1. 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

2. 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.

3. 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

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

5. 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

6. 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),

7. 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
6-11C Combat and Operational Stress Control.pdf

8. 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;

9. 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

10. 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

11. For Official Use Only

12. Thank you