 Okay, good afternoon everybody. We're gonna go ahead and get started with the afternoon program Again, my name is George Jarrow. I'm the director of behavioral health services at Dominican Hospital today's symposium is being taped for future cable cast on community television of Santa Cruz County again for other people to Take advantage of the information today. They didn't have a chance to attend in this our second part of Today's program. We're going to focus on military and veterans and suicide Janet camp RN PhD has 20 years experience working with veterans She currently serves as the national VA mental health director for suicide prevention she is responsible for Provider in patient education in areas of suicide awareness and prevention current assessment and treatment strategies and new findings in the area of suicide and assisting in the implementation of suicide prevention programs throughout the VA system Dr. Kemp directs and advises the suicide prevention Coordinators at each local VA and as the national program manager for the veterans crisis line Please welcome Dr. Kemp. Thank you all for the kind invitation to be here and to talk about Something that that's incredibly important to me, but but also to our nation and our nation's security I think you've heard the the headlines on the news. You've read the newspapers Certainly the word epidemic is is used on a fairly Common basis. I'm not sure that's that's the right word to use but the approach I think we need to take that any suicide among our nation's actively serving military members or our veterans is one suicide too many and the numbers are certainly appalling and often we look at at war as time goes on and Look back at what we call the signature injuries or the signature Injuries or illnesses of that conflict and truly in this particular war, perhaps PTSD traumatic brain injury and suicide might be the signature illnesses and injuries that Hopefully we'll have learned from and be able to Improve not only soldiers health and veterans health, but America's health So we need to take what we learn and move it on I'm going to start with a video called behind the scenes and this is a depiction of kind of what it's like to work on a regular basis at the veterans crisis line And we'll talk about the crisis line a little later in the presentation But right now, I think it's helpful just to kind of hear a little bit of all coming on a daily basis Using to cut herself. How often do you feel like this? Really something like this happens every day Well, we're here you could have a crisis at two three o'clock in the morning But I can assure you right you can call here 24-7 and we will pick up the phone We will pick it up by the second ring It takes a gift and a special person even a friend to meet you where you are And walk with you We've taken over 400,000 calls from People who have been in various levels of distress some of them just want information They just want to make sure there's someone to talk to They just want to make sure that there's somebody there and Others just want to tell someone that they're going to die. You feel a little bit better. How about your paranoia? Four years in the United States Air Force a licensed mental health counselor an army officer in the reserves And I got home from Afghanistan in 2008. I spent 14 years active duty in the Air Force from 91 to 99 So didn't go go for I've always worked with veterans. I'm a veteran myself And you can also help him get housing, you know through these the proudest moments of my life or serve in my country I think We cannot do enough to help veterans They deserve as much help as this country can give to them nothing less A veteran will wake up in the middle of the night from a nightmare and they don't want to disturb their wife So they call us and we just sort of talk him down and get him tucked back in for the night Sometimes it's weeks and weeks of ongoing pain and struggle and they finally get our number And give us a call and we connect them to services I'm trying to understand what it is. She's saying did she say you tried to hurt yourself in front of her All we offer is our attention and sometimes that's enough and so to me That's the best summary of of the job of responder when you're dealing with somebody who's suicidal I think said I listen to the veterans I listen to what they say, you know, and not just hearing them You know actually listening to it over trying to figure out What the problem is and how how they can be helped and help themselves Veteran will first pick up the phone dial the the crisis number and then they'll hear If you're a veteran if you're a family member of a veteran If you're in active-duty services, please press one They'll press one and then there will be just a brief delay while the call is routed to Canandaigua and Then and then they'll hear an individual person saying This is You know, I had a guy call it said, you know, I don't know what to expect and I said, well Why don't we start with your name? You know tell me what's going on? You know, let's talk about it I've got no problem sitting and letting of that You know cuss swear, you know cry Whatever it is that they need to do to be able to feel better, you know, and that's what we're here for a Lot of veterans are unemployed There is of course a significant homeless population Relationship problems you name it. I mean, you know alcoholism drug addiction There's all there's all kind of things a lot of times I find that the crisis line that it's almost as if it's a Confessional they can't see the face of the person sitting across from them And so it makes it so that they feel more comfortable to say things that perhaps they would feel nervous about saying in front of Somebody who's sitting directly in front of them. It's been incredible. We never advertised the chat service It just opened up on the website and we've had Several thousand chatters. It does help to call. I'm glad to hear that We're always here for you So I hear it. I hear it sir. You're really frustrated Okay Okay All right, okay Well, I'm really glad you called us because that's part of your safety plan and you're doing the right thing No one's gonna knock on your door, sir. That's a promise. You're telling me right now. You can be safe. So All right, I'm really glad to hear that you're contracting for safety you're following all of the right things that your treatment team has advised you to That I'm glad to hear that sir I'm glad to hear that You can't do therapy an hour with somebody whose life is in crisis so the best help I can offer is Helping them first of all sort out whether they want to live or die and There are some Wonderful tools for that just the way you and I have been able to talk pretty well today on the phone You can get that that kind of relationship with a counselor to the collaboration with the SPC is one of the Most impressive pieces of this whole venture We're able to hook them up with their local suicide prevention coordinators Get some appointments within that day or the next day Get consults sent and make sure that they get the care that they needed their local facilities I had a gentleman that had the gun out in his hand Ready to do it. I'm tired. I just can't take this anymore the nightmares the flashbacks It's overwhelming. I'm drinking all the time You know you're having these suicidal thoughts and I want somebody to be able to You know is for you to be able to talk to somebody as we talk through it together He made a safety plan. He agreed to be referred to the suicide prevention coordinator Which is a huge part of what we want to do is get them connected and he also agreed to call us back Well, I'm glad that you you feel comfortable calling us And you know that we're here for you 24-7 So he was safe and he was willing to call us back and we were able to connect him through a conference call with his brother Which turned out really well We have the opportunity when we do a consult to the suicide prevention coordinator to ask the vet that we're speaking with Kind of at the end of the column. We're getting things wrapped up Do you mind if I give you a call back in a couple of weeks? Just check in and see what see what's going on and see how you're doing and I don't think I've ever had a vet say No, are you in crisis today? So we follow up to see what's transpired in two or three week period and If that individual is still in crisis, we'll do another consult We'll wrap their VA services around them again Veterans do call go crisis line. It surprises me every day The number of people who take us up on that offer and we're able to talk We're able to find some reasons for him to live the outweighed the reasons to die. Yes, I think we changed lives save lives I think that you know a lot of guys are on the verge you know and right there and You know they get that connection from us, you know, and they get the help call. We'll talk to you When you first come home, there's a lot of stress, you know the family has expectations of you You're going through your own Process of being home again. You don't have to be suicidal to call the crisis line You can have a crisis that other people might think are not crisis if you think it's a crisis call That's what's important there that if you ask us to walk a mile with you We'll say no we'll walk to with you if you're on a crisis call Okay, so Lesson number one if you're gonna show a video at a conference make sure you're not in it because it's really embarrassing but listen number two Veterans are having issues and We need we need to be there for them a Few facts that that go along with what you heard this morning We know that anywhere between 30 and 32 maybe even up to 34,000 US deaths from suicide per year Occur and that those are numbers that the latest numbers that we have from the Center for Disease Control and Prevention We we know that approximately or we think that approximately 20% of these are veterans and we get that from the National Violent Death Reporting System and for those of you who Don't know there really is no good number in the United States of the number of veterans every year who die by suicide That's just not a number that we keep It's not a number that states are required to submit when they submit their death records to the CDC every year I think most of you do know there's quite a delay in the period of time between when the data is available And today so we just recently got The 2009 data and haven't really even had an opportunity to analyze that completely that but I'll share a little bit about what we know So one of the things that we are working with and that the Secretary of Veterans Affairs has asked the governors of all of the states to share their data with the VA about veteran suicide More immediately and as of today we have data from about 40 of the 50 states The other states are in the process of sending it into us California has promised to send us the data and we're excited about that. We expect it any day From them and we hope within the next few months We'll be able to roll that up and have a better more accurate picture of the number of veteran deaths every year But if you do the kind of pen and pencil Arithmetic with using the 20% number it works out to about 18 deaths a day are by veterans And that we know that about five of these deaths occur among veterans receiving care in the veterans health care administration Which leaves I mean you can can do the math 13 that aren't getting care in the VA And we don't know whether they're not getting care anywhere, which we suspect Or are getting sort of a random type type care We know also that there are about between 950 and a thousand suicide attempts every month among our veterans who get care in the VA and we are able to To track those but again, those are only the attempts that we know about And we anticipate or we expect that there are several that many many more that we don't know about We do know that 11% of those who attempted suicide in in the way We figure years which is different than the rest of the world, of course In 2009 and did not die as a result of this first attempt did make a repeat suicide attempt Within within an average of nine months after that first attempt And I think that that's an important number for for us to talk about I don't think that that's unique to veterans and we do know that Those second attempts and third attempts often are much more lethal than the first attempt and there may be Even some practice type behavior that goes on in these very initial attempts We know that seven percent of those who had a suicide attempt resulted in death Among those who survived their first attempt in reattempted suicide within nine months approximately six percent of those died from Suicide so the numbers are adding up as time goes on We know that 33% of recent suicides in our system have had a history of previous attempts And that 19 of those who died by suicide were last seen Actually in primary care as opposed to mental health services, so I think that's an also important thing to to remember Often these people have do have a depression PTSD or mental health diagnosis But most often they're seen by their primary care physician as their last Contact or in primary care by someone We know that there's evidence of about a 21% excess of suicides through 2007 among our newest war veterans When we compare their mortality to the US general population and that's after we adjust for age sex race and And the fact that we figure our years differently. So I think that that's a number to be aware of and There's preliminary evidence that really suggests there are decreased suicide rates in veterans among this very young age group Veterans who use VA health care services relative to veterans in the same group who don't since 2006 And we think that means a couple things Hopefully it means that that what we've put into place may be effective. It may be starting to make a difference But probably what it means is that people who are getting care in this age group in the VA are getting care as opposed to Veterans in the same age group who are coming back not hooked up in the VA services and most likely not hooked up into community resources either So I think think there is a little bit of hope in that statement that that perhaps treatment is is helpful and treatment works And we need to capitalize on that More than 60% of suicides among Utilizers of our services are among patients with a known diagnosis of a mental health condition And remember this is this includes all age group and actually within the VA the age group of veterans That that were concerned about varies from those who are 18 and 19 years old right up And to those who are in their 80s and we have suicides among all of those age groups Another thing that I think is important To to think about is that veterans are more likely than the general population to use firearms As a means for suicide and Lisa spoke about that a little bit this morning about the lethality of that method One of the things that's concerning when we talk about women veterans is that women veterans suicides rates are Actually quite a bit higher than women non-veteran suicide rates in the United States And one of the reasons for that we believe is that women veterans are more likely to use guns as a method of choice Than women who are not veterans So they're more familiar with guns. They're more likely to have them in their homes And they're more likely to choose that method So I think we need to to think about that when we when we work with women veterans And I did want to talk just briefly For a few minutes about the Action Alliance if you all are not familiar with the Action Alliance Several years ago in 2001 the National Strategy for Suicide Prevention was published And this did provide a saw with kind of a blueprint of Suicide prevention activities that we should be looking at and using as a model for how we we focus suicide prevention programs 2001 was a long time ago and we have learned things since then and it's time to Reestablish this national strategy to to change it to look at it to see where we've Succeeded as a nation and perhaps where we haven't One of the things that did ask for was a public-private partnership To really help guide the goals and objectives in this national strategy And so that the Action Alliance was reformed last year It is a public-private Partnership and Is co-chaired By John McHugh who McHugh who is the Secretary of the Army? As well as Golden Smith who is the private co-chair who's the president and CIO of the National Association of Broadcasters, so they're two pretty powerful people And Gordon Smith is a prior senator whose son actually died by suicide So this is a near and dear venture to his heart And there are several task groups that are formed under this Action Alliance you can look it up Online you all you have to do is Google Action Alliance Several of us here have been involved in the the new development of the new strategy And we're encouraging input from everyone so I encourage you to get online and to look at the site and To get involved where and when you can So that was my PSA for for the afternoon So when we look at veteran suicide the VA's developed a basic strategy for suicide prevention Suicide prevention requires ready access to high quality mental health and other health care services Which is supplemented by programs designed to help individuals and families number one engaging care and Number two address suicide prevention in high-risk patients So we kind of had to choose some areas Where we thought we could make the biggest difference when dealing with the enormity of the problem and so our whole first set of Strategies involve access to care engaging people in care And getting people to seek Services and to help them do that And then we have along with that a what we call an enhanced Package of care for people that we've deemed to be at high risk and often these are people who have already attempted suicide or those who Exhibit a lot of the the risk factors have called the crisis line have told us that they Are thinking of hurting themselves or killing themselves Or otherwise We know to be in that high-risk group We've established a couple of hubs of expertise one of these is the Center of Excellence in Canada Agua That that I work out of and another one is the Mental Illness Research and Education Clinical Center in Denver, Colorado Which really focuses in on the kind of biological aspects of suicide as well as specific clinical interventions So our Myrick and Denver works closely with people that you've already heard about This morning David Jobes being one of those and Greg Brown and Barbara Stanley Have also collaborated with us on lots of our projects coming out of the Myrick We've developed some national programs for education and awareness our The VA version of the gatekeeper training program is called operations save Know the signs as the question validate the feelings and expedite help We have several programs available for education and training Online that are also available for us to share. I mean once something is developed in the VA It's public information. So if you want any of these let us know And they're available. We have a suicide risk management training for clinicians program We've done a lot of work in the area of traumatic brain injuries and suicide We have a women veterans and suicide program and older veterans and suicide program and we've partnered with AAS to provide primary Care provider training We've also developed a crisis line Which you've heard a little bit about we've partnered with SAMHSA and our lifeline partners to provide this service. We use the national number We feel very strongly that that veterans live all across the country and that veterans and the rest of the country Should have the opportunity to call the same number and get services We've opened it up to active duty service members. And so the first thing you'll hear if you call the national Lifeline number is if you are a veteran or a member of the service Please press one and those calls are connected to the center. You just saw in Canada We think people need options. So we really support local Crisis lines. We have lots of transfer agreements back and forth with local crisis lines across the country And we're we're here to to help people veterans move. And so We want them to get services where they live And we've developed veterans chat and veterans texts, which we'll also talk about in a minute We have suicide prevention coordinators across our country and all our VA's And we've developed a lot of federal partnerships to help us get this done Our suicide prevention coordinators are located at all of our medical centers in our largest community-based clinics And they have a lot of responsibilities But primarily they're responsible for tracking people at high risk and making sure that they get the care that they need They have a lot of reporting responsibilities. They answer these referrals from the crisis line They do outreach and education in the community But their primary goal is to make sure that veterans don't slip through the cracks And we think that this is making a difference. I think you all know enough probably about the VA system to know that we have a lot of cracks And it would be silly for me to stand up here and pretend that that we don't Because we do and then the the numbers of veterans who are getting care is increasing I think it's also silly for me to stand up here and tell you we're keeping up We're doing our best. We're doing the best that any large system could do. We probably provide on a national basis Better care than than any other really large health care system out there But these people are at extremely high risk. They need that extra sort of Wrapping our services around them and shepherding them through the system and making sure that they're not waiting in long lines for prescriptions or Making sure they're not waiting for weeks to get appointments Etc. Etc. And that's what the suicide prevention coordinators have been able to do for high-risk folks So I would encourage you if you're taking care of a veteran in the community And you need to get them VA services or you need to get them hooked up into the VA system Use the suicide prevention coordinator to help you make that happen And it's a it's a kind of an expedited expedited process The gatekeeper training is Provided to all of our new employees when they start working at the VA We think that that's incredibly important And I think that lessons learned from that are the stories that come back to us We've had stories from people who drive our vans dropping veterans off after appointments When the veteran has said to them you don't need to pick me up next week I won't be needing my appointments anymore something after the van driver got the appointment clicked in in his head and said I Wonder why they said that and so they referred that patient To the suicide prevention coordinator at their site and sure enough that veteran did have plans to kill themselves And really didn't expect to need that appointment next week So getting all of our employees and people who work with veterans Listening for those kinds of cues I think is incredibly important We're also working with the student veterans of America and as Lisa pointed out this morning a lot of our veterans are returning back to college campuses and school programs And some of them are struggling with being able to keep up with their family responsibilities life responsibilities going to school making good grades Financial concerns all at the same time And I think that we need to put those extra efforts into making that easier for them so we're Working on developing the training specifically for them. We have developed an operation save training specifically for American Indians and Native Americans in Alaska And are continuing to work specifically with that population As well We talked about the other training initiatives so one of the things that that that we've discovered is that We truly think we can make a difference for these this group of Patients that we determined to be at high risk For for whatever reason and one of the things that has proven to be somewhat effective is that anyone who comes into the VA who screens positive on our regular routine PTSD screen or our Regular depression screen we refer on to for for a suicide screen and a suicide risk screen Or assessment Which has been I think Better for us as opposed to doing kind of across the board suicide screens to everybody who walks in I think by broadening our net a little bit We're catching more people who perhaps might be at risk And I would if you're working with veterans. I would advise Using the the normal depression screens and if people do screen positive Always ask the suicide risk questions. I think it should be a normal part of of what you do along with that there are specific questions that get asked of veterans when they come into the VA that probably now should be part of America's Screening repertoire and those are people's exposure to trauma if they've served in in combat zones And if they have had any period of time while they were serving or since they've served Where they have lost consciousness For any period of time. So if they've ever had the possibility of a traumatic brain injury I think it's important that we know that That along with PTSD And depression are kind of the signature wounds like I mentioned of this war They also carry with them an increased rate of suicide with this group of people So to be aware of that to ask the questions to normalize asking those questions in your everyday Intakes I think is really important when you're working with veterans It's amazing to me Even still today while we're at war how many emergency rooms Don't ask the question. Are you a veteran or have you served? With any particular group of people, but I think when People within the age group of people who could have served in Iraq or Afghanistan Walk into an emergency room male or female You certainly need to ask the question. Are you a veteran? And then along with that come another whole set of questions Were you exposed to combat was there ever a period of time when you were unconscious or you hit your head? Or do you know you have a traumatic brain injury and have you ever had symptoms of a stress disorder? I think those are important questions to ask When we identify someone at high risk, we do have a chart notification system So we're able to put a flag on their record That is visible by everyone who opens up that record to know that they are at high risk of suicide We do this with the veterans permission And it does let people like pharmacists know that if someone shows up in the pharmacy for the third time in a month because they've lost their prescriptions or Their their drugs aren't working or they didn't know that they were supposed to take them at a certain period of time And they need more those are things that we need to be aware of It lets people in the emergency room know that this person needs to be asked a whole different set of questions When they come in perhaps they're not really there because they have a headache or their back hurts We've also fully embraced the safety plan methodology and for everyone who's determined to be at high risk and who has a flag on their record It's required that they have a safety plan We've developed our safety planning and I'll talk about it in a minute with Greg Brown and Barbara Stanley We have a manual which certainly you can download it is on the suicide prevention resource center best practice Listen is available for anyone who wants to use it We require that their treatment plan be modified to include the the whole idea of suicidology that we ask the questions that Treatments are structured around their suicidology their suicidality first Which include all of those evidence-based treatments that that we now know may be effective such as CBT and DBT Problem-solving and motivational interviewing etc. Etc. As well as the CAMS concept We require that we talk about means restriction with veterans and this is a Touchy subject with veterans. I mean we don't ever want to in any way imply that we are Restricting people's rights to bear firearms or to keep themselves safe or to carry a gun I mean that's not what this is all about what it is all about is keeping them safe and at the very least Providing those kind of stalling tactics that Lisa talked about earlier We do provide gun locks to any veteran who wants them We've partnered with the National Sports Suiting Association to do this. We've developed materials about gun safety that we we provide we're in the process now of Going to and providing these materials that all the yellow ribbon events across the country so that when Reservists and guard members come back. They have the opportunity To get a gun lock and to know how to use it To keep themselves safe, but to keep their children and families safe, too. So I think that's gun safety is The the buzzword of the day and we're really concentrating our efforts on that We've also looked at blister packaging ways to restrict medication prescribing amounts those types of things which is more difficult, but We're pursuing those This part of their safety plan We do require that veterans identify if they possibly can to friend or a family member who we can contact If we need to find someone, you know, one of our biggest challenges both from a suicide prevention coordinator and medical center of You as well as on the crisis line is that if someone doesn't show up for an appointment or calls the crisis line as in an obvious Distress and and is in a crisis It's it's detrimental As you all know lots of times to call the police These people have PTSD sometimes lights and sirens are not a good thing to To put in front of them sometimes it's our only option and we need we'll Will do it to keep people alive, but it's not our first choice ever when people miss appointments We don't want to call the police to go to their house to bring them in But we do need someone to call we need someone to take on that Responsibilities so we want to call their neighbor or their brother or their their sister who who often are more than willing to take on This this task of going and making sure they're okay and finding out why they miss their appointment or what the problem is and Just having that contact information has made of an incredible difference And we do follow up for these people if they don't show up for appointments Which is an awesome task unto itself Other parts of the enhanced care package do include a mailing program So they do get we can't send postcards in the VA because of the privacy rules, but we can send letters in envelopes So we we do that the safety plan Specifically is included in the veterans medical record We do ask that all of the providers become familiar with that The veteran gets a copy of it and it includes six specific steps, which Greg and Barbara helped us develop One of those is the the first one is the identification of warning signs. What really truly does make a Difference in you what what do you need to be aware of? When do you start feeling bad? And why? Internal coping strategies What what are the first things that that I can do? We do have a PTSD coach mobile phone app which Has been developed and a lot of our veterans now have that on their phones and are using it It's free From you can download it and it's certainly worth worth doing We have them again identify social contacts who could distract from the crisis family members of friends Professionals and agencies to contact for help and how they can make their environment safe as all part of their plan We require that veterans are seen within seven days of discharge from The facility if they've been admitted for any reason And then we require weekly visits for the first 30 days and we do require that the flags stay on their record for 90 days After this attempt or high-risk designation And we've just kind of faced the fact that this is a high-risk period and despite what they tell us or How they're feeling we're going to keep them on the high-risk list and provide that high level of care The crisis sign I talked about a little bit It's a toll-free confidential resource that connects veterans in crisis and their families and friends with responders we do have a Crisis responder training program that that people go through about a third of our responders are veterans themselves Another third are families of veterans And then another third are long-term VA employees We've answered now close to 600,000 calls Since we launched in 2007 we've actually called for rescues close to 30,000 times and In 2009 we did add an anonymous online chat service, which I mentioned in the video We never really advertised. We just opened it up And now we're up to 30,000 chats that have come in and that's growing daily the number of people who are aware that that's there and get in One of the things that we've been able to do this past year is partner with the American Foundation of Suicide Prevention Dr. Anne Haas and develop an online Self-assessment tool we we noticed that veterans especially What we think now we're our youngest group of veterans and a large number of active duty service members We're getting on the website. They were kind of cruising around. They were looking at resources They'd come back to the main page. They'd go somewhere else. They'd come back to the main page They might get in three or four times in a night And you just had the feeling that they wanted to click on the button that says chat with a counselor But they just couldn't make themselves do it so we have another option now that they can take a self-assessment quiz and remarkably Thousands of people are getting in to take that quiz and then at the end of that they have the opportunity to stay in There and talk to a counselor or to get a message back within 15 minutes from a counselor or not to to pursue it And most of them stay in you know once they've kind of taken the quiz and they have a way to start the conversation They'll stay in and talk to us. So Even if the assessment itself is not valuable, but we we think it is One of the huge values is that it's a conversation starter. It's a way to start that conversation So I think that's exciting especially for this newest group of people The other thing we opened up in November is a texting service Where people can actually text us And tell us that they're in trouble and again it's not that we're able to have therapeutic conversations Over the the texting service as you all know characters are limited But it's that connection and once we've connected with them a few times Often we can say I have your number. Can I call you? They say yes, they've made that connection They're a little bit more comfortable With with talking with us or they'll say no But I'll get into the chat, you know, because we always offer that as an option too So I think we've learned that we have to be there where veterans are to make a difference I'm looking at it like it's going to change itself And then the other thing I want to spend some time talking about is the whole idea of Messaging around the suicide message. I think many of you probably saw our initial attempts back in 2007 to Advertise our crisis line and to put the word out there that that we had one And those were kind of born out of a desire to get the number out there to let people know that they could reach out for help In that in the you know three or four years that that we've been doing that We've learned in a tremendous amount about messaging and we've spent a lot of time trying to figure out What is the best way to get the message across that we're there to help and that suicide is a problem? And that treatment works without At the same time portraying this sort of dismal bleak picture about veterans in general And I think one of the mistakes we made in the beginning was that in our effort to get people mental health services and to to talk about the problem Was that we kind of painted a picture that? Perhaps you shouldn't hire veterans when they come back from serving because they might have mental health conditions Or perhaps you shouldn't be friends with a veteran because they might be violent or Or cause trouble in your communities and perhaps you should stay away from veterans because they're not stable So while those are extremes in the backs of people's minds I think we painted some inaccurate very bad pictures that perpetuated the problem And I think we tend to do that sometimes around the whole area of mental health and suicide To begin with so I think it's incredibly important to number one Like we heard this morning Normalize those those thoughts that yes people do think about killing themselves Yes, people do have emotional difficulties. Yes, mental health is important And it's something that we probably all struggle with at different parts in our of our lives and different times of our life But at the same time While those are sort of normal thoughts so is getting better and so is our ability to to change our lives to get help and to be really productive members of society And at the same time we need to portray that image that that veterans have Just gone through incredibly difficult Situations by far the majority of them have been deployed Into combat situations. They've survived. They've come home. They've made incredibly difficult situations Bearable they've made incredibly difficult decisions over and over again They've contributed as a member of a team to an extremely successful effort and all of those are truly attributes that will help any employer Build a productive workforce that they'll be good members of any team Which would would hire them to do jobs and they'll be really fully engaged active members into a community Once they can transfer those skills that they learned in the military to community settings So it's our task to help them do that So creating those messages has been a challenge and and we need everyone's help to be able to do that One of our newest ventures is called make the connection net And I would encourage you all to get on that website, but it's stories of veterans by veterans telling their story about some of the challenges they've had and the successes they now have in their lives and so Certainly use that use it with the veterans that you work with Encourage them to get on there and look at stories And then they can really customize the story according to the era that they served in and their gender and what branch of the military They were in And I think it's very useful We've also developed a kind of Matter-of-fact a different approach to Advertising the crisis crisis line We did actually even change the name of the crisis line from the suicide hotline to the veterans crisis line in an effort to get People to call earlier one of the things that we were hearing is that veterans felt like your service members Especially felt that they couldn't call it because they weren't really suicidal yet And that they had to wait until they had like a gun in their hand before they could call the the suicide hotline so to kind of Help people realize that they should call ahead of time We called it to the we changed the name and have to tell you the calls increased by about 20,000 the first month it was Amazing the difference that that change in messaging make and we did have a big splurge in a big push at the same time Which I'm sure contributed to that But I think it made a difference We have the usual kind of Shatsky stuff. We've got the key chains and the wristbands and the Wallet cards and things and there's a table in the back a little round table that has a lot of these products on them I'd encourage you to take them, but you also can order them from us And we'll send them to to you of course At no charge in the our Website is www.veteranscrisisline.net And there's all sorts of links on there So back to the crisis line we went live On January 25th of 2007 and we got our first call at 11 20 I mean I actually was one of the strongest proponents of not opening up this crisis line I I thought there was the national lifeline. We should use that we should have people referred that veterans to us I Thought that you know the majority of veterans are males males don't call a crisis line Why would we waste energy and resources on doing this? And I was told Jan we're going to start a crisis line I said okay, so we did it and I've never been so wrong about anything in my entire life I mean the calls just started coming in and they have not stopped We started with four lines. We're now up to 25 going seven days a week plus The the computers for the chat services and now the texting commuters Computers and so we can actually take anywhere between 30 and 35 veterans at any given point in time in some way Into the lifeline the partnership with the lifeline has been incredible And they also provide backup services for us, you know, we are located in canadaigua, new york We do get a fair number of bad weather days there And ice storms the lines occasionally go down And lifeline snaps up and picks up the calls and calls don't go unanswered. We have no queue We have no waiting space and it's a kind of a round robin response. So it works well We have lots of staff Calls come into the crisis line. We do do phone interviews. We actually have a computer application where we do an assessment We assess for emotional functional psychological conditions We determine what type of call that's coming in and and what we need to do about that And the beauty of the whole system is that we are able to for those veterans who agree to it Enter their medical record if they're already getting care in the VA. So we have that kind of background We can also drop a Consult into their record for their local suicide prevention coordinator and let them know that it's there And the suicide prevention coordinator is required to follow up within 24 hours to that call So I think that's something we're able to do in the VA, which is a unique opportunity that we need to take advantage of Veterans chat Again, I've talked about a little bit And we do have some new initiatives starting Which include involving all providers in our prevention strategies When we looked at our newest numbers and when we were able to look at these 2009 numbers that have just come out and bounce them up against our system One of the things that we realize is we are making a difference in certain groups of people We're making a difference with with mental health patients in the VA So with those patients who are diagnosed with a mental health disorder We're able to demonstrate that we're decreasing those rates We're making a difference in middle-aged men, which is Kind of unique in the fact that in the nation though the rates in middle-aged men or the older bracket of middle-aged men Is actually going up over time our numbers are coming down So we think we're we're effective with that group of people They also by the way are more likely to have a mental health diagnosis because they've been in the VA system a little longer One of the things all of that did while it's very encouraging and we know where we think we're on the right track And this enhanced care package might be working one of the things that's a little disheartening is that we're not making a difference in People who number one don't have a mental health diagnosis and our younger veterans who who need us Desperately and while our rates in those groups aren't going up. They're not coming down either So we really need to work on Kind of our more general public health approach to suicide prevention more perhaps Universal screening, but we think we really need to work with all of our providers not just our mental health providers to be able to provide Better services and and better assessment skills So at this point I want to show another video that that we've developed called ask the question And we're in the process now of distributing this through the VA and the suicide prevention coordinators are using it as a As a tool again, it certainly you can steal it if you want I know how to ask a lot of very personal questions, but this one is different These are thoughts I Never thought I could tell anyone how could I admit to something like that? You know thinking about killing myself Nothing good is gonna come to this conversation. I mean, where does it end up me on drugs or locked up in jail? I Thought asking about suicide could push them toward it. That's actually not true It was such a relief to finally finally talk about it It was so painful holding on to the worst secret ever So what are some of the approaches that you've found to be effective when working with veteran patients in detecting suicide risk? One of the ways that I'm able to determine it is especially if it's an initial visit with the patient when I'm going through social history I'm able to kind of find out, you know, are they married are they divorced are they separated what's their job situation? There's other things that might Determine that they might be undergoing some stress and then I'm able to kind of carry through from there and get a little more in depth So we've been working on treating your back pain now for several months and you're still not getting any relief Yeah, the pain in my back hurts just so tired and I'm getting some headaches too Is there any unusual stress in your life? Maybe you should talk to my wife. She says I act all stressed out and I get angry about things more often Yeah, how they interacting with their friends their spouse family stuff like that You know, it's usually is a good indicator that to me that Something has changed that I need to explore that a little bit more carefully Can you tell me more? I'm just a little irritable. I guess That's a pretty common concern with a lot of veterans. So what are you doing with yourself these days? Not much My wife wants to go out, but I I prefer to stay at home Watching a few games on TV and having a few beers. That's enough for me. How do you feel about life in general or? positive or Do you feel hopeless? I think that sometimes when people get hopeless They feel that they have no one and so I try to make that personal connection To them so that they feel like they have somebody who's on their side who will kind of join them and trying to work through this Hopeless? No, I wouldn't necessarily say that I'm just pretty well worn out. I'm just so tired of all this to care much well Maybe a bit hopeless Have you ever had thoughts of suicide? No No No While the veterans with your pain and worries sometimes feel like they just want to end it all I just want to make sure that that you're okay, and then you'd be willing to share with me if that's how you felt And we know that it's okay to ask the question. We know it's important to ask that question and it seems And one is first practicing with such was you know the responsibilities are huge and The hesitation of caution is oh if I ask the question And they can now going to start to think about it They're am I giving in the thought and they're going to now go ahead and be at higher risk of committing suicide and the answer is no You're not speaking to something potentially that the individual hasn't thought about and asking the question is immensely important Asking about suicide can be difficult. What are some of the ways you've done it? There's a lot of concern on my part that the question is received as well as possible so The sense of engagement is important But then it's also fairly easy because I believe in what we're trying to do and that is to try to help the individual So making them comfortable as comfortable as possible To hear the question to make it safe To phrase the question in a way that's non-threatening non-judgmental I Think that's just really important because I mean Patients have a lot of ambivalence about whether whether they're going to be honest with their provider or not when it comes to suicide And the more comfortable you are the more The easier it is going to be for them to be honest and really feel like that they're going to get a useful response And get help or get something that's going to actually make a difference for them Other vets with your pain worries feel like ending it all. Do you ever feel that way? well sort of I mean the thought has entered my head, but I'm just tired. That's all and that's not so strange Is it no no not at all, but how often do you feel that way? Seems like more all the time daily. No, but quite a bit more lately Have you actually ever tried I'm wondering how you would respond if someone says yes What do you say to the veteran next? At that point, you know I look at things like assessing the severity or the acuity and the level of risk You know is this passive suicidal ideation where the person is just kind of thinking and they'll make comments like well Wouldn't really matter if I died Versus more of an active suicidal ideation of you know, do you have any guns at home? Have you have you ever thought about ways you might be thinking about doing that is you know Do you think this is something we should really be looking hard at sooner than later and try to get from them? Their perception of the acuity of the situation and and the weight of it. I know never It's just that I've thought about it a lot lately My wife and I fight a lot, and I feel it's my fault that things go wrong It's depressing that I feel I'm letting her down. Have you ever actually put a plan together? I told my wife I wish I'd gotten it in Korea Why did I survive and I wouldn't be in this mess right now But I know what I would do I mean, I wouldn't do it near her. I'd go off alone somewhere. I got a gun When someone's agreed to tell you about this they really they picked you and so you have to finish that conversation You know you have to kind of sit with them and talk about what that really means versus immediately rushing to Kind of what needs to go in the computer or whatever else to make it okay for providers to recognize that It might not be a comfortable conversation for them But then there are many things about what we do that aren't comfortable and having a comfortable conversation is not always our objective our objective is to as best we can provide resources and help in managing a whole range of clinical issues of which suicide is an extremely important one So you've got to always keep that door open Even when the patient says no even that the patient's honestly says no You need to let that patient know that if sometime in the future. Yes, they're having suicidal thoughts They know they can come to you and lay it out there. I Know things seem tough right now But I think we can help Step by step one at a time Maybe even bring in your life and family to help out Maybe Okay, sure So you've been working with a veteran the veteran has acknowledged that they have thoughts about suicide What kinds of things can you do to help decrease the risk of suicide? safety planning exists as a as a full intervention And there's training available. I mean suicide prevention coordinators have training for clinicians who would like to do that with their patients And it's a very useful intervention that's very collaborative and allows the veteran to leave with something to help them When they're outside of the appointment There are programs in place to help you with this take the load off your shoulders I'm going to refer you to someone to talk to about this. Is that okay? well, that sounds good and Thanks Thank you for helping here. I've got so many problems that seem to be peaking now But you're the only one I've been able to tell all this to And that's the sense that comes out of that conversation And it's really oftentimes. I mean you can you feel it. It's almost present in the room shoulders drop Sive relief while I can finally talk to something that's just been frightening me or Worrying me or all kinds of things. They just feel okay. And when we've done this well, I think We often will see that response Are there any other examples that you can give where you've had an impact on the veteran's level of risk? An example that comes to my mind was a veteran. I met probably a couple of years ago now and he was in my office and He had a very bright affect kind of superficially Maybe a little too jovial But then he he kind of made comments in between it that made me concerned So I kind of pursued the line of questioning and determined that he was suicidal and in fact He was very suicidal and he said that he'd been practicing going out into the woods by his house His wife frequently left on business and he wanted to do it while she was gone So and he kind of wanted to let somebody know that so that she wouldn't find his body I mean he had thought about it very well his problem in the main sticking point for him was that who was feed his dogs After he killed himself before you know the wife returned And his wife happened to be in the waiting room and so I said How do you think your wife was gonna feel about that? You know whether she finds your body or not Well, she's probably not gonna be I said do you mind if we bring her in and talk about this and he allowed me to bring her in We actually ended up he agreed to go to the emergency room because because he was so cute and You know it they came back several times and you know and he got on some medications He did very well and you know, they both really thank me for being able to intervene So yeah, I think it does make a difference. I Saw a gentleman had done six tours in Somalia in Iraq, etc. Came in for complaints of knee pain And we were talking and it just seemed that the physical complaints that he had just weren't quite all of it We weren't too intuitive than anything else. Oh By the way, how are you sleeping? I'm not so good Next thing you know, I asked the question and he breaks out in tears This is real experience. He just breaks out in tears. He's 26 years old He goes, how do you talk to somebody about what it means to shoot somebody? You know, and he was in the right environment the entire staff was there it was a it was a VA clinic That was taking care of veterans So that piece engaged him Everyone did what they were supposed to do and brace the guy coming in in ways They had no they could never have anticipated and so each one sort of did what they were supposed to do Which was care for the individual and I just happen to be the last one and that's and in that stream And it worked and so it's it's following the little bit of nuances. It's it's a big piece of what we're supposed to You know what we can do It's so personal But it's really an honor that he thought so much of me that he was willing to tell me He chose to tell me so that I could help save him I expected my visit with the doctor be about my health problems, you know, but but we were able to talk And it was it was such a relief to finally connect with someone, you know, and right now and start talking about what was really bothering me. I was frankly amazed that he opened up to me But helping him get help and begin to get connected with services was as rewarding as Identifying a silent heart attack during a routine physical. I can finally see the light ahead I'm finally getting the support I need I'm not alone anymore So I think that It's important for all of us to ask those questions but most importantly to Encourage the the providers around us to ask the questions and as a mental health provider to be there to assist that provider in In dealing with the answers and I think one of the things that's starting to work for us is The whole idea of integrated mental health services into primary care and that there's a mental health provider there It's a huge step for those primary health care providers to ask those questions And encouraging to sit there and listen to the answers and be supportive but we also have to provide a Place for them to send the veteran to provide the mental health care to do those in-depth assessments to really ask The the mental health related questions and to do complete Suicide risk assessments to have that backup makes it a lot easier for people in community settings to to do this So we've got to work together to make this happen And I think that's the lesson I'm learning every day that I do this job is that Veteran and military member suicide is a huge incredible problem it's tragic and it's appalling that people would risk their lives Serving in combat and deployed situations survive that And then choose to take their own lives by suicide because they don't think they have any other options And it truly is going to take all of us To make sure that they know that there are other options to be there to offer those other options and to help them Find out what those those other options and opportunities are It's going to require all of us to employ those stalling techniques until we can get people help and get them services it's going to take all of us to to serve as those gatekeepers to be aware of Our neighbors and our friends as these young soldiers come back and become integrated into the community And it's going to help Their families their their families are also in incredible stress right now So we've got to be there But at the other end are huge rewards and I think that that's the thing that as As providers sometimes we don't reap the benefits of and I think you saw a little bit of that in that last video That when you really are able to make a difference in a person's life the reward for that is Incredibly overwhelming and fulfilling And we we just need to keep pursuing to get that done There are a lot of messages out there again You're welcome to get on to the website to download any of them to use any of our materials You have suicide prevention coordinators In in all of your communities and I can help you connect with them In in one way or another and if you have any questions My email address Which I don't know there it is is some pretty easy to end at camp at va.gov Feel free to to contact me and I will be glad to Expound on this, but I think I'll take questions if that's That's good Please somebody have questions Hi, Jan, and thank you for your work I'm my name is April Burns, and I'm a GI rights hotline counselor, and I'm noticing that although I Was hoping that we're going to have some time to talk about military member suicide Which was not touched on at all Okay, one of the things in truly I'd work for the VA. I know veterans kind of inside and out I was fortunate to serve on the the military suicide prevention task force Which did a pretty thorough assessment of the military suicide prevention strategies and efforts and I think one of the things that That came out for us during those task force investigations and and we did Go to about 20 bases across the country. We talked to Soldiers and marines and sailors and and men and women is that military service members are people too And that a lot of the the risk factors involved in suicide Age gender those sort of non things that you can't do anything about as well as exposure to trauma Separation disconnection Lack of belonging this etc. etc are things that happen inherently in being in the military That you're often serving away from your friends in your family While you have very strong cohesive military groups often you're broken away from those for reasons of Deployment or you come back and they don't you stay they come back etc You are exposed to lots of traumatic situations just in the daily work that that you do And so all of those are magnified and I think General awareness of that is the most important thing we can bring to the situation. There are certainly Things that we don't know about deployments and the multiple deployments and the effect that that has on suicide rates, etc But one of the things that we do know is that when we looked at military suicide deployment itself does not make a tremendous difference in someone's risk and So while the exposures to trauma are there it etc The fact that someone was deployed to Iraq doesn't necessarily put them into a high-risk category So it's all of those other things that That come into play that we all know about and know how to deal with another kind of common issue Within military and veteran suicide is the the use of alcohol and illegal substances is often a Stress reliever a way to cope with time on your hands a way to be part of the crowd and the group coping mechanisms for For being deployed or for for being Away from your family, etc. And we all know that that adds Injury into the situation and then just one more factor I want to bring in then I'll take lots more questions is the whole concept of TBI and that may be the one element of Combat itself that provides a physical Increased risk factor for service members both while they're serving and when they return and Lots of soldiers suffer mild TBI eyes or moderate TBI's while they're serving continue to serve And that does play a role in how they cope with military life from that point forward so Okay, because I deal with people directly who are in the military now many of them are women rape harassment bad diagnosis abusive Treatment of our military members when they're in Very bad medicine Being given a lot of different kinds of medicines from different doctors who never talked to each other and There are so many things that people are not willing to look at within the military that are causing these Suicides and I'm disappointed that that wasn't addressed and I'm also disappointed that there doesn't seem to be a place for Those medical members to reach out and to get the help they need because they certainly are not getting that help within the military And I was hoping that because I know the veterans and military Are combining a lot more in there and working together This is one thing that is not being addressed by the veterans community nor is it being addressed by the military So what what could I what could what what can I provide so where's their hotline? So where's their hotline and who do they call? I mean they call us, but we aren't psychologists All right, and they can call us and we okay, that's what I wanted. Yeah They certainly can call us and again when you when you call that number you hear if you're an active duty service member call this line We do have contacts for them. We do have ways to get them help Depending on what branch they serve in and and where they're located they need advocacy. Yeah We certainly can service their advocacy People and we do that on a Regular basis We partner with Other outside agencies sometimes there's a reluctance Understandably on their part to sometimes reveal who they are We don't insist that they do that, but we connect them with organizations such as given hour And and the reason and and also the gi writes hotline Dot org and I recommend everyone go there. We are a resource for them as well Yeah, so we certainly should take that resource from you and refer folks to it You know we do have a lot of partnerships with people and I guess that's the other part of what we've learned is that we're not Going to do this by ourselves like I said and we do have partnerships with organizations such as vet for vets Warriors for warriors That's prevail where we do transfer people back and forth Especially if they want to maintain that anonymous nature of who they are so we don't let people drop through the cracks And if they don't want to be referred back to the chaplain on their base We find them in an alternative resource if you are working with active duty service members However, we have found that that usually the best resource on bases are the chaplains Who have not found that yeah, so but they will go to the to the service member in the middle of the night Wherever they are the ones we've connected with have been it's extraordinary But I'm sure they're not all that way. I'm sure of that Thank you. All right. We do the best we can with with the information. We have to do a lot better. That's right What else? That was a hard question I have a question I'm a veteran and when I was in the army I was under the impression that I was not eligible for VA services unless I retired and It was only after my health insurance went up to $1,800 per month And I contacted the VA that I knew that I was eligible for VA services Have things changed since the time I was in I mean are people Educated before their discharge that they they are eligible for VA services if they're on our boot discharge We hope so And it that that required a lot of changing And people's eligibility really varies depending on the era that they served in because the laws have changed Back and forth over the years People currently serving and people who have served in support of the OEF OIF war Are eligible? No questions asked for services if they enroll within the first five years of returning Or or their discharge So it behooves all of us and we we go to their post deployment Exercises we go to the yellow ribbons we go Everywhere we possibly can to tell tell these service members that they need to enroll They don't ever need to use our services, but they need to enroll within that first five years to guarantee Services especially if something happens later in life when they lose their insurance or if they need our services They need to have been enrolled. So that's the public message of today is enroll within the first five years After that it gets more difficult And it's always harder to to prove things after the fact than it is to Express them at the time. So I think that's a public message to take away from here The second question When I had my initial intake medical intake it was a schedule for an hour long and The routine question and he was entering everything into the computer as I answered But he did a thorough assessment of PTSD and suicide. Is that part of the? Formalized intake procedure in the VA medical clinics now it is okay. It is And and in their lives, I mean it is and it will be and it needs to be and we encourage that but it but in there does slide the bit of the problem is that it's pretty comprehensive and There's a lot of people coming back so finding ways to complete that Efficiently and quickly has become our challenge, but yes it is Hi there. Hi. My question is about ethnic variations. Does your team notice any difference in dealing with different people with different ethnic backgrounds? You know as much as our team does notice it and but it's pretty much anecdotal information Because the VA does not track ethnicity For for various reasons One is we don't it's not right It's voluntary and we don't we can't or nor do we really want to force people to answer those questions But in different locations in the country and with teams who work with particular groups of people we do notice some variations Also, we notice on death certificates when they come back to us some some trends And and we follow veterans follow pretty much the population in the United States Not only in regards to ethnicity, but also in regards to geographic location And ages so I think we're we're more alike than different than the general population There are groups of people that inherently have a higher penetration of veterans as members of their groups one of those are American Indians and Native American in Alaska And so I think we need to to pay attention to that another group of people that amazingly presents a challenge to us are people from American Samoa and some of our territories that have a high number of veterans in them I Think that there's something inherent in serving in those populations Becoming part of a military unit and then going home where the connections are even bigger The loss of connection is even greater. So From that perspective, yes, did that answer your question well I was wondering within some of those variations that you're seeing is there anything that you could alert us to yeah, I think that The Intermountain West is a huge area of concern for us Not only because of its geographic location. Also There's a lack of access to VA care as well as general mental health care and the high percentage of firearms And gun ownership in those areas And we have very high rates of veteran suicide in that in that particular area another area that's of Immediate concern to us is the Northwest Portland, Oregon, but those states and up into Alaska. I think for much the same reasons Great. Thank you Which isn't to minimize the suicide of anyone anywhere any time so Is EMDR catching on as a treatment modality and if not, you know why I think it is in in particular locations, and I think it boils down to availability and Providers who are trained to provide that We do encourage people to get the training to do it Yes another area that we were kind of branching off into which is New for the for the VA is the use of cams modalities complementary medicine modalities There they're much More well accepted in that the current group of Veterans that that we're working with and they're asking for it We've got a whole series of demonstration projects going on now Using mindfulness-based meditation strategies, and now I understand the reason why they might work a little better, right? But we're excited about that and think that they hold really promising things for us I Excuse me my question is related to the sexual assault and in the correlation between sexual assault in the military and Suicidality and what kind of programs that you you know have for that Yeah, and I think again, I'm gonna relate back to general population numbers that that we know exposure to trauma is a huge risk factor and so Military sexual trauma is a huge risk factor and we know that We also know it exists in both men and women and that we we offer Suicide prevention Activities with our military sexual trauma Groups and treatment and therapy. I mean that the two walk Pretty closely hand-in-hand When we look back at our numbers Actually our rates Among women veterans The actual numbers of women veterans who get care in the VA who died by suicide Number-wise is Really too low for us to draw Conclusions about the rates from does that make sense? But we suspect that it's a big problem But when you're only dealing with one or two in a location if you double that you've only got If you had one you've got two and so That's really quite not enough to draw statistical evidence from but But there's there's some correlations there and so it's built into our treatment for military sexual trauma Do you think I'm gonna go back to your comment earlier though in that While people are still serving In the military, I think the army has made huge strides and that's the program I'm familiar with not not the other branches In dealing with military sexual trauma issues, but I think the stigma of Reporting those issues and making it okay for women to talk about them We haven't moved much at all And that's an incredibly difficult situation for people to to serve in and We have a lot more work to do in that area Well, I think that's actually across the board in terms of reporting sexual assaults and probably even worse of the military Do you think there's Has there been to your knowledge like a higher increase in the more recent wars as opposed to the past or do you have any I? Couldn't answer that Intelligently, well, thank you just emotionally. Yeah, thank you Hi, my question has to do with the sustainability of funding for the services that you're talking about specifically as it might be related to the plan drawdown of services across the forces It's a really good question we've been fortunate in the past few years in in both the Department of Defense and the VA to To get the funding that we needed and required to to do these programs and I can speak to To the VA's program is that I've close to 20 million dollars a year invested in specifically into suicide prevention activities if you count the crisis line and the suicide prevention Coordinators and and the people across the country my job for for examples, so I think we've been in a rather Unique and ideal position to be able to put these things into place It will It will depend on future funding if we can continue to grow and expand these programs Of course, the military's is drawing down Considerably and the resources that they have to provide These services and Understandably there won't be as many people in the military to to provide these services to But there they'll move to the veteran population And if the resources continue In this area, I think they will for a few years But if traditionally we look at other conflicts and other wars and other things that have happened It becomes less a factor in the in community people's minds and in politicians minds It's not quite as popular to fund as it was while we were at war I mean, it's not that people don't want to fund it. It just isn't the priority that it was so I think it behooves us to keep these issues in the forefront of Of Congress and and our funders as a round-the-body answer to that question Join me. Thank you. Dr. Kim