Suicide awareness in the Department of Defense (DOD) is not a new issue. For over 30 years the Navy and Marine Corps have tracked and documented suicide rates among Department of the Navy (DON) service members (Stander, Hilton, Kennedy, & Robbins, 2004). Yet, with all the research out there, there is little programmatic research about the epidemiology of these suicides (Hourani, Warrack, & Coben, 1999). The military suicide rates, given in deaths per 100,000 members, are often used as a tool to laud or denigrate the military culture, mission, or lifestyle. In either the pro- or anti-military efforts, just the conversation about military suicide rates compared to civilian rates is suspect and must be dissected. Officers must be mindful that the demographics and stressors of military members create a situation where just talking about suicide numbers and treatments between civilian and military is comparing apples to hammers. The current or future professional military officer has to understand what those statistics actually mean before he or she can accurately understand the culture within which his or her subordinates face their challenges.
The Population of Concern
Both common sense and research show that individuals who kill themselves, whether military or civilian, are likely to have experienced recent stressful events or triggers reminding them of past events (Hall, 2008; Stander, et al., 2004). Active duty military members, by virtue of being part of that group, are gainfully employed by the U.S. government to put themselves in stressful situations. Civilians generally do not purposefully force themselves into stressful activities as a part of their day-to-day duties (Hourani, et al., 1999; Grossman, 2009). That being said, if a stressful work environment is a major contributor to suicide, the two demographics in comparison are not being equitably compared by this factor alone. Additionally, by virtue of the expectation on the military for being exposed to near constant stressful events, military service members are trained in ways to handle and cope with stress in a way not available to the general population. This training is not always perfect, but it is reasonable to assume that the average military member is more acclimated to stressors than the average civilian. This makes the advent of their needing external help all the more critical, and suicidal ideologies or successful suicides all the more poignant. Tang and Crane (2006) report that a person’s perceptions of the severity of stressors create different levels of vulnerability for suicidal behavior. Training about coping mechanisms have proved helpful in dealing with the unique stressors of military members (Grossman, 2009; Hall, 2008), but because of the reporting standards researchers cannot be sure they are getting accurate data about suicide incidence and prevention.
The statistics we see from civilian suicide rates also come from both employed and unemployed people. “A more appropriate comparison group for active-duty personnel should be drawn from [only] employed civilians” (Hourani, et al., 1999, p. 301). This is not the only lurking variable when tagging the military as having a lower or higher rate of suicide in its population. Suicide rates vary greatly in any population based on employment status, age, gender, social-economic status, education, race, or any other number of variables. With this in mind, it is important to know that the Department of Defense (DOD) demographic make-up does not reflect the U.S. population along the same lines (Hall, 2008; Stander, et al., 2004).
Access to firearms is noted when speaking ill of the military, and good training availability is cited with each success story. In either case, it appears that researchers and authors can make the points they desire to by adjusting the reporting data, demographics, and geo-situational make-up (like Hall, 2008, using Iraq based-soldiers only) when creating data reports. Before exploring the avenues available for attacking the problem, practitioners should familiarize themselves with the reality of the data available.
Statistics praising the military.
In a study by Hourani, et al. (1999), the DOD’s rates of suicide are compared favorably to the general U.S. population where the authors wrote that the twelve-year statistic for the DON during 1980-1992 was 11 per 100,000 compared to the civilian populations’ rate of 15 per 100,000. For multiple reasons, the success implied is unfounded and misrepresented; the numbers simply do not line up. Half of all active service members are under age 25 (Hall, 2008). In the U.S. the third leading cause of death for ages 15-24 is suicide (Martin, Ghahramanlou-Holloway, Lou, & Tucciarone, 2009). In civilian terms that number is 10.3 per 100,000. In the same study, Martin, et al. (2009) points out that between 1999 and 2004, 54.6% of all suicide deaths were attributed to firearms. Reading in Hall (2008) or Hourani, et al. (1999) one might be lead to assume that the military alone was at risk of firearm-assisted suicide based on the affinity for owning firearms and access to them (particularly the Marine Corps and Army). Humeau, Papet, Jaafari, Gotzamanis, Lafay, & Senon, (2007: as cited in Martin, et al., 2009) report that 18 of 19 studies proved a positive correlation between firearm access and the risk of suicide. Still, if everyone owning a gun were at an extremely higher risk of suicide, the rates for military should be far greater.
Lack of education is also cited as a contributing factor by Martin, et al. (2009). “The data actually show that our military force is more educated than the population at large” (Hall, 2008, p. 27). This does not fit with the Martin, et al. implication that the lower socio-economic demographic of the military contributes to its high suicide rates.
Another gap in reporting continuity is the elderly. The elderly account for 0% of the active-duty military, but are 10% of the U.S. population. Sadly, they account for approximately 20% of national suicide deaths (Hoyert, Arias, Smith, Murphy, & Kochanek, 2001). How does one compare two populations (DOD and civilians in this case) and exclude 10% of one group that causes 20% of the variable being reported? “While females attempt suicide more often than males, the aggregate U.S. suicide rate of females from 1999–2004 was about four times less than for males” (Martin, et al., 2009, p. 103). So while the military is primarily male (Hall, 2008), they still are grossly underrepresented in the broad demographic of active duty service members as compared to the U.S. population. This difference also must be considered when interpreting statistics about suicides and suicidal thoughts. Students and practitioners must expose themselves to a broad range of research articles in order to make sense of the differences between reporting and comparison data.
Statistic uncomplimentary to the military.
Hall (2008) reports with an alarming tone that the suicide rate in Iraq and Kuwait during 2005 was 19.9 per 100,000 members where the “leading suicide risk factors were relationship issues at home and in theatre, followed by legal actions, problems with fellow comrades, and command and duty performance” (p. 154). But are these explanations or numbers even meaningful? I argue that they are not. Here the failure of the DOD system to prevent suicide as an implied comparison to the civilian population is unfounded and misrepresented. There is no resource for reporting the number of employed U.S. citizens from similar demographics and correlating work-related stress levels to the military members’ potential for suicidal completion. The age, gender, and employment status for the two populations simply do not correlate. It is critical to appreciate this distinction before passing out statistics on the success or failure of a DOD suicide prevention program.
Understanding Programs in Place
Boundless articles are available to extolling the virtues of suicide awareness, prevention, and intervention programs. There are statistics available critically describing in-place processes for suicide prevention too. Rather than consuming the most enthusiastic sales pitches published by researchers describing how they successfully approached the problem, military leadership needs absorb the data available to make informed decisions about which methodology will work best for each unique situation in regard to suicide and suicidal intentions.
For example, Hall (2008) reports that among service members who received suicide prevention training, the number who perceived it as useful for the overall prevention of suicide was as low as 55% in 2005. Ironically, this statistic is drawn from living people; that is, people who did not kill themselves report than suicide prevention training was useless. An open-minded person can understand the value in reporting that a training program lacks 100% effectiveness, but one that is designed to prevent people from killing themselves can be graded as successful if its participants do not leave and end their lives or are able to prevent others from doing so. Whether they had ever intended to and therefore found the training useless, or were talked out of hurting themselves and therefore found their intentions embarrassing, it seems that getting meaningful data from the training class like this is unlikely to reflect its true value. In this case the value of the report is that it provides a tool for the course designers to adjust their programs over time in efforts to improve them.
Death Before Dishonor
The forte of the military’s credos is also its biggest weakness; it is a serious barrier to saving service members from themselves. In one sense the U.S. military population is representative of the American population and “where is doesn’t mirror America, it exceeds America” (Garamone, 2005; as cited in Hall, 2008, p. 27). In another sense the traditional military service member and his or her family are often seen as a separate culture from American society altogether. The culture forces its members to adhere to the “unquestionable [nature of]… the nobility of service to one’s country” (Hall, 2008, p. x) and makes all personal difficulties subordinate to the difficulties and sacrifices demanded by that service.
In that effort, military service members are conditioned to be self-regulating. They are encouraged to self-soothe, solve their own personal issues (both at home and work), and make the success of unit operations their highest priority (Hall, 2008). Service members are even told that their self-worth is predicated on the success of the unit’s mission (Grossman, 2009). This is a dangerous combination. Whatever the variables combined to make a person at risk for suicidal ideations or attempts, the culture of the U.S. military inadvertently encourages and enforces an ethos where being weak is unacceptable. Members are taught that asking for help is being weak, which is dishonorable. The credos “Death Before Dishonor” clearly reinforces that death, by any means, is more honorable than dishonor. Sadly, this bold principle does not delineate how that noble death is delivered. All service members are likely to know someone who, in an attempt to escape the shame of dishonor, took their own life to retain honor.
How to Handle What We Learn
Immediate, face-to-face real-time intervention is the key. Statistical analysis may guide a person’s opinion of how well the system is doing, but should not be taken at face value when making decisions about intervention techniques. Leadership must attempt to understand the often self-imposed restrictions service members place upon themselves to reach out for help. These same leaders should understand that service members will likely be met with imagined or actualized barriers to career success after they reach out for help. In a personal communication with Dr. Mary Wertsch, as cited in Hall (2008), one Naval officer stated, “You can be depressed while in command of an aircraft carrier but you will be relieved of command if you seek help for treatment of depression” (p. 12). This is exactly the point. If you were the manager of the local Piggly Wiggly, you could freely seek counseling for depression, family problems, or drug abuse and still keep your good standing with the company. The service member has no such right. If he or she seeks help, the treatment will remove him or her from the team, relinquish certain qualifications that psychotropic drugs or the ingrained stigma of weakness prohibit (carrying a gun, flight status, or others). He or she will then have to face his or her peers to explain this lack of qualification. The career and social barriers are almost insurmountable; for some suicide may be the only option they see (absence of seeking help) to escape the dishonor of whatever stressor or trigger has caused those thoughts.
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