Risk management approach: Building a “Layered Defence” 

Canadian Armed Forces Suicide Prevention Action Plan

In reality, as mentioned in the Treasury Board Guide to Integrated Risk Management, “risk is unavoidable and present in virtually every human situation.” To ensure comprehensiveness, the CAF SPAP will apply a risk management approach that targets risk factors in a multi-layered approach.

The Treasury Board Guide to Integrated Risk Management, provides a succinct description of risk management as follows:

Risk management …involves a systematic approach to setting the best course of action under uncertainty by identifying, assessing, understanding, making decisions on, and communicating risk issues…  It does not necessarily mean risk avoidance in the case of potential threats. Rather, risk management equips organizations to make decisions that are informed by an understanding of their risks, and ultimately to respond proactively to change by mitigating the threats, and capitalizing on the opportunities…

Risk management involves three critical functions, all of which will be addressed in the CAF SPAP:

  1. Assess and understand the risk;
  2. Eliminate, reduce and/or mitigate risk factors whenever possible; and
  3. Establish layered defenses to create, or enhance, protective “barriers” and minimize the chance of an adverse event.

The SPAP aims to reduce the risks of suicide across the organization through a broad and proactive approach in line with the Canadian Armed Forces and Veterans Affairs Canada Joint Suicide Prevention Strategy that includes:

  1. Prevention.
    Actions taken to prevent suicidality such as research, education campaigns and enhancing factors that protect against suicide, including improving member health and well-being;
  2. Intervention.
    Actions taken when an individual becomes suicidal. The focus of the intervention phase is on identification, treatment and care of an individual who is displaying suicidal thoughts and behaviour; and
  3. Postvention.
    Actions taken after an individual has died by suicide such as providing support and care to for family, friends and caregivers of the person who has ended their life by suicide, understanding the reasons for the suicide, and identifying lessons learned.

This broader organizational approach of risk reduction is a proactive approach in accordance with many community health and wellness models. Whether one considers issues like heart disease, cancer, or mental health, there are multiple factors that contribute. By focusing on improving the overall health and wellness of CAF members and Veterans, the joint strategy will improve the likelihood that CAF members and Veterans can navigate and manage the stressors and demands of military training, operations, employment, and post-military life.

The CAF takes this broader perspective because of the significant foundational work on suicide prevention that has been done within the organization to date, including the identification of specific suicide risk factors and key protective factors that can reduce the risk of suicide. One of the foundational pieces of this strategy has been the core work produced by the CAF Health Services on suicidality. The modified Mann Model (Figure 3) below depicts this approach. It indicates the various potential stressors that could impact negatively on our members as well as the broad potential prevention, intervention, and postvention areas of engagement available to reduce the risk of suicide. Some of the foundational work on risk factors and protective factors associated with suicidology referred to above are outlined below.

Figure 3

Figure 3. Zamorski, M.A. (2010), Report of the CF Expert Panel on Suicide Prevention

A flow diagram depicting potential stressors that could negatively impact a person, leading to a Suicidal Act, and interventions that could be beneficial. The potential stressors are Leadership and Organizational Factors (including Barriers to Care and Delivery of Effective Care), and Individual Risk and Resilience Factors: Other Work-Related Stress, Work-Related Stressful Life Events, and Other Stressful Life Events, which combined with a Mood or Other Psychiatric Disorder could lead to Suicidal Ideation. Suicidal Ideation could lead to a Suicidal Act, if it is accompanied by feelings of Impulsivity, Hopelessness, Pessimism, and/or Emotional Dysregulation, and External Environment factors including Access to Lethal Means and Imitation are present.

Intervention interventions:

  • A. Education and Awareness Programs for:
    • Primary Care Providers
    • Members
    • Gatekeepers
  • B. Screening Assessment;
    • C. Pharmacotherapy
    • D. Psychotherapy
    • E. Follow-up Care
  • F. Restriction of Access to Lethal Means
  • G. Media Engagement
  • H. Organizational Interventions to Mitigate Work Stress / Strain
  • I. Selection / Resilience Training / Risk Factor Modification
  • J. Interventions to Overcome Barriers to Care
  • K. Systematic Clinical Quality Improvement Efforts

Risk Factors

“The likelihood that someone will think about, attempt or die by suicide may increase or decrease due to a complex interplay of these factors, which may include individual, relational, socioeconomic and/or cultural factors (ref A).” Some of the factors that have been associated with an increased risk of suicidality are identified in the sub-paragraphs below. These risk factors are not specific to military members; however, some of these risks can be exacerbated by the military lifestyle. Increased risk for suicidality may include:

  1. A prior suicide attempt;
  2. Suicide ideation and/or self-harming behaviour;
  3. Suicide by a family member or friend;
  4. Mental disorders;
  5. Substance abuse;
  6. Relationship conflict, discord or loss;
  7. Few sources of supportive relationships (sense of isolation);
  8. Feelings of burdensomeness to others;
  9. Significant loss (financial, relationship, etc);
  10. Chronic pain;
  11. Adverse events in personal history (trauma, abuse, including in childhood);
  12. Access to lethal means;
  13. Harassment, discrimination and/or bullying;
  14. Stigma associated with help-seeking behaviour; and
  15. Hopelessness.

Protective Factors

“The risk of suicide can be mitigated by strengthening protective factors… Strengthening protective factors should be an ongoing process in order to counter suicide risk and build resilience for individuals, families and communities (ref A).” The sub-paragraphs below identify some protective factors that can reduce risk and inhibit suicidality:

  1. Psychological, physical and spiritual resiliency;
  2. Positive social, community and family connections;
  3. Good mental and physical health;
  4. Strong self-esteem;
  5. Better management of life stressors, including coping and problem-solving skills;
  6. Reasons for living (family, purpose, etc);
  7. Restriction of access to means;
  8. Education / awareness about mental health, suicide (including reducing the stigma associated with seeking care and/or support);
  9. Access to appropriate health care and social services (including reducing barriers to care);
  10. Assessment / management / treatment of:
    1. suicidal behaviours,
    2. mental health disorders,
    3. substance use disorders;
    4. physical disorders; and
  11. Responsible media reporting.

At the most basic level, the CAF SPAP sets out to develop a layered defense along seven specific lines of effort (LoE). Each LoE will include a number of initiatives that promote the elimination, mitigation or reduction of the risks identified above, and/or strengthen and enhance the identified protective factors. In this way the CAF & VAC will create layered defenses to counteract the risk factors for suicide. These LoEs are mutually supporting and are depicted in Figure 4, below.

Figure 4

Figure 4. Suicide Prevention LoEs: Layered Defense
(adapted from James Reason’s Risk Management Model)

The “Layered Defense” model is utilized extensively to manage risk in critical sectors, such as flight safety, where risk is inherent and the impact can be severe. The model recognizes risk is inherent and unavoidable in all aspects of life, both personal (we accept risk every time we bike, play sports or travel) and professional (we accept risk during operational deployments and training). “Smart-risk” however means that we understand the risk in relation to the benefits and do everything reasonable to reduce risk. There is also, unfortunately, a real risk that some of our members will have thoughts of suicide, make a suicide attempt or eventually, perhaps, die by suicide. The model recognizes that there is no single infallible defensive method, process, technique or action that can prevent all suicides. Each defensive layer has gaps and weaknesses. What it attempts to illustrate is that we can reduce the risks and promote the protective factors that can potentially prevent a tragedy by putting in place as many layers of defense as possible (our seven LoEs).

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