Supporting a loved one in the military is truly a duty of its own. It is even more so if the military personnel suffers from trauma related to their military experiences. As a helping professional taking this course, it is likely you have studied suicide, motivations for suicide, ideations, assessments, and interventions.Think about what the family of an active duty military personnel or a veteran might face if their loved one becomes suicidal. How does the family react? What recourse does a family have? Could it be different for active duty personnel versus a veteran? For this Assignment, review this week’s resources.
The Assignment (1 page):
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
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).
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
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
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).
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
• 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 a1140 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
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
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
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