After identifying veteran suicide as its highest clinical priority, the military is making a major new push to prevent deaths by suicide, with numerous efforts underway both in the Department of Defense (DoD) and the Department of Veterans Affairs (VA).
There is good reason for this heightened activity: For decades, suicide rates were lower among active-duty personnel than they were in the general population, but they are now about the same. Veterans, meanwhile, are 1.5 times more likely to die by suicide than nonveteran adults. Reasons for these sobering numbers may include high exposure to trauma, stress and burnout, isolation and loneliness, easy access to and familiarity with guns, and difficulties reintegrating into civilian life.
The DoD and VA recognize that standard clinical interventions, while helpful on an individual level, are not enough to address these problems, said psychologist Matthew A. Miller, PhD, MPH, executive director for VA Suicide Prevention in the Office of Mental Health and Suicide Prevention. As a consequence, they are funding a range of so-called “upstream” approaches—public health efforts to prevent suicide on community and other environmental levels. Psychologists are playing a key role in these endeavors, which include spearheading community programs run by veterans, training fledgling Air Force personnel on team-based approaches to healthy living, and working with veteran-related organizations to make suicide prevention part of their organizational fabric.
VA clinical psychologist Bryann DeBeer, PhD, who is heading some of these initiatives, said the approach is about giving the nation’s service members as many options for healthy living as possible. “There is no wrong door here.”
Encouraging veteran communities
Veterans are highly qualified to help fellow veterans build mental health resiliency. That is the philosophy behind Together With Veterans, or TWV, an initiative funded by the VA Office of Rural Health aimed at reducing suicide rates among rural veterans. These veterans are an important group to focus on because they are about 20% more likely to die by suicide than urban-based veterans owing to factors such as greater access to lethal means, reduced access to good health care, geographic isolation, and loneliness, said Nate Mohatt, PhD, a community psychologist who helped launch and was principal investigator of the program until 2022. (The program is now headed by VA psychologist Lisa Brenner, PhD, and will continue its funding until 2024.)
TWV draws in part from an initiative that began in Nuremberg, Germany, called the European Alliance Against Depression. That endeavor, which has grown to include some 100 partner organizations, aims to create public environments that help reduce stigma and encourage people with mental health problems to seek help.
TWV takes a similar tack, explained Mohatt, now a lead scientist at the information technology consulting company Booz Allen Hamilton, where he is advising the DoD on mental health and suicide prevention research. “Instead of taking a clinical approach to prevent suicide among a single individual who is actively suicidal,” he said, “it’s a whole-community, population-health approach to reducing suicide rates.”
Key to TWV’s successful implementation are two related factors: community buy-in and community ownership. A VA team begins the process by identifying rural veterans who are leaders in their community and are passionate about preventing suicide among fellow veterans. Once these individuals express interest, they are prompted to enlist the support of fellow local veterans—a vital step, because the program will not work unless the entire community is on board, Mohatt said.
Next, veteran leaders undergo a series of trainings as they begin to mobilize their community partners. “We work with them to give them the tools, the training, and the technical assistance they need to implement a very complex, intensive, community-based project,” Mohatt explained. The leaders learn what it takes to become expert community organizers, from tapping fellow veterans to run meetings and coordinate logistics to creating and implementing community-wide action plans using a range of “best practice” approaches.
Overall, leaders are guided to undertake actions in six areas geared to increasing connection, education, and safety among veterans, Mohatt added. It is important that they take all of these actions, he said, “because if you just do one, we don’t know that you’re going to reduce suicide rates. But if you do a bunch of different things—synergistically meeting your community’s gaps and needs across all of these focus areas in a coordinated way—it will reduce suicide rates.”
An example of this work is taking place near the small city of Sparta, Wisconsin, in the vicinity of the Tomah VA and Fort McCoy, a ready-reserve training center. There, TWV codirectors Tom and Laurie Graber—Tom is a veteran, and he and Laurie are cofounders of a Christian ministry called Acres of Hope—have done extensive outreach with their board of directors to help connect veterans in the community. Some of their efforts include hosting a monthly pancake breakfast to tell veterans about TWV, establishing a local office, and supplying free gun locks to gun owners, because these devices have been shown to curb suicide rates (see, for example, Anestis, M. D., & Anestis, J. C., American Journal of Public Health, Vol. 105, No. 10, 2015opens in new window).
In addition, the Grabers and their growing TWV team have planned regional outings, including to a veterans park called The Highground–Camp Victory, which uses therapeutic recreation and adaptive sports to bolster mind, body, and spirit.
Tom Graber said the work is incredibly synergistic—that once he meets with a veteran, a chain reaction occurs. A chat with a restaurant owner led the man to volunteer his restaurant for the pancake breakfast. A TWV board member who worked at an Ace Hardware offered to take gun locks to the store, telling Graber that she would put a Together With Veterans tag on each gun sold and hand each customer a gun lock.
These efforts tackle a root cause of suicide: loneliness and isolation, Graber said. “A lot of our rural veterans are getting older and their spouses are dying,” he said. “Maybe they have health issues and can’t get appropriate care. Most of them don’t use social media. So the bottom line is that a lot of older veterans become isolated, and that is a major reason that people consider suicide.”
Mohatt’s team piloted the TWV model at sites in northwest Montana and in Carteret County, North Carolina, and the intervention is now being rolled out in 31 rural communities nationwide. While it will take a few years to see if it reduces suicide rates on a larger scale, interim results in northwest Montana are encouraging. Over two years, the TWV group there recorded nearly 10,000 positive community encounters related to veteran suicide prevention—solid numbers, considering that the overall veteran population there is only around 12,000, Mohatt said. In addition, the group trained 431 veterans in an evidence-based suicide prevention protocol, gave 216 referrals to veteran care, provided 32 homelessness services to veterans, and conducted 315 one-on-one check-ins with vulnerable veterans.
Seeing those numbers in context is important, said Mohatt, because at the time of the project there was only one VA suicide prevention coordinator serving the entire state of Montana. “It would have been impossible for that person to provide all of those services in this one large rural area,” he said. And TWV and other VA projects with a community focus will be getting a big boost in the near future: The VA plans to hire at least 200 community engagement and partnership coordinators “whose sole job is to collaborate with communities to do work like this,” Mohatt said. (See Tapping communities to prevent veteran suicides.)
Building resilient Air Force teams
In another upstream suicide prevention effort, psychologist Peter A. Wyman, PhD, a professor of psychiatry at the University of Rochester, has developed a group intervention for U.S. Air Force units that has been shown to increase positive team connections and cohesion and, relatedly, reduce suicide risk and depression.
Called Wingman-Connect, the initiative—framed as training for career success and health and well-being, rather than overtly targeting suicide prevention—squares with the growing recognition that positive social connections and shared healthy norms can facilitate mental health and reduce suicide risk, Wyman said.
“There’s been a growing concern in some parts of the military about a loss of cohesion and community among service members,” a traditional feature of military life. For example, fewer Air Force personnel live on bases than in the past, leading to less connectedness, Wyman said.
The intervention is distinctive in its small-group focus, Wyman said. “It recognizes that protective strengths and skills aren’t just individual—that they also involve small group units, the groups that people are connected to through friendship, working, and learning relationships,” he said. “It also recognizes that individuals often learn these strengths best when they learn them together with people who are a part of their natural networks.”
In a first iteration of the model, Wyman’s team worked with Air Force personnel who were just learning about their career and job roles at the branch’s largest technical training school, in Wichita Falls, Texas. During six hours of training spread over three days, groups of 30 to 40 airmen completed group exercises emphasizing cohesion, shared purpose, and the value of a healthy unit. They also learned and shared skills related to job success and mental health, such as kinship, balance, guidance, and purpose, noting which team members—including themselves—were particularly strong in one or more of those skills. Finally, they mapped out their unit’s entire network of strengths, observing how each member contributed to the strength of the whole.
In a randomized controlled trial reported in JAMA Network Open (Vol. 3, No. 10, 2020)opens in new window, Wyman demonstrated that compared with airmen who received stress-management training only, those in the Wingman-Connect groups had fewer suicidal thoughts, depression symptoms, and occupational problems at one month, and they maintained the gains related to depression at six months. Those who saw the biggest benefits—airmen most likely to become more connected to their team—were the airmen at greatest risk of depression and suicide before the intervention, the researchers also found. The findings suggest that team cohesion, support, and shared healthy norms can provide powerful protection against the suicidal risk factors of loneliness and isolation, Wyman noted.
With additional funding from the Air Force, Wyman is now tailoring the model for airmen who are in arguably the most stressful phase of their careers: their first few years on the job.
“The highest period of vulnerability for health problems is really in that first year or two or three after the training, when the demands, stressors, career challenges, and personal relationship problems all come together,” he said. A pilot of the adaptation found that it could be successfully delivered and that airmen found it useful. Wyman’s team is also planning a study that will increase the length of the intervention to encompass the training and initial career phases, include a longer follow-up period, and determine how to prepare Air Force personnel to deliver the intervention with high fidelity.
The fact that the military is open to a suicide-prevention approach that is not specifically geared to suicide but could affect long-term mental health and quality of life is extremely heartening, Wyman added.
“I am very impressed by how supportive very high-level military leaders are about the importance of really proactive prevention,” he said. “The Air Force is extremely supportive of this work and is eager to work on developing it further as something that could be more of a force-wide deploy.”
Helping organizations become veteran savvy
In another VA-funded project that addresses environmental factors, DeBeer, who directs the VA Patient Safety Center of Inquiry–Suicide Prevention Collaborative at the VA Rocky Mountain MIRECC (Mental Illness Research Education and Clinical Center) for Suicide Prevention, has been helping organizations develop stronger veteran suicide-prevention programs using a “learning collaborative” model. That approach brings members of organizations together with research-implementers to learn, execute, and sustain evidence-based interventions.
A central aim of this work is to bring better suicide-prevention services to the many veterans who do not use the VA health care system—some 52% of the veteran population as of 2016, according to VA data (PDF, 1.29MB)opens in new window. This aligns with the purposes of the Mission Act, passed by Congress in 2018 to expand and improve veteran care, including in the community.
“In my opinion, the VA has truly built the strongest veteran suicide prevention program available, but not everyone is coming into contact with it,” said DeBeer. “The aim of these learning collaboratives is to take these best-practice methods that have been implemented in VA and other systems and to support organizations in implementing them.”
DeBeer headed an initial pilot of this idea from 2018 to 2021, with grant funding from the VA National Center for Patient Safety and the Rocky Mountain MIRECC. In that project, her team worked with 13 organizations in the Denver and Colorado Springs metro areas that come into contact with but do not necessarily focus on veterans, including offices of public safety, libraries, and community mental health centers (that project won the Veterans Health Administration’s Community Partnership Award for 2021 as well as a commendation from VA Secretary Denis McDonough). She is now running a second pilot project, funded by the VA National Center for Patient Safety for 2022 and 2023, that will use some of the same methods to help improve suicide-prevention services in several non-VA health care organizations that receive funding through the Mission Act to serve veterans in the community, but with more of a focus on health care systems and care coordination.
The learning collaboratives take place over 16 months between the VA team and a team chosen by the organization, with the organization’s team making the final calls about what to use. “We don’t want to be overbearing with the organization; we want to listen to them and support them in implementing better suicide prevention,” DeBeer said. “It’s up to them as to how that occurs.”
To start, the two groups do an assessment of the organization’s suicide-prevention status. Next, they come up with a set of recommendations and an action blueprint based on that assessment. Depending on the chosen goal, the partners then create an action plan to help realize the blueprint, using a standard implementation science methodology that involves planning a potential change, trying it out, observing the results, and acting on what is learned. They also address contextual factors such as who will actually be implementing the changes, and they develop data collection systems to assess progress and make changes as needed.
Along the way, both sides “get really specific about timelines for different goals and who is responsible for meeting them,” DeBeer said. The VA team may commit to providing resources by the next meeting, for example, while the organization’s team may agree to doing research on a specific topic and sharing their findings.
The system, described in the Federal Practitioner (Vol. 37, No. 11, 2020)opens in new window, appears to be a winning one. “People end up getting a lot done because we break it down into manageable chunks,” DeBeer said. Over two years, the 13 community organizations enacted 92 implementations, as well as strong measurements that they can apply to future action plans.
One system that undertook this training was a veterans’ homelessness organization that DeBeer worked with during the first pilot. The organization’s team was eager to undertake this work because many veterans entering the system struggled with mental health disorders and suicidal ideation and behavior, but team members did not know how to help because mental health was not an organizational focus.
Working with DeBeer’s team, the organization developed several plans that turned into actions. These included proactively screening clients for mental health symptoms, embedding mental health screening into the organization’s electronic health record, giving staff additional training in suicide prevention, and integrating that training into the organization’s policies—important, because “we know from implementation science that if we don’t codify these changes into the organization, they may not continue once those [trained] individuals leave,” DeBeer said.
When she last spoke with the team, members reported that they were excited about their progress. “After a few months, they realized that about 1 in 10 of the veterans they were seeing were positive for mental health symptoms but weren’t getting any care,” DeBeer said. “And they were connecting those individuals to care.”
The work is about much more than just training an organization’s staff, though training is a part of it, DeBeer added. “We’re supporting organizations to make comprehensive and sustainable changes that will last—empowering them to act in ways that will prevent veteran suicide.”
