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veterans that connect them with teams of non-veterans programs, though well-funded, were not implemented by the
in pursuing community impact, and provide additional VA, nor was funding spent on the development of proactive
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opportunities for professional networking to facilitate vet- veteran suicide prevention outreach programs. These efforts
erans’ career prospects. ” were further expanded to include the formation of teaming
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arrangements and partnerships with other veteran care fo-
In sum, current research indicates that military culture or lack cused non-profit organizations such as the Wounded Warrior
thereof for individuals who are disconnected from the military Project, Operation Deep Dive, Guard Your Buddy, the Amer-
due to end term of service (ETS), combat injuries, etc., are at ican Legion (AL), Veterans of Foreign Wars (VFW), Disabled
increased risk for suicide. This increased risk is more so than American Veterans (DAV), and other state and communi-
for veterans who maintain contact with some semblance of ty-based veteran support organizations to provide peer-peer
the military culture. The ability to effectively address military- resources (such as Vet-to-Vet), education, and support. 58
related loneliness and identify individual and group factors
that contribute to elevated risks of suicide, as well as resilience Internal research conducted by the VHA has shown signifi-
factors that protect against suicide, are essential to informing cant improvements in suicide prevention outcomes on pop-
suicide prevention efforts. ulation samples through the simultaneous implementation of
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both proactive programs and reactive treatment. Although
clinical improvement is seen in this two-pronged assault on
Evidence-Based Treatments
suicide, the numbers have remained at 17 veteran deaths by
Over the decades, various institutions and organizations have suicide each year. Congressman Boss, in a 2018 hearing be-
5
worked to develop treatment options to prevent suicide. Eye fore the US House of Representatives Committee on Veterans
movement desensitization and reprocessing (EMDR), cognitive Affairs, Sub-Committee on Health, spoke of having noticed
behavioral rherapy (CBT), and dialectical behavioral therapy outstanding clinical trial outcomes from new and modified
(DBT) are the three most frequently applied and most flexi- treatments and the integrations of proactive and reactive ap-
ble evidence-based approaches in the prevention of suicide. proaches but with no success in reduction of veteran suicide
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However, they are certainly not the only options available. deaths per year. 58
Other options include rational emotive behavioral therapy
(REBT) and brief intervention strategies (BIS). Newcomers Although the congressional hearing did not manage to reveal
to the evidence-based repertoire include mindfulness exercise much in the way of establishing a causal element that main-
rraining (MET) and the integration of MET into existing ap- tains high suicide rates in the face of advanced and clinically
proaches such as CBT and rational emotive behavioral therapy effective treatments, another study concerning CBT-SP efficacy
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(REBT). Most recently, an extension to CBT, called cognitive did reveal possible areas that undermine the efficacy of the
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behavioral therapy for suicide prevention (CBT-SP), has risen treatment approach. Dr. Craig Bryan of the National Center
to show significant positive outcomes for suicide prevention. 58 for Veterans Studies at the University of Utah revealed in a pa-
per published in September 2018 that the efficacy of CBT-SP
Although these methods show superiority over the standard or was dependent upon the proper implementation of the three-
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basic levels of empirically-based treatment by examining and part process by clinicians. He noted that incomplete crisis
treating more in-depth elements of cognition and condition- response plans (CRP) and means reduction plans (MRP) were
47
ing, there remains a veteran suicide death toll of 17 per day seen in many CBT-SP cases across the VA system. Further, he
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in the United States, which has remained consistent for over a noted that many of the clinicians implementing CBT-SP did
decade. 5,47 Government executive, congressional, and agency not possess the proper level of training in CBT-SP and that this
leadership (as well as the public) are beginning to question was a leading reason for the improperly conducted CBT-SP
the efficacy of the treatment methodologies currently being cases that led to poor outcomes for the patients. 59
used to prevent suicide among the American veteran popula-
tion. 58,60 Questions such as which of the treatment approaches Another study, conducted by the University of Colorado’s
are effective and among them, which is the most effective, have Rocky Mountain Mental Illness Research group, revealed ad-
been pondered and debated for decades. But now, there is a ditional areas for improvement for contemporary detection
new focus on what the hindrances are to the implementation and evaluation of veterans at risk of suicide by VHA clini-
and positive outcomes of treatment. cians. Pease et al. inferred through their study that the level
of experience accumulated by the evaluating clinician plays
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The authors’ review of the available and most contemporary a role in effective suicide risk assessment. However, this
peer-reviewed literature has demonstrated that the VHA ap- study comprised only long-term suicide prevention coordina-
proaches suicide prevention through both a proactive and re- tors (SPC) and was not inclusive of other similar professional
active methodology. Until more recent times, the VHA was fields such as psychiatrists, clinical psychologists, and clinical
primarily reactive in that it would treat veteran patients who counselors. 62
were actively in a suicidal crisis. However, research began
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to appear that suggested proactive programs, such as veteran- The suicide risk assessment process used by the VHA does not
focused community outreach and psychoeducation programs include consideration for the cultural elements of either the
by state, VHA, and DoD agencies, reduced suicide attempts. patient or the clinician. 58,60 According to research conducted
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This led VHA leadership and professionals to see that the at the University of Melbourne, culture plays a significant role
word “prevention” contained a primary inference of proactive in how suicide is viewed by people of varying cultural back-
efforts to thwart suicide. From this perspective, the VHA be- grounds. The study further described a failure to properly
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gan to develop proactive programs that provided education, assess risk factors and warning signs by clinicians with little to
assurance, resources and helped veterans combat the stigma no cross-cultural training or experience, which could increase
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of seeking mental health treatment. However, media outreach the likelihood of attempted or completed suicide behaviors.
Risk Factors and Suicide Reduction Services for Veterans | 137