U.S. Marine Corps Community Approaches to Prevention New York State Suicide Prevention Conference 18 September 2017 William P. Nash, MD Director of Psychological Health Headquarters, Marine Corps william.p.nash@usmc.mil

Disclaimer Disclosures The views expressed in this article are those of the author, alone, and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the U.S. Marine Corps. Disclosures The author has no financial relationships to disclose. No off-label medication uses will be discussed.

Tools for Community-Based Prevention Stress Continuum Model: for community members to recognize warning signs for suicide Integrated suicide model: for community members to recognize risk factors for suicide For Official Use Only

Institute of Medicine Intervention Spectrum Targets a symptomatic individual Targets a high-risk group Targets an entire population IOM, 2014, 2009

Challenges for Indicated Prevention Identifying individuals already experiencing significant (but subclinical) distress or dysfunction Getting past stigma barriers so that help will be welcomed Fitting tools for intervention into the hands of community members (like First Aid) For Official Use Only

A Target for Indicated Prevention: Stress Injuries Normal Stress Stress Injury You choose it (largely) Temporary Reversible Functioning is maintained Integrity is maintained It happens to you (largely) Possible lasting change (scar) Cannot be undone Functioning is diminished Integrity is diminished Nash, W.P. (2007). Combat Stress Adaptations and Injuries. In C.R. Figley & W.P. Nash (Eds.). Combat Stress Injury: Theory Research and Management. New York: Routledge. Nash, W.P., Silva, C., & Litz, B.T. (2009). The historical origins of military and veteran mental health stigma, and the stress injury model as a means to reduce it. Psychiatric Annals 39(8), 789-794.

USMC Stress Continuum Model READY REACTING INJURED ILL Baseline “Good pain” “Bad pain” Diagnosable mental disorder Transient distress or dysfunction Persists beyond the stressors Full recovery May leave a “scar” Ubiquitous Specific causes: Life threat Loss Moral injury Wear-and-tear http://www.marines.mil/Portals/59/Publications/MCRP 6-11C Combat and Operational Stress Control.pdf

Nash et al., 2013; Bryan et al., 2014; Bryan et al., 2015; Moral Injury Events Scale (MIES) Subscales: Perpetration Other, Perp Self, Betrayal   Strongly Disagree Moderately Disagree Slightly Disagree Slightly Agree Moderately Agree Strongly Agree 1. I saw things that were morally wrong. 1 2 3 4 5 6 2. I am troubled by having witnessed others' immoral acts. 3. I acted in ways that violated my own moral code or values. 4. I am troubled by having acted in ways that violated my own morals or values. 5. I violated my own morals by failing to do something that I felt I should have done. 6. I am troubled because I violated my morals by failing to do something I felt I should have done. 7. I feel betrayed by leaders who I once trusted. 8. I feel betrayed by fellow service members who I once trusted. 9. I feel betrayed by others outside the U.S. military who I once trusted. Nash et al., 2013; Bryan et al., 2014; Bryan et al., 2015;

Toward an Integration of Suicide Theories Theory Major Tenets Interpersonal Psychological Theory (IPT) Suicide risk is the product of three factors: Thwarted belongingness Perceived burdensomeness Acquired capability for suicide Socio-Ecological Model (SEM) Risk factors for adverse health or social outcomes interact across several social domains: Individual Immediate relationships Cultural norms and practices Stress-Vulnerability Model (SVM) Suicide is the result of the interaction between: individual vulnerabilities (genetic, psychological, social, spiritual), and Current life stressors

Reduced Aversion to Death Integrated Model of Suicide Risk Factors Will to Die Reduced Aversion to Death Suicide Risk Individual Loss of honor; shame, guilt Physical disabilities Mental disabilities Emotional or physical pain Painful childhood Intense or chronic stress Lack of self-forgiveness Interpersonal Sexual or physical assault Relationship failure Occupational failure Social rejection, feeling like an outcast Being harassed or bullied No mentors or close friends Loss of shared identity Institutional Policies discouraging help-seeking Prejudice against mental illness Culture of perfectionism Culture of black-and-white thinking Perceptions of institutional unfairness Individual Prior suicide attempts Mental disorders Brain injury or illness Impulsivity Immaturity Intense or chronic stress Experience with death Physical courage Interpersonal Family history of suicide Suicide of someone close Help-seeking signals go ignored Institutional Access to weapons Cultural acceptance of suicide

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