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Reports from Interactive Session Groups
Activity on the second day of the symposium was built around six discussion groups, each focused on a specific population addressed in the previous day’s presentations. Timothy Strauman (Duke University) provided a summary of several themes that emerged from the previous day’s talks. These include the observation that “there are extensive data documenting that the social determinants of health in general are directly applicable to the specific challenge of reducing suicide risk in veterans.” He commented one benefit of this is that as a result of this, “we can draw on that literature.” The second theme is that in addition to approaching suicide prevention and management as an acute problem, adopting a broader perspective will make it possible to better “manage, reduce, and eliminate risk of suicide.” Third, Strauman noted the central importance of “the intersection of multiple social forces and multiple identities,” and the way that intersectionality might figure in suicide risk within a specific population. Fourth, he pointed to the fact that while factors contributing to suicide risk in veterans might seem intractable, panelists from day 1 of the symposium show collaborative efforts that “have already begun to make a difference.” Fifth, and last, Strauman noted that interventions that reduce veterans’ rates of suicide risk are also “effectively addressing other threats to their health and wellbeing.”
Having set the stage in this way, Strauman turned to Molly Checksfield Dorries, who provided a brief overview of breakout group logistics. She explained the plan wherein each group would discuss how various adverse social determinants impact its focus population, and then “design, implement, and evaluate” a community intervention that might address these
challenges specifically for the focus population. A common set of questions coordinated group discussion of these three points: population, adverse social determinant, and community intervention. These populations included older veterans, LGBTQ+ veterans, veterans living in rural communities, veterans with co-occurring mental health and substance use disorders, Black veterans, and women veterans.
OLDER VETERANS
The discussion group that focused on older veterans chose to address the adverse social determinants of legal problems, familial and social problems, and lack of access to care and transportation, the reporter for the group said. One of the challenges this group identified was a lack of trust in the VA, the health care system, and government policies—the sense that these did not have their “best interest as a priority,” he noted. A program addressing this might involve “education and exposure to local resources and services from the VA and other service providers;” the reporter explained that this education could be undertaken not just by the VA itself, but by community, state, and federal offices and organizations. Local non-profits could be especially important in this work, “being the boots on the ground” and peer leadership that might connect with veterans who are unhappy with the services available through the VA, he said. The reporter said that barriers to this approach might include the credibility of the organization, especially if new and relatively unknown. The group envisioned a “holistic approach” to support, “just encompassing everything to get that veteran or their family member help,” he said. The reporter said the group also discussed the importance of training first responders, including law enforcement, in crisis intervention and deescalation. The group also discussed how crisis intervention teams value the insight from social workers or therapists because these experts provide special training for how to interact with a veteran in crisis in ways that lead to a “healthy conclusion.”
LGBTQ+ VETERANS
The participant reporting for the LGBTQ+ group said that they chose to identify their own social determinant of health, and that they identified “enacted perceived, or anticipatory discrimination as a key undercurrent of a variety of problems that our population experiences.” Group discussion centered the question of whether there is a need for new programs or are there existing programs that might work for LGBTQ+ communities but cannot be evaluated as such because there are no data or the programs do not reach that population.
The reporter listed a number of “different partner organizations that should be at the planning table in our community,” including LGBTQ+ veteran organizations, VA peer support, as well as “nontraditional veteran spaces” like wellness centers, alternative therapies, community health care, and substance use treatment. The vision of partnership also included “bridging” LGBTQ+ care coordinators at the VA with the VA Center for Faith-Based and Neighborhood Partnerships. This collaboration would, ideally, make space in programs for “folks can be their whole selves. . . . Very often what we find is that LGBT+ veterans are not identifying as veterans.”
While the group discussed a variety of different outreach materials, “we landed on implementing an evaluative rating scale for community organizations to assess their readiness or competency for working within the LGBT+ and veteran space.” The aim was to connect patients with LGBT+ resources “and be physically and psychologically safe in those spaces.” The reporter noted that this would result in “an LGBT+ care continuum, a map of vetted service providers.”
One challenge the reporter mentioned was “the futility of it all.” The massive scale of change needed can be daunting; she noted that one possible solution to this is to “bring this to life on a granular level, human to human” to create an important interpersonal connection. Evaluation posed another barrier; “how do you measure and evaluate if this is working if we do not have the data to begin with?” The group focused on tangible ways of evaluating progress—“number of gatekeeper trainings . . . number of gun locks distributed”—as well as the rate of suicide among LGBTQ+ veterans. Uncovering the latter would involve attempts to partner with “the medical examiners’ offices, vital statistics, and data from the state, the CDC, and the VA.”
VETERANS IN RURAL COMMUNITIES
The reporter for the group focused on rural veterans said that they focused on logistics: “everything from firewood to broadband to access to trucks and transportation—all as vehicles for suicide prevention.” The reporter identified some themes identified by the group; these included coalition building and service connection. Coalition-building might involve simply one person from the VA who “is a trusted source in a local community” that an individual might feel comfortable turning to even if they have doubts about the VA or mental health care. The group came up with the idea of building an academy that might teach how to build coalitions as well as teach skills like the ability to train others, grant writing, sustainability, capacity building, networking, he said. The group also noted that last in the coalition theme is the idea that “statewide coalitions ultimately can unify efforts across rural counties, making them more efficient” and
highlighting “the fact that these broad sets of needs that individual communities have really all are still suicide prevention.”
The second theme was service connection, meaning, “a sense of purpose.” The reporter explained, “No matter where the veteran is and what is going on in their life, how do we help at the individual [or] community level . . . to get [people] engaged in ways that help their lives continue to make sense.” Ramchand, moderating this portion of the symposium, mentioned We Got Your Six, a coalition for veteran community-based organizations as relevant to this group.
Challenges identified include volunteer burnout and varying levels of integration between service providers and communities, Strauman reported. He also noted that there seem to be challenges around limitations as to what a person who works for the VA would be able to do “in terms of helping somebody else write a grant or manage funds.”
MENTAL HEALTH
The group focusing on mental health chose as their adverse social determinants, “familial and social problems with mental health . . .; not knowing the symptoms of PTSD or brain injury . . .; and, a lack of understanding,” stated the reporter for the group. They also discussed “community response to the death by suicide of a veteran in the community and how it impacts other veterans; financial conditions and financial literacy for veterans; the feeling of isolation and loneliness, lack of access to care and to community; and . . . lack of access to transportation,” he said.
One intervention the group developed was to start the process of transitioning from active duty to veteran earlier in a career, before the point of separation, the reporter said. Challenges identified by the group included too many options for veterans to choose from, he said. Varying quality of care was another concern, he noted, as was a lack of communication about services available. In the case of the latter, this encompassed communication between organizations as well as advertising messaging: “A lot of times, one place will not know what another place has to offer.”
Components of this community intervention included what the reporter for the group called “the magic wand one”: the removal of all barriers to access needed services. The development of a centralized and informed source of knowledge for all available services in a particular community is another component, he said. Another key aspect of this community intervention was various forms of education: training for law enforcement focused on veteran needs; education for family and friends “on what the special needs of a retiring military person might be;” and financial education for veterans. The group reporter stressed the importance of securing funding to support services, and especially legislative advocacy for funding. Another component
was the use of support structures like veteran peer support networks to help with the transition; an audience participant noted that in using veteran peer specialists, the support could be “all-encompassing of the veteran instead of just recovery coaching” or support for other mental health issues. The group also included the idea of creating a storytelling space, where veterans can talk “about their process of retiring and then integrating into the civilian world,” he said, adding that this can normalize conversation about this process, including concerns and issues that might have arisen.
Organizations that might be brought into this include “local mental health authorities, the VA, local nonprofits, workforce training organizations and services, and the faith-based community,” the reporter for the group stated.
Ramchand noted that the chat conversation included mention of the Department of Labor’s Transition Assistance Program and local chapters of the American Foundation for Suicide Prevention (AFSP), as well as suicide postvention teams through the VA. He also mentioned that more resources were being added to the chat by symposium participants.
Bruce Crow, who served as the VA’s point of contact for the symposium planning committee, pointed to the importance of acknowledging the emotional impact of veteran suicide—something not normally considered a social determinant of health but that does impact the individual. This could be an approach that “broadens our thinking about what constitutes a social determinant,” he commented.
BLACK VETERANS
The reporter for the group focusing on Black veterans stated that this group chose to focus on financial/employment problems. This was in part because this adverse social determinant of health acted as a “catch-all” for this population, he said. It reflects the more general findings that “African American veterans generally do well in every category compared to the African American community, but they still do worse when it comes to the veteran community.” This is true of unemployment rates, with Black veterans having higher rates of unemployment and unemployability than the general veteran population, he noted. The reporter pointed to the Center for Minority Veterans report as the source of this observation. He also noted that underemployment contributes to financial/employment problems.
The reporter for the group emphasized that the lack of data on this population are a huge barrier to designing and implementing interventions. He noted that data exists, but it is scattered across institutions and “is just not in a place where we can . . . make really good scientific analysis.”
The group highlighted systemic bias, especially in terms of access to benefits, as one aspect of financial/employment problems as an adverse
social determinant of health for Black veterans. “How many African Americans who apply for benefits get denied?” This included support in the wake of military sexual trauma, the reporter noted.
Another challenge in this area discussed by the group was the lack of organizations that serve the Black veteran community, the reporter stated. He noted that there is often not proportional representation among stakeholders in these organizations. Of his own experience, the reporter commented, “Normally, I am the only African American in the room” alongside “White males, older, who are Republican.” The reporter observed that this contrasts with the active duty population, which is more diverse. He also explained that in these contexts, race is often treated as a “divisive topic,” which “really stops the conversation.”
The reporter said the group considered that this lack of support for African American veterans may stem from a gap between Black legacy services (including the NAACP, the Urban League, the Congressional Black Caucus), which often “do not bring out the veteran issues,” and veteran services, which often underserve Black veterans. The reporter mentioned the NAACP as one organization that does work at this intersection.
The group highlighted better data collection as a foundational part of any intervention that might address financial/employment problems, the group reporter said. “If I do not have the data, I cannot justify building a service.” “We have to have more intersectional data,” he commented in specific reference to Black women veterans and military sexual trauma.
Two strategies the group thought of to increase the store of data on this population included working with data already collected by the NAACP, and funding research at Historically Black Colleges and Universities. The reporter said the group also emphasized the importance of raising awareness around the work and needs of Black veterans. He suggested the creation of an award named after Alwyn Cashe, an African American recipient of the Medal of Honor; this award “would be presented every year to the veteran or a spouse of a veteran who did something for the community,” the reporter said, as an effort to raise awareness.
WOMEN VETERANS
The reporter for this discussion group focused on women veterans stated that the topic they addressed was the importance social connection in the prevention of suicide among women veterans. The group created a “holistic transitional roadmap to civilian life” with the aim of providing “structure and navigational support to decrease the chance of personal crisis that could lead to suicide.” The reporter emphasized the benefit of a holistic approach rather than focusing solely on career or another area of life, which research has shown leads to a feeling of unfulfillment. This is
an upstream approach, she noted, including supporting transition before members leave active service.
This holistic approach covered four domains, the reporter for the group said: career and vocation; health (physical mental, emotional, relational, spiritual); relationships (family, friends, co-workers; “Who is in your support network beyond service?”); and time and money. The group emphasized the central role of collaboration and coalition-building, and partnering with existing organizations, in implementing this roadmap. “We want to collaborate between multiple entities to provide resources and support from military service through civilian life.” This is “partnering on a grand scale,” she noted, and might span the local, state, and federal levels.
The reporter for the group also reported the group’s discussion regarding barriers to this intervention. One such challenge includes lack of access to service members on military bases. The EGS Sponsorship program would be a good partner “since they already have the seeds and groundwork on the bases.” Marketing would also need to be “phrased appropriately” when communicating about collaboration between different service providers to people who might resist branching out. Training and staffing is also an important component of implementation, particularly in collaborative situations, she said. The participant also noted that measuring data and doing evaluation could present challenges when looking to create a holistic view of transition; one route might be through data from the VA’s Personal Health Inventory, which is easily accessible and “asks all of these holistic questions.” Devising surveys to study this question is also an option.
One purpose of this holistic roadmap would be to help give women service members transitioning out of active military service a plan that supports a sense of purpose and sense of clear vision for the future, the reporter noted, so that “hopefully [the veteran will] get pulled by the vision instead of getting pulled back by the pain or uncertainty or lack of clarity.” The reporter also pointed to resources, including a mental health app from the VA that includes resources for military sexual trauma and PTSD.
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