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February 2016 Article of the Month
This month's article selection is by Chaplain John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.


Ramchand, R., Ayer, L., Geyer, L. and Kofner, A. "Factors that influence chaplains' suicide intervention behavior in the Army." Suicide & Life-Threatening Behavior 46, no. 1 (February 2016): 35-45.


SUMMARY and COMMENT: In recent years, a good deal of research has highlighted chaplaincy for military personnel and veterans, and while this focuses on a special context and population, it offers productive questions and insights for pastoral caregiving in general. This month's article points up the important role that chaplains play in the Army's efforts to address suicide risks, but it particularly looks at factors that affect chaplains' actions, and that should be valuable for all pastoral caregivers to consider. The study revolves around the idea of chaplains as gatekeepers, in light of the US Surgeon General's definition referring to "individuals in a community who have face-to-face contact with large numbers of community members as part of their usual routine [and who are trained to] identify persons at risk of suicide and refer them to treatment or supporting services as appropriate" [p. 36; and for more on gatekeeping, see Items of Related Interest, §I, below].

Online surveys were analyzed from 868 Chaplains and 410 Chaplain Assistants (CAs), solicited via a comprehensive email list provided by the Army Chief of Chaplains, excluding those in the Army National Guard. "Response rates were 41% among active duty chaplains, 22% among active duty CAs, and 19% among chaplains and CAs (combined) in the reserves" [p. 37]. Measures revolved around a conceptualization of four factors affecting suicide intervention behaviors proposed in a report of Rand Corporation report with Ramchand and Ayer as two of the co-authors [--see Items of Related Interest, #1, below]. The factors were:

1)  knowledge about suicide
(i.e., declarative and perceived knowledge about suicide, depression, and resources available for at-risk individuals),
2)  beliefs and attitudes about suicide prevention
(i.e., whether individuals believe suicide is considered preventable, etc.),
3)  reluctance to intervene
(i.e., perceptions individuals may have that it is not their responsibility or that it is inappropriate to intervene), and
4)  self-efficacy to intervene
(i.e., the extent to which individuals feel comfortable and competent to identify, care for, and facilitate referrals for those at risk of suicide). [p. 36]

Analysis was conducted using Structural Equation Modeling (SEM), a statistical method that allows for the assessment of complex relationships between variables [--see Items of Related Interest, §VI, below], with "[e]fficacy, reluctance, and stigma...treated as latent variables; [and] training, likelihood to intervene..., intervention behavior..., sex, rank..., and mental health education...entered into the model as observed variables" [p. 39]. Several figures and tables [pp. 39-42] provide a rich report of correlations, to supplement the description of results in the text.

Among the findings:

  • "As expected, greater self-reported likelihood to intervene was significantly related to more frequent intervention behavior..., and all three latent constructs (efficacy, reluctance, and stigma) were correlated with each other in the expected directions for both chaplains and CAs." [p. 41]

  • "For chaplains, more hours of training was related to higher efficacy..., which was associated with both greater likelihood to intervene…and more frequent intervention behavior.... In addition, more hours of training was associated with lower stigma..., which was in turn associated with both greater likelihood to intervene...and more frequent intervention behavior.... Training was also directly related to frequency of intervention behavior among chaplains.... For CAs, on the other hand, training was unrelated to efficacy, reluctance, stigma, likelihood to intervene, or frequency of intervention behavior. [pp. 41-42, italics added]

  • "For chaplains and CAs, both higher reluctance…and higher stigma...were related to lower frequency of intervention behavior." [p. 42]

  • "[H]igher ranking chaplains reported more frequent intervention behaviors..., higher efficacy..., and lower reluctance...than lower ranking chaplains; and higher ranking CAs reported higher efficacy..., lower reluctance..., and lower stigma…than lower ranking CAs. [p. 42]

Among the authors' comments in their Discussion section: "the findings regarding the negative effect of stigma on intervention are cause for concern…[, and more] research is needed to explore how the stigma attached to mental health care hinders chaplains and CAs from referring soldiers to behavioral health care providers" [p. 43]. Also,

In both samples, reluctance to intervene was directly related to less frequent intervention behavior (and lower likelihood of intervening among CAs). Although greater reluctance is associated with greater stigma, it is important to note that reluctance is still significantly associated with decreased intervention behaviors in models that control for stigma. In other words, stigma does not fully explain the relationship between reluctance and intervention behavior. Hours of training was not associated with reluctance among chaplains or CAs, suggesting that training may not be effective for addressing high levels of reluctance in these groups. More research is needed to identify why, other than mental health stigma, chaplains and CAs are reluctant to refer potentially suicidal individuals to behavioral health care providers. [p. 43]
Regarding the finding that "[h]igher ranking chaplains were more confident, less reluctant, and intervened more frequently compared to lower ranking chaplains," the authors opine that "[t]his could be related to age, experience, or differences in other factors such as cohort" [p. 43]. However, they do not explore this further nor explicitly raise the effect of the power dynamics of rank.

The authors sum up the significance of their study:

The Army relies heavily on chaplains and CAs to prevent suicide; however, there has been little research on this critically important group. By applying SEM to a large sample of Army chaplains and CAs, we were able to describe the relationships between several factors relevant to suicide prevention, and to identify areas where future research and training should focus to ensure that chaplains are able to effectively identify, care for, and refer soldiers at risk of suicide. [p. 44]
Yet, beyond the military context, this research implicitly raises a number of questions for chaplaincy in general: How much training do chaplains (in other settings) receive about suicide intervention, and how well is that training countering any chaplains’ reluctance? How does a chaplains' sense of self-efficacy play into interventions in different contexts, and what can be done to strengthen that factor in chaplains? How much is stigma about suicide an issue for chaplains (and from what ground – social, religious, personal -- is that stigma rooted)? Are there analogs to the effect of rank, as found in this research, for chaplains in other settings? Army chaplains occupy a specific place in a highly organized military structure, and in some ways this would obviously seem empowering (even bolstering the confidentiality dynamic), but many chaplains in other settings work in much more informal organizations with ambiguous structures, so how might that influence the likelihood and ability to intervene with suicidal individuals? For this reader, the article sharpened my thinking of chaplains as "gatekeepers" for suicide intervention (broadening my sense of that terminology) and led me to reassess what factors help or hinder my capacity to intervene effectively with patients at risk.


Suggestions for the Use of the Article for Student Discussion: 

There is much in this article to engage advanced researchers around methodology and statistical analysis, but the article should be accessible for any chaplain and may be a particularly good "test" article to see how students who do not have knowledge of statistics can still read for content. Discussion could begin with feedback from the CPE group of what it was like to read an article with complex statistical diagrams. Did these intimidate or in some way put off students from reading for content? Did students jump from the introductory pages to the Discussion section, and if so, did they bother venturing into the Method and Results sections at all? Were students able to relate to the material even if they themselves weren’t connected to the military context? Discussion could turn to the broad subject of suicide intervention, and students own thoughts (and experience) of training, efficacy, reluctance, and stigma. Have they been involved with patients at risk of suicide? If any student has presented a verbatim that would pertain to this, perhaps that pastoral encounter could be recalled in the form of a group exercise about possible responses and courses of action when a patient indicates a suicide risk. How might this article raise the question of referrals to other providers? Finally, the students could listen to the 15-minute podcast available from the principal author [--see Items of Related Interest, §II, below], to further engage the group in the topic.


Related Items of Interest:

I.  Two of our featured article’s co-authors also co-authored the following report, available online from the Rand Corporation:

Burnette, C., Ramchand, R., and Ayer, L. "Gatekeeper Training for Suicide Prevention: A Theoretical Model and Review of the Empirical Literature." Santa Monica, CA: Rand Corporation, 2015. [(Description from the Rand Corporation website:) In recent years, the rising rate of suicides by military personnel has generated concern among policymakers, military leaders, and the public at large. Based on a recommendation from an earlier RAND report on preventing suicide among military personnel, this report reviews the literature on gatekeeper models of suicide prevention to better understand what is known about the effectiveness of gatekeepers and gatekeeper training. The report presents a theoretical model describing how gatekeeper training may influence individual knowledge, beliefs, and attitudes that may, in turn, result in intervention behaviors. It then reviews the evidence supporting each of the relationships presented in this model, and concludes with recommendations for advancing research in this field.]


II.  A podcast on "Army Chaplains and Suicide Prevention" by the principal author of our featured article, Rajeev Ramchand, PhD, is available from the Spirituality Mind Body Institute (SMBI) at Teachers College, Columbia University. This is part of a podcast series on Suicide in the Military, connected with the American Psychological Association’s special March 2015 issue of the journal Spirituality in Clinical Practice, (vol. 2, no. 1).


III.  One of the leaders in spirituality & health research in the military context is Marek S. Kopacz, MD, PhD, a Health Science Specialist with the US Department of Veterans Affairs, who has written the following piece in the March 2015 theme issue of the journal Spirituality in Clinical Practice, (vol. 2, no. 1). [Note: The other articles to which Dr. Kopacz refers, appearing in the same issue of the journal, are: Bryan, C. J., Graham, E. and Roberge, E., "Living a life worth living: spirituality and suicide risk in military personnel" (pp. 74-78); and Currier, J. M., Kuhlman, S. and Smith, P. N., "Spirituality, meaning, and suicide" (pp. 82-83).]

Kopacz, M. S. "Spirituality and suicide prevention: charting a course for research and clinical practice." Spirituality in Clinical Practice 2, no. 1 (March 2015): 79-81. [(Abstract:) In their commentary, Bryan, Graham, and Roberge (2015) examine how spirituality can be conceptualized as a protective factor against suicide. The commentary submitted by Currier, Kuhlman, and Smith (2015) offers a review of the extant literature examining the relationship between spirituality and suicidal behavior as well as several ethical considerations related to applying spirituality in clinical practice. The present article looks to add to these discussions by providing further insight into understandings of spirituality as well as suggest additional steps which could be useful in developing the applicability of spirituality to suicide prevention efforts targeting current and former military personnel.]


IV.  Other recent articles of interest relating to active duty military personnel or veterans at risk of suicide are:

Currier, J. M, Kuhlman, S. and Smith, P. N. "Empirical and ethical considerations for addressing spirituality among veterans and other military populations at risk for suicide." Spirituality in Clinical Practice 2, no. 1 (March 2015): 68-73. [(Abstract:) Given troubling suicide rates among military veterans and active duty personnel, there is increasing interest in the possible clinical utility of incorporating spirituality in prevention efforts. However, there has been limited empirical research and discussion of ethical challenges involved in integrating spirituality into preventive and treatment interventions with military populations. As such, the purpose of this commentary is to (a) briefly summarize supporting evidence for addressing spirituality in preventive and treatment interventions with military populations and (b) introduce several ethical concerns that providers may need to consider as they attempt to attend to spiritual concerns among veterans and other military personnel who might be at risk for prematurely ending their lives.]

Kopacz, M. S. "Providing pastoral care services in a clinical setting to veterans at-risk of suicide." Journal of Religion & Health 52, no. 3 (September 2013): 759-767. [(Abstract:) The value of enhanced spiritual wellbeing has largely been overlooked as part of suicide prevention efforts in Veterans. The aim of this qualitative study is to examine the clinical pastoral care services provided by VA Chaplains to Veterans at-risk of suicide. This study was conducted using in-depth interviews with five Chaplains affiliated with a medical center located in upstate New York. This study was able to show that some at-risk individuals do actively seek out pastoral care, demonstrating a demand for such services. In conclusion, a pastoral care framework may already exist in some clinical settings, giving at-risk Veterans the opportunity to access spiritual care. ]

Kopacz, M. S., Currier, J. M., Drescher, K. D. and Pigeon, W. R. "Suicidal behavior and spiritual functioning in a sample of veterans diagnosed with PTSD." Journal of Injury & Violence Research 8, no. 1 (January 2016): 6-14. [(Abstract:) BACKGROUND: Spiritual well-being has been lauded to exert a protective effect against suicidal behavior. This study examines the characteristics of spiritual functioning and their association with a self-reported history of suicidal thoughts and behavior in a sample of Veterans being treated for post-traumatic stress disorder (PTSD). METHODS: The sample includes 472 Veterans admitted to a PTSD Residential Rehabilitation Program. Measures included the Brief Multidimensional Measure of Religiousness and Spirituality, PTSD Checklist - Military Version, Combat Experiences Scale, and individual items pertaining to history of suicidal thoughts and attempts, spiritual practices, and select demographics. RESULTS: Problems with forgiveness and negative religious coping were uniquely associated with suicide risk, above and beyond age, gender, or ethnicity, combat exposure, and severity of PTSD symptomatology. Organizational religiousness was associated with decreased risk for thinking about suicide in the presence of these covariates. Daily spiritual experiences were inversely associated with suicidal thoughts. Differences in spirituality factors did not distinguish Veterans with both suicidal ideation and prior attempts from those who had ideations absent any prior attempts. CONCLUSIONS: The findings suggest that enhanced or diminished spiritual functioning is associated with suicidal thoughts and attempts among Veterans dealing with PTSD.]

Kopacz, M. S., Nieuwsma, J. A., Jackson, G. L., Rhodes, J. E., Cantrell, W. C., Bates, M. J. and Meador, K. G. "Chaplains' engagement with suicidality among their service users: findings from the VA/DoD Integrated Mental Health Strategy." Suicide and Life-Threatening Behavior available online ahead of print from the journal as of 8/12/15. [(Abstract:) Chaplains play an important role in supporting the mental health of current and former military personnel; in this study, the engagement of Department of Veterans Affairs (VA), Army, Navy, and Air Force chaplains with suicidality among their service users were examined. An online survey was used to collect data from 440 VA and 1,723 Department of Defense (DoD) chaplains as part of the VA/DoD Integrated Mental Health Strategy. Differences were noted for demographics, work setting characteristics, encountering suicidality, and self-perceived preparation for dealing with suicidality. Compared to DoD chaplains, VA chaplains encounter more at-risk service users, yet feel less prepared for dealing with suicidality]

Kopacz, M. S., McCarten, J. M. and Pollitt, M. J. "VHA chaplaincy contact with veterans at increased risk of suicide." Southern Medical Journal 107, no. 10 (October 2014): 661-664. [(Abstract:) OBJECTIVES: To examine the extent to which chaplains interact with military veterans at increased risk of suicide and select characteristics related to those at-risk veterans who present for chaplaincy services. METHODS: The nationwide network of chaplains affiliated with the Veterans Health Administration (n = 990) was e-mailed a letter inviting those who have contact with at-risk veterans to complete a survey. This letter included an Internet link, connecting respondents to an online survey collection service. One hundred eighteen chaplains (11.91%) responded to the survey. RESULTS: More than half of the respondents reported that veterans at increased risk of suicide constitute either <5% or 5% to 10% of the overall population of veterans under their care. At-risk veterans are most often identified based on open admission of suicidal behavior or red flags in their treatment file. Veterans typically do not look for chaplains from their own faith tradition, will seek care from >1 chaplain, and present at a moderate-to-high level of risk. CONCLUSIONS: The present study finds that some at-risk veterans look to chaplains for supportive services. The findings also allow for opportunities for future research. (Note: see also a Commentary on this article by Ryan D. Aycock on p. 665 of the same issue of the journal.)]

Kopacz, M. S., McCarten, J. M., Vance, G. C. and Connery, A. L. "A preliminary study for exploring different sources of guilt in a sample of veterans who sought chaplaincy services." Military Psychology 27, no. 1 (January 2015): 1-8. [(Abstract:) Limited research has suggested that experiencing guilt may contribute to the risk of suicidal behavior in some veteran populations. Using data collected by chaplains, this study compared the frequency with which 94 veterans with a history of suicide ideation experienced guilt relative to 670 veterans without a history of ideation. We then compared main sources of guilt reported by ideators and nonideators. Ideators reported experiencing guilt significantly more often than nonideators. No differences were noted for the source of guilt among those who reported frequently experiencing this emotion. Ideators with an infrequent experience of guilt significantly more often named life and the military as the main source of this emotion. Clinicians should be mindful of the need to appropriately assess for and address guilt among veterans at increased risk of suicide. A variety of sources, not limited only to military experiences, may contribute to a veteran's sense of guilt.]

Kopacz, M. S. and Pollitt, M. J. "Delivering chaplaincy services to veterans at increased risk of suicide." Journal of Health Care Chaplaincy 21, no. 1 (2015): 1-13. [(Abstract:) The present study quantitatively examines the delivery of chaplaincy services to Veterans at increased risk of suicide as well as how chaplains collaborate with other healthcare providers. An on-line survey was distributed to the nationwide network of U.S. Department of Veterans Affairs chaplains, yielding a response rate of 11.91% (N = 118). Most chaplains reported some form of training in suicide prevention, approximately half were involved in safety planning, and the majority reported not engaging in firearm safety counseling. Chaplaincy services were usually delivered through in-person, group, and phone consultations. Respondents were generally satisfied with their collaboration with other healthcare providers, most often collaborating with psychologists, social workers, and counselors. As a descriptive study, the findings serve to inform the delivery of chaplaincy services to at-risk Veterans. Recommendations include expanding service delivery options, developing competency in safety planning and counseling, as well as increasing institutional awareness of chaplaincy services.]

Kopacz, M. S., Rasmussen, K. A., Searle, R. F., Wozniak, B. M. and Titus, C. E. "Veterans, guilt, and suicide risk: An opportunity to collaborate with chaplains?" Cleveland Clinic Journal of Medicine 83, no. 2 (February 2016): 101-105. [This is an editorial.]

Ramchand, R., Ayer, L., Geyer, L. and Kofner, A. "Army chaplains' perceptions about identifying, intervening, and referring soldiers at risk of suicide." Spirituality in Clinical Practice 2, no. 1 (March 2015): 36-47. [(Abstract:) In U.S. Army policy, chaplains and chaplain assistants (CAs) are explicitly identified as primary gatekeepers; however, research on their perceptions about their roles identifying, caring for, and referring soldiers in suicidal distress is scant. In this study, we estimate perceptions of Army chaplains and CAs in domains relevant to gatekeeping, including intervention efficacy, reluctance to intervene, stigma, and past intervention behavior. We do so using an online survey that was administered to all chaplains and CAs in the Army's Active Component and Reserves in 2012. Response rates ranged from 41% of all chaplains in the Active Component to 19% of chaplains and CAs in the Reserves. Almost half of all chaplains and CAs thought they could use more suicide prevention training. Although chaplains reported greater perceived ability to intervene with individuals at risk for suicide relative to civilian samples, they also reported more reluctance to intervene. This reluctance may be explained in part by high reports of stigma regarding mental health treatment. These findings suggest that the Army should implement specific suicide prevention training for chaplains and CAs that focuses on providing acute behavioral health treatment, reducing mental health stigma, and encouraging chaplains to collaborate with other behavioral health resources.]

Ramchand, R., Ayer, L., Geyer, L., Kofner, A. and Burgette, L. "Noncommissioned officers' perspectives on identifying, caring for, and referring soldiers and marines at risk of suicide." Psychiatric Services 66, no. 10 (October 2015): 1057-1063. [This analysis of surveys from 1,184 soldiers and 796 marines is noteworthy in part for the finding that “chaplains were the preferred referral source, primarily because of the confidentiality they afford.”]


V.  Our Network has cited many articles over the years that involve or pertain to military personnel and veterans, but four of our Articles-of-the-Month have focused explicitly on chaplaincy in this context. See the pages for May 2014, December 2013, October 2013, and November 2005.


VI.  Structural Equation Modeling (SEM), is a statistical method that may be thought of as combining variance/regression analysis and factor analysis. This sophisticated approach requires level of familiarity with statistics, but a number of online resources offer introductions to SEM. See, for example: The Basics of Structural Equation Modeling, by Diana Suhr, PhD, University of Northern Colorado.



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