This story has been updated.

In a letter last week to the Secretary of Veterans Affairs, 35 U.S. Senators urged the agency to create a comprehensive outreach plan to connect the nation’s almost 2 million post-9/11 veterans to benefits and services.

Calls to veteran’s crisis hotlines have been rising alongside news of the Taliban’s swift takeover of Afghanistan in the wake of the U.S. withdrawal and the suicide bombing at the Kabul airport that took as many as 200 lives, including 13 U.S. service members.

The statistics are grim: the suicide rate for active-duty military hit an all-time high in 2020, with 571 taking their lives. Veteran suicides have exceeded 6,000 per year from 2008 through 2017. A recent study from Brown University’s Cost of War Project estimates that as many as 30,177 active-duty personnel and veterans of the post-9/11 wars have died by suicide — more than four times the number of service members killed in action or by accident.

“There are a lot of anxious, sad, really struggling warriors out there right now in light of what’s happening [in Afghanistan],” said Jodi Burns, executive director of the Special Forces Charitable Trust, which supports the U.S. Army’s Green Berets, who make up almost two-thirds of Special Forces casualties since 9/11, and their families.

For Burns, the July 2020 suicide of Christian Marckesano, a decorated Green Beret who served six tours in Afghanistan plus other combat tours and was known as “the real Captain America” by his buddies, was the final straw.

“Thoughts and prayers just aren’t enough,” she said. “I wanted to do something, so I started digging, to see what was out there.”

She found Sound Off, a nonprofit started by San Antonio native William Negley, who has been working for years to develop an app enabling veterans and service members to anonymously connect with mental health clinicians or fellow veterans.

A protective option

The anonymity is what attracted Burns. The stigma around appearing weak, or fear that seeking help will derail a career, stops too many warriors from getting help that could save their lives, she said.

“It’s about being able to talk and say the words out loud, before it bubbles up and they explode,” Burns said. “If you can let a little air out of the balloon, it won’t pop.”

The Special Forces Charitable Trust signed a partnership agreement with Sound Off on Sept. 8. The trust will pay for some number of clinician sessions, encourage its members to sign up to become peer supporters, and publicize the app to its members. Last month, the Navy SEAL Foundation became the first veterans organization to sign a similar agreement. Operation Healing Forces has also signed on, said Negley, as has an organization that supports members of the intelligence community.

For Negley, a former CIA officer and son of a mental health professional, it was another statistic, this one from a Rand study, that stuck with him: 47% of those who deployed post-9/11 and likely suffer from PTSD do not seek help.

Steeped in the CIA’s culture of clandestine action and pseudonymous cover, the idea of an anonymous mental health care option seemed obvious to Negley.

“It doesn’t matter how much money the [government] spends on suicide prevention efforts if the person won’t even come and sit on a couch,” he said. In 2013, sitting in a secure room in Kandahar, he registered the domain name Sound Off.

He had no idea at the time how difficult it would be to turn his idea into a reality. He’s worked with an ever-growing team of software engineers, lawyers, and mental health experts to tackle technical and regulatory issues. Fundraising has been its own challenge, especially before he had a viable product to demonstrate.

“We are running the razor’s edge, skidding financially into Veterans Day,” Negley said. Sound Off will hold its third annual fundraising luncheon the day before, on Nov. 10, at the Witte Museum.

The partnerships offer a path forward for the fledgling nonprofit, which doesn’t have the money or infrastructure to publicize the app to the hundreds of thousands of veterans and service members across the country who might benefit from it.

Negley also acknowledges that if it weren’t for an event in 2017 that brought the crisis of military suicide into his own family, Sound Off might not even exist.

The cause becomes personal

On June 9 of that year, Negley’s brother-in-law, a former member of the Navy Special Warfare Development Group, more commonly known as SEAL Team 6, shot himself in the front seat of his car in Boerne while FaceTiming with his wife, Sydney Negley Mulder, who was at the couple’s home in Virginia Beach.

William “Bill” Mulder had retired less than five months earlier after a highly decorated, 20-year career in Navy Special Warfare. His wife said he began wrestling in 2009 with insomnia and bouts of combat fatigue, rage, depression, and anxiety, which he treated mostly with heavy drinking. She begged him to get help.

But telling leadership what he was experiencing was simply out of the question, he told his wife. More than once, she said, he uttered the words that still ring in her ears: “I could get sh– canned from the command.”

After his brother-in-law’s death, Negley said he was loath to do anything that might look like he was exploiting the tragedy. But Mulder said she couldn’t imagine not sharing her family’s story if it meant helping another service member or veteran avoid a similar fate.

“I believe in Sound Off,” Mulder told the San Antonio Report. “It could be so valuable to these guys, and no one is doing it. The complete anonymity is so significant.”

The ongoing stigma around military suicide can be seen in the many online stories and tributes to Bill Mulder; few note that he took his own life. Mulder said last year she asked the Navy SEAL Foundation, which regularly posts tributes on Twitter, to please include that her husband died by suicide.

“They were like, ‘whoa, whoa, whoa,’” she recounted. “I said we just cannot sugarcoat this. We cannot omit this anymore. This is the reality of combat, of serving his country for 20 years.” The foundation honored her request, prompting “an overwhelmingly positive reaction, with people reaching out to say thank you for bringing this to light.”

 

Mulder joined the Sound Off board, and she and her brother hit the road to raise money. Negley is keenly aware of the impact of his sister’s contributions — and Bill’s.

“Here I was, running around with the Rand study, talking about the 47%,” he said. “But when my sister comes up and rips her soul out of her chest, then I say, ‘Here’s the data,’ people listen.”

Alternatives to traditional therapy

Creating a truly anonymous mental health option is an innovative concept, said Katy Dondanville, an associate professor in the department of Psychiatry and Behavioral Sciences at UT Health San Antonio.

A licensed clinical psychologist, Dondanville runs a program that trains civilian mental health providers to provide treatment for PTSD to veterans and service members who seek help outside the VA.

Those who are given the opportunity to fill out a mental health screening form anonymously do report more problems, she said. The obvious catch? “When they’re anonymous, we can’t follow up with care.”

She said confidential options, like the Department of Defense-sponsored website Military OneSource can act as a bridge, bringing veterans and service members into care outside the military or VA medical system, “but it’s not anonymous,” Dondanville said. Sound Off could also act as a bridge, she said, attracting those for whom even a confidential option is a nonstarter.

As someone who researches innovative PTSD treatment delivery, Dondanville is keenly aware of the barriers to, and limitations of, the traditional, in-person “therapy once a week” model — not least of which is that there simply aren’t enough mental health practitioners to meet the nation’s need, much less for active-duty military and veterans.

But evidence shows that other options can be effective, including telehealth, which includes telephone and online services. Therapy via text, through apps like Talkspace and Better Health, are increasingly popular.

Even artificial intelligence-enabled chatbots can be helpful, Dondanville said. While they’re not appropriate for treating PTSD, they have been shown to be effective for cognitive skill-building, offering reflective listening and problem-solving.

Consumers are driving demand for all those options, she said, and the research is following.

Sound Off recently added Clara, an AI-enabled chatbot to its app, Negley said, as a potential third channel of support along with licensed counselors and Battle Buddies — vets who are willing to get peer support training so they can offer an empathetic ear to users who may not be ready to connect with a clinician. Clara will offer “in the moment” interventions like guided deep breathing, as well as basic cognitive behavioral therapy-based tools.

Dondanville does see risk with clinicians working with anonymous users in crisis, given that they have a “duty to warn” when a patient shares what the clinician believes is an imminent threat to harm themselves or someone else.

Changing the trajectory

Negley emphasizes that Sound Off is not a crisis tool.

“That’s not why I built this,” he said. “I think about the man or woman 10 years earlier than that, having their first panic attack or first nightmare. Too many of those people are like Bill — they are sure as sh– not going to their command site and say, ‘I’m having panic attacks.’ What if those people could instead just lightly start to engage — how might that change the trajectory of their next decade?”

He acknowledged that crises could still arise, and said clinicians are told to “do exactly what they should do, to the extent they can.” That might mean asking for a user’s name. But Sound Off does not have the ability to hack a user’s profile, Negley said, as that would violate the promise of anonymity and destroy Sound Off’s credibility.

As part of Sound Off’s new effort to use partnerships to get the word out, it chose to begin with organizations that serve the Special Forces community. That’s in part because these elite forces have borne such a heavy cost since 9/11, but also because they are likely more open to new approaches.

“Whether it’s using a new weapon system or this kind of support, the special operations community is not just the fighting tip of the spear, but also the technology tip,” said Sound Off board chairman James Patrick, a former Green Beret. “It’s a community used to experimentation, trying new things.”

Patrick sees the potential for an anonymous model of mental health care beyond the military, including law enforcement and first responders.

First, however, Sound Off must prove it can scale to fulfill its new partnership agreements. Negley and his team have just launched a more comprehensive version of the app, which by Oct. 1 will be available in several additional states. (Although telemedicine is starting to change the licensure landscape, today clinicians may only work in the states they’re licensed in. Battle Buddies, however, can help anyone, anywhere.)

Negley hopes other veterans service organizations will partner up, giving Sound Off some combination of financial support to pay for clinicians, more Battle Buddies, and promotion of the app to their existing networks of veterans and service members.

In return, the organizations will get data on how many members it helps.

A bare-bones, beta version of the app launched in Texas just before the pandemic hit, but didn’t serve many people, because there was little money to get the word out.

One clinician who signed up to offer her services was William Negley’s mother, Susan Clements Negley, whom he credits with his awareness of the importance of mental health care. A licensed counselor and Jungian analyst, she’s been working with veterans experiencing PTSD her entire career.

After watching “a whole generation of Vietnam veterans whose mental health and recovery we did not serve well,” Susan Negley said she was hopeful that post-9/11 veterans would get the care they deserved.

On the app, she connected with a veteran who would eventually come to meet with her in person. The pair have been working together for the past year and a half.

“We had our first few talks through the app, which is the way it’s designed to work — the initial relationship is anonymous and no-cost,” she said. But “in a best-case scenario, a trusting relationship is built” that can move off the app if the participants choose to do so.

Americans have been traumatized by so many recent crises that Susan Negley worries that “we may all be getting a little numb. But we cannot turn away from these men and women. There is a whole new generation to support.”