Professional tips: How to Save More Vets from Suicide

The following presents a review of an article written by Dr. Peter Gutierrez and Dr. Natalie Riblet, written by Dr. Barry Austin Goodfield, DABFM, founder of Operation New Outlook.

The reviewed article appeared in VA Research Currents; Research news from the U.S. Department of Veterans Affairs (May 2017 issue). The article’s title: “Studies Probe Pre-Suicide Contact with Mental Health Care Among Vets, Soldiers”

Dr. Natalie Riblet, a psychiatrist at the White River Junction VA Medical Center in Vermont, led the study relating to Veteran suicides. She spoke about why a recent psychiatric hospitalization may be a risk factor for suicide.

Dr. Peter Gutierrez, a clinical research psychologist at the VA Eastern Colorado Health Care System, co-authored the other study, which relies on data from Army STARRS, the Army Study to Assess Risk and Resilience in Service Members.

The study, published in April 2017 in the Journal of Consulting and Clinical Psychology, looks at 569 Army soldiers who died by suicide from 2004 to 2009. It says about 50 percent of the soldiers accessed health care in the month before their death and about 25 percent in the week prior. Most of those visits were in a mental health unit.

“This suggests that opportunities exist to intervene with a substantial proportion of suicide decedents in the months before death by focusing on patients in [mental health] treatment,”

Gutierrez explains that health providers carry a burden to be aware of which of their patients are at risk based on factors that typically don’t change much: age, gender, and prior history of suicide-related behaviors. When providers sense an elevated risk of suicide, he says, they should routinely ask their patients about thoughts of suicide, preparation for a suicide attempt, and level of intent to engage in self-harm.

Gutierrez says there are other warning signs health providers should monitor:

  • Significant agitation. “That often manifests as a dramatic change in quality of sleep, and it’s something that’s pretty easy to ask about. How have you been sleeping this week? Have you been having trouble falling asleep and staying asleep? Are you waking up too early? Does this represent a dramatic change in how you were sleeping in the last month?”
  • A dramatic increase or decrease in alcohol and substance abuse. “At an international meeting I attended,” says Gutierrez, “data were presented that suggests a huge percentage of chronic problem drinkers who die by suicide quit drinking entirely or dramatically decrease how much they drink about 48 hours before their suicide. That’s a pretty narrow window, but it suggests that assessing for major changes in substance abuse is important.”
  • Social withdrawal. “Asking about social withdrawal, which is a dramatic change to the extent in which people are socializing over the past month, may well be a warning sign. Seriously pondering the probability of ending one’s own life is incredibly daunting, and in order to sort of focus the necessary attention to make it possible, many people withdraw.”
  • Eye blinking. “It appears that when suicide is imminent, the rate at which people blink their eyes lengthens dramatically. Most people blink every three seconds or so. That may extend to every 25 or 30 seconds for a person considering suicide. I wouldn’t say this is necessarily a warning sign at this point. But we definitely need to study this more.”

Doctor Goodfield’s observations:

We know that elevated flutter rate or eye blinking quickly is an indicator of anxiety. The faster the flutter rate the greater the anxiety. Conversely, It can be said the slower the flutter rate or eye blinking the more the individual is in an altered state of consciousness. They are physically present but psychologically absent. This person is in a trance state, That is, they may appear to be lost in thought or simply not paying attention to what is being said and what is happening around them. They are lost in the thought of life versus death when deliberating the issue of suicide, period.

This is not to say that people who are ”away,” or daydreaming, or lost in thought are suicidal.  What is suggested, however, is that people seriously considering suicide are more involved with thoughts from the past and considerations of their bleak future.

Their fears from the past get projected into the future and wipe out involvement and commitment to the needs and the demands of the environment here and now. They’re simply not home.

What would we expect to see nonverbally with individuals in this state?

  • Eyes with white showing below the iris. This look strongly reflects an individual absent from being present. This is one of the indicators used by clinicians doing hypnosis to evaluate the subject’s susceptibility to trance induction. The more white showing under the eyes, the more likely one can infer that this is a subject who is not only hypnotizable, but is in an altered state much of the time. This is an important variable for the clinician concerned about suicidal ideations.
  • Eyes with a glazed look about them. Once again, the clinician should be looking for the degree to which the veteran appears to be present and responsive to the questions and activities going on around him or her. It is safe to say, with regard to suicide, the more absent the patient, the greater the risk.
  • Eyes that are moist as if they have or are about to cry. Moist eyes or eyes that appear shiny may reflect recent crying and or sadness where the patient tried to hold back his or her tears. A “stiff upper lip” attitude does not guarantee that that which is held back is not observable. This is particularly true when looking at the eyes of a patient on the edge of life or death.

Gutierrez’s study doesn’t specifically look at what would drive a soldier to die by suicide. But he notes that other articles using Army STARRS data found that service members with relationship problems, such as a divorce or child custody battle, as well as those with legal troubles, could be at higher risk.

Many suicides after unplanned discharges

For their study, Riblet and her team reviewed VA clinical reports of death by suicide within seven days of discharge from all VA inpatient mental health units from 2002 to 2015. The reports looked, in part, at the root causes of the suicide. The study, which is expected to be published soon in The Journal of Nervous and Mental Disease, cites 141 reports of suicide during that period, 43 percent of which (61) followed an unplanned discharge. That means the discharge occurred against medical advice or the patient unexpectedly requested to move up the discharge after it was scheduled for a later time.

The study says inpatient teams should be aware of the “potentially heightened risk” for suicide in patients taking an unplanned discharge.

“Our findings suggest that even when—and especially when—patients leave inpatient psychiatric care precipitously or against our advice, we still need to do everything we can to arrange a solid follow-up plan,” she says. “This may require some continued work around follow-up planning and communication with patients in the hours and days following an unplanned discharge.”

Doctor Goodfield’s comment:

Whenever a patient, whether in a hospitalized setting or in an outpatient circumstance, makes the decision to unilaterally terminate the treatment process, it should be of major concern to the clinician. This is especially true when suicide is a topic in the treatment process. When suicide is being discussed as an alternative to an unsuccessful life experience, the clinician should give the patient additional attention and perhaps even additional sessions to address this thought process. This includes refocusing the treatment that they are getting and the reaction that they have to it.

When a veteran feels abandoned or on some level that his/her needs are not being met in the treatment they are receiving, they may simply choose to walk away in frustration and anger. Hopelessness or impotence may also lead to inappropriate solutions including giving up on life itself.

When the veteran feels they are overmedicated and perceive their therapist as uninvolved with their issues it is not hard to understand why the veteran might give up on the therapeutic process designed to give insight and alternatives to the problems that brought them to the VA in the first place.

It is not appropriate to chase the patient who appears suicidal. It is however, essential to express genuine concern. This must be followed by specific action to re-address the issue leading to the thought of terminating the treatment process before both agree that the process is over.

Suicidal patients are difficult to deal with and are often seen to be a heavy burden on the therapist. This is no excuse for not following a potentially suicidal patient who terminates therapy before it is officially over. But it certainly can explain why the therapist could become reluctant to reengage in a frustrating experience with someone who is as ambivalent and perhaps even passive aggressive as the one who left treatment.

The study says the risk for suicide may be the greatest in the first few days after discharge. VA/DoD clinical practice guidelines recommend a follow-up within seven days of discharge from hospitals and emergency rooms for patients who remain at high risk of suicide. The guidelines say the patients and family members should receive suicide-prevention information, such as a crisis hotline, as well as treatment plans for psychiatric conditions and for suicide-specific therapies.

But precautionary measures can only do so much. Riblet says in some cases a patient who dies by suicide may exhibit no warning signs prior to the incident. “Available instruments to help in the suicide risk assessment process are also not perfect, and no instrument can predict with absolute certainty who will die by suicide,”

In The Goodfield Method the client or patient is always given regular feedback with video analysis of their nonverbal behavior. This approach highlights deeper unconscious feelings of and to the client. In nearly all cases, strong indications of dissatisfaction in the treatment process are very apparent.

Moreover, this emotional exposure forms the basis for redirecting the therapeutic process to the causality and the need for redirection within the treatment process. When you’re observant and involved, the patient can always feel it. It is the difference between intrinsic and extrinsic motivation. This may lie at the heart of the veteran leaving therapy before the clinical work is complete.

The Goodfield Method’s Use of The Non-Verbal Leak (NVL) could provide an important opportunity for the clinician treating individuals who are seriously considering suicide. By definition, two emotions exist side by side: anxiety and ambivalence. Given these two variables, a clinician concerned about a high-risk of suicide with a  particular patient could ask that individual on video a few pointed questions that might elicit their true unconscious feelings about life and death. 

Suicide Prevention Using the Nonverbal Leak of The Goodfield Method™  The following are ten questions that could be used to determine risk factors with a potentially suicidal patient:

Question 1: How committed are you to your treatment?

Question 2: How effective do you feel the treatment that you’re currently receiving is in helping or hindering your recovery to fully functioning? 

Question 3: On a scale of one to 10, what number would you give to your level of progress in the treatment of your current condition, ten being best?

Question 4: What specifically do you need now to improve the possibility of a successful treatment program?

Question 5: How committed are you to continuing your life on the path it is currently on?

Question 6: What impact do you feel the medication that you are taking is having on your outlook on life; specifically, do you feel it is helping or hindering you? 

Question 7: State one thing that you feel would change your life for the better now, for example a change in your relationship with a person or an event? 

Question 8: Say your name.

Question 9: What do you see when you look at yourself saying your name? What do you see in your facial expression when you say your name? How does that feel? 

Question 10:  Say the name of someone important to you. What do you see when you say that persons name? How does that feel? 

Her research speculates that poor communication between providers may contribute to insufficient knowledge of a patient’s risk for suicide after discharge. “However, we do not know whether better risk assessment or provider communication would actually decrease post-discharge suicide risk,” she says. “This is an area where we need more research.”

They simply don’t see the value or the point of continuing. Sometimes this is a fatal conclusion as the statistics of twenty lost veterans a day indicates. Let me be clear: in no way do I cast aspersions on the men and women who dedicate their lives to helping our veterans. They are doing a difficult job with limited resources in an overwhelming circumstance. Day after day they bring help and hope to our veterans.