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Suicide and Homicide Risk Management

Chapter 26

SUICIDE AND HOMICIDE RISK 

MANAGEMENT: RATIONALE AND 

SUGGESTIONS FOR THE USE OF UNIT 

WATCH IN GARRISON AND DEPLOYED 

SETTINGS

SAMUEL E. PAYNE, MD*; JEFFREY V. HILL, MD†; and DAVID E. JOHNSON, MD‡

INTRODUCTION

RATIONALE FOR UNIT WATCH

SUICIDE RISK ASSESSMENT

RECOMMENDATIONS FOR UNIT WATCH PROCEDURES

In Garrison

Deployed Settings

MEDICOLEGAL ISSUES

SUMMARY

*Colonel, Medical Corps, US Army; Chief, Outpatient Behavioral Health Services, Dwight D. Eisenhower Army Medical Center, Building 300, Room 

13A-15, 300 South Hospital Road Fort Gordon, Georgia 30905

†

Lieutenant Colonel, Medical Corps, US Army; Chief, Child and Adolescent Psychiatry, Landstuhl Regional Medical Center, Landstuhl, Germany, CMR 

402 Box 1356, APO AE, 09180; formerly, Chief, Outpatient Psychiatry, Landstuhl Regional Medical Center

‡

Major, Medical Corps, US Army; Chief, Behavioral Health, US Army MEDDAC Bavaria, IMEU-SFT-DHR, ATTN: OMDC Schweinfurt, Unit 25850, 

APO AE 09033 

An earlier version of this chapter was originally published as: Payne SE, Hill JV, Johnson DE. The use of unit watch or command interest 

profile in the management of suicide and homicide risk: rationale and guidelines for the military mental health professional. Mil Med. 

2008;173:25–35.
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Combat and Operational Behavioral Health

Unit watch procedures are routinely used in both 

garrison and operational settings as a tool to enhance 

the safety of unit personnel when a soldier presents 

with suicidal or homicidal thoughts. To date, no specific body of literature or US Army publication offers 

either a rationale or a set of guidelines for their use. 

This chapter provides both a rationale and a set of 

suggestions for the use of unit watch based on fundamental military psychiatric principles, review of the 

relevant literature, and anecdotal experience. Finally, 

the chapter includes a discussion of the medicolegal 

issues specific to the use of unit watch. 

RATIONALE FOR UNIT WATCH

The management of suicidal and homicidal patients 

in the military environment is somewhat different from 

the management of such patients in the civilian sector for several reasons. One reason is that the military 

community provides additional resources, such as the 

chain of command and fellow soldiers, to assist the 

military clinician in addressing suicide and homicide 

risk. Another important reason is the necessity of 

managing suicide and homicide risk in a deployed or 

geographically isolated setting. Finally, management 

of suicide and homicide risk in the military requires 

addressing the challenge of heightened access to firearms in many settings. Unit watch has evolved within 

these circumstances as a practical and effective means 

to enhance the safety of the soldier and others and has 

gained some legitimacy in the psychiatric community.1–3 Unit watches have been used in many environments from the battlefield to the garrison, primarily 

in cases involving a level of risk that is concerning but 

does not necessarily warrant hospitalization. 

Psychiatric hospitalization, although often necessary for patients at high risk for attempting suicide or 

homicide, is not always the best option for managing 

suicide or homicide risk in a military setting for several reasons.1

 Hospitalization necessitates removal of 

the soldier from the unit and in some cases (notably 

those involving low to moderate risk of suicide) may 

delay recovery, especially when the symptoms are precipitated by battle fatigue.4–6 Anecdotally, the authors 

have observed cases in which hospitalization seemed 

to exacerbate the symptoms by placing the soldier in 

the role of a psychiatric patient. Psychiatric hospitalization carries significant stigma in the military as in 

the general population and may permanently impede 

the soldier’s reintegration into the unit. Fellow soldiers 

often make comments about hospitalized soldiers 

being “psycho” or needing to be “locked in a rubber 

room.” Some soldiers lose their sense of self-worth and 

belonging when they are separated from their units 

and cannot maintain occupational functioning. 

The unit watch (also known as the “command interest profile”) is a term describing the use of the military 

system to limit the suicidal or homicidal soldier’s access to people, places, or objects that might increase 

that soldier’s chances of harming self or others. Based 

on recommendations from the clinician, a variety of 

interventions are carried out by the command team, 

which may include searching the soldier’s belongings 

and living quarters for dangerous items, removing 

such items from the soldier’s possession, prohibiting 

access to alcohol and drugs, minimizing contact with 

people who may negatively influence the soldier’s 

mental health, continuously observing the soldier, 

and ensuring that the soldier returns for mental health 

follow-up.

A unit watch is an excellent example of the military 

clinician working with the command team to address a 

soldier’s mental health needs in the least restrictive setting possible through application of the time-honored 

military psychiatric principles of “PIES” (proximity, 

immediacy, expectancy, and simplicity), or “BICEPS” 

(brevity, immediacy, centrality, expectancy, proximity, and simplicity).7,8 Many soldiers with suicidal or 

homicidal thoughts have been experiencing stressful 

life circumstances. Sometimes these circumstances are 

the direct result of the wartime environment and may 

represent battle fatigue. Suicidal or homicidal thoughts 

may occur in the absence of a diagnosable mental illness and may respond to simple interventions such 

as rest, expectation of recovery, command attention, 

and support from other members of the soldier’s unit. 

Utilization of the PIES doctrine has demonstrated that 

suicidal or homicidal soldiers often benefit from brief, 

immediate care and support near their units. The unit 

watch is one mechanism for enhancing safety while 

providing this care and support.

A unit watch can reduce the chances of misperception about the soldier’s condition because unit members see and interact with the soldier on a daily basis. 

Soldiers often report that just talking to other unit 

members proved helpful. Commanding officers and 

senior noncommissioned officers often provide invaluable support for soldiers on unit watch by listening to 

the soldier’s concerns, sometimes modifying their style 

of interaction with the soldier based on a heightened 

sensitivity to the soldier’s personal problems, and by 

providing social support and advice as they perform 

their roles in “watching” the soldier. 

INTRODUCTION
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Suicide and Homicide Risk Management

Though often useful, unit watch may not always 

be the best approach. The treating mental health 

professional uses clinical judgment to determine the 

best course of action. One factor to consider is that 

a unit watch carries some risk of stigmatization by 

peers. Fellow soldiers may become frustrated with 

the soldier because of increased workload and potentially increased hazards as they attempt to cover the 

soldier’s battlefield responsibilities or provide personnel to monitor the soldier. This frustration may be 

exacerbated if the soldiers experiencing suicidal and 

homicidal thoughts, who often have a limited ability 

to give and receive social support, have already marginalized themselves. Many soldiers on unit watch 

have described to healthcare professionals episodes 

of ridicule and verbal harassment by both peers and 

leaders in their units. Regardless of the setting, stigma 

associated with receiving mental healthcare can be 

significant.9

 Adequate education of the unit leaders, 

who then train unit members to envision a unit watch 

as analogous to “helping a family member in distress,” 

may help alleviate some of the stigma. 

Leadership, unit cohesion, and group identification 

play decisive roles in a soldier’s ability to cope with 

peacetime or wartime duties. A unit watch may focus 

the command team’s attention on issues or stressors 

affecting their soldiers. In addressing these stressors, 

the command team may provide enhanced support 

to the soldier and may actually resolve some of the 

issues that are contributing to the heightened suicide 

or homicide risk. Ideally, the command team will 

consistently communicate the expectation that the 

unit watch is a team effort designed to help one of 

their own and to enhance both unit cohesion and the 

soldier’s ability to contribute. Such support can reduce 

the agitation and hopelessness often present in soldiers 

with suicidal or homicidal thoughts.4,10 Working with 

a command to ensure a unit watch environment that 

builds social support can be extremely helpful for the 

soldier. Strengthening such social support may play a 

key role in the soldier’s recovery.11,12

Although some risk remains, the authors contend 

that unit watch significantly reduces the risk of a soldier accessing lethal means such as firearms, ropes, 

medication, or knives. Of these weapons, firearms 

deserve special mention. In 2004 and 2005, firearms 

were the most common method of suicide completion 

within the US Army (62% and 69%, respectively, per 

year).13,14 By limiting access to firearms, a unit watch is 

likely to reduce the soldier’s risk of suicide completion 

early in the course of treatment, thus allowing time 

for the treatment and supportive interventions by the 

command to take effect.

Among US Army soldiers attempting or completing 

suicide in 2005, 57% of attempts and 17% of completions involved alcohol or drug use.14 Such substance 

use may impair judgment and lower inhibitions 

against acting on suicidal or homicidal impulses. A 

properly executed unit watch ensures that soldiers at 

risk are not given access to alcohol or drugs, thereby 

reducing risk. Also, by limiting contact with people 

who might exacerbate the soldier’s condition or become a victim of the soldier’s homicidal intent, a unit 

watch may further reduce risk and prevent adverse 

outcomes. 

Finally, the utilization of a unit watch for a soldier 

who presents with “military-specific” suicidal or 

homicidal ideation may be highly effective in reducing secondary gain, a term that describes the tangible 

advantages and benefits that result from being sick.15

The terms “military-specific suicidal ideation” and 

“military-specific homicidal ideation” refer to the 

verbal expression of suicidal or homicidal thoughts 

with the implicit (as determined by the clinician) or 

explicit goal of avoiding a military duty such as a 

field training exercise or deployment, of receiving a 

transfer to another unit or occupational specialty, or of 

obtaining a separation from active duty. In such cases, 

soldiers essentially imply or state that they may or will 

kill themselves or a leader in their unit unless they are 

allowed to achieve the stated goal. Such statements 

are often accompanied by allegations of harassment 

against the unit chain of command that may or may 

not be well founded. In many cases of military-specific 

suicidal or homicidal ideation, the soldier’s threats are 

directly linked to a desire to get out of the military. 

Such soldiers may believe that reporting suicidal or 

homicidal thoughts is an easy way to “get chaptered” 

(seek honorable administrative discharge) without 

negative consequences. In the absence of risk factors 

requiring hospitalization, military-specific suicidal or 

homicidal ideation is an indication for a unit watch, 

thus conserving inpatient treatment services for other 

service members who are more likely to benefit from 

these services. Additionally, soldiers in the unit rapidly 

develop an awareness that the mental health system 

is not there primarily to provide an escape from duties and responsibilities, but to provide supportive 

treatment, helping them function more effectively in 

a military environment. 

While useful in the management of military-specific 

suicidal or homicidal ideation in garrison, unit watches 

in a theater of operations are even more valuable. 

Military-specific suicidal and homicidal ideation are 

arguably two of the most common presenting behavioral health symptoms on today’s battlefield and could 

easily develop into an evacuation syndrome if not 

managed appropriately.11 A force that is well-versed 

in unit watches from its garrison experience is much 

more likely to successfully employ the intervention 
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Combat and Operational Behavioral Health

in wartime or other operations and thus benefit significantly in conserving its fighting, or peacekeeping, 

strength. However, the system as utilized in garrison 

requires modification in a deployed setting (discussed 

later in the chapter).

Two caveats warrant discussion when considering 

the rationale for the use of unit watch as a tool for 

enhancing the safety of soldiers at risk for suicide and 

homicide. The first is that although the unit watch may 

be beneficial for the soldier, it is only one component of 

a multifaceted treatment plan. Military mental health 

clinicians must provide psychological and pharmacologic treatment, as appropriate, to soldiers who present 

for care, whether or not a unit watch is used to enhance 

safety. For example, treating symptoms such as anxiety 

and insomnia is often essential in reducing suicide 

risk.1 Treatment of these symptoms should be a priority in soldiers presenting with suicidal thoughts, and 

treatment should occur independently of the decision 

to utilize a unit watch.

The second caveat is that essentially no research exists that directly addresses the safety and efficacy of a 

unit watch as an intervention. The Army Suicide Event 

Report (ASER) does provide some data that obliquely 

address the safety of “under command observation” 

(defined further on the ASER form as “eg, CIP,” a reference to command interest profile). In calendar year 

2004, ASER data were received for 54 of 70 suicide completions and 259 other suicide events (including both 

suicide attempts and other events that did not involve 

a suicide attempt, eg, hospitalization and evacuation 

for suicidal thoughts). In that year, one soldier who 

completed suicide (1%) and one (.4%) who attempted 

suicide were under command observation.13 In calendar 

year 2005, 2 of the 723 reported suicide events (.2%) in 

the active duty Army population occurred while the 

soldier was under command observation (of the five 

ASER reports identified as “under command observation,” two cases involved ideation only with no attempt, 

and one was from another branch of service). During 

the same year, none (0%) of the 71 completed suicides 

reported to the Suicide Risk Management and Surveillance Office occurred under command observation.14

(ASERS were not submitted for 12 of the 83 completed 

suicides that year; therefore, 71 reports were available.) 

Considering the widespread use of unit watch procedures in the US Army, these data offer some support 

to the hypothesis that unit watches are safe and may 

be effective in reducing suicidal behaviors in the shortterm while treatment is initiated. Although a controlled 

study evaluating the safety and efficacy of unit watch 

procedures may be difficult to design, research about 

this common practice is certainly warranted. In the 

meantime, the decision to use unit watch must be based 

on clinical judgment and experience with consideration 

of the potential risks and benefits. 

SUICIDE RISK ASSESSMENT

Essential to the appropriate use of unit watches 

is the ability to assess and document the soldier’s 

risk for suicide in a format that clearly explains the 

clinician’s decision-making process. Much has been 

written about the factors most often associated with 

completed suicide in both the civilian population and 

the US military population.14–17 These factors can be 

incorporated into a risk assessment that guides the 

clinician in appropriately choosing a unit watch or 

hospitalization. Although discussion of a comprehensive suicide risk assessment is beyond the scope of this 

chapter, a few risk factors are particularly relevant in 

a military setting.

One of the risk factors most highly correlative with 

completed suicide is diagnosis. Almost 95% of patients 

who attempt or commit suicide have a diagnosis of a 

mood disorder, a psychotic disorder, a substance-abuse 

disorder, dementia, or delirium. In populations under 

30 years of age, the most common diagnoses among 

suicide completers in one study were antisocial personality disorder and substance-abuse disorders.18 Based 

on anecdotal experience, a significant proportion 

of soldiers presenting with military-specific suicidal 

thoughts do not meet criteria for these diagnoses. 

However, the absence of a psychiatric diagnosis must 

be interpreted with caution in the active duty Army 

population, because the ASER data from 2005 indicate 

that only 26% of suicide completers were given a psychiatric diagnosis. 

An “unambiguous wish to die” over a “primary 

wish for change” as well as “communication internalized” (self-blame) versus “communication externalized” have been cited as important factors associated 

with high suicide risk.19 The majority of soldiers with 

military-specific suicidal thoughts are primarily interested in a change (leaving the military, the theater of 

operations, or their units) and are angry at an external 

entity (the military or their chains of command), rather 

than blaming themselves for their dissatisfaction. Additionally, the association of suicide completion with 

a conflicted romantic relationship or recent divorce 

has been particularly well described in the military 

population.16

When many or all of the above-described risk factors for suicide completion are absent, this is often 

an indication that a unit watch is more appropriate 

than hospitalization. It is important that the clinician 

clearly document these and other factors in a formal 
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Suicide and Homicide Risk Management

suicide-risk assessment that provides a rationale 

for the decision to utilize a unit watch. In a military 

setting, collateral history from the unit commander 

or from others in the unit is an important source of 

information in the suicide-risk assessment. Current 

practice in the field of suicide-risk assessment also 

emphasizes the ongoing nature of the evaluation. 

Individuals on unit watch should undergo frequent 

reassessments by the mental health professional to 

determine whether the suicide risk has increased to 

the point that inpatient hospitalization is now indicated. Homicide risk assessment and management is 

similar to that described for suicide-risk assessment 

and management, with examination of risk factors 

and frequent reassessment playing crucial roles in 

the decision process.

RECOMMENDATIONS FOR UNIT WATCH PROCEDURES

In Garrison

There are many different approaches to the implementation of unit watch in the military system. A 

model for conceptualizing the role of unit watches in 

a garrison setting is presented in Table 26-1. Whatever 

approach is taken by the clinician, the unit watch should 

be regarded as a “temporary profile,” a recommendation to a commander regarding the soldier’s temporary 

duty restrictions that is likely to be helpful in ensuring 

the soldier’s health and welfare. Most Army commanders are familiar with the concept of unit watch and will 

support such recommendations, especially when notified via a memorandum signed by the mental health 

professional. The memorandum format ensures that 

instructions are written and easily understood. 

The memorandum is given to the soldier’s escort, 

usually a noncommissioned officer, who signs for its 

TABLE 26-1

MANAGING SUICIDE AND HOMICIDE RISK in garrison

Full Duty Buddy Watch 24-Hour Watch Admit to Psychiatric 

Ward

Least restrictive  Most restrictive

Actions Return to duty 1. Secure weapons and medication

2. Soldier is under direct observation from first formation 

until lights out

1. Secure weapons and 

medications 

2. Soldier is under direct 

observation 24 h/day

Admit to psychiatric ward

Examples 1. SI/HI without plan/

intent, few 

risk factors, 

contracts for 

safety

1. Primary indication is “military-specific” SI/HI, no intent, 

few risk factors

2. SI/HI due to psychiatric 

disorder but risk level does not 

warrant 24 h watch or hospitalization

 3. Step down from unit watch

1. Primary indication 

is “military-specific” 

SI/HI with plan and/

or intent but few risk 

factors

2. SI/HI due to psychiatric disorder but risk 

level does not warrant 

hospitalization

1. High suicide or homicide 

risk requiring psychiatric 

hospitalization 

2. Suicide/homicide risk 

not diminishing after (no 

more than) 5 days despite 

treatment while on 24 h 

or buddy watch

Advantages 1. RTD

2. No stigma

1. Less stigma than 24 h watch

2. Some safety precautions

3. Lower personnel demands 

than 24 h watch

4. Reasonable likelihood of RTD

1. High level of safety 

precautions

2. Reasonable likelihood 

of RTD

Highest level of safely 

precautions

DisadvantagesNo safety precautionsFewer safety precautions vs 24 

h watch

Stigma, high personnel 

demands for unit

Low likelihood of RTD, 

stigma, loss of social 

and occupational roles 

that sometimes support 

recovery

HI: homicidal ideation; RTD: return to duty; SI: suicidal ideation
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Combat and Operational Behavioral Health

receipt and is instructed to deliver it to the commander 

or first sergeant. This allows the clinician to release 

the service member with a recommendation for a unit 

watch at times when the clinician may not be able to 

contact the commander immediately. As with all medical profiles, the commander may choose to ignore the 

clinician’s recommendation, but then assume significant responsibility for the outcome of the case. 

The garrison system proposed in this chapter consists of two types of unit watches. The first is called 

a “buddy watch”; it recommends that the soldier be 

under direct observation only from first formation 

until lights out, rather than 24 hours a day, for up to 5 

days from the initiation of the watch until a reevaluation occurs. This watch is generally for lower-risk 

individuals, provides more flexibility for use (eg, over 

a weekend), and is generally better received by the 

chain of command and the soldier. It is valuable in a 

EXHIBIT 26-1 

buddy watch memorandum

DATE:

MEMORANDUM FOR (COMMANDER, UNIT)

SUBJECT: Buddy Watch for _______________________ (Soldier’s name and last 4)

1. The soldier was evaluated at the ___________ Behavioral Health Clinic. The results of the evaluation indicate 

that this Soldier is at some risk for self-harm or harm to others. The risk level at this time does not warrant hospitalization, but a Buddy Watch for both support and safety is recommended.

2. Buddy Watch procedures are as follows:

a. Command should assign someone to constantly monitor the soldier from first formation until lights out. The 

Soldier may be allowed to go to the latrine alone if the latrine doorway is monitored by the buddy or NCO 

assigned to watch the Soldier. During the night, constant monitoring is not required, but the soldier must 

not sleep in a room alone. Actions that specifically identify a Soldier on a Buddy Watch to large numbers of 

unit personnel (e.g. having the Soldier wear a road guard vest throughout the day) are not authorized.

b. Health and welfare inspection of the soldier’s room to remove hazardous material (e.g. pills, knives, etc.). 

c . No access to alcohol or dangerous objects such as:

 1) Personal weapons, knives, cigarette lighters, jewelry with sharp edges, blow dryers (silverware other than 

sharp knives is acceptable). .

 2) Pills (medication should be dispensed one dose at the time by medic, PA, NCO, etc).

 3) The Soldier may carry a military-issued firearm if the firing pin or bolt has been removed from the 

weapon.

d. It is recommended that the Soldier perform his/her regular (noncombat) duty and PT. Physical exercise often 

improves behavioral health symptoms.

3. This plan will be in effect from today until it is terminated by the Behavioral Health clinician in agreement with 

the commander. Continuing a buddy watch after a Behavioral Health clinician has recommended termination 

is not authorized and may be perceived as harassment.

4. If this Soldier’s condition worsens, the Soldier’s supervisor should call the Behavioral Health clinic at xxx-xxxx 

during duty hours or bring the Soldier to the __________ Emergency Room after hours. If phone contact cannot 

be established with a Behavioral Health clinician during the duty day, escort the Soldier immediately to the 

Behavioral Health clinic for evaluation. 

This Soldier’s next appointment at the _______________ Behavioral Health clinic is on_____________________(date)

at__________________________ (time).

________________________________ ______________________________

Representative from Command Clinician

Adapted from a form developed at the 2nd Infantry Division, initially by Captain Sally Chessani (now Colonel Sally Harvey), licensed 

clinical psychologist. 

NCO: noncommissioned officer; PA: physician’s assistant; PT: physical training
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Suicide and Homicide Risk Management

variety of situations, including the typical presentation 

with military-specific suicidal ideation and very few 

risk factors for suicide completion.

Another scenario in which this watch may be useful 

is in managing soldiers who are urgently commandreferred for verbal expression of suicidal thoughts or 

self-injurious behavior the previous night when they 

were intoxicated. On presentation, the service member 

may have no current suicidal ideation, may claim to 

have no memory of the statements or self-injurious 

EXHIBIT 26-2 

24-hour watch memorandum

DATE:

MEMORANDUM FOR (COMMANDER, UNIT)

SUBJECT: 24 Hour Watch for _______________________________ (Soldier’s name and last 4)

1. The Soldier was evaluated at the _____________ Behavioral Health clinic on ______________________ The results 

of the evaluation indicate that this Soldier is at some risk for self-harm or harm to others. The risk level at this time 

does not warrant hospitalization , but a 24 Hour Watch for both support and safety is recommended.

2. 24-Hour Watch procedures are as follows:

a. Continuous monitoring should occur at all times, including accompanying the soldier to the latrine and 

during meals. 

b. The soldier should sleep in a room with a unit member who is awake at all times or in a dayroom (cleared 

of dangerous items) near the Staff Duty/CQ area so that the Soldier is constantly monitored throughout 

the night. Other actions that specifically identify the Soldier on a 24 Hour Watch to large numbers of unit 

personnel (e.g. having the Soldier wear a road guard vest throughout the day) are not authorized and may 

be perceived as harassment. 

c. Health and welfare inspection of the soldier’s room to remove hazardous materials (e.g., pills, knives, weapons, etc.). Instead of removing the Soldier’s weapon, the weapon may be inactivated (e.g., removing the bolt 

or firing pin from an M-16.

d. Other than family members, visitors from outside the unit must be cleared by the commander.

e. No access to alcohol or dangerous objects such as:

1) Personal weapons, knives, cigarette lighters, jewelry with sharp edges, blow dryers (silverware other 

than sharp knives is acceptable).

2) Pills (medication should be dispensed one dose at a time by medic, PA, NCO, etc.).

3) The Soldier may carry a military-issued firearm if the firing pin or bolt has been removed from the 

weapon.

3. Soldier should perform his/her regular (noncombat) duty and PT. Physical exercise often improves behavioral 

health symptoms.

4. This plan will be in effect from today until it is terminated by the Behavioral Health clinician in agreement with 

the command. Continuing a 24 hour watch after a Behavioral Health clinician has recommended termination is not 

authorized and may be perceived as harassment.

5. If this Soldier’s condition worsens, the Soldier’s supervisor should call the Behavioral Health clinic at xxx-xxxx 

during duty hours or escort the Soldier to the Emergency Room (or TMC in theater) after duty hours. If phone 

contact cannot be established with a Behavioral Health clinician during the day, bring the Soldier to the Behavioral 

Health clinic during duty hours for evaluation. 

6. This soldier’s next appointment at the_______________________ Behavioral Health clinic is 

on________________________ at _______________________.

________________________________ ______________________________

Representative from Command Clinician

CQ: charge of quarters; NCO: noncommissioned officer; PA: physician’s assistant; TMC: troop medical clinic
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Combat and Operational Behavioral Health

EXHIBIT 26-3 

Information paper for commanders

MCXC-BH

INFORMATION PAPER

SUBJECT: Management of Soldiers with Suicidal or Homicidal Ideation

1. References: FM 4-02.55 COMBAT AND OPERATIONAL STRESS CONTROL, FM 22-51 Leader’s Manual for Combat 

Stress Control

2. Purpose. To provide information to commanders regarding the use of unit watches in the management of Soldiers 

who express suicidal and homicidal ideation.

3. Overview:

When it is brought to the commander’s attention that a Soldier has expressed suicidal ideation, the commander 

should immediately contact his supporting behavioral health activity to insure that an evaluation of risk is performed. Procedures for this are not within the scope of this information paper. Once the Soldier is evaluated, the 

behavioral health professional will have examined the risk factors (e.g. the psychiatric diagnosis, any history of 

previous attempts, family history of attempts, the presence and lethality of a plan for suicide) and will make recommendations to the commander. These recommendations will include one of the following: return to full duty with 

close monitoring and support for low risk soldiers, Buddy Watch (or Basic Precautions in Operational environments) 

for low to moderate risk Soldiers, 24 Hour Watch for moderate risk Soldiers, and hospitalization for soldiers at high 

risk. The value to the soldier and commander of Basic Precautions, Buddy Watch, and 24 Hour Watch as opposed 

to hospitalization are as follows:

The soldier is able to maintain occupational functioning at some level and maintains social connection in the unit. 

This helps to prevent feelings of worthlessness and a sense of isolation that sometimes result from psychiatric 

hospitalization.

The soldier avoids the stigma that is unfortunately commonly associated with psychiatric hospitalization. While 

there may be some stigma associated with a unit watch, at least the soldiers in the unit see the soldier on a daily 

basis and are much less likely to develop misperceptions about the Soldier’s problem, e.g. that the Soldier is “psycho” and is “locked in a rubber room”. These misperceptions are prevalent in our culture and are sometimes very 

damaging in the Soldier’s reintegration to the unit after a psychiatric hospitalization.

The Soldier has the opportunity to address his or her concerns with the chain of command. NCOs often provide 

significant relief from depressed feelings when they listen to and support a Soldier who has expressed suicidal 

ideation. In this way, the unit implements the Army’s concept of the unit as the Soldier’s “family” and provides 

extra care and support to a unit member in distress.

Soldiers with “military specific” suicidal ideation (e.g. “I will kill myself if you don’t let me out of the Army”) 

become aware more rapidly that the behavioral health system does not provide an escape route from their duties 

and responsibilities, though it does react to help the Soldier adjust to their situation. This message is transmitted to 

the entire unit and is likely to lessen the number of Soldiers who develop “military specific” suicidal ideation. This 

MAY ENHANCE RETENTION AND COMBAT READINESS by reducing the number of soldiers that seek out the 

mental health system as an escape route from the Army.

The unit chain of command gains significant experience in managing Soldiers who express suicidal ideation. This 

experience and familiarity with unit watches MAY ENHANCE COMBAT READINESS because the unit will most 

likely need to employ similar procedures in an operational environment. The proficient use of unit watches in a 

combat setting may prevent an “evacuation syndrome” in which significant numbers of Soldiers who express suicidal 

thoughts are evacuated from theater because units have not been trained in the management of this problem.

4. Types of Unit Watches:

a. Buddy Watch: A unit member is assigned to constantly monitor the soldier from first formation until lights out. The 

soldier should not sleep in a room alone but constant monitoring is not required at night. The Soldier will follow 

up with Behavioral health within 5 days (usually sooner) of the initiation of the watch so that the risk level can 

(Exhibit 26-3 continues)
431

Suicide and Homicide Risk Management

act, and may demonstrate minimal risk factors for a 

suicidal act. However, there is clearly some risk, especially if alcohol use is resumed. The buddy watch 

significantly minimizes the opportunity for continued 

alcohol use, and thus may reduce the suicide risk while 

outpatient treatment, including referral to the Army 

Substance Abuse Program, is initiated. Other situations 

in which a buddy watch may be valuable are situations 

in which “stepping down” from hospitalization or 24-

hour watch is prudent. Exhibit 26-1 is an example of 

specific procedures for buddy watch. 

The second type of unit watch is called a “24-hour 

watch,” avoiding another commonly used term, “CQ 

(charge-of-quarters) watch,” for two reasons. Some 

units do not have a CQ duty and the commander 

may infer from the term that the unit is being asked 

to perform a task for which it is not equipped. The 

commander may also infer from “CQ watch” that the 

clinician is recommending that the soldier be moved 

to a central area (eg, dayroom) in the unit where observation is possible by soldiers performing CQ duty. 

Moving the soldier to a central area is sometimes necessary but should be avoided whenever possible because 

such a move may enhance the sense of humiliation or 

stigma. The primary characteristic of a 24-hour watch is 

that the soldier is under constant observation during a 

24-hour period, after which an evaluation by a mental 

health officer must take place. Specific procedures for 

be reassessed. If significant risk remains at that point, the Soldier is often hospitalized so that the unit’s combat 

readiness is not unduly affected by an extended period of observation of the soldier.

b. 24-Hour Watch: A unit member is assigned to constantly monitor the Soldier throughout an entire 24 hour period. 

Unit commanders often use a Staff Duty NCO or CQ personnel for this purpose. This type of watch is generally 

only used in “military specific” suicidal ideation where the Soldier is making specific threats related to a wish for 

release from the Army or a deployment but does not have other risk factors (eg, a depressive disorder, a history 

of suicide attempts) that would warrant hospitalization. The Soldier will generally be seen back within 24 hours 

due to the time-intensive nature of this procedure for the unit. At that point, the clinician will again assess the risk 

and make a determination regarding the appropriate recommendation.

c. Recommendation for Basic Precautions: While a recommendation for Basic Precautions is not technically a unit 

watch, it is a set of safety precautions used only in an operational environment. The essential elements of Basic 

Precautions are that the Soldier does not participate in combat (or “off-FOB”) duties and that the firing pin or bolt 

is removed from the Soldier’s weapon. 

5. The Homicidal Soldier:

Soldiers who express homicidal thoughts should also be referred to Behavioral Health for an evaluation so that the 

mental health professional can rule out a mental disorder as a cause of the homicidal thoughts, assess the risk, and 

initiate treatment if there is evidence of a behavioral health disorder. In the absence of a serious behavioral health 

disorder contributing to the homicidal thoughts, the presence of homicidal thoughts is often not an indication for 

psychiatric hospitalization. The mental health professional will generally take steps to insure that the commander 

warns the personnel who are threatened, and may recommend a Buddy Watch or 24 Hour Watch as a method of 

protecting the threatened individual. If the risk level is very high, the commander has the option of consulting SJA 

regarding the possibility of placing the Soldier in pretrial confinement if hospitalization is not indicated. 

6. Summary:

The use of unit watches is a valuable tool for the commander in supporting Soldiers and enhancing combat readiness. Behavioral Health clinicians will work with you to determine the appropriate management tool and will 

hospitalize the Soldier if the risk level warrants this intervention. Behavioral Health clinicians can not predict suicide 

or homicide but are trained to follow clear guidelines about the level of risk that warrants hospitalization. Your 

supporting Behavioral Health clinicians will insure that your Soldier receives the most appropriate intervention 

for their level of risk.

________________________________ ______________________________

Representative from Command Clinician

CQ: charge of quarters; FOB: forward operating base; FM: field manual; NCO: noncommissioned officer; SJA: Staff Judge 

Advocate

Exhibit 26-3 continued
432

Combat and Operational Behavioral Health

EXHIBIT 26-4 

STANDard OPERATING PROCEDURES FOR BUDDY WATCH AND 24-HOUR WATCH

STANDARD OPERATING PROCEDURES

Buddy and 24-Hour Unit Watch

1. PURPOSE: To establish procedures for the use of Buddy and 24 Hour Unit Watches in the management of Soldiers undergoing evaluation and treatment for suicidal statements or behaviors.

2. SCOPE: All personnel assigned to or working in the Department of Behavioral Health.

3. GENERAL:

a. All patients seen in the clinic who describe a history of current or recent (i.e. within the past two weeks) 

suicidal ideation, suicide attempt, or homicidal ideation must be seen by a Behavioral Health clinician prior 

to release of the soldier. (Risk assessments after clinic hours will be performed by Emergency Department 

staff, in consultation with the on-call Behavioral Health clinician.)

b. The evaluation of potential for harm will include a thorough psychiatric history and examination of risk 

factors. The suicide risk factors assessed will include at a minimum the following: history of previous attempts, frequency and duration of suicidal ideation/plan/intent, access to lethal means, presence or absence 

of substance abuse, signs and symptoms of mood and anxiety disorders, current significant stresses, social 

supports, reality testing, and any family history of completed suicide. The homicide risk factors assessed 

will include at a minimum the following: history of previous violence, frequency and duration of homicidal 

ideation/plan/intent, and determination of access to lethal means.

c. The disposition should be appropriate based on the assessment and must address the safety of all involved.

d. Documentation of the assessment will be completed on the day of the evaluation.

4. PROCEDURES:

a. A Buddy Watch may be recommended to the commander if there is some risk for harm to self or others, but 

the mental health officer clearly documents a risk assessment explaining that the Soldier’s risk is not high 

enough to warrant hospitalization. The Buddy Watch allows for monitoring the Soldier while treatment is 

initiated, and may have advantages over hospitalization. These are described in Attachment C.

b. A 24-Hour Watch may be recommended for Soldiers who require more constant supervision than provided 

by a Buddy Watch and is typically implemented for Soldiers who make specific threats to harm themselves 

or others in order to avoid duty or to force a discharge from service (eg, “I will kill myself if you don’t let 

me out of the Army”). The risk assessment explaining the clinician’s conclusion that the Soldier’s risk is not 

high enough to warrant hospitalization must be clearly documented.

c. The procedures for Buddy Watch and 24-Hour Watch are explained in detail in Attachments A and B. The 

essential difference in these two procedures is that a Soldier on Buddy Watch requires observation only from 

first formation until lights out, whereas a Soldier on 24 Hour Watch must be observed at all times.

When a Soldier is placed on a watch, the Behavioral Health clinician will make an attempt to contact the commander 

to discuss the reasons for the watch and other pertinent concerns. The appropriate form will be forwarded to the 

commander through the Soldier’s escort. If the commander requests additional information about unit watch or expresses uncertainty about unit watch, the information paper titled Management of Soldiers With Suicidal or Homicidal 

Ideation will be forwarded to the commander through the Soldier’s escort. A Soldier on a Buddy Watch will be seen 

for a follow up appointment at least every five working days until the watch is discontinued. A Soldier on a 24-Hour 

Watch will be seen for re-evaluation within 24 hours. A Behavioral Health clinician will evaluate the Soldier at each 

return appointment until the watch is discontinued. The decision to recommend discontinuation of a unit watch will 

be made only by a Behavioral Health clinician. A memorandum recommending discontinuation of the watch will be 

signed by the Behavioral Health clinician and forwarded to the commander.

Unit watches are recommendations to commanders. Behavioral Health clinicians must discuss their recommendations 

with the commander and be sensitive to specific command and unit circumstances. In all cases, the safety of the Soldier 

and others that might be at risk will be the primary concern.

The Buddy Watch or 24-Hour Unit Watch will only be used for soldiers who have been assessed for their level of risk 

by a clinician at this institution. Unit watches may be utilized by Emergency Department clinician if the on-call mental 

health care clinician has been consulted by the Emergency Department clinician and they are in agreement regarding 

the disposition.
433

Suicide and Homicide Risk Management

this watch are outlined in Exhibit 26-2. 

The procedures outlined for both types of unit watch 

are designed to give the commander specific guidance 

regarding measures to ensure the soldier’s safety. This 

written guidance helps to reduce confusion, which often results if a more vague verbal recommendation for 

a unit watch is used to communicate with the chain of 

command. The 24-hour watch is at times useful in the 

management of a soldier with military-specific suicidal 

or homicidal ideation who has very few risk factors 

except for a verbalized threat, such as “I will kill myself 

(or my squad leader) if I have to go back to my unit.” 

It is often, though not necessarily, used in conjunction 

with an environmental change, for instance, an agreement with the commander that the service member 

will be moved to a different platoon, if the threats of 

suicide or homicide are specific to alleged harassment 

by a noncommissioned officer in the service member’s 

section, squad, or platoon.

In addition to the memoranda outlining specific recommendations, the authors suggest that a unit watch 

information paper (Exhibit 26-3) be forwarded to the 

commander, especially if the commander expresses 

confusion or skepticism about the recommendation for 

a unit watch. This document provides education for the 

command team and may alleviate concerns about the 

safety and value of a unit watch. Command support 

of the unit watch is crucial. If not fully informed and 

educated about the unit watch, unit leaders may feel 

compelled to intervene further and attempt to force the 

mental health system to psychiatrically hospitalize the 

service member. 

Exhibit 26-4 is an example of a standard operating 

procedure for the behavioral health team, providing a 

general guide for the use of unit watch in a garrison setting. Clinicians’ beliefs about the need for psychiatric 

hospitalization in various situations differ significantly, 

so no absolute guidelines about which clinical factors 

require hospitalization over unit watch are included in 

this chapter. This variation in decisions regarding hospitalization reinforces the critical role of documenting 

the clinical assessment and decision-making process in 

each case. Finally, when the clinician decides to recommend discontinuation of the unit watch, it is helpful to 

forward to the command team a standard document 

with this recommendation. Commanders may wait for 

such written notification before discontinuing a watch. 

Exhibit 26-5 is a sample memorandum.

EXHIBIT 26-5 

UNIT WATCH DISCONTINUATION MEMORANDUM

Date: 

MEMORANDUM FOR (Commander, Unit)

SUBJECT: Release from Twenty Four Hour Watch/Buddy Watch for _____________________________

SSN: _____________________________________________________________________

1. The above named service member was recommended for Twenty Four hour Watch/Buddy Watch on ________ .

2. The above named service member was evaluated at _____________ Behavioral Health clinic again on ________ . I 

currently do not believe that the service member is an imminent risk to self or others and recommend the service 

member be removed from Twenty-Four Hour Watch/Buddy Watch.

3. Although this service member is not currently at significant risk for dangerousness to self or others, please understand that the service member’s risk level may change.

4. If the service member experiences a recurrence of suicidal or homicidal thoughts or demonstrates other behaviors 

indicating there is risk for harm to self or others, the service member should be escorted to the clinic (duty hours) 

or to the Emergency Department (after hours) for evaluation. 

5. The service member’s next scheduled appointment at Outpatient Behavioral Health Services is on __________________ 

at ____________.

6. Point of contact for this memorandum is the undersigned at xxx-xxxx. 

________________________________

Clinician
434

Combat and Operational Behavioral Health

Deployed Settings

The garrison system for unit watch must be modified to function in a deployed setting for two reasons. 

The first is a recognition that access to lethal weapons is 

heightened immeasurably in a deployed setting; thus, 

the buddy watch must be removed from the range of 

options. The 24-hour watch is used instead for soldiers 

at heightened risk who do not require hospitalization. 

Another option for lower risk soldiers used during the 

deployment has been dubbed “basic precautions.” The 

essential elements of the basic precautions profile are 

removal of the firing pin (or bolt) from the soldier’s 

weapon and suspending combat duties until further 

notice. Exhibit 26-6 shows the basic precautions memorandum that was used to successfully communicate to 

the commander the necessary precautions by one of 

the authors (SP) during a 2006–2007 deployment. During this deployment, basic precautions were applied 

extensively in a variety of situations, including those 

involving vague suicidal or homicidal thoughts but 

few other risk factors in soldiers requiring a period of 

treatment before return to full duty. 

The second reason is that, depending on the unit, 

the clinician may have ready access to a “patient hold” 

area such as that operated by the medical company 

in a brigade support battalion. Although traditional 

combat stress control doctrine has emphasized separation of soldiers presenting with psychiatric issues 

from those presenting with medical and surgical 

illness, utilization of the patient hold area for brief 

management of suicide risk has been effective in 

deployed settings. Based on these two modifications, 

a model for conceptualizing the role of unit watches 

in a deployed setting is presented in Table 26-2. This 

model was used by one author (SP) to train primary 

care clinicians and mental health professionals in the 

management of suicide and homicide risk during the 

2006–2007 deployment. The following is an example 

of a unit watch used in a deployed setting. 

Case Study 26-1: A 31-year-old married African-American man deployed to a combat zone came to the mental 

health clinic after learning that his wife planned to leave 

him. He stated that if only he was given the chance to go 

home, he could save his marriage. He reported that he was 

EXHIBIT 26-6 

Basic precautions

________ TMC

FOB ____, Iraq

Date _________________

MEMORANDUM FOR Commander,

SUBJECT: Basic Precaution for _____________________________ SSN:________________________

This service member was evaluated at the FOB ______ TMC. Based on this evaluation of the service member’s recent 

behaviors and current mental status, the following precautions are recommended to the commander for the service 

member’s support and safety. The evaluation did not indicate a high enough risk of dangerousness to warrant hospitalization or a unit watch at this time.

2. Precautions:

a. Remove the firing pin (or bolt) from this service member’s weapon.

b . No combat or “Off-FOB” duties until further notice.

c. Service member should perform duties not involving combat operations and should participate in PT. PT may 

help improve the service member’s behavioral health symptoms.

3. If this service member’s condition worsens, the service member’s supervisor should call FOB ________ TMC Behavioral Health at xxx-xxxx or escort the service member to the TMC for evaluation.

This service member’s next appointment at FOB _______ TMC is on_______________________

at __________________________ with ___________________________________________.

________________________________ ______________________________

Representative from Command Clinician

FOB: forward operating base; PT: physcial therapy; SSN: social security number; TMC: troop medical clinic
435

Suicide and Homicide Risk Management

suicidal and would kill himself if he wasn’t allowed to leave. 

During the initial evaluation, he didn’t describe a defined 

plan for carrying out his suicide and reported never before 

experiencing suicidal thoughts. He denied any previous 

mental health history, had no medical illness, and was not 

using alcohol, street drugs, or medications. A 24-hour watch 

was recommended to the commander, along with frequent 

mental health treatment to help him cope with his emotional 

crisis. On meeting to discuss a safety plan for the soldier, 

the command team reported that he had recently been 

serving well in his role as a member of a logistics team. 

During the meeting the soldier’s first sergeant reminded 

the soldier how proud the battalion commander was of the 

soldier’s proficiency in a recent task. He then expressed 

how the command team valued the soldier, not just as a 

“number” but as a person and team member. The command 

team agreed to provide 24-hour supervision for the soldier 

in a nonstigmatizing manner by removing the bolt from his 

weapon and removing his ammunition and knives from his 

possession, as well as allowing him to remain on base where 

he would probably not need his weapons. He was allowed to 

choose the soldiers who would be assigned to monitor him, 

selecting those with whom he felt the closest connection. 

He was then returned to duty with mental health follow-up 

planned in 2 days. He reported that during the day while on 

24-hour watch he spent time talking to his escorts about his 

problems. During this time period, he continued his usual 

work schedule and came to the clinic every other day for a 

brief assessment and supportive therapy. Within 2 weeks, 

he had come to terms with his pending divorce, realizing that 

his presence at home would probably not have affected his 

wife’s plans. He also noted that his distress over the loss of 

his marriage wouldn’t resolve by throwing away his life or 

military career. The 24-hour watch was discontinued at that 

point. His bolt, ammunition, and knives were returned to him 

and, though his wife did leave him, he was able to continue 

with the mission and complete the deployment. His emotional 

state had returned to near baseline approximately 1 month 

after his initial presentation. After several months of monthly 

follow-up, he required no further treatment for the remainder 

of the deployment. 

The soldier in this case presented with suicidal 

ideation in acute emotional crisis after learning of his 

wife’s plan to divorce him. His access to a weapon and 

his primary stressor of interpersonal loss placed him at 

significant risk for a suicide attempt. However, he did 

not have a formulated plan for suicide, a significant 

medical or mental health history, or a substance-use 

TABLE 26-2

MANAGING SUICIDE AND HOMICIDE RISK during deployment

Full Combat 

Duty

Basic Precautions 24-Hour Watch (or admit 

patient to hold)

Evacuation to Combat Support Hospital

Least restrictive  Most restrictive

Actions Soldier verbally 

contracts for 

safety

1. Secure bolt from weapon 

until further notice

2. No off-FOB duties until 

further notice

1. Secure weapons and 

medications 

2. Soldier is under direct 

observation 24 h/day

Enact evacuation procedures

Examples Suicidal 

thoughts, few 

risk factors, 

able to contract 

for safety

1. Primary indication is 

military-specific SI/HI

2. Psychiatric disorder with 

SI/HI but risk not high 

enough to warrant unit 

watch

3. Step down from unit 

watch

1. Military-specific SI/

HI but risk not high 

enough to warrant 

hospitalization

2. Psychiatric disorder 

with SI/HI but risk not 

high enough to warrant 

hospitalization

1. Suicide or homicide risk 

high enough to warrant 

hospitalization

2. Medically serious suicide 

attempt (overdose, lacerations requiring sutures)

3. Suicide/homicide risk not 

diminishing after (no more 

than) 5 days despite treatment while on unit watch

Advantages 1. RTD

2. No stigma

1. Much less stigma than 

unit watch

2. Some level of safety precautions

1. High level of safety 

precautions

2. High likelihood of RTD

3. Consistent with PIES

Highest level of safety precautions

DisadvantagesNo safety precautionsFewer safety precautions vs 

unit watch

1. Stigma

2. “Sick role” with patient 

hold

Low likelihood of RTD, 

stigma, violates PIES unless clearly indicated

FOB: forward operating base; HI: homicidal ideation; PIES: proximity, immediacy, expectancy, and simplicity; RTD: return to duty; 

SI: suicidal ideation
436

Combat and Operational Behavioral Health

problem. Thus, his treating clinician decided that the 

appropriate treatment setting would be to ensure the 

patient’s safety via a 24-hour watch, long enough for 

his immediate emotional crisis to resolve. An adequate 

nonstigmatizing safety environment was created for 

the soldier, and the unit provided emotional support 

as well as safety. As expected, his emotional crisis 

resolved within 2 weeks and his symptoms resolved 

within 1 month as he gained understanding and acceptance of his changing life situation. 

In a garrison or deployed setting, the clinician must 

clearly document the suicide or homicide risk assessment, giving a clear rationale that makes the case for 

the specific treatment setting (eg, buddy watch, 24-

hour watch, basic precautions, patient hold) rather 

than hospitalization or evacuation. The military unit 

is a unique and cohesive community that often allows 

these interventions to effectively reduce suicide or homicide risk. However, because these interventions are 

relatively unknown in the civilian sector, meticulous 

documentation of suicide risk factors and the reason 

that unit watch was considered a safe intervention 

for the soldier are essential in each case. Documentation of discussions with command, education given 

to the command, and assurance that the command is 

capable of carrying out a proper unit watch are also 

recommended. Finally, the widespread use of the 

unit watch by military mental health providers, and 

its inclusion in the American Psychiatric Association 

practice guidelines, may help establish this as an 

appropriate, if not yet evidence-based, intervention 

within the military.1 

MEDICOLEGAL ISSUES

The legal implications of using a unit watch are of 

concern to many clinicians. There is no exact equivalent to the unit watch in the civilian sector, although 

it is loosely analogous to sending a patient home with 

parents or family members who promise to watch the 

patient and confiscate weapons or excess pills. Suicide watches in a prison may use similar procedures, 

despite the obvious differences between a prison environment and an Army barracks. Although the need 

for collaboration with the legal community on these 

issues is obvious, no literature specifically addresses 

this aspect. The following brief summary lays out the 

basic medicolegal issues involved. 

Mental health clinicians in the civilian community 

have serious concerns about liability when a patient 

completes a suicide or commits a homicide. Many 

malpractice lawsuits involve plaintiffs who complete 

suicide after a psychiatric assessment concluded that 

hospitalization was not indicated. Factors in finding 

the mental health clinician liable for damages often 

include inadequate risk assessment or inadequate 

response to that risk.20 Inadequate documentation of 

the risk assessment is a frequent factor that leads to 

a verdict against the clinician. Failure to frequently 

reevaluate the suicide risk may also be a basis for a 

finding of malpractice. Prison staff and supervisors 

have been found liable in cases of completed suicides 

in civilian prisons because of their responsibility for 

the health and well-being of their wards. Insufficient 

training of personnel or inadequate adherence to 

standard operating procedures may result in findings 

of negligence. 

Military commanders and clinicians have a unique 

protection from liability in the form of the Feres doctrine, which is an exception to the Federal Tort Claims 

Act. The doctrine stems from Feres v US,

21 which consolidated three lawsuits concerning the injury or death 

of three service members due to possible negligence 

on the part of the military. Two of the cases involved 

physician malpractice. The US Supreme Court ruled 

that there was no cause of action under the Tort Claims 

Act for wrongful death of or personal injury to a member of the armed forces if the injury or death was “in 

the course of activity incident to their service in the 

Armed Forces.”21 Many lawsuits alleging malpractice 

or seeking consortium for loss of finances have been 

barred because of the Feres doctrine, including suits 

in which unit commanders were accused of failure 

to take appropriate actions when there was direct 

evidence of a soldier’s suicidal intent. Legal action 

by both active duty members suing through military 

courts and civilian dependents suing through federal 

courts have been barred. 

The suicide of a soldier while that individual is 

under unit watch could potentially call into question whether the mental health clinician did not fully 

appreciate the suicide risk or did not ensure that an 

adequate intervention was used. The commander 

could also be questioned concerning the competence 

of the unit to perform a unit watch. Another issue is 

that soldiers performing the watch may have little or 

no experience with the procedures involved in a unit 

watch, and they may not fully appreciate that serious adverse outcomes might result if the procedures 

are not strictly followed. Although lawsuits are often 

barred through the Feres doctrine, the military may 

nonetheless take disciplinary action against physicians or commanders if an internal investigation uncovers fault or negligence. Monetary payments may 

be given out for compensable events. Department of 
437

Suicide and Homicide Risk Management

Defense Directive 6025.13 outlines the procedures for 

investigation of potential provider malpractice.22 If 

the surgeon general for the specific military branch 

makes a determination that an adverse privileging 

action should be placed against a physician, then that 

finding will be entered into the National Practitioner 

Data Bank (NPDB).22,23(pA-3) The NPDB is a database that 

provides information concerning specific areas of a 

practitioner’s licensure, including professional society 

memberships, medical malpractice payment history, 

record of clinical privileges, adverse licensure actions, 

withdrawal of clinical privileges, and other negative 

actions taken against an individual healthcare practitioner. Such information is provided through legally 

authorized queries to assist state licensing boards, 

hospitals, and other healthcare entities in establishing the qualifications of the healthcare practitioners 

they seek to license, hire, or privilege. These actions 

are representative of the military’s ongoing efforts to 

ensure that military healthcare is comparable to civilian 

standards. A survey of all military malpractice cases 

from 1978 to 1987 revealed that of 14 cases involving 

attempted or completed suicide, six cases resulted in 

monetary settlements totaling $754,000.24

The use of unit watch for management of homicide 

risk is perhaps the easier case to make. The landmark 

Tarasoff decision, although binding only within the state 

of California, gave clinicians the responsibility to take 

measures to protect the potential victim if the clinician 

believes there is a probability that the patient will commit murder.25,26 In the Tarasoff case, a patient told his 

psychiatrist that he planned to kill a female love interest. The murder was carried out, and the psychiatrist 

was found liable for not taking action such as alerting 

the victim and committing the patient. Many states 

now require Tarasoff-like duties to protect potential 

victims, either through case or statutory law. However, 

there is no federal law regarding this issue (federal law 

applies to the military). Some states have ruled that 

psychiatrists are liable for violent acts by their patients 

even when no specific victim can be identified, when 

no specific threat was made, or when homicides occur 

several months after a risk assessment.27–29

The military psychiatric community commonly 

assumes that a duty to protect exists, despite the lack 

of clear statutory guidance. The Feres doctrine would 

not exempt a military clinician from potential liability 

if an active duty patient hurt or killed an individual 

not on active duty; in such a case, relevant state law 

would be applicable. Unless one is familiar with the 

laws of each state, the best practice in the military is 

to adhere to a Tarasoff-like standard of care. The use 

of unit watch to prevent an individual from carrying 

out an act of homicide would be an added medicolegal 

(and ethical) safeguard when a clinician is assessing 

a soldier’s threats. 

In the authors’ experience, a large proportion of 

soldiers presenting with homicidal ideation toward 

their chains of command have diagnoses of adjustment disorder, personality disorder, or, sometimes, 

alcohol-abuse disorder. In the absence of a severe 

mental disorder, these service members do not meet 

criteria for hospitalization, but are often hospitalized 

because the clinician believes that it is necessary to 

protect the potential victim. As an alternative measure, 

unit watch helps protect potential victims by limiting 

access to lethal means and providing an observer to 

notify the chain of command or authorities if the potential perpetrator takes any confrontational action. 

As an adjunct to the unit watch, additional clinical 

actions in the case of a potential homicide sometimes 

include a recommendation that the commander move 

the soldier to another section of the unit (in the case of 

homicidal ideation toward an immediate supervisor), 

that the commander warn the potential victim about 

the homicide threat, and that the commander give 

both parties a direct order to avoid all contact except 

as necessary in the performance of their daily duties. In 

many cases, these interventions may actually be more 

effective in minimizing risk than simply notifying the 

local police and the potential victim, in keeping with 

the civilian standard of care when the patient does 

not meet commitment criteria because of the lack of 

evidence of a severe mental disorder. 

SUMMARY

Although there are no simple answers in the assessment and management of suicide and homicide risk 

in any setting, military clinicians practice in a unique 

community that necessitates a uniquely military approach to the issue. The recommendations and information presented in this chapter may help validate and 

standardize a military approach, and will hopefully 

stimulate research in this area. For example, publication of a case series of soldiers successfully managed 

with unit watch according to the guidelines discussed 

above would further validate this technique. A retrospective or prospective study comparing various outcome measures for soldiers at a post where unit watch 

is commonly used with outcomes for a control group 

of soldiers at a post where unit watch is not commonly 

used might also be possible. Optimization, validation, 

and eventually incorporation of this chapter’s recommendations into the curricula in military behavioral 
438

Combat and Operational Behavioral Health

health training programs, combat operational stress 

control doctrine, and other military publications will 

contribute to a wealth of resources available to military 

mental health professionals to support and guide the 

successful management of suicide and homicide risk 

in the active duty population.

Acknowledgment

The authors would like to express their sincere thanks to Colonel Sally Harvey for developing an earlier 

version of the example unit watch forms used in this paper. These forms have been modified and utilized 

in two major conflicts, Operation Iraqi Freedom and Operation Enduring Freedom; in peacekeeping operations in the Balkans; and in garrison settings throughout the United States, Europe, and Asia.

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