Feature Article

Contest winner: Suicide risk assessment and management guidance for military psychologists

A brief overview of best practices in suicide prevention and associated resources is provided.

By Laura L. Neely, PsyD, Jennifer Tucker, PhD, Jamie T. Carreno, PhD, Geoffrey Grammer, MD, and Marjan Ghahramanlou-Holloway, PhD

The primary objective of this article is to enhance competencies of military psychologists in the area of suicide risk assessment and management. A comprehensive review of suicide risk assessment and management is beyond the scope of this article. However, a brief overview of several best practices in suicide prevention, along with associated resources, is provided.

Military Psychologists and Suicide Prevention

Suicidal self-directed violence remains a significant public health problem for the U.S. Armed Forces. Since 2010, suicide has become the second leading cause of death, unrelated to war, within the Department of Defense (DoD; Armed Forces Health Surveillance Center, 2012). Given the scope of the problem, military psychologists can play a significant role in the prevention of suicidal self-directed violence among service members and their families. Knowledge about evidence-based practices in suicide risk assessment and management serves as a foundational core for subsequent dissemination of best practices.

Suicide Risk Assessment

Clinical Practice Guideline Resources

Military psychologists can benefit from two disseminated guides on suicide prevention: (1) “Clinical Practice Guideline for Assessment and Management of Patients at Risk for Suicide” (2013), disseminated by the U.S. Department of Veterans Affairs and DoD; and (2) Air Force “Guide for Suicide Risk Assessment, Management, and Treatment” (2013), disseminated by the U.S. Air Force Medical Operations Agency and the Uniformed Services University of the Health Sciences.

Recommendations for Suicide Risk Assessment

Overall, a thorough suicide risk assessment is always dependent on a solid understanding of factors contributing to a patient's suicide ideation and/or behavior. Military psychologists are encouraged not to simply rely on a single indicator to determine a patient's risk for suicide. Instead, three sources of information can ideally guide the suicide risk assessment determination: (1) clinical interview where the patient is asked about past and current suicide thoughts, intent, and plan as well as risk and protective factors; (2) self-report and/or clinician-administered, psychometrically sound instruments; and (3) collateral information (if available with the proper patient authorization) from military unit, peers, medical records, and/or family members. Table 1 provides a brief summary of recommended psychological instruments.

Suicide Risk Management

Safety Planning Intervention

The Safety Planning Intervention (SPI; Stanley & Brown, 2008, 2012) may be used as a stand-alone (e.g., in the emergency room) or as an adjunctive intervention. The SPI has been recognized as a best practice by the Suicide Prevention Resource Center and the American Foundation for Suicide Prevention Best Practices Registry for Suicide Prevention. The SPI includes four evidence-based risk reduction strategies: (1) means restriction, (2) problem-solving and distress tolerance coping skills, (3) social support and use of emergency contacts, and (4) motivational enhancement to increase engagement in appropriate treatment. Military psychologists are encouraged to work collaboratively with the suicidal patient in developing a safety plan to be used to manage a future suicidal crisis. A safety plan app is now available free of charge, on iTunes.

Cognitive Behavior Therapy

A 10-session outpatient cognitive behavior therapy (CBT) protocol (Brown et al., 2005) has proven efficacious in reducing suicide attempts in adult outpatients. Findings indicate that an average of nine hours of individual outpatient CBT reduces the likelihood of repeat suicide attempts by approximately 50 percent. The adapted inpatient intervention is called postadmission cognitive therapy (PACT). PACT is administered in approximately six to eight face-to-face individual sessions (60-90 minutes) over the course of three to six days during inpatient psychiatric hospitalization. A full description of the inpatient model is provided by Ghahramanlou-Holloway, Cox, and Greene (2012) in “ Cognitive and Behavioral Practice .” A case study is provided in “ Clinical Case Studies” (Neely et al., 2013).

Hope Box

Military psychologists may use a sample CBT activity that involves the construction of a “hope box” to help their suicidal patient challenge suicide-activating thoughts (e.g., “I am a burden to my family and military unit”). The purpose of the hope box is to help patients directly challenge their maladaptive thoughts by being reminded of previous successes, positive experiences, and current reasons for living, especially at times of extreme distress. The National Center for Telehealth and Technology has recently developed and disseminated a Virtual Hope Box smartphone application that can be used by military psychologists to guide their suicidal patients through the process of building, storing, and accessing one's hope box through a mobile device.

Continuing Education

Military psychologists are an integral asset to the DoD's mission in suicide prevention. To maintain competencies in implementing best practices in suicide risk assessment, management, and treatment, military psychologists must take an active role in obtaining continuing education on the topic. The American Association of Suicidology and the American Foundation for Suicide Prevention are two avenues for gaining additional education on suicide prevention. Moreover, military psychologists can serve as an important resource for one another. Timely supervision, consultation, and effective communication with colleagues are key ingredients in maximizing patient care and minimizing risk. Journals such as Archives of Suicide Research , Suicide and Life-Threatening Behavior and Military Psychology provide additional opportunities for enhancing knowledge of military suicide. Finally, the Military Suicide Research Consortium and the Army Study to Assess Risk and Resilience in Servicemembers, or Army STARRS , can serve as a solid source of reliable information on military suicide prevention research.

Table 1

Recommended Psychological Instruments for Suicide Risk Assessment





General assessments with suicide-specific items

Revised Behavior and Symptom Identification Scale


Eisen et al. (2004)

Beck Depression Inventory (2nd ed.)


Beck et al. (1996)


Beck Hopelessness Scale


Beck & Steer (1988)


Mini-International Neuropsychiatric Interview 6.0, Suicidality Subscale


Sheehan et al. (1998)


Outcome Questionnaire


Lambert et al. (2004)


Patient Health Questionnaire


Kroenke et al. (2001)


Suicide-specific assessments

Acquired Capability for Suicide Scale


Van Orden et al. (2008)

Columbia–Suicide Severity Rating Scale, Military Version


Posner et al. (2011)


Suicide Behaviors Questionnaire–Revised


Osman et al. (2001)


Suicide Status Form


Jobes (2006)


Scale for Suicide Ideation


Beck et al. (1979)


The views expressed in this article are those of the author and do not reflect the official policy of the Department of Defense and/or the United States government.

Funding Acknowledgment

Support for the Laboratory for the Treatment of Suicide-Related Ideation and Behavior has been provided to Ghahramanlou-Holloway (principal investigator) by the Department of Defense, Congressionally Directed Medical Research Program (W81XWH-08-2-0172), Military Operational Medicine Research Program (W81XWH-09-2-0129; W81XWH-11-2-0106), and National Alliance for Research on Schizophrenia and Depression (15219).

Point of Contact Information

Marjan Ghahramanlou-Holloway, Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Room 3050, Bethesda, MD 20814-4799.


Armed Forces Health Surveillance Center. (2012). Deaths by suicide while on active duty, active and reserve components, U.S. Armed Forces, 1998–2011. Medical Surveillance Monthly Report, 19 (6), 7–10.

Beck, A. T., Kovacs, M., & Weisman, A. (1979). Assessment of suicidal ideation: The Scale for Suicide Ideation. Journal of Clinical and Consulting Psychology, 47, 343–352. http://dx.doi.org/10.1037/0022-006X.47.2.343

Beck, A. T., & Steer, R. A. (1988 ). Manual for the Beck Hopelessness Scale . San Antonio, TX: Psychological Corporation.

Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Manual for the Beck Depression Inventory–II. San Antonio, TX: Psychological Corporation.

Brown, G. K., Ten Have, T., Henriques, G. R., Xie, S. X., Hollander, J. E., & Beck, A. T. (2005). Cognitive therapy for the prevention of suicide attempts: A randomized controlled trial. Journal of the American Medical Association, 294 , 563–570. http://dx.doi.org/10.1001/jama.294.5.563

Eisen, S. V., Normand, S.-L. T., Belanger, A. J., Spiro, A., III, & Esch, D. (2004). The Revised Behavior and Symptom Identification Scale (BASIS-R): Reliability and validity. Medical Care, 42, 1230–1241.

Ghahramanlou-Holloway, M., Cox, D., & Greene, F. (2012). Post-admission cognitive therapy: A brief intervention for psychiatric inpatients admitted after a suicide attempt. Cognitive and Behavioral Practice, 19, 233–244. http://dx.doi.org/10.1016/j.cbpra.2010.11.006

Jobes, D. A. (2006). Managing suicidal risk: A collaborative approach . New York, NY: Guilford Press.

Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16 , 606–613.

Lambert, M. J., Morton, J. J., Hatfield, D., Harmon, C., Hamilton, S., Reid, R. C., . . . Burlingame, G. M. (2004). Administration and scoring manual for the Outcome Questionnaire, 45. Salt Lake City, UT: OQ Measures.

Neely, L., Irwin, K., Carreno Ponce, J. T., Perera, K., Grammer, G., & Ghahramanlou-Holloway, M. (2013). Post-admission cognitive therapy (PACT) for the prevention of suicide in military personnel with histories of trauma: Treatment development and case example. Clinical Case Studies, 12, 457–473. http://dx.doi.org/10.1177/1534650113501863

Osman, A., Bagge, C. L., Gutierrez, P. M., Konick, L. C., Kooper, B. A., & Barrios, F. X. (2001). The Suicidal Behaviors Questionnaire–Revised (SBQ–R): Validation with clinical and nonclinical samples. Assessment, 8 , 443–454. http://dx.doi.org/10.1177/107319110100800409

Posner, K., Brown, G. K., Stanley, B., Brent, D. A., Yershova, K. B., Oquendo, M. A., . . . Mann, J. J. (2011). The Columbia–Suicide Severity Rating Scale: Initial validity and internal consistency findings from three multisite studies with adolescents and adults. American Journal of Psychiatry, 168, 1266–1277. http://dx.doi.org/10.1176/appi.ajp.2011.10111704

Sheehan, D. V.a, Lecrubier Y., Sheehan K. H., Amorim, P., Janavs, J., Weiller, E., . . . Dunbar, G. C. (1998). The Mini-International Neuropsychiatric Interview (M.I.N.I.): The development and validation of a structured diagnostic psychiatric interview for DSM–IV and ICD–10 . Journal of Clinical Psychiatry, 59 (Suppl. 20), 22–33.

Stanley, B., & Brown, G. K. (2008). Safety plan treatment manual to reduce suicide risk: Veteran version. Washington, DC: U.S. Department of Veterans Affairs.

Stanley, B., & Brown, G. K. (2012). Safety planning intervention: A brief intervention to mitigate risk. Cognitive and Behavioral Practice, 19 , 256–264. http://dx.doi.org/10.1016/j.cbpra.2011.01.001

U.S. Air Force Medical Operations Agency. (2013). Air Force guide for suicide risk assessment, management, and treatment . San Antonio, TX: Author.

U.S. Department of Veterans Affairs & U.S. Department of Defense. (2013). VA/DoD clinical practice guideline for assessment and management of patients at risk for suicide . Washington, DC: Author.

Van Orden, K. A., Witte, T. K., Gordon, K. H., Bender, T. W., & Joiner, T. E., Jr. (2008). Suicidal desire and the capability for suicide: Tests of the interpersonal–psychological theory of suicidal behavior among adults. Journal of Consulting and Clinical Psychology, 1, 72–83. http://dx.doi.org/10.1037/0022-006X.76.1.72