Stories - Blogs

Hopefully, the title hooked you. Now what am I talking about? And who is “us”? The “what” is conversations about firearm safety and suicide prevention. The “who” is healthcare providers. Let’s take a few steps back…

Why Firearm Safety Matters in Suicide Prevention

In the U.S. and military communities, firearms play a uniquely lethal role in suicide:

• Civilian deaths: Firearms account for ~52% of suicide deaths (Centers for Disease Control; CDC, 2024).
• Active-duty service members (Department of Defense; DOD, 2024):
  Firearms: 7% of attempts → 65% of deaths
  Self-poisoning (overdose): 54% of attempts →< 6% of deaths
• Lethality gap:
  Self-poisoning: ~2 in 10 attempts end in death
  Firearms: ~9 in 10 attempts end in death (Johns Hopkins, 2023; Wintemute, 2019)

Takeaway: Even if the number of attempts doesn’t change, reducing firearm access can save lives because of how disproportionately lethal firearms are. That points us toward one of the most effective interventions: Lethal Means Safety Counseling (LMSC), which includes conversations about firearm safety and suicide prevention.

The Trust Problem

If patients don’t trust us to have these conversations, we miss out on one of the most effective strategies to prevent suicide.

How do we know trust is low? Anestis and colleagues (2021) examined which messengers are most and least trusted when discussing firearms and suicide. The most trusted groups: military personnel, veterans, and law enforcement—all communities with firearm experience.

And who’s at the bottom? Us! Physicians and other medical professionals—just above casual acquaintances and celebrities. This pattern was consistent across gender, race, and gun ownership status. In other words, we are only slightly more trusted than strangers!

Other studies echo the theme. For example, half of firearm owners report believing it is never appropriate for healthcare providers to discuss firearms (Betz et al., 2016).

So—what’s driving this lack of trust, and what can we do about it? While we don’t have data explicitly outlining the pitfalls, we can extrapolate based on what we know about how trust is built (and eroded) in interactions with healthcare providers. Below four missteps are illustrated along with how to turn each into a rapport building-conversation.

Common Patient Concerns (and Solutions)

“We judge their choices.”→ Biased Communication
Example: A military spouse shares concerns about being alone at home with her children during her husband’s upcoming deployment. She’s excited about a firearm safety class she just completed in preparation for buying a gun for protection. The provider’s eyes widen:

“Wait—you have three small children at home. Is that really safe?”

Problem: The provider is communicating a biased opinion about gun owners with small children. This assumes that the patient is being inherently unsafe when she is actually discussing proactive steps to be a safe firearm owner. The message the patient hears:

“You are a bad parent; you are putting your children in danger!”

Trust building response:
“I’m glad you’re looking forward to the class. Firearm safety is especially important with kids in the home, and it sounds like you’ve already taken proactive steps, that’s awesome. So when does your husband deploy…”

Solution: Be culturally responsive. As providers, it is our responsibility to not only respect the values and norms of a patient’s culture (e.g., military-connected), but to also be aware of the intersectionality of different aspects of a patient’s identity (e.g., parent, military spouse, gunowner, etc.) within that culture.

Issue: “We want to take their guns.”→ Ignore Patient Autonomy
Example: A service member discloses suicidal thoughts without intent or plan. The provider responds:

“That’s concerning. You’ll need to turn your weapon over to your command until we can be sure you are safe.”

Problem: While reducing access to lethal means may ultimately be necessary, the unilateral approach strips autonomy and discourages future disclosure.

Trust building response:

“Sounds like things have been really difficult. Can you tell me more about what led to those thoughts? From there, we can come up with a plan together to help keep you safe during those tough times.”

Solution: Balance patient safety and autonomy. Conduct a thorough risk assessment with curiosity and concern, then collaborate to develop a Safety Plan with strategies the patient is both willing and able to implement.

Issue: “We don’t know anything about firearms.”→ Lack of Competence
Example: In 2015, an E3 preparing for a Permanent Change of Station (i.e., moving to a new duty station) worries about storing her firearms. The provider shrugs:

“That’s easy, just buy a gun safe and ship it with your household goods” (HHG).

Problem: This overlooks the cost of the safe itself, its weight, and the fact that safes counted against HHG weight allowances at the time—revealing a notable knowledge gap.

Trust building response:

“Let’s start with how you’re storing your firearms now. Then we can check local laws at your new duty station and figure out the best plan together.”

Solution: Be informed. You don’t need to be a firearm expert, but you do need to demonstrate competence in firearm safety basics and relevant regulations/laws. Online courses (e.g., virtual firearm safety, LMSC training) can help, as can familiarity with DoD and local regulations.

Issue: “We act like know-it-alls.”→ Maintaining the Knowledge Gap
Example: A patient says:

“I’m thinking of buying a gun. I don’t feel safe at home.”

The provider replies:

“Trust me, that’s not the way to stay safe. Get a dog instead.”

Problem: The asymmetrical tone conveys “I know better than you—this isn’t up for debate.” It dismisses the patient’s concern, weakens rapport, and misses an opportunity to bridge the knowledge gap between provider and patient.

Trust building response:
Provider:

“No one likes feeling unsafe at home. What’s making you feel this way?”

Patient:

“There’s been more crime in my neighborhood.”

Provider:

“I understand. I do worry about relying on firearms for protection, because research shows that having a gun at home can nearly triple the risk of homicide. Other security options can reduce break-ins without increasing risk of harm. Would you be open to talking through some of those together?”

Solution: Ask, explain, collaborate. Gather more information, share rationale, and avoid assumptions. Provide explanations to reduce asymmetry.

Closing Thought

We may not earn everyone’s trust overnight. But we can take steps—through cultural responsiveness, collaboration, competence, and transparency—to be worthy of the trust we are striving for. The trust it takes to save lives.

Resources
CALM (Counseling on Access to Lethal Means): Training offered by the Suicide Prevention Resource Center that provides information on how to have a discussion with patients about lethal means. (https://sprc.org/online-library/calm-counseling-on-access-to-lethal-means/)

Means Matter: Website from the Harvard T. H. Chan School of Public Health with resources & trainings on the topic of reducing suicidal individuals’ access to lethal means. (https://www.hsph.harvard.edu/means-matter/)

Defense Suicide Prevention Office: Webpage with a suite of lethal means safety tools. (https://www.dspo.mil/Home/Tools/Resource-Library/Lethal-Means-Safety/)

VA Lethal Means Safety & Suicide Prevention: Webpage with resources, including information on secure firearm storage. (https://www.va.gov/reach/lethal-means/)

“Let’s Talk about Your Guns” Podcast: A series of podcasts from the Center for the Study of Traumatic Stress about gun safety. (https://www.cstsonline.org/suicide-prevention-program/podcasts/lets-talk-about-your-guns)

Project Child Safe: Firearm safety education program that offers free educational resources, including gun locks. (https://projectchildsafe.org)

Stanford University - Clinicians and Firearms 2.0: This CME/CE course equips clinicians with the knowledge and communication strategies needed to discuss firearm injury prevention with patients effectively. It includes modules on firearm basics and safe storage. (https://online.stanford.edu/courses/som-ycme0051-clinicians-and-firearms-20-curriculum-firearm-injury-prevention-medical?utm_source=chatgpt.com)

BulletPoints Project - Preventing Firearm Injury: A free, self-paced course that takes about 60 minutes to complete. It provides an opportunity for participants to earn one Continuing Education (CE) credit. The course covers firearm injury prevention and safe storage options. (https://continuingeducation.bulletpointsproject.org/courses/preventing-firearm-injury/)

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.

Adria Williams, Ph.D., is a Military Behavioral Health Psychologist at the Center for Deployment Psychology (CDP) with the Uniformed Services University of the Health Sciences. Dr. Williams is a suicide prevention subject matter expert and trainer.

References

• Anestis, M. D., Bond, A. E., Bryan, C. J., Bryan, A. O., & Knox, K. L. (2021). Trust in healthcare providers and willingness to discuss firearm safety: Results from a national survey. Preventive Medicine, 145, 106445. https://doi.org/10.1016/j.ypmed.2020.106445
• Betz, M. E., Miller, M., Barber, C., Beaty, B., & Miller, I. (2016). Lethal means access and assessment among suicidal emergency department patients. Depression and Anxiety, 33(6), 502–511. https://doi.org/10.1002/da.22486
• Centers for Disease Control and Prevention (CDC). (2024). Suicide mortality in the United States, 2000–2022. NCHS Data Brief, No. 509. https://www.cdc.gov/nchs/products/databriefs/db509.htm
• U.S. Department of Defense, Defense Suicide Prevention Office. (2024, November 14). Annual Report on Suicide in the Military, Calendar Year 2023 (ARSM CY 2023). https://www.dspo.mil/Portals/113/2024/documents/annual_report/ARSM_CY23_final_508c.pdf
• Wintemute, G. J. (2019). The epidemiology of firearm violence in the twenty-first century United States. Annual Review of Public Health, 40, 5–19. https://doi.org/10.1146/annurev-publhealth-031914-122535

by Ariana Bazzi and Jaime Rodden

An exciting collaboration between the Uniformed Services University Department of Medical and Clinical Psychology and the Center for Deployment Psychology is investigating a standardized training program for eating disorders within military settings.

About the PreparED Study
The PreparED study centers around a standardized online educational program on eating disorders. The 85 minute course consists of an introduction by Dr. Tanofsky-Kraff describing the unique presentation of eating disorders in military populations followed by modules on Assessment, Medical Complications, Treatment, and Military-Relevant Considerations. Ultimately, the PreparED curriculum is intended to give healthcare providers a clear and comprehensive all-in-one guide to understanding eating disorders in the military.

The Big Picture
Eating disorders appear at higher rates among our service members compared to the general population. This increased vulnerability is often tied to the unique pressures of military life, such as constant exposure to high-stress environments, and the significant impact of conditions including, but not limited to posttraumatic stress disorder and major depressive disorder. To address this critical need, Columbia University Medical Center, has developed a publicly accessible online course and partnered with our study team to train military providers. The curriculum is designed specifically for future healthcare professionals, including students and trainees to provide them with the essential knowledge and practical tools to better understand, identify, and support individuals affected by eating disorders, ultimately aiming to improve care for those who have served.

Participant Eligibility and Study Activities
Medical providers and providers from the Defense Health Agency (DHA) serving as a primary care or other direct care provider to military-connected patients are eligible to participate in the study. Participants are provided with a SurveyMonkey link to take a pre-survey. Participants are then asked to complete the online 70 minute course and post-course survey within a month from completion of the pre-survey.

Get Involved
For more information about the PreparED study, visit our website at https://deploymentpsych.org/Eating-Disorders-Base or reach out to the Research Assistant Ariana at Ariana.Bazzi.ctr@usuhs.edu To participate in the study, review the informed consent document: https://www.surveymonkey.com/r/QXSTNH2

By Marjorie Weinstock, Ph.D.

In our suicide prevention trainings at CDP, we discuss current theories of suicide risk, specifically emphasizing those of that fall within the “ideation-to-action framework” (Klonsky & May, 2016). This framework posits that the development of suicidal ideation and the progression from ideation to suicide attempts are distinct processes with distinct explanations. In conjunction with this discussion, we also spend a substantial amount of time talking about risk and protective factors, both in the civilian population and among military-connected individuals.

Given that context, I wanted to share an article I recently read that looks specifically at risk and protective factors distinguishing U.S. veterans with a history of suicidal ideation from those who have made a suicide attempt (Cenker & Zalta, 2025). These authors analyzed data from 620 veterans with a history of suicidal ideation or attempts; this sample was drawn from the Military Health and Well-Being Project, a national survey of approximately 1,500 post-Vietnam U.S. veterans.

Cenker and Zalta found that veterans with a history of past attempts reported higher levels of moral injury, loneliness, and substance use than those who had only experienced suicidal ideation. In addition, those with past attempts also reported lower levels of meaning and purpose in life and lower levels of social support. These findings suggest that the transition from suicidal thoughts to behavior in veterans is associated with more intense psychosocial stressors alongside fewer protective resources.

Last year during Suicide Prevention month, I wrote a blog looking at suicide risk during the transition from military to civilian life. Data has shown that the first year following separation from the military is one of increased risk for Service members (U.S. Department of Veterans Affairs, 2024). During this period of transition, Service members may experience disruptions of personal identity, including a sharp contrast between military and civilian values (Sokol, et al., 2021). They may also experience disruptions to social connections during this period of transition, including a simultaneous loss of military social connections and difficulty rebuilding civilian ones (Sokol, et al., 2021). Thus, Cenker and Zalta’s (2025) findings, which highlight the protective nature of both meaning and purpose in life and social support, provide additional evidence that these are particularly salient clinical targets in this population.

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.

Marjorie Weinstock, Ph.D., is a counseling psychologist currently serving as an Associate Director at the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.

References:
 Cenker, D. P., & Zalto, A. K. (2025). Risk and protective factors that distinguish United States
      veterans with a history of suicidal ideation and suicide attempt. Journal of Psychiatric
      Research, 188, 126-132. https://doi.org/10.1016/j.jpsychires.2025.05.059
 Klonsky, D.E., May, A. M., & Saffer, B. Y. (2016). Suicide, suicide attempts, and suicidal
      ideation. Annual Review of Clinical Psychology, 12(1), 307-330.
      https://doi.org/10.1146/annurev-clinpsy-021815-093204
 Sokol, Y., Gromatsky, M., Edwards, E. R., Greene, A. L., Geraci, J. C., Harris, R. E., & Goodman,
      M. (2021). The deadly gap: Understanding suicide among veterans transitioning out of
      the military. Psychiatric Research, 300, 113875.
      https://doi.org/10.1016/j.psychres.2021.113875
 U.S. Department of Veterans Affairs, Office of Suicide Prevention. (2024). 2024 National
      veteran suicide prevention annual report: Part 2 of 2: Report findings.
      https://www.mentalhealth.va.gov/docs/data-sheets/2024/2024-Annual-Report-Part-2-
      of-2_508.pdf

In our suicide prevention trainings at CDP, we discuss current theories of suicide risk, specifically emphasizing those of that fall within the “ideation-to-action framework” (Klonsky & May, 2016). This framework posits that the development of suicidal ideation and the progression from ideation to suicide attempts are distinct processes with distinct explanations. In conjunction with this discussion, we also spend a substantial amount of time talking about risk and protective factors, both in the civilian population and among military-connected individuals.

Given that context, I wanted to share an article I recently read that looks specifically at risk and protective factors distinguishing U.S. veterans with a history of suicidal ideation from those who have made a suicide attempt (Cenker & Zalta, 2025). These authors analyzed data from 620 veterans with a history of suicidal ideation or attempts; this sample was drawn from the Military Health and Well-Being Project, a national survey of approximately 1,500 post-Vietnam U.S. veterans.

Cenker and Zalta found that veterans with a history of past attempts reported higher levels of moral injury, loneliness, and substance use than those who had only experienced suicidal ideation. In addition, those with past attempts also reported lower levels of meaning and purpose in life and lower levels of social support. These findings suggest that the transition from suicidal thoughts to behavior in veterans is associated with more intense psychosocial stressors alongside fewer protective resources.

Last year during Suicide Prevention month, I wrote a blog looking at suicide risk during the transition from military to civilian life. Data has shown that the first year following separation from the military is one of increased risk for Service members (U.S. Department of Veterans Affairs, 2024). During this period of transition, Service members may experience disruptions of personal identity, including a sharp contrast between military and civilian values (Sokol, et al., 2021). They may also experience disruptions to social connections during this period of transition, including a simultaneous loss of military social connections and difficulty rebuilding civilian ones (Sokol, et al., 2021). Thus, Cenker and Zalta’s (2025) findings, which highlight the protective nature of both meaning and purpose in life and social support, provide additional evidence that these are particularly salient clinical targets in this population.

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.

Marjorie Weinstock, Ph.D., is a counseling psychologist currently serving as an Associate Director at the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.

References:
Cenker, D. P., & Zalto, A. K. (2025). Risk and protective factors that distinguish United States
veterans with a history of suicidal ideation and suicide attempt. Journal of Psychiatric
Research, 188, 126-132. https://doi.org/10.1016/j.jpsychires.2025.05.059
Klonsky, D.E., May, A. M., & Saffer, B. Y. (2016). Suicide, suicide attempts, and suicidal
ideation. Annual Review of Clinical Psychology, 12(1), 307-330.
https://doi.org/10.1146/annurev-clinpsy-021815-093204
Sokol, Y., Gromatsky, M., Edwards, E. R., Greene, A. L., Geraci, J. C., Harris, R. E., & Goodman,
M. (2021). The deadly gap: Understanding suicide among veterans transitioning out of
the military. Psychiatric Research, 300, 113875.
https://doi.org/10.1016/j.psychres.2021.113875
U.S. Department of Veterans Affairs, Office of Suicide Prevention. (2024). 2024 National
veteran suicide prevention annual report: Part 2 of 2: Report findings.
https://www.mentalhealth.va.gov/docs/data-sheets/2024/2024-Annual-Report-Part-2-
of-2_508.pdf

13x
The factor by which "(o)lder men are more likely to die by firearm suicide compared with older women," according to an article in JAMA Network Open -- Sex Differences in Trends of Firearm Suicide Among Older Adults, 2014 to 2023. "However," the article points out, "female gun ownership has surged in recent years, with nearly one-half of all new gun owners being women.

This cross-sectional study reveals an increasing trend of suicide deaths by firearm among older women. Although the firearm suicide rate and FS/S ratio among older men remain high, the trend among older women may have important long-term implications. The proportion of older adults in the US is projected to grow from 17.3% in 2022 to 21.6% by 2040, with women accounting for a larger share of this increase. Research has shown a steady decline in the FS/S ratio among women from 41.5% in 1991 to 35.3% in 2013. However, our analysis of data from 2014 to 2023 highlights a significant upward trend among older women, suggesting a narrowing sex gap in firearm suicide that aligns with changes in gun ownership demographics.

By Linda Thompson, Ph.D.

Suicide is a serious public health concern, especially for young adults who have experienced trauma. While a history of trauma can be a risk factor for suicide, we have a limited understanding of the specific mechanisms through which stress responses might contribute to this heightened risk. In a recent study, my colleagues and I investigated the links between suicidal thoughts and behaviors, and how individuals respond emotionally and physically to stress. Ninety-four undergraduate students (Mage​=20.30; 61.7% women) were selected based on their lifetime exposure to at least one DSM-5 defined traumatic event.

The Study’s Approach
 To see how participants reacted to stress, they completed two different breathing tasks in a controlled experimental lab setting:

• Voluntary Hyperventilation Challenge: This task involved breathing rapidly for three minutes. It’s designed to bring on physical sensations like fast heart rate or feeling lightheaded, which can sometimes trigger memories of traumatic events.
• Normal Breathing Control Task: This was a comparison task, similar in setup but with a regular calm breathing rate.

Throughout these tasks, we measured:

• Suicidal Thoughts and Behaviors: Participants completed the Suicide Behaviors Questionnaire-Revised at baseline, which asks about four key areas: suicidal thoughts or attempts over their lifetime, suicidal thoughts in the past year, threatening a suicide attempt, and how likely they felt to attempt suicide in the future.
• Self-Reported Psychological and Physiological Reactivity: Participants rated how they felt emotionally (e.g., helplessness, feeling unreal, urge to escape) and physically (e.g., tingling, shaking, chest pain, lightheadedness) using a part of the Panic Attack Questionnaire before and after each breathing task. We created a single "stress score" for each participant by subtracting their symptom change during the normal breathing task from their symptom change during the fast breathing task.

Key Findings

• Emotional Reactions Linked to Suicidal Ideation: Past-year suicidal ideation was significantly and positively associated with self-reported psychological reactivity to stress. This suggests that individuals reporting suicidal thoughts in the past year experienced a greater emotional distress during the stress-inducing task.
• No Clear Link to Physical Reactions: None of the four dimensions of suicidality, including past-year ideation, were associated with self-reported physiological reactivity to stress.

Conclusions
 Our findings suggest that more recent suicidal ideation might be uniquely connected to a heightened emotional response to stress. This could be explained by how individuals with current suicidal thoughts interpret or “appraise” stressful events, perhaps seeing them as more threatening or overwhelming. Interestingly, we didn't see a link between suicidal thoughts or behaviors and self-reported physical reactions to stress. One possible explanation for this is a growing body of research on interoceptive deficits, which suggests that people at risk for suicide might have a reduced awareness of their body's internal signals. For example, their heart rate could rise during stress, but they might not consciously notice it as others would. This disconnect between mind and body could be even more pronounced in those who have previously attempted suicide. However, more research is needed, especially using physiological measures to more objectively assess an individual's stress response.

Clinical Takeaway
 Understanding these specific patterns of reactivity can aid in developing more focused and effective support programs. This may include prioritizing the assessment of recent suicidal ideation and exploring how individuals interpret everyday stressors. These insights can directly inform treatment planning and guide the selection and development of interventions aimed at improving coping and reducing distress. It also highlights a growing interest in strategies that help people connect with and understand their bodily sensations, especially when they have a reduced awareness of these signals.

Limitations
 It’s important to note that this study, like all research, has its limitations. The study's findings are based on self-reported physical reactions, and suicidal thoughts and behaviors were assessed at baseline rather than as a component of the experimental design. The study's population was also limited to trauma-exposed undergraduate students with recent alcohol use (part of a larger project). These characteristics are important to keep in mind when thinking about how broadly these findings apply to other populations.

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.

Linda Thompson, Ph.D., is a Postdoctoral Fellow with the Center for Deployment Psychology. Dr. Thompson earned her doctorate in Behavioral Science, Psychology from the University of North Texas and a master’s degree in Psychology from San Diego State University.

Study Reference
 Thompson, L. M., Kearns, N. T., Rafiuddin, H. S., Contractor, A. A., & Blumenthal, H. (2025).
      Associations of Suicidal Thoughts and Behaviors with Psychological and Physiological
      Reactivity to a Hyperventilation Task Among Trauma-Exposed Emerging Adults.
      Archives of Suicide Research, 1–16. https://doi.org/10.1080/13811118.2025.2524414

Additional References
 Kearns, N. T., Blumenthal, H., Contractor, A. A., Guillot, C. R., & Rafiuddin, H. (2021). Effects of
      bodily arousal on desire to drink alcohol among trauma-exposed college students.
      Alcohol, 96, 15–25. https://doi.org/10.1016/j.alcohol.2021.07.002
 Norton, G. R., Harrison, B., Hauch, J., & Rhodes, L. (1985). Characteristics of people with
      infrequent panic attacks. Journal of Abnormal Psychology, 94(2), 216–221.
      https://doi.org/10.1037//0021-843x.94.2.216
 Osman, A., Bagge, C. L., Gutierrez, P. M., Konick, L. C., Kopper, B. A., & Barrios, F. X. (2001).
      The Suicidal Behaviors Questionnaire-Revised (SBQ-R): Validation with clinical and
      nonclinical samples. Assessment, 8(4), 443–454.
      https://doi.org/10.1177/107319110100800409

Suicide is a serious public health concern, especially for young adults who have experienced trauma. While a history of trauma can be a risk factor for suicide, we have a limited understanding of the specific mechanisms through which stress responses might contribute to this heightened risk. In a recent study, my colleagues and I investigated the links between suicidal thoughts and behaviors, and how individuals respond emotionally and physically to stress. Ninety-four undergraduate students (Mage​=20.30; 61.7% women) were selected based on their lifetime exposure to at least one DSM-5 defined traumatic event.

The Study’s Approach
To see how participants reacted to stress, they completed two different breathing tasks in a controlled experimental lab setting:

• Voluntary Hyperventilation Challenge: This task involved breathing rapidly for three minutes. It’s designed to bring on physical sensations like fast heart rate or feeling lightheaded, which can sometimes trigger memories of traumatic events.
• Normal Breathing Control Task: This was a comparison task, similar in setup but with a regular calm breathing rate.

Throughout these tasks, we measured:

• Suicidal Thoughts and Behaviors: Participants completed the Suicide Behaviors Questionnaire-Revised at baseline, which asks about four key areas: suicidal thoughts or attempts over their lifetime, suicidal thoughts in the past year, threatening a suicide attempt, and how likely they felt to attempt suicide in the future.
• Self-Reported Psychological and Physiological Reactivity: Participants rated how they felt emotionally (e.g., helplessness, feeling unreal, urge to escape) and physically (e.g., tingling, shaking, chest pain, lightheadedness) using a part of the Panic Attack Questionnaire before and after each breathing task. We created a single "stress score" for each participant by subtracting their symptom change during the normal breathing task from their symptom change during the fast breathing task.

Key Findings

• Emotional Reactions Linked to Suicidal Ideation: Past-year suicidal ideation was significantly and positively associated with self-reported psychological reactivity to stress. This suggests that individuals reporting suicidal thoughts in the past year experienced a greater emotional distress during the stress-inducing task.
• No Clear Link to Physical Reactions: None of the four dimensions of suicidality, including past-year ideation, were associated with self-reported physiological reactivity to stress.

Conclusions
Our findings suggest that more recent suicidal ideation might be uniquely connected to a heightened emotional response to stress. This could be explained by how individuals with current suicidal thoughts interpret or “appraise” stressful events, perhaps seeing them as more threatening or overwhelming. Interestingly, we didn't see a link between suicidal thoughts or behaviors and self-reported physical reactions to stress. One possible explanation for this is a growing body of research on interoceptive deficits, which suggests that people at risk for suicide might have a reduced awareness of their body's internal signals. For example, their heart rate could rise during stress, but they might not consciously notice it as others would. This disconnect between mind and body could be even more pronounced in those who have previously attempted suicide. However, more research is needed, especially using physiological measures to more objectively assess an individual's stress response.

Clinical Takeaway
Understanding these specific patterns of reactivity can aid in developing more focused and effective support programs. This may include prioritizing the assessment of recent suicidal ideation and exploring how individuals interpret everyday stressors. These insights can directly inform treatment planning and guide the selection and development of interventions aimed at improving coping and reducing distress. It also highlights a growing interest in strategies that help people connect with and understand their bodily sensations, especially when they have a reduced awareness of these signals.

Limitations
It’s important to note that this study, like all research, has its limitations. The study's findings are based on self-reported physical reactions, and suicidal thoughts and behaviors were assessed at baseline rather than as a component of the experimental design. The study's population was also limited to trauma-exposed undergraduate students with recent alcohol use (part of a larger project). These characteristics are important to keep in mind when thinking about how broadly these findings apply to other populations.

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.

Linda Thompson, Ph.D., is a Postdoctoral Fellow with the Center for Deployment Psychology. Dr. Thompson earned her doctorate in Behavioral Science, Psychology from the University of North Texas and a master’s degree in Psychology from San Diego State University.

Study Reference
Thompson, L. M., Kearns, N. T., Rafiuddin, H. S., Contractor, A. A., & Blumenthal, H. (2025).
Associations of Suicidal Thoughts and Behaviors with Psychological and Physiological
Reactivity to a Hyperventilation Task Among Trauma-Exposed Emerging Adults.
Archives of Suicide Research, 1–16. https://doi.org/10.1080/13811118.2025.2524414

Additional References
Kearns, N. T., Blumenthal, H., Contractor, A. A., Guillot, C. R., & Rafiuddin, H. (2021). Effects of
bodily arousal on desire to drink alcohol among trauma-exposed college students.
Alcohol, 96, 15–25. https://doi.org/10.1016/j.alcohol.2021.07.002
Norton, G. R., Harrison, B., Hauch, J., & Rhodes, L. (1985). Characteristics of people with
infrequent panic attacks. Journal of Abnormal Psychology, 94(2), 216–221.
https://doi.org/10.1037//0021-843x.94.2.216
Osman, A., Bagge, C. L., Gutierrez, P. M., Konick, L. C., Kopper, B. A., & Barrios, F. X. (2001).
The Suicidal Behaviors Questionnaire-Revised (SBQ-R): Validation with clinical and
nonclinical samples. Assessment, 8(4), 443–454.
https://doi.org/10.1177/107319110100800409

By Jenny Phillips, Ph.D.

As noted by the VA’s National Center for PTSD, the majority of research into defining and understanding moral injury (MI) has been conducted with military service members and veterans, given that military-related experience tend to put people at greater risk for encountering potentially morally injurious events (PMIEs). Military PMIEs include many aspects of military service and combat, including killing or harming others, developing strategies or decisions that put others at risk, experiencing conflicting emotions when harming or killing others, and having to select or triage injured comrades with limited medical resources.

With the relatively high prevalence of MI in the general military having been established, a significant emphasis of research on MI in the military has been on identifying methods/tools for assessment and developing interventions for effective treatment. One critical aspect that is often overlooked though, is the consideration of situations where the doctor becomes the patient, or when health care providers experience MI themselves. This topic has become a bit better understood with the publication of two papers, one narrative review and one qualitative study, both examining MI in military medical personnel.

The first of these two publications is a review of MI across studies that included medical personnel and first responders from a diverse sampling of health care and emergency response professions (Rimon & Shetlef, 2025). The authors sought to better understand aspects of MI prevalence, risk, and outcomes within these populations. Although studies that focused exclusively on military populations were excluded, papers that included populations with military backgrounds, health care settings within military institutions, and outcomes relevant to military personnel were represented in the review and discussed by the authors. They noted that the reviewed studies identified unique challenges faced by military health care providers, including hierarchical decision making and dual obligations to mission and patients as contributing to elevated risk for MI in this group (Rimon & Shetlef, 2025). Several also discussed the frequent exposure of military clinicians to PMIEs in combat zones and operational environments. The authors note that military providers may experience conflict between their roles as a caregiver and as a service member, potentially forcing them to put mission over individual moral judgement and to follow orders that may conflict with professional and medical ethical standards. As a result, MI in military providers is frequently associated with symptoms such as sleep disturbances, anger, guilt, and long-term emotional distress (Rimon & Shetlef, 2025).

While the Rimon & Shetlef review takes a high-level approach to characterizing and understanding MI in military providers, a smaller qualitative study by Cole and colleagues (2025) examined MI on a much more personal level. A dozen military medical providers participated in semi-structured interviews about their experiences as military medical officers and their perceptions of moral injury. Through analysis of participant responses, the authors identified three primary themes regarding how military physicians experience moral injury (Cole, Shumaker, & Rudinsky, 2025). The first was an inability to provide standard of care that hindered their ability to fulfill the Hippocratic Oath. Within this theme, providers identified their position under their commander within the command hierarchy and a lack of resources in austere operational environments as contributing to an inability to provide adequate care. The second theme revolved around the ambiguity of caring for foreign nationals in both humanitarian and combat missions. When rendering humanitarian aid, some participants noted distress around leaving the situation without providing adequate follow-up care or feelings that the effort was primarily for show or diplomacy, not true impact. In combat situations, providers cited MI from conflicting thoughts and emotions around providing medical aid to enemy combatants and detainees. The final theme was personal impact, focused primarily on reconciling their own sense of morality with their military mission, resulting in cognitive dissonance, a loss of personal identity, and often MI (Cole, Shumaker, & Rudinsky, 2025). The authors go on to provider recommendations for better supporting and preparing military medical providers to cope when faced with these issues and dilemmas.

Fortunately, there are resources for health care providers, whether military or civilian, who are experiencing MI. While not military-specific, one helpful source for thinking about MI in medical providers is the Moral Injury in Health Care Workers website from the VA’s National Center for PTSD. Here you can find more information about potential sources and impacts of MI in health care workers, as well as self-care recommendations and support strategies for co-workers and leaders. The Consortium for Defense Psychology (CDP) also has links to recorded webinars on Adaptive Disclosure-Enhanced (AD-E) and Acceptance and Commitment Therapy for Moral Injury (ACT-MI), both strategies for addressing MI that can be used with affected health care workers.

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.

Jenny Phillips, Ph.D., is the Associate Director of Program Evaluation for the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, MD.

References:
 Cole, R., Shumaker, J. T., & Rudinsky, S. L. (2025). “It’s there and you’re changed forever”: military
      physicians’ perceptions of moral injury. Journal of Military Ethics, 1-13.
 Rimon, A., & Shelef, L. (2025). Moral Injury Among Medical Personnel and First Responders Across
      Different Healthcare and Emergency Response Settings: A Narrative Review. International Journal of
      Environmental Research and Public Health, 22(7), 1055.

By Paula Domenici, Ph.D.

Moral injury remains a murky concept, despite the growing body of literature on this important topic. While there’s not a consensus on exactly what moral injury is, Phelps et al. (2024) describe it as enduring psychological, social, and spiritual distress that can occur when individuals are exposed to high-pressure situations that violate or clash with their deeply-held moral beliefs or values. Moral injury may stem from one’s own actions or inactions, the actions of others, or a perceived betrayal by trusted leaders or institutions. In military contexts, including those with complex rules of engagement, moral injury may occur after engaging in or witnessing acts that conflict with one’s sense of right and wrong, such as causing harm to civilians, being unable to prevent the loss of life, seeing human suffering, or feeling deeply misled by command.

Litz et al. (2022) nicely differentiate moral injury from moral distress, noting that moral injury requires exposure to potentially morally injurious events (PMIEs) that involve both agentic acts (committing or failing to prevent transgressions oneself) and non-agentic experiences (witnessing or being directly affected by others' transgressions). In contrast, moral stress involves exposure to moral stressors that are less severe or lower-magnitude transgressive experiences. Moral distress is a preclinical condition with less functional impairment than moral injury.

Refinements in the definition of moral injury like those mentioned above, as well as the development of psychometrically-validated measures, are helping us better understand this concept. The Moral Injury Outcomes Scale (MIOS; Litz et al., 2022) has individuals consider whether they have been exposed to different types of PMIEs, and if they have, they proceed to respond to 14 items based on two subscales: shame and trust violation. Afterwards, they indicate the impact of moral injury symptoms on different aspects of their life by responding to an eight-item functional outcome measure adapted from the Brief Inventory of Psychosocial Functioning. Learn more about the MIOS here: https://sites.bu.edu/litzlab/additional-resources-on-moral-injury/.

Last year, I wrote about another useful self-report measure called the Moral Injury and Distress Scale (MIDS; Norman, Griffin, Pietrzak, McLean, Hamblen, & Maguen, 2024). Discover more about it here: https://ptsd.va.gov/professional/assessment/te-measures/mids.asp.

Between 2-10 November 2023, Litz et al. used the MIOS to survey a nationally representative sample of 3,002 U.S. veterans online about exposure to PMIEs and identify rates of moral distress and moral injury. The results are hot off the press (Litz et al., 2025). The goal was to estimate the prevalence and significance of these conditions to help educate clinicians and inform future directions in the field. The authors stress that “understanding the prevalence and characteristics of moral distress and moral injury is essential for tailoring prevention efforts, supporting affected individuals, and informing clinical and policy decisions.” Based on the survey results, 44.7% of the respondents endorsed PMIEs. What do you think about this rate? Are you surprised? More specifically:

• 45.2% reported non-agentic experiences in which they witnessed others’ transgressions
• 40.2% reported non-agentic experiences in which they were directly affected by others’ transgressions
• 14% reported agentic experiences in which they committed or failed to prevent transgressions

Interestingly, exposure to PMIEs was more likely among veterans who were female, younger, lower-income, unmarried, and had some college education. PMIE exposure was also more likely to be reported by veterans who had deployed to a warzone or held junior enlisted ranks. According to the authors, these findings suggest that exposure to PMIEs is not an inevitable part of military service. In other words, we shouldn’t make the assumption that all service members experience PMIEs. Why veterans with these backgrounds were more apt to experience PMIEs is unclear. Also, I’m curious if those who completed the survey may have underreported PMIEs, particularly PMIEs involving acts of perpetration.

With respect to rates of moral distress and moral injury in the full sample, these were relatively low. The prevalence was 4.1% for moral distress and 5.9% for moral injury. Keep in mind that lower overall rates were expected, since veterans who did not endorse PMIEs were included in the rates but were not at risk for these conditions. However, even among those who reported experiencing PMIEs, the rates were not very high—9.1% for moral distress and 13.1% for moral injury. The authors suggest that these relatively low rates underscore that, like PTSD, moral distress and moral injury are tied to specific stressful events and that PMIE exposure, in and of itself, does not automatically lead to moral distress or moral injury. At the same time, for those who suffer from moral distress or moral injury, providing access to psychoeducation, support, and treatment is critical. Additionally, it’s essential when working with clients that we try to prevent moral distress from morphing into moral injury—a much more debilitating and enduring condition.

Certain factors were associated with a greater likelihood of moral injury, including Hispanic ethnicity, not being married, older age, and endorsing agentic PMIEs (events involving committing or failing to prevent transgressions). Moral distress was more likely among those veterans who were female, older, had deployed to warzones (especially multiple times), and those who had experienced agentic PMIEs. Based on these findings, the authors propose that moral distress and moral injury are shaped by a person’s characteristics and social support, as well as occupational, structural, and broader institutional factors that influence how they process and recover from transgressive experiences. I’m glad to see research results like this on prevalence rates in veterans, yet the findings reveal we have much more to uncover.

Additional Resources
 For more information about moral injury, visit the National Center for PTSD: https://www.ptsd.va.gov/understand/related/moral_injury_ptsd.asp

For a practical book on moral injury, with chapters dedicated to different clinical approaches for helping clients with moral injury, check out Addressing Moral Injury in Clinical Practice: https://www.apa.org/pubs/books/addressing-moral-injury-clinical-practice

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.

Paula Domenici, Ph.D., is the Director, Civilian Public & Private Partnerships (CP3) at the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. She oversees the development of courses and training programs for providers on evidence-based treatments for service members and veterans.

References
 Litz, B. T., Plouffe, R. A., Nazarov, A., Murphy, D., Phelps, A., Coady, A., Houle, S. A., Dell, L.,
      Frankfurt, S., Zerach, G., & Levi-Bels, Y., and the Moral Injury Outcome Scale Consortium.
      (2022). Defining and assessing the syndrome of moral injury: Initial
      findings of the moral injury outcome scale consortium. Frontiers in Psychiatry,
      13, 923928. https://doi.org/10.3389/fpsyt.2022.923928

Litz, B. T., Walker, H. E., Pietrzak, R. H., Rusowicz-Orazem, L. (2025), The prevalence of moral
      distress and moral injury among U.S. veterans, Journal of Psychiatric Research, 189,
      435-444. https://doi.org/10.1016/j.jpsychires.2025.06.031

Norman, S. B., Griffin, B. J., Pietrzak, R. H., McLean, C., Hamblen, J. L., & Maguen, S. (2024).
      The moral injury and distress scale: Psychometric evaluation and initial validation in
      three high-risk populations. Trauma Psychology: Theory, Research, Practice, and Policy,
      16(2), 280-291. https://doi.org/10.1037/tra0001533

Phelps, A., Adler, A. B., Belanger, S. A., Bennet, C., Cramm, H., Dell, L., Fikretoglu, D., Forbes,
      D., Heber, A., Hosseiny, F., Morganstein, J. C., Murphy, D., Nazarov, A., Pedlar, D.,
      Richardson, J. D., Sadler, N., Williamson, V., Greenberg, N., & Jetly, R. (2024).
      Addressing moral injury in the military. BMJ Military Health, 170(1),
      51-55. http://dx.doi.org/10.1136/bmjmilitary-2022-002128

By Kristyn Heins, Ph.D.

Any parent would tell you the “why” questions start when we are young, usually around two- or three-years-old. The constant need to know the reason behind function, choices, and existence is inherent in us. We want to understand, and maybe if we can understand something, we feel more comfortable with it. The question of “why” helps us understand our surroundings, and this curiosity keeps us learning and growing. As we get older our “whys” tend to become more existential or morality based. Questions like why do people act the way they do, or why do I struggle with right and wrong? These create an opportunity for personal growth and introspection. But what about when we cannot explain things? What if there is no ability to answer, “why”? The loss of a loved one to suicide can create this eternal, uncertain “why”.

When we can answer a “why” question we feel more in control, perhaps more certain. But there are many situations in life where we cannot find these answers. Why do bad things happen to good people? Why do we experience suffering? Why do we exist? The lack of certainty or answers for these questions can cause significant emotional distress or internal turmoil. When thinking about suicide, we are faced with many unanswered “whys”. Why didn’t they tell me how they felt? Why didn’t they ask for help? Why was there no other option? For surviving family members, these “whys” can complicate, elongate the grief process, and even impact their ability to return to some resemblance of normal. How do we as clinicians, or even as friends or family help people navigate this vexing cycle of the unknown?

As a provider, when someone comes for help after the loss of a loved one to suicide, we may assume a normal grief and loss process. We can work through Kubler- Ross’s stages, we can tell them there is no right timeline for grieving, we can process emotions, but what we cannot do is answer their question of “why.” Because we really do not know why people die by suicide. We have theories of suicide, we know risk factors, we can identify warning signs, but this is one of life’s “why” questions that we cannot answer with firm scientific data. The reality is, even with insight into stressors and symptoms, even if a note is left, we never know what that final thought was. We need to be able to support our clients in their struggle to understand why, and also assist them with accepting the lack of resolution.

So how can we start this process of addressing the lingering why questions? At the core of all therapy is positive unconditional regard. Suicide can carry a stigma that other losses, like terminal illness or accidental death, do not. Family and friends may even question if it is acceptable for them to openly grieve. Normalizing this concern, and providing the supportive environment to grieve is a key component for processing. Addressing the existential piece can be more complex and difficult to navigate. Sometimes the unknown can help provide comfort, if reframed in a useful way. While we do not have a definite answer for why, this allows us to create our own narrative that brings peace. We get to decide how we understand the circumstances and accept them. For example a family member may be able to emotionally accept a death by suicide when put in context with physical suffering, loss of job, or other extreme stressors, even if these factors were only a piece of the situation. When we choose to write the narrative of understanding, we get to assign the meaning. We accept the view that helps us cope and brings understanding.

With acceptance of the unknown, or creating a narrative that helps with coping, we can focus on addressing the other complexities that arise after a loss from suicide. A suicide can cause post-traumatic stress disorder symptoms, and trauma focused treatment may help with processing. Families may benefit from systems therapy, particularly as the system has been altered. Cognitive therapy can be utilized to address unhelpful thought patterns and work to increase resocialization. When someone is able to reach a point of acceptance, they can move into more targeted therapies.

Working with our patients, we can focus on finding the narrative that brings enough resolution that they can start to think about the future, and what forward movement looks like for them. These lingering questions of “why” may continue to arise, but with support, understanding, and a narrative that brings solace, surviving family members may start to see a path forward.

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.

Kristyn Heins, Ph.D., is a Licensed Professional Counselor serving as a Military Behavioral Health Counselor for the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. In this role, she supports the CDP’s efforts of training clinicians in evidenced-based practice focused on suicide prevention.