Craig J. Bryan, PsD, ABPP

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 

 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 

 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.

Moreover, the majority of military suicide victims have no history of deployment.

 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.

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.

 Levels of fearlessness rise as combat exposure increases, especially combat marked by higher levels of violence.

 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.

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.

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.

 Suppression has even been directly linked to suicide-related behaviors.

 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

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.

Fluid vulnerability theory proposes that suicide risk exists on 2 dimensions: baseline risk and acute risk.

 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 (

 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.

 Other functions (or purposes) of suicidal behaviors are shown in the

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.

The research base for effective treatments for suicidal behaviors is limited relative to our knowledge base for treating other psychiatric and behavioral disorders; very few studies explicitly investigate suicidal behaviors as a primary outcome variable, which limits our ability to understand treatment effects. There are a large number of uncontrolled studies of treatments for suicidal individuals, including case studies and single-sample longitudinal follow-up studies, but these types of studies cannot provide causal information about treatment effectiveness.

Furthermore, treatment studies for other associated psychiatric conditions (eg, depression, psychosis) might report suicidal behaviors as a secondary or tertiary outcome. However, the methods used to measure or define suicide-related constructs in these studies are often inconsistent and/or unreliable, making it difficult to accurately understand treatment effects across studies. Of the many treatments that have been tested, the clearest and most consistent empirical support has been found for certain cognitive-behavioral treatments, which generally reduce the likelihood of subsequent suicide attempts by about 50% for up to 2 years posttreatment.

Tragically, the greatest barrier for effectively treating suicidal service members arises from the limited implementation of empirically supported treatments by mental health clinicians across disciplines. Interventions with limited, inferior, or no empirical support and that are based instead on personal experience rather than scientific evidence are often used.

 Those service members who do choose to access specialty mental health care are therefore unlikely to receive the treatments that have been shown to best reduce psychological suffering and the likelihood for future suicidal behaviors. Effective treatments share several critical elements

• Such treatments are based on clearly articulated, easily understood, scientifically supported theoretical models that integrate cognitive, emotional, behavioral, and physical phenomena

• These treatments view suicidal behaviors as a problem of emotional regulation and problem solving-not as a symptom of psychiatric illness-and therefore target suicide risk independent of diagnosis

• Effective treatments ensure that providers are trained to a predetermined minimal competence and supervised throughout treatment to minimize deviation from the treatment protocol

• These treatments provide clear guidelines for how to address patient nonadherence and/or loss of motivation

• They identify “what is wrong” with the patient and teach the patient “what to do about it” and “how to do it” with in-session practice and skills development

• They emphasize the suicidal patient’s self-reliance, self-control, and personal responsibility for choices and behaviors and respect the patient’s capacity to take his or her own life

• They teach patients how to identify personal emergencies, how to resolve them, and how to appropriately access support when needed

To date, no suicide treatment studies have been published using military samples, although 2 randomized clinical trials of cognitive-behavioral treatments (1 for outpatient clinics and 1 for inpatient units) are currently under way in military settings. Both treatments are adaptations of the same empirically supported cognitive-behavioral treatment, and are therefore based on the 7 elements described above.

Based on what we know (and don’t know) about military suicide, 3 overarching lessons can maximize clinicians’ ability to assist service members in crisis.

1. Remember that combat can increase vulnerability to suicide by increasing the likelihood of other, more proximal causes for suicide (eg, life stressors, emotion-regulation problems). In treating patients, clinicians should be careful not to be distracted from these proximal risk factors by overemphasizing combat exposure.

2. Remember that the military has a unique cultural context that views death and emotional distress in ways that differ from the views of civilians. Clinicians should not discourage these qualities. Rather, they should help foster and maintain a more adaptive “warrior mindset.”

3. Finally, remember that there are few effective treatments for suicidal behaviors. Mental health professionals should seek out and receive adequate training and supervision in the evidence-based treatments for suicidal behaviors and use these as front-line interventions.

By being committed to cultural competence and evidence-based practice, mental health professionals are poised to have a positive impact on the problem of military suicide.

 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.



Army Health Promotion, Risk Reduction, Suicide Prevention Report 2010

. Washington, DC: US Dept of the Army; 2010.



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Articles

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.

Craig J. Bryan, PsD, ABPP

Articles

Suicide Among Service Members