42. Serving Those Who Served

Contagious Conversations  /  Episode 42. Serving Those Who Served





Claire Stinson: Hello and welcome to Contagious Conversations. I'm Claire Stinson, host of today's conversation. Every episode, we hear from inspiring leaders and innovators who make the world healthier and safer for us. All Contagious Conversations is brought to you by the CDC Foundation, an independent non-profit that builds partnerships to help the Centers for Disease Control and Prevention save and improve more lives.

Joining me today is Nicola Winkel, project director for the Arizona Coalition for Military Families, a nationally recognized public-private partnership focused on building Arizona's statewide capacity to care for, serve, and support service members, veterans and their families and communities. In her role, Nicola oversees the coalition's Be Connected Program, a support ecosystem for service members, veterans and their families. Nicola is also the spouse of a veteran herself and has over 20 years of experience in nonprofit program development and implementation. In this episode, we discuss the crisis of veteran suicide, the steps being taken to offer support, and the impact of community-based approaches to veteran suicide prevention. Welcome, Nicola.

Nicola Winkel: Thank you. It's great to be here.

Claire Stinson: We're really glad to have you be part of this conversation today. So, let's get started. According to the Centers for Disease Control and Prevention, suicide is currently the 11th leading cause of death for Americans overall and actually rose 33% between 1999 and 2019. Veterans in particular have a higher risk for suicide. Can you give us a sense of the challenges many of our veterans are facing and the scale of this problem among our service members and veterans in particular?

Nicola Winkel: Yeah, absolutely. We always say that service members and veterans are people just like everyone else. So, they experience the same life, joys, challenges, stressors, experiences–but layered on top of that is another set of circumstances, another set of stressors that have to do with military service, training, deployment, reintegration, transition. So, there's really sort of those multiple layers which can create a heightened impact and a higher risk for them than maybe other segments of the population.

Claire Stinson: Talk to me a little bit more about this. Do you think that many Americans know that this is such an issue for veterans?

Nicola Winkel: Well, I do think that it's been more on the radar in the past decade than maybe before. I think there's been more awareness that this is a particular challenge for our military and veteran community, and I think there is agreement on the importance of addressing this and really working together to serve and support those who have served our country. So that awareness I do think is there. Some who maybe aren't purposefully interacting with the population as much may not know just how many service members and veterans there are living in our community. So, it is important to continue to build that awareness, but there's more now than there has been before.

Claire Stinson: That's interesting. Thank you for explaining that. And those numbers that we mentioned are staggering. So, such an important issue and I'm glad we're talking to you about this today. So, tell us about the mission of your organization, the Arizona Coalition for Military Families.

Nicola Winkel: Yeah, the coalition, we're a statewide public-private partnership. We're a collective impact initiative, and we're here to connect the military, government and community in support of Arizona's 500,000 service members, veterans and their families. And we work together to advance initiatives and efforts on behalf of the population that we serve and to really ensure that our service members, veterans and their families have what they need, they have access to care, and that we're addressing all those social determinants of health in a coordinated way.

Claire Stinson: An important mission. Thank you for explaining that. So, the upstream model for suicide prevention talks about preventative and risk factors for suicide. Can you tell us about how these factors may relate to the veterans' increased risk?

Nicola Winkel: Yeah, I think when you look historically, a lot of times suicide prevention has really been equated with more like crisis intervention, kind of stopping in that moment or leading up to that crisis moment. And upstream prevention is really about widening that opportunity for connection to support of intervention with an individual and across a population. So instead of waiting for that crisis moment where really in the end there's a lot of luck involved, like, is this person connected to someone who knows what to do? Do they know a phone number to call? Are they willing to call? There's too much luck involved in that particular moment. So, our goal with upstream prevention is to stretch out the amount of time that we have to connect with people.

So, with our effort here in Arizona, we are very intentional about encouraging people to connect, to support wherever they are. We use something called the stress continuum from the Navy and Marine Corps where it's like, are you green, yellow, orange, red? And so, we're used to that sort of, okay, we're going to intervene when someone's orange or red. But we're encouraging people no connect to support and resources when you're green or yellow. There's still things we can help you with. And what you're wanting to do is sort of build that connection point so that as they might be struggling more, they may be more willing to reach out for help.

So, this is very important when you look at risk and protective factors, obviously we want to be increasing those things that support people. We want to be decreasing the things that increase their risk. So, this is a way for us to be able to say, let's help when problems are smaller and more manageable and not wait necessarily until they have spiraled to a place of crisis.

Claire Stinson: That's a really interesting way of thinking about that, and it explains the upstream approach really well. Let's go ahead and address this before it reaches the crisis point. So, the Arizona Coalition for Military Families is a community-based veteran serving organization. Why are these organizations so vital to veteran suicide prevention?

Nicola Winkel: Well, it really takes a lot of intentionality to do this work. So, you can have many different organizations and they're all doing fantastic work in the community, but the way collective impact works is then you can harness the good of all that effort into a common direction and you can do more systemic and community-wide change that involves all those organizations, but advances your work together. So, I believe that organizations like the Coalition and other similar ones across the country are a really important element for tying together all of this effort across government, community-based organizations, all different sectors and partners, and really ensuring that we have a strategic direction for what we're doing and that all of that effort is really channeled into good that can impact our community.

Claire Stinson: Absolutely. So, I know you work with a lot of veterans in your work. What is their engagement like with these community-based organizations?

Nicola Winkel: It's really incredible to work in this community because a vast majority of the people who work and serve in the organizations and agencies, most of them have some sort of connection to the military. Either they themselves are currently serving or have served in the past, or they're a family member, or they've just had a long history of working in this field. For most of us, there's a dual sort of role for it. It's something that's professionally important to us, but it's also something that's very personal to us.

And the other benefit to all this is that you have all these people with lived experience who are then contributing to bettering things for their fellow service members, veterans and their families. This is a community where you see incredibly high engagement. There's a lot of passion, there's a lot of care and there is a lot of understanding of the importance of making improvements and having an impact in this area. It is not optional to us–it is absolutely vital.

Claire Stinson: Well, it sounds like you're making an amazing impact. So, we're going to talk in a minute about a project the CDC Foundation has supported and veterans serving organizations selected for this project are implementing programs using the community integration model and the connectedness model. Can you explain for us what these models are and how they work in real life settings?

Nicola Winkel: Yeah, absolutely. And both of these models are things that we use here in Arizona in our work with our community. And they're really about two things. One is, kind of what I mentioned earlier, which is kind of organizing and connecting and linking together the many–I mean, we're talking about hundreds of organizations across a state that are doing a piece of the puzzle, if you will, and linking them together so that you have what we refer to as our ecosystem of support. And that involves just thousands of people, hundreds of organizations, different sectors and systems all working together.

And through our Be Connected Program, we created kind of a common front door, which is a support line that we tell anyone to call anytime. It's not advertised as a crisis line. It's really designed to say, ‘We're here for you, and you can contact us.’ And people call it every single day for all sorts of different reasons. So that front door then becomes a connection point to the hundreds of partners we have across the state and the many different public and private sector services that are available.

As far as connectedness, that's such a vital thing. It's not just veterans and their families. The Surgeon General report just came out about loneliness being a public health issue in the United States, but we definitely see that also for our veteran population. And that disconnect that was only kind of heightened throughout the pandemic of course, is a real factor. That social isolation and disconnectedness is definitely a risk factor for suicide, and combined with other risk factors that our veterans may have, it's very concerning. So, strengthening those connections between the individuals and our ecosystem of support and then also to helping them build their social support system is so vital.

One of our newest services that we're really excited about rolling out is our Coaching into Connection program. And this is specifically focused on this issue of social isolation and that risk factor for suicide. And it's also kind of just built on the premise that if you have people who are socially isolated or disconnected, a small percentage of them can probably just make the decision to be more connected and go out and do things. But for a lot of people, there's just too many barriers, whether they're internal or external, to getting over the hump of doing that.

And so our connection coaches are veterans, and they're simply here to walk alongside someone and figure out what do you like? What is interesting to you? And it's going to be totally different from one person to another. One person likes sports and one person likes outdoor recreation, someone likes crafts or book clubs or wants a support group or faith-based community. But it's really just acknowledging that we want to wrap that support around people, walk alongside them and recognize that they are individuals and help build that connection. So, those two models are something that we're sort of practicing and using day-to-day in our community.

Claire Stinson: That's amazing. And I love your idea of explaining that common front door. Do you guys find that it is helpful for a veteran to speak to another veteran that has that shared experience to help them through some bad times?

Nicola Winkel: I think it does. I mean, for us, we always say that we need everyone in this effort. We cannot limit it to only someone who served. So, part of what we do is provide training to people, to our community members who want to help so that they can be more equipped to serve. But that being said, the people who have military service on our team are incredibly important because there is sort of a bond and an understanding there. If you think of Be Connected as a front door, the wider you can open that front door, the better. And I think that that knowledge and understanding goes a long way to opening that door. And then we're inviting people in and saying, ‘We're not just going to hand you a list of things and send you on your way.’ We're here for those who need it and want it to provide that resource and care navigation and help them get to what they need. Because for some that is a very important part of them connecting to the systems and services that are going to help them move forward.

Claire Stinson: We'll be right back with Nicola Winkel.

Sadly, approximately 22 veterans die each day by suicide. The CDC Foundation is proud to support organizations like the Arizona Coalition for Military Families and their work to intervene before veterans reach a crisis point. To learn more about the CDC Foundation's efforts to prevent veteran suicide, go to www.cdcfoundation.org and search veterans suicide.

If you are or know of a veteran experiencing a crisis, dial 988, then press 1 for help.

And now back to our conversation with Nicola Winkel.

It sounds like you have lots of different touch points and lots of different ways that veterans can interact and engage with you all, so that's amazing. So, we mentioned earlier a little bit about a CDC Foundation project. Over the past five years, the CDC Foundation has supported a variety of projects related to veteran suicide prevention. One of these efforts is called the Veteran Suicide Prevention Evaluation Project, and it supports veteran-serving organizations in using evaluation to build evidence on the effectiveness of veteran suicide programs. Tell us a little bit about your organization's involvement in this project.

Nicola Winkel: So, we feel extremely fortunate to have been a part of this project. It's shortened to VSPE, so that's how we refer to it. But we feel really fortunate to have been a three-time grantee under this project. It has been absolutely instrumental in building our internal capacity around data and evaluation and advancing our work. I truly think we're years ahead of where we would've been if it had not been for participation in this project. And it's just been such a tremendous experience and really helped to grow our suicide prevention efforts.

When you talk about that work of going upstream, what we've really seen is it takes an incredible amount of intentionality to move in that direction because so much of our historical work around suicide prevention is really focused on that crisis intervention. So then if you're going to move upstream, you've got to almost swim against the tide a little bit. This has really helped provide us a very helpful framework to really think about how Be Connected is going to have the impact that we're seeking to have on our community. We have a successful background in suicide prevention, but scaling it up to this large of a population of 500,000 people, it requires a different approach. And that's what this project has really helped provide for us.

Claire Stinson: Thank you for explaining that. And I know we're so grateful for your partnership. Can you talk a little bit about the biggest impact on your organization with the increased capacity for evaluation?

Nicola Winkel: Yeah, so it really made it so that evaluation has just become woven into everything that we do. It's not like a separate thing where it's like, ‘Oh, we should really do some evaluation.’ It's more like that's sort of something that's always top of mind, and it really provided us with that sort of framework and structure for how to think about evaluation, how to have it be an integral part of our sort of operation, if you will.

But then practically, sort of the evolution of our three years in participating with the project, we did three very different projects, but they built upon each other to really help us to be where we were at today. So, in year one, we did a project that was focused on whether Be Connected was sort of achieving its goal of being an upstream prevention program. If you set up a phone line, well, first of all, if you set up a phone line and nobody calls, that's not real helpful. So, we knew from our utilization that people were calling, but then if you are saying, ‘We're an upstream program,’ but most of the people who call you are calling in crisis, you may not be reaching your target audience. So, our first-year project was actually focused on that question of are we achieving that goal of reaching people sort of in an upstream segment of the population?

And so we did an evaluation project with support from the CDC and their technical assistance. And it was really interesting because what we found was that about 85% of the people calling were what we would consider low acuity, meaning that by providing support via the phone and sort of basic resource connection and navigation, we were able to address the needs that they had. About 14.5% were more like moderate acuity. So, they needed more intensive help maybe over a longer period of time they had more complex issues, but still something that were within the scope of the program. And then about .5% were sort of more in that crisis mode and they needed access to that. And that's something that's built into Be Connected to directly provide connection to crisis services.

So, that was a really encouraging thing because it helped us to see that we were in fact sort of reaching the intended kind of audience with our services. And then the second year, we focused on developing data tools to help us understand risks. So something we figured out very early on in the life of Be Connected was that this disparity in veteran suicide–which in Arizona over the past decade has been about double the risk of the general population for Arizona veterans–what we determined very early on is that you're not going to reduce that disparity by focusing on 500,000 people. It's just mathematically not possible. So, it became very clear that what we actually need to do is identify segments of the population that are at greatest risk and be proactive about reaching out to and engaging them.

So, in year two, the data tools that we created were about taking existing data sources from CDC, from other resources available, here in Arizona as well as nationally, and basically figuring out how do we segment our population to better understand risk factors so that we can then, as a community and as partners, be proactive with them. Really the third year was for us to move more toward that implementation of how do you then operationalize it? You have the data, you have the understanding, how do you then translate that into action?

Claire Stinson: Thank you for explaining that. It certainly seems like you guys are doing your research and you're really looking at how you can best reach this population. So, it's really interesting to hear your process and how it's changed over the years. So, this is a really heavy issue. I think it's really important that we're having this conversation. We always like to end our episodes on a positive note. What do you see as our greatest opportunity to address this issue and protect our veterans?

Nicola Winkel: That's a great question. Our work in suicide prevention with the military and veteran population goes back over a decade. And I'll just share a little bit about this–because I think it provides context for why we have hope for this to be able to be done–which is from 2008 to 2010, the Arizona National Guard had three consecutive years of the highest number of suicides they had ever had in the history of the organization. This was at the height of the post 9/11 deployments. The deployment tempo was extremely high. You had units coming, you had units going, you had units coming back with 50% unemployment at a time when the economic conditions were not great. And there was just immense stress on the service members, on the family members and then on the force as a whole. And you had these military entities that weren't necessarily equipped to deliver the services that needed to be done to support. The infrastructure was getting there, but it was still catching up with this tempo of deployment and the stress on the force.

So, the Adjutant General at the time, he came to the coalition and other partners and just said, ‘I don't believe that there's nothing that could have been done to prevent these deaths, so you tell me what needs to be done and we will do it.’ So, I give him a lot of credit for being willing to say, ‘I'm just going to believe this is possible and I'm going to trust the people around me who have experience in this area to help me devise a solution.’ And we built this very ground-up, grassroots sort of effort within a military infrastructure that is obviously mostly top-down.

We went top to bottom all the way around. 8,000 [National] Guard members trained to be helpers, family members trained to be helpers, set up a 24/7 response system. So, if your battle buddy is struggling at 2:00 AM this is a phone you call, and someone will pick up and they will tell you exactly what to do. We completely changed the culture around getting help, made it normal, made it accepted. You had command messaging and everything aligned. And what happened was the three years this program was in operation, we went from three years consecutive of the highest number of suicides ever to zero suicides for those three years.

And so you're talking about dozens of lives likely saved. And every death by suicide is not just the individual, not just the family, but the whole sort of network around that person. And then when you talk about a military environment, you're talking about their unit, the force as a whole, it has an effect, and it's a traumatic effect. So, you are really reducing that effect, not just only on that individual and their family, but also on all those people around them.

So, the important lesson that we took away from that really unique experience and opportunity to have that kind of an impact was it is possible. Even when things look very, very bad, it is possible to turn the tide on these situations with intention and with a thoughtful and strategic approach to it.

So, as we zoomed out, we really thought, okay, we know that there's this disparity in veteran suicide in Arizona. Let's zoom out, take the lessons we learned from that project with the guard, and let's figure out how we can apply that to our veteran population in general. And it's different because it's 500,000 people. It's not a closed system. It's not a single chain of command. So, there's a lot of differences. But we believe–and we have hope that with that same kind of thoughtful intention, with our public and private sector partners working together, with us pulling in a common direction–we believe it's possible to have an impact over time.

And so our strategy now is about how do we reduce risk in these segments of our population that are at greater risk? And that can be a combination of factors like age, disability status, geographic location, economic issues. We know what the risk factors are, and if we can reduce risk in individuals by increasing access to care, increasing access to support, improving their social determinants of health, reducing social isolation, we can reduce risk in those individuals. Our theory and belief is that over time, over many years, that we can then reduce the disparity in the rate of suicide across the whole population. So, we're going into this with eyes wide open, but also with the belief that it can be done because I think that's an important starting place when you're doing work with issues that are as complex as suicide, that belief is an important thing to carry you through.

Claire Stinson: Absolutely. And it sounds like you all are being very thoughtful and very intentional in your work, and it sounds like there is a lot of hope. So, thank you for being a part of this conversation. Thank you for explaining this complex issue that is facing our veterans. We really appreciate you being a part of Contagious Conversations.

Nicola Winkel: Thank you for having me.

Claire Stinson: Thanks for listening to Contagious Conversations, produced by the CDC Foundation and available wherever you get your podcasts. Be sure to visit cdcfoundation.org/conversations for show notes. And if you like what you just heard, please pass it along to your colleagues and friends, rate the show, leave a review and tell others. It helps us get the word out.

Thanks again for tuning in and join us next time for another episode of Contagious Conversations.