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Preface
I am a veteran’s advocate advising veterans on overcoming barriers to receiving VA benefits. I provide this advice free of charge as a service to veterans; as a veteran myself, I consider it my duty to help veterans in need. Mostly, I help veterans formulate a plan to ensure they receive and get appropriately compensated for their service-related disabilities. Approximately one thousand veterans contact me annually seeking advice on virtually every possible VA related topic. Nearly all of these veterans are very frustrated with the VA system and I am often their last resort for help. Sadly, I frequently speak to veterans on the verge of suicide. I can relate to these veterans, as I am a suicide survivor.
In 2013, I was unemployed and my savings were nearly exhausted. Finding and maintaining employment due to my service-related disabilities proved to be impossible. Desperate, I filed for VA and social security disability. Some months later my VA disability was approved and I was so, so very relieved and thankful that I could now support my family with the basic essentials; unfortunately, my reprieve was short lived. Seven months after being awarded compensation, I received a new decision letter from VA now denying the previously awarded benefits. At first, I was literally frozen in shock, but quickly a very deep and dark depression set in.
I stopped talking, I stopped eating, and I stopped drinking fluids until after several days I walked into my basement and tried to hang myself. It’s only through dumb-luck or perhaps divine intervention that I am here today. Once I was able to pull myself together, I immersed myself in the VA disability compensation process, regulations, laws, and case law. I quickly discovered that VA had made several horrible errors. I was able to favorably resolve the situation; however, I suspected that other veterans were similarly affected. This incident sparked me to become a veterans advocate with a particular interest in suicide prevention.
I routinely scour the internet for news related to veteran suicide and have found reports of veterans committing suicide after contact with VA. Paul Shuping and Brieux Dash committed suicide after receiving disappointing VA disability claim decisions (Dash was in VA care at the time). I wonder could anything have been done to prevent their suicides or my attempt? All three of us had known mental health conditions. Several other veterans (Kenneth Hagans, Justin Miller, and Cameron Anestis) died after direct contact with VHA for mental health issues. Any veteran will be disappointed with a denial of benefits or poorly delivered benefits; however, veterans with mental health conditions may react, and I think predictably, in the extreme.
The first step to preventing suicide is identifying those veterans at risk. Once a veteran is identified as at risk, VHA and VBA systems must clearly identify that veteran as at risk; thus, in future encounters with the veteran VA employees will be well aware that they are dealing with an at-risk veteran. When dealing with an at-risk veteran, processes must be in place to ensure a flawless delivery of benefits. We must ensure such a system is in place. This paper will address steps to establish or improve current VA suicide prevention processes. My observations and recommendations are based on my direct experience with thousands of veterans, my awareness of unutilized data sources within VA data systems, and on good old common sense.
VA Suicide Prevention
I will address suicide prevention efforts on several fronts; (1) learning from veteran suicide victims, (2) identifying veteran experience suicide risk, (3) learning from the living, (4) ensure data accuracy, (5) develop a veteran specific predictive model, and (6) save lives now. Each of these items can be standalone projects; however, for best results all elements should be incorporated within current suicide prevention strategies. The Behavioral Health Autopsy Program (BHAP) currently has the responsibility for collecting data per veteran suicides. BHAP needs to expand the data collection effort to include all data resulting from these projects.
Learning from veteran suicide victims
The effort under this project is to collect data that currently resides within VA records. Currently there is no generally accepted models, tools, processes, or practices that accurately assess risk of suicide or is predictive of who will likely or likely not act on suicidal thoughts. Also, there is no generally accepted theories of why veterans are more likely to commit suicide than non-veterans. Perhaps the answers we seek that would allow for a better understanding of veteran suicide are rooted in data collection.
The data collection theory we need to operate under is a “whole-life” one; in other words, we must collect data from before, during, and after service. For those of us who are data driven decision makers, we know that all data related to our topic may be important; thus, all data of record must be collected for analysis. Data are collected at the VISN 2 Center of Excellence for Suicide Prevention (CoE); however, it is not clear that all available information about veteran suicide victims are collected.
Negative Experience VHA Data
I suspect that VA is not collecting VHA veteran negative experience information. Applications and requests for VHA services are routinely denied. Denials are issued for healthcare (not all veteran are eligible for VA healthcare), travel reimbursement, payment for outside the VA emergency room treatment, the Program of Comprehensive Assistance for Family Caregivers, community care, clothing allowance, and other aspects of healthcare services. Many veterans are dissatisfied with healthcare services and voice their complaints to VA hospital social workers, patient advocates, and medical staff: some of these veterans are flagged by Disruptive Behavior Committees. Denials and other negative experiences no doubt result in stresses that impact every aspect of the veteran’s life: this data is within the VHA record and must be captured for analysis.
VBA Data
I suspect that VA is not collecting the data from VBA claim files (c-file). Many benefits are managed by the VBA; home loan certificate of eligibility, home loans, education programs, vocational rehabilitation, disability compensation, and pensions. There are subcategories within each of these benefit areas, for example disability compensation offers benefits for a veteran’s seriously disabled child, an automobile allowance/adaptive equipment, compensation under 38 U.S.C. 1151, individual unemployability, special monthly compensation, aid and attendance, and specially adapted housing/special home adaptation. All VBA programs have eligibility criteria and an application process; during these processes, relevant data are collected to determine if a benefit will be awarded to the veteran.
The most significant data held by VBA is gathered per claims for disability compensation determinations. To be awarded compensation a veteran must show an event in service, a currently diagnosed disability, and a nexus between the event in service and the current disability. The event in service is typically within the veteran’s service medical records which are included within the veteran’s c-file. The current disability is garnered from VA or private treatment facilities. VBA conducts a compensation and pension medical examination (C&P exam) to confirm the claimed condition is current and determines if the disability is related to service. The C&P examiner completes a disability benefit questionnaire (DBQ) which notes symptoms and the severity level of the claimed condition. It should be noted that the vast majority of C&P exams are conducted by contractors and the results of contractor provided exams do not post to a veteran’s VHA health record.
Veterans often write statements to support their claims that describe how the disability impacts their life. A veteran’s statement is extremely important as it is a record in the veteran’s own words. VHA and VBA generated records containing notes that proport to be a record of conversations held with the veteran are often not accurate when examined by the veteran. Many veterans have complained to me about inaccurate accounts of conversations noted in VA records. My own experience with both the VHA and VBA record keeping has found inaccurate notes to be the norm. After a veteran’s death, the statements contained within the c-file are likely the only record where an accurate account of a veteran’s feelings and observations about their physical and mental health can be viewed.
The following information is found only in the VBA c-file; VBA benefit approvals and denials, private health treatment records, private independent medical opinions, VBA contractor generated DBQs and medical opinions, service personnel record, service medical records, marriage licenses and divorce decrees, number of children dependents, social security disability determinations, medical evaluation board (MEB) determinations, personal statements in support of claims, and witness statements in support of claims. VBA records tell a story about the veteran’s service experience, as well as, their current struggles with physical and mental health conditions. Often, if not mostly, this information is not known to family, friends, and the VHA. To get a more complete picture of a veteran’s life details and mental health status after suicide, VBA c-file data must be captured for analysis.
Identifying Veteran Experience Suicide Risk Factors
An effort to gather veteran experience data must be initiated. We know that veteran and non-veteran populations have comparable psychosocial, demographic, health care utilization, psychiatric diagnoses, acute psychiatric symptoms, and general suicide risk factors. We also know that veterans are more likely to commit suicide than non-veterans. In reviewing publicly available studies on veteran suicide, researchers and clinicians haven’t really tried to determine why veterans are more likely to commit suicide than non-veterans: certainly not from the veteran experience perspective.
I have not found any comprehensive study or data surrounding what is unique to the military and the veteran experience and how these unique experiences may or may not impact suicide risk. There are only two life experience elements completely unique to veterans; military experiences and Department of Veteran Affairs (VA) experiences. After a suicide we must, completely and thoroughly, gather and analyze the data related to the veteran’s VA and military experiences if we really want to properly gauge veteran specific suicide risk factors.
VHA and VBA
VA data shows approximately 40% of veteran suicides victims had VHA encounters within two years of their death. DOD data shows approximately 60% of military suicide victims had healthcare encounters within 90 days of their deaths. How do these percentages compare with veteran suicides victims utilizing private healthcare? Are specific healthcare services involved? Was there a VHA program or benefit being considered for approval? Was the patient advocate or social worker contacted? Were there successful outcomes? Was there dissatisfaction with the health care? There are answers to these and other relevant questions that just may give us a glimpse into the veteran’s state of mind before death. We just may find that for some veterans with specific life experiences that the VHA experience adds a significant suicide risk factor.
I have found no data whatsoever in reference to veteran suicide and VBA encounters. I suspect there is an increased suicide risk tied to unfavorable outcomes from both VBA and VHA encounters and these negative outcomes also act as trigger events for many suicides. We cannot ignore the immediate or latent effect of unfavorable VHA and/or VBA encounters; until we collect and analyze the relevant data, we will not know the extent of the problem.
Military Experiences
Military life is often harsh. The physical and mental stresses are many. Discipline is at the core of all of the services and at a level civilians will never encounter. There are many regulations that must be followed. Infractions of any type are often met with severe punishments. The military experience will leave a lasting impression on a veteran’s life and most veterans view their service as the most significant accomplishment in their life. A significant accomplishment to be sure; however, that doesn’t necessarily mean that the military experience was a positive one. I suspect that those veterans with negative experiences during their service are more susceptible to suicidal ideation and suicide.
The information collected through BHAP is limited to after service and more recent data. To get a complete picture of the veteran’s life stresses, military personnel and service medical records must also be reviewed. As well as, interviews with the veteran’s family and friends must include questions about before service and during service stresses. We cannot ignore the impact of long-term stress on the veteran’s mental health. I have no doubt that long-term stress is a significant suicide risk factor; until we collect and analyze the relevant data, we will not know the extent of the problem.
I recommend the following military specific data be collected if not currently being collected: branch of service, military occupational specialty (MOS), branch of service physical fitness program assessment, physical fitness performance, type of discharge, earlier discharge, weight gain during service, weight program participant, disciplinary actions, drugs and alcohol involvement, rank, areas of assignments, deployments, length of assignments, environmental exposures (cold, desert, burn pits, etc.), time spent on field training exercises, time away from family, service immunizations, preexisting conditions, years of service, retired per length of service, retired medically, crime victim, combat, accidents, blast exposure, MEB determinations, education while in service, service education level, MOS transferable skills to after service employment, blast TBI, non-blast TBI, bars to reenlistment, Qualitative Management Program (QMP) selectee, and others.
Learning from the living
The perfect time to gather information about preservice and during service experiences is when veterans are initially seen for mental health services: this information can also easily be gathered from veterans currently in treatment. Veterans with known mental health conditions not currently in treatment can be sent a questionnaire. We also need to know about their access to guns. I have no doubt that many veterans are hesitant to speak of preservice experiences as they fear that information will impact their VA disability compensation. The same is true about their access to guns; if a veteran believes the VA will take steps to seize their guns, they won’t tell VA they have guns. The preservice, during service, and access to guns information is extremely important in assessing current suicide risk; thus, processes must be put in place to guarantee the veteran that this information will not be used against them in anyway.
Ensure Data Accuracy
The data I’ve reviewed from the VAOIG, BVA, and GAO; as well as, my own experience in assessing tens of thousands of VA disability claims tells me that the accuracy level of VBA claims for compensation determinations are very low; however, VBA reports high accuracy rates. VBA bases their accuracy assessments on their internal quality program; thus, it is no surprise VBA reports high quality. There is a danger in allowing people doing a job to assess their own performance: this is especially true when reporting data that bears directly on suicide risk assessments. The only report I’ve found concerning the accuracy of suicide data collection is a 2015 GAO report that assessed the BHAP, in which they concluded “GAO’s recent work has found that the demographic and clinical data that VA collects on veteran suicides were not always complete, accurate, or consistent.” This conclusion is disturbing to say the least.
I am sure that VHA has made some efforts to better collect the data after the GAO report; however, the BHAP is the main effort in collecting suicide related data and simply speaking there is no room for error given the importance of the data. I know of no VA program specifically impowered to assess the quality or completeness of the data received at the CoE. We cannot leave the responsibility for quality assessments to the individual sections or departments that collect and report the data nor can we assign that responsibility to the CoE. VA has a vested interest in presenting the appearance that the ship is on the right course; thus, VA cannot be relied upon to carryout data quality assessment responsibilities.
I suggest a third-party entity develop, implement, and conduct the routine duties of a standard quality program to ensure CoE and other stakeholders are fully informed on data quality. The notion that VA department managers or staffs can adequately and reliably assess data quality must be discouraged. A quality program must be managed and lead by quality professionals if the desired outcome is actual quality. If VA decides to create their own program or already has a quality program for the data received at CoE, then a third-party entity must be hired to conduct regular audits. The data received at CoE is far too important to leave quality to chance.
Develop a Veteran Specific Predictive Model
Once all of data I recommend is collected, a more informed veteran specific predictive model can be built. There is a lot of excitement around machine learning and certainly there is an advantage to having artificial intelligence do the work of assessing suicide risk. The algorithms developed by computer programmers and mathematicians are only as good as the data relied upon to create them. Regardless of the method used to create the predictive model, we must have volumes of appropriate and accurate data before a reliable algorithm can be created; meaning, we will need to reexamine CoE data over past years to draw out the additional data I’ve suggested. This will be, of course, a costly effort; none the less, it must be done.
I would think a better-informed predictive model can be visualized with the most recent full years data; however, we will need at least five years of the most recent data to create a viable model. The more years the better, but it is likely that five years will contain an appropriate sample of the veteran population. This means gathering data from veteran suicides from 2017-2021: approximately 30,000 deaths. During this process the BHAP data can be examined for accuracy and completeness: the same is true for any other data collected at CoE. This would be a perfect time to establish a professionally lead quality program for CoE data.
Save Lives Now
This effort involves steps we can take immediately to mitigate veteran suicides. I expect the data collection effort I am recommending will indeed improve our understanding of veteran suicide risk factors; however, we cannot wait on the projects to complete before we take common sense action. The real question here is “what is the value of a veteran’s life?” Do we take action to implement system wide policies even if that action will only save the lives of 1000 veterans? Naturally, we all would likely answer yes to that question, but if what if only 100 lives would be saved? Or 10? What if only a single veteran’s life is saved, should we still implement far reaching policy initiatives? My answer is even if there are costs and efforts involved, a single life is worth saving. Regardless of your answer, I have little doubt the projects noted under the “Save Lives Now” initiative will save many lives.
In writing we are taught to know our audience. I think the same is true for suicide prevention. I am not so sure the VA knows exactly the nature of the suicidal veteran. Let me paint that picture: a suicidal veteran may have experienced before, during, and after service stresses and traumas which have forced that veteran to the edge of the cliff. The veteran may be irritable, irrational, or combative. The veteran may have run to the edge or walked slowly. That veteran may just stand there and consider options or just blindly stare. Regardless of how or why, it must be understood that the veteran is “at the edge.” One step forward is death.
The problem here is we don’t really know which veterans are at the edge; thus, the VA must not push or startle a veteran with any level of identified suicide risk as that veteran may be that veteran at the edge. Keep in mind that for the veteran at the edge, even one wrong word or perceived trouble of any kind will result in a nudge over the edge. The point here is that VA must treat veterans with any level of suicide risk with a degree concern above normal; meaning, doting i’s and crossing t’s. With that being said, let’s save some lives.
Enabling Flags Across VA Systems
Veterans identified as at high-risk for suicide receive a High Risk for Suicide – Patient Record Flag (HRS-PRF) within VHA systems so that VA employees are well aware of the veteran’s risk status when considering treatment options. I suspect that high-risk flags are not shared across all VHA and VBA systems; thus, many VA employees working on veteran related issues are not aware that they are dealing with a veteran at high-risk of suicide. Within VHA, HRS-PRF should be visible to all employees directly encountering a veteran with the HRS flag and anyone making determinations concerning that veteran. All reasonable steps in line with VHA policies and procedures must be taken to ensure positive outcomes for these at-risk veterans. VBA must be notified of HRS-PRF status veterans.
The VA/DoD Clinical Practice Guideline for the assessment and management of patients at risk for suicide notes “approximately half of all suicide-related deaths occurred in the low-risk categories.” Why is VA limiting their flag system to just the high-risk category? From a preventive managerial perspective, it doesn’t make sense to only tag high-risk veterans. I understand that there are less veterans in the high-risk category than the low-risk category, yet both groups have equal fatalities; certainly, if I was dealing with the production of widgets and had limited resources, I would pay more attention to the high-risk category. Of course, we aren’t dealing with widgets in a manufacturing environment. Even a veteran labeled at low risk maybe near the edge. All at risk veterans should be afforded the same care as high-risk veterans. I recommend we flag all at risk veterans if we really want to prevent as many suicides as possible.
VBA
As noted in the preface, veterans have committed or attempted suicide as a direct result of VBA benefit determinations; thus, it is incumbent upon the VBA to take special care when dealing with at risk veterans. To my knowledge, VBA has no flag system in place to inform its employees that they are dealing with an at-risk veteran. VBA must establish a flag system to inform their benefit decisionmakers of at-risk veterans and share that flag status with the VHA. Once the flag system is established, VBA will have to review all mental health service connections for DBQs with suicidal ideation then add the at-risk flag. Going forward, VBA suicide risk assessments can be completed during mental health C&P examinations.
Make No Mistake Benefit Determinations
There are times in the business world where extra steps are taken to ensure high value clients receive flawless delivery of services. The extra steps are taken to ensure the continuation of the business relationship. To ensure the continued life of veterans, I suggest we treat all at-risk veterans as high value clients and go the extra step to ensure the flawless delivery of benefit determinations. Any time a VHA/VBA benefit, service, program, or determination of any kind will be denied to a veteran; VA will be required to review that determination, at the management level, before that denial is communicated to the veteran.
When I say reviewed at management level, I do not mean a review of the denial; I mean a full de novo review of the benefit by the manager. Should the benefit remain denied, I recommend that hospital social workers or mental health professionals communicate the denial news to the veteran. It’s a really bad idea to spring the denial on the veteran without any forethought. At least a social worker or mental health professional can be ready with resources or alternatives to help mitigate the benefit denial’s impact: they can also help formulate a plan to enable the veteran to move forward on a positive foot.
Outreach
Public Law 110-110 requires VA to provide for outreach to and education for veterans and the families of veterans in reference to mental health. VHA directive 1160.07 assigns the patient level outreach and education effort to the Suicide Prevention Coordinator (SPC) or a Suicide Prevention Team. The directive is so general in reference to outreach with no details whatsoever about exactly how information will end up in the hands of veterans and their families nor is there any mention of what metrics are in place to gauge the effectiveness of outreach activities. Current outreach efforts seem to be targeted at local organizations in the hope some information will trickle down to veterans and their families: a logical outreach activity; however, to me the most important outreach activity is direct contact with veterans with known mental health conditions.
Approximately 60% of veteran suicides are among veterans without recent contact with VHA. Is there an individualized outreach effort to veterans that were in treatment, but stopped or for veterans that sought help yet never began treatment? How about the veterans receiving VA disability or pension for mental health conditions who are not in treatment? Has VHA coordinated with VBA to get their contact information and then provided outreach information to these veterans and their families? VA knows there is a large block of veterans with known mental health conditions; many of which, are not in treatment. I recommend we provide outreach to these veterans and their families per direct personal contact.
SPC teams at all VHA facilities should begin an outreach effort to all veterans with known mental health conditions that are not currently in treatment or who’ve sought treatment for mental health yet never began treatment. I contacted 100 veterans with mental health conditions known to VA (currently not in treatment) to ask if VA has ever contacted them directly by mail, email, or phone to provide any information or enquire about their wellbeing. All 100 said VHA has never contacted them in reference to mental health. If VA has an individualized outreach effort it doesn’t appear to be effective as statistically speaking at least one of the 100 should have answered that VA had contacted them. My own experience mirrors the 100.
I was in regular treatment at VA for several years and was on mental health medications. I decided to stop going. I was little surprised VA never called to ask why. I also did not renew my meds and stopped taking them, yet still VA didn’t notice. It’s been several years now, but no outreach from VA. The law says to “encourage veterans to seek treatment and assistance for mental illness.” This includes regular encouragement even for those veterans who stopped, never started, or are resistive to treatment. Often just the thought that someone cares will be enough to get a veteran into treatment. Not contacting these veterans gives the appearance that VA really doesn’t give a damn; certainly, that’s how I see it.
An individualized outreach effort needs to be personal per an actual video or phone call. If you want to convince veterans VA cares, mailing or email won’t do as a contact method as both are too impersonal. This effort should not be just another responsibility for SPC, there must be a person with the primary responsibility to provide individualized outreach services.
YouTube
There are several veterans popular within the veteran community that make videos targeting only veterans. VA should consider providing outreach information by advertising on these channels or producing some joint videos with these individuals.
Last Words
I am an outspoken critic of both VHA and VBA. I have zero tolerance for mismanagement as a management professional. I have written to VHA, VBA, VA, and congressional leaders for years with recommendations for improving veteran services; sadly, not once have I heard back. No one wishes more than I for VA to do better. Hopefully, there is something in this paper that will help my brother and sister veterans stay alive. I want to end with a note about Paul Shuping.
He was 63 with multiple healthcare concerns and was collecting VA disability at a less than full rate. He was getting good care for his health care needs at the local VA. He found purpose in helping other veterans match with service dogs. One of his close friends said “He seemed like he was thriving.” All outward appearances were of a disabled veteran that was doing well. Then the VA decision notification denying full disability came in the mail, then he was dead. He was found in a VA parking lot with a self-inflicted gunshot wound to the head.
I’d bet good money he was considered a low risk for suicide and that the VA decision was wrong. Ninety percent of the VA decisions I review are full of VA errors. I have no doubt that my “save lives now” plan would have saved Paul’s life and prevented my attempt: let’s save that next veteran. We can’t stop all suicides, but we can prepare better to prevent foreseeable suicides and mitigate where possible. Looking in on VA from the outside, it seems VA can do better. I hope Mission Daybreak finds some solutions from outside the VA; but truthfully, I doubt it. I think the key to successful veteran suicide prevention efforts resides within the data at VA and in some very simple and common-sense mitigation efforts. Thank you and good luck.
