Military Social Work- Assignment: Family Suicide Risk Intervention Plan

Suicide and the Warrior

Soldiers killed themselves at the rate of one per day in June (201 O) mak­

ing it the worst on record for Army suicides. There were 32 confirmed

or suspected suicides among soldiers in June.... Only the Marine Corps

has a higher suicide rate.

-G. Zoroya, 201 Oa

Introduction

Suicide is one of the most difficult experiences for any of us to comprehend

(Schneidman, 1996). It is hard to understand the depth of pain, despair, and loss

of hope that the individual who commits suicide feels. Suicide is a leading cause

of death in the United States. According to the American Foundation for Suicide

Prevention (2011), approximately 32,000 individuals commit suicide every year,

and national statistics show that 650,000 people arrive in emergency rooms each

year having attempted suicide (Goldsmith, Pellmar, Kleinman, & Bunney, 2002).

According the World Health Organization, more than eight hundred thousand

suicides occur globally each year; some estimates are more than a million suicides

per year (Krug, Dahlberg, Mercy, Zwi, & Lozano, 2002). These statistics may un­

derestimate the true numbers, given suspicious deaths and individuals who do

not go to the emergency room and consequently are not included in statistics on

suicide. Historically, men in the United States are four times more likely than

women to commit suicide (Dublin & Bunzel, 1933); that trend has not changed

much today (Joiner, 2005). Sadly, combat veterans are increasingly committing

suicide. Statistics demonstrate that veterans are committing suicide at a rate that

far exceeds that of the nonveteran population (Hampton, 2007; Kaplan, Huguet,

McFarland, & Newsom, 2007).

55

56 THE COSTS OF COURAGE

We do not know exactly how many suicides there are each year as a direct

result of combat experience, most notably from the Afghan and Iraq wars. Al­ though there are some generally agreed-on numbers, we cannot eliminate so­

called accidental deaths, which may in fact be suicides. Shay (2008) shares a com­

munication with a military officer who noted the number of motorcycle accidents that have occurred among recently returning veterans. The officer re­

ferred to the deaths as a "holocaust," and Shay suggests that these deaths may

well be suicides that go unnamed as such. The DOD is so concerned about these accidents that it has begun motorcycle training and safety courses in several

places.

Suicide Theory

Until recently, suicide was not a common topic of study, although it was men­ tioned in the literature and in religious treatises. Statistics on suicide do not re­

veal the true percentage of the population that commits suicide. Ivanoff and

Riedel (1996) identify factors that present errors and bias in making estimations

from the statistics:

(1) The choice of statistics used to make estimates, (2) sub-cultural dif­

ferences in hiding suicide, (3) the effects of different degrees of social

integration, (4) the failure to keep statistics on salient subgroups, (5)

significant variations in the social imputations of suicide motives, (6) the

failure to assess and record accurately certain self annihilation behav­

iors as suicide, and (7) more extensive and professionalized collection of

statistics among certain populations. (p. 2359)

Suicide is not believed to be the result of a single disease or event. Gunnell and Lewis (2005) identify several possible factors that may predict suicidal be­

havior, including depression, schizophrenia, psychosis, serotonin deficits, early

childhood abuse, sexual assault, a family history of self-harm, access to the means

of committing suicide, terminal physical illness, impulsiveness, social and envi­

ronmental stressors, and war.

Durkheim (1897/1951) was the first to develop a methodology for studying suicide. He identified three categories of suicide: (1) egoistic suicide, (2) anomic

suicide, and (3) altruistic suicide. He argued that the first two categories repre­

sented individuals who were poorly integrated into society and individuals who were highly integrated into society, respectively. The anomic category represents

individuals who have lost social integration through trauma or catastrophe.

57 Suidde and the Warrior

One of the best-known suicide theorists is Schneidman (1996), who intro­

duced the notion that humans can be divided into two groups-suicidal and non­

suicidal. He further divides the suicidal group into committed, attempted, and

threatened. He argues that suicide comes from psychological and emotional

pain, which he calls "psychache," which is preceded by denied or distorted psy­ chological needs. This pain becomes intense and overwhelming. Another factor

in Schneidman's suicide theory is lethality. When individuals become suicidal,

they learn not to fear lethal self-harm, and they come to believe that suicide is

the only solution to their psychache. Schneidman argues that to prevent suicide,

we have to reduce psychache.

Beck (1991) theorizes that hopelessness is the primary antecedent for suici­

dal thoughts, suicidal rumination, suicide attempts, and completion. The Beck

Hopelessness Scale has been applied in repeated studies, and intensity of hope­

lessness has been found to be a successful predictor of suicidal thinking. Beck ar­ gues that hopelessness is an acquired cognitive pattern that can be altered

through cognitive therapy. He has successfully demonstrated both prediction of

and reduction in suicide with cognitive therapy. Cognitive therapy can help re­

duce and correct cognitive distortions that lead an individual to feel hopeless. In

his research, Beck found that individuals with high hopelessness scores were

eleven times more likely to commit suicide than individuals with low scores.

Joiner (2005) argues that suicide is an acquired behavior: "the case is made

that people desire death when two fundamental needs are frustrated to the

point of extinction; namely the need to belong with or connect to others, and the need to feel effective with or to influence others" (p. 47). According to

Joiner, when people get used to dangerous behavior and lose their sense of dan­

ger, then suicide attempts becomes a possibility if they have the means to com­ mit self-harm. With practice attempts, suicide becomes the norm, overcoming

self-preservation and thus making death a viable alternative to life. For Joiner, if

individuals have acquired the competence and courage to commit self-harm,

then suicide becomes possible through habituation. Although past suicide at­

tempts are a major predictor of future suicide, child sexual and physical abuse are

also associated with potential lethal self-harm. In addition, feelings of being a

burden and of having unmet needs of emotional and psychological belonging

contribute to suicide. Joiner also points out that aggression and violence are in­

dicators of suicide in that they lower inhibitions to self-injury; for example, pris­

oners are at higher risk of committing suicide than are their nonincarcerated

civilian counterparts.

58 THE COSTS OF COURAGE

Another type of suicide is heroic suicide, or what Durkheim (1897/1951)

called altruistic suicide. Riemer (1998) argues that there are four components to heroic suicide: (1) the act occurred during combat, (2) the act involved sacrifice of

one's own life for one's comrades, (3) death was certain by choosing the act, and

(4) death immediately followed the act. Durkheim argued that altruistic suicide

derives from an excess of social integration. Intense social integration is what mil­

itary training is all about. Success in combat depends heavily on cohesion among

the troops. The Medal of Honor has often been awarded to individuals for heroic

suicide. There have been 3,467 such medals awarded in U.S. history. Recently, Pri­

vate First Class Ross A. McGinnis saved four of his comrades' lives by covering with

his body a fragmentation grenade that was tossed into the gunner's hatch. He

yelled, "Grenade!" to prepare his fellow Soldiers for the blast. He didn't think, he

acted, and in doing so, he sacrificed his life (Medal of Honor Citation, 2008).

Statistics

Military service members are predominately male (85 percent), and the majority

are between the ages of seventeen and twenty-six. This age group is at a high

risk for suicide.

The U.S. Departments of Defense (DOD) and Veterans Affairs NA) are

gravely concerned with the growing number of suicides among military person­

nel and veterans. In 2007, there were 108 confirmed suicides in the Army; 166 sui­

cides were reported in Iraq and Afghanistan. According to the U.S. Army (2007)

Suicide Event Report, the suicides were committed among young enlisted, un­

married white males. Firearms were used most often. Drugs and/or alcohol were

involved in 30 percent of the suicide cases. Many of the suicides and attempts

were preceded by a failed intimate relationship. It is difficult to know how to in­

terpret this as sufficient to lead to suicide, given that many people have failed re­

lationships and do not attempt or commit suicide. Marriage and having young

children were identified as preventative. Not surprisingly, the study found a sig­

nificant relationship between suicide and number of days deployed to Iraq or

Afghanistan. In addition, the study found that many of the soldiers who were

medically evacuated for psychiatric problems were also found to have engaged

in self-harm behavior.

Stigma and Barriers to Seeking Help The military faces a paradox between the mentality of having the right stuff and

seeking help for problems related to reactions to combat. Hoge et al. (2004)

59 Suicide and the Warrior

conducted a mental health assessment of Soldiers and Marines before deploy­

ment to a combat zone and then three to four months after they returned home. They found that being in combat was highly associated with generalized

anxiety and major depression and that PTSD was significantly higher on return.

Very few sought mental health treatment. Hoge et al. asked the Soldiers and

Marines (N = 731) who screened positively for a mental health problem what prevented them from seeking help. They rated the thirteen survey items, and

the results were telling:

• 65 percent of those who met screening criteria for a mental health dis­ order reported that they would be considered weak.

• 63 percent indicated that they were concerned that their unit leadership would treat them differently.

• 59 percent responded that members of their unit might have less confi­ dence in them.

• 55 percent indicated that it would be difficult to get time off of work for treatment.

• 51 percent indicated thattheir leaders would blame them for the problem. • 50 percent were concerned that it would hurt their career.

• 45 percent reported that it was difficult to schedule an appointment, and 41 percent reported that doing so would be too embarrassing.

• 38 percent indicated that they did not trust mental health professionals. • 25 percent indicated that mental health care doesn't work and costs too

much money.

• 22 percent indicated that they didn't know where they could get help.

• 18 percent reported that they did not have adequate transportation.

It is clear from the responses of those individuals who met the screening cri­

teria that the greatest impediments to seeking assistance are fear of being seen

as weak and fear of what leadership would think. Too many Soldiers and Marines

believe that asking for help means the loss of a career. Hoge et al. (2004) point out that the results indicate a public health problem

that requires immediate attention. They argue that more attention needs to be

given to PTSD and that it should be screened for along with major depression. The stigma associated with seeking assistance for mental health care can be re­

duced by making it clear to all military personnel that, just as physical injuries are

expected in combat, so are mental health issues and PTSD. PTSD, major depres­

sion, and generalized anxiety are related to combat. The greater number of fire

fights an individual experiences, the greater is the likelihood that he or she will

60 THE COSTS OF COURAGE

experience PTSD, major depression, or generalized anxiety. Along with physical

wounds, mental health injuries are an occupational hazard of being a combatant.

The Human Face of Suicide

As noted before, the current wars in Iraq and Afghanistan are unlike wars that

we have experienced before, in that the Army and Marines have borne the brunt

of combat. The wars have not proceeded as national policy makers predicted.

They turned into guerilla wars, in which Soldiers and Marines never know who

the enemy is-man, woman, or child. From this perspective, Iraq is not unlike Vietnam, except that the fighting is mostly located in urban areas. It is important

to keep in mind that participating in war is not the same for every individual. Al­

though all military personnel are trained to various degree for combat, not all participate in combat. Soldiers and Marines are most likely to participate in low­

intensity or high-intensity combat (Castro & McGurk, 2008). The farther away you

are from combat, the less likely you are to experience war-related stress, with the

exceptions of certain military specialties, such as those in the medical field or mortuary workers (Kulka et al., 1990).

Castro and McGurk (2008) administered a well-being survey of Soldiers and

Marines to assess their experiences. One of the most frustrating experiences they report is living within the rules of engagement (ROE). Soldiers and Marines can­

not fire at the enemy until they are fired on or attacked. The rules may change often and at anytime. Logically, the chances for survival go down for soldiers who

are waiting to be fired on. Castro and McGurk (2008) reported that more than

650 Soldiers and Marines described an event that occurred during deployment that caused them "intense fear, helplessness, or horror" [p. 11). Their responses

on their fears and the situations they encountered included the following:

• "My sergeant's leg getting blown off."

• "Friends burned to death, one killed in blast."

a ' 1 Mortars coming into your position and not being able to move."

• "A Bradley [armored fighting vehicle] blew up. We got two guys out, three were still inside. I was the medic."

• "A friend was liqu[e]fied in the driver's position on a tank, and I saw everything."

• "A huge fucking bomb blew my friends head off like 50 meters from me."

• "Marines being buried alive."

61 Suicide and the Warrior

• "After my Bradley hit an IED, the driver[']s hatch wouldn't open and smoke started filling the interior."

• "Ambush on patrol & Marines caught in the open."

• "Doing raids on houses with bad intel."

• "Convoy stopped in dangerous areas due to incompetent commanders." • "Working to clean out body parts from a blown-up tank."

• "Fear that I might not see my wife again like my fallen comrades."

• "Finding out two of my buddies died, knowing I could do nothing about it."

• "Getting blown up or shot in the head."

• "Just seeing dead people on a lot of missions."

• "I had to police up my friends off the ground because they got blown up."

• "Mortar attacks, lost a close Marine." • "My best friend lost his legs in an IED incident."

• "Seeing, smelling, touching dead blow[n] up people.

111 "Sniper fire without an obvious source."

These experiences are not "normal" and are likely to produce direct trauma,

depending on the individual. The concept of transitional density (Bain, 1978)

addresses the accumulation of stressful (and traumatic) events. Embedded in

transitional density is the idea that each person and group (and family) has an

"overwhelmed" or breaking point; at that point, a person simply can't take any­

more stress and continue to function. The transitional density phenomenon is well illustrated by a statement from the director of the Army Suicide Task Force.

Brigadier General Colleen McGuire said, "Our current research and prevention

efforts are identifying common denominators that lead Soldiers to take their

own [lives]. It's often a combination of many factors that overwhelm an individ­

ual" (quoted in Tan, 2009b, p. 25).

Combat experiences are horrifying enough, but less is said or written about

how the combat experiences of our warriors with the enemy affect them. There

is nothing that addresses going berserk during a combat operation. Getting into

this state of mind often occurs after doing things beyond the realm of what war­ riors are trained to do. We have read reports of such incidents since the begin­

ning of the wars in Iraq and Afghanistan. Sometimes such situations drive war­

riors to commit atrocities. According to Grossman (1995), "Those who commit

atrocity have made a Faustian bargain with evil. They have sold their conscience,

62 THE COSTS OF COURAGE

their future, and their peace of mind for a brief, fleeting, self-destructive ad­

vantage" (p. 222). They will always live with their actions. The following para­

graphs discuss an Army Times article that featured the story of First Sergeant Jeff McKinney, who committed suicide on July 11, 2008 (Kennedy, 2008a):

Everything changed July 11 in the right sunshine of Adhamiya, Iraq.

That day, while out on a simple meet-and-greet patrol, McKinney stepped out of his Humvee and yelled, "F-k this!"

He raised the barrel of his M4 (carbine) to his chin and squeezed

off two shots. The first sergeant-who sang Sesame Street songs to his

men and teased them just enough to make them feel like family-left

his Soldiers shattered. (p. 30)

Everyone thought it was a sniper but then realized what happened. One

witness, his driver, said, "That's not First Sergeant McKinney" (p. 30). McKinney's family was devastated, and he had no history of mental health problems.

The family compiled information from the Army's investigation. Recent

events that McKinney had witnessed included a five-hundred-pound bomb that

killed five of his men and an Iraqi interpreter and another bomb that had almost

killed him and the soldiers around him, and he had comforted a soldier whose

leg was amputated after a roadside bomb explosion. McKinney had stopped

sleeping and eating, and he had started feeling that he couldn't protect his fel­ low soldiers. A soldier found him staring into space, he had noticeably lost

weight, and he had trouble during morning briefings-but he continued going

on patrol. Several studies by the Army, the DOD, and the RAND Corporation on suicide

found that troops do not seek help for mental health problems for several rea­ sons, including stigma and fear of being considered weak or incompetent, fear

of hurting their career, and feeling that they will abandon their fellow soldiers if

they fail to go out on patrol. Soldiers seem to believe that seeking help might mean that they don't have the "right stuff" (Kennedy, 2008a, p. 31).

According to Kennedy (2008a), 47 percent of soldiers who commit suicide

are older than thirty. At least half are sergeants, who are experienced soldiers.

First Sergeant McKinney knew his job, and his men respected him. His good friend pointed out that McKinney knew a\1140 soldiers' names and faces, who

was married, and whether they had children. His soldiers trusted him.

63 Suicide and the Wawior

McKinney's father said his son was not the same after serving in Samarra,

Iraq. Sergeant McKinney told his father that when in Samarra his squad came

under attack from shots fired from a school, the soldiers returned fire. Children

in the school died, and the cries of their mothers haunted McKinney. He said to

his father, "I'll never be the same again."

On his next assignment in Iraq he served as a tactical operations center bat­

tle captain, along with a good friend of his who was in the same position. He did

not like not being with his fellow soldiers, and when someone died he assumed

responsibility for that soldier's death. Casualties increased. McKinney's battalion

was attacked. It was the worst attack an Army battalion had been in since Viet­

nam-thirty-one men were killed.

McKinney was transferred to Alpha Company, where he worked to dean up

some problems with the soldiers. He took more time planning missions and en­

couraged the newly arrived captain. McKinney made sure his troops were taken

care of. McKinney assessed each soldier when he or she returned from patrol to

determine whether they had any signs of mental health problems. He experi­

enced the same things as his soldiers. When they didn't have any air-conditioning

and were low on food, he did the same. He suffered what they suffered.

On June 21, McKinney and a platoon responded to an explosion from an im­

provised explosive device (IED) that had blown up an armored vehicle and killed

five soldiers. McKinney helped pick up the dead bodies. On June 24 another IED

blew up just a few feet from him and his fellow soldiers. On June 26 another IED

incident occurred, and a soldier Jost a leg at the hip. When he met the soldier's

father (a contractor in Iraq), McKinney cried and asked for forgiveness.

McKinney stopped eating and sleeping for Jong periods of time. He was tak­

ing Ambien to help him sleep. On July 7, McKinney and his men were on a night

mission, and McKinney was in good spirits. Upon returning from the mission,

McKinney stayed up all night preparing for a change of command, which went

well the next day. Later he commented, "This place is a mess. I'm failing this com­

pany" and "I feel Jil<e I'm useless, like I don't have a real job" (Kennedy, 2008a,

p. 32). His father said, "That wasn't Jeff, he was squared away. But there was

... death all around him and he couldn't do anything about it, and he didn't

want anyone else to get hurt" (Kennedy, 2008a, p. 32).

Mcl<inney called his wife and told her, "I feel really weird. I can't think

straight. I'm not doing a good job" (Kennedy, 2008a, p. 32). McKinney told the

64 THE COSTS OF COURAGE

captain he was failing the company, but the captain refuted what he said. Later

"he refused to sleep and on several occasions, 'zoned out' for several hours"

(Kennedy, 2008a, p. 32). On July 10, the captain ordered McKinney to get some

sleep. The captain thought McKinney may have incurred a traumatic brain injury

when the IED exploded on June 24.

On the next mission McKinney's driver was told to keep an eye on him be­

cause "he wasn't himself" (Kennedy, 2008a, p. 33). The captain met with McKin­

ney to go over the mission plans; he let McKinney go on patrol with the unit be­

cause he didn't want the soldiers to lose confidence in him. He seemed to believe

that McKinney was competent. Later, the captain reported that McKinney shook

and was confused when a call came in on the radio. For a while he played with

a round from his weapon. At some point he stopped, got out of the vehicle, and

yelled, "F-this!" (Kennedy, 2008a, p. 33). He then killed himself.

PTSD: A Risk Factor for Suicide

Posttraumatic stress disorder is a risk factor for suicide, and the number of war­

riors with PTSD has increased exponentially as each year of the war has passed.

It is not surprising that symptoms of anxiety, depression, and PTSD-or mental

health problems in general-are highly associated with time and intensity of

combat (Castro & McGurk, 2008). Soldiers are 3.5 times more likely to experience

PTSD in association with intense combat than are soldiers with noncombat expe­

rience (Castro & McGurk, 2008).

In 2007, 115 soldiers killed themselves, or 18.1 per 100,000 soldiers. Army sta­

tistics for 2008 indicate that suicide was highest among deployed (30 percent)

and after deployment (35 percent) compared with personnel who had not yet

deployed (35 percent) (Alvarez, 2008; Tan, 2009a). The National Institutes of

Health (NIH) has begun to study suicides among soldiers; in the coming five years,

the NIH will study suicide completion and suicide attempts among thousands of

soldiers.

Tarabay (201 O) reports that more soldiers are dying from suicide than are

killed in combat. In 2009, 245 died by suicide; as of May 2010, suicides were at

163. The military has instituted many suicide prevention programs to counsel sol­

diers and help them identify the warning signs in their buddies. Several factors

have been associated with suicides, such as prescription drugs, substance use

problems, discipline, and mental health issues. The most obvious association is

65 Suicide and the Warrior

multiple deployments, but the military is hesitant to admit that is a cause. The

rate for suicides in 2009 was twenty per hundred thousand soldiers (Lothian,

2011). Prior administration policy was to not send letters of condolence to suicide

victims' next of kin. The Obama administration has changed that policy. President

Obama said, "We need to do everything in our power to honor their service, and

help them stay strong for themselves, for their families and for our nation"

(Lothian, 2011, p. 1).

Suicide in the Army

Anyone familiar with news about the current wars knows that the Army is expe­

riencing a rise in the tide of suicides among troops (Cavallaro, 2007; Kennedy,

2008b; Tan, 2008, 2009b}. The suicide trend line is on the increase: 87 in 2005, 102

in 2006, 115 in 2007, and 143 in 2008. The Army has reported that its suicide rate

has doubled since the invasion of Iraq. Tan (2009a} reported that in January 2009

the Army's suicide rate was higher than that of combat deaths. Incidents of sui­

cide had risen from 87 in 2005 to 143 in 2008, which led the Army to initiate two­

to four-hour stand-downs for soldiers to receive suicide prevention training. Ini­

tially, the Army attributed the suicide rate to relationship problems, legal and fi­

nancial problems, poor job performance, alcohol and drug abuse, and belief of

failure in combat (Alvarez, 2008). Many senior Army staff have made statements

to the effect that disrupted and ended relationships often drive a soldier to com­

mit suicide. In contrast to the fact that the number of suicides is related to time

in combat the Army's chief of command policies and programs said, "You can't

really say it's a cost of war. There are a lot of stressors that go into that,"

(Kennedy, 2008c, p. 10).

In 2009 the suicide rate was 20 per 100,000 soldiers, surpassing the national

rate (Kennedy, 201 Ob}. In 2010 there were 434 suicides by active-duty personnel,

compared to 381 in 2009 (Donnelly, 2011). Recently, at Fort Hood in Texas there

were four suicides in three days despite major efforts at suicide prevention by

the Army (Gerhart, 2010; Zoroya, 2011). All of the soldiers had deployed to Iraq,

and two of them more than once. The commander at Fort Hood has ordered

that all brigade-level commanders assess each soldier in their unit for risk of sui­

cide and take appropriate action. Army leadership links the suicide rates to a

focus on the war that superseded the Army's focus on soldiers before 2001

(Kennedy, 2010b}. This is the second year that the military reports more deaths

66 THE COSTS OF COURAGE

to suicide than to combat in Operations Iraqi Freedom and Enduring Freedom

(Donnelly, 2011). However, the number of suicides may still be underreported,

as the services do not track suicides uniformly and are reluctant to report on the

numbers.

Suicides are also occurring after deployment when soldiers return to military

installations in the United States. Recent reports from various installations indi­

cate increasing numbers of suicides. At Fort Campbell, Kentucky, the command­

ing general shut down the installation to engage in suicide education and pre­

vention after eleven suicides were committed there in 2008, followed by sixty-four in 2009 (Commander shuts down Fort Campbell, 2009). In an effort to

prevent and reduce suicides, the Army vice chief of staff, General Peter Chiarelli,

issued the Army Campaign Plan for Health Promotion, Risk Reduction, and Sui­

cide Prevention (Cavallaro, 2009). Army commanders are responsible for imple­

menting the plan. Part of this plan is a response to drug testing, in which soldiers

have tested positive for a range of substances. The plan includes a focus on

restoring discipline among the ranks, which has declined with eight years of on­

going combat.

The stigma and shame of asking for help with psychological problems is a

long-standing issue. Some leaders in charge of units still tell soldiers that going

for help will interfere with career advancement, even though all services have

worked to reduce the stigma. The Department of Defense continues to assert

that the national rate of suicide for the same age and gender of civilians is nine­

teen per hundred thousand and that the Army suicide rate is lower, at seventeen

per hundred thousand. An Army medic challenges this, pointing out that the

Army screens potential recruits for psychological illness and that before the war,

the Army had a suicide rate of eleven per hundred thousand soldiers. He points

out that the suicide rate is a direct reflection of the stress of a protracted war.

Given the lack of resources, especially therapists, there is dim hope that the situ­

ation will improve. At present, reports indicate that the Army's suicide rate has

increased to twenty per hundred thousand soldiers (Cogan, 2010).

Recent reports indicate that suicide is the third leading cause of death for

Army National Guard soldiers (Salzer, 2011; Soldier suicide rate, 2008; Studenicka,

2007). Since the policy changes that created the total force (l<nox & Price, 1999),

not only has the National Guard continued its state responsibilities for natural

disasters but also many units have been called to duty in Iraq for support and in

67 Suicide and the Warrior

some cases direct combat. Many Guard soldiers have had deployments of up to

eighteen months (Soldier suicide rate, 2008). Unlike soldiers who live and work

at military installations, guard members live in their communities with their fam­

ilies and friends and may not have ready access to psychological support. More­

over, they may live at a distance from mental health providers with knowledge

of military service and combat. In 2006, the National Guard Bureau initiated a

suicide prevention program and appointed a manager at the national level.

States have also identified part-time suicide prevention managers for the Guard.

The Guard has implemented the ACE suicide prevention program-ask your

buddy, care for your buddy, escort your buddy-and all ranks will be trained in

and responsible for suicide prevention (Studenicka, 2007).

Currently, the Army is stretched to the limits of endurance. One of the most

important interventions for suicide prevention is soldiers caring for one another,

according to the Army psychiatrist and consultant to the Army surgeon general

(Cavallaro, 2007). Soldiers receive "tip cards" to help them express concern for

their friends and fellow soldiers that tell them to ask, "What's going on-are you

thinking about killing yourself?" The cards encourage soldiers to remain calm

and try to remove anything that could inflict injury (removing a gun or pistol may

not be possible and should not be forced). They then should calmly take the at­

risk soldier for help, and they should never leave him or her alone.

The Army is undertaking several actions as part of the Army Campaign Plan

for Health Promotion, Risk Reduction, and Suicide Prevention (Cavallaro, 2009),

including increasing discipline and promoting the buddy system, as well as edu­

cating to prevent self-injury. Commanders are adding reports on drug testing to

their monthly reports, and they are becoming more aware of what is going on

with their soldiers. Army suicide manuals from the 1980s are being updated to

address issues in today's Army. The plan also includes assessments of soldiers' de­

ployments and redeployments, as well as the moving of mental health services

into hospitals to facilitate use and reduce stigma. A more direct attack on stigma

is the replacement of the term mental health with behavioral health. The num­

ber of behavioral health military personnel (psychologists and social workers) will

increase with an accompanying decrease in the use of medicines as a substitute

for therapists. The plan also involves the use of various technological approaches

to monitor the reporting of suicide risk and to increase information available to

individuals who intervene in a suicidal risk situation.

68 THE COSTS OF COURAGE

Suicide is at a record high for the Army and the Marines. Deployments and

redeployments and combat have taken their toll. "The greater and greater de­

mand is destroying our military," stated Dr. Charles Figley in an interview (Tan,

2009a, p. 14). "People are starting to think, this is as good as it is going to get.

. . . They're just fried" (Tan, 2009a, p. 14). Many soldiers have simply given up

hope-and hopelessness is correlated with suicide.

Suicide and Deployment to Combat

There is a clear connection between combat exposure and the development of

PTSD. There is also growing evidence of an increased risk of suicide for individu­

als diagnosed with PTSD (Guerra & Calhoun, 201 O; Marshall et al., 2001; Oquendo

et al., 2005; Sareen, Joulahan, Cox, & Asmundson, 2005). Using the Beck Scale for

Suicide Ideation (Beck & Steer, 1991) and the Beck Depression Inventory (Beck,

Steer, & Brown, 1996), Guerra and Calhoun (2010) found that the risk of suicide

was uniquely associated with PTSD among 393 veterans. Interestingly, comorbid­

ity with major depressive disorder or alcohol abuse was not found to increase sui­

cide risk. Guerra and Calhoun found that the strongest bivariate relationship was

between numbing (detachment and limited affect) and suicidality, whereas the

weakest was between avoidance (avoiding particular thoughts or feelings and

talking about trauma) and suicidality. The authors also found that when PTSD

and MDD symptom clusters were examined together, they were positively and

highly predictive of suicidality. In particular, the scores on the numbing cluster of

PTSD diagnosis and the cognitive-affective dimension of depressive symptoms

were highly correlated with suicidality. An important finding from this study is

that persons diagnosed with PTSD should be regularly assessed for suicidality re­

gardless of other presenting problems. Also, firearms are the most common sui­

cide method, followed by hanging (Kang & Bullman, 2008).

Killing, Suicide, and Acquired Capability

There are few empirical studies examining the effects of killing men, women,

and children on Soldiers and Marines. Fontana, Rosenheck, and Brett (1992)

questioned the relationship between killing and suicide attempts among Oper­

ation Iraqi Freedom veterans. The study found that failing to prevent death or

injury and killing while in combat are associated with suicide attempts. The study

also found that being threatened with being killed or injured was associated

with PTSD. Hendin and Hass (1991) found that feelings of guilt after combat,

69 Suicide and the Warrior

particularly regarding the death of women and children, were strongly predic­

tive of both suicide attempts and suicide ideation. They also found that several

suicidal veterans associated killing women and children with a state of rage or

fear. Killing and its effects on people engaged in combat have not been thought

of as predictive of suicidality and more studies are needed. The few studies iden­

tified are discussed later in this chapter.

In military speak, killing is an acquired capability, one of many complex fac­

tors associated with suicidal behavior. Selby et al. (2010) argued that the more ex­

perience service members have with killing, the greater is their acquired capabil­

ity for suicide and their own death. Service members are taught to kill efficiently,

and combat exposure affirms their capability for killing. Selby et al. also argued

that repeated exposure to killing in combat desensitizes soldiers, in that it de­

creases the power of fear and pain and makes them less terrorizing. For exam­

ple, learning to parachute with training leads to less fear of jumping out of the

plane after repeated exposure and experience. In fact, this habituation may con­

tribute a physiological rush that fills the body with excitement. Initially, service

members may experience killing as profoundly stressful, which over time be­

comes attenuated by repeated exposure in combat {Selby et al., 2010), thus re­

ducing service members' fear of death, even by suicide. Military training and re­

peated combat exposure may cause individuals to habituate to killing and death,

even their own. Habituation may help explain the number of suicides by military

service members. Maguen et al. (2011) found a similar relationship between killing and suici­

dal ideation and desire for self-harm. In some cases, both were present. The study

found that depression and PTSD symptoms contributed to suicidal ideation and

killing; ironically, PTSD symptoms mediated killing and desire for self-harm. The

researchers advocate that suicide assessment should include an exploration of

killing experiences, particularly killing that has resulted in guilt in the context of

screening for suicidal risk. Maguen et al. (2011), citing Litz et al. (2009), add that

moral injury may also influence killing and suicidality. In Achilles in Vietnam, Shay (1994) defines moral injury as "the deforming effect on good character, caused

by betrayal of what's right in a high-stakes situation by someone who holds au­

thority that is the most damaging part" {p. 294). The act of killing may be expe­

rienced as a moral injury, accompanied by confusion between military training

and personal values and morals, thus resulting in the inability to forgive oneself,

guilt, and shame {Litz et al., 2009). These are complex issues that require more

70 THE COSTS OF COURAGE

research, especially on the relationship of acquired capability and habituation to

death through engagement in killing.

Suicide in the Navy and Marine Corps

The Department of the Navy's (DON} DON Suicide Incident Report (DONSIR} has

tracked risk factors associated with Navy and Marines suicides for more than

thirty years (Stander, Hilton, Kennedy & Robbins, 2004). The information is used

to strengthen suicide prevention programs. Dennett (1988) has noted that there

is no rigorous counting of suicides, and inconsistencies in counting make the re­

sults questionable. The Navy and Marine Corps both have directives authorizing

commanders to identify a point of contact to complete the DONSIR and return

the report within three to four weeks after a suicide; however, as Stander, Hilton,

Kennedy, and Robbins (2004) point out, the contact may not have access to all

the necessary information to complete all elements of the DONSIR. The informa­

tion collected is then forwarded to the Naval Health Research Center for data

entry and analysis (Stander et al., 2004).

According to Stander et al. (2004), the data collection has three primary pur­

poses: to assess prevalence of known suicide risk factors, to gather all the psy­

chological forensic information, and to enumerate suicide risk factors associated

with being in the military. The information that constitutes the DONSIR includes

military and medical records, counseling records, toxicology and autopsy reports,

investigative reports, and interviews with military personnel. No significant oth­

ers are contacted for information (Stander et al., 2004). Between 1999 and 2001,

Navy personnel had a suicide rate lower than that of the U.S. general population.

It was reported that minorities in the Navy had higher suicides than nonminority

Sailors. The incidence of suicide for women in the Navy was comparable to the

suicide rate of the general U.S. population. Suicides tended to occur in people's

homes while they were not on duty; service members most frequently commit­

ted suicide with firearms or by hanging. As had the Army, the Navy found that

relationship failures and work-related issues were common to most suicides. The

DONSIR asks about behavioral and emotional maladjustment; it identified

twenty-three suicide indicators, and alcohol abuse was often present. The five

most frequently reported emotional indicators were depression, guilt, shame, re­

morse, and anxiety. Those who had committed suicide had contact with medical

and mental health providers in the prior year, and in some cases within thirty

days before the suicide.

71 Suicide and the Warrior

In the Marines, the suicide rate among combat troops doubled from nine in

2006 to eighteen in 2007. Between 2003 and 2007, the Marines suffered a total

of 143 suicides. At that time the Marine Corps did not find this alarming because

the suicide rate was lower than the national rate. In a report by Walker (2008),

the overall rate of suicides for all Marines rose 37 percent from 2006 to 2007. In

2009 the Marines instituted a suicide prevention program in an effort to reduce

that rate. Recent statistics on suicide among Marines increased in 201 Oto twenty­

four per hundred thousand (Zoroya, 2010a, 2010b). As does the Army, the Ma­

rine Corps attributes suicides to relationship problems, financial and legal diffi­

culties, and poor performance. Once again, although these factors are troubling,

they are common to many young people who do not solve their problems

through suicide. These suicide statistics do not account for Marines who have

committed suicide at home after having been in combat. Three months after a

tour of duty in Iraq, Major John Ruocco, a forty-year-old Cobra helicopter pilot,

hung himself after telling his wife the prior day that he would get help (Kerr,

2007). He had lost weight; he couldn't sleep; he was numb; he had nightmares;

and he was depressed, distracted, and withdrawn from his family. The following

is an excerpt from the Army 7i'mes:

Marine Widow Describes the Pain That Suicide Brings

Kim Ruocco is the widow of Maj. John Ruocco who committed suicide

three months after returning from duty in Iraq. She has a master's de­

gree in social work and she didn't see it coming and has since become

an advocate for suicide prevention. She has counseled suicidal clients

and once helped her husband develop a suicide prevention presenta­

tion. The Marine Lieutenant Colonel (Lt. Col.) who asked her to speak

said, "When a man's widow is standing in front of you, with [family] pic­

tures in the background, it brings you the reality." He said, "He had

everything going for him. His kids adored him. He was loved and re­

spected. None of his friends saw it coming." She recently spoke to

Marines at Camp Lejeune, North CarolinaLI about her experience. The

presentation changed perceptions of suicide. The Lt. Col. said[,] "Be­

fore, they might not have gone up to someone and ask if they're OK.

Now, they said they're much more likely to go up to them and ask." Kim

offers her services to the Tragedy Assistance Program for Survivors

(TAPS). She is now organizing a group of individuals who have lost a

72 THE COSTS OF COURAGE

loved one to suicide to make presentations to troops. Her final com­

ment was, "My husband would have given his life for any one of those

Marines. Now, in a way, he has. Suicide is an ugly topic and ugly act­

but, if you can save someone else's life it's not as tragic." (Jowers, 2009,

p. 11)

Marine spokespersons have reported that 60 percent of the Marine Corps com­

prises people younger than twenty-five years old. The Marine Corps is working

to identify Marines who may be at risk and get them assistance. They are devel­

oping mental health teams, with a chaplain and psychiatrist, to be assigned to

units. Marines still have problems with stigma from seeking mental health assis­

tance, and that attitude is even stronger among higher-ranking individuals. In

spite of the stigma Marine suicides have come down in recent months (Walker,

2010).

Suicide in the Air Force

Air Force rates of suicide have been reduced from previous levels as a result of an

innovative suicide prevention program. Increasing suicide rates affected all ser­

vices during the 1980s and 1990s (Welton & Blackman, 2006). During those years

the suicide rate was 11 per 100,000 in the Navy; 12.2, in the Air Force; and 13.7,

in the Marines. In 2004 Air Force suicide rates increased to thirteen per hundred

thousand (Caruso, 2004); however, none of the suicides involved personnel who

were in or had been in war zones. The Air Force implemented a suicide preven­

tion program that focused on reducing the stigma of actively seeking help and

required participation of every service member, regardless of rank (Knox, Litts,

Talcott, Feig, & Caine, 2003). The program's holistic approach encompassed

eleven initiatives (U.S. Air Force Suicide Prevention Program, 2005).

The first initiative addressed leadership. Senior leaders and commanders

were engaged to get the whole community involved in suicide prevention.

Squadron commanders were provided training in suicide prevention and were

charged with involving the whole military community. The second initiative inte­

grated suicide awareness and prevention in all Air Force training and education.

The third was to train commanders to recognize suicidal behaviors, to seek men­

tal health assistance, and to encourage affected individuals to seek help. The

fourth initiative addressed tracking community prevention efforts. In doing so, the Air Force updated the Medical Expense and Performance Reporting System

73 Suicide and the Warrior

(MEDPRS), which examines prevention services and patient care efforts. The fifth

initiative addressed community education. Every year, all Air Force personnel and

civilians employed by the Air Force receive formal education on suicide preven­

tion. The sixth initiative developed a policy for the actions taken following an ar­

rest and/or an investigative interview, which is considered a high-risk period for

suicide. Rather than release the individual, the investigator releases the individ­

ual to his or her supervisor. The supervisor then assesses the individual's mental

and emotional state. If the supervisor concludes that there is a risk of suicide, he

or she calls in a mental health provider.

The seventh initiative focuses on intervention for traumatic incidents

(known as critical incident stress management). The Air Force has traumatic stress

teams all over the world to respond promptly to traumatic incidents, such as sui­

cides, terrorist attacks or serious accidents, and trauma that affects personnel in

groups. The team conducts a traumatic stress intervention, which assists person­

nel in processing and managing their thoughts and feelings about the incident.

The eighth initiative created a comprehensive cross-organizational review to

identify issues at all levels (individual, family, installations, and community) that

may affect Air Force readiness. The review also examines quality of life for mili­

tary personnel and families with two systems: Integrated Delivery System (IDS)

and Community Action Information Board (CAIB). The goal is to resolve and find

solutions to issues. Another goal is to support the installation of social agencies

so that they can cohesively provide services to the military community.

The ninth initiative addresses confidentiality with military personnel. In gen­

eral, information about military personnel is shared on a need-to-know basis. In

the military, confidentiality about mental health problems is extremely limited.

Service personnel know this, which contributes to their not seeking mental

health assistance. This initiative complements the limited military patient­

psychotherapist privilege established in 1999, which limits legal authorities' ac­

cess to patient records. The Limited Privilege Suicide Prevention Program was de­

veloped to improve access to services, and it aims to increase confidentiality

when an individual seeks mental health services.

The tenth initiative provides commanders with an IDS Consultation Assess­

ment Tool, which they can use to determine the strengths and weaknesses of

their units. They can use the information to improve the well-being of military

personnel. Finally, the eleventh initiative provides for the collection of data on

suicide through the Suicide Event Surveillance System. The database can be

74 THE COSTS OF COURAGE

analyzed to identify risk factors that contribute to suicide for use in future pre­

vention programs. The eleven initiatives of suicide prevention are elaborated in the Air Force Suicide Prevention Program (2005). Recently, the program was

evaluated for its effectiveness (l<nox et al., 2010); the evaluation found that Air

Force suicides had decreased significantly since the program's implementation.

Postdeployment Suicide

Suicide is on the rise among veterans. At present there is no effective tracking

system, so there are no official numbers. As addressed earlier in this chapter, sui­

cide rates are fraught with statistical issues and biases that lead to inconclusive

results. Also, the deaths of veterans who commit suicide may be classified as ac­

cidents or other nonsuicide events. As suicides among veterans have increased, family and friends have gone

public about what happened to their loved ones. In 2007 CBS began investigat­

ing veterans' deaths; for five months, several reporters investigated suicide

among veterans (l<eteyian, 2007). The researchers at CBS made a Freedom of In­

formation Act request to the DOD for the number of suicides over twelve years.

Between 1995 and 2007, the DOD reported that 2,200 active-duty personnel had

committed suicide, not including veterans. Not satisfied, CBS approached the

V/>ls director of mental health, Dr. Ira l<atz, and asked for the same information.

The researchers also contacted all fifty states for data on suicide among veter­

ans. Forty-five states released the information with assurances of confidential­

ity. For 2005, CBS identified 6,256 suicides by those who had served in the mili­ tary (Malbran, 2007). The results also indicated that in 2004 and 2005 the suicide

rate among veterans was almost twice as high as among nonveterans. There

seems to have been some internal conflict at the VA about the numbers, which calls into question the reliability and validity of the numbers they had and did

not want to release. The VA position has been that there is a problem but not,

as others have concluded, an epidemic. l<atz later wrote to CBS that there "are

about 18 suicides a day among America's 25 million veterans," and 6,570 vet­

eran suicides per year (l<eteyian, 2008). In 2007, the DOD began monitoring the

psychological and physical health of veterans (postdeployment combat person­ nel and personnel who have ended military careers) at three and six months fol­

lowing combat (l<err, 2007).

Stigma remains a major barrier to seeking help and contributes to the in­ crease in suicides. l<err (2007) spoke with Shad Meshad, an Army veteran with

75 Suidde and the Warrior

thirty years of experience counseling veterans. He reported that he receives two

or three calls a week regarding suicidal veterans or their family members. He said, "One of the biggest challenges for troubled vets is the stigma of a mental

health disorder. It's very, very hard for you to reach out and say, 'I'm hurting.' It

is hard for men to do it, but particularly [for] a Soldier [or Marine] who's endured

life-and-death situations" (p. 3).

At the end of 2006, the pervasive stigma was well illustrated by events at

Fort Carson, Colorado, and was reported in seven broadcasts by National Public Radio (Zwerdling, 2009). Fort Carson providers with requests from soldiers for

mental health assistance told them there was nothing wrong with them, dis­

missed some as cowards, and discharged some from the service. Since that time

there have been seventeen suicides. These reports led to investigations by the

Senate, the Government Accountability Office (GAO), and the Pentagon. In an

effort to reduce stigma, the Army started a program at Fort Bragg, North Car­ olina, in which they moved the behavioral (mental) health personnel into med­

ical facilities (Kerr, 2007). A DOD task force has recommended that outreach to

the troops, including screening and prevention, may get them into clinics more

quickly. Even so, the military health system is overloaded and has insufficient

qualified providers to promptly reach everyone concerned (Kerr, 2007). Sadly, the

officers in charge of military health at the highest levels continue to say that

there is no direct correlation between war and suicide.

The Veterans' Health Administration (VHA) is overwhelmed with requests

for assistance for physical and mental health, and there aren't enough resources

and providers. After veterans make a request, they are often told that they will

be put on a waiting list, and they can end up waiting months. They may die or

commit suicide before they can get help. Given the numbers of veterans who suf­

fer from PTSD, it is likely that the deaths will continue to increase. The number

of veterans making PTSD disability claims increased from 120,265 in 1999 to

215,871 in 2004, almost an 80 percent increase (Kerr, 2007). Until recently, the VA

medical centers did not serve family members. A recent GAO report reveals that the VA has developed an initiative and several pilot programs to include families

in psychoeducation and in support of the veteran (GAO, 2008c).

In 2008 the psychiatric researcher Thomas lnsel, director of the National In­

stitute of Mental Health (NIMH), reported that postwar suicides may exceed com­

bat deaths (Goldstein, 2008). There are insufficient resources and providers in the

health and mental health system, particularly in rural areas. In a survey of 191

76 THE COSTS OF COURAGE

military members and spouses, respondents reported that their military experi­ ence had damaged their mental health (Goldstein, 2008).

Joshua Omvig Veterans Suicide Prevention Act of 2007

One veteran's suicide led to the Veterans Suicide Prevention Act. His story is

found on his memorial Web page, Joshua Omvig Life Story and Time Line (http://

joshua-omvig.memory-of.com/Legacy.aspx). Joshua Omvig had completed an

eleven-month tour in northern Iraq. He was twenty-two years old and had served with the 339th Military Police Company. In 2005, he was on leave visiting his fam­

ily just before Thanksgiving. One week he was in Iraq, and one week later was

back home. Initially, he did not speak about his experiences in Iraq. He began

having symptoms of PTSD and shared his concerns with his family. Family mem­ bers encouraged him to seek help, but he did not, fearing that it would adversely

affect his military career. He was in pain (the "psychache" that Schneidman

[1998] writes about) and shared with his mother that he felt dead inside. He later

shot himself in front of his mother (Jacobs, 2006; Magee, 2006).

Omvig's parents testified before the Senate Committee on Veterans Affairs on April 25, 2007, and told their son's story to the panel. As a result of their ef­

forts and the efforts of others, Congress passed the Joshua Omvig Veterans Sui­

cide Prevention Act into law on November 6, 2007 (Cvetanovich & Reynolds,

2008; Lindsey, 2007). The act requires the VA to develop a suicide prevention pro­

gram to address the growing number of veterans who commit suicide by requir­

ing that all veterans' affairs staff receive mental health training, that every VA

medical center have a suicide counselor, that veterans receiving care at a VA fa­

cility will have a mental health screening and receive treatment when appropri­

ate and at the veteran's request, and that veterans have twenty-four-hour access

to the VA for mental health care and an available VA suicide hotline (the VA had already put a hotline in place at the time of the prevention act).

The act is progressive. It enables the VA to do something that it has been un­

able to do in the past. It has a provision that states that the VA must engage in outreach and education for veterans and their family members to teach family

members how to recognize when a veteran is in trouble and how to help. The

act also requires the VA to conduct best-practices research on mental health care

for veterans who have experienced sexual trauma (including sexual assault, ha­

rassment, and issues related to gender) while in the military. Finally, both veter­ ans and family members can receive peer support counseling, and the VA will

77 Suicide and the Warrior

conduct specific research into best practices in suicide prevention in conjunction

with the Department of Health and Human Services, the Substance Abuse and

Services, the NIMH, and the Centers for Disease Control and Prevention {Cve­

tanovich & Reynolds 2008; Lindsey, 2007). There is hope that these efforts will

stem the rising tide of suicides among veterans.

Finally, it is time for the DOD to accept the responsibility that it not only has

the mandate to create warriors but also a responsibility to teach warriors about

what can happen to them in the course of battle. Warriors must learn that killing

another human being comes at a great personal cost, one that they must bear

and that changes their lives forever. In On Killing, Grossman (1995) argues that

our military service members are proficient at teaching warriors how to kill ef­

fectively and efficiently as individuals and in groups. The other side of the mis­

sion needs to be to facilitate the transition from over there to back here; Battle­

mind Training was created for this purpose. Veterans bring the war home, it is

inside them, and they will carry it for the rest of their lives. Their worldview

changes with each combat experience. Military leaders fail the troops when they

assert that there is no correlation between war and the act of killing, suicide

ideation, attempt, and completion.

History teaches us that after each war, veterans may or may not be able to

do the final about-face alone {Butler, 1935). Veterans who have experienced in­

tense combat will most likely be adversely affected by their experiences at some

point in time, immediately or months or years later. Our culture has mytholo­

gized war and warriors, and the film industry has contributed greatly to this

myth. Recent film tributes to the so-called Greatest Generation such as Saving Pri­

vate Ryan, as excellent as the movie is, tell only one side of the story and fail to

address the darker side of that generation's combat experience. In his recent

book Soldier from the War Returning, the historian Childers (2009) documents

the great suffering of World War II warriors, many from the time they returned

home to their deaths. These veterans have been portrayed as coming home well

adjusted with no problems and as going right back to work, getting married, and creating a good life for themselves and their families.

As Childers (2009) points out, evidence reveals something very different.

Upon returning from combat, World War II veterans discovered that during the

war, the country had suffered also. There were few jobs, and more than 2 mil­

lion veterans were out of work. Because of a housing shortage, many had to

live with relatives, friends, or anyone who would rent them a room. Many lived

78 THE COSTS OF COURAGE

anywhere they could, including cars, old boxcars, decommissioned trolley cars,

tra_ilers, basements, and some lived in those places with their wives and chil­ dren. Homelessness and alcoholism were rampant, and veterans were desper­

ate and angry. Prices of food, clothing, and other necessities had increased dur­

ing the war. There were shortages of meat and clothing. Many soldiers' street

clothes consisted of their uniform. The country was in poor economic shape.

There was no easy adjustment for many returning veterans. Many were diag­

nosed with psychoneurosis (later identified as PTSD). For all service members

who have returned from combat in later generations, the impact of combat has

not changed much. It is no wonder that the VA is the largest mental health in­

stitution in the world.

Hidden Epidemic of Female Veteran Suicides

A 2010 study of 5,948 female veterans reported that female veterans were three

times more likely than women civilians who never served in the military to com­

mit suicide (Kennedy, 2010a; McFarland, Kaplan, & Huguet, 2010). Female veter­

ans, age thirty-four and younger, had a 13.4 suicide rate per 100,000 of women veterans, compared to 4.4 among civilian women. The gap between military

women and civilians suicides was the largest for younger women who were

thirty-four years and younger and smallest for older women. The rate was higher among female veterans than among male veterans, who kill themselves twice as

often as civilians. The high rate of female veteran suicides was attributed to mil­

itary-related sexual trauma, as well as exposure to combat and injuries such as

TBI.

Social Work and Suicide Survivors

Survivors of a person who commits suicide face unending loss and the pain that

accompanies it. Social workers can help survivors-spouses, children, parents, sib­

lings, grandparents, aunts, uncles, cousins, stepparents, fellow service members and their spouses, friends-learn to live with ongoing grief. It is thought that

there are at least six survivors for every suicide victim (Lambrecht, 2009), and that

is likely an underestimation. One of the best resources for learning about sup­ porting suicide survivors is the Tragedy Assistance Program for Survivors (TAPS).

The program was created by Bonnie Carroll (2009), a former member of the Air

National Guard who realized that there was little to no support for families ex­

periencing the death of a service member when she lost her military husband in

79 Suicide and the Warrior

a tragic aircraft accident. Carroll and her colleagues, with support from federal

and state agencies, created the family support for survivors program based on

core principles (Burton, 2009; Carroll, 2009): to support survivors by providing

emotional help, finding hope, and learning to live with loss. It is a peer-based support program with crisis care, casualty casework, and grief and trauma edu­

cation resources. Today TAPS has assisted more than thirty thousand surviving

family members, professional caregivers, and casualty assistance personnel to

work with military family members experiencing a death. The program addresses the loss of a service member, including loss by suicide, and offers educational pro­

grams for helping professionals who work with suicide survivors, both adults and

children. A family who experiences the death of a service member is affected in some

ways that are different from civilian families experiencing the death of a loved

one. Never before in the history of our country have military families been so

stressed by multiple deployments, which challenge the integrity of the family. To

add suicide to that stress can be overwhelming and create barriers to adapting

for the family. Moreover, the body of the deceased may be extremely deformed,

not all there, or nonexistent because of injuries suffered in a war zone. After the

burial, which may take months, the family living on post or base or in a military

community usually moves back home or near relatives. This brings changes in

roles for adults and possibly a loss of or change in status, and for children it

brings changes in schools, friends, and familiar teachers. It may take considerable time to access benefits and adjust to a major change in lifestyle.

One of the most important services TAPS offers is helping survivors realize

that they are not alone and that they can share surviving suicide loss with others

who have the same experience. People benefit from being with others who are

going through the same survivor experience and loss. In the case of suicide, the

family most often experiences it as a sudden and traumatic, chaotic loss (LaMorie,

2010). Family, friends, and others may attach stigma to the death, which can con­

tribute to intense and lengthy, unresolved grieving. Kim Ruocco, the surviving spouse of Marine Major John Ruocco, a decorated Marine Corps Cobra pilot who

died by suicide in 2005 a few months after returning from Iraq, said, "I thought

my life was over when my husband took his own life. I felt alone, confused and

isolated. I didn't know anyone who had experienced this kind of loss. I felt

ashamed and confused, angry and exhausted, too devastated to even look for

help" (LaMorie, 2010, p. 28).

80 THE COSTS OF COURAGE

Kim Ruocco has a master's degree in social work, and she helped create the

Suicide Support and Education Program that TAPS offers (LaMorie, 2010). The

program provides direct support to survivors who are in crisis and need assistance

with grieving after a suicide. It also provides long-term support to survivors. Both

programs are directed at adapting and healing, and they emphasize peer sup­ port, spirituality, education, and remembrance of the loved one. Ruocco said of

her experience with the program: "TAPS carried me through those first years by

offering a multitude of support. I am now using my strength, gathered over time

with the constant, loving care of TAPS, to help others" (LaMorie, 2010, p. 20). The

TAPS programs help people positively channel their loss and grief. In an article

on the Suicide Support and Education Program, LaMorie (2010) writes, "After the

flag is folded and the day turns to dusk, the suicide death of a military service

member profoundly affects the lives of those they loved and left behind" (p. 29).

The TAPS program makes a difference in the lives of survivors, who move on but

never away. Social workers need to be prepared to help survivors grieve, find so­

cial support, assist with practical issues, and come to accept that their loved one

is dead (Hall, 2008). Children who experience death have fewer coping resources than adults and

generally cope as well as the adults who surround them (Hall, 2008). For children

the Joss is enormous and may affect them for the rest of their lives (Campagna &

Cohen, 2010). Today the military's operational demands are constant, and chil­

dren are highly aware of the risks of duty and may experience a greater aware­

ness of loss, transition, trauma, and grief. Multiple sources reinforce this aware­ ness, as the loss may have been public and presented repeatedly. Approximately

1.5 million school-age children have a military parent(s) on active duty, and many

more have service members who are siblings, grandparents, or other relatives.

Children who have parents in the National Guard or Reserve may not have other

military people around them who understand their loss and sacrifice.

According to Campagna and Cohen (2010), children may experience a sense of loss of safety as the person who died is no longer there to protect them. They

may become angry at the circumstances that brought about the loss. They may

lose their faith, not understanding why God could let this happen. Their re­

sponses may range from very adaptive (e.g., taking pride in their parents' ser­

vice) to very maladaptive (e.g., having trauma symptoms and getting "stuck" on the traumatic nature of the death). Adaptive grief means accepting the death as

permanent and feeling the pain, remembering the person and holding on to

81 Suicide and the Warrior

memories, and accepting and adjusting to new changes. Traumatic grief reflects

characteristics of posttraumatic stress. Children may act out, become depressed,

have physical health problems, become angry and experience intrusive thoughts,

have nightmares or greater anxiety than normal, or become withdrawn from

family and friends. It is important that children receive special attention if they are having adjustment problems, and play therapy or trauma-focused cognitive­

behavioral counseling may facilitate healing. Grief is a process, and it should be

individualized for each child. Social workers should become familiar with the TAPS programs and their

publications for children including the quarterly magazine Journey of Grief for

five- to twelve-year-olds. Also, TAPS holds Good Grief Camps, where adult sur­

vivors and their children come together with loss, trauma, and grief counselors

and other families who have had the same experience. Social workers can learn

more from the webinars that TAPS regularly offers. Social workers need to know of bereavement counseling offered in their communities and that TRICARE (mil­

itary health care) does not cover the costs of bereavement counseling (Hall,

2008).

Memorial Day, 2011, marked the seventeenth year of the Good Grief Camps.

The camps are safe, supportive environments for all participants to tell their story

with peers of the same age. The experience reinforces an understanding that

those in grief are not alone. At the camp a mentor accompanies each child

through the weekend. In addition, TAPS sponsors regional Good Grief Camps

throughout the states with activities for children and seminars for adults. Partic­

ipants report overwhelmingly positive experiences.

If we are going to send warriors to the killing fields, we owe them the right

to the knowledge of what the cost may be, and we must ensure them that tran­

sition and healing can follow. Warriors have a right to reclaim their lives. Some

need more assistance in making the transition from combat to home. Ongoing

assessment is required for the transition to be successful, and the social work pro­

fession has a major role to play in facilitating that transition.