Description

Veterans who live in rural America are more likely to die by suicide than urban veterans.

Together with Veterans (TWV) was designed and is being implemented and evaluated to promote community-based suicide prevention in rural communities throughout the United States. TWV is a multilevel, evidence-based suicide prevention program for rural veterans. TWV is carried out via collaboration between the Rocky Mountain Mental Illness Research, Education and Clinical Center (MIRECC) for Suicide Prevention, the Western Interstate Commission for Higher Education Behavioral Health Program (WICHE BHP), local veterans, and other community participants. Through these partnerships, TWV supports the dissemination of best practices in public health suicide prevention to rural communities consistent with the goals of the National Strategy for Preventing Veteran Suicide.

The TWV guiding principles are:

• Veteran-driven
• Collaborative
• Evidence-informed
• Community-centered

The Together With Veterans Suicide Prevention Strategies are implemented using a five-phase process to support rural communities in developing a local veteran suicide prevention action plan. Six evidence-based suicide prevention strategies (Provide Suicide Prevention Training, Enhance Primary Care Suicide Prevention, Promote Connectedness and Help Seeking, Improving Communication Across Veteran Serving Programs, Enhance Behavioral Health Suicide Prevention, Promote Lethal Means Safety) are used by TWV to support local planning efforts. These strategies are designed for community-wide implementation to increase awareness and knowledge about veteran suicide and improve community response to the needs of local veterans.

The following groups served as pilot sites for TWV and have helped with the development of a TWV online toolkit:

• Veterans Coalition of Northwest Montana (Kalispell, MT)
• Veterans Coalition of the San Luis Valley (San Luis Valley, CO)
• Veterans Coalition of the Crystal Coast(Carteret County, NC)
• Northeastern Colorado (Morgan, Washington, Yuma, Phillips, Sedgwick, and Logan Counties)

In early October 2019, 4 additional rural communities participated in a TWV training academy and are starting the program:

• Angelina County, Texas
• Macon County, North Carolina
• Southwestern Virginia (Wythe County and surrounding counties)
• Northern New Hampshire (Coos County and neighboring areas)

As of December 2022, there are 31 communities in 25 states plus Guam currently enrolled in TWV. Three communities have completed the program.

• Alaska
  • Together With Juneau Veterans (Enrolled)
• Arizona
  • Veterans Coalition of Central Arizona (Enrolled)
• Arkansas
  • White County Veterans Community Partnership (Enrolled)
  • US Veteran Outreach of Arkansas (Enrolled)
• California
  • Together With Veterans Coulterville (Enrolled)
• Colorado
  • Veterans Coalition of the San Luis Valley (Completed)
  • Colorado Veterans Suicide Awareness and Prevention (Enrolled)
• Guam
  • Guam Together With Veterans (Enrolled)
• Hawaii
  • Hawai'i Mental Restorations Foundation (Enrolled)
• Illinois
  • Together With Tri-State Veterans Illinois (Enrolled)
• Kansas
  • Together With Veterans Morris County (Enrolled)
• Michigan
  • Upper Peninsula Veteran's Coalition (Enrolled)
• Minnesota
  • Koochiching Warriors Initiative (Enrolled)
• Mississippi
  • Veterans Coalition of the Mississippi Delta (Enrolled)
• Montana
  • Veterans Coalition of Northwest Montana (Completed)
  • Northeast Montana Veterans Coalition (Enrolled)
• Nevada
  • Nye County Together With Veterans (Enrolled)
• New Hampshire
  • Lakes Region Veterans Coalition (Enrolled)
• New Jersey
  • Salem County (Enrolled)
• New Mexico
  • Taos Together With Veterans (Enrolled)
• North Carolina
  • Veterans Coalition of the Crystal Coast (Completed)
  • Western North Carolina Veterans Purpose (Enrolled)
• North Dakota
  • Together With Veterans Minot (Enrolled)
• Oklahoma
  • TWV at Bartlesville (Enrolled)
  • Delaware County Together With Veterans (Enrolled)
• Oregon
  • Together With Veterans Northwest Oregon (Enrolled)
• Pennsylvania
  • TWV North Eastern PA (Enrolled)
  • Greene Together With Veterans (Enrolled)
  • Together With Veterans Cambria County (Enrolled)
• Texas
  • Together With Hill Country Veterans (Enrolled)
• Virginia
  • Southwest Virginia Together With Veterans (Enrolled)
• West Virginia
  • West Virginia Veterans Outreach Coalition (Enrolled)
  • Tri-County Veteran's Suicide Coalition (Enrolled)
• Wisconsin
  • TWV at Sparrows Nest (Enrolled)

Since its launch in 2015, Together With Veterans has been funded by a grant from the U.S. Department of Veteran Affairs Office of Rural Health.

For more information regarding TWV, see the program's website.

Services offered

TWV has identified 4 guiding principles that are at the core of each community effort:

1. Veteran-driven – Veterans have agreed to invite TWV to work in their communities and are a part of the leadership team.
2. Collaborative – Community partners actively support veterans, understand the ramifications of veterans' mental health struggles, and are committed to being a part of the education and strategy process.
3. Evidence-informed – Strategies vetted by TWV that have proved effective in reducing suicide are adopted at the local level. Leaders attend a Training Academy to learn the strategies and how to use tools to inform their decision making and aid in implementation.
4. Community-centered – Partners develop and continually revise an action plan based on community evaluation.

TWV is implemented using 5 suicide prevention best-practices:

1. Reduce stigma and promote help-seeking
2. Promote lethal means safety
3. Provide suicide prevention training
4. Enhance primary care suicide prevention
5. Improve access to quality care

The services provided by Together With Veterans are made possible through the support of two leading agencies:

• Rocky Mountain Mental Illness Research, Education and Clinical Centers (Rocky Mountain MIRECC) – Located in Colorado, Rocky Mountain MIRECC investigators design studies to prevent suicide and disseminate best practices. Other services provided include:
  • Leadership expertise
  • Program evaluation
  • Research expertise
  • Resources and tools for implementing best practices

• Western Interstate Commission for Higher Education Behavioral Health Program (WICHE BHP) – Located in Colorado and serving the western half of the U.S., WICHE collaborators implement TWV on a local level by guiding communities through the following:
  • Managing site recruitment and implementation
  • Supporting local communities using evidence-based implementation support including:
    • Training (TWV Training Academy)
    • Tools (implementation toolkit and web-portal)
    • Technical assistance (implementation coaching)
    • Quality improvement (supporting learning communities across sites)

Results

Together With Veterans is making a difference for the veterans and partners who have participated. Every quarter, TWV reaches many rural veterans through direct contact at meetings, regional events, or local coordinators.

Data collection is ongoing.

TWV in Publications and News:

• Beehler, S., LoFaro, C., Kreisel, C., Dorsey Holliman, B., & Mohatt, N.V. (2021). Veteran peer suicide prevention: A community-based peer prevention model. Suicide & life-threatening behavior, 51(2), 358-367. Article Abstract
• Kreisel, C. J., Wilson, L. K., Schneider, A. L., Mohatt, N. V., & Spark, T. L. (2020). Reducing rural veteran suicides: Navigating geospatial and community contexts for scaling up a national Veterans Affairs program. Suicide & life-threatening behavior, 51(2), 51(2), 344-351. Article Abstract
• Mohatt, N. V., Billera, M., Demers, N., Monteith, L. L., & Bahraini, N. H. (2018). A menu of options: Resources for preventing veteran suicide in rural communities. Psychological Services, 15(3), 262-269. Article Abstract
• Mohatt, N. V., & Helm, S. (2017). Brief Report: Stigma as a Barrier to Community Readiness for Suicide Prevention among Rural Veterans. The Community Psychologist Rural Interest Group. Report
• Monteith, L. L., Holliday, R., Brown, T. L., Brenner, L. A., & Mohatt, N. V. (2021). Preventing Suicide in Rural Communities During the COVID-19 Pandemic. The Journal of Rural Health, 37(1), 179-184. Article Abstract
• Mohatt, N. V., Kreisel, C. J., Hoffberg, A. S., Wendleton, L., & Beehler, S. J. (2020). A Systematic Review of Factors Impacting Suicide Risk Among Rural Adults in the United States. The Journal of Rural Health, 37(3), 565-575. Article Abstract
• Monteith, L.L., Wendleton, L., Bahraini, N.H., Matarazzo, B.B., Brimner, G., & Mohatt, N.V. (2020). Together With Veterans: VA National Strategy Alignment and Lessons Learned from Community-Based Suicide Prevention for Rural Veterans. Suicide & life-threatening behavior. Article Abstract
• Monteith, L.L., Smith, N.B., Holliday, R., Dorsey Holliman, B.A., LoFaro, C.T., & Mohatt, N.V. (2019). "We're Afraid to Say Suicide": Stigma as a Barrier to Implementing a Community-Based Suicide Prevention Program for Rural Veterans. The Journal of nervous and mental disease. Article Abstract

Other features can be found at TWV in the News.

Challenges

Through community readiness assessments collected from participating sites, the following challenges were discovered to affect community readiness for implementing suicide prevention programs:

• Because suicide is a topic not often discussed among community members or covered by local media outlets, a general lack of community awareness and misconceptions about the risk and reality of suicide among the veteran population was noted.
• In rural communities, desire for privacy and general wariness of mental healthcare may get in the way of one's willingness to get help. Stigma may come from structures within the community or the general public.
• Lack of access to mental health services. Even when services are available, veterans may be more likely to seek help from trusted friends and family rather than medical professionals.
• Veterans may associate having mental health struggles with negative consequences.

Replication

Read how the process unfolded in one Colorado community in Veteran Suicide: A Growing Problem in Colorado.

Contact Information

Lisa A. Brenner, Ph.D., Director
Rocky Mountain MIRECC
720.723.6488
Lisa.Brenner@va.gov