Wednesday, December 5, 2012

Suicide in the military - One is too many

You may remember that I posted a very informative paper written by Julia Dougherty Aten MSW (she is also my mentor)  a few months back but unfortunately I had to remove it. I have revised it here because I feel that her research on the data is very important to understand the complexity and the wide spread dilemma associated with suicide in the military and added some information I received from a former Social Worker who conducted the return briefs for Soldiers come back to the states through Joint Base Lewis-McChord, thank you both.
Increasing numbers of active duty military, reserves, and veterans are committing suicide. Smith (2011) stated that every 80 minutes, a military veteran will take his or her life.  The problem of military suicide is at epidemic proportions even though the Department of Defense and/or the Veterans Administration is not willing to define the current suicide rates as an epidemic (Smith).  Veterans and active duty military suicides account for 20% of all suicides in the Unites States even though only 1% of Americans have served or are currently serving in the military.  Suicidal ideation is associated with depression and PTSD, both of which often go unrecognized within the military and veteran communities (Smith).
            According to Braswell and Kushner (2010), military suicide is not a new problem. Official statistics from European countries during the 19th century detailed suicide rates were higher in the military than the general public.  This was a well-known fact and suicide experts of the time discussed suicide.  The first accounts of suicide in the military date back to Esquirol (1838), who was the leader of the French asylum movement (Braswell and Kushner).

Problem Overview

            Since 2001, the suicide rate among members of our military has increased exponentially (Braswell and Kushner, 2010). This increase has continued even with improving behavioral health care for service members serving in Iraq and Afghanistan.  The outcry in response to the increase in military and veteran suicide generally blames all the bad things within the military on the stress of repeated deployments, and the hardships of military life (Braswell and Kushner). Military analysts link the increase in suicide in the military to the stress of repeated deployments and combat.  In reality, Pentagon data shows that 70% of service members in the Army who committed suicide had never deployed or only had deployed one time.  The other branches detail comparable statistics (Braswell and Kushner).

Current Statistics

United States Army

                        The US Army began formulating suicide statistics in 1980 (Zoler, 2012).  In 1985, there were 15.8 suicides per 100,000 active duty soldiers.  In 2006, the Army surpassed this statistic with 17.5 suicides per 100,000 active duty soldiers (Zoler). In 2008, the suicide rate for active duty Army soldiers exceeded the civilian rate for the first time in history.  Since 2008, the suicide rate has continued to rise.  In 2009, 160 active duty soldiers committed suicide.  In 2010, 305 active duty Army, National Guard, and reserve soldiers took their own lives (Zoler).

            According to Zoler (2012), in 2011, the Army had the highest suicide rate in history with 164 confirmed cases of active duty soldiers committing suicide.  This was the seventh year in a row that suicide rates had steadily increased.  For the first three months of 2012 there appears to be no slowing of suicides within the Army (Department Of Defense, 2012). The DOD reported 45 potential suicides, 20 confirmed suicides, and another 25 cases still being investigated for active duty army personnel.  During the same period in 2011, the Army had reported 25 cases of potential suicide.  There has been a steady increase in suicides in the National Guard, especially in the Midwest states (Department Of Defense, 2012).  Soldiers in an active duty status and inactive status committed suicide at the rate of 25 per month in 2010 (Zoler).  Suicide doubled within the National Guard where were in an inactive status during 2010 (Zoler).  The increase in suicide rates reported by the Army among active duty soldiers is not limited to the Army.

United States Marine Corps

            According to the Department Of The Navy (2008), the Marine Corps started recording and reporting suicide statistics in 2002.  There were 26 confirmed suicides in 2003 (Department of the Navy).  There were 26 suicides in 2003, and by 2008 there were 42 suicides, and a record 52 suicides in 2009 (Marine Corps Community Services, 2009).  There was a decrease in 2010 to 37 suicides and in 2011 there were 33 suicides.  As of February 2012 there has been 8 confirmed cases of suicide within the Marine Corps (Marine Corps Community Services, 2012).  While statistics show a decrease in suicide, there were Marines attempting to take their own lives in 2012 than ever before.  The Marine Corps reported there were 146 attempted suicides in 2008, 164 in 2009, and 172 in 2010, and 186 in 2011(Marine Corps Community Services, 2012). The Marine Corps is a smaller branch and their suicide per 100,000 Marines outpaces the Army in most years since 2002

            The higher rates of suicide among the Army and Marines have been linked to these branches being significantly more involved in combat in Iraq and Afghanistan (Zoler, 2012). The DOD reports that there is an average of 10 failed suicide attempts for each Soldier or Marine that takes their own lives.  It is estimated that more than 1,600 active duty Army and Marine’s attempted suicide in 2011 (Zoler).
                                                          United States Air Force

            The Air Force has fewer personnel in direct combat, but Air Force suicides were at a 17-year high in 2010 (Svan, 2010).  The Air Force reports that relationship problems are the number one reason Airmen take their own lives.  Chief Master Sergeant of the Air Force James Roy reported that 100 Airmen committed suicide in 2011 and the total for 2012 may surpass this figure (Ricks, 2012).  The numbers of Airmen who have committed suicide in 2012 are a 40% increase over the same time period in 2011. The Air Force has not released the numbers for 2012, but some sources think that there were at least 18 suicides in January alone (Ricks).  If this figure is repeated monthly the Air Force could reach 200 suicides in 2012, which could put them ahead of the active duty Army.   Few Air Force officials believe that suicides will reach this number, but it is clear that suicide in the Air Force is on the rise (Ricks).

United States Navy

The Navy started tracking suicides in 2001, and that year there were 40 suicides (Navy Personnel Command, 2012).  There were 45 suicides in 2002, 44 in 2003, 40 in 3004, 37 in 2005, 38 in 2006, 40 in 2007, 39 in 2008, 46 in 2009, 39 in 2010, and jumped to 51 in 2011.  Master Chief Petty Officer of the Navy Rick West stated financial issues were a big factor in suicide within the Navy.  39% of Sailors that committed suicide in 2011 were facing disciplinary actions (Navy Personnel Command).

The DOD reported that in 2009 service members with a history of Absent Without Leave (AWOL) was found in 10% of suicides, 15% were facing military disciplinary actions, 12% were facing civilian legal problems, and 27% had been experiencing difficulties in their job (Navy Personnel Command, 2012). The ability to find extrapolated statistics for suicides varied greatly for each branch of the military.   The Navy/Marine Corps had the most detailed statistics available that outlined number of suicides, attempted suicides, gender, race, age, marital status, pay grade, and years in service.  The Army and Air Force statistics found only stated number of suicides and were vague on attempted suicides.                

Glantz (2010) reported that suicide statistics for veterans may be understated.  The VA identifies veteran suicides by matching suicides that are recorded in the National Death Index with those veterans that are enrolled in the VA.  There is no nationwide tracking system that identifies all veterans who commit suicide.  Due to this lack of data the true numbers of veterans taking their own life is not known. There are only 6 million of the nation’s 22 million veterans enrolled in VA health services (Glantz). 

According to Harrell and Berglass (2012), the reports that an average of 18 veterans commit suicide every day is taken from the Centers for Disease Control’s National Violent Death Reporting System, which only gets data from 18 states.  By summer 2012, there should be better data on suicide rates for veterans because of a partnership between Veterans Affairs Secretary Eric Shinseki and 49 state governments.  These states have committed to furnish the statistics of veteran’s deaths within their states.  It is reported that 950 veterans that were enrolled in VA health care attempted suicide each month between 2008 and 2010 (Harrell and Berglass).

Stigma against mental health problems in the military and limitations for veterans to access confidential mental health care is one reason active duty and veterans are not getting mental health treatment.  Half of those with significant symptoms and do access treatment are only getting minimal care. (Tanelian & Jaycox, 2008).  According to the American Psychoanalytic Association (2009), the military, VA, and DOD have made attempts to remove the stigma of seeking mental health care.  Stigma against mental illness is permeated throughout society and not just within the military.  Reducing stigma has been a long-term effort, but service members speak out that stigma is still alive and well within the military (American Psychoanalytic Association).                                                                                                                          

Stigma of mental illness prevents people from seeking help and this leads to a greater risk of suicide.  Suicide can seem like the only option for a stigmatized person (American Psychoanalytic Association (2009).  In the military, stigma towards mental illness is strong and many military service members deny any form of mental health difficulty.  This puts the military population at greater risk of suicide.  A service member who admits to suicidal ideation is often perceived as weak, shameful, sinful, and selfish and this keeps them from seeking help early when treatment could possibly turn things around for the person (American Psychoanalytic Association). The military states that they are reducing the stigma of mental illness and that military leadership is leading the fight against stigma. It is only recently all active duty Army bases conducted a “stand-down” which stopped all normal duty day activities and required all soldiers and leaders to attend classes and activities that addressed suicide. According to Dreazen (2012), on January 18, 2012 Major General Dana Pittard whom is the commanding general of the Fort Bliss Army post wrote on his official blog:                                                                                                

"We lost a Fort Bliss Soldier to an apparent self-inflicted gunshot wound. I heard the tragic news as I walked out of a memorial service for another one of our Soldiers who decided to kill himself at home on Christmas Day so that his family would find him. Christmas will never be the same for his two young daughters he left behind. I have now come to the conclusion that suicide is an absolutely selfish act. Soldiers who commit suicide leave their families, their buddies and their units to literally clean up their mess. There is nothing noble about suicide. I care about each and every one of our Soldiers, family members and civilians at Fort Bliss. I know there are a lot of people hurting out there, especially with the future Army personnel cuts on the horizon. If you are hurting mentally or emotionally, then seek and get help; but don’t resort to taking your own life. I am personally fed up with Soldiers who are choosing to take their own lives so that others can clean up their mess. Be an adult, act like an adult, and deal with your real-life problems like the rest of us. SEEK HELP! If you need help, please call 915-779-1800 or 800-273-TALK (8255). It is a confidential call. Please look after each other; please do not allow your buddy to make a rash decision that will have permanent life-ending consequences. Choose life.” (Dreazen, 2012).                                    

According to Dreazen (2012), what General Pittard wrote on his blog is pervasive inside the military and is just one example of how leaders feel about suicide.  He retracted his statement after public outrage within and outside of the military, but the damage was already done.  “Thanks to many of you and your feedback, I have learned that this was a hurtful statement.  I also realize that my statement was not in line with the Army’s guidance regarding sensitivity to suicide. With my deepest sincerity and respect towards those whom I have offended, I retract that statement” (Dreazen, 2012).  He wrote on his blog what many in the military think about suicide and his words perpetuate the already existing stigma inside the military (Dreazen). So many people in the military that are in distress do not seek help for the very reason that General Pittard wrote in his blog.  This stigma leaves with service members as they transition out of the military and reintegrate back into the civilian community (Dreazen). Attitudes like Pittard’s are pervasive in the military despite the push to reduce stigma, Barbara Van Dahlen, the founder of Give an Hour, an organization that matches troops with civilian mental-health providers stated:

"Soldiers who are thinking about suicide can't do what the general says: They can't suck it up, they can't let it go, they can't just move on.  They're not acting out of selfishness; they're acting because they believe they've become a burden to their loved ones and can only relieve that burden by taking their own lives. His statement -- whatever motivated it can do little good for those who are already on the edge." (Dreazen, 2012).                                       

Barnett (2012) stated destigmatisation should be addressed to mental illness as well as suicide.  General Peter Chiarelli, vice chief of staff of the Army, the service’s leading fighter against suicide, stated that the hardest part of reducing suicide is reducing the stigma.  “I’m not going to kid myself.  As hard as I try, and I brief every brigade combat team going out, both in the National Guard and in the active component…I see the head going up and down…In their mind, they really don’t believe these injuries are as serious as the injuries that they can see”  (Barnett, 2012).                      

            Dr. Jonathan Shay (2002) stated that unit cohesion is an essential tenant for military members in combat.  He detailed isolation and despair in veterans that he treated from the war in Vietnam because of the lack of unit cohesion.  Unit cohesion is essential for trust and trust is a main protective factor against suicide.  Shay stated that soldiers run a risk of moral injury from repeated combat tours.  Shay believes that a moral injury occurs when the concepts of trust and right and wrong are lost during combat.  A moral injury can result from believing that they failed while under fire, or from the failure of a commander that does not lead properly. When the soldier returns home he is hyper vigilant and does not trust anyone.  This leads to difficulty living life (Shay).

            According to Shay (2002), the moral injury would be lessened if soldiers were treated like a person instead of device with interchangeable parts to one of looking at the soldier in a holistic sense.  Shay repeatedly states that money is not the answer to the mental problems plaguing service members, but it is the shallow of how trauma affects a person who serve in combat. Shay proposes that what is missing is the buildup of trust, and insists that “competence is an ethical imperative” (Shay, p. 223) and the military must demand a high ethical standard for leadership and this will reduce the trauma in combat and the horrors of returning home (Shay).

            Currently there are two methods for conducting pre and post deployment health assessments they are:

1.         Telehealth- this is the main way they do these screenings overseas -Most of the troops give the standard answer- I’m fine. They know how to cheat on the exams given and they know what to say to get out of that office fast. They deny anything wrong even when you see it clear on their face and are pulled away before you can investigate further. Since you are not on site you as the therapist are at the mercy of the assistants. You can’t even give them your information and ask they return as you are at a completely different site.

2.         The 2nd method seen on CONUS (Continental United States) bases consist of the providers breaking into teams one team did a “briefing “the others did an “interview”. Buses- of troops are brought over to a building. Each troop is handed a questionnaire to fill out- they are given these by cadre in uniform, the Soldiers’ command is in the room with them. They are allowed to talk- the scoring mechanism is on the sheet- they are told- high scores go to see therapist, medium go to see therapist , low scores go to a mass briefing and can re-board the bus.  (Here’s a Caveat, these soldiers are NOT from this base (seen with many National Guard Units who do the screening at bases outside their respective states) - if they do not pass redeployment assessment they stay for treatment- you are just coming off a long deployment and are told that if you have an issue it will be even longer before you get home.) The tests are scored right there in front of the troop and they are broken into groups. Some escorted to the next building – EVERYONE KNOWS the next building has the counselors in it. The rest are taken into rooms and given a 5-10 minute brief on PTSD and resources then dismissed. This brief is VERY short- if the providers go to long they are reminded of time constraints. Now….remember that bus- the troops are taken back to the bus. However, their fellow Soldiers who were taken to the other building have to meet with a therapist- everyone is waiting on the bus for those people to finish. EVERYONE now knows as the troop walks back to the bus that he scored “moderate to high” for issues. The worse you are often the longer it takes- each person meets with the therapists for 15-20 minutes unless they are so severe they require full escort to the impatient ward.

The problem with this method is: The troops share how to pass the exam- they opening tell each other how to answer to avoid having to talk to someone- The cadre does not stop this and the command encourages this. Even stating they need to hurry up so we can get home. There is no privacy- if you have an issue EVERYONE knows it the moment you are taken next door, or placed in “that” group.  They are hostage to their test- admit issue and you are delayed in going home- answer that you are fine and you are headed home.

            While the military continues to address suicide with “stand-downs” and numerous PowerPoint briefs to commanders at all levels the biggest population that must be addressed is the lower enlisted ranks. When Soldiers, Marines, Airmen and Sailors understand the complexity and the severity of suicide and the wounds that many military and active duty members face then will the acceptance of seeking help be successful.


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