1. Integrating Suicide Prevention into the Practicum Experience
Ruth Miller-Thomas, LCSW
Outpatient Mental Health
Salt Lake City VA Medical Center

2. Who is in the Audience? VETERANS? FAMILY MEMBERS OF VETERANS?
This time of year can be particularly difficult on Veterans and their families.
Why do you think that is?

3. Who are our Interns? Second year Master’s level students
10 from the University of Utah
4 from other local Universities
Interns include students taking online MSW courses locally from major out of state Universities

4. Process for Practicum Placement at the VA
Write statement of interest letter
Include at least two letters of recommendation
Applications reviewed and scored by Social Work Student Intern committee
Top applicants interviewed and scored by committee panel
Veterans given consideration, but not automatic placement
Applicants notified about approval or denial of their placement

5. Student Practicum Placements
PTSD team (includes clinical training to treat MST)
TBI/ Polytrauma
OEF/OIF team
IPU
ACT (Access Crisis Team)
Homeless team
Outpatient Mental Health
SUD team
Medical Social Work
Geriatric Emphasis Program
Women’s clinic
Primary Care

6. Student Practicum Placements
Advantages of VA Internships
Social workers all over the hospital/diversity of experiences available (one stop shop)
Most placements with interdisciplinary teams
Many placements include considerable clinical training
Large age range of clients (18 – 90+)
Chief of Social Work emphasizes our clinical skills and builds our professional reputation
Salt Lake VA has large (200 + employees) and very good mental health service (ranked high nationally)

7. Questions?
Is there anything else about student placement you would like to know?

8. Suicide Prevention Team

9. Creation of VA SPT’s
Why is there a Suicide Prevention Team at the Salt Lake VA?
Joshua Omvig OEF/OIF Army Veteran died by suicide in 2005
Parents testified before Congress advocating for more resources for Veterans
Joshua Omvig Bill passed in 2007 specifying:
mandatory training for VA staff and contractors
mental health assessments for Veterans
Suicide Prevention Teams at each VA
research on best practice for Suicide Prevention
treatment for MST (Military Sexual Trauma)
establishment of 24/7 Veterans Crisis Line
outreach and education for Veterans and their families

10. SLC VA Mental Health Crisis System Overview
Veteran enters MH crisis system through their MH provider or the Emergency department
Veteran in crisis meets with an ACT (Access Crisis Team) member in Emergency Department
ACT member does a detailed MH assessment
ACT member admits Veteran to hospital or creates a safety plan with Veteran and discharges him/her home
ACT member notifies Suicide Prevention Team through a Suicide Behavior Report that Veteran has attempted suicide or has SI with plan and intent

11. Role of Suicide Prevention Team in MH Crisis
Suicide Prevention team staffs Veteran and makes a clinical determination about whether to activate a medical record flag
Suicide Prevention team follows up by telephone with Veteran for 90 days
Suicide Prevention Team recommends weekly visits or contacts with MH professional at VA
Connects Veteran to 24/7 Veteran’s crisis line; chat line also available ( then press 1)

12. Question
Why does a person who has had SI or a recent inpatient psychiatric stay due to SI (etc) need more frequent mental health follow up?

13. Role of Suicide Prevention Team
Train all VA staff (and interns!) on suicide prevention strategies
Identify Veterans at high risk for suicide, or self- harm behavior
Provide enhanced and intensive case management services with the goal of improving and maintaining Veteran’s physical, mental, and emotional health

14. Role of Suicide Prevention Team
Collect and analyze data about high risk Veteran population in order to improve mental health provider’s ability to:
(a) recognize and intervene in life threatening behaviors
(b) implement enhanced treatment strategies prior to life threatening behaviors
(c) promote and develop positive supports for High Risk Veterans that will help stabilize their lives long term

15. Role of Suicide Prevention Team
Not “front line” staff
Work with ACT (Access Crisis Team) and other mental health providers to help keep Veterans safe
ACT is main crisis resource at VA
Activate “High Risk” flags on Veteran’s medical charts after a suicide attempt or serious suicidal thoughts, intent and plan [this is a National flag that can be seen by anyone accessing Veteran’s chart]
Maintain ongoing relationships with community agencies and other Suicide Prevention Teams across the country coordinating smooth coordination of care

16. Role of Suicide Prevention Case Managers
Contacting Veterans:
Contact or attempt to contact every Veteran on our case load at 7,14, 21, 30, 60, 90 days post discharge, or from the date they were flagged
Call to check safety, support, treatment compliance, and overall functioning
Complete suicide risk assessments every 30 days
Serve as an additional contact and support to the Veteran as well as the mental health prescriber
Information bridge between Veteran and provider

17. Question
Would anyone be willing to briefly share how Suicide Prevention works at your agency?

18. Student Training at SLCVA
All new VA employees required to take SAVE training
Clinical SAVE training presented to Social Work practicum students
Students offered a one day rotation with the Suicide Prevention Team
Many students interact with at least 1 suicidal Veteran in the course of their placement
SPT always available for consultation

19. What is Operation SAVE Training?

20. SAVE Training
Nationally developed VHA educational suicide prevention slide show
S - Signs of suicidal thinking
A- Ask the question
V- Validate Veteran’s/person’s experience
E- Expedite or Encourage treatment

21. Question?
Who has interacted with a suicidal person in their professional life?
In their personal life?

22. S – Signs of Suicidal Thinking
Learn to recognize these warning signs:
Hopelessness/ Feeling trapped
Rage, anger, seeking revenge
Feeling like a burden on family or support system
Increasing alcohol or drug abuse
Engaging in risky behaviors
Withdrawing from friends, family or society
Anxiety, agitation, unable to sleep or sleeping all the time
Dramatic changes in mood
Feeling unable to “fit in”
Gives away valued possessions

23. Factors that may Increase Risk
Current ideation, intent, plan, access to means
Previous suicide attempt or attempts
Alcohol / Substance abuse
Current or previous history of psychiatric diagnosis
Impulsivity and poor self control
Hopelessness – presence, duration, severity
Recent losses – physical, financial, personal
Recent discharge from an inpatient psychiatric unit
Family history of suicide
Sexual orientation
History of abuse (physical, sexual or emotional)
Co–morbid health problems, especially a newly diagnosed problem or worsening symptoms
Age, gender, race (elderly or young adult, unmarried, white, male, living alone)

24. Increased Risk Factors in Veterans
Frequent deployments
Deployments to hostile environments
Exposure to extreme stress
Physical/sexual assault while in the service (not limited to women)
Length of deployments
Service-related injury
TBI
PTSD

25. A – Ask the Question BE DIRECT Here are some examples:
Are you thinking about killing yourself?
Are you thinking of suicide?
Have you had thoughts about taking your life?
Have you had thoughts about suicide in the past week?

26. Tips When Asking the Question
Remain calm
Listen more than you speak
Maintain eye contact
Do not argue
Use open body language
Limit questions-let the Veteran/ person do the talking
Be supportive
Be honest-there are no quick solutions but help is available

27. V- Validate Person’s Experience
Talk openly about suicide. Be willing to listen and allow the Veteran/person to express his or her feelings.
Recognize that the situation is serious
Do not pass judgment
Reassure that help is available

28. Expedite or Encourage Treatment
What should I do if I think someone is suicidal?
Don’t keep the Veteran’s/person’s suicidal behavior a secret
Do not leave him or her alone
Try to get the person to seek immediate help from his or her doctor or the nearest hospital emergency room, or
Call 911
Reassure the Veteran/person that help is available
Call the Veterans Crisis Line at , Press 1
National Crisis Lifeline is

29. Expedite or Encourage Treatment
Safety Issues:
Never negotiate with someone who has a gun
Get to safety and call 911
If the Veteran/person has taken pills, cut himself or herself or done harm to himself or herself in some way
Call 911

30. Expedite or Encourage Treatment
Remember: When a Veteran/person at risk for suicide leaves your facility, provide suicide prevention information to the Veteran/person and his or her family
When concern for suicide is not imminent
then press 1 for Veteran’s Crisis Line
for National Crisis Lifeline

31. Veteran’s Crisis Line

32. Short VCL Video

33. Safety Planning

34. Safety Planning
Safety planning is a brief clinical intervention that can help protect a person who is at risk for suicide
The intent of the safety plan is to help person lower their imminent risk of suicidal behavior
Consistent with the Recovery Model, the safety planning approach views people as collaborators in their own care and empowers them with more effective means to cope

35. Safety Planning
Safety plans include five basic steps. When the first step fails to decrease the level of suicide risk, the Veteran is instructed to move on to the next step, and so forth.
The steps of a safety plan are as follows:
1. Recognizing warning signs
2. Using internal coping strategies
3. Finding people and social settings that provide distraction from thoughts of suicide.
4. Contacting family members, friends or professionals who may offer help to resolve a crisis
5. Making the environment safe

36. Safety Planning Making the Environment Safe
Risk reduction strategy designed to prevent suicide by restricting access to common means of suicide
Major premise of means restriction is some patients may act on suicidal thoughts impulsively. Delaying impulse to obtaining preferred means gives person time to reconsider and seek help.

37. Safety Planning Making the Environment Safe
Educating healthcare provider is first objective in implementing comprehensive means restriction program
Best approach is using common sense and having a good safety plan.
By remaining aware of this information, you should be able to help person create appropriate safety plan reinforcing means restriction.

38. Resources Mental Health Vet Centers
VHA provides specialty inpatient and outpatient mental health services at its medical centers and community-based outpatient clinics. All mental health care provided by VHA supports recovery, striving to enable a person with mental health problems to live a meaningful life in the community and achieve his or her full potential.
For more information on VA Mental Health Services visit
Vet Centers
Vet Centers are VA community-based centers that provide a range of counseling, outreach, and referral services.
For more information about Vet Centers and to find the Vet Center closest to you visit

39. Resources Make the Connection Post-Traumatic Stress Disorder (PTSD)
MakeTheConnection.net is a one-stop resource where Veterans and their families and friends can privately explore information about physical and mental health symptoms, challenging life events, and mental health conditions. On this site, Veterans and their families and friends can learn about available resources and support. Visit to learn more.
Post-Traumatic Stress Disorder (PTSD)
Each VA medical center has PTSD specialists who provide treatment for Veterans with PTSD. For more information about PTSD and to locate the VA PTSD program nearest you visit
PTSD Coach App: The PTSD Coach application, allows phone users to manage their symptoms, links them with local sources of support, and provides information on PTSD. Visit

40. Resources Veterans Crisis Line/Chat/Text National Crisis Lifeline
, Press 1
Text to
National Crisis Lifeline
International Trans Lifeline
US: (877) Canada: (877)

41. References
1Suicide facts. (2016). Retrieved August 1, 2016, from SAVE Suicide Awareness Voices of Education, B-F1EC-3F FCB4E6
2United States Suicide Injury Deaths and Rates per 100,000 in Retrieved August 2, 2016, from Centers for Disease Control and Prevention WISQARS,
3Suicide Facts at a Glance. (2015). Retrieved August 1, 2016, from Centers for Disease Control and Prevention,
4CDC. (2016, July 6). Assault or Homicide. Retrieved August 1, 2016, from National Center for Health Statistics,
5U.S. Department of Veterans Affairs (2016). Suicide among Veterans and other Americans Washington, DC: Office of Suicide Prevention.
6Based on suicide/ suicide attempts reported within the VA Suicide Prevention Application Network (SPAN) during calendar year 2014.