The President’s Roadmap to Empower Veterans and End the National Tragedy of Suicide (PREVENTS). On March 5, 2019, Executive Order 13861 was signed establishing a 3--year effort known as PREVENTS. Its three main areas of focus include: 1) National Suicide Prevention Campaign; 2) improving suicide prevention research, and 3) building partnerships. 68 988 / Veterans Crisis Line. The Veterans Crisis Line is a confidential resource that connects Veterans in crisis and their family members with qualified and trained responders in the VA. 72 Veterans and loved ones can connect via phone by dialing 988 or via online chat through http://www.veterancrisisline. net. Alternatively, Veterans can send a text message through their cellphones to 838255. Once the crisis line is contacted, Veterans and family members can receive confidential support 24 hours a day, 7 days a week. 68 It is important to note that Veterans can seek help via this confidential resource even if they are not registered with the VA system. The responders on the crisis line are trained to assist veterans with mental health problems and those struggling with the transition to civilian life or relationships. Many of the responders are Veterans themselves and understand what Service members have been through and the challenges they and their families face. 68 Hannon Act of 2019 (P.K. 116-171). In October 2020, the Hannon Act was signed into law. Section 201 of the Hannon Act established the Staff Sergeant Parker Gordon Fox Suicide Prevention Grant Program (SSG Fox SPGP), a $174 million, three-year program to enable VA to provide resources for community-based suicide prevention efforts. It also provides the VA with opportunities to expand suicide prevention efforts. One of its goals is to improve local community capacity to conduct outreach to Veterans and families, provide them with suicide prevention services, and connect them to resources within the community. 68 The Veterans COMPACT Act of 2020 (P.L. 116-214) . The Veterans COMPACT Act was signed into law in December 2020. It enables the VA to implement programs, policies, and reports related to transitioning Service members, suicide prevention, and crisis services; mental health education and treatment; and improvement of services for women Veterans. 68 Veterans Benefit Administration. The suicide prevention efforts within this administration are focused on improved data sharing toward enhanced suicide risk prediction and identification; increased coordination for Veterans with financial insecurity; and implementation of suicide training for the Veterans Benefits Administration personnel. 68 Domestic Policy Council. This interagency group creates and amplifies suicide prevention efforts across various agencies related to suicide prevention for Veterans. 68 In summary, the VA believes that every veteran’s suicide is a tragedy. The VA relies on multiple sources of information to identify deaths due to or are most likely due to suicide. It has undertaken the most comprehensive analyses of veteran suicide rates in the United States.
The VA has examined over 50 million veteran records from 1979 to 2014 from every state. In addition, the VA has expanded current initiatives and developed new ones to help veterans and their families and reduce the rate of suicide among veterans. The ongoing collection of data and strategic initiative development, such as the #BeThere campaign, highlights the VA’s ongoing commitment to the mental health and well-being of our veterans. BEFORE MOVING ONTO THE NEXT SECTION, PLEASE COMPLETE CASE STUDY 5 ON THE NEXT PAGE. Risk of Imminent Harm Through Self-Injurious Behaviors Not every self-injury is a suicide attempt. Non-suicidal self-injuries (NSSI) are defined as “behaviors engaged in with the purposeful intention of hurting oneself without intentionally trying to kill oneself”. Other terms used are self-injurious behavior, self-mutilation, cutting, deliberate self- harm, delicate self-cutting, self-inflicted violence, parasuicide, and auto aggression. Forms of NSSI include scratching, plucking hair, interfering with wound healing, cutting, burning, or hitting. 50 Evaluating between Non-Suicidal Self-Injury and a Suicide Attempt To accurately predict suicide risk and identify those at the highest risk for suicide is an important task. It is imperative to differentiate between Non- Suicidal Self-Injury (NSSI) and a Suicide Attempt (SA). While both behaviors are injurious to the body, it is necessary to determine the individual’s injury intent. Clinicians must understand the distinction between NSSI and SA to make a sound decision regarding treatment and hospitalization. An NSSI is not a suicide attempt. It is most often used to try to regulate emotional pain or self-soothe – not as a means of ending one’s life. 75 Usually, NSSI behaviors are performed to feel better and/or deal with significant negative feelings. Other reasons for NSSI include tension reduction, emotion regulation, anger expression, self-punishment, or a decrease in dissociation. Suicidal behaviors, however, are more lethal (e.g., gunshot wounds, handing). 50 Tattoos and body piercings are not considered NSSI, unless they are created with the specific intention to self-harm. Often NSSI is inflicted on the hands, wrists, stomach, or thighs but can occur anywhere on the body. 76 Evidence-Based Practice: A review of 22 empirical studies found that the adolescent lifetime prevalence of self- injury is 13 to 23%. The typical age of onset is between 12 and 14 years of age. Risk factors for NSSI include a history of sexual abuse, a higher number of adverse childhood events (ACEs), depression, anxiety, eating disorders, alexithymia, hostility, low self-esteem, antisocial behavior, smoking, and emotional reactivity. 52
While self-injury is a risk factor for suicide, they differ in several important ways, including but not limited to 75 : • Expressed intent: The expressed intent of NSSI is almost always to feel better, whereas for suicide, it is to end feeling (and subsequently, life) altogether. • The method used: Methods for NSSI typically cause damage to the surface of the body only; suicide-related behaviors are potentially lethal. Notably, it is uncommon for individuals who engage in NSSI and who are also suicidal to identify the same methods for each purpose. • Level of damage and lethality: NSSI is often carried out using methods designed to damage the body, but not to injure the body sufficiently enough to require medical intervention or to end life. Suicide attempts are always more lethal than standard NSSI methods. • Frequency: NSSI can vary in frequency, often contingent on experience of stress and other difficult emotions; suicide-related behaviors are much rarer. • Level of psychological pain: The amount of distress experienced when engaging in NSSI is often significantly lower than that which gives rise to suicidal thoughts and behaviors. Moreover, NSSI tends to reduce arousal for many of those who use it and, for many individuals who have considered suicide, is used as a way to avoid attempting suicide. • Presence of cognitive constriction: Cognitive constriction is black-and-white thinking – seeing things as all or nothing, good or bad, one way or the other. It allows for little ambiguity. Individuals who are suicidal often experience high cognitive constriction; the intensity of cognitive constriction is less severe in individuals who use NSSI as a coping mechanism. • Aftermath: The aftermath of NSSI and suicide can be strikingly different. Although unintentional death does occur with NSSI, it is not common. After a typical NSSI incident, well-being and functioning improve for a short amount of time. The aftermath of a suicide- related gesture or attempt is precisely the opposite. Despite the different intentions associated with NSSI and suicidal thoughts and behaviors, it is important to note that they share common risk factors. These include but are not limited to 75 : • History of trauma, abuse, or chronic stress. • High emotional perception and sensitivity. • Few effective mechanisms for dealing with emotional stress. • Feelings of isolation (this can be true even for people who seem to have many friends or connections). • History of alcohol or substance abuse. • Presence of depression or anxiety. • Feelings of worthlessness.
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