by Michael D. Anestis, M.S.
I came across two articles in the past 24 hours that both focus on a topic that has been a central component of my work over the past year: suicide in the military. This topic has been garnering a significant amount of media attention recently as the data on soldiers and suicide have shown to be quite troubling. In an article in the Journal of the American Medical Association (JAMA), Bridget Kuehn (2009) presented a concise summary of these statistics, as well as new efforts on the part of the military to study suicidal behavior in soldiers and to develop effective interventions.
Amongst the numbers Kuehn presented:
- Suicide rates amongst active-duty soldiers reached a 28-year high in 2008, with several cases still being investigated and likely to add to the total.
- The suicide rate in active duty solders in 2008 (likely to settle at approximately 20.2 per 100,000) surpassed that of civilians with similar demographics (19.5 per 100,000 in 2005), marking the reversal of a long-standing trend of lower rates in military populations relative to civilians.
- In 2005, males utilizing Department of Veterans' Affairs (VA) services had a suicide rate of 37.2 per 100,000 compared to 13.6 per 100,000 for females using VA services.
In a separate article, CNN discussed the roles of multiple deployments and stress on suicide rates in the military. Both articles point towards a variety of factors that are contributing to the vulnerability of soldiers to suicidal behavior. For one, there is a stigma regarding seeking mental health treatment. Not unlike the stigma in civilian populations, this situation leads individuals who recognize their own struggles to avoid seeking effective care because they fear repercussions. Some fear seeking such treatment will preclude reaching certain career goals and others fear that they will be perceived poorly by others because of their symptoms. Although some individuals do manage to handle such situations on their own, this invariably leads to a large number of individuals experiencing increasingly severe and dangerous symptomatology treatable only under effective clinical care.
Additionally, there is a higher demand than supply for effective mental health treatment services in this population. Further complicating things, empirically supported treatments and systematic diagnostic assessment procedures have not been universally adopted, meaning that when care is available, it is not always necessarily based upon what has actually been shown to be effective. This situation is by no means unique to the military, but rather represents a failure on the part of the field itself to effectively disseminate vital information as needed.
Another vulnerability discussed in both articles is a tendency for soldiers to experience relationship difficulties. This particular vulnerability dovetails with the discussion we had regarding Joiner's (2005) interpersonal-psychological theory of suicide on PBB the other day. The theory indicates that individuals must have both the desire and capability for suicide before death by suicide is likely. The desire component is comprised of two variables: thwarted belongingness and perceived burdensomeness. Thwarted belongingness is characterized by an individual's sense that he or she does not have meaningful connections to other people. Perceived burdensomeness is defined by an individual's sense that he or she does not make meaningful contributions to the world and that his or her presence serves as a liability to others. In a paper I co-authored with Craig Bryan, Michelle Cornette, and Thomas Joiner (2009), we discussed a variety of ways in which deployed soldiers may develop these risk factors. The loss of close friends during deployment or a failure to integrate socially with other soldiers while deployed could contribute to a soldier's sense of thwarted belongingness. Additionally, returning home from deployment, some soldiers report that despite the knowledge that others care deeply for them, they feel disconnected because their love ones can not relate to their deployment experiences. Such social detachment can also contribute to a soldier's sense of thwarted belongingness.
With respect to perceived burdensomeness, soldiers who are wounded while deployed and no longer able to perform functions they previously performed are likely to feel a sense of burdensomeness. Additionally, difficulty re-integrating into civilian life after performing the important duties of a soldier can leave an individual feeling as though he or she is no longer useful. All of these sensations are based on distorted automatic thoughts and misinterpretations of the environment, but they are compelling to the individual who experiences them and difficult to challenge without help. In one of the only studies to date that has attempted to empirically measure the components of Joiner's (2005) theory in military populations, Brenner and colleagues (2008) found consistent themes of burdensomeness and thwarted belongingness along with a heightened tolerance of physical pain in deployed soldiers.
In each of the papers that have considered Joiner's (2005) theory in military populations, authors have been careful to note that there is no reason to expect that military service inherently increases an individual's vulnerability to the desire for suicide, but rather that there are certain types of experiences (e.g. loss of fellow soldiers) that would increase that risk. In fact, there is reason to believe that military service serves as a buffer against the desire for suicide for many individuals by creating close-knit groups who perform overtly beneficial services. The situation is different for the acquired capability for suicide, however. In the paper I co-wrote with Bryan and colleages (2009), we argued that the nature of service in the military, even for those who do not see combat, serves as a vulnerability for the acquired capability, which is defined by an increased tolerance of physiological pain and a diminished fear of death and is developed through repeated exposure to painful and provocative events (for a more thorough description of this variable, consult our article on interpersonal-psychological theory of suicide).
There is compelling evidence to support the idea that certain aspects of military service, including combat experiences and training in weapon usage, might serve to increase the acquired capability for suicide. For one, male veterans in the general population have been shown to die by suicide at a significantly greater rate than male non-veterans in the general population. Additionally, male veterans are 58% more likely to utilize firearms as their attempt method (Kaplan, Huguet, McFarland, & Newsom, 2007). Nye and Bell (2007) found that the re-experiencing symptoms of PTSD - in which individuals experience visceral flashbacks often involving hallucinations - are the most predictive of suicide attempts in Vietnam war veterans. By consistently re-experiencing painful and provocative events capable of inducing PTSD, it seems reasonable that an individual may experience an increase capability for suicide.
These studies are all indirectly related to Joiner's (2005) theory, but, in addition to impressively funded NIMH research sponsored by the military, a number of other studies are underway that will test these concepts more stringently and provide valuable data. One of the psychologists directly involved in such work is Craig Bryan, a captain in the United States Air Force, who has written a valuable article on the integration of empirically supported treatments for Post-Traumatic Stress Disorder (PTSD) in military populations that will serve as the Psychotherapy Brown Bag featured article for April (publication date: 4/1/09). Until then, we invite your thoughts on this topic.
Why do you think suicide rates in the military have increased so drastically in recent years? What do you think could be done? What studies have you heard about that might provide a good basis for understanding this issue? And remember, while we believe that a data-driven approach to understanding psychological phenomena and treatments is vital, ideas not yet tested by data are welcome too. Such thoughts are simply seen as preliminary, in need of testing, and are a valuable initial step in the scientific process!
Mike Anestis is a doctoral candidate in the clinical psychology program at Florida State University.
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