- US soldiers are four times as likely to die by suicide than in combat.
- Rates of military suicides have increased dramatically since 9-11.
- Extreme individual behaviors such as suicide are difficult to predict and prevent.
- Military attitudes about mental health must change if we are to stem the tide of soldier suicides.
When you contemplate the dangers of military service, your concerns likely center on the risk of combat. This is no surprise. Combat casualties get press and the hero label; they're honored with holidays and parades and memorials and monuments. The risk to our soldiers, we are primed to believe, is posed by the enemy, on the battlefield. In reality, the gravest danger our military personnel face is not combating death, but suicide.
A recent (June 2021) report by Thomas Suitt of Boston University has concluded that soldiers in the US armed forces die at their own hands at four times the rate of dying at the hands of any enemy:
“Suicide rates among the United States public have been increasing for the past 20 years, but among active military personnel and veterans of the post-9/11 wars, the suicide rate is even higher, outpacing average Americans…This paper estimates 30,177 active-duty personnel and veterans of the post 9/11 wars have died by suicide, significantly more than the 7,057 service members killed in post-9/11 war operations.”
What are the reasons for this? This is not a simple question. First, human consequences are multiply determined. Eventualities like suicide are brought about by a constellation of factors, working in concert. Moreover, the military is a complex system, and generalizations about it are bound to be found wanting since soldiers’ experiences and circumstances vary greatly. Still, some risk factors are well known. For example:
Access to firearms. “Simply owning a gun triples the risk of suicide. About 65 percent of active military suicides involve a firearm. Among veterans, the rate is even higher: almost 70 percent. By contrast, firearms account for death in 48 percent of suicides in the general population.” Using a firearm increases the odds that a suicide attempt ends in death.
Military culture. Military culture is rigid, hierarchical, and demanding. It discourages reflection, abhors weakness, stigmatizes mental illness, and fetishizes toughness and aggression. Fearing that mental health difficulties will go on their record or undermine their peer reputation, many soldiers avoid or forego treatment. Untreated trauma and mental health problems tend to get worse.
PTSD and trauma. PTSD and traumatic experiences are predictors of suicide, both in and outside the military. People often assume that military trauma relates solely to combat experience. This is not the case. More common is the trauma of sexual abuse and harassment. “The repeated threat or experience of sexual violence, harassment, or assault within the military context…affects over 23 percent of women in the military...In addition to sexual assault, sexual harassment also affects both women (55 percent of women in the military) and men (38 percent of men in the military).”
In fact, combat deployment alone is not associated with increased suicide rates. Non-deployed troops have an even higher risk of suicide. The reasons for this are not quite clear. "Some have suggested the possibility that physicians appropriately screened out those with mental health conditions before deployment or that access to mental health resources is more readily available to deployed components than non-deployed ones.”
Reintegration into civilian society. Leaving the service for civilian life is akin to immigrating to a new land. Your previous identity, language, habits, and history become largely irrelevant. You have to start over, learn a new culture, establish a new identity and community. This can be highly stressful and disorienting. “Not only must new veterans wrestle with the aftereffects of their military experience, but they also must manage the severe culture shock of reintegrating to the slower pace of civilian life and their new role in it. A great deal of culture shock comes from the swift transition from high operational tempo and little sleep to a significant amount of unfilled time.”
When you suddenly have time to reflect on your experience, you may begin to feel regret, guilt, and grief, and a downward spiral may ensue. “It is difficult for many veterans to return to civilian life with none of the clout their position previously conferred or the sense of purpose their role provided. It meant losing an identity around which they had built their entire world.”
While the culture lauds and hails as heroes those who enlist and go to war, it tends to suspect and stigmatize those who return, viewing them as cultural “others,” dangerous, or broken—not unlike how we regard immigrants. Without a feeling of belonging, and as their struggles increase their sense of being a burden to others, veterans may enter a downward spiral leading to depression and elevated suicide risk. Drinking, a part of military culture, may escalate, as may drug use—to manage physical and emotional pain. Both are predictors of suicide.
Moral injury. Another, less well-understood contributor to military suicide is “moral injury,” which involves damage to the soldier’s sense of goodness and humanity as a result of what they had done or witnessed during service. “Moral injury is at its core the loss of one’s sense of self due to a transgression against one’s most deeply held beliefs and moral values.”
The risk of moral injury is exacerbated by the fact that army culture gives much responsibility but little power to the individual soldier. The soldiers are expected to act as autonomous moral agents after having been indoctrinated into a military culture that demands obedience. Blame for immoral action (or inaction) is usually assigned to individual soldiers, even though they have no say in making the crucial decisions about whether and how to go to war.
The above concerns, however, do not explain directly the recent uptick post 9/11. To explain that, we may need to look into recent trends both within and outside the armed forces. The report lists several potential candidates.
The changing nature of war. “Since the post-9/11 wars began, we have seen a tremendous rise of improvised explosive devices (IEDs) in warfare, significantly increasing the number of traumatic brain injuries (TBIs) and polytrauma cases among service members.” IEDs use contributes to a constant state of fear and vulnerability, increasing soldiers’ chronic stress burden.
Medical advances. “Advances in medical care have allowed service members to redeploy after severe physical trauma. These compounding traumas contribute to worsening suicide rates as service members deploy and redeploy after sustaining severe injuries.” Ironically, then, advances in medical technology and care increase soldiers’ chances of re-trauma, which is associated with an increased risk of PTSD, which has a significant association with suicidal behavior. If PTSD is accompanied by at least two other mental health conditions like anxiety, depression, or alcohol abuse, suicide odds rise dramatically.
Relatedly, these medical advances, while saving lives, may not be able to deliver a quality of life to badly injured soldiers. The report notes: “Modern medical advances have the benefit of allowing service members to survive physical traumas; however, their quality of life following severe physical trauma can put them at a greater risk of suicidal behaviors. For instance, veterans with severe, prolonged pain stemming from physical trauma – sometimes referred to as pain syndrome – are 33 percent more likely to attempt suicide than those with no, mild, or moderate pain.”
Lack of popular support. The report notes that recent post 9/11 wars have not enjoyed wall-to-wall popular support. “Diminishing approval of the wars, coupled with damaging veteran stereotypes, may contribute to today’s rising service member and veteran suicide rates.”
Pre-existing mental health vulnerabilities. Changes in the mental health profile of recruits may have something to do with the uptick in suicide, as recruits bring into the service their pre-enlistment vulnerabilities. The report notes: “annual counts and rates of mental disorders among active duty service members increased by about 65 percent from 2000 to 2011.90 Suicide rates themselves nearly doubled in that time from 10.1 to 19.7…Nearly three-quarters of new soldiers in the Army report previous traumatic experiences upon joining the service, and a fifth of those experiences is child abuse. Research strongly links childhood abuse to suicidal behaviors, even when accounting for new traumas service members may experience in the military.”
Addressing the suicide crisis in the military is not going to be easy, notes the report. Ending the U.S.’s post-9/11 wars would help. Cultural changes are needed. “The military needs to promote help-seeking attitudes and frame them positively. Accordingly, medical screenings for PTSD, TBIs, depression, and suicidal ideation must be universal, communicated across all channels, and taken seriously.” Limits should be placed on redeployments and dwell time. Moral injuries, sexual trauma, and other non-combat traumas need to be regarded on par with physical wounds. The V.A needs reform.
The report concludes: “Unless the U.S. government and U.S. society makes significant changes in the ways we manage the mental health crisis among our service members and veterans, suicide rates will continue to climb. That is a cost of war we cannot accept.”