5

Community Interventions for Suicide Prevention and Support for Veterans

The second session of the symposium featured panelists discussing various community interventions to address social, cultural, and economic determinants of suicide risk, said Strauman. The first panel focused on coalitions and interventions focused specifically on suicide prevention; the second panel featured presentations on specific points of intervention—housing, and place more generally—and on a collaborative method of intervention, all through the lens of addressing social determinants of health in order to lower the risk of suicide among veterans. The second panel of this session occurred on the second day of the symposium and is described in the next chapter.

Speakers in the first panel included Nicola Winkel (Arizona Coalition for Military Families), who reported on prevention efforts in Arizona. Joseph Simonetti (VA Rocky Mountain Mental Illness Research, Education, and Clinical Center [MIRECC] for Suicide Prevention) discussed community-driven firearm suicide prevention. And the panel’s third speaker, Debra Houry (Centers for Disease Control and Prevention), described the CDC’s technical package on suicide prevention.

UPSTREAM PREVENTION BY ADDRESSING SOCIAL DETERMINANTS OF HEALTH

The Arizona Coalition for Military Families and the Governor’s Challenge

Winkel spoke about veteran suicide prevention through state-level support of community prevention efforts. She discussed the work of the Arizona Coalition for Military Families (ACMF), a state-level “public-private partnership and collective impact initiative,” established in 2009, whose current program Be Connected, established in 2017, serves Arizona service members, veterans, and their families. Be Connected focuses on upstream prevention of suicide across all social determinants of health. She also briefly discussed the Governor’s Challenge, a national program similarly aimed at coordinating community efforts in suicide prevention.

Winkel noted that the ACMF focuses on “all helpers, organizations, and communities to create a coordinated ecosystem of support.” The program Be Connected has provided resources and care navigation to service members, veterans, family members, and helpers in more than 70,000 encounters over the past five years. Winkel described the program as a “team of teams,” including partnerships across systems and sectors, and involving a host of participants: people who answer the support line phones, care navigators, career navigators, community outreach navigators, people fostering community engagement, and the risk reduction operations team.

Be Connected grew out of an earlier program run by the ACMF, Be Resilient. That program, in place from 2011 to 2013, focused on members of the Arizona National Guard, which had the highest rates of suicide in the history of the organization for three years running (2008–2010), Winkel explained. In the three years Be Resilient was in place, there were no suicides within the Arizona National Guard. Building on this experience and knowledge gained, the ACMF developed Be Connected, an expanded program meant to serve the whole military population, she said. Since 2020, the ACMF, with technical assistance from the CDC, has been working to develop a data tool that enables “a proactive focus on engaging those at highest risk,” she said.

Winkel explained how several features of the Be Connected program were part of this effort to proactively engage those at highest risk. The program is comprehensive in its scope, engaging with “all aspects of the military veteran and family experience” including social determinants of health, and points throughout the life course of the individual, she said. It is similarly inclusive in terms of people served and helpers involved, Winkel noted. This breadth extends to its collaborations with partners representing a range of public and private sectors, she said. Such breadth leads to “greater impact.” Winkel pointed to agencies and organizations in states and communities the country, including the Governor’s Challenge and Mayor’s Challenges, that are engaging in similar efforts and, significantly, “engaging with their counterparts in other states, territories, [and] communities” to strengthen local efforts. Winkel noted that the ACMF has worked with the Service Members, Veterans, and their Families Technical Assistance Center for more than a decade, providing technical assistance to every other state and territory nationally during that time.

Winkel also described Be Connected as rooted in a public health approach that integrates “crisis response, treatment, and proactive prevention.” She commented that this also means “not using the exact same approach for every service member, veteran, and family member” but instead adopting “an upstream prevention model” that has a “layered approach of universal, selective, and indicated efforts” and seeks to provide support before a situation becomes urgent. The goal of Be Connected is to “provide earlier intervention to reach people all across the stress continuum,” which gives “more opportunity to connect with people and practice prevention strategies,” Winkel said.

Winkel pointed to a current project guiding the work of the ACMF and Be Connected—as a grantee of the CDC around developing a logic model that allows for “outcome evaluation of our upstream prevention approaches and our risk reduction strategies.” The logic model allows for evaluation of short-term and intermediate-term goals that contribute to the “ultimate goal” of reducing death by suicide by improving social determinants of health, she said.

Winkel reviewed some universal strategies employed by Be Connected to improve social determinants of health. These include:

• Inclusive messaging. Winkel noted that the messaging around Be Connected is inclusive in two vectors, who it serves and at what point a person might draw on those services. Messaging emphasizes that “we are here to serve everyone who was touched by . . . military service and those who are helping them.” Additionally, materials focus not just on “active crisis” but connecting earlier on the stress continuum.

• A public service campaign. Be Connected partnered with the Arizona Broadcasting Association to put out TV and radio ads, and public service announcements statewide.
• A support line that provides resource and care navigation. Winkel reports that the support line team has had more than 70,000 encounters in the last five years. An evaluation of callers revealed that about 85 percent were at “low acuity” category of risk; 14.5 percent needed more intensive and ongoing support; about 0.5 percent were in the crisis category, meaning that the program was effectively reaching people pre-crisis.

Selective strategies of prevention target higher-risk segments of the population, said Winkel. “If you know who the segments are, how do you then translate that into a functional program or approach?” Winkel noted that Be Connected has taken a proactive approach that involves identifying high-risk groups, developing and implementing targeted programs, collecting data and evaluating outcomes, and iterating in ways that are responsive to that data and “lessons learned.” One example of this that Winkel pointed to a project run with the State Department of Veterans’ Services where that agency proactively refers veterans with a known or potential disability directly to the Be Connected team, which then connects them to resources needed for issues outside their disability claim. Another example Winkel gave was developing projects that support service members as they transition out of the military; these include programs focused on support navigation, mentorship, and food insecurity.

Indicated strategies employed by Be Connected work at the individual level, Winkel said. This includes training and equipping “helpers” in the community “because they are the ones who are best positioned to identify and connect and support” veterans. Be Connected has trained more than 6,000 people in resource navigation in Arizona, she reported. It is part of “an ongoing effort to ensure that we have . . . thousands of open doors across the state of people who are willing, ready, and able to help get someone connected.”

COMMUNITY-DRIVEN EFFORTS TO PREVENT FIREARM SUICIDE

Simonetti presented on community-based efforts to prevent suicide by firearm, first discussing why these efforts are critical in solving the larger problem of firearm suicide. “There is a longstanding acknowledgement of the fundamental role that communities play [in] determining health outcomes generally,” noted Simonetti. With respect to firearm injuries in particular, community interventions may reach where health care systems cannot, constrained as they are by “important limitations,” present in a system’s reach, credibility, resources, and focus. First, health care systems are limited by the simple fact that they “can only intervene on the people they see,” said Simonetti. He noted that in the VA, the clinical population is less than half of the total U.S. veteran population. Second, health care systems “have unique credibility” within this population, Simonetti said, which is not necessarily better or worse than the credibility afforded to other potential messengers, but truly different. As such, “community efforts have a unique opportunity to talk about firearm suicide prevention in a way that clinical systems do not.” Third, hospital systems and clinics have time constraints, competing priorities, and “varying levels of comfort and . . . knowledge” among the clinical staff. Fourth, community-based outreach allows for a focus on “some of the fundamental factors driving suicide outcomes” as theorized by the “socio-ecological model” rather than those identified in the bio-medical approach.

Simonetti noted the promising increase of prevention work at the community level over the past 10 years, and turned to a short overview of some of these efforts. The first was work through the VA by Mohatt to build “community-driven and community-based infrastructure for suicide prevention in rural areas.” One aspect of this project is to develop coalitions of veterans who work to “normalize and reinforce conversations about firearms as well as suicide risk at the community level,” especially in rural areas that are disproportionately at risk for suicide by firearm, said Simonetti. As one example, he referenced a veteran coalition in Montana that hosted a suicide prevention table at a local firearm show.

Providing firearm storage options for at-risk veterans is another area where community-based programs might have more success than clinical practice settings, said Simonetti. Temporarily storing firearms outside of the home can protect at-risk veterans and others, he noted, and reported that clinical practice data as well as “preliminary data from national studies” show that “veterans do in fact hold on to firearms for other individuals at risk or store their own firearms out of their homes when they are going through really hard times.” Simonetti pointed to the Armory Project, a Louisiana-based coalition of firearm retailers and VA researchers who offer firearm storage options to at-risk veterans.

While the VA and other health care systems might have limitations, Simonetti said, there are still ways of contributing “to this conversation on

firearm injury prevention and suicide risk at the community level.” The VA has partnered with the American Foundation for Suicide Prevention and the National Shooting Sports Foundation to co-develop materials on firearm injury prevention that are disseminated through “a variety of firearm industry and community suicide prevention channels.”

Simonetti also pointed to “a number of organic initiatives” independent of the VA and other health care systems that do similar work. One such program is Walk the Talk America, a program run by “really dedicated individuals” in the firearm community whose stated goal is to raise awareness about guns, mental health, and suicide prevention. Those who run the program “know this role better than most people.” Another program is the Overwatch Project, which encourages participants (including service members as well as veterans) to ask “hard and . . . uncomfortable questions about suicide risk in an effort to support their peers and normalize these conversations about . . . the link between firearm access and suicide risk.” All of these programs are dedicated to raising awareness and normalizing conversation around suicide.

One of the central challenges to the prevention of suicide by firearm is striking a balance between the protection of oneself in a crisis by limiting access to firearms and, on the other hand, “a common perception in the United States that one needs to maintain ready access to a firearm for protection from other people,” Simonetti said. Approximately two-thirds of veterans who own firearms keep their firearms in case they need protection from other people. Simonetti pointed to public service announcements as one intervention strategy that can reduce the stigma around “making changes to one’s firearm access” as a way of protecting oneself or others; he commented that while such messaging may not be obviously community based, it plays a key role in normalizing conversation about the link firearms and suicide risk at both national and community level. He noted that such prevention efforts have been focused on increasing awareness about this link; one opportunity for development is community-driven efforts that focus on “the other side of the equation,” that is, “helping at-risk persons navigate their concerns about victimization risk and whether or not they truly need to maintain firearm access in these situations,” said Simonetti.

Simonetti summed up his presentation by reiterating the affordances of community-driven intervention efforts: to extend beyond clinical settings; to leverage the expertise of those within these communities; to identify and harness resources within the community that might only be known about by its members; and to normalize discussion about the link between firearms and suicide risk within the community. This normalization of conversation about this topic “can ideally change the risk parameters of the communities themselves,” Simonetti concluded.

THE CDC TECHNICAL PACKAGE ON SUICIDE PREVENTION

Houry gave an overview of the CDC’s technical package on suicide prevention, “Preventing Suicide: A Technical Package of Policy, Programs, and Practices” (https://sprc.org/news/preventing-suicide-technical-package-policy-programs-practices, 2017). She began by sketching the criteria for inclusion in a technical package. Following this, she detailed the seven strategies at the core of the CDC technical package on suicide prevention.

This technical package includes “strategies based on the best available evidence to help communities and states focus on priorities with the greatest potential to prevent a public health problem”—in this case, the risk of suicide, Houry explained. Each program, practice, or policy included in the technical package has to meet at least one of the listed criteria, she continued:

• Be a meta-analysis or systematic review.
• Show impact on suicide or significant impact on risk or protective factors for suicide.
• Show that there was evidence from at least one rigorous evaluation showing preventative effects on suicide or significant impact on risk or protective factors for suicide.

Houry emphasized that this range is in response to the fact that suicide itself is not caused by a single factor, “and therefore will not be prevented by any single intervention.” The technical package gathers “prevention strategies and approaches that address the range of suicide risk and protective factors at the individual, relationship, community, and societal levels.” She said, “preventing suicide requires strategies at all levels of society.” Houry also noted, “by building on community strengths and focusing not just on treatment but on this coordinated approach to prevention, we can meet the immediate needs of those already affected today while preventing future risks.”

The seven strategies of suicide prevention central to this technical package include strengthen economic supports (1); strengthen access to and delivery of suicide care (2); create protective environments (3); promote connectedness (4); teach coping and problem-solving skills (5); identify and support people at risk for suicide (6); and lessen harms and prevent future risk (7).

The first strategy, strengthen economic supports, responds to the link between financial wellbeing and risk of suicide, Houry noted. She explained, “Strengthening household financial security provides individuals with financial means to lessen stress and hardships associated with . . . unanticipated financial problems.”

Strengthening access to and delivery of suicide care can take a number of forms, Houry said. These might include implementing laws that require insurers to cover mental health conditions on par with physical health conditions; “reducing provider shortages in underserved areas through financial incentive programs and expanding the reach of telehealth;” and developing health care systems that emphasize patient-centered care (including continuity of care, continuous quality improvement, and promotion of equity for all patients).

Creating protective environments by making positive changes can have a major impact on individuals, Houry said. Such changes might include reducing access to lethal means, including focused intervention at suicide hotspots; implementing policies aimed at reducing excessive alcohol use; and implementing organizational policies and values such as the promotion of seeking health care, changing social norms, and bringing awareness to helping services. As an example of the latter, Houry pointed to the U.S. Air Force’s community-based Suicide Prevention Program, a required training associated with a decline in suicide of more than 30 percent as well as declines in family violence and homicides.

A sense of connectedness can decrease isolation and increase a sense of belonging, both protective factors against suicide, Houry said. She pointed to peer norm programs, which “can normalize protective factors such as health-seeking and reaching out to trusted adults.” Sources of Strength is a school-based program; it is associated with “improvements in adaptive norms, connectedness to adults, and school engagement.” This program has been adapted in the Air Force, where it is called Wingmen Connect. Urban greening initiatives and group exercise are other examples, Houry said.

Teaching necessary coping and problem-solving skills is the fifth strategy Houry discussed. One domain is social-emotional learning, she said; programs in this domain can help children and youth to “develop and strengthen communication and problem-solving skills, resolve problems and relationships at school and with peers,” and can help them address “other negative influences such as substance abuse, which can be associ-

ated with suicide,” said Houry. She pointed to the Youth Aware of Mental Health Program as one example of this kind of education, with a focus on teaching children and youth about positive mental health practices. Another domain is parenting skills; Houry noted that The Incredible Years is an example of a training program for parents, teachers, and children¹ that has been shown to “decrease risk factors from suicide such as substance abuse and to increase protective factors, including emotion regulation and social competence.”

One aspect of the strategy of identifying and supporting people at risk for suicide is “gatekeeper training,” where teachers, coaches, primary care providers, and other community members learn to identify and effectively respond to people who may be at risk of suicide, said Houry. Her example here is the Applied Suicide Intervention Skills Training, which “helps counselors, emergency workers, and others to identify and connect with individuals at risk for suicide and assist with linking individuals to resources.” Evaluations have shown a reduction in suicide attempts in counties implementing gatekeeper training. She noted that crisis intervention is another effective part of this strategy, with services like Lifeline making “space or time” between suicidal ideation and harmful behaviors. Another component of this strategy, Houry said, is psychotherapy focused on building problem solving and emotional regulation skills, including the program Improving Mood-Promoting Access to Collaborative Treatment. This strategy also includes treatment focused on preventing reattempts, which is an “especially important” element, she noted. Such intervention might take a number of different forms of follow-up contacts over varying periods of time.

The seventh strategy Houry described was lessening harms and preventing future risk, meant to prevent suicide contagion; this involves “postvention approaches . . . implemented after a suicide has taken place” to support those who know someone who died by suicide. The StandBy Response Service is an initiative by the Australian government that provides support to individuals and communities impacted by suicide, Houry noted. She also pointed to “safe reporting and messaging” about suicide that can prevent suicide risk through the inclusion of stories of hope and resilience, prevention messages, and links to helping resources.

Houry concluded by noting that the CDC is providing funding to groups in 11 states to support the implementation of “this comprehen-

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¹ Other important work to highlight includes the Creating Opportunities for Personal Empowerment (COPE) cognitive-behavioral therapy-based program for children, teens and young adults, which has more than 20 studies to support its efficacy in reducing depression, suicidal ideation, alcohol use and anxiety, and improving healthy behaviors. It is being implemented in primary care practices with reimbursement as well as primary and secondary schools and universities.

sive approach” outlined in the technical package, with several participant organizations focusing on veteran suicide prevention. She also pointed to the Veteran Suicide Prevention Evaluation programs, which helps to build “evaluation capacity for upstream suicide prevention programs.”

DISCUSSION

Simonetti began the discussion by addressing the challenge of finding effective, “shared” language to use around firearm safety within the firearm community and veteran population. He pointed to data showing that a difference in how clinicians and firearm owners define or think about “what firearm safety really is.” He noted that there are some trainings around “cultural competence in firearm injury prevention;” he also urged talking with members of the community—“whether that is veteran engagement at a local facility [or] walking into a firearm retail store and having a conversation with somebody”—as a way of developing a shared language.

Winkel spoke to the importance of “an ecosystem approach” to prevention intervention that provides mental health support for families of veterans as well as veterans themselves. Inclusive messaging is key to communicating the possibility of this, she noted.

Answering a question about the intersection of change to COVID-19 and veteran suicide, Houry said that thus far, there is no evidence of an increase in suicide deaths during the pandemic. However, she said, there has been an increase in risk factors, including economic instability, unemployment, social isolation, disruption of access to treatment. She advocated for prevention of suicide deaths as a result of these increased risk factors; such prevention could include “continuing to focus resiliency, connectedness, preventing ACEs [adverse childhood experiences]” and also attending particularly to those groups where mental health distress has been shown to increase (including underrepresented minority groups and essential workers, including health care providers and health care workers), Houry said.

Simonetti noted the promise of on-site storage options being developed within the firearm retail community, but observed that there is no codified approach or set of resources for engaging with shops to promote this. He pointed to the VA in New Orleans, and across Louisiana, as an instance of an agency engaging with gun shops on this topic. From those conversations, he said, they have seen the importance of having someone from the firearm community. He mentioned that some of the main challenges are how the operator of the on-site storage facility would know when to give the gun back, and what their liability would be around that transfer. Later in the discussion, Simonetti also spoke to the complexity of messaging in striking a balance between protecting oneself from suicide risk and from violence from others; misinformation can skew the message, he said, but Simonetti

noted that he worries more about the way two different people might receive and internalize the same message in different ways. He pointed to the importance of developing a shared language, communicating risk in a way that all will hear and understand.

Brenner, the panel moderator, posed the question of how best to implement the strategies and approaches discussed in the technical package and tool kits from various programs discussed by Houry and Winkel. Winkel commented on the essential nature of community groups partnering with programs and agencies that can provide technical assistance, helping to “translate information and intent into a plan” and building in evaluation of outcomes, as well. Houry pointed to the CDC resource Violence Prevention in Practice, which goes through some of the steps involved with implementing aspects of the technical package. Both spoke to the importance of helping community groups evaluate, choose, implement, and sustain specific intervention strategies based on the needs of the community they are serving.

Brenner also raised the question of challenges communities can face in partnering with state governments (whether programs or agencies) if there is not an alignment between the organization and the government or where community and state or federal leaders are not moving in the same direction. Winkel emphasized the hard work involved in building partnerships, especially across sectors and communities

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