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Community Interventions to Prevent Veteran Suicide: The Role of Social Determinants: Proceedings of a Virtual Symposium (2022)

Chapter: 8 Discussion of Interactive Session Reports and Synthesis of the Symposium

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Suggested Citation:"8 Discussion of Interactive Session Reports and Synthesis of the Symposium." National Academies of Sciences, Engineering, and Medicine. 2022. Community Interventions to Prevent Veteran Suicide: The Role of Social Determinants: Proceedings of a Virtual Symposium. Washington, DC: The National Academies Press. doi: 10.17226/26638.
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8

Discussion of Interactive Session Reports and Synthesis of the Symposium

Strauman (Duke University) opened the general discussion of the breakout groups by highlighting some themes that came to the fore in the individual presentations. One such theme was “the importance of thinking about facilitating transitions for different groups.” Another theme centered “getting local,” or, “the importance of addressing social determinants at a very localized level” in part by empowering communities to do some of this work. A third theme was the use of “non-mental health professionals for suicide prevention.” Among those mentioned were veteran service organizations, trained law enforcement personnel, and veteran peer mentorship programs, he noted. Related to the third theme was a fourth, the emphasis placed on the potential for suicide prevention “outside the clinical setting.” The repeated call for more data on these subgroups—and not just more, but better, more accessible, more granular data collected not just as an afterthought—was the fifth and last theme highlighted by Strauman.

Strauman also added his own reflections on the material. Noting the “strong people” doing work in this area, he wondered how to incorporate the passion and commitment of individuals at the level of processes and programs so that when a strong person leaves, the organization or program continues to thrive. “How do we build . . . and sustain that enthusiasm and excitement and commitment and passion and bake it in as a process?” Strauman also emphasized the importance of acknowledging the different experiences, perspectives, and knowledge that each individual brings to collaborative and community work “so that we can work together to find that middle ground so that we can work collaboratively toward the solution.”

Suggested Citation:"8 Discussion of Interactive Session Reports and Synthesis of the Symposium." National Academies of Sciences, Engineering, and Medicine. 2022. Community Interventions to Prevent Veteran Suicide: The Role of Social Determinants: Proceedings of a Virtual Symposium. Washington, DC: The National Academies Press. doi: 10.17226/26638.
×

CROSS-CUTTING THEMES ACROSS INTERACTIVE SESSIONS

Summarized below are cross-cutting themes among discussion groups that were identified during the full group discussion. These themes emerged in multiple discussion topics, and discussed in greater detail when the groups convened together.

Military Sexual Trauma

Discussion turned first to the association between MST and suicide. One symposium participant commented that it is not just an issue for women veterans; “three out of four sexual assaults that occur are actually male veterans.” She suggested that advocacy by women veterans do stand to improve the situation for everyone affected. She also noted that the changing role of women veterans (in that women can be members of units that were previously not open to them) should be part of the larger discussion about MST. Moderator and committee member Rajeev Ramchand added that caring for the current cohort of veterans involves helping deal with the aftermath of MST in the past; and at the same time, “we prepare for the safety of future veterans.” In this, he remarked, “it is so important for the DoD [Department of Defense] to be working on preventing MST and creating social environments that do not perpetuate MST.” One participant noted that existing and new legislation that doesn’t support women veterans even though they exist in high numbers and have a disproportionately high suicide rate, and “the main reason is military sexual trauma.”

Evelyn Lewis observed that MST is “endemic throughout the military.” She noted that 2021 had the “highest number of MSTs within the service academies that had ever been recorded since they’ve been collecting the data.” Lewis also stressed the importance of approaching this problem with patient’s perspective and also “the big picture” in mind: that is, other challenges that arise as a result of MST. She said MST is so traumatizing that it is an average of 12 years before the individual will begin to talk about it; this can result in the destruction of families, marriages, drugs abuse, homelessness: “All kinds of things just simply because they have not dealt with the initial MST experience and what it did to them.” Another symposium participant pointed to the legal system as “the only way we are going to get rid of military sexual trauma” and referenced legislation passed by Texas in 2021 that moves the responsibility for investigating and prosecuting MST from military forces to law enforcement.

John Blosnich emphasized the necessity of having data in order to plan interventions. “Imagine if you are trying to plan an intervention for a group you cannot measure and in some cases were kind of disallowed to measure,” he said. Blosnich also made a second point about social

Suggested Citation:"8 Discussion of Interactive Session Reports and Synthesis of the Symposium." National Academies of Sciences, Engineering, and Medicine. 2022. Community Interventions to Prevent Veteran Suicide: The Role of Social Determinants: Proceedings of a Virtual Symposium. Washington, DC: The National Academies Press. doi: 10.17226/26638.
×

determinants of health often being at the root of “what we actually have to address within a health care system.” He observed that adverse social determinants of health are “generating these social problems that come to a finer point for minority populations that we have to wrestle with.” Blosnich advocated for “very honest conversations about the politics that undergird some of the social problems we are looking at.”

Cohort Effect

Ramchand reported that a symposium participant observed via chat that while historically, suicide risk has been highest for senior citizens, recent evidence shows an increase in rates among young people. The symposium participant wondered how to know if this higher prevalence is “cohort specific,” and will remain associated with that cohort through their life course, increasing in older age. In response, Lewis commented that nationalized perspective can show something different than a state or community view. “Suicide is so personal; you just cannot nationalize it.” She noted that while the national number shows an uptick in young people dying by suicide, in Florida—for example—it is “the older generation” who has the highest prevalence of death by suicide, compared with other age groups. “We miss that [when] we try to nationalize the problem and use that as a solution.” Ramchand agreed, commenting that being careful when thinking about rates and numbers is perhaps the point. “The national data does suggest that the numbers of suicide are much higher among the older veterans nationally.” But, he said, the rate of suicide among the younger age cohort has certainly increased.

Turning back to the question of whether this is a cohort effect, Strauman said that he did not know, but offered two ways of looking at it. Looking at international data shows “the same basic trend”—a “sort of depths of despair phenomenon” visible in the United States and internationally. But, he noted, it is also reasonable to think that it may not be “simply a cohort effect, because the kind of risk factors we have been talking about predict this increase in suicide rates, particularly in younger and middle-aged people across these different countries.” He acknowledged that this big picture perspective “overlooks a whole lot of variability that is regional and cultural and personal,” but looking at the increase from this perspective does seem to indicate that “the variability in these predictors” may be behind it. Strauman noted that this increase in suicide rates among younger people was one impetus for the symposium itself and the posing of these kinds of questions. “We have to do it at multiple levels,” he noted. It is important not to lose sight of the fact that suicide is about “one person at a time,” and also use regional, national, and international data in the work of understanding what is driving this increase.

Suggested Citation:"8 Discussion of Interactive Session Reports and Synthesis of the Symposium." National Academies of Sciences, Engineering, and Medicine. 2022. Community Interventions to Prevent Veteran Suicide: The Role of Social Determinants: Proceedings of a Virtual Symposium. Washington, DC: The National Academies Press. doi: 10.17226/26638.
×

The Impact of a Long War

Building on the conversation about a cohort effect being behind the increase in suicide rates among young people, a symposium participant pointed to the possible impacts of an “elongated war.” He noted that the present war is not defined in the same way as earlier wars, which have a defined starting point and an ending point, and neither does it fit in between these wars the way other conflicts, such as the Cold War or the “post-Desert Shield/Desert Storm” eras. In this case, he noted, “we still have people in Iraq. We still have people in Bosnia. We still have people in different places [and] we still do not understand what it is doing to them.” He noted that three words sometimes associated with World War 2 veterans are honor, courage, and dignity. By contrast, words associated with a veteran of Iraq or Afghanistan might be “broken,” “PTSD,” and other negative words.

Suicide as a Manifestation of Societal Stress, Businesses as Potential Collaborative Partners

One important domain to look into is “suicide as a manifestation of societal stress” in the same way that “domestic violence, substance abuse, [and] child abuse” are, said an symposium participant. He reiterated the importance of connecting veterans with resources, especially but not only before and during separation. He drew attention to companies as potential partners, and pointed to Optum Serve, a program by Optum at the United Health Group, which he represented, as an example. Optum Serve supports veterans in this way and has a strong peer support system with “a number of virtual and interactive platforms,” he said. He urged listeners to look into what such businesses might offer, as they look for collaborative partners and build coalitions.

Incarcerated Veterans

A symposium participant raised the importance of research around incarcerated veterans. He mentioned that in his home area of Southern Nevada, over the past three years, there has been an increase in veterans being incarcerated; upon release, he said, an increased percentage has become homeless or “lost in the shuffle.” Ramchand noted that one place to look at this intersection between the veterans in the criminal justice system and suicide risk might be through the medical-legal partnerships at the VA and elsewhere. He also mentioned a group of researchers looking at suicide prevention in criminal justice settings, but noted that this is different than this point of release is also “another point of transition” where “some veterans could be at risk, doubly at risk” perhaps.

Suggested Citation:"8 Discussion of Interactive Session Reports and Synthesis of the Symposium." National Academies of Sciences, Engineering, and Medicine. 2022. Community Interventions to Prevent Veteran Suicide: The Role of Social Determinants: Proceedings of a Virtual Symposium. Washington, DC: The National Academies Press. doi: 10.17226/26638.
×

SYNTHESIS OF THE SYMPOSIUM

Strauman concluded the symposium with a synthesis of the sessions. He began by highlighting several terms that capture what he saw as key themes. The first of these terms was “holistic,” which highlights the idea that an individual’s needs “cannot be put into a single category” and addressed only within that limited scope. This points to the importance of seeing that “suicide prevention is something that benefits people in other ways and other kinds of interventions have suicide preventive value.”

Strauman’s second highlighted term was “individualized,” which pointed to the importance of designing suicide prevention measures that are “in a modality that makes [the targeted] people comfortable as individuals.” He pointed to the many discussions in the symposium about intersectionality, including identities, communities, people’s histories, cohort effects, and individual experience. Third, Strauman highlighted the concept of “ceding power to individuals and communities,” a phrase borrowed from an audience participant. Fourth on Strauman’s list was how “urgent” the problem of MST is, as seen in part through the data coming out of service academies, as mentioned in the group discussion by Lewis. “It is something that people I think at the national level may not be comfortable talking about, but it is a conversation that has to occur,” he said.

The fifth term Strauman included in his synthesis was “logistics,” meaning “how do we get the resources that people need to them.” This might include “everything from broadband to trucks” as well as help connecting to services and resources; and such work must be done at all levels, he commented, including “individual community meetings” as well as “virtual, online, national conferences, and academies.” “Politics” was the sixth and last term Strauman mentioned, calling it “an elephant in the room.” He commented, “some of these topics are not going to be [politically] popular, and yet we owe it to our veteran population to be as courageous and open as we can about it in these discussions.”

Ramchand continued the synthesis by highlighting the conversation around the need for more, better quality, and more timely data. He reflected, “It was really encouraging to hear you all talk about how you also prioritize the need for data to help you strengthen your programs and your intervention efforts, [and] your evaluation efforts.” Ramchand also pointed to a theme throughout the symposium around “thinking outside the box,” that is, thinking how suicide prevention might be done outside of the clinical setting as well as in it. He praised the work being done by clinicians in the bio-medical field, but noted “it is a limited supply out there who are doing that work.” Expanding beyond this group is important as need expands, he said.

Lewis echoed the call for more and better data, and also reminded the group that behind the data are real people. “As we conduct the research

Suggested Citation:"8 Discussion of Interactive Session Reports and Synthesis of the Symposium." National Academies of Sciences, Engineering, and Medicine. 2022. Community Interventions to Prevent Veteran Suicide: The Role of Social Determinants: Proceedings of a Virtual Symposium. Washington, DC: The National Academies Press. doi: 10.17226/26638.
×

and collect this data, the people impacted by these issues are waiting on us, relying on us, depending on us to come back to the table with solutions to the issues that impact their lives on a daily basis.” She noted that “it is incumbent upon us to get this right now,” meaning, to get data that will “have the greatest impact on the lives of those who are in need of answers.”

Bruce Crow, who served as the VA’s point of contact for the symposium planning committee, expressed his appreciation for the work done by the National Academies, particularly the Planning Committee, for putting together the symposium. He noted that he is coming away from the symposium “with a sense of optimism, looking at the people who are involved, the perspectives, the commitment, the passion [for] preventing veteran suicide, the level of interest.” He expressed “great hope that we are indeed going to make a difference.”

Suggested Citation:"8 Discussion of Interactive Session Reports and Synthesis of the Symposium." National Academies of Sciences, Engineering, and Medicine. 2022. Community Interventions to Prevent Veteran Suicide: The Role of Social Determinants: Proceedings of a Virtual Symposium. Washington, DC: The National Academies Press. doi: 10.17226/26638.
×
Page 67
Suggested Citation:"8 Discussion of Interactive Session Reports and Synthesis of the Symposium." National Academies of Sciences, Engineering, and Medicine. 2022. Community Interventions to Prevent Veteran Suicide: The Role of Social Determinants: Proceedings of a Virtual Symposium. Washington, DC: The National Academies Press. doi: 10.17226/26638.
×
Page 68
Suggested Citation:"8 Discussion of Interactive Session Reports and Synthesis of the Symposium." National Academies of Sciences, Engineering, and Medicine. 2022. Community Interventions to Prevent Veteran Suicide: The Role of Social Determinants: Proceedings of a Virtual Symposium. Washington, DC: The National Academies Press. doi: 10.17226/26638.
×
Page 69
Suggested Citation:"8 Discussion of Interactive Session Reports and Synthesis of the Symposium." National Academies of Sciences, Engineering, and Medicine. 2022. Community Interventions to Prevent Veteran Suicide: The Role of Social Determinants: Proceedings of a Virtual Symposium. Washington, DC: The National Academies Press. doi: 10.17226/26638.
×
Page 70
Suggested Citation:"8 Discussion of Interactive Session Reports and Synthesis of the Symposium." National Academies of Sciences, Engineering, and Medicine. 2022. Community Interventions to Prevent Veteran Suicide: The Role of Social Determinants: Proceedings of a Virtual Symposium. Washington, DC: The National Academies Press. doi: 10.17226/26638.
×
Page 71
Suggested Citation:"8 Discussion of Interactive Session Reports and Synthesis of the Symposium." National Academies of Sciences, Engineering, and Medicine. 2022. Community Interventions to Prevent Veteran Suicide: The Role of Social Determinants: Proceedings of a Virtual Symposium. Washington, DC: The National Academies Press. doi: 10.17226/26638.
×
Page 72
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On March 28 and 29, 2022, the Board on Behavioral, Cognitive, and Sensory Sciences at the National Academies of Sciences, Engineering, and Medicine held a virtual symposium entitled Community Interventions to Prevent Veteran Suicide: The Role of Social Determinants to gain a better understanding of social determinants influencing the recent increase in suicide risk and how currently available practice guidelines can inform community-level preventive interventions, particularly those targeting veteran populations. Presenters and participants explored the relevant social, cultural, and economic factors driving changes in suicide risk among veterans and ways that current best practices for suicide prevention and treatment can be applied at the community level. This publication summarizes the presentations and discussion of the symposium.

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