The seemingly relentless rise in military suicide rates, beginning in 2004 and depicted in sobering graphs such as Figure 1, has become a source of frustration and alarm for the mental health community, military leaders, and US society as a whole. This frustration is due in large part to our remarkable lack of success in curbing the problem despite impressive (and expensive) efforts and initiatives. What is not as widely recognized is that suicides are on the rise across all branches of the armed services—not just the Army. It seems likely that limited public awareness of rising suicide rates across the entire military is partly a result of the relatively smaller raw numbers of deaths in the comparatively smaller (in terms of total personnel) branches.
Perhaps the greatest and most widespread misunderstanding about military suicide is its relationship with combat deployments. The typical story line our society has constructed to explain military suicide is that the service member deploys, experiences repeated traumas, returns to the United States with posttraumatic stress disorder (PTSD), and then commits suicide.
Without a doubt, this is the tragic sequence of events for many service members. But the misconception that this is the typical story of military suicide leads us to overlook the fact that the overwhelming majority of combat veterans do not experience PTSD and subsequently kill themselves. Consequently, we potentially miss other, more proximal causes for suicidal behaviors, including relatively “routine” life issues. Relationship problems, discipline/legal problems, financial problems, and injury/illness are the most common precipitants for suicide among the military.1
Moreover, the majority of military suicide victims have no history of deployment.2 Thus, the link between combat and suicide appears to be indirect—combat increases vulnerability to more proximal risk factors for suicide, such as poor emotion regulation; guilt or shame; relationship, financial, or legal problems; psychiatric illness). Unfortunately, there are no available data to explicitly test this or other proposed pathways from combat exposure to suicidal behaviors, although a number of studies are currently under way to explore these associations.
The military context
To effectively address the problem of military suicide, we must view suicide from within the context of the military culture. The military differs from the general population of the United States both in terms of demographics (ie, greater proportion male, younger age) and in its cultural norms, each of which can create both protective factors against and vulnerabilities to suicide that are critical for successful prevention and treatment. Therefore, understanding suicide among service members requires recognition of the cultural context within which service members live, train, and work.
Fearlessness about injury and death is an important and desirable quality of an effective service member. Thus, it is conditioned throughout military training via the opponent process, in which an initially negative emotional response (eg, fear, anxiety) is dampened via repeated exposure to aversive or painful experiences (eg, injury, death), and the “opponent” emotional response (eg, exhilaration) is reinforced. This opponent process explains many service members’ description of combat as “fun” or “exciting.”
This opponent process is not necessarily “bad,” but rather it is a learned process that can be highly functional, since service members who fear death during combat have the potential to inappropriately freeze or flee when the optimal response is to fight. Ironically, this warrior attribute can simultaneously function to diminish an important protective factor against suicide.
Fear of death differentiates those who have attempted suicide from those who have merely thought of it, and it is associated with lower levels of past and current suicidality.3-5 Levels of fearlessness rise as combat exposure increases, especially combat marked by higher levels of violence.6,7 The very small relationship between combat and fearlessness, in combination with generally elevated levels of fearlessness among service members with no combat exposure relative to civilians, suggests that military members might “intrinsically” be less afraid of death than civilians, regardless of their combat exposure.4
What is already known about suicide among service members?
■ Rates of suicide in the US military have steadily risen since 2004.
■ The majority of service members who die by suicide have never been deployed.
What new information does this article provide?
■ It proposes that combat exposure is an indirect, not direct, contributor to suicide.
■ It proposes that military suicide must be viewed from within the context of the military culture.
■ It proposes that suicide prevention requires a combination of cultural competence and commitment to evidence-based practice.
What are the implications for psychiatric practice?
■ Certain cognitive-behavioral therapies are the only treatments shown to be effective for reducing suicidal behaviors.
■ Clinicians should seek out training and supervision in military cultural issues and empirically supported treatments for suicidal behaviors.
Mental toughness
Service members often deal with suffering by using emotional avoidance and suppression coping strategies (eg, “suck it up,” “just don’t think about it, move on”). Suppression has long been considered problematic within the mental health disciplines because of its association with increased emotional distress.8-10 Suppression has even been directly linked to suicide-related behaviors.11 Less recognized within the mental health disciplines is the fact that suppression and avoidance can actually reduce the frequency of emotionally distressing or trauma-related thoughts in the short term.8,9
