Suicide and the Military
© by Amy Menna, Ph.D., LMHC, CAP & Gift From Within
www.giftfromwithin.org



When someone commits suicide, it is a tragedy. When we are losing more soldiers to suicide than the Afghanistan war, it is an epidemic. In June of 2010, there were over 32 confirmed or suspected suicides among soldiers. Studies confirm that individuals in the military are at higher risk than the general population due to the conditions in which they are exposed. Wartime pressures are at a high, and soldiers are coming back from combat showing signs of psychiatric illnesses and addictions. These risk factors provide a cocktail conducive to thoughts of suicide. It is time to take a closer look at them.

This article is about prevention. It will detail some of the warning signs soldiers' exhibit prior to a suicide attempt and will discuss preventive measures. This article is for everyone as it has been estimated that 65% (PTSD Research Quarterly) of the general population know someone who has died by suicide. Military efforts to reduce risk have been improved and new programs are being created. Suicide prevention rides on the shoulders not only of the government, but reaches to other soldiers as well as civilians. It is imperative that we are armed with awareness and prevention.

Disorders Commonly Found Among Suicidal Soldiers

The military has identified Post Traumatic Stress disorder, other mental illnesses and addiction as a predictor of risk for suicide. Knowledge of these disorders will equip individuals to identify when someone is at risk and provide the support they need. The following disorders are commonplace among soldiers who commit suicide. They will be explained in detail as to some of the signs and symptoms. Please note that meeting the following criteria does not necessarily mean that someone is suicidal. These are simply red flag disorders associated with thoughts of self-harm. This is not an exhaustive list of predictors and soldiers may exhibit other behaviors that signal concern.

Post Traumatic Stress Disorder

Post Traumatic Stress Disorder (PTSD) may result from exposure to a traumatic event. It is the bodies and the mind's way of responding to an overwhelming situation involving fear and, often seen in soldiers, the threat or witnessing of death.

PTSD is characterized by three clusters of symptoms: intrusive, arousal, and avoidance. All three of these need not be present to be concerned about the possibility of suicide among a soldier.

Intrusive Symptoms: These are symptoms that literally intrude a soldier's life. They are thoughts and feelings associated with combat that come "out of the blue." Intrusive symptoms may come in the form of nightmares, flashbacks, or negative reactions to anything associated with combat or the military in general.

Arousal Symptoms: When someone is experiencing intrusive symptoms, their anxiety will begin to peak. This is a result of not knowing when the individual will experience the next intrusive symptom. This response mirrors the "fight" response to a stimuli. An example of an arousal symptom is an exaggerated startle response commonly known as being "jumpy" or "watchful waiting." The soldier may feel "on edge" all the time as if something is going to harm him or her. These symptoms may manifest themselves in irritability or explosiveness.

Avoidance Symptoms: It is normal to want to avoid something that is painful. Intrusive and arousal symptoms are painful enough to where the soldier may make every attempt to avoid the pain associated with them. This is the "flight" response. Avoidance symptoms include not wanting to talk about the combat or military experience, not remembering key events, "checking out" when reminders of the trauma are presented, or engaging in drug and alcohol use.

Depression

Depression is common in individuals who have thoughts of suicide. It is important to note that there is a normal depression that comes along with having a traumatic event in the past. This does not necessarily mean that it will lead to suicide.

Some symptoms of depression include:

• Feelings of helplessness and hopelessness - feeling as if nothing will get better and there is nothing that one can do to better the situation
• Loss in interest in daily activities
• Loss of ability to experience joy and pleasure
• Appetite or weight changes - either losing or gaining a significant amount of weight
• Irritability and restlessness - tolerance level of stress is low
• Loss of energy - feeling fatigued or physically drained
• Low feelings of self worth or excessive guilt
• Concentration problems
• Changes in sleep pattern - either sleeping significantly more or less than normal

Anxiety

Anxiety can be described as a constant state of hypervigilance. It is constantly feeling as if something bad is about to happen. Anxiety can manifest itself both mentally and physically. Symptoms of anxiety vary from person to person. Some individuals may feel more panic at certain times, while others may feel nervous about everything no matter what the significance.

Symptoms of anxiety include:

• Feelings of panic or fear
• Feeling uneasy most of the time
• Obsessive thoughts
• Negative thoughts about the future
• Ritualistic behavior such as checking doors or washing hands
• Problems sleeping
• Sweaty or tingling hands
• Shortness of breath
• Heart palpitations
• Muscle tension
• Inability to stay calm
• Explosiveness

Addictions

At times, addiction may accompany a history of trauma or the disorders described above. A simple description of addiction is continued use despite consequences associated with the use of a substance. To illustrate, if a soldier continues to have problematic behavior (i.e. aggressiveness or increased depression) when using alcohol yet continues to use it, abuse issues may be present.

Symptoms of addiction include:

• Marked increase in tolerance to the substance (i.e. are able to use considerably more than they were able to in the past)

• Withdrawal symptoms

• Difficulty cutting down or controlling use of substance

• Increased time and energy spent on obtaining and using the substance

•Social and occupational roles may be compromised by substance use (i.e. missing work due to a hangover)

• Negative consequences associated with use of substances

• Desire to cut down coupled with unsuccessful attempts

Warning Signs

Following is a list of warning signs a soldier may exhibit when he or she has suicidal thoughts or plans. It is important, when assessing the situation, that there is open communication with the soldier as well as those around him. It would be helpful to identify some of these issues from speaking directly to the soldier. Other times, a discussion with a loved one may be an avenue to evaluate the signs and discuss the level of concern. If there are signs, a trained professional may be able to help. Please refer to the references listed below.

1. Disorder listed above
2. Threatening to kill themselves
3. Talking about death or being "passively suicidal"
4. Feeling like there is no reason to live
5. Rage or uncontrolled anger - wanting to seek revenge
6. Engaging in high risk activities
7. Abusing drugs or alcohol
8. Withdrawing from friends and family
9. Dramatic mood changes - impulsivity or poor self-control
10. Irrational thinking or paranoia
11. Sleeping too much or too little
12. Giving away possessions
13. Recent losses - physical, financial, or personal
14. Family history of suicide
15. History of abuse - physical, sexual, or emotional
16. Having feelings of being trapped, hopelessness, despair, shame, humiliation, disgrace or anger
17. Making arrangements "just in case" they passed away

Reasons Soldiers may Deny the Presence of Suicidal Thoughts

Lines of communication regarding suicide should be open. In speaking with the soldier directly, one opens him or herself up as someone who is knowledgeable and can be helpful. However, there are times that the above references signs may be present and the soldier may deny them. Here are a few reasons why soldiers deny any suicidal thoughts or plans.

1. The belief of a stigma that goes along with mental illness or suicidal thoughts. Many soldiers believe that, if they discuss these thoughts, they may be labeled as "crazy" or "unstable."

2. Fear of being judged for being "weak." Soldiers are taught to continue fighting despite pain. They believe that if they ask for help, it means that they are not able to handle it on their own.

3. Soldiers may feel also fear that the person they tell may "over react" and hospitalize the soldier. If hospitalized for psychiatric disturbance, there may be consequences unknown to them or they may fear being discharged from the service.

Veteran Specific Risks

The following are some risk factors specific to veterans. Remember that being in combat, dealing with death, or simply having to live two lives (that of a soldier and that of a civilian) is enough to necessitate a screening for suicidal thoughts. The following are specific risks for suicidal thoughts or behaviors:

1. Frequency and lengths of deployments
2. Deployment to hostile environments
3. Exposure to extreme stress
4. Physical or sexual assault while in the military
5. Service related injuries
6. Being a sexual minority

Factors that may Decrease the Risk of Suicide

There are several factors that serve to protect an individual from having thoughts of suicide. The protective factors listed below should be fostered in any soldier whether they are on leave or discharged.

1. Positive social support
2. Spirituality
3. Sense of responsibility to family
4. Children in the home
5. Pregnancy
6. Life satisfaction
7. Positive coping skills
8. Positive problem-solving skills
9. Counseling

How to Help

Some soldiers may exhibit outward signs of suicidality such as the characteristics and signs described above. Others may suffer more silently. Neither of these are beyond help. Opening up a dialogue about thoughts of self-harm is imperative. It is important that the soldier get back to a state where he or she again feels safe and secure. It is strongly encouraged that, if there is cause for concern, one must not only engage in some of the strategies below but enlist the assistance of a trained clinician.

1. Ask, ask, ask - The topic of suicide does not generally flow into normal conversation. If the soldier has any of the following warnings, it is important to ask whether he or she has any thoughts to harm himself or herself. It is important to note that they may not be entirely truthful about his or her thoughts or feelings. The soldier may be trying to reconcile his or her death but not want to tell anyone. It is important to watch for the warning signs and intervene when appropriate. Remember, asking will not harm anything.

Some questions to ask are:

a. Some individuals experiencing the same situation as you have had thoughts of harming themselves or committing suicide. Do you have any of these thoughts?

b. Are you feeling hopeless about the future or even the present?

c. Do you feel trapped?

d. Have you ever thought of taking your own life or had a suicide attempt?

2. Be willing to listen - allow them to express their feelings without interpretation or judgment. Remember that it is reasonable to ask specific question about particular feelings (i.e. are you feeling hopeless).

3. Validate the soldier's feelings. Don't give a lecture on the values of life. Be prepared to listen and provide support.

4. Be available to them. Show interest and understanding. It is important that they know that there is care and support out there.

5. Offer hope that there are alternatives available.

6. Take action in removing firearms, pills, and anything else that can be lethal.

7. Do not act shocked or ask why. Be careful not to have a negative reaction to their feelings or thoughts.

8.Get professional help. It is important to ask a trained counselor to intervene. Professional support is necessary when dealing with suicidal thoughts. Do not agree to keep it a secret. Encourage them to attend counseling or reach out to their support system. If the soldier is referred to counseling, it would be helpful to have someone go with him or her. Be a resource that is active in his or her recovery. Offer to go with the soldier to appointments and follow up.

A Word for Caregivers

Caring for others can be a wonderful and rewarding experience. At the same time, it can be stressful. Caregiver burnout, also known as compassion fatigue, happens when individuals focus on others at the expense of their own self-care. It is important to note that anything that has to do with combat or the military experience can be stressful both for the soldier and those who love and care for him or her.

Some signs of compassion fatigue can mirror what some soldiers go through when they return from service. Symptoms of PTSD, depression, anxiety, and addiction can all be manifestations of compassion fatigue. It is important that care givers take care of their own emotional well being in addition to being there for others.

Counseling for caregivers may prove to be beneficial not only to the caregiver, but to the soldier. If the caregiver is better equipped with knowledge and adequate self-care, he or she is apt to provide more supportive care. Dr. Frank Ochberg, the Founder of Gift from Within has written an excellent article for partners of patients with PTSD. His article can be found at http://www.giftfromwithin.org/html/partners.html

Conclusion

Suicide is a serious and very real problem with individuals returning from service. The military has been responding to this epidemic but the responsibility also rests on the shoulders of those who love and care for soldiers. Signs and symptoms of suicidality need to be taken seriously and protective measures need to be taken. Please try and learn all you can about suicide prevention, PTSD, depression, anxiety, and addiction. There are also trained professionals in this area. Below are some of the resources available on the internet.

Through opening up a dialogue about this serious topic, soldiers will be provided with the understanding and care that they need. Military personnel continue to serve this country on a daily basis. It is imperative that we serve them as well.

Amy Menna has a Ph.D. in Counselor Education and Supervision. She is a Licensed Mental Health Counselor, and Certified Addictions Professional. She is in private practice and lives in Tampa, Florida.

Resources

Post Traumatic Stress Disorder

•National Institute for Mental Health - http://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-ptsd/index.shtml
• National Center for PTSD - http://www.ptsd.va.gov/
• Information and Links for PTSD - http://www.ptsdinfo.org/
• DVD: PTSD & Veterans: A Conversation with Dr. Frank Ochberg

PTSD and the Military

• Military Pathways - https://www.militarymentalhealth.org/Welcome.aspx
• PTSD Resources - http://giftfromwithin.org/html/military-family-resources.html
• Veterans and PTSD: http://giftfromwithin.org/html/veterans-and-ptsd.html

Depression

• Depression and the Military - http://www.militarymentalhealth.org/resources/what-military-families-should-know-about-depression.aspx
• Courage to Care - What Military Families Should Know About Depression - http://www.centerforthestudyoftraumaticstress.org/csts_items/CTC_depression_family_sheet.pdf

Anxiety

• National Institute for Mental Health - Anxiety Disorders - http://www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml
• Anxiety Disorders Association of America - http://www.adaa.org/

Addictions

• National Institute on Drug Abuse - http://www.nida.nih.gov/NIDAHome.html
• Substance Abuse Mental Health Services Administration - http://www.samhsa.gov/
• National Institute on Drug Abuse - http://www.nida.nih.gov/NIDAHome.html
• Substance Abuse Mental Health Services Administration - http://www.samhsa.gov/
• Trauma Addiction: Safety and Stabilization for the Addicted Survivor of Trauma Dr. Eric Gentry

© Dr. Amy Menna & Gift From Within 2011 - http://www.giftfromwithin.org/