Preventing Veteran Suicide: a landscape analysis of existing programs, their evidence, and what the next generation of programs may look like.

Ramchand, R. et al. (2025, April 16).

RAND.

https://www.rand.org/pubs/research_reports/RRA3635-1.html

Preventing veteran suicide is a national priority for government, veteran advocacy groups, and the private sector. This attention has led many individuals and organizations to leverage their expertise to create, expand, or promote activities that they hope will prevent future deaths. While the number and array of diverse approaches reflect a nation committed to a common goal, they also can create confusion. Advances in technology also generate questions about the future of veteran suicide prevention.

In this report, the authors analyze current and emerging activities to prevent veteran suicide. They introduce the RAND Suicide Prevention Activity Matrix, a framework that organizes current approaches, how they complement each other, how they might change, their evidence for preventing veteran suicide, and why they might (or might not) work. This framework places 26 categories of activities in a matrix based on whom the activity targets (the veteran directly, those who regularly interact with the veteran, or social influences) and what the activity is intended to accomplish (address social conditions, promote general well-being, address mental health symptoms, provide mental health supports, and prevent suicide crises). Entities committed to preventing veteran suicide and seeking to design evidence-informed, comprehensive suicide prevention strategies will benefit from the framework and evidence reviewed in this report, in addition to the recommendations the authors developed from these data.

Key Findings

• The authors identified 307 suicide prevention programs, 156 of which were currently operating and 226 that were proposed to expand existing services or initiate new programs.
• These organizations' suicide prevention activities were categorized across 26 suicide prevention activity categories and organized into the RAND Suicide Prevention Activity Matrix.
• Among the 156 current programs, there is a strong focus on those that aim to build social connections and those that offer case management or noncrisis psychological counseling.
• Veterans are the primary focus of most current programs, but many programs are also offered to family members and friends — often in addition to serving veterans directly.
• Nonprofit organizations operate most current programs, and just under half of the programs are accessed virtually or via a combination of in-person and virtual access.
• Among the 226 proposed programs, the most common types are multifunctional digital health platforms (mobile health applications), suicide risk assessment tools, and real-time monitoring.
• The following activity types have a robust evidence base for preventing suicide: community-based suicide prevention initiatives, suicide risk assessment, noncrisis psychological treatment, crisis psychological clinical services, and pharmacotherapy (for those with mental health conditions).

Recommendations

• Organizations charged with developing, investing in, implementing, or evaluating comprehensive suicide prevention strategies should prioritize implementation of evidence-based prevention activities.
• When implementing a suicide prevention activity, organizations should consider the context in which the activity is intended to be delivered.
• Organizations should conduct a needs assessment to identify gaps in suicide prevention activities.
• Organizations should apply different thresholds of evidence when considering different suicide prevention activities.
• Organizations should invest strategically in research that can fill notable gaps in knowledge.

The Interpersonal Theory of Suicide: State of the Science

Robison, M., et al. (2024).

Behavior Therapy, 55(6), 1158–1171.

https://doi.org/10.1016/j.beth.2024.04.008

Abstract

In this state-of-the-science review, we summarize the key constructs and concepts within the interpersonal theory of suicide. The state of the scientific evidence regarding the theory is equivocal, and we explore the reasons for and some consequences of that equivocal state. Our particular philosophy of science includes criteria such as explanatory reach and pragmatic utility, among others, in addition to the important criterion of predictive validity. Across criteria, the interpersonal theory fares reasonably well, but it is also true that it struggles somewhat—as does every other theory of suicidality—with stringent versions of predictive validity. We explore in some depth the implications of the theory and its status regarding people who are minoritized. Some implications and future directions for research are also presented.

Highlights

• The full Interpersonal Theory of Suicide (ITPS) has yet to be empirically tested.

• However, the ITPS provides explanation, clinical utility, and predictive validity.

• The IPTS may be intensified by non-humanness, lack of agency, and discrimination.

• Minoritized people may benefit by integrating the IPTS and Minority Stress Theory.

Here are some thoughts:

The article reviews the empirical and theoretical foundations of the Interpersonal Theory of Suicide (ITS), which seeks to explain suicidal ideation and behavior. The theory identifies four central constructs: thwarted belongingness (a perceived lack of meaningful social connections), perceived burdensomeness (the belief that one’s existence is a burden on others), hopelessness about these states improving, and the capability for suicide (fearlessness about death and high pain tolerance). While thwarted belongingness and perceived burdensomeness contribute to suicidal ideation, the capability for suicide differentiates those who act on these thoughts.

The article highlights that perceived burdensomeness has the strongest link to suicidality, driven by a tragic misperception that others would be better off without the individual. Thwarted belongingness emphasizes subjective feelings of isolation rather than objective social circumstances. Hopelessness compounds these states by fostering a belief that they are permanent. The capability for suicide, often acquired through exposure to painful experiences or self-harm, explains why only some individuals transition from ideation to action.

Despite its clinical utility, testing ITS comprehensively remains challenging due to measurement limitations and the complexity of suicide. For example, constructs like perceived burdensomeness overlap with suicidal ideation in measurement tools, complicating empirical validation. Additionally, the theory’s applicability across diverse populations, including minoritized groups, requires further exploration.

Clinicians can use ITS to identify risk factors and tailor interventions—such as fostering social connections or addressing distorted beliefs about burdensomeness. However, its predictive validity is limited, underscoring the need for ongoing refinement and research into its constructs and applications.

A systematic review of research on empathy in health care.

Nembhard, I. M., et al. (2023).

Health services research, 58(2), 250–263.

https://doi.org/10.1111/1475-6773.14016

Abstract

Objective

To summarize the predictors and outcomes of empathy by health care personnel, methods used to study their empathy, and the effectiveness of interventions targeting their empathy, in order to advance understanding of the role of empathy in health care and facilitate additional research aimed at increasing positive patient care experiences and outcomes.

Data Source

We searched MEDLINE, MEDLINE In‐Process, PsycInfo, and Business Source Complete to identify empirical studies of empathy involving health care personnel in English‐language publications up until April 20, 2021, covering the first five decades of research on empathy in health care (1971–2021).

Study Design

We performed a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta‐Analysis (PRISMA) guidelines.

Data Collection/Extraction Methods

Title and abstract screening for study eligibility was followed by full‐text screening of relevant citations to extract study information (e.g., study design, sample size, empathy measure used, empathy assessor, intervention type if applicable, other variables evaluated, results, and significance). We classified study predictors and outcomes into categories, calculated descriptive statistics, and produced tables to summarize findings.

Principal Findings

Of the 2270 articles screened, 455 reporting on 470 analyses satisfied the inclusion criteria. We found that most studies have been survey‐based, cross‐sectional examinations; greater empathy is associated with better clinical outcomes and patient care experiences; and empathy predictors are many and fall into five categories (provider demographics, provider characteristics, provider behavior during interactions, target characteristics, and organizational context). Of the 128 intervention studies, 103 (80%) found a positive and significant effect. With four exceptions, interventions were educational programs focused on individual clinicians or trainees. No organizational‐level interventions (e.g., empathy‐specific processes or roles) were identified.

Conclusions

Empirical research provides evidence of the importance of empathy to health care outcomes and identifies multiple changeable predictors of empathy. Training can improve individuals' empathy; organizational‐level interventions for systematic improvement are lacking.

A pdf is here.

Here are some thoughts:

The systematic review explores the significance of empathy in health care, analyzing its predictors, outcomes, and interventions to enhance it among health care professionals. The review, which spans 455 studies from 1971 to 2021, reveals that empathy is predominantly studied through cross-sectional, survey-based methods, with a focus on physicians, medical students, and nurses. Empathy is positively linked to better clinical outcomes, patient experiences, and provider performance, including improved adherence to treatment plans and reduced burnout. Key predictors of empathy include provider demographics, characteristics like personality traits and well-being, and behaviors such as communication skills. Educational interventions, particularly training programs and workshops, have proven effective in boosting empathy levels, though organizational-level interventions remain underexplored.

Hope for Suicide Prevention

Ellen Barry

The New York Times

Originally published 21 Feb 24

Here is an excerpt:

Research has demonstrated that suicide is most often an impulsive act, with a period of acute risk that passes in hours, or even minutes. Contrary to what many assume, people who survive suicide attempts often go on to do well: Nine out of 10 of them do not die by suicide.

Policymakers, it seems, are paying attention. I have been reporting on mental health for The New York Times for two years, and in today’s newsletter I will look at promising, evidence-based efforts to prevent suicide.

A single element

For generations, psychiatrists believed that, in the words of the British researcher Norman Kreitman, “anyone bent on self-destruction must eventually succeed.”

Then something strange and wonderful happened: Midway through the 1960s, the annual number of suicides in Britain began dropping — by 35 percent in the following years — even as tolls crept up in other parts of Europe.

No one could say why. Had medicine improved, so that more people survived poisoning? Were antidepressant medications bringing down levels of despair? Had life in Britain just gotten better?

The real explanation, Kreitman discovered, was none of these. The drop in suicides had come about almost by accident: As the United Kingdom phased out coal gas from its supply to household stoves, levels of carbon monoxide decreased. Suicide by gas accounted for almost half of the suicides in 1960.

It turns out that blocking access to a single lethal means — if it is the right one — can make a huge difference.

The strategy that arose from this realization is known as “means restriction” or “means safety,” and vast natural experiments have borne it out. When Sri Lanka restricted the import of toxic pesticides, which people had ingested in moments of crisis, its suicide rate dropped by half over the next decade.

The info is here.

Here is my summary

The article discusses new suicide prevention measures in the U.S., where suicide rates have risen 35% in recent decades. This contrasts with global trends of declining suicide rates.

• It highlights how installing barriers on bridges, buildings, and other high structures can deter impulsive suicide attempts. Many communities are now considering such barriers.
• Research shows most who survive a suicide attempt go on to live their lives and not die by suicide later. This suggests preventing access to lethal means in moments of crisis can save lives.
• Restricting access to highly lethal means like guns and toxic pesticides has significantly reduced suicide rates when implemented in other countries.
• In the U.S., red flag laws that temporarily remove guns from high-risk individuals have been associated with drops in firearm suicides.
• Educating gun owners on safe storage habits is another promising approach, as is providing incentives for measures like locking devices or gun safes.
• Even brief counseling for gun owners has proven effective in getting people to voluntarily store guns securely and prevent access during periods of risk.

In summary, the text highlights several evidence-based strategies for reducing access to lethal means during periods of acute suicide risk, thereby giving people a chance to recover and survive their suicidal crises.

Racism in the Hands of an Angry God: How Image of God Impacts Cultural Racism in Relation to Police Treatment of African Americans

Lauve‐Moon, T. A., & Park, J. Z. (2023).

Journal for the Scientific Study of Religion.

https://doi.org/10.1111/jssr.12863 

Abstract

Previous research suggests an angry God image is a narrative schema predicting support for more punitive forms of criminal justice. However, this research has not explored the possibility that racialization may impact one's God image. We perform logistic regression on Wave V of the Baylor Religion Survey to examine the correlation between an angry God image and the belief that police shoot Blacks more often because Blacks are more violent than Whites (a context-specific form of cultural racism). Engaging critical insights from intersectionality theory, we also interact angry God image with both racialized identity and racialized religious tradition. Results suggest that the angry God schema is associated with this form of cultural racism for White people generally as well as White Evangelicals, yet for Black Protestants, belief in an angry God is associated with resistance against this type of cultural racism.

Discussion

Despite empirical evidence demonstrating the persistence of implicit bias in policing and institutional racism within law enforcement, the public continues to be divided on how to interpret police treatment of Black persons. This study uncovers an association between religious narrative schema, such as image of God, and one's attitude toward this social issue as well as how complex religion at the intersection of race and religious affiliation may impact the direction of this association between an angry God image and police treatment of Black persons. Our findings confirm that an angry God image is modestly associated with the narrative that police shoot Blacks more than Whites because Blacks are more violent than Whites. Even when controlling for other religious, political, and demographic factors, the association holds. While angry God is not the only factor or the most influential, our results suggests that it does work as a distinct factor in this understanding of police treatment of Black persons. Previous research supports this finding since the narrative that police shoot Blacks more because Blacks are more violent than Whites is based on punitive ideology. But whose version of the story is this telling?

Due to large White samples in most survey research, we contend that previous research has undertheorized the role that race plays in the association between angry God and punitive attitudes, and as a result, this research has likely inadvertently privileged a White narrative of angry God. Using the insights of critical quantitative methodology and intersectionality, the inclusion of interactions of angry God image with racialized identity as well as racialized religious traditions creates space for the telling of counternarratives regarding angry God image and the view that police shoot Blacks more than Whites because Blacks are more violent than Whites. The first interaction introduced assesses if racialized identity moderates the angry God effect. Although the interaction term for racialized identity and angry God is not significant, the predicted probabilities and average marginal effects elucidate a trend worth noting. While angry God image has no effect for Black respondents, it has a notable positive trend for White respondents, and this difference is pronounced on the higher half of the angry God scale. This supports our claim that past research has treated angry God image as a colorblind concept, yet this positive association between angry God and punitive criminal justice is raced, specifically raced White.

Here is a summary:

The article explores the relationship between image of God (IoG) and cultural racism in relation to police treatment of African Americans. The authors argue that IoG can be a source of cultural racism, which is a form of racism that is embedded in the culture of a society. They suggest that people who hold an angry IoG are more likely to believe that African Americans are dangerous and violent, and that this belief can lead to discriminatory treatment by police.

Here are some of the key points from the article:

• Image of God (IoG) can be a source of cultural racism.
• People who hold an angry IoG are more likely to believe that African Americans are dangerous and violent.
• This belief can lead to discriminatory treatment by police.
• Interventions that address IoG could be an effective way to reduce racism and discrimination.

Teaching Empathy to Mental Health Practitioners and Trainees

Ngo, H., Sokolovic, et al. (2022).

Journal of Consulting and Clinical Psychology,

90(11), 851–860.

https://doi.org/10.1037/ccp0000773

Objective:

Empathy is a foundational therapeutic skill and a key contributor to client outcome, yet the best combination of instructional components for its training is unclear. We sought to address this by investigating the most effective instructional components (didactic, rehearsal, reflection, observation, feedback, mindfulness) and their combinations for teaching empathy to practitioners.

Method: 

Studies included were randomized controlled trials targeted to mental health practitioners and trainees, included a quantitative measure of empathic skill, and were available in English. A total of 36 studies (37 samples) were included (N = 1,616). Two reviewers independently extracted data. Data were pooled by using random-effects pairwise meta-analysis and network meta-analysis (NMA).

Results:

Overall, empathy interventions demonstrated a medium-to-large effect (d = .78, 95% CI [.58, .99]). Pairwise meta-analysis showed that one of the six instructional components was effective: didactic (d = .91 vs. d = .39, p = .02). None of the program characteristics significantly impacted intervention effectiveness (group vs. individual format, facilitator type, number of sessions). No publication bias, risk of bias, or outliers were detected. NMA, which allows for an examination of instructional component combinations, revealed didactic, observation, and rehearsal were included among the most effective components to operate in combination.

Conclusions:

We have identified instructional component, singly (didactic) and in combination (didactic, rehearsal, observation), that provides an efficient way to train empathy in mental health practitioners.

What is the public health significance of this article?

Empathy in mental health practitioners is a core skill associated with positive client outcomes, with evidence that it can be trained. This article provides an aggregation of evidence showing that didactic teaching, as well as trainees observing and practicing the skill, are the elements of training that are most important.

From the Discussion

Despite clear evidence on why empathy should be taught to mental health practitioners and how well empathy interventions work in other professionals, there has been no systematic integration on how best empathy should be taught to those working in mental health. Thus, the present study sought to address this important gap by applying pairwise and network meta-analytic analyses. In effect, we were able to elucidate the efficacious “ingredients” for teaching empathy to mental health practitioners as well as the relative superiority of particular combinations of instructional components. Overall, the effect sizes of empathy interventions were in the moderate to large range (d = .78; 95% CI [.55, .99]), which is comparable to previous meta-analyses of randomized controlled trials (RCTs) of empathy interventions within medical students (d = .68, Fragkos & Crampton, 2020), health care practitioners (d = .80, Kiosses et al., 2016; d = .52, Winter et al., 2020), and mixed trainees (adjusted g = .51; Teding van Berkhout & Malouff, 2016). This effect size means that over 78% of those who underwent empathy training will score above the mean of the control group, a result that clearly supports empathy as a trainable skill. 

The research is here.

Threat Rejection Fuels Political Dehumanization

Kubin, E., Kachanoff, F., & Gray, K. 

(2021, December 4).

https://doi.org/10.31234/osf.io/ds24w

Abstract

Americans disagree about many things, including what threats are most pressing. We suggest people morally condemn and dehumanize opponents when they are perceived as rejecting the existence or severity of important perceived threats. We explore perceived “threat rejection” across five studies (N=2,404) both in the real-world COVID-19 pandemic and in novel contexts. Americans morally condemned and dehumanized policy opponents when they seemed to reject realistic group threats (e.g., threat to the physical health or resources of the group). Believing opponents rejected symbolic group threats (e.g., to collective identity) was not reliably linked to condemnation and dehumanization. Importantly, the political dehumanization caused by perceived threat rejection can be soothed with a “threat acknowledgement” intervention.

General Discussion 

Does perceived threat rejection sow political divisions? Results suggest perceiving the “other side” as rejecting realistic (more than symbolic) threat increases moral condemnation and dehumanization, lending support to the asymmetry hypothesis. DuringCOVID-19, those who relatively favored social distancing saw opponents as rejecting realistic threats and morally judged and dehumanized them. In contrast, support for social distancing did not reliably relate to perceiving the other side as rejecting symbolic threat—and symbolic threat was not robustly associated with moral judgment or dehumanization.

Within a novel threat context, people who were more willing to sacrifice their group’s culture to prevent realistic threats to health or resources viewed opponents as rejecting realistic threats and in turn morally condemned and dehumanized them. Similarly, people who were more willing to endure realistic threat to protect their culture, viewed opponents as rejecting symbolic threats, in turn morally condemning and dehumanizing them, yet these effects were significantly weaker than for realistic threat rejection. Our findings are consistent with research suggesting people condemn behaviors which are perceived as causing concrete (realistic) harm rather than abstract (symbolic) harm (Schein & Gray 2018).

Using a threat-acknowledgement-intervention, we decreased the tendency of people who tended to prioritize protecting the group from realistic threat (i.e., those who tended to support social distancing)to morally judge and dehumanize opponents who prioritized protecting the group from symbolic threat (i.e., those who tended to resist social distancing). Our intervention did not require opponents to compromise their stance –this intervention worked by simply having opponents acknowledge both realistic and symbolic threats when providing a rationale for their position. 

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Note: Helpful research when working with politically intense patients who frequently bring in partisan information to discuss in psychotherapy.

Want To Reduce Suicides? Follow The Data — To Medical Offices, Motels And Even Animal Shelters

Maureen O’Hagan
Kaiser Health News
Originally published September 23, 2019

Here is an excerpt:

Experts have long believed that suicide is preventable, and there are evidence-based programs to train people how to identify and respond to folks in crisis and direct them to help. That’s where Debra Darmata, Washington County’s suicide prevention coordinator, comes in. Part of Darmata’s job involves running these training programs, which she described as like CPR but for mental health.

The training is typically offered to people like counselors, educators or pastors. But with the new data, the county realized they were missing people who may have been the last to see the decedents alive. They began offering the training to motel clerks and housekeepers, animal shelter workers, pain clinic staffers and more.

It is a relatively straightforward process: Participants are taught to recognize signs of distress. Then they learn how to ask a person if he or she is in crisis. If so, the participants’ role is not to make the person feel better or to provide counseling or anything of the sort. It is to call a crisis line, and the experts will take over from there.

Since 2014, Darmata said, more than 4,000 county residents have received training in suicide prevention.

“I’ve worked in suicide prevention for 11 years,” Darmata said, “and I’ve never seen anything like it.”

The sheriff’s office has begun sending a deputy from its mental health crisis team when doing evictions. On the eviction paperwork, they added the crisis line number and information on a county walk-in mental health clinic. Local health care organizations have new procedures to review cases involving patient suicides, too.

The info is here.

Mental health practitioners’ reported barriers to prescription of exercise for mental health consumers

KirstenWay, Lee Kannis-Dymand, Michele Lastella, Geoff P. Lovell
Mental Health and Physical Activity
Volume 14, March 2018, Pages 52-60

Abstract

Exercise is an effective evidenced-based intervention for a range of mental health conditions, however sparse research has investigated the exercise prescription behaviours of mental health practitioners as a collective, and the barriers faced in prescribing exercise for mental health. A self-report survey was completed online by 325 mental health practitioners to identify how often they prescribe exercise for various conditions and explore their perceived barriers to exercise prescription for mental health through thematic analysis. Over 70% of the sample reported prescribing exercise regularly for depression, stress, and anxiety; however infrequent rates of prescription were reported for conditions of schizophrenia, bipolar and related disorders, and substance-related disorders. Using thematic analysis 374 statements on mental health practitioners' perceived barriers to exercise prescription were grouped into 22 initial themes and then six higher-order themes. Reported barriers to exercise prescription mostly revolved around clients' practical barriers and perspectives (41.7%) and the practitioners' knowledge and perspectives (33.2%). Of these two main themes regarding perceived barriers to exercise prescription in mental health, a lack of training (14.7%) and the client's disinclination (12.6%) were initial themes which reoccurred considerably more often than others. General practitioners, mental health nurses, and mental health managers also frequently cited barriers related to a lack of organisational support and resources. Barriers to the prescription of exercise such as lack of training and client's disinclination need to be addressed in order to overcome challenges which restrict the prescription of exercise as a therapeutic intervention.

The research is here.

America’s Suicide Epidemic Is a National Security Crisis

Fredrik Deboer
Foreign Policy
Originally published April

Here is an excerpt:

Too many in our culture, meanwhile, still place the blame for suicide on its victims. It’s common, after high-profile suicides like that of actor and comedian Robin Williams, for some to argue that suicide is “the coward’s way out,” that taking one’s own life is somehow a cowardly act. Such attitudes are a flagrant failure of empathy, as well as a misunderstanding about the relationship between suicide and mental illness and addiction, both of which are strongly associated with suicide risk. Like many social problems, suicide does not have single and obvious causes but rather a concert of contributing factors working together. To blame suicide on a lack of personal character demonstrates ignorance about the nature of the problem. But such thinking contributes to the country’s persistent and deep inability to grapple with suicide in an open and healthy way.

The article is here.

Why Therapist Should Talk Politics

By Richard Brouillettee
The New York Times
Originally published March 15, 2016

Here is an except:

Typically, therapists avoid discussing social and political issues in sessions. If the patient raises them, the therapist will direct the conversation toward a discussion of symptoms, coping skills, the relevant issues in a patient’s childhood and family life. But I am growing more and more convinced that this is inadequate. Psychotherapy, as a field, is not prepared to respond to the major social issues affecting our patients’ lives.

When people can’t live up to the increasingly taxing demands of the economy, they often blame themselves and then struggle to live with the guilt. You see this same tendency, of course, in a variety of contexts, from children of divorce who feel responsible for their parents’ separation to the “survivor guilt” of those who live through disasters. In situations that may seem impossible or unacceptable, guilt becomes a shield for the anger you otherwise would feel: The child may be angry with her parents for divorcing, the survivor may be angry with those who perished.

The article is here.