Occupational Therapy and Veteran Suicide: A Call to Action

Prevalence of Suicide

To understand the epidemic of veteran suicide, it is important to compare the prevalence of suicide in the veteran population with that in the civilian population. Between 2001 and 2014, veteran suicide rates increased by 32%, whereas suicide rates among adult civilians increased by 23% (VA, 2016). The risk of suicide among veterans is 21% greater than among the civilian population (VA, 2016). This comparison led to the identification of veteran suicide as a top priority by the VA (2016). In addition, suicide is a leading cause of death among other subgroups in the general population; it ranges from the second to the fifth leading cause of death in all age groups, from adolescents to older adults, in the general population (CDC, 2014).

These statistics suggest that occupational therapy practitioners working in many practice settings have the potential to encounter both veterans and civilians at risk of suicide. Because suicide rates are increasing among veteran and civilian populations, and because the populations affected by suicide are not limited by military affiliation, age, or gender, suicide prevention is a profession-wide responsibility.

Mental Health and Occupational Performance

Risk factors linked to suicide include barriers to occupational performance, highlighting opportunity for the profession to assert its distinct value in addressing the mental health needs of veterans (AOTA, 2014, 2016a, 2016b). Risk factors associated with veteran suicide include a psychiatric diagnosis (e.g., posttraumatic stress disorder [PTSD], depression, anxiety, substance abuse), feelings of being a burden or lack of belonging during the transition to veteran status, social isolation, and relationship problems (Ilgen et al., 2010; Lusk et al., 2015). The most common occupational performance challenges of veterans involve driving, productivity, physical health, relationship issues, and sleep disturbances, with the latter two explicitly associated with suicide risk (Pigeon, Britton, Ilgen, Chapman, & Conner, 2012; Plach & Sells, 2013). Untreated psychiatric conditions have wide-ranging and negative consequences for veterans and society in general that include lost work productivity, relationship dysfunction, increased risk for substance use, and suicide (Tanielian et al., 2008). Defining occupational therapy’s role in suicide prevention requires an understanding of the association between psychiatric disorders and barriers to occupational performance related to suicide risk.

Occupational therapy practitioners skillfully evaluate the interaction between a client’s context (e.g., feelings of being a burden and lack of belonging) and environmental factors (e.g., social isolation, relationship issues), which may interfere with occupational engagement and increase suicide risk (AOTA, 2014; Lusk et al., 2015). Occupational therapy practitioners can make a distinct contribution to suicide prevention through use of a person–environment–occupation perspective when assessing barriers to occupational engagement. Barriers may include psychiatric diagnosis, lack of coping skills, difficulty with role changes, and lack of access to mental health care (AOTA, 2014; Lusk et al., 2015).

The promotion of adaptive coping strategies, such as meaningful relationships with friends and family, and access to mental health care can help reduce feelings of social isolation and lack of belonging associated with suicide (Lusk et al., 2015). Facilitation of adaptive coping strategies and promotion of social inclusion through group or individual interventions also have the potential to prevent mental illness (AOTA, 2014, 2016a, 2016b). Using a client-centered approach and therapeutic use of self, occupational therapy practitioners build trusting therapeutic relationships, which are important in addressing sensitive mental health issues related to suicide (AOTA, 2014, 2016a, 2016b). By facilitating social inclusion and participation in meaningful occupations, occupational therapy practitioners can promote mental health for at-risk veterans, thus reflecting the profession’s overarching goal of “achieving health, well-being, and participation in life through engagement in occupation” (AOTA, 2014, p. S4; AOTA, 2016a, 2016b).

Occupational Therapy Literature on Suicide Prevention

To strengthen occupational therapy’s research base in support of evidence-based practice, the profession must identify and address the gaps in its literature. A comprehensive literature search of journals such as Occupational Therapy Journal of Research, American Journal of Occupational Therapy, and Occupational Therapy in Mental Health, in addition to several databases, yielded few research studies related specifically to occupational therapy and suicide prevention. None of those studies involved the veteran population; instead, they focused on interventions with people diagnosed with traumatic brain injury, stroke, or depression. However, it is not difficult to find research on occupational therapy’s role with people challenged by psychosocial issues associated with suicide risk including depression, PTSD, and anxiety.

One of the rare occupational therapy contributions to the peer-reviewed literature on suicide is an article by Gutman (2005), “Understanding Suicide: What Therapists Should Know.” Gutman argued that occupational therapy practitioners should increase their awareness of suicidal ideation and behavior and learn effective interventions to prevent suicide in their clients. For Gutman’s recommendations to come to fruition, gaps in research on the topic of occupational therapy and suicide prevention must be closed.

Barriers to Addressing Suicide Prevention

Barriers experienced by occupational therapy practitioners in addressing suicide prevention include deficits in occupational therapy curricula, lack of educational resources, and limited perceptions of their role in addressing prevention (AOTA Task Force on Health and Wellness, 2006). A lower percentage of occupational therapy practitioners work in mental health settings than in other settings (AOTA, 2015), posing a barrier to the profession’s ability to meet the mental health needs of veterans. This dearth also contributes to a limited availability of Level II fieldwork opportunities in mental health. Furthermore, many occupational therapy curricula do not mandate a Level II fieldwork placement in a mental health setting (AOTA, 2011b). Addressing these barriers to suicide prevention presents opportunities for the advancement of the profession to meet the needs of at-risk populations.

Opportunities for Occupational Therapy in Suicide Prevention

Occupational therapy practitioners are likely to encounter veterans in almost any practice setting; therefore, educational curricula should prepare entry-level practitioners for the reality of encountering all people at risk of suicide (AOTA Task Force on Health and Wellness, 2006; Cogan, 2014; Plach & Sells, 2013). Developing educational materials on suicide prevention and incorporating the topic of prevention and health promotion into occupational therapy entry-level curricula should be a priority for occupational therapy leaders and educators (AOTA Task Force on Health and Wellness, 2006; Hildenbrand & Lamb, 2013). In addition, we must increase our involvement in prevention policy through professional publications and political lobbying efforts (Hildenbrand & Lamb, 2013). By establishing partnerships, engaging in advocacy, and supporting intervention research in suicide prevention, the profession has the potential to define itself as a distinct contributor in the area of preventive service provision (AOTA Task Force on Health and Wellness, 2006).

A Case for Suicide Prevention Training as a Professional Competency

Strategic directions of the Centennial Vision include “linking education, research, and practice, [and] demonstrating and articulating our value to individuals, organizations, and communities” (AOTA, 2007, p. 614). Boyer (1990) defined the scholarship of integration as “making connections across the disciplines, placing the specialties in larger context, [and] illuminating data in a revealing way” (p. 18). Appraising evidence on suicide prevention from other disciplines and linking the evidence to the Occupational Therapy Practice Framework: Domain and Process (3rd ed.; AOTA, 2014) strengthen the profession’s role in suicide prevention. Sufficient evidence supports education and training in suicide prevention for health care professionals who work among vulnerable populations (Mann et al., 2005). In a systematic review of suicide prevention strategies, Mann et al. (2005) found that gatekeeper training programs for health care providers helped reduce suicide rates in military populations. Such training includes education on identifying suicide risk factors, learning intervention strategies, and increasing comfort levels with offering assistance to people who may be contemplating suicide (Mann et al., 2005; World Health Organization [WHO], 2010). Taking the initiative in suicide prevention, the Canadian Association of Occupational Therapists and the Canadian Association for Suicide Prevention (CASP) recently partnered to provide evidence-based gatekeeper training to occupational therapy practitioners (CASP, 2016).

A systematic review of suicide prevention programs in veteran populations demonstrated that multifaceted interventions are most effective at reducing suicide risk (Bagley, Munjas, & Shekelle, 2010). Multifaceted interventions include gatekeeper training, didactic education, suicide awareness videos, individual and group counseling, life skills training, and family education, all of which are within the scope of occupational therapy practice (AOTA, 2014). Occupational therapy practitioners who are trained in such techniques have the competence and skills necessary to address suicide risk.

Emerging research on interventions such as meditation and sensory-enhanced yoga with veterans and military personnel has demonstrated effectiveness in treating PTSD, combat stress, and depression (Bormann, Thorp, Wetherell, Golshan, & Lang, 2013; Stoller, Greuel, Cimini, Fowler, & Koomar, 2012). A meditation program for veterans with PTSD resulted in significant reductions in PTSD symptoms and depression, both of which have been correlated with increased risk of suicide (Bormann et al., 2013). Sensory-enhanced yoga reduced stress and anxiety in a sample of military personnel at risk for PTSD, and additional research on its efficacy in mitigating constructs related to suicide risk in veterans should be considered (Stoller et al., 2012). Research within the occupational therapy profession has supported the prevention of mental illness in at-risk populations (AOTA, 2016a, 2016b). The identification of veteran suicide as a priority by the VA (2016) creates opportunities for occupational therapy practitioners, leaders, and researchers to examine their role in suicide prevention and to consider further research on the efficacy of occupation-based interventions in the veteran population.

This evidence substantiates the compelling need to increase the number of health care professionals trained in supporting veterans with PTSD and depression (Tanielian et al., 2008). Research supports a link between suicide prevention training and lowering suicide rates, and such training should be considered by individual states as a required occupational therapy professional competency (Mann et al., 2005; WHO, 2010).

In addition, legislation is needed to support suicide prevention training among health care professionals. Washington State is leading the United States in addressing suicide, setting a national precedent by passing the Matt Adler Suicide Assessment, Treatment, and Management Act of 2012, which mandates suicide prevention training for occupational therapy practitioners and other health care professionals. To date, Washington and Kentucky are the only states to mandate such training for occupational therapy practitioners (American Foundation for Suicide Prevention, 2016). The minimum standards of suicide prevention training for health care professionals include issues specific to veteran suicide (Washington State Legislature, 2015). This legislation highlights that the population affected by suicide is not limited by military affiliation, age, or gender and that the issue of suicide prevention is a profession-wide responsibility.

At the national level, the Clay Hunt Suicide Prevention for American Veterans Act (Pub. L. 114–2; 2015) calls on the nation to improve mental health service provision in the veteran population. The deficiency of mental health treatment available to veterans with PTSD and depression contributes to increased suicide rates and demands national attention (Tanielian et al., 2008). The lack of professionals certified and trained in mental health warrants the involvement of occupational therapy practitioners. Training in suicide prevention can be used to establish this professional competency.

Implications for Occupational Therapy

Occupational therapy practitioners have not only a professional responsibility to address veteran suicide but also the potential to promote positive mental health among veterans (AOTA, 2016a, 2016b). Implications for improving suicide prevention efforts by the profession include the following:

Conclusion

As the number of military personnel transitioning to veteran status increases over the next 20 years, our profession needs to take action to help lower the prevalence of veteran suicide (VA, 2014, 2016). Taking action involves increasing professional education and advocacy for system-level change to promote suicide prevention. Occupational therapy practitioners, researchers, and leaders have a professional responsibility to play a role in filling the literature gap, to articulate how the profession can contribute to addressing the mental health needs of veterans, and to advocate at the state level for suicide prevention training as a required professional competency. To align with Vision 2025 by optimizing “health, well-being, and quality of life for all people” (AOTA, 2017, p. 1), the profession must act now and refuse to accept the status quo regarding the veteran suicide epidemic.