Although suppression is certainly not a coping strategy unique to service members, the military’s valuing of strength, resilience, courage, and personal sacrifice in the face of adversity can create a cultural context within which difficulty in coping with emotional distress can be perceived as a weakness. Clinicians should therefore recognize that service members might be reluctant to abandon avoidance-based coping strategies because they work, albeit for only short periods, and because avoidant coping is consistent with their core identity of being mentally tough.
Why service members kill themselves
Fluid vulnerability theory proposes that suicide risk exists on 2 dimensions: baseline risk and acute risk.12 Baseline risk is affected by the individual’s historical risk factors and predispositions and therefore varies among individuals. In this sense, baseline risk is akin to an individual’s “set point” for experiencing a suicidal crisis; some people are inherently more likely to kill themselves than others. Increased baseline risk is a likely contributor to recent rises in military suicide rates for at least 2 reasons.
First, combat exposure and trauma increases vulnerability to suicide. Second, because military qualification standards were relaxed for a period to offset recruitment and retention shortfalls, a larger number of individuals have entered the military with previously disqualifying characteristics that are well-established risk factors for suicide (eg, limited education, criminal history, and medical and psychiatric histories).
The acute dimension of risk is more familiar to the mental health professional. This is the short-term dimension of risk that coincides with emotional crises, typically in response to an external or internal triggering event. The most common triggering events among service members include relationship, legal/disciplinary, financial, and medical problems. For recurrently suicidal individuals, acute episodes are often triggered by internal states such as emotional distress or negatively valenced memories.
Although the suicidal crisis is experienced as an interaction of thoughts, emotions, behaviors, and physical symptoms—or “the suicidal mode”—it is the cognitive domain that primarily separates suicidality from other psychiatric conditions (Figure 2).12,13 For example, depressed mood, sleep impairment, hopelessness, and substance use are common features for many different psychiatric conditions, but certain beliefs and thought processes are specific to the suicidal state (eg, “I’m a burden to others,” “I can’t take this anymore”).
Suicidal crises resolve when the various systems of the suicidal mode, especially the suicidal belief system, are deactivated, at which point patients return to their baseline risk level. With each activation of the suicidal mode, the mode becomes more easily activated again. Being suicidal is therefore a self-reinforcing system: it becomes easier to again become suicidal in the future. Fluid vulnerability theory is therefore a diathesis-stress model of suicide that accounts for individual differences and the learned nature of suicidal behaviors over time.
Service members kill themselves to alleviate the psychological pain and suffering associated with the active suicidal mode. Attempting to reduce undesirable or aversive experiences is the primary motivator for maladaptive behavioral patterns in general, and self-injurious behaviors in particular.14-18 Other functions (or purposes) of suicidal behaviors are shown in the Table.
It is important to note that although service members might be motivated to attempt suicide for a variety of reasons (eg, to avoid a deployment), in all cases there is also the desire to reduce psychological pain and suffering. Service members who opt to die by suicide are unable to effectively alleviate their suffering, in large part because of significantly impaired decision-making and problem-solving capacity that limits their ability to consider options other than suicide as a method to reduce psychological pain. Thus, suicide can be understood as the fatal outcome of psychiatric illness.