by Michael D. Anestis, M.S.
Today's article will take another look at the impact of combat exposure on military populations as it relates to mental health outcomes. In prior articles, we have discussed the potential impact of combat exposure on the acquired capability for suicide, as well as the risks for post-traumatic stress disorder (PTSD) and new data on effective PTSD treatment for soldiers. I was inspired to address this issue today by a friend and colleague, Eddie Selby, a renowned researcher on borderline personality disorder (BPD), who alerted me to the publication of an article in the Journal of Psychiatric Research examining the impact of particular types of combat exposure on risk-taking behaviors in a sample of soldiers returning from Operation Iraqi Freedom (OIF; Killgore et al., 2008).
In this article, Killgore and colleagues (2008) reported on data they collected from a sample of 1,252 soldiers at two time points. Data was first collected during each soldier's first three days back in the United States following a 12-month deployment in Iraq. During this initial data collection phase, the researchers asked each soldier whether or not they had encountered specific types of combat exposure (e.g., "working in areas that were mined or had IEDs," "being attacked or ambushed," "handling or uncovering human remains") during their deployment. Data was then collected from these same soldiers three months later. During this second data collection phase, the researchers asked each soldier to what degree he or she had engaged in a wide range of risk taking behaviors (e.g., alcohol and drug use, verbal and physical aggression).
The authors hypothesized that greater combat exposure would predict a greater amount of post-deployment risk-taking behavior. They based this hypothesis on a number of factors, and cited prior research that had linked combat exposure to a host of problematic mental health outcomes, including PTSD, depression, somatic illness, and substance abuse (Beckham et al., 1998; Helzer et al., 1987; Hoge et al., 2004; IPGSG, 1987; Jordan et al., 1991; Prigerson et al., 2002). The authors also predicted that specific types of combat exposure - those involving exposure to or the experience of violence and death - would be more strongly related to risk-taking behaviors. We'll return to this point later, but for those of you who have read our earlier articles on the acquired capability for suicide (see link above), this should sound familiar.
Using a principal components factor analysis, the authors found that their list of specific types of combat experiences yielded a total of seven groups (the article provides precise information on the nature of these groups and the statistics that enabled them to draw this conclusion):
- Violent combat exposure
- Human trauma exposure
- Survived close call
- Buddy killed/injured
- Killed enemy
- Killed friendly/non-hostile
- Pride in mission
After compiling all of their data, the authors reported several interesting findings. First, overall exposure to combat did, in fact, predict a greater rate of risk-taking behavior in soldiers returning from OIF. More specifically, greater exposure to violent combat, exposure to human trauma, and killing an enemy were all highly predictive of post-deployment risk-taking behaviors, although effect sizes were fairly small. The relationship between these three types of combat exposure and risk-taking behaviors was also demonstrated with specific behavioral outcomes, including frequency and quantity of alcohol use and both physical and verbal aggression. The fact that the most violent forms of combat exposure exhibited the strongest relationship with subsequent risk-taking behaviors is important, as it implicates violence as a pivotal factor in the relationship. These findings thus point towards the idea that, when exposed to such trauma, individuals' responses to provocative stimuli change, thereby altering the value of particular types of behaviors and the manner in which such individuals evaluate potential consequences. In other words, imagine you no longer feared the consequences of crashing your car. In that scenario, do you think you might then feel tempted to drive extremely fast in order to experience that thrill? Alternatively, imagine you were playing poker, but not with real money. Without the feared risk of losing your actual money, would you be more likely to make large, risky wagers? The same principle can be applied to a variety of other behaviors.
These findings are important for a variety of reasons. First, it represents the continued efforts on the part of the military to systematically assess and understand vulnerabilities in soldiers, thus providing a foundation upon which effective treatments can be designed to help the men and women who serve our country in battle. Second, they provide additional insight into a phenomenon we have discussed at length on PBB and to which I alluded earlier in this article: the acquired capability for suicide. Recall that the acquired capability refers to the degree to which an individual is able to enact lethal self-harm, as demonstrated by habituation to both physiological pain and the fear of death (Joiner, 2005). This capability is acquired through repeated exposure to pain and provocation and has been supported empirically in a number of published articles (e.g., Van Orden et al., 2008). In this article, Killgore and colleagues used the term "invincibility," which I like quite a bit. In a sense, they argue that exposure to the most gruesome elements of combat creates a sense on the part of a soldier that he or she can survive anything. On the one hand, a sense of strength and resilience is a highly positive attribute that can reduce hopelessness. At the same time, however, taken to an extreme, such a perspective can change the manner in which an individual evaluates the potential danger of a situation and increase the likelihood that he or she will engage in harmful behaviors. Should these behaviors constitute painful and provocative events, this would then theoretically lead to an increase in the acquired capability for suicide and thus represent an important risk for a highly problematic outcome.
The take home message from this article is somewhat complicated. Obviously, combat exposure has a powerful impact on soldiers. This is not a new insight, but the particular type of impact it has is, in fact, quite novel. Reducing combat exposure would clearly be beneficial; however, this is not a realistic option. Given the emphasis researchers place on adapting to real world phenomena, an alternative approach thus needs to be found, as focusing purely on the benefits of not being exposed to violent combat would produce little to no effect and would not assist us in developing effective interventions for soldiers in need of help. The authors suggest that one such alternative is for clinicians treating soldiers post-deployment to frequently assess risk-taking behaviors and to work with their clients to reduce the perceived value of such experiences in an effort to decrease the likelihood of later consequences. An additional approach, given that the combat exposure itself is likely to significantly increase the acquired capability for suicide prior to post-deployment risk-taking behaviors, would be for clinicians to emphasize the desire for suicide by increasing soldiers' sense of belongingness with others and their belief that they are making meaningful contributions to the world around them.
Ultimately, these findings point yet again to the powerful impact of the exposure to and experience of violence, pain, and death, on mental health outcomes. It is easy to look at such findings and feel hopeless and distraught; however, it is important to note that there is a massive amount of research currently being conducted on this phenomenon and that there are many brilliant individuals devoting their professional lives to developing effective interventions. Understanding how individuals become vulnerable to problematic outcomes is thus not an upsetting activity at all, but rather the first step in helping to reduce that vulnerability and restore soldiers' lives and mental health.
If you would like to learn more about the acquired capability for suicide and the impact of combat on mental health, we recommend the following products, all of which are available through our online store:
- Why People Die by Suicide
- The Interpersonal Theory of Suicide: Guidance for Working With Suicidal Clients
- Treating Suicidal Behavior: An Effective, Time-Limited Approach (Treatment Manuals For Practitioners)
- On Killing: The Psychological Cost of Learning to Kill in War and Society
Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University
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