The suicide rate in the US military has steadily climbed over the past 5 to 7 years despite aggressive efforts by the military and the mental health community to counter this trend. Successful suicide prevention will require improved understanding of the link between combat and vulnerability to suicide, recognition of cultural differences between military and civilian populations, and enhanced commitment by mental health clinicians to empirically supported treatments for suicide risk.
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
? 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.
? 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.
? 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.
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
1. Department of Defense Task Force on the Prevention of Suicide by Members of the Armed Forces. The Challenge and the Promise: Strengthening the Force, Preventing Suicide, and Saving Lives. Washington, DC: US Dept of Defense; 2010.
2. Department of the Army. Army Health Promotion, Risk Reduction, Suicide Prevention Report 2010. Washington, DC: US Dept of the Army; 2010.
3. Linehan MM, Goodstein JL, Nielsen SL, Chiles JA. Reasons for staying alive when you are thinking of killing yourself: the reasons for living inventory. J Consult Clin Psychol. 1983;51:276-286.
4. Bryan CJ, Morrow CE, Anestis MD, Joiner TE. A preliminary test of the interpersonal-psychological theory of suicidal behavior in a military sample. Pers Individ Diff. 2010;48:347-350.
5. Van Orden KA, Witte TK, Gordon KH, et al. Suicidal desire and the capability for suicide: tests of the interpersonal-psychological theory of suicidal behavior among adults. J Consult Clin Psychol. 2008;76:72-83.
6. Bryan CJ, Cukrowicz KC, West CL, Morrow CE. Combat experience and the acquired capability for suicide. J Clin Psychol. 2010;66:1044-1056.
7. Bryan CJ, Cukrowicz KC. Associations between types of combat violence and the acquired capability for suicide. Suicide Life Threat Behav. 2011;41:126-136.
8. Shipherd JC, Beck JG. The effects of suppressing trauma-related thoughts on women with rape-related posttraumatic stress disorder. Behav Res Ther. 1999;37:99-112.
9. Beck JG, Gudmundsdottir B, Palyo SA, et al. Rebound effects following deliberate thought suppression: does PTSD make a difference? Behav Ther. 2006;37:170-180.
10. Hayes SC, Wilson KG, Gifford EV, et al. Experiential avoidance and behavioral disorders: a functional dimensional approach to diagnosis and treatment. J Consult Clin Psychol. 1996;64:1152-1168.
11. Najmi S, Wegner DM, Nock MK. Thought suppression and self-injurious thoughts and behaviors. Behav Res Ther. 2007;45:1957-1965.
12. Rudd MD. The suicidal mode: a cognitive-behavioral model of suicidality. Suicide Life Threat Behav. 2000;30:18-33.
13. Bryan CJ, Rudd MD. Managing Suicide Risk in Primary Care. New York: Springer; 2010.
14. Nock MK, Prinstein MJ. A functional approach to the assessment of self-mutilative behavior. J Consult Clin Psychol. 2004;72:885-890.
15. Joiner TE. Why People Die by Suicide. Cambridge, MA: Harvard University Press; 2005.
16. Loo R. Suicide among police in a federal force. Suicide Life Threat Behav. 1986;16:379-388.
17. Smith GW, Bloom I. A study of the personal meaning of suicide in the context of Baechler’s typology. Suicide Life Threat Behav. 1985;15:3-13.
18. Rudd MD, Joiner TE, Rajab MH. Treating Suicidal Behavior: An Effective, Time-Limited Approach. New York: Guilford Press; 2001.
19. Linehan MM, Comtois KA, Murray AM, et al. Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder [published correction appears in Arch Gen Psychiatry. 2007;64:1401]. Arch Gen Psychiatry. 2006;63:757-766.
20. Linehan MM, Armstrong HE, Suarez A, et al. Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Arch Gen Psychiatry. 1991;48:1060-1064.
21. Brown GK, Ten Have T, Henriques GR, et al. Cognitive therapy for the prevention of suicide attempts: a randomized controlled trial. JAMA. 2005;294:563-570.
22. Baker TB, McFall RM, Shoham V. Current status and future prospects of clinical psychology: toward a scientifically principled approach to mental and behavioral health care. Psychological Sci Public Interest. 2008;9:67-103.
23. Barlow DH, Levitt JT, Bufka LF. The dissemination of empirically supported treatments: a view to the future. Behav Res Ther. 1999;37(suppl 1):S147-S162.
24. Groopman J. How Doctors Think. Boston: Houghton Mifflin; 2007.
25. Wenzel A, Brown GK, Beck AT. Cognitive Therapy With Suicidal Patients: Scientific and Clinical Applications. Washington, DC: American Psychological Association; 2008.