Psychiatric Annals

CME Article 

Preventing Suicidal Self-Directed Violence Among Survivors of Military Sexual Trauma: Understanding Risk and Applying Evidence-Based Principles

Ryan Holliday, PhD; Jessica Wiblin, PhD; Nicholas Holder, PhD; Georgia R. Gerard, MSW; Bridget B. Matarazzo, PsyD; Lindsey L. Monteith, PhD

Abstract

Military sexual trauma (MST), which is defined as sexual harassment and/or assault during a person's military service, is associated with suicidal self-directed violence. Suicide risk assessment and intervention with survivors of MST should be patient-centered and informed by an understanding of the impact of interpersonal trauma and military service on the survivor's lived experience. Considerations for assessing and intervening upon suicide risk with survivors of MST are discussed, with a particular focus on safety planning, lethal means safety, and psychotherapy. We conclude by discussing necessary future research in suicide prevention in this population. [Psychiatr Ann. 2020;50(10):437–443.]

Abstract

Military sexual trauma (MST), which is defined as sexual harassment and/or assault during a person's military service, is associated with suicidal self-directed violence. Suicide risk assessment and intervention with survivors of MST should be patient-centered and informed by an understanding of the impact of interpersonal trauma and military service on the survivor's lived experience. Considerations for assessing and intervening upon suicide risk with survivors of MST are discussed, with a particular focus on safety planning, lethal means safety, and psychotherapy. We conclude by discussing necessary future research in suicide prevention in this population. [Psychiatr Ann. 2020;50(10):437–443.]

Approximately 3.9% of men and 38.4% of women report experiencing military sexual trauma (MST), which is defined as sexual harassment or sexual assault during a person's military service.1 MST is associated with numerous negative biopsychosocial consequences.2–5 This includes increased risk for suicidal ideation, suicide attempt, and suicide.6 Psychiatric symptoms and diagnoses (eg, depression, substance use disorder, and posttraumatic stress disorder [PTSD]) are also prevalent among survivors of MST4,5 and partially account for the association between MST with suicidal ideation and suicide attempt.7

In addition to increased risk of psychiatric diagnoses, several factors related to experiences during and after MST are thought to perpetuate suicide risk. One such factor includes the experience of institutional betrayal.8 For example, survivors of MST often report that the military institution fosters an environment in which MST is more likely to occur and that the institutional response to MST is inadequate. These perceptions are associated with suicide attempts in survivors of MST.8 Further, perceived institutional betrayal may result in negative perceptions and mistrust of the federal government, including the Department of Veterans Affairs (VA), where many treatment resources for survivors of MST are available.9

Survivors of MST also often disclose difficulties trusting others or establishing a sense of safety after their experiences,9,10 and such negative posttraumatic beliefs are salient predictors of suicidal ideation and attempt.10 Further, survivors of MST may generalize these perceptions to health care providers, particularly given the power differential inherent to the patient-provider relationship. Negative experiences at VA health care facilities (eg, sexual harassment of female veterans by male veterans) may further reinforce these beliefs.11 Theoretically, perceptions of betrayal, mistrust, and danger may delay or impede initiation and engagement in mental health care and receipt of suicide-focused assessment and intervention.9 For these reasons, suicide prevention-focused care for survivors of MST necessitates a nuanced, trauma-informed, and culturally specific (eg, understanding of military culture) approach.

Application of Evidence-Based Principles to Prevent Suicide Among Survivors of MST

Assessment

Suicide prevention necessitates identifying suicide risk early, assessing it in a comprehensive manner, and providing patient-centered, evidence-based care. Widespread screening can facilitate this process. In the VA health care system, the Patient Health Questionnaire-912 and Columbia-Suicide Severity Rating Scale13 are used to identify elevated suicide risk. Consistent with the newly revised VA/Department of Defense Clinical Practice Guideline for the Assessment and Management of Patients at Risk for Suicide,14 veterans who screen positive for elevated acute risk receive a comprehensive suicide risk evaluation. Comprehensive evaluation should occur via a robust clinical interview that can be augmented with empirically validated assessment tools. Data gathered in this process should be integrated to gain a nuanced understanding of the veteran's desire for death. These data can then be synthesized to determine acute (ie, hours to days) and chronic (ie, longer-term) level of risk (ie, low, intermediate, high). Once this is determined, providers can work collaboratively with the patient to develop a personalized suicide risk mitigation strategy that corresponds to level of risk.14

Several factors unique to survivors of MST are important to attend to when conducting routine suicide risk assessment and planning for safety (see Table 1 for MST-specific considerations and potential solutions). Many of these factors pose challenges that can be attenuated with use of a trauma-informed approach. As previously mentioned, survivors of MST may contend with difficulty trusting or feeling safe with other people. These difficulties may be exacerbated in health care settings where the provider may be the same gender as the victim's perpetrator or within an institutional setting wherein the survivor has experienced feelings of betrayal. This situation is particularly concerning for suicide risk disclosure, which is facilitated by trust and a sense of safety.15

Considerations for Suicide Risk Assessment and Intervention with Survivors of MSTConsiderations for Suicide Risk Assessment and Intervention with Survivors of MST

Table 1.

Considerations for Suicide Risk Assessment and Intervention with Survivors of MST

Using a trauma-informed approach includes a provider's acknowledgment that answering questions about suicidal thoughts and behavior is vulnerable and potentially distressing. Without acknowledging these interpersonal dynamics, providers may inadvertently intensify the power differential that exists between the patient and provider. Exacerbating power dynamics may be particularly problematic given that survivors of MST often report sexual harassment or assault perpetrated by a higher-ranking person, and they may experience such power-differentials as a reminder of their trauma.16 To prevent the formation of this dynamic as well as the potential for distress or guardedness that can follow, providers can work collaboratively with their patients to provide transparent information about why suicide risk is being assessed and what suicide risk assessment and subsequent intervention might entail. The explanation should be detailed and patient-centered so it can serve to inform the patient of their options, build trust, and increase transparency.

In conducting suicide risk assessments with survivors of MST, providers should also be attuned to common reactions of stress and trauma (eg, physiologic or cognitive-affective responses). Should the survivor appear to be experiencing a stress- or trauma-related reaction, providers can compassionately and openly invite discussion of these reactions so as to normalize these reactions while also validating these reactions within the context of prior distressing experiences. Should the survivor of MST report they are feeling dysregulated or overwhelmed, providers can use this as an opportunity to practice empirically supported techniques (eg, cognitive reframing, deep breathing exercises, dialectical behavior therapy [DBT] coping skills) in real time. Further, providers should tailor their questioning to be open-ended and nonjudgmental to ensure assessment free of bias.

Intervention

Based on the severity of acute and chronic suicide risk, a number of interventions can be implemented to mitigate such risk (Table 1).

Safety planning. For those persons who are found to be at elevated risk for suicide, safety planning is a brief, empirically supported intervention for preventing suicide attempts and can be used to facilitate coping to prevent or manage episodes of elevated acute suicide risk.17 Specifically, providers and patients work collaboratively to identify early warning signs (eg, feeling hopeless about the future or believing that one is a burden to those around them). In the presence of these warning signs, providers can help the survivor to identify effective internal coping strategies (eg, deep breathing) and external coping strategies (eg, going to a park with friends) they can use when distressed. Should these coping skills prove to be inadequate, providers can also delineate mental health and emergency resources to contact if necessary.

Providers should again be cognizant of the potential role of MST-related sequelae and psychiatric symptoms while safety planning. Survivors of MST, especially those with PTSD, may use avoidance and risky behaviors to cope. Such behaviors may include nonsuicidal self-directed violence, disordered eating, risky sexual behaviors, and substance use.3 These strategies may be reinforced by the provision of immediate relief (eg, emotion regulation, avoidance of distressing emotions), but often have negative long-term social, financial, legal, or health-related consequences, which may further exacerbate risk for suicide. Given the potentially reinforcing nature of avoidance and risky behaviors, providers can facilitate insight into the long-term consequences of risky behaviors, as well as help the survivor differentiate between healthy and unhealthy forms of coping. Motivational interviewing18 is a particularly useful tool for exploring the discrepancy between MST survivors' goals and such behaviors. Motivational interviewing can help survivors to explore their own motivation for decreasing risky behaviors, as well as enhance their self-efficacy and increase their optimism for change.

Lethal means safety. Lethal means safety interventions focus on decreasing access to a method of attempting suicidal self-directed violence (ie, a lethal means).19 In general, during lethal means safety interventions, providers work with patients to identify the presence of potentially lethal means of suicide (eg, firearms, medications, toxic substances, or sharp objects) and explore strategies to decrease access. This is likely especially salient for those with access to firearms, as military personnel and veterans often have increased access to and knowledge of firearms, which is associated with greater suicide risk.20 As lethal means safety interventions have empirical support,19 it is thus critical to assess a patient's access to lethal means as part of suicide risk assessment and prevention. In addition, it is important to consider that treatment of MST-related sequelae may increase the availability of lethal means through prescription of medications with potential for overdose.

It is similarly important for providers working with survivors of MST to be aware of the potential function of veterans' access to lethal means. Prior interpersonal violence, including military sexual assault, has been noted as a potential reason that some veterans acquire firearms and store them unsafely (eg, loaded or unlocked). Specifically, some survivors of MST note they acquired firearms for self-protection from subsequent interpersonal violence.21 Additionally, survivors of MST engaging in nonsuicidal self-directed violence also may wish to maintain access to certain means (eg, knives) as a method of emotion regulation. In such circumstances, a trauma-informed approach to lethal means safety is even more important. Providers may consider motivational interviewing strategies to validate the factors that may increase a survivor of MST's desire for access to a weapon (eg, self-protection), while also providing education about risks and working collaboratively to identify acceptable and feasible solutions.18,21

Targeting Drivers of Suicide Risk

Psychiatric symptoms and substance use. Many evidence-based psychotherapies, such as cognitive-behavioral therapy, acceptance and commitment therapy, and interpersonal therapy, have efficacy in treating psychiatric diagnoses that are prevalent among survivors of MST (eg, depression, PTSD, substance use disorders). Initial research suggests that survivors of MST are likely to benefit from these treatments, which may in turn reduce suicide risk among military personnel and veterans. For example, effective treatment of MST-related PTSD using cognitive processing therapy22 appears to reduce suicidal ideation and suicide-related beliefs in survivors of MST.23,24 However, research on the efficacy of most treatments specifically for survivors of MST remains limited.25 Importantly, survivors of MST may experience difficulties with emotion regulation and distress tolerance,26 and providers must decide when it is necessary to interrupt a treatment protocol for psychiatric symptoms (eg, PTSD or depression) to focus on stabilization of acute distress or suicidality. Safety planning can be integrated into evidence-based psychotherapy to ensure acute suicide risk is appropriately managed while treating psychiatric symptoms.27,28

Many survivors of MST present with multiple psychiatric comorbidities. In such situations, it can be difficult to identify which diagnosis to target initially. Dual-diagnosis treatments (eg, concurrent treatment of PTSD and substance use disorders using prolonged exposure)29 may be particularly beneficial, especially if substance use is a therapy-interfering behavior. At times, the presence of acute suicide risk (eg, current hospitalization), may delay the initiation of an evidence-based treatment for a specific psychiatric diagnosis. In these instances, providers can consider treatments that enhance coping skills and that also have demonstrated efficacy in reducing suicidal thoughts and behaviors (eg, DBT). In general, it is essential to consider the short-term and long-term impacts of different treatment courses on survivors of MST's acute and chronic suicide risk in these circumstances. For example, a course of DBT may provide coping strategies for managing acute distress, but likely will not ameliorate the PTSD symptoms (eg, intrusive thoughts, negative posttraumatic cognitions) that may contribute to chronic suicide risk.

Cognitions regarding trust, safety, and betrayal. For some survivors of MST, beliefs regarding trust, safety, and betrayal may be identified as drivers of suicide risk.8,10 In these circumstances, providers may choose interventions that target these beliefs. First-line interventions for PTSD (eg, cognitive processing therapy) are often effective at helping patients to identify and address distorted beliefs about self, world, the future, and others after a traumatic experience, including military sexual assault.30 When PTSD treatment is not indicated, providers can use cognitive and behavioral approaches to address underlying beliefs that may affect suicide risk and treatment engagement among survivors of MST. Challenging unhelpful beliefs related to trust, safety, and betrayal may be an iterative process that takes time, particularly when beliefs have been reinforced by prior or recent events. In these instances, the provider should continue to work with the survivor of MST to reframe cognitive and behavioral exercises as “experiments” wherein the survivor can continually gather “data” to help inform and ultimately shift beliefs and behavior. Clinicians may help the client reflect and redesign exercises that were not initially successful and also help the client challenge “all or nothing” conclusions about exercises (eg, “a man made an inappropriate comment while I was practicing an exposure exercise in the waiting room, so I should never go to a doctor's appointment again”).

Hospitalization

Finally, hospitalization may be warranted in circumstances when safety cannot be maintained independently (eg, patient reports suicidal ideation with intent and refuses to create a safety plan and has a history of pharmacotherapy noncompliance). However, providers should carefully weigh the decision to hospitalize a survivor of MST because data indicate that hospitalization can adversely impact the patient and is, at times, contraindicated.31 Advantages of hospitalization may include more immediate, increased safety against suicidal self-directed violence, initiation or titration of pharmacotherapy, and teaching of coping skills. However, hospitalization does not allow the patient to practice important coping strategies for managing distress on an outpatient basis, which is likely particularly helpful for those experiencing a chronic history of suicide ideation or self-directed violence. In addition, providers should consider whether hospitalization will adequately address drivers of suicide risk. If it does not, it is likely that risk for suicide will persist after discharge.31

As such, patients are likely to experience increased benefit from outpatient care, which facilitates their ability to learn and implement coping strategies to use during acute suicidal crises. Further, providers can consider, in these instances, increasing the intensity of outpatient care, such as using a DBT approach of concurrent group and individual therapy with between-session phone coaching as necessary. In light of this, and to ensure the autonomy of the patient is maintained, hospitalization should always be considered a final step. Moreover, whenever possible, hospitalization should occur voluntarily, particularly to ensure that it is not further traumatizing for survivors of MST.

Gaps in Understanding and Future Directions

Suicide intervention research specific to samples of survivors of MST remains limited. Thus, providers are currently required to rely on research conducted in other samples (eg, non-military trauma or veterans with combat trauma). Although data from other samples are informative, interventional research focused on addressing suicide risk among survivors of MST is warranted.25 Future research should include randomized clinical trials of specific suicide risk-reduction interventions as well as acceptability and feasibility trials of such interventions with this population. Such research is integral to informing current evidence-based treatment, as well as steps for tailoring interventions specific to this population.

Until such research is conducted, providers can and should use general empirically supported approaches to suicide risk assessment and intervention. Specifically, providers should use evidence-based, structured methods of assessing suicide risk in addition to a robust clinical interview. As indicated, appropriate evidence-based safety planning interventions should be administered. These assessment and interventional approaches should be further tailored to the needs of survivors of MST by considering the role of military cultural factors, psychiatric comorbidity, as well as specific drivers of suicide risk (eg, perceived safety, trust, and betrayal). In implementing these practices, providers can ensure that their routine suicide risk assessment and intervention is evidence based, culturally sensitive, trauma-informed, and consistent with clinical practice guidelines.

References

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Considerations for Suicide Risk Assessment and Intervention with Survivors of MST

Clinical approach MST-related consideration Potential solutions
Assessment Perceptions of distrust and danger may be heightened when working with providers of the same gender as the MST perpetrator or when a power differential is present Perceptions of institutional betrayal may generalize to federal entities (eg, VA) and preclude health care initiation, engagement, or disclosure Engage in an open, detailed informed consent process, discussing the purpose of suicide risk assessment and potential interventions that may follow Prioritize maintaining patient autonomy in their clinical decision-making processes Discuss common reactions to stress and trauma and identify them as they occur. Normalize and validate the emotions occurring while continuing to reinforce the purpose and utility of suicide risk assessment Ask open-ended and nonjudgmental questions (eg, “have you had any thoughts about killing yourself?” rather than “you haven't had any thoughts about suicide, right?”) to ensure assessment is free of bias
Safety planning Avoidance or risky behavior (eg, self-directed violence, risky sexual behavior, substance use) as a means of coping Collaboratively weigh the short-term benefits of these strategies with potential long-term consequences Distinguish healthy forms of distancing (eg, taking a brief break before returning to an environment or social situation; identifying unhealthy situations and removing oneself) versus unhealthy forms of avoidance (eg, entirely removing oneself from a situation anytime stress is experienced) Use motivational interviewing to identify discrepancies between goals and current behaviors
Lethal means safety MST survivors may be prescribed medications that could be used for a suicide attempt Access to firearms or desire to maintain access to items to engage in nonsuicidal self-directed violence (eg, knives) Knowledge of and familiarity with firearms due to military training Discuss strategies to decrease access to excess medications Explore reasoning for access to these lethal means, especially during episodes of elevated acute suicide risk Use motivational interviewing to explore perceptions of reducing access to lethal means and develop patient-centered strategies to reduce access Do not directly confront the MST survivor regarding access; instead take a trauma-informed approach that validates the potential function of the lethal means access (eg, feeling safe from being sexually assaulted again) while collaborating and identifying acceptable and feasible strategies to decrease lethal means access
Psychotherapy MST survivors may have experienced numerous stressful or traumatic experiences throughout their lifetime MST survivors often present with a number of psychiatric comorbidities Heightened acute suicide risk may prevent initiation of evidence-based treatment for psychiatric diagnoses Perceptions of distrust, lack of safety, and betrayal may affect the psychotherapeutic process Difficulties with emotion regulation or distress tolerance often accompany MST A number of evidence-based treatments can benefit MST survivors, even those with extensive trauma histories Providers can consider dual-diagnosis treatments that address psychiatric symptoms and substance use concurrently (eg, concurrent treatment of PTSD and substance use disorders using prolonged exposure) Should initiation of evidence-based psychothreapy for a psychiatric diagnosis be precluded due to suicide risk, providers can consider evidence-based treatments specifically targeted at acute and chronic suicide risk to address distress tolerance and emotion regulation difficulties, as these may exacerbate suicide risk and impede other evidence-based treatments Providers can target distorted beliefs of trust, safety, and betrayal using cognitive and behavioral approaches Emphasize that reframing beliefs may take time and can be exacerbated by prior or between-session events. If this occurs, providers can support identifying new learning and problem-solve barriers to enhance success of future exercises Should the MST survivor present to a session with a crisis, providers should weigh continuing the current course of treatment or focusing on acute stabilization. Providers can work with patients to weigh potential benefits and drawbacks to interrupting treatment, particularly in relation to short-term and long-term suicide risk and collaboratively decide on next steps
Hospitalization Perception that one has no power or control may mirror feelings or cognitions during or after the survivor's experience of MST Providers should provide comprehensive informed consent regarding the purpose and utility of hospitalization (eg, to maintain safety when the patient cannot autonomously). If possible, hospitalization should occur voluntarily to ensure the patient does not feel re-traumatized by the experience Hospitalization should be considered only as a final resort
Authors

Ryan Holliday, PhD, is a Clinical Research Psychologist, Rocky Mountain Regional VA Medical Center, Rocky Mountain Mental Illness Research, Education and Clinical Center (MIRECC) for Veteran Suicide Prevention; and an Assistant Professor, University of Colorado Anschutz Medical Campus. Jessica Wiblin, PhD, is an Advanced Fellow in Women's Health, Health Services Research and Development Center for the Study of Healthcare Innovation, Implementation & Policy, and the VA Greater Los Angeles Healthcare System. Nicholas Holder, PhD, is an Advanced Research Postdoctoral Fellow, San Francisco Veterans Affairs Health Care System, Sierra Pacific Mental Illness Research, Education and Clinical Center, and University of California San Francisco, School of Medicine. Georgia R. Gerard, MSW, is a Social Worker, Rocky Mountain Regional VA Medical Center, Rocky Mountain MIRECC for Veteran Suicide Prevention. Bridget B. Matarazzo, PsyD, is the Director of Clinical Services, Rocky Mountain Regional VA Medical Center, Rocky Mountain MIRECC for Veteran Suicide Prevention; and an Associate Professor, University of Colorado Anschutz Medical Campus. Lindsey L. Monteith, PhD, is a Psychologist, Rocky Mountain Regional VA Medical Center, Rocky Mountain MIRECC for Veteran Suicide Prevention; and an Associate Professor, University of Colorado Anschutz Medical Campus.

Address correspondence to Ryan Holliday, PhD, Rocky Mountain Regional VA Medical Center, Rocky Mountain MIRECC, 1700 N. Wheeling, Aurora, CO 80045, email: Ryan.Holliday@va.gov.

Grant: This work is supported in part by the Office of Academic Affiliations, Advanced Fellowship Program in Mental Illness Research and Treatment, Department of Veterans Affairs; Department of Veterans Affairs Office of Academic Affiliations through the Advanced Fellowship Programs in Health Services Research and Development and in Women's Health; San Francisco Veterans Affairs Health Care System; Sierra Pacific Mental Illness Research, Education, and Clinical Center; the University of California San Francisco; and the Rocky Mountain MIRECC for Veteran Suicide Prevention.

Disclaimer: The views expressed are those of the authors and do not necessary express the views of the Department of Veterans Affairs or the United States Government.

Disclosure: The authors have no relevant financial relationships to disclose.

10.3928/00485713-20200908-01

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