be honest and direct.
Use open-ended questions such as: "How are things going?" or "How are you dealing with…?"
Listen and pay attention to both words and emotions.
Repeat back what they say using their own words.
Ask directly about thoughts or plans for suicide (“Are you thinking about suicide?”). Don't worry – this will not put new ideas in their heads.
Express concern about them and a willingness to help. People who survive a suicide attempt are usually shocked to find out how many people care about them.
If suicidal thoughts are present, or have been explicitly reported by a credible source, or if you are not sure that they are safe, encourage voluntary evaluation at Medical immediately. Also immediately inform the chain of command.
Keep them safe—DO NOT leave them alone. Take steps to remove potential means of self-harm including firearms, pills, knives, and ropes.
Involve security if agitated or combative.
The command should escort the Marine to the Military Treatment Facility (MTF) or civilian Emergency Room (ER) if the MTF is unavailable.
Follow up and verify that the Marine was evaluated.
If psychiatric hospitalization is required, inquire with MTF staff about what assistance is needed (e.g., arranging for necessary belongings, child care, or pet care).
If you are satisfied that suicidal thoughts are not present, work with the Marine to get them the help they need to solve their other problems and return to a state of full personal readiness.
Continue to monitor the Marine for red flags until you are convinced they are no longer at risk.

If a Marine says they are suicidal and has a plan to carry out their wish to die, do not leave them alone for any reason. If you must step away, assign a capable Marine to stay with the person until assistance arrives. If they ask to retrieve something from their car or room, have another Marine go and get the item to reduce the risk of fleeing or self-harm. Remove all potential means of self-harm from their area such as firearms, pills, knives, rope, and machinery. Involve security if necessary to protect the Marine from harming themselves or others. The person may be so intent on suicide that they become dangerous to those attempting to help him.

Rely on the advice of mental health provider or the ER as to whether you should transport the person or send them via ambulance to an evaluation. If the advice is to transport them in your vehicle, each door must have a person assigned to prevent the person from killing themselves by exiting the moving vehicle. Have someone accompany the person during and after the evaluation to serve as your POC for disposition of the Marine. Have your POC provide the mental health provider with the unit commander's telephone number for feedback following the evaluation.

During duty hours you should contact your Military Medical Treatment Facility (MTF). After duty hours contact the base or civilian ER. Mental health evaluations must be conducted in a location where medical support and security are available. This will generally be in a medical setting and not at the member's home or unit. An ER will likely be the safest and most appropriate venue for conducting after-hours suicide risk assessments. If there is not an ER on base, the MTF duty crew will generally handle suicide risk assessments similarly to other medical emergencies, using the local community medical or mental health facilities.

What to Avoid

The idea is for leaders to let their Marines know they are safe and in good hands if they ask for help. If you can communicate your genuine concern for your Marine they will tell their fellow Marines that seeing you was the right thing to do and that you had their best interests in mind. Here are some things that may destroy their trust, close the lines of communication, or deter other Marines from asking for help in the future:

Minimizing or not taking the problem seriously. Saying, “is that all?”
Overreacting to the problem.
Giving simplistic. Saying, “all you have to do is…”
Telling the Marine to “suck it up,” or “get over it”.
Keeping the problem a secret rather than getting appropriate chain of command involved.
Telling personnel who don't have a need to know, making the problem a source of unit gossip.
Ignoring the problem and hoping it will go away.
Delaying a necessary referral for more specialized help.

What to Expect after Taking Action

Suicide risk assessment is best accomplished as a collaborative effort between the Marine, a qualified mental health professional and others who know the Marine and have observed the Marine's daily activities. Here is roughly how the process should go:

Most Marines will consent voluntarily to evaluation and treatment.

If found at high enough risk for suicide, the Marine will be hospitalized for safety and further evaluation and treatment.
If not, appropriate outpatient treatment will be recommended and the Marine will be returned to the command.
Upon return to the command, Medical should communicate to the command:
- Current level of risk.
- Recommended protective measures and monitoring, if any.
- Administrative recommendations (duty status, suitability, separation/retention).
- Medical follow-up appointments.
- What to do if the Marine's risk of self-harm increases or does not improve.

Commanders, SNCOs, and supervisors, with the consent of the Marine, may be asked by the evaluator to provide information that might otherwise be unavailable. Leaders are encouraged to contribute to the evaluation by sharing observations related to the member's functioning in the duty section. This is important, because the Marine may minimize problems during the evaluation, leading to inadequate diagnosis of the problem.

Mental health providers can also serve as consultants to unit leaders regarding the management of Marines found to be at risk for suicide, even if hospitalization is not indicated. Although it is impossible to accurately predict whether or not a Marine is going to attempt or complete a suicidal act, mental health providers can offer a comprehensive assessment to estimate the level of risk. Assessments are based on known risk factors and allow providers to make recommendations for appropriately responding to the risk.

If hospitalization was at a civilian facility, prompt re-evaluation at the MTF following discharge is essential, because civilian providers may not understand the special risks of the military environment or fitness-for-duty issues. Leaders will be notified as to the time of this appointment. Leaders can help ensure that the Marine attends the post-discharge appointment.

The unit as well as the mental health provider should monitor Marines who have recently been evaluated or discharged from a psychiatric hospital to ensure safety is maintained and any relapse is recognized early. Unit leaders should consider the following to ensure appropriate monitoring and support:

The Mental Health provider responsible for the member's care will share information about the member's status that is important for leaders to know.
The mental health provider should see the member regularly in follow-up. Additional visits with a Chaplain, SACO, or FAP staff do not substitute for face-to face contact with a mental health provider.
Someone in the unit should check in with the member daily to monitor their condition, provide support, and ensure their needs are being met.
Leaders should share information about the member's status at work with the MTF (e.g., declines in performance, recent disciplinary action, etc.)

Troubleshooting

Marine refuses voluntary evaluation for suicide risk: If you have sufficient cause to be concerned that the Marine might be suicidal, but the Marine does not want to be evaluated contact your local medical treatment facility for advice. In general, for risk of suicide consent is not required to transport your Marine to the medical treatment facility or local emergency room.
Marine found at some risk but not hospitalized: If your Marine is evaluated by Medical and found to have some suicide risk, but not enough to warrant hospitalization, then you will need to work with Medical on the best course of action. Upon return to the command, Medical should communicate:
- Current level of risk.
- Recommended protective measures and monitoring, if any.
- Administrative recommendations (duty status, suitability, separation, and retention).
- Medical follow-up appointments.
- What to do if the Marine's risk of self-harm increases or does not improve.
Treatment is offered, but Marine refuses treatment: There may be times when a Marine will display some suicidal symptoms at the evaluation, are not imminently dangerous, are returned to full duty by Medical but, against medical advice, refuse to return to the MTF for follow-up care. These situations are challenging since a member who is not at imminent risk for self-harm cannot be mandated to receive medical or mental health treatment. It is essential that leaders and mental health providers collaborate to maximize the Marine's ongoing safety. Upon return to the command, Medical should communicate:
- Current level of risk.
- Recommended protective measures and monitoring, if any.
- Administrative recommendations (duty status, suitability, separation/retention).
- Medical follow-up appointments.
- What to do if the Marine's risk of self-harm increases or does not improve.
Marine is treated but is not getting better: If your Marine is in treatment but does not appear to be improving, you will need to work closely with Medical on the best course of action. They may:

Have other treatment approaches available to them (different medications or therapies).
Recommend changing the Marine to Limited Duty status to receive additional treatment.
Recommend administrative actions or medical retirement in cases where long-term improvement is unlikely with any reasonable treatment.