Hearing Veteran Narratives is Key to Suicide Prevention

Current suicide assessment practices of the VA are reductive and do not allow for the individual’s narrative to be heard.


Despite attempts from the U.S. Department of Veteran Affairs (VA) to reduce veteran suicide, it remains staggeringly high, with approximately 21 veterans dying from suicide each day. The risk of suicide for veterans is significantly higher (21%) than for the general population, although like veteran suicide rates, suicide rates for the general population have increased steadily over the past two decades.

In a new article for Psychiatric Services, VA psychiatrist Mark Warren and psychologist Leigh Smithkos, highlight some of the problems associated with the evaluation procedures at the VA, exploring how although they are well-intentioned, are falling short. Others have argued that the VA’s suicide prevention efforts are contributing to the continued rise in veteran suicide. The authors write:

“If we approach our work with suicidal patients in a bureaucratic, policy-driven, and overly regimented manner, we risk adopting the reductionist view that screening instruments and standardized assessments are sufficient to reduce veteran suicide.”

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New suicide risk evaluation procedures have been put in place across the VA system that require clinicians to complete a standardized comprehensive evaluation for certain individuals during the initial meeting. It is a lengthy process, taking 30-45 minutes, and is even needed for individuals who have been shown, through other measures or previous relationship to the clinic, to pose no risk of suicide.

A potential unintended consequence of policies such as the new evaluation procedures is clinician burnout. Policies that do not match the available resources of the program require the clinician to take on a heavier workload. Clinician burnout has been shown to be caused, in part, by “excessive workload, clerical burden, and inefficiency in the practice environment [and] loss of control over work.”

In addition to lengthy, and at times unnecessary, evaluation procedures, VA clinicians are also required to provide same-day care to any veteran needing behavioral healthcare. While intended to provide veterans with needed care immediately, an unintended consequence of this mandate is that clinicians are pressured to maintain full schedules, which may negatively impact their ability to do good therapeutic work.

Another consequence of the policy of the VA may be the destruction of the therapeutic relationship or the relationship between therapist and client. In order to accurately and more completely understand the individual, their triggers for suicide, and overall behavioral risk, it is imperative that the clinician hears the story of the patient.

The authors point to research that supports their work, highlighting the effectiveness and cost-efficiency of brief interventions that attempt to elicit patient narrative. They argue that although the current tools using for screening and behavioral risk assessment do attempt to get a narrative from the patient, poor implementation, which may be the result of a lack of training or time, or overuse of screening tools, can prevent this narrative from being asked for or heard by the clinician.

Warren and Smithkos argue for an approach to risk assessment and suicide prevention that allows for more of a balance between standardized assessments and the use of clinical skills that emphasize the meaningful engagement with patients through hearing the individual’s story.

The authors write, “Suicide is a problem of humanness, not solely of health care,” arguing that a more balanced approach could allow for better care for veterans, and the overall reduction of veteran suicide.



Warren, M. B., & Smithkors, L. A. (2020). Suicide prevention in the U.S. Department of Veterans Affairs: Using the evidence without losing the narrative. Psychiatric Services, 1-3. (Link)


  1. Question would be, how much better or different did the soldiers fare in WW1?
    How helpful is it to have therapy for trauma?
    How helpful is it to be dragged back to trauma over and over by therapy?
    To talk about the bad stuff, to focus on it?
    How helpful is it’s opposite, the meds that contribute to numbness or psychosis
    and possible suicide?

    There are some psychologists that realize that putting teenagers into therapy after a school shooting might be unhelpful.
    The mind tries to work stuff out by itself and the ‘experts, it’s therapies and/or drugs’ can greatly inhibit.

    The best treatment is within community, healthy involvement, goals, challenges that are not too difficult.
    I think the mind does best when it is completely oblivious to the possibility, that something is therapy.
    It cannot immerse itself in being IN the moment when aware of ‘work’ being done.
    But for some stupid reason, everything has become therapy. Even woodworking and cooking classes, horseback riding, canoe trips. Everything needs an expert and a logbook with observing the ‘victim’.

    Obviously some minds are better equipped to deal with adversity, it is mostly those who were not equipped to begin with, that suffer adversity.
    Perhaps better screening before sending unsuspecting people out to fight others battles.

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  2. You also need to know about your patient’s experiential world, to establish what you’re going to treat and how you’re going to do it. Treating depressed moods is more than handing out a bottle of pills and hoping your patient doesn’t eat them all at one sitting.

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    • Actually a “mentally ill” ‘subject’ needs to know the mind of it’s superior. Anytime we enter a relationship with a healer and a sick, the sick benefits greatly by knowing the sickness of it’s healer. If the sick is afflicted, it remains vulnerable to catching a secondary illness. 🙂
      Unless of course, the healer has no sickness, no aberration of norm.

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    • One thing that rattles psychiatry is the fact we are far from capable of being of equal strength, mentally and physically. To psychiatry, to medicine, this is failure on the one exhibiting less strength. It is an illness or disorder.
      That view is the most simplistic approach to ever have gained a hold on a few men obsessed with their innate ability to judge others. To make this an occupation is a circus. A circus they readily admit and leaves them grappling for answers. But the questions were created by their obsessions, their assumptions.
      It is akin to beating your head against a wall.
      Who are the insane?
      Psychiatry and medicine made suffering or even being different, their business to be the expert of. Yet they never became experts and still grapple and grapple with much more than they ever did.
      No lightbulb goes off in their heads.
      Right to the end of their lives, they think about others states. Our minds think best about others, designed to do so, yet some chose to make a profession out of their awesome ability.
      They thought that this innate ability was only allowed to a few. Never has psychiatry figured out that this is what we all do.
      I have never met a shrink who I did not make assumptions about. In fact right down to seeing thin lips, how the lips squeezed together, and reading into their eyes and body movements, how they carried that body.
      One really does not need 8 years of study, one does not need descriptors of what one sees or feels.
      It is trying to weed through the information coming through, the connections the mind forms when presented with an item or person. There is no final conclusion, except that which the mind agrees with
      Psychiatry only assesses from the wired pathways in it’s own brain, and thinks it can be impartial lol.

      You can only be impartial after 20 years of “seize the brain” drugs.

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  3. Until and UNLESS, the military as a whole, the VA, *ALL* of psychology & psychiatry, *ALL* *AGREE*, that the pill-pushing poly-pharmacy of psychiatry is the single greatest PREVENTABLE CAUSE of veteran’s suicides, little will change. In other words, “too much drugs” is the #1 cause of veterans’ suicides…. But as usual, the *TRUTH* gets ignored…. Very little will change…. Use of medical cannabis is probably the single biggest break-through in the VA “mental health” arena, but main-stream media will NOT touch that story….

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  4. So glad to see this article. It’s something that’s been close to my heart for more than a decade. In my book,When Johnny and Jane Come Marching Home: How All of Us Can Help Veterans, which was published in 2011 and won three top national awards for nonfiction. https://www.amazon.com/When-Johnny-Jane-Come-Marching/dp/150403676X/ref=as_li_ss_il?crid=1QTVHBGHEWJI&keywords=when+johnny+and+jane+come+marching+home&qid=1554480516&s=gateway&sprefix=When+johnny+and,aps,220&sr=8-1-fkmrnull&linkCode=li1&tag=whejohandja0d-20&linkId=1dbd7dedc192a717801d8a2ccc9ed082&language=en_US
    there is an entire chapter about “What the VA Is Doing and Why It’s Not Enough,” and Chapter 6 (much different in the revised version and more up-to-date) is all about the importance of JUST LISTENING to veterans and how anyone can do it. Readers might also want to check out listentoaveteran.org, especially the very brief video at the top of the page, where I describe what the listening sessions are, why/how I conceived of them, and a bit about outcomes. We have a lot of data on outcomes in addition to that. It would be great if the VA were to bring Listen to a Veteran! which is extremely simple and nonpathologizing and helpful to the VA. And it costs nothing. But so far, no VA people have been willing to bring this to their facility.
    Our film about this, “Is Anybody Listening?” isanybodylisteningmovie.org was screened on Capitol Hill in D.C. and on Parliament Hill in Ottawa, had 140 showings on PBS stations across the U.S., had many endorsements from highly respected veterans’ entities and veterans, and has won numerous awards.
    Veterans interested in having a nonveteran (NOT a therapist, just a person!) listener or in learning more, please don’t hesitate to get in touch via listentoaveteran.org

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