Identifying and Managing Veteran Suicide Risk: Proceedings of a Workshop (2023)
Chapter: 2 Suicide Risk Among Veterans
2
Suicide Risk Among Veterans
DEATH IS EVERYWHERE.
WHEREVER THERE IS WAR, DEATH FOLLOWS, AND IT IS EVERYWHERE.
REFLECTION.
MIRROR, MIRROR ON THE WALL, WHO AM I AFTER TWIN TOWERS FALL?
I AM NO LONGER DISGUISED IN CAMOUFLAGE DESERT GEAR.
I’M CLICKING MY HEELS AT ATTENTION, PRAYING FOR GOD TO TAKE ME OUT OF HERE.
THESE COMBAT SCARS MARK MY SOUL.
BULLET ROUNDS WERE SHOT TO PART MY BODY FROM MY SOUL.
I JUST CAN’T RECOGNIZE WHO I AM.
MY GOD, I CAN’T EVEN RECOGNIZE WHOSE I AM.
—Allen Levi Simmons, from “Bombs Over Baghdad”1
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1 The complete poem was presented by Allen Levi Simmons during the workshop. The presentation was introduced by Carl A. Castro who noted that this presentation highlights the artistic skills of many veterans. Simmons added that he wrote the poem a couple of years after he returned from Afghanistan and found healing in poetry. To view his presentation of the complete poem, visit https://www.nationalacademies.org/event/05-23-2023/workshop-on-identifying-and-managing-veteran-suicide-risk-in-non-va-healthcare-settings
HISTORICAL CONTEXT AND CURRENT ISSUES
Carl A. Castro (Col., U.S. Army-ret.; Suzanne Dworak-Peck School of Social Work, University of Southern California; workshop planning committee member) asserted that in 1981, the rate of suicide across the Department of Defense (DOD) was one of the lowest in the world, which led DOD to eliminate all of its suicide prevention research—without evidence to understand why the statistics were so low. Castro remarked that even as the rate of suicide steadily increased over the following decade, DOD remained slow to take action. Jeannette E. South-Paul (Col., U.S. Army-ret.; Meharry Medical College; workshop planning committee member) noted that since the wars in Iraq and Afghanistan began, the number of suicides among U.S. veterans has “skyrocketed” and now far exceeds that of those without a history of military service. She indicated that veterans of Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn experience higher rates of major depression, posttraumatic stress disorder, sleep disorder, generalized anxiety disorder, and alcohol and substance use disorders than the general population, yet less than half of the millions of people who served in those missions have been receiving care in VA facilities.
Castro pointed out that the stigma around both physical and mental illness—often conveyed as “weakness” or as “personal problems” that should be kept to oneself—remains a significant issue in the military. Furthermore, “military culture,” which varies by service branch, is vastly different from “American culture.” He compared veterans to “foreigners” as they transition out of this military culture, which they might have embraced at a young age, and back into American culture. Other than employment assistance and a description of available benefits, little guidance is offered during this transition process specifically to navigate this difficult culture change. He mentioned that transition periods should be viewed as opportunities to excel, yet they often create vulnerability and hardship for veterans.
South-Paul emphasized that although the military provides three or more months of training to new service members, the structured transition process out of the military lasts only a few days. Veterans who realize they need help during the transition process are often provided little direction. Castro added that identifying and managing suicide risk is further complicated by several issues. Combat trauma, the trauma of a fellow service member’s injury or death, sexual assault, sexual orientation, and gender identity issues are all important when trying to understand veterans’ perspectives on seeking mental health care and on dying by suicide. South-Paul stressed that the data on suicide risk are only helpful when the individuals and their experiences are considered.
THE EXPERIENCES OF VETERANS AND THEIR FAMILIES IN SEEKING CARE
Castro and South-Paul moderated a panel discussion among three veterans and a caregiver who spoke about their personal experiences with suicidal ideation and mental health care and offered suggestions to better meet the needs of veterans and their families in the future.
Identifying the Need for Care and Next Steps2
South-Paul asked the veterans on the panel when they first became aware of their need for mental health care and how they determined the next steps to obtain that care.
Fetima McCray (veteran, U.S. Marine Corps; federal employee; member of Disabled Veterans of America) realized that she needed help while still on active duty. Despite efforts to “work past” her problems, her “Marine mask started to slip” and friends noticed signs that she was suffering from depression and disassociation. She recalled her concern after deciding to begin therapy that admitting to mental health struggles would validate the stereotype of “weakness”—an issue that is particularly difficult for women in the military. To avoid being viewed as a “risk,” she initially chose not to disclose that she was participating in therapy; however, she soon recognized that honesty about her alcoholism, depression, and suicidal ideation would be necessary for healing.
Bryan Moore (1SG, U.S. Army-ret.; Caregivers on the Homefront) recounted his experience in Afghanistan on December 18, 2010, when he was contemplating which weapon to use to end his life while holding the key to the arms room. Upon taking a “personal inventory” in that moment, he recognized that he was suffering from alcoholism; however, he did not enter rehabilitation for another two years—after accepting the fact that admitting his issues publicly would end his 23-year military career.
Allen Levi Simmons (veteran, U.S. Marine Corps; Give an Hour Ambassador) reflected on his experience suffering from traumatic brain injury in December 2010 after surviving a rocket-propelled grenade blast and engaging in his first gunfight with the Taliban in Afghanistan. No one asked if he was unwell and he assumed he would simply recover. However, a year after separating from the Marine Corps in July 2011, he began to experience extreme paranoia and fear while also battling suicidal ideation and memory loss. After his anxiety peaked in 2013, during an emotional breakdown at work, his supervisor (also a veteran) contacted VA and
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2 For VA resources about suicide prevention, see https://www.va.gov/health-care/health-needs-conditions/mental-health/suicide-prevention/
arranged for an appointment. Only after he considered crashing his vehicle into a barrier while en route to this appointment did he realize that he needed help.
Improving Care for Veterans and Their Families
Castro inquired about what VA could do differently to encourage veterans to seek and continue care, as well as to better include family members in this care.
Simmons encouraged VA to develop a culture of “open arms” instead of focusing only on the business of providing care. For example, during his first visit to the OEF/OIF clinic, he wished he had been greeted with an embrace and words of comfort before being asked to complete paperwork.
Shawn Moore (spouse/caregiver of Bryan Moore; Elizabeth Dole Foundation) explained that when she observes changes in her husband’s behavior, she asks him whether he is thinking about suicide and takes him to a VA facility for care when necessary. However, she described the challenges that arise when providers do not seek her input, communicate about her husband’s treatment plan, or understand the influence of her husband’s experiences. Furthermore, she mentioned several instances in which, despite being listed as the designated caregiver in her husband’s medical records, she was not notified when he was admitted to a VA facility for suicidal ideation. She emphasized that the less VA includes her in her husband’s care, the less likely he will be to seek care from VA. She advocated for all of VA’s providers to put the VA’s Campaign for Inclusive Care3 into practice.
B. Moore elaborated on the frustration that arises from this lack of communication between VA and his wife, who could provide much more reliable explanations of his reasons for needing care—especially when he is either incapacitated from drugs or alcohol or no longer having symptoms when he arrives for a care appointment. S. Moore added that veterans should always be given options about their care and an opportunity to understand and advocate for their care, which would increase trust between the veterans and their VA providers.
McCray stressed that “competent care” requires an understanding of the “machine” culture of the military as well as how the mindset adopted to be successful in the military—“no one cares . . . keep running”—might be detrimental to the individual. She championed providing competent care for the whole person, who has a “heart, mind, soul, and history,” instead of treating the veteran as a “cog in the machine.” No matter how
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many programs VA offers, she continued, if its providers see only “Veteran #45638” or fail to understand how the “machine” might cause emotional scars, these programs will not be successful. Such emotional scarring is particularly evident for veterans like McCray who experienced the trauma of sexual assault while serving. She explained that she did not have a “safe space” to report what happened or hold the assailant accountable, and she was made to feel that she was “too human” to be successful in the military. She urged VA to show empathy, compassion, and sympathy to individuals who have served, especially during their transition from military service to civilian life; this would allow them to feel “heard and seen” rather than feeling that VA care is another “extension of the machine.”
Castro added that only approximately 40–50 percent of veterans seek care from VA rather than from other providers. Echoing McCray’s sentiment, he suggested that the remaining 50–60 percent avoid VA health care because they no longer want anything to do with the military—they see VA health care as an annex of the military. He commended VA for the services it provides but indicated that significant progress remains.
Giving Veterans a Voice
South-Paul reflected on the value of an open-arms approach, the benefits of including family members in care, and the importance of treating veterans as human beings. She posed a follow-up question asking for additional actions that could give veterans the voice to obtain the care they need.
B. Moore highlighted the value of offering personalized care instead of prescribing the same treatment to all veterans who have similar symptoms, especially when that treatment only works for 50 percent of those individuals.
Simmons voiced his support of VA system but encouraged a change in mindset, such as asking veterans who they are and what stories they have to share instead of thanking them for their service. He also advocated for increased awareness about both the behaviors that could indicate suicide risk (e.g., avoidance, drug and alcohol use) and the programs that VA offers so that friends and family can help the veteran understand how VA or other care facilities could help.
S. Moore described family members as the “first line of defense” because they interact with the veteran far more frequently than does a medical provider. If they are taught the signs and symptoms of mental health crises, they could save veterans’ lives. She encouraged increased efforts to ensure that these tools are provided to all military family members.
McCray expressed her gratitude for VA benefits but reiterated the need for providers to better understand the military experiences of individuals
and to offer more personalized care. She asserted that even though understanding the person, not just the veteran, takes extra work and time, doing so is essential to care for the veteran competently—veterans should be “seen as who they are, not just the symptoms of what they do.”
