“We’re not going to cure our way out of this crisis.”
Of all the words I’ve heard from suicide experts over the last five years in the course of researching, writing, and producing the PBS film Facing Suicide and writing this book, none have borne reexamination more than these spoken to me by Eric Caine, MD, professor emeritus of the University of Rochester Medical Center. Dr. Caine spent years as a psychiatry department chair and clinical psychiatrist and has helped countless patients climb out of the agony of a suicidal crisis. But at heart he’s a public policy wonk, looking at the big picture and asking, How can we change our society to reduce suicide? How can we change health care itself? Sure, caregivers can help individuals with treatments such as CBT, DBT, CAMS, SSRIs, ketamine, and lithium, and often save their lives. Again and again individual patients win this battle, and this is a source of hope. I’ve presented some of these cases in this book, and there are tens of thousands more each year.
But we are indisputably losing the war. On average, despite suicide reduction measures, more people in America die by suicide each year than died the year before, and this has gone on since at least 1999. Suicide ravages the United States.
So far we’ve explored the power of important safety measures as simple as keeping an eye on those close to you, watching for suicide’s signs, and connecting suicidal people with impactful care. We’ve seen how the Safety Plan Intervention can stabilize some patients and CAMS can reduce suicidal ideation. We’ve examined aspirational efforts in brain scans and digital technologies that show future promise for anticipating suicides. We’ve stepped inside the circles of danger described by Thomas Joiner’s interpersonal theory and seen their expository and predictive power. For the most part, these measures have been individual-focused, aimed at helping one person at a time.
We’re not going to cure our way out of this crisis.
For the remaining chapters of this book, we’ll explore efforts that have made meaningful reductions in suicide across whole populations. This, many experts claim, is the natural and desirable evolution of suicide reduction. It’s where the field of suicidology appears to be headed. Population-based strategies are sometimes called systems approaches. There aren’t very many, and the most prominent in the United States was relatively short-lived. But according to Caine and many other suicidologists, they represent the ultimate hope, a big net that doesn’t rely on treating suicidal individuals one at a time and curing our way out of this crisis. Instead, systems approaches protect populations by trying to alter suicide outcomes upstream of suicidal events, well before they occur, and then using proven therapies and medicines to stop suicidal behavior in those who slip through the dragnet. But the effect is the same: substantial suicide reduction.
The following is the first paragraph of a 2001 US Air Force report on suicide reduction. It comes with a plot twist worthy of a horror film.
In the spring of 1996, the Air Force’s most senior leaders sensed that the details of far too many suicides were crossing their desks in daily reports of major events. In May of that year, the suicide of Admiral Jeremy Boorda, the top-ranking officer in the US Navy, caused them to take an even closer look. It was time to take more aggressive action against the problem of suicide among Air Force members.
Like teenagers in a cabin in the woods, the Air Force’s upper command felt foreboding. But they were convinced to take action when one from their own echelon tragically took his life. When the Air Force Suicide Prevention Program began in 1996 the situation was critical and getting worse. Suicide had recently become the second-biggest killer of Air Force service members after accidents, responsible for almost one-quarter of all active duty deaths. Fewer than a third of those who killed themselves had contacted Air Force mental health services. At the time, suicide rates in the Air Force were about 40 percent less than those in the United States population at large, but growing fast. I found this stunning. I had become so accustomed to astronomical active duty and veteran suicide numbers—up to forty-four veteran suicides per day according to a recent but contested account—that it seems remarkable that just thirty years ago the Air Force suicide rate was only a little more than half the civilian rate. Still, by the standards of 1996, when the Air Force Suicide Prevention Program was introduced, suicide among airmen had become rampant.
David Litts, MD, now a retired colonel, functioned as the “chief of staff” in the development effort and cultivated the key insight that suicides should be viewed as community problems rather than individual ones. As it turns out, the biggest risk factors among members of the Air Force aren’t very different from civilian risk factors. The majority of suicides involved problems with relationships, the law, and finances. What mainly prevented help-seeking was stigma, the shame and disgrace associated with mental health conditions. The facets of stigma paralleled those we explored in Chapter Five. People with suicidal ideation fear their own minds’ destructive drives, and they fear what others think of them. They worry about social and religious condemnation, which has pushed suicide into a claustrophobic dungeon for centuries. Self-reliance, highly valued in military personnel, made Air Force members embrace a stoic, go-it-alone mindset and reject help-seeking. Alien to their thinking was Christine Moutier’s maxim that mental health problems are health problems, no different from heart disease or broken bones.
The experts found that airmen were wary of repercussions for seeking professional help, such as losing their jobs and getting drummed out of the Air Force. They believed their managers and commanders inspected their mental health records, an absolute barrier for some to seeking help. Overall, the Air Force seemed to have lost one of its distinguishing characteristics, a supporting interconnection among personnel of all ranks best summed up by an old but frequently used adage, “The Air Force looks out for its own.”
But that all changed. Working with experts, Air Force brass assembled a suicide prevention program that wasn’t one program but many overlapping programs. Their shared theme was community cohesion. Reducing suicide became everyone’s responsibility. According to Eric Caine, who was instrumental in evaluating the program as it developed, it started at the top. “It began with leadership, it was a top-down effort, there’s no question. The vice chief of staff and surgeon general of the Air Force at the time saw suicide as one of the biggest problems that the Air Force family faced, and they really viewed it as a family. They looked at what the World Health Organization had recommended and they put together a sort of throw-everything-including-the-kitchen-sink plan. It’s hard to know what element worked the most, but they threw in all the elements.”
Eleven elements defined the plan, and they systematically attacked risk factors among Air Force members. To point out a few, when examined by mental health professionals, patients at risk for suicide were given greater confidentiality; their mental health issues around suicide would not impact their Air Force careers. Suicide prevention was included in all military training for all ranks and all civilian employees in the Air Force. All were taught warning signs for suicide, how to care for fellow members they deemed at risk, and how to encourage early help-seeking.
Right after an arrest or criminal investigation is a high-risk time for suicides, and so is immediately after traumatic events like terrorist attacks and suicides themselves. Planners focused extra resources and procedures on these moments to deal with destructive emotions.
The scale of the suicide reduction plan becomes clear if you witness the small town that is an Air Force base, with a town’s commensurate sprawl and population. There are about 800 active US Air Force bases around the world, with a total population of about 330,000. Travis Air Force Base in California (2023 population about 8,020) is a living township, with innumerable airplanes, trucks, and other vehicles and vast numbers of people whose job it is to fly them, drive them, and keep them all running. These Air Force officers, enlisted personnel, and civilians have to be fed, housed, clothed, and entertained, and many go to church. Many are retirees. Caine said, “So there’s housing, there’s health care, there’s legal, there’s judge advocacy, there’s chaplaincy, you can go on and on and on about the elements. And they pulled all those together, along with medical and the investigation services, and educated them about suicide. They created a culture of caring. They had a phrase that attacked stigma. ‘Strong men—and women—can ask for help.’ ”
The program was an immediate success. In a few years, suicides in the Air Force were cut in half. The year 1994 saw sixty-eight suicides; 1999 had just thirty-four. In 1999, the Air Force suicide rate was 9 per 100,000, lower than the national rate of 11 per 100,000. For eleven years after launch, the reduction was sustained, resulting in an overall 33 percent reduction in suicides from the years preceding the intervention. Through 2008, with the exception of 2004, the Air Force Suicide Prevention Program also significantly decreased the risk of other violence-related outcomes, such as accidental death and domestic violence. But 2004 was important. It displayed stress fractures that would ultimately threaten the program.
In the program’s heyday, however, the Air Force had achieved an amazing milestone—it had reduced suicide rates while there had been no reduction in suicide rates in the civilian population of the United States since the 1940s. The Air Force Suicide Prevention Program has been copied by institutions, and even nations, around the world.
There was just one problem. All the Air Force’s success took place in peacetime. How would it hold up in the crucible of war? In 2001 the United States invaded Afghanistan. In 2003 it invaded Iraq. By 2004 the stress fractures opened. Caine was there. “We saw the first cracks in the Air Force Suicide Prevention Program in late 2003, 2004. And at the time we had a discussion [about] what was causing it. Now the three colonels who had overseen the program basically said we think everybody is still doing it because the command structure said it’s important. And some of us said, well, you know we’re at war now and it’s very hard to do this even if the command structure says do it.
“And my colleagues and some of the people in the Air Force did some surveys and published them and the thing that was really clear was that a lot of the program implementation was falling off the screen because it was wartime.”
The study got midlevel leaders back on track and energetically reimplementing the program. For a while, that worked. But after 2007, the fissures reappeared, and this time they didn’t heal. Caine identified one prominent reason: a massive downsizing in the ’80s and ’90s as the Cold War ended, the Berlin Wall came down, and the Soviet Union dissolved.
Caine said, “In 1985 the Air Force had about 650,000 service members. In 1995 it had about 350,000.” Later, at war in both Afghanistan and Iraq, the Air Force was stretched too thin. “It was 24-7 for everyone,” said Caine. “When the Army and the Marines withdrew from Iraq, the Air Force didn’t withdraw. The Air Force didn’t withdraw from Afghanistan or Europe or the borders with Russia. The Air Force has been on overtime.”
Control of the skies has become a mainstay of modern warfare, so the Air Force wasn’t able to let up. This took a toll on every service member. Caine said, “If you’re working multiple shifts or twelve- or fourteen-hour shifts, or even if it’s eight hours a day but it’s six or seven days a week, you’re on edge and it’s hard to keep going. It’s hard to develop community. It’s hard to maintain family relationships.”
And it was hard to rigorously implement the Air Force Suicide Prevention Program. After 2008, suicide rates returned to preprogram levels and continued to rise. Now, by 1990s standards, suicide is out of control in the Air Force. The year 2020 saw 582 Air Force service members die by suicide, and the next year 519. No one can explain the 2021 dip, and no one expects the downward trend to continue. No one knows the genesis of suicide’s dramatic upward curve among the armed forces except to suggest it is a consequence of America’s “forever wars.”
Nevertheless, the USAF’s achievement can’t be overstated. It has demonstrated that a multifaceted, overlapping, community-based approach can reduce the rate of suicide over a number of years. Its enduring public health message is that suicide rates in large institutions may be decreased and that, for programs to be successful, interventions must be regularly supported and checked for compliance. Reductions in suicide rates cannot simply be maintained by a program’s momentum. The USAF’s strategy for preventing suicide should be tried out in other job-related communities, such as law enforcement and corporations, to see if the programs can work with other groups.
Meanwhile, the Air Force isn’t accepting its setback in suicide rates. Instead, the USAF is developing exciting high-tech tools to tackle suicide reduction.
The light comes up. You are in in a dimly lit apartment with empty beer bottles on the floor. Takeout containers litter the tables, and the shades are down, increasing the gloom. The place could use a power wash. And so could the airman in it. He’s a slight man in a wrinkled T-shirt, downing a beer, when you startle him. He looks to be in his early thirties.
“Jesus, you scared me,” he says. “Just because a guy leaves his door open doesn’t mean he wants visitors. What’s up?”
Two phrases float in white letters in the foreground. You choose one and say out loud, “I saw the Instagram post. Wanted to check in on you.”
He’s suspicious. “Only checking in. I’m fine. It’s just some stupid drunk post, all right? You know how girls are.”
“It doesn’t seem like nothing, Mike. Can we sit down and talk about it?”
He gives you a hostile glare.
Meet Airman Mike. He’s the star of a virtual reality module expertly designed by a provider of immersive training experiences called Moth+Flame. Created for the USAF, the module’s goal is to plunge service members into Mike’s suicidal crisis and teach them the skills to get him to safety. Once you don the Oculus virtual reality headset, you’re immersed in Mike’s apartment, and pretty soon in Mike’s problems.
“What do you know about my problems?” Mike snarls. “You don’t know me.”
At regular junctures in your conversation, options for what you can say appear on the screen. For the experience to work, you must choose one option and say it out loud. The backstory, which you uncover, is that Mike’s wife, Nicole, found pictures of Mike and another woman on his phone. Nicole’s tearful outburst went straight to divorce and who will get the children. Mike tried to grab her. She fell and hit her head.
“I did not try to hurt her, okay?” Mike insists. “But if she tells them that I did, come on, you know what that means. That’s Article Fifteen. My life’s over. There’s no Nicole. I don’t know where she’s going to take the kids. There’s no Air Force. I’m done.”
Article Fifteen means Mike could get kicked out of the Air Force on charges of domestic violence. And there’s one more thing. Mike’s been making Instagram posts. They contain veiled threats about killing himself. What do you do now?
Air Force colonel Matthew Sandelier works at the Pentagon’s Office of Force Resiliency (OFR), which was developed to prevent violence and promote resilience of personnel across the Air Force and the Space Force. At Travis Air Force Base he told me, “The virtual reality research program happening here at Travis is a new and interesting method of delivering the kind of bystander intervention training that we’ve been providing for quite some time. When it comes to content delivery, virtual reality has got great benefits.”
Chiefly, it bypasses time-consuming and costly lectures and role-playing, which was how the Air Force trained for interventions in the past. Now the VR program shoulders the load by training airmen how to apply the ACE concept, which has been used in the USAF for decades. ACE—which stands for Ask, Care, and Escort—is the essence of how to care for an individual in a suicidal crisis. As we’ve discussed, one should ASK the question “Are you thinking about killing yourself?” CARE is a broad term for ridding the environment of deadly means of suicide, mainly firearms, medicines, and poisons. Then ESCORT the individual to safety, which in the Air Force comes with specific guidelines. Get the service member into the hands of his superior or a therapist or faith leader such as a chaplain or rabbi, or take him or her to a hospital emergency department.
Colonel Sandelier said, “It allows our airmen to not only hear and understand what a bystander event may look like and how to apply the ACE training in a situation, but actually do that in an interactive manner, get that kind of immersion in the situation and not just hear about it in a classroom with ten or twenty of their peers. With VR they can receive that training individually, and get feedback. Does Mike survive that situation, and has the airman executed his duty in the way he should?”
Well, does Mike survive?
Now you are back in Mike’s apartment, and he’s even more agitated. He says, “There is no helping, man. This has been going on for way too long. All right? Because I see what I see when I look in the mirror. My whole life has been leading to this. This. And it just keeps repeating, just keeps going over and over again. Why? Why? Hell, I can’t even be here. I cannot be here. I’m sorry.”
“Mike, I got to ask. Have you thought about taking your own life?”
Mike is tearful. “Sometimes I think that I’m not good for people. It’s not good for people to be around me. So, do I think that people would be better off if I wasn’t a burden to them? Yes. Yes, I have.”
“I don’t mean to overstep, but I think you need help.”
So far, you’re doing well. You’re listening. Closing down the conversation by saying something like “Man up and get your act together” will get you kicked out of the apartment. You can assume Airman Mike then kills himself.
However, keep the conversation open, offer options and an understanding shoulder, and Mike won’t kill himself. He’ll repeatedly ask you to leave but you won’t. Why not? Because you never, ever leave someone in a suicidal crisis alone.
You say, “I’m not going to leave you here alone. We’ll get through this together.”
And you will. If you absorb the coaching provided by the training module, you will get through the crisis together with Airman Mike. You’ll escort him to his first sergeant’s home and pass him into caring hands. And even though it’s just virtual reality, it will feel good.
Obviously, this is a very specific scenario. Other modules were created for different individuals in different situations, including one for a woman on the brink of suicide and another that addresses sexual assault.
Air Force officials have more reasons besides efficiency for adopting immersive VR modules aimed at reducing suicide. They hope a VR experience will succeed where years of traditional instruction have failed. The year 2021, the last for which records are available, was a good one for the Air Force. While the Army’s suicide rate increased, the Marine Corps, Navy, and Air Force (including Space Force guardians) all had declines. Only the Air Force’s decline was substantial, with a reduction to about 2011 levels. But 2021 was an outlier; on average, USAF suicides are climbing. The year 2015 had been the highest number of suicides, sixty-four, in the Air Force in the twenty-first century, but was surpassed in 2019 when eighty-four active duty Air Force members took their lives.
The Air Force, however, isn’t about to throw in the towel. The VR prevention module isn’t the only innovative tool up their sleeve. Colonel Sandelier told me, “Another is a program called Wingman Connect. Our new airmen are being immersed in a new type of resilience training, where they are put in a group environment and really taught how to develop appropriate supportive group dynamics. Wingman Connect teaches each airman to build the kind of social network needed to detect when airmen are under distress, when they’re self-isolating. The group can sense that self-isolation and immediately bring that person back in. They can elevate each other based on their strengths to the point where the entire group is stronger than any of the individuals is.”
Wingman Connect is an “upstream” intervention because from day one on the job, airmen are trained in small groups. If suicide is a “disease of isolation,” as it’s often called, then small groups trained to manage career and personal challenges together, and to sense when any airman pulls away, may provide a cure. And it may short-circuit mental health issues that could later result in self-harm. Studies have shown that Wingman Connect is the first preventive program to lessen suicidal ideation, depressive symptoms, and occupational conflicts in the Air Force community. I think it’s tempting but a mistake to view military suicides as separate from suicides among civilians in the United States. Instead, it’s another facet of our nation’s suicide crisis, and like that crisis, it defies easy explanation. Yes, individuals who choose military careers may come with risk factors that aren’t evenly distributed in the general population. Recruitment policies may draw more people with risk factors into some parts of the military. Military careers expose individuals to danger and strong emotions. But to ask why suicide steadily increases in the armed forces is to ask why, since 1999, suicide rates in the US have been on the rise; between 2007 and 2018, overall suicide rates have increased by a third; and suicide among ten- to twenty-four-year-olds has increased by nearly 60 percent. It’s not a coincidence that the Air Force suicide rates also increased; it should have been expected. So the mystery of Air Force and other military suicides folds into the larger, confounding mystery that should haunt us all.
Lieutenant General Brian Kelly, formerly the Air Force’s deputy chief of staff for manpower, personnel, and services, said, “Suicide is a difficult national problem without easily identifiable solutions that has the full attention of leadership.” He said the Air Force seeks immediate, midterm, and long-range answers to a military and nationwide problem. It is encouraging to know the Air Force has achieved this seemingly impossible goal before.