BTM259 – Keith Hotle – Stop Soldier Suicide — Behind The Mission

Welcome to episode 259 of Behind the Mission, a show that sparks conversations with Sikarma trusted partners and educational experts. My name is Duane France, and each week I'll be having conversations with podcast guests that will equip you with tools and resources to effectively engage with and support military service members, veterans, and their families. You can find the show on all the podcast players or by going to psycharmor.org/podcast. Thanks again for joining us on Behind the Mission, where we share the stories behind the mission of organizations and individuals that serve and support service members, veterans, their families, and caregivers. Our work and mission are supported by generous partners who also believe that education changes lives. If you're an organization that supports those who served and those who care for them, we'd like to talk to you about sponsoring episodes of the show to share your efforts, as well as ensuring that we're going to be able to continue to provide great content with engaging guests. In our show notes, you'll see a link that says partnership opportunities. You can send a message to our team to explore ways that you can support the show.

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You can support us by sharing this episode with someone that you think might enjoy hearing it, and by going to your podcast player of choice and hitting the follow or subscribe button. Even if you heard about this from someone who shared it with you, if you follow the podcast, not only will you get all the new episodes when they're released, but it'll help others find the show. And if you're feeling really generous, please give us a rating or review. Your feedback is important, and your opinions about the show really matter to others who are looking for great content. We'd also like to hear about how PsycArmor has helped you in your efforts to learn, grow, and serve. If you have a story about how PsychArmor has helped you, we'd love to hear it. In our show notes, you can see a link to provide feedback where you can share your PsychArmor stories. You can find the show on all of the podcast players by going to psycharmor.org/podcast. On today's episode, we're having a conversation with Keith Hodel, the Chief Executive Officer of Stop Soldier Suicide, a nonprofit with the goal of reducing service member and veteran suicide by using enhanced data insights, focused client acquisition, and suicide-specific intervention services. As you can likely tell, our discussion includes the topics of suicide, suicide loss, and personal experiences related to them. Please ensure that you're engaging with this content at a time that feels safe for you. If you or anyone you know is experiencing a crisis, please reach out to 988 and press 1 for the Veteran Crisis Line. So let's get into my conversation with Keith and come back afterwards to talk about some key points.

Keith, thanks for taking the time to join us to talk about Stop Soldier Suicide and suicide prevention for the military-affiliated community. Before we get into that, I'd like to provide you an opportunity to share a bit about yourself and why this work is so important to you.

Yeah, thanks, Dwayne. So I've been doing suicide prevention for 20-plus years. I started in the work really on the heels of my own suicide loss. My first wife struggled with bipolar disorder and unfortunately took her own life. And I was at a crossroads in my career and decided I would move from practicing trial attorney into trying to do some good and got involved at the state level with the suicide prevention efforts in Wyoming. I believe at that time it was the second state-level suicide prevention program in the country and was able to really go from zero to one in building what that state-level system looked like from a public health perspective, what kinds of programming and outreach and stigma reduction efforts. And it was all really new to a lot of us in the field. We were coming off the Surgeon General's call to action in 2001, and folks were really at that point looking at this as more of an epidemic-level public health kind of issue across the country. So I spent 10 years working in that space, started the State Suicide Prevention Task Force that still exists today, and really had a lot of, I think, enduring impact in making Wyoming at that time really a forefront. And as you might imagine, given the rural nature of the country, Wyoming and the Western states have always had really high suicide rates. Was able to do that, followed that up with— I built a first state-level community prevention effort. In other words, it was a state consortium that drove all the local prevention efforts, including suicide. I was there for 3 years and unfortunately we lost our funding for that and then moved into the veteran space in 2018 with Stop Soldier Suicide. And at that point, my entire family was military. My dad was a little bit older, and so he and all of his 4 brothers served in World War II and was constantly immersed in the importance of service and sacrifice and all the real efforts of the military in making us safer. And also the sacrifice when they come back home and transition back and find themselves unfortunately at much greater risk of suicide than the general population. And that's tied into Stop Soldier Suicide's mission, which is to make military service a protective factor instead of a one that sometimes, unfortunately, is tied with higher suicide.

Yeah, I really appreciate you sharing, obviously, your personal story. I think many people that come to work in suicide prevention come to it from a place of loss or personal experience, maybe from a place of training. But thinking about that progression from the state level to your coalition work and then now to your national work with Stop Soldier Suicide, that's pretty typical. Again, early 2000s, there's a broader focus. This isn't an individual issue, this is a public health issue. But then there's funding gaps, and really you went through the gamut.

Yeah, yeah, I really did. And now with some other things we're doing, it's— I've really been extremely fortunate in my career to be able to tackle the issue from a couple of different directions. At Stop Soldier Suicide, we do that preeminently with our Roger Wellness Program, which is clinical treatment. And that was something that when I started working for Stop Soldier Suicide in 2018, I talked with the founders. And at that point, they were doing mostly resourcing and referral for veterans. And their view was, look, we know this is important. We know this is helping veterans. Let's think about what we can do that has a direct attribution to saving lives. And so we started really from scratch and pulled in every evidence-based clinical practice we could, starting with assessments and, you know, safety planning and evidence-based treatments, and put those together into a treatment model that we think really is best in class in terms of locating, acquiring, and serving those veterans who are most at risk of taking their life.

When I talk to organizations who want to support let's say veteran mental health and wellness with a small w, it's always good to have a clinical basis, maybe not a clinical background necessarily, but anytime you're talking, especially about suicide, mental health in these issues, it's always good to have some basis related to licensed mental health workers. As you've mentioned, Stop Soldier Suicide is doing a lot of work in this space. We know that suicide in the military and veteran population is an extremely important topic. As you mentioned, I was in Colorado for many years. The Central Mountain West had higher rates. Veterans obviously had higher rates than the general population. So I'm wondering if you could share a little bit more about how Stop Soldier Suicide works to address this issue as a partner with other organizations, being its own nonprofit.

Yeah, I sometimes try to frame it as we are the brain surgeons in the room, if you will. We have one clarified purpose, and that is to provide evidence-based treatment to those veterans that have been assessed at medium or high risk and therefore have, based on what we can understand about them, have the greatest risk of taking their life within the next year. As I mentioned earlier, that involves extensive assessment. Once we've screened somebody and said, okay, we think this person may be at high risk, but we know that screening is, it just helps you identify red flags, right? And so we say, okay, this person needs a fulsome assessment. And that may be an hour and a half, it could be 2 hours. It's however much time it takes for us to really understand that veteran's circumstances, risk states, warning signs, protective factors, so that we know then how do we help guide that veteran through a potential suicide crisis onto a trajectory towards kind of sustained protection, as well as through the resourcing and support arm of what we do to help them live sustainable, thriving lives, if you will.

I really like how you identified that. Many people think about screening questions or just something, a simple 5-question or 10-question, that many people think that makes them automatically at risk or something like that. But what you're talking about is very clearly, the screening just indicates that there might be smoke there, but you need to go beyond the screening to do the assessment to determine whether or not there's a fire.

Absolutely. The first question I was ever asked when I started my job back in 2005 was by the Attorney General of Wyoming, who was very involved in the effort. And I'd been there about a month and he called me into the state capitol and said, I want to know how many lives you've saved so are. Me being a younger guy, a little bit on my heels, you know, it's one of those, well, I'll get back to you, sir, kind of answers. But the reality is that after 50 years of extensive research into the risk factors and the drivers of suicide and some, a lot of really strong theoretical work that's been done about why people take their own lives, what we know is that Even after an assessment, we're barely better than a coin flip of being able to tell if that person actually would die by suicide absent an intervention. But what we do know is that once we get them into our clinical care, that we do a very, very good job of determining what their risk level is and tailor then an approach to keep that person safe and then follow up with that program over time to make sure that treatment has stickiness to it. But it's very difficult. It's easy to understand what the risk factors are. When you think about mental health, for example, Dwayne, it's 60% of people may have a mental health condition in the span of a lifetime. We can't treat 60% or 11 million veterans with suicide-specific care. So we do everything we can to support anybody that comes through the door, but really focus our treatment efforts on those that flag really high for imminent suicide risk.

[Speaker] Yeah, we really appreciate it. And those of us in the field get that same question is, how can you quantify this? And I usually describe it as figuring out the problem of veteran suicide. It's not like veteran homelessness. If you house a veteran, they are no longer homeless. If you perhaps have an intervention, that doesn't mean that that veteran will never be suicidal or have suicidal ideation through the rest of their life. It means at that point in this situation, like you said, there have been enough protective factors, but things could happen 15, 20, 30 years down the road that it's really hard to be able to dial it in like that.

Yeah, I think that one of the things that I appreciate most about our service model is the evidence-based practices we use are cognitive behavioral therapy-based. And so what we do is we teach the veterans who are struggling with suicidality very individualized, very dependent on life experience and external circumstances. But it is really teaching them that skill set to use to say, okay, when I understand that I'm beginning to fall into this hole or headed that direction, here are the skills that I learned through Stop Soldier Suicide and through my treatment provider that helped me then recognize that and engage in behaviors that Hopefully we'll forestall that pathway.

And one thing as a clinician, CBT works really well for veterans because they're used to doing what they're told and following a set schedule and doing this step by step. Now, so you mentioned that going beyond screening to the assessment and then into treatment, and curious if you can share a little bit about how veterans might find out about Stop Soldiers, maybe they're referred to Stop Soldier Suicide. Your focus is really on those veterans that are at moderate to high risk for suicide behaviors.

How do veterans get connected to your program?

Yeah, I'll go a little bit to the left of that and say, for the reasons we've talked about earlier, you know, trying to acquire those veterans most in need is a big puzzle piece for us. And so we do digital advertising to try to flag for indicators that veterans who are at higher risk have. Referrals from trusted partners, because if you take a step back the way you think, all roads ultimately are geared towards eventually to lead to some kind of treatment or intervention, from gatekeeper training to awareness raising and all of that. And so referrals from trusted partners who may not be equipped to deal with a suicidal veteran, but recognize that somebody that they're working with is in trouble, You know, those are our best referrals because those are prescreened, if you will, as somebody that, that needs particular attention. And yeah, they can find us at goroger.org. If you're concerned about somebody or if you're worried about your own suicidality, we'll put you in direct contact with somebody 24/7. And then we will get that person— don't want to overstate our current metrics, but within 3 days, they're usually in front of somebody. Beginning the assessment process.

Yeah, no, I think that's great. You've mentioned a couple times about risk factors, individuals being at medium and high risk. Being in this field, I know there's not a top 10, right? There's not a give me the list of 5 things like that.

And that's, and maybe that's even the old way that it used to be.

Here are the 5 signs. And it's much, much more complex than that. But I'd really be interested in to hear about some of the things that Stop Soldier Suicide has done to not just provide the treatment, but also to identify some of the risks that, as you mentioned, could be in place for service members, veterans, and their families?

Yeah, one of the first things we did with our vice president of clinical evaluation, who was actually consulting with us at the time, and then we stole him, but we looked at virtually every instrument and scale that was designed to flag risk in different ways. And we said, we want to build the best assessment tool that helps us understand what individual suicide risk factors does this person have and how do those interplay with each other to put this person at a particularly high state of risk as compared to somebody who may have a risk factor or two. By virtue of the assessment, we can say, yeah, this person is pretty stable. They may have some chronic suicidality and they may be a perfect candidate for treatment. but we understand that their risk state right now is relatively low. And then we do a reassessment and safety planning at every session to make sure that, that situation hasn't changed. But it really was about building the best assessment tool and then documenting that assessment across all of our clients so that we could then examine what we are seeing in terms of the Metro clients flagging for risk and what are the commonalities among their risk factors among this population that reached out to us for help.

Yeah. And I think nobody wants this to happen, obviously, to their loved one or even in general. So everybody wants to know what's the magic formula to be able to figure this out. Now, one of the things that I've appreciated about Stop Soldier Suicide, in addition to your clinical work, have some other projects that are really aimed at doing exactly what you're talking about is maybe identifying some of the unique or dynamic risk factors such as the Black Box Project. I wonder if you could share more about that and maybe some other programs that you'd like to highlight.

Yeah, the Black Box Project is really our major project other than Roger Wellness. And when I think about Black Box, particularly the state to which it's evolved over the last 5 years, I think of this as really in terms of legacy. When I think of the work that I've done and so many good people in the field have done, both from a public health perspective and through clinical work, we know that we are pulling people out of the river, if you will, saving lives one at a time. But as, as we all know, being able to identify based on just a catalog of risk factors isn't very good at helping us know which person will die by suicide. And so we started this project with one hypothesis in mind, and that is if we could understand better what those private moments were like for people in the hours, days, weeks, and months before they died, we would be able to provide opportunities for us and for people that we could share our findings with to intervene earlier or in time. We know that for roughly half of people who die by suicide, that decision window is 10 minutes or less. And that doesn't necessarily align with a treatment appointment. We also know that when people get to that point, they may be even more reluctant to reach out for help for a number of reasons. So our theory was, if we could understand what those moments look like, we'll have better opportunities to intervene earlier and understand that journey. And so we began by collecting the devices of veterans who had taken their own lives donated to us by families who want to partner with us to solve this problem. And that really was the beginning of the Black Box Project. And so we worked with AWS and some other folks to build the infrastructure needed to extract the data off the devices, to run machine learning against it, and then begin to pull those insights together as to, okay, what does that private journey look like? Because somebody may present That's perfectly fine, as we well know in many cases, but they're struggling on the inside. And who is going to know or what is going to know that better than this device they interact with 100 times a day in ways that you can't understand from a public-facing perspective? And so that really is the platform that we've developed.

As I was thinking, you go back to your early work, 2001, I started this work clinically in the mid-teens and how it's evolved over time. One, we didn't have iPhones in 2001, right? You didn't have this device that you were carrying around. And so many of the ways that you could find these things out, whether somebody left a note or talking to family or things like that. But I think now we're at a place where, one, the technology, all the information is there on that device, but we also have the technology to make sense of it.

Yeah, yeah, absolutely. And In the middle of our journey from 5 years ago today, we've seen generative AI explode. And there are certainly dangers in that, but there's also opportunities as we try to struggle with how do we make those interfaces and interactions safer for people that increasingly rely on that. So we think that Blackbox will provide us with the ability to take the findings from it and apply those in a number of different constructs, one of which would be to help make that technology safer, but also the clinical insights part of it, which is, okay, what are we seeing in these private moments that can inform clinicians about things to be particularly aware of that may vary from what we currently understand about risk states and risk factors?

I think another thing that I really appreciate about this project is I have a colleague who says trying to understand the aftermath of a death by suicide is trying to make sense of the nonsense. You're saying that the families are donating these and they're very personal, right? They're very intimate, but they're donating this in an effort to ensure that other service members, veterans, don't reach this point themselves.

Yeah, 100%. I mean, one of our team members does nothing but work with these families to help them understand what this project is, to make sure that they are comfortable loaning us these devices, ensuring them that privacy first is a number one consideration for the work that we do, and that no personal identification would ever be disclosed beyond our organization. But The trust and the belief that these families have in their desire to make sure no other family goes through this kind of loss, which as you know, is unique to every kind of death. It's been an inspired experience for all of us working on this project to work with those families and appreciate their generosity to do this in a very difficult situation.

And I think that, and even as you mentioned with your own personal story, but many of us come into the field to ensure that No one else experiences the things that, that we experience. Perhaps some as attempt survivors, some as lost survivors. No, I think this is great. You have shared the website on the Roger Wellness, but if folks want to find out more about Stop Soldier Suicide in general, maybe the Black Box Project, how can they do that?

We just stood up a webpage. It's bbxproject.org. Anybody who is interested in the program, can go to. It shares the story of Black Box, but also the kind of the milestones and the direction and the individual projects that we have. And then for the larger organization, it's stopsoldiersuicide.org, stopsoldiersuicide, all one word,.org. Any of those sites that we mentioned will take you to more about the work that we're doing and how we're trying to make a difference in this space.

That's great. And I will make sure that links to all of those websites are in our show notes. Keith, thank you so much for coming on the show today.

No, thanks so much, Duane. I appreciate it.

If you're an organization that supports those who serve to those who care for them, we'd like to talk to you about sponsoring episodes of the show to share your efforts, as well as ensuring that we're going to be able to continue to provide great content with engaging guests. In our show notes, you'll see a link that says partnership opportunities, and you can send a message to our team to explore ways that you can support the show. If you'd like to provide some feedback and share your story about how you partner with PsychArmor to learn, grow, and support those who served and those who care for them, please click the share PsychArmor stories link in the show notes. This conversation with Keith reminded me how often people come into suicide prevention work because of something deeply personal. In Keith's case, it was the loss of his first wife. For many others in this field, there's a similar moment that changes the direction of their work. My own path into this work was shaped by a crisis intervention with a member of my own family. Experiences like that tend to change how you see the issue. Suicide stops being an abstract public health issue and becomes something very real and very pressing. That leads to my first reflection on this conversation. One of the things that Keith talked about was how suicide prevention has evolved over the last couple of decades. In the early 2000s, when he began this work, there was a growing realization that suicide wasn't just an individual problem. It was a public health issue. That shift mattered because it changed the kind of responses that people began to build. Instead of focusing only on individual awareness or crisis response, communities started building broader systems, coalition prevention strategies, outreach efforts, and clinical programs designed to intervene earlier. But Keith highlighted an important reality about this work. Even with the decades of research, predicting suicide is incredibly difficult. Someone may have all of the risk factors that indicate someone is likely to experience a suicidal crisis, and that person may not die by suicide. They might not even experience significant suicidal ideation. Another person may not have the known risk factors in their life and yet struggle with thoughts and behaviors related to suicidal self-injury. Keith talked about the difference between screening, assessment, and treatment. Screening tools are helpful, but they're really just an early signal. As I said during our conversation, they tell us that there might be smoke, but they don't necessarily tell us whether there's a fire. That's why clinical assessment matters. It takes time to understand a person's circumstances, their warning signs, their protective factors, and how all of those things interact in their own lives. And even then, suicide risk is not something that we can perfectly predict. As Keith mentioned, even with an assessment that indicates higher risk, we're barely better than a coin flip at predicting who might die by suicide. That can feel uncomfortable for people who want certainty. We all want a checklist. We want 5 warning signs that tell us exactly when someone is in danger. But suicide prevention doesn't really work that way. What we can do, and what organizations like Stop Soldier Suicide are trying to do, is build systems that increase the chances that someone gets the right help at the right time. That means identifying people who may be at elevated risk, doing deeper clinical assessments, then connecting them with evidence-based care. And that care isn't just to help them recover from past trauma or overcome their reactions to the stressors in their life that are related to known risk factors. The therapy and treatment is designed to teach them skills that would prevent or reduce the impact of future crises. The Roger Wellness Program that Keith described relies heavily on cognitive behavioral approaches that help veterans recognize when they're starting to move towards a dangerous place psychologically. The goal isn't just to get someone through a single crisis moment. It's to help them develop tools that they can use repeatedly throughout their lives. And that's important in suicide prevention because unlike some other challenges like homelessness, there isn't always a clear endpoint when the problem is permanently solved. Someone may learn to manage suicidal thoughts right now, and go years or decades without experiencing them again. But life circumstances can change. Stress, loss, health challenges, other factors can shift someone's risk later in life. So prevention is not just about intervening once. It's about helping people learn skills that help them navigate difficult moments whenever they arise. The second reflection that stayed with me from this conversation relates to the Black Box Project. What Stop Soldier Suicide is attempting with this project is fascinating. The idea is to better understand what someone's private experience looked like in the hours, days, weeks, or months leading up to their death. To do that, Stop Soldier Suicide is analyzing data from digital devices that family have donated after losing a loved one to suicide. And that's a remarkable act of generosity on the part of those families. As Keith mentioned, trying to understand suicide after the fact is challenging. Families are left with questions that don't often have clear answers. But many of them likely choose to participate in projects like this because they want something meaningful to come from their loss. They want the possibility that what happened to their loved one might help prevent another family from going through the same experience. What's also interesting is how technology has changed the landscape of suicide research. 20 or 30 years ago, the main ways researchers tried to understand suicide was through interviews or written notes, conversations with family members after the fact. Today, we all carry devices that capture a huge amount of information about our behavior—what we search for, what we read, who we communicate with, and how we interact with the world. Those devices may contain clues about someone's internal state that weren't visible to the people around them. The challenge now is figuring out how to responsibly use that information. There are obviously serious questions about privacy and ethics, and Keith and the team at Stop Soldier Suicide are keenly aware of those issues. But there is also real potential to learn things that we've never been able to see before. Patterns that might help clinicians, researchers, and technology companies identify earlier points where intervention could happen. And ultimately, that's the goal. As Keith said, a lot of suicide prevention today is about pulling people out of the river, intervening when someone is already in crisis. Work like the Black Box Project is trying to get ahead of that point earlier in the person's life, leading up to the point of crisis before they fall into the river in the first place. If we can better understand that journey, we may be able to recognize the warning signs earlier, intervene sooner, and create more opportunities for someone to get the help they need before they reach that point of crisis. And that's the work that has the potential to shape the future of suicide prevention for years to come. So I hope you appreciated this conversation with Keith. If you did, we'd appreciate hearing from you. Submit a review or comment on Spotify or Apple Podcasts. While you're there, hit the follow or subscribe button. It helps others find the show. You can also share your PsychArmor stories by clicking on the link in the show notes. For this week's PsychArmor Resource of the Week, I'd like to share the PsychArmor course, The Basics of Veteran Suicide Prevention. This course is designed to equip you with knowledge to make a difference, providing you with essential insights and practical abilities to positively impact your community by nurturing hope, healing, and resilience. You can find a link to the resource in our show notes. So thank you again for taking the time to listen to this episode. Make sure to take a look at the show notes, which you can find in the podcast app as well as on the PsychArmor website, psycharmor.org/podcast. While you're there, you can find hundreds of online training videos delivered by nationally recognized subject matter experts who are committed to educating the civilian community about military culture. All of these courses are free to individual learners. You wouldn't be listening if you didn't care, and it's that curiosity and passion for supporting service members and their families that we want to encourage and increase. Come back each week for another conversation and make sure to engage with PsychArmor on social media to let us know what you think about the show. I'd like to express special thanks to Operation Encore and Navy Seahawk pilot Jerry Maniscalco. For our theme song, Don't Kill the Messenger. This show was produced by Headspace and Timing, and all rights to the show remain reserved by PsychArmor. Much appreciation to the team at PsychArmor that makes this show happen. Carol Turner, Vice President of Strategic Communications, who keeps me on track and is an outstanding guest coordinator, and support and transcripts by Emma Atherall. Feel free to share the show. In fact, we ask that you do so, but make sure to let folks know where you heard it. Join us next time for another great episode, and until then, stay aware, get educated, and be well.