Background and Purpose
The U.S. Department of Defense (DoD) has always been concerned about suicides among service members, and the increase in suicides over the past decade has heightened that concern. Previously, DoD asked the RAND Center for Military Health Policy Research to identify best suicide prevention practices and ascertain whether the military services' suicide prevention programs used them. The results of that research were reported in The War Within: Preventing Suicide in the U.S. Military (Ramchand, Acosta, et al., 2011), which recommended that DoD provide formal guidance to commanders about how to respond to suicides among military personnel. This study aims to help DoD create such guidance, and it does so in three ways.
First, this study critically reviews the scientific evidence to date on how to respond to suicide across four domains: surveillance, preventing subsequent suicides, grief support, and respecting and honoring the deceased and his or her loved ones. It then presents current DoD policies and practices in each domain to identify gaps and opportunities for improvement.
Second, in compiling this study it became apparent that there is little scientific evidence on how best to respond to suicides. However, there is a series of resource guides to which DoD leaders may turn. We reviewed a large number of these resource guides and describe systematically what they recommend and what research evidence exists to support these recommendations.
Third, we wanted to assess how DoD and installations respond to suicide in practice. To do so, we conducted a qualitative study to learn more about the experiences of military suicide loss survivors through focus groups at a national loss survivor conference.*
We chose this multimethod approach to provide a comprehensive review of postvention policies and procedures informed by a variety of perspectives. For example, the scientific literature may help identify which postvention programs have been shown to be effective. However, a review of DoD policies and procedures is necessary to determine whether and how such programs are or could be implemented in the military. Our review of the resource guides also helped identify other promising approaches in need of scientific testing. Focus groups with friends and family members of personnel who have died by suicide helped us understand the impact, costs, and benefits of current DoD postvention policies and procedures. We incorporated all these perspectives into 12 recommendations that DoD or its suborganizations could adopt to strengthen their responses to suicide.
How DoD Policies and Procedures Map onto the Research Evidence and Resource Guidelines and Recommendations
Suicide surveillance is defined as the tracking and reporting of information related to suicide, and accurate surveillance enables policymakers and practitioners to respond to trends or design targeted interventions. Suicide surveillance is challenging due to variability in the degree to which suspected suicides are investigated, jurisdictional variation in the requirements for making a suicide determination, and regional differences in how equivocal deaths—or those for which the cause of death is indeterminate—are investigated. Primarily based on expert opinions, the evidence provides guidance to medical examiners in making cause-of-death determinations, determining which core data elements should be included in surveillance systems, and deciding how to conduct psychological autopsy studies. Resource guides offer few recommendations regarding surveillance; those that do generally stress the importance of preparing to respond to a suicide before one occurs and incorporating surveillance activities in such a plan, or the importance of treating loss survivors with sensitivity during death-scene investigations.
Data on military suicides derive from military criminal investigations, autopsies conducted by the Armed Forces Medical Examiner System, and command-directed investigations (i.e., line-of-duty [LoD] investigations). The purpose of LoD investigations is to ascertain whether an event occurred due to negligence or misconduct on the part of the service member. Suicide deaths among active-duty personnel are generally determined to occur “in the line of duty,” though they may be considered “not in the line of duty” if the investigating officer presents evidence of mental soundness on the part of the service member who died. Such determination affects loss survivors' eligibility for benefits provided by both DoD and the U.S. Department of Veterans Affairs (VA).
DoD's suicide surveillance activities are centered on the recently established DoD Suicide Event Report (DoDSER). These surveillance efforts are standardized for service members on active duty, but suicides in the National Guard and reserves are not tracked in a consistent way and often rely on civilian cause-of-death determinations and surveillance. DoDSER surveillance efforts generally surpass those in civilian settings, particularly for active-duty suicides. The DoDSER data elements have heavy overlap with the core elements recommended by national guidelines. However, noticeably absent is a field identifying the source of each DoDSER data element. Given the different sources from which data may derive, combining data elements from multiple sources and treating all data fields as equally valid and reliable could create biases in how similar constructs are reported and analyzed.
Suicide Prevention After a Suicide Death
There is evidence that surviving family, friends, and colleagues may be at increased risk for suicide after a suicide death. There is also evidence of associations between media coverage of celebrity suicides and suicide rates among the general population. With respect to media coverage, associations are strongest for “authentic” coverage versus fictional portrayals in magazines or television shows, accounts in daily newspapers, and sensationalistic coverage.
No randomized controlled trials of interventions implemented immediately after a suicide have shown reductions in suicide deaths or interruptions of suicide clusters. However, panels of experts have established guidelines for how communities should respond to suicides and for how media should report on suicides. In the case of community responses, there is one published study showing that community adoption of an intervention was associated with a subsequent reduction in suicides (Hacker et al., 2003). Other postvention models exist and include an approach focused on consoling loss survivors at the death scene (which may lead to increased referral to supportive resources) and training community members to act as gatekeepers following a suicide. There is less evidence that adhering to certain media guidelines is effective.
Evidence from suicide prevention strategies more generally may be relevant and could be applied to help guide postvention activities. Universal screening for suicide risk in school settings has been able to identify persons who are thinking about suicide but who have not asked for help on their own or who have not been identified by school personnel. Such approaches may be relevant to DoD. In addition, the delivery of high-quality behavioral health care has been associated with reductions in suicides and nonfatal attempts. It is not known whether DoD is providing evidence-based care consistent with research recommendations for preventing suicide among those receiving treatment.
Resource guide recommendations related to preventing suicides after a suicide focus largely on having a plan for discussing suicide in advance, a process for identifying individuals at potentially increased risk, and communication guidelines that generally adhere to the recommendations for media coverage of suicide. In addition, there are recommendations to enhance or rejuvenate suicide prevention programs.
DoD currently has no policies or procedures addressing what to do after a suicide death to prevent subsequent suicides, and there is a limited evidence base to describe the state of the art in this area. Thus, it is virtually impossible to assess how DoD practices map onto state-of-the-art postvention procedures to prevent suicide. However, DoD, the services, and military organizations have responded to aggregate and noticeable increases in suicide rates or numbers in three ways. First, they have revised their existing suicide prevention programs. For example, the Air Force Suicide Prevention Program was created after a period of increasing suicides in the Air Force and reinvigorated after a later increase. Second, they have held mandatory “stand-downs,” requiring large groups (or an entire service) to focus all or part of a day on suicide prevention or resilience-building. Third, they have evaluated their existing approaches to suicide prevention.
Grief Support After a Suicide
It is expected that loss survivors will experience a profound sense of loss and grief after a suicide. Although there is no evidence to date that those who experience a suicide loss display a unique form of grief, for some, the grief may become debilitating and reach the threshold of what is termed “complicated grief.” There is no evidence to date on how complicated grief can be prevented, but there are evidence-based methods for treating complicated grief, primarily through cognitive behavioral therapy.
We found that resource guidelines regarding grief support fell in two general areas. First, there were recommendations for counselors and other support personnel to stress that loss survivors grieve differently and to expect differences in how loss survivors process their loved one's death. In addition, there were recommendations about caring for care providers, as counseling bereaved individuals can lead to compassion fatigue and distress. There were also communication guidelines, including how organizations should reach out to loss survivors, though there is no evidence to suggest that one method is better than another. Recommendations regarding memorial services often conflicted with each other; again, there is no evidence to suggest whether organizations should have memorial services or what these services should entail. Other recommendations were similar to those for suicide prevention, including having plans prepared in advance and a process for identifying bereaved individuals at high risk for mental health problems and suicide.
DoD offers various resources to help loss survivors grieve. Casualty assistance officers (CAOs) are resources for next of kin after any death of a service member. Other military-sponsored programs include standard mental health counseling, military family life consultants, Military OneSource, chaplains, and family readiness programs. Each service also offers survivor-specific support groups. Organizations outside DoD, such as the Tragedy Assistance Program for Survivors, Gold Star Wives, and the VA, also offer support and bereavement counseling for loss survivors. It is not known whether DoD and outside organizations are providing evidence-based care consistent with research recommendations.
Respect and Honor
There is almost no literature to guide appropriate ways to respect and honor decedents or their loved ones. Resource guidelines provide procedural recommendations, such as protecting the confidentiality of suicide decedents and their loved ones. In addition, the guidelines for respecting and honoring loss survivors largely overlapped with those focused on grief support, such as the importance for organizational leaders to “reach out” to loss survivors, and conflicting evidence about holding memorial services.
In contrast, there are a large number of DoD processes and procedures for respecting and honoring the fallen, including guidelines for memorials and funeral services, posthumous awards and honors, and presidential letters of condolence for those service members who take their own lives in a combat zone. There are also legal and policy requirements regarding how next of kin are to be notified and how the body will be transported. There are a number of benefits for which loss survivors may be eligible, administered by either DoD or the VA. When suicide deaths are determined not to have occurred in the line of duty, loss survivors may be ineligible for certain types of benefits, as shown in Table 1.
Table 1. Loss Survivor Benefits, Administering Department, and Effect of LoD Determination
|Benefit||Administering Department||Affected by LoD Determination|
|Loss survivor benefit plan||DoD||Yes|
|Disbursement of pay and allowances||DoD||No|
|Dependency and indemnity compensation||VA||Yes|
|Servicemembers Group Life Insurance||VA||No|
|Dependents' Educational Assistance Program||VA||No|
|Burial in a national cemetery||VA||No|
|TRICARE health and dental care||DoD||No|
Perspectives of Military Suicide Loss Survivors
The military suicide loss survivors with whom we spoke made comments that centered around five themes. First, experience with CAOs or casualty assistance call officers varied. Several participants said they were paired with an officer who was caring, helpful, and knowledgeable, while other participants were paired with an officer who presumably lacked empathy and knowledge about the grief process and military administrative process. Second, loss survivors perceived administrative documents and processes, which they are encouraged to complete soon after the death, as overwhelming and challenging to navigate. Loss survivors also noted that the investigation into the details of the event was difficult to understand. Third, many loss survivors talked about being “in a fog” after their loss. They stated that grief resources and support services were challenging to navigate and too overwhelming to sort through, with one loss survivor telling us, “You don't know what you need.” A fourth theme that emerged was that loss survivors felt that suicide deaths were treated differently from deaths by other means and were not given the same “honor or glory.” Finally, loss survivors felt that parents and next of kin of the suicide decedent were treated differently from their spouses and that more services were needed for these other family members.
In light of the study results, we offer a series of 12 recommendations (presented in Table 2) that span seven general categories:
- Further strengthen the existing suicide surveillance system by adding elements to the DoDSER, enumerating suicide rates among members of the reserve component, and conducting in-depth investigations on suicide decedents.
- Prepare an organizational response to suicide by developing a plan that specifies actions and responsible actors and ensures sufficient resources.
- Work with the media to encourage factual reporting and minimize sensationalism of suicides.
- Identify individuals at high risk.
- Establish greater uniformity across CAOs in the ways they handle suicide deaths, consistent with standards.
- Educate leaders, CAOs, and other support personnel about complicated grief; train health care providers on evidence-based treatments for complicated grief.
- Reconsider whether eligibility for DoD and VA benefits should be affected by LoD determinations, and support loss survivors in making informed decisions when benefits are dispensed.
Table 2. Study Recommendations
|Further strengthen the existing suicide surveillance system by adding elements to the DoDSER, enumerating suicide rates among members of the reserve component, and conducting in-depth investigations on suicide decedents.||
1. Incorporate fields in the DoDSER that identify data sources and the timing and severity thresholds for stressful life events.
2. Create a process to enumerate suicides among reservists and members of the National Guard not on active duty.
3. Conduct psychological autopsies on all or a sample of confirmed suicides and on a specified control group on an ongoing basis.
|Prepare an organizational response to suicide by developing a plan that specifies actions and responsible actors and ensures sufficient resources.||
4. Ensure that installations and military organizations are ready to respond to suicide with a detailed plan, dedicated staff responsible for implementing the plan, and sufficient resources to enact the plan.
5. Ensure that installations include in their suicide response plan a process for guiding any memorial services they conduct.
|Work with the media to encourage factual reporting and minimize sensationalism of suicides.||6. View the media as a partner and encourage journalists to comply with media guidelines.|
|Identify individuals at high risk.||7. Implement a systematic process for identifying and referring at-risk individuals. Screening may help prevent future suicides, though there is little evidence suggesting how frequent, widespread, or extensive it should be.|
|Establish greater uniformity across CAOs in how they handle suicide deaths, consistent with standards.||8. Prioritize reducing variability in the quality of CAOs.|
|Educate leaders, CAOs, and other support personnel about the grieving process, including complicated grief; train health care providers in evidence-based treatments.||
9. Make leaders and CAOs aware that grief is a normal process following death, and sudden deaths, such as those from suicide, may produce different manifestations of grief.
10. Ensure that care providers and others (e.g., military psychologists and psychiatrists, mental health providers, family counselors) who may come into contact with grieving loss survivors are aware of the symptoms of complicated grief and the cognitive behavioral approaches that have demonstrated efficacy in treating complicated grief.
|Reconsider whether eligibility for DoD and VA benefits should be affected by LoD determinations, and support loss survivors in making informed decisions about benefits.||
11. Consider modifying eligibility for the Survivor Benefits Plan and Dependency and Indemnity Compensation to ensure that suicide loss survivors have access to these benefits.
12. Ensure that the timing and presentation of benefits take into account loss survivors' ability to process this information in the acute period following their loss.
Ramchand, Rajeev, Joie Acosta, Rachel M. Burns, Lisa H. Jaycox, and Christopher G. Pernin, The War Within: Preventing Suicide in the U.S. Military, Santa Monica, Calif.: RAND Corporation, MG-953-OSD, 2011. As of May 6, 2014:
Hacker, Karen, Jessica Collins, Leni Gross-Young, Stephanie Almeida, and Noreen Burke, “Coping with Youth Suicide and Overdose: One Community's Efforts to Investigate, Intervene, and Prevent Suicide Contagion,” Crisis: The Journal of Crisis Intervention and Suicide Prevention, Vol. 29, No. 2, 2008, pp. 86–95.
* Throughout this study, we use the phrase loss survivors to refer to the family and friends of a person who has taken his or her own life.
This research was sponsored by the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury and conducted within the Forces and Resources Policy Center of the RAND National Defense Research Institute, a federally funded research and development center sponsored by the Office of the Secretary of Defense, the Joint Staff, the Unified Combatant Commands, the Navy, the Marine Corps, the defense agencies, and the defense Intelligence Community.