I’ve drawn heavily from the words of two military wives:  Ms. Deborah Mullen, wife of former Chairman of the Joint Chiefs of Staff and retired Navy Admiral Mike Mullen, and Kristy Kaufmann, wife of an Army soldier and executive director of the Code of Support Foundation.  I’ve reviewed the symptoms of post-traumatic stress (including suicide and suicide attempts), and the inadequate mental health treatment currently available to military spouses.  Today I’m going to go into more detail about the stresses experienced by military families.  I’ll conclude with Deborah and Kristy’s suggestions for ways the Departments of Defense and Veterans Affairs could better serve the mental health needs of military families.

In January, 2011, Deborah Mullen addressed the Military Health System Annual Conference.  She opened with a direct quote from a letter by a young military spouse.  “It is infinitely worse to be left behind,” she read, “a prey to all the horrors of imagining what may be happening to the one you love.  You slowly eat your heart out with anxiety and to endure such suspense is simply the hardest of all trials that come to an army wife.”

The letter’s young author?  Libby Custer, wife of General George Custer, writing in May of 1876.  “The nature of war changes,” Ms. Mullen observes.  “Weapons get smarter . . . tactics get sharper . . . breakthrough medical advances save more and more lives.  But the stress and the anxiety felt by those who are left behind NEVER changes.”

Besides the agony of waiting, other sources of stress for military spouses and families include reintegration and reunion challenges, Deborah explains.  “A combat tour may last a year, but the effects of that tour on the service member and family may last much longer.”  Spousal and child abuse cases are rising in military families.  Families of service members who’ve sustained serious physical injuries may endure long-term relocation to receive treatment, and children “may be left at home with family or friends”, breaking the immediate family apart.

Or maybe the returning service member has suffered the signature wound of our Iraq and Afghanistan conflicts: an “invisible” wound from PTSD or TBI.  Spouses and children “don’t understand why their parent looks the same, but isn’t the same,” Deborah continues.  And “for those children whose mom or dad died – either by the enemy or by their own hand – this war will never really end.”

How can the DoD and VA better serve the mental health needs of military families?  Deborah Mullen and Kristy Kaufmann, writing for the New York Times, make the following key suggestions:

1. Really listen to military families, look at things through their eyes, to better understand their special needs and challenges.

2. Provide “home-centered” assistance for families in crisis, in which counselors and other assistance personnel come directly into the home to provide needed support.

3. Do a better job of following up on the results of programs currently in place.  New programs are being created all the time, but too often they aren’t reviewed and modified, as necessary, to become truly effective.

4. Develop a more holistic strategy that integrates military families and community support.  Society has a crucial role to play in helping keep military families strong and healthy.

“Ultimately,” Deborah concludes, “spouses tell me they don’t need another program, they don’t need more training.  What they need – what they want – is time.  Time with their spouses.  Time together with their family.  Time with a counselor or a doctor or a minister.  They want time to explore and understand what is happening to them . . . and the patience and understanding of loved ones, friends and the system itself.”

“If you have a broken family,” Kristy warns, “chances are you’re going to have a broken soldier – and vice versa . . . . It will take a nation working together to keep us strong.”

As a young Marine wife told Ms. Mullen, “It doesn’t matter if it’s the first day they’re gone, or the last day before they return home, you’re scared all the time.  You pretend to be happy, but you’re living in fear.”  And, Deborah urges, military spouses should not have to face that fear alone.

Through my work, I’m committed to the health and well-being of our nation’s service members and their families.  I don’t want them to be left alone to struggle with their issues of emotional trauma and post-traumatic stress.  I encourage you to join me, in whatever way you can.

I quoted two military wives – Ms. Deborah Mullen, wife of former Chairman of the Joint Chiefs of Staff and retired Navy Admiral Mike Mullen, and Kristy Kaufmann, wife of an Army soldier and executive director of the Code of Support Foundation – as they eloquently spoke out about this troubling issue.  Deborah pointed out that stigma still exists against military spouses admitting their mental health challenges and post-traumatic stress.  Depression, anxiety, sleeplessness, panic attacks, and self-medication with alcohol and drugs have become a part of military spouses’ lives, as well as the lives of their active duty and veteran partners.

I ended my last post with the question: What happens for the desperate spouses who do gather the courage to seek treatment within the Department of Defense and Veterans Affairs mental health services?  I draw my information here directly from Ms. Mullen’s address to the 2011 Military Health System Annual Conference.

Ms. Deborah Mullen addresses the 2011 Military Health System Annual Conference

The experience of spouses who seek help is “disappointing”, Deborah states.  “Misdiagnosis.  Lengthy waiting periods.  Red tape.”  Obstacles that “discourage and indeed damage the healing process”.

At the same military post hospital, she reveals, two spouses who sought treatment for help with classic PTS symptoms – one with suicidal thoughts – were prescribed five and seven medications each, with no followup appointments.  And, “Neither was ever referred for psychological help.”

I’m going to make a very strong statement here.  I believe a system that would allow a general practitioner to prescribe multiple, heavy-duty medications for psychological symptoms and then not see the patient again, is broken.  This is especially true for patients with suicidal thoughts.  Several prescription anti-depressants have been recently shown to create or intensify suicidal thought ideation.  I believe the actions of the doctors at this post hospital were unethical and unconscionable.

But there is even more going wrong for suffering military spouses within the mental health approach of the DoD and VA.  According to Ms. Mullen, spouses refer to it as the “15 and one rule”.

“It goes like this,” she explains.  “No matter WHAT may be bothering you from a health perspective, you are allowed to discuss only one symptom and only then for 15 minutes.  That’s it, no exceptions.  If we accept, as we have, that spouses suffer a PTS all their own . . . and if we know, as we do, that PTS manifests itself in many different ways in many different people, why would we not accept the need to treat the whole person?  Why would we fail to look at the totality of issues confronting a young spouse?  And why would we ask that young spouse not to confront them all herself?”

As a professional in the mental health field, with over 40 years of experience, I’m appalled and angry at what I see as insensitive and unprofessional practice within the military health system.  Patients must have the time and opportunity to reveal an accurate picture of the issues they face and the symptoms they experience.  With suicide as a potential outcome for desperate patients, I would characterize the treatment protocols for military spouses as very irresponsible and dangerous.

Kristy Kaufmann has strong words of her own on an additional obstacle.  “The fact is,” she wrote in a New York Times opinion piece last fall, “even if everything in the Pentagon and the VA were working perfectly, the government simply does not have the resources – or culture, for that matter – to support the level of need after 10 years of war, and it never will.”

Are you angry yet?

Combat and active duty experiences create their own patterns of post-traumatic stress for our service members.  What are the special problems that enter the lives of military spouses and families, leaving trauma in their wake?  I will return to answer that question next week.

Two voices have recently spoken up about this underreported issue.  Deborah Mullen, wife of former Chairman of the Joint Chiefs of Staff and retired Navy Admiral Mike Mullen, delivered an address to the Military Health System Annual Conference in early 2011 on the topic.  Kristy Kaufmann, wife of an Army soldier and executive director of the Code of Support Foundation (a nonprofit organization dedicated to bridging the gap between civilians and military America), published an opinion in the New York Times last November.

Both Deborah and Kristy point out that we have no accurate accounting of rates of spousal suicides within the military, due to privacy rules, and that this in itself is part of the problem.  Recent studies of military suicide have excluded the mental health of military family members, “effectively ignoring half of the problem”, Ms. Kaufmann stresses.

Only anecdotal evidence exists on the numbers of suicides and suicide attempts.  “Three Army wives I knew personally all took their own lives,” Kristy writes.  “Suicide attempts and completions among family members occur far more often than many realize or care to acknowledge.”  She adds that “suicide among service members, veterans and families is an indicator of the amount and duration of stress we continue to bear.”

“War comes home,” Kristy eloquently tells us.  “No soldier comes back the same, which means no family is ever the same.”

Deborah Mullen’s revelatory conference speech deserves to be read in its entirety.  She points out that there are many specific programs in place to help spouses with challenges such as the day-to-day demands of being a single parent or being a new caregiver to a wounded veteran.   But, “we are still discovering, still revealing, fissures and cracks in the family support system,” she observes.

The first “fissure” she mentions is “secondary post-traumatic stress”, and I see this as an extremely important and relatively misunderstood phenomenon.  Secondary post-traumatic stress, or secondary trauma, is the stress and trauma we are not directly exposed to but experience through someone else’s eyes and memories.  It is also the pain we feel as we watch someone we care about suffer and change from those first-hand experiences.  Kristy put it well: War comes home.

Suicide is the most extreme and tragic symptom of secondary trauma, but there are plenty of other symptoms as well. Ms. Mullen clearly identifies many of them.  “Families experience depression, anxiety, sleeplessness, and headaches,” she observes, as well as cold sweats, lost concentration, panic attacks, and dread of contact with the outside world.  Many spouses are “unable even to get out of bed, to get dressed, prepare meals, or leave the house.  Some won’t even get their children off to school, leaving the care of little ones in the hands of older siblings.”

“We shouldn’t be surprised,” Ms. Mullen continues, “to learn that some spouses turn to the same remedies that troops with PTS turn to – alcohol, prescription drugs, and some even contemplate suicide.”

The military branches have recognized for some time the stigma attached to mental health issues within the ranks.  Programs have been put in place to address the issue so that more service members can get the care they need and deserve.  But Deborah Mullen points out something I think most people are unaware of: the stigma against military wives seeking help for their own mental health challenges.

First of all, she believes, they’re “embarrassed” to seek help.  They also “worry that in doing so, they could negatively impact a husband’s or wife’s military career.”  As a final straw, “the service member even warns the spouse against getting help.”  “The services have worked hard to reduce mental health stigma in the ranks,” Deborah states, “but we need to continue to work to eliminate it from our homes as well.”

What happens for the desperate spouses who do gather the courage to seek treatment within the Department of Defense and Veterans Affairs mental health services?  Deborah Mullen’s insider assessment paints a bleak, disturbing picture.  I will begin with that distressing portrait when I return next week.

I don’t buy it.  Those numbers are way too low.

While we must wait for the full study to be published before drawing firm conclusions, Mancini’s contention that “the prevalence of PTSD among veterans” is “substantially lower than is commonly believed” should be a cause for concern. 

I want to see how the researchers set up the study, look at the guidelines and approach they used, and examine how they interpreted their data.  Researchers always go into a study with a goal, something they hope to prove, and possibly even additional agendas they are not fully conscious of.  These agendas can color the findings they report.  The study results quoted in Mancini’s piece on the low prevalence of PTSD among returning service members are so counter to what I’ve seen in my work that I suspect some bias crept in.

Mancini states that “many assume that humans are inherently vulnerable to trauma”, but that “a growing body of scientific research is telling another story”.  Only the first part of that statement is true.  Our nature as human beings, our biology and psychology, program us to respond to traumatic events in patterns that ensure our survival.  Almost everyone has heard of the “fight, flight, or freeze” responses, arising from our sympathetic and parasympathetic nervous systems.  These responses to danger make it possible for us to survive and then learn from threatening experiences.

Trauma, short-lived or lasting, arises when we fail to complete our natural trauma response.  Because we can bury and refuse to deal with the painful and overwhelming events of our lives, the intense emotions aroused by trauma (leading to that fight-flight-freeze) may never be released.  This happens all the time.  We can go back and resolve past trauma, but we are always “inherently vulnerable” to it, and our vulnerability to trauma increases the more we bury our previous “invisible wounds”.

The authors of the British Journal of Psychiatry study defend their results by characterizing their respondents as “not seeking treatment” and “representative of the military as a whole”.  They add that “[the participants’] reports were confidential and had no bearing on their military careers”.

I want to make a couple of points here.  First, and most importantly, why didn’t the study include service members who were seeking treatment?  How could the researchers’ study be “representative” without them?

Secondly, confidentiality is certainly an essential factor in getting accurate disclosure, but did the researchers take into account the lingering mindset of stigma within the ranks attached to a diagnosis of PTSD?  Most service branches have campaigns in place to de-stigmatize the invisible wounds of combat, but that message hasn’t yet been fully embraced by the military culture as a whole.

Mancini reports that “about 83 percent of respondents showed a pattern of resilience: they exhibited a normal-range ability to cope with stress both before and after deployment”.  What I want to know is, how did the study’s researchers define “normal-range ability”?  I have first-hand experience with government agencies who work with veterans, and I can absolutely state that their baseline definitions of good coping function are set appallingly low.  Their “good enough” is far from what I consider healthy, as a professional in the psychotherapy field for over 40 years.  I believe the average person would agree with me, and wouldn’t want to see the men and women who have served our country limited to life on such unsatisfactory and unfulfilling terms.

I am particularly suspicious – convinced, even – that the study’s parameters or methods were flawed due to their finding that service member resilience went up with multiple deployments.  This is absolutely counter to everything I’ve witnessed in my work and what many other professionals in my field have seen as well.

I also “do not want to stigmatize those with the disorder” of PTSD, as Mancini cautions.  But I also don’t want to minimize or mislead the military or the public about the true dimensions of what I and many of my colleagues believe will be a hidden epidemic.  I give Mancini credit for stressing that “even an estimate of 1 in 10 represents a public health issue of the first magnitude, requiring our full attention and resources”.  How much more, then, will be required if the real prevalence of PTSD is closer to 30 percent, which is my opinion?

Mancini closes his piece with a truly alarming statement.  He starts well by saying that “PTSD is a treatable condition and a realistic and informed understanding of our inherent coping abilities can only assist treatment”.  But he goes on to propose that “perhaps one day, even prevention of this debilitating disorder” will be possible.  That Mancini could make such a proposal betrays a profound misunderstanding of the nature of human beings and our innate, invaluable trauma response.

To prevent PTSD we would have to rid the world of cruelty, abuse, violence, and evil.  Or we would have to develop into one of two kinds of people: impervious automatons, able to turn off our feelings at will; or psychological super-humans, able to easily experience and quickly and completely resolve every shock, crisis, and horror, from the cradle to the grave.

My take on this?  Won’t happen anytime soon.

Many factors contribute to the current unacceptably high rates of military suicide.  I’ve written before about a recent policy brief by Dr. Margaret Harrell and Nancy Berglass of the Center for a New American Security, “Losing the Battle: The Challenge of Military Suicide”, which identifies several causes and recommendations for this unfolding tragedy.  Combat injuries, including such invisible wounds as PTSD and traumatic brain injury; mental health issues such as depression and anxiety; other symptoms of trauma such as sleep disturbances, substance abuse and addiction, and high-risk, adrenaline-fueling behaviors – all can play a role.  Harrell and Berglass also observe that the relative absence of three protective factors – belongingness, usefulness, and an aversion to pain or death – are crucial predictors of a service member or veteran’s likelihood of succumbing to suicidal tendencies.

In a New York Times op-ed piece responding to Harrell and Berglass’ study, Peter D. Kramer, a clinical professor of psychiatry at Brown University, proposes another factor overlooked in the policy brief: relatively high unemployment rates among young veterans of Iraq and Afghanistan.  In “The Best Medicine Just Might Be a Job”, he cites an astronomical unemployment rate of 28 percent for male veterans 18 to 24 years old.

Kramer respects the “comprehensive” brief but expresses his concern about the omission of unemployment among the list of causes identified.  While he characterizes himself as “hardly an expert”, he reveals that “study after study correlates unemployment with suicide”.  “When soldiers leave the military,” he continues, “they lose what service provides: purpose, focus, achievement, responsibility and the factor the CNAS report calls ‘belongingness’.  The workplace can be stressful, but especially for the mentally vulnerable, there is no substitute for what jobs offer in the way of structure, support and meaning.”

High unemployment rates among veterans have no one simple cause.  In “As Wars End, Young Veterans Return to Scant Jobs”, Shaila Dewan of the New York Times (who cites unemployment rates for veterans aged 20 to 24 at 30 percent) lists several issues and challenges for both employers and potential veteran employees.  Employers “fear the aftereffects of combat or losing reservists to another deployment”, and veteran job-seekers need to learn basic interview skills while often still “overwhelmed by the transition from combat to civilian life”.

Veterans can be characterized as mature for their age, disciplined, and possessing valuable skills transferable to the marketplace, Dewan emphasizes.  But employers aren’t so sure military service training and experience really translate to civilian industry.

And the competition for jobs is high.  Veterans often serve as reservists or in the National Guard and Dewan points out that this can impose a particularly heavy burden on companies.  Employers of reservists potentially face losing their valuable staff to deployments of up to 12 months in length, while being required to guarantee a job on the reservist’s return.  Even though it is illegal to discriminate in hiring based on military service and status, these requirements can make it nearly impossible for small companies to survive and compete in our difficult economy.

And, in my experience with veterans, both characterizations mentioned above are true.  Former service men and women are more mature and disciplined.  They are skilled, purpose-driven individuals with the kind of values I respect.  But they can also be very troubled individuals, still reeling from their traumatic, combat-related, employment-complicating experiences.  They are often in need of help to work through their lingering psychological invisible wounds.

I assist service members and veterans in this kind of healing.  I hope to do even more when our non-profit, Sonoma Coast Trauma Treatment, begins accepting veterans into its planned comprehensive, case-managed treatment program, which will include providing job-readiness training and skills.  Another promising development to address veteran unemployment is the creation of entrepreneurship programs specifically tailored for vets.

The Wall Street Journal recently reported on several of these programs in “Military Veterans Prepare for a New Role”, by reporter Sarah E. Needleman.  Independent-minded veterans who want to start their own businesses, but lack business start-up know-how, are starting to have a resource in “business accelerators”. Accelerators are programs offering everything from cubicle space and peripherals like Internet and copy/fax services, to expert guidance with business plans, financing, and marketing.

I’m familiar with the business accelerator model.  In my community, my good friend Dr. Michael Newell heads up Sonoma Mountain Business Cluster, an excellent “incubator” program for emerging technology start-ups.  Michael and his team of talented mentors, with the financial backing of local businesses, support aspiring men and women with innovative ideas by providing the best possible opportunity to transform their ideas into jobs and income through facilities, services, and training.  The business school of Sonoma State University also gets involved, helping incubator members create high-quality business plans.  A program of this sort would be an excellent resource for returning veterans in our community and I would love to see one get established.

I recognize the causes and solutions for veteran unemployment are complex.  Nevertheless, I also believe, with Dr. Kramer, that veteran unemployment is a factor we need to consider in addressing our tragedy of military suicide.  We must do a better job of providing employment-related “structure, support, and meaning” for returning vets.  Meaningful work is essential in the process of restoring our service members and veterans, who have sacrificed so much for us, to health and wholeness, and to a place of value in their families and communities.  We owe them nothing less.

Two thousand eleven is drawing to a close.  For many of us – and I include myself – this has been a difficult year of losses, changes, and transitions.  But my 2011 has also been an important year of opportunities and growth.  I hope you have found this to be true in your life, as well.

In this season of celebration, I wish each and every one of you these blessings:

Faith – in someone or something bigger than yourself

For me, it’s God.  I was raised a Jew, and became a Christian.  My faith is the bedrock of all that I am.

Hope – for the future, for a better world, for a life filled with meaning and purpose

I urge you: never stop moving forward.  Find your calling and work to fulfill it.

Love – for the people near to you, for those who are hurting or in need, and for yourself

I firmly believe that close, loving relationships are a vitally important part of our lives.

Comfort – in that you aren’t alone, we are all imperfect and human and fallible, and help will be there if you reach out for it

Connecting with and caring for others, I’ve found, and accepting their support in return, is at the heart of healing.

Joy – in moments of heartfelt recognition that life is good, even in the midst of pain and difficulty

Joy is a feeling far beyond happiness.  It goes deeper, it feels stronger; it comes to us through struggle as something essential, right and true.

Peace – in this world, in our hearts, with each other

Let go of the past and the things that don’t matter.  Practice thankfulness.  Give of yourself and receive.  In surrender, gratitude, and selflessness we find peace.

Charis – grace – and Shalom – peace – to you and yours in this season of light.

And now, onward.  I’m ready.  I have big plans.  Bring on 2012.

Last week I presented some statistics and observations from the study; today I will review the authors’ findings and recommendations.  I will also add some observations of my own.

“Losing the Battle” identifies the following as obstacles to reducing military suicides:

1.    Military personnel transfers complicate efforts to help individuals struggling with mental health issues

2.    Army personnel transfers occur too soon after deployment

3.    Commanders are not always aware when subordinates are the subject of an investigation

4.    The mental health screening process following deployment is flawed

5.    A cultural stigma attached to mental health care persists in the armed services

6.    Military hazing persists

7.    The number of care providers is insufficient

8.    Legal restrictions prevent military leaders from discussing privately owned weapons

9.    There is excess prescription medication in the military community

10.  Unit commanders have limited visibility into service members’ medical problems

11.  Infrequent interaction among drilling Guardsmen and Reservists limits unit leaders’ ability to recognize and help subordinates struggling with mental health issues

12.  The National Guard has too many suicide prevention programs

13.  The true number of veterans who die by suicide is unknown

14.  Understanding and addressing the challenge of suicide requires cooperation beyond the traditional jurisdictional boundaries for many organizations, including the Department of Defense, Veterans Affairs, Health and Human Services, and Congress

All these points are important and I have comments I could make on each one.  That would make for an extremely lengthy post, however, so I will limit myself to pointing out what I feel are the crucial issues.  I encourage you to read the entire report for yourself.

Harrell and Berglass’ findings recommend structural, procedural, informational, and cultural changes.  Everything from national government policy, to the intimate conversations between a small unit leader and his troops can be improved.  But I see what I call a “red thread” – a key problem or idea – running through all their observations.

That “red thread”, which has become overwhelmingly evident to me through over forty years of experience in the trauma treatment profession, is the essential understanding that suicide is a symptom of trauma, and that it feeds on secrets and isolation.

Look at the findings.  Each recommendation addresses one of three things.  First, the report addresses the issue of isolation by underscoring the risks of losing connection with struggling service members and veterans through transfers, quick troop dissolution after deployment, and numerous barriers to communication between leaders and individual troops.  Next, the report highlights the destructive nature of secrets, through a culture of shaming personnel for the “weakness” of mental health repercussions from combat service, and through a “don’t-go-there” atmosphere around discussing drugs, personal firearms, and hazing.

Lastly, the report exposes the current limitations of the DoD or VA to address deficiencies in care for emotionally wounded and potentially suicidal personnel, including an insufficient number care providers, inaccurate data-gathering, flawed screening processes, inconsistent prevention programs, and lack of coordination across services and agencies.

Units break up and vital relationships of trust and shared experience are lost.  Admitting to having trouble dealing with emotions and memories will lead to ridicule or negative consequences for military careers.  It’s alarmingly clear that there are too many subjects – besides sexual orientation – for which the message has been “don’t ask, don’t tell”.

Double binds exist.  Commanders and unit leaders want to be able to help their troops, and are prevented from doing so by confidentiality regulations and by cultural taboo.  Revealing the unspoken problems – the secrets service members and veterans won’t tell, so that they can get the help they need with their suicidal thoughts – can create problems for them both in the present and future.

Here’s my message to all our combat troops, past and present: What you can’t, or won’t, talk about – because you’re not supposed to, or no one’s there to listen – can be deadly.  I’ve seen this over and over in my practice.  There is no shame in being affected by horrific events and experiences beyond your ability to handle on your own.  The truth really can set you free.  If you can’t yet tell it within the system, find someone outside the system and break the silence.

CNAS is the only Washington think tank led by veterans of the wars in Iraq and Afghanistan.  It has conducted research on military wellness since 2008 because CNAS believes keeping our forces physically and emotionally healthy is vital for national security.  CNAS is also a close partner with Michelle Obama and Jill Biden in their valuable Joining Forces Initiative.

Joining Forces is “a comprehensive national initiative to mobilize all sectors of society to give our service members and their families the opportunities and support they have earned” and focuses on issues of employment, education, and wellness.  As part of the initiative, CNAS hopes to “build and strengthen the network of government agencies, nonprofit organizations, community and philanthropic institutions, businesses and individuals and help them connect in meaningful ways with those who have served.”

That’s a lot of background, but I want you to understand the importance and expertise of this group so committed to our nation’s forces and their families.  Their recent report, “Losing the Battle: The Challenge of Military Suicide”, by Dr. Margaret C. Harrell and Nancy Berglass, tackles our unfolding tragedy head-on, providing accurate statistics and information, as well as recommendations for the future.

Harrell and Berglass reviewed materials from the Departments of Defense and Veterans Affairs, and from independent studies, to gather up-to-date facts and statistics on military suicide.  They reported the numbers I quoted in last week’s post for veteran suicides – including the finding that one veteran takes his life every 80 minutes – but added, “It is impossible, given the paucity of current data, to determine the suicide rate among veterans with any accuracy.”  Then they add the disturbing statistic that although veterans make up only 1 percent of the population, veteran suicides represent 20 percent of all suicides in America.

Harrell and Berglass also researched suicide rates among service members.  Their findings are as alarming for personnel on active duty as for veterans.

1. Between 2005 and 2010, service members took their own lives at a rate of approximately one every 36 hours

2. Army suicides have been rising steadily since 2004, to a record high of 33 deaths in July of 2011 among active and reserve soldiers

3. Marine Corps suicides have increased steadily from 2006, dipping only slightly in 2010

4. Air Force suicides have increased significantly since 2007

5. Soldiers who deploy to Iraq and Afghanistan are more likely to commit suicide than those who do not deploy

6. There are definitive links between suicide and injuries suffered during deployment

7. Traumatic brain injury (TBI) sufferers are 1.5 times more likely to die from suicide

8. Suicide risk among service members is heightened by factors which include chronic pain, post-traumatic stress disorder (PTSD), depression, anxiety, sleep deprivation, substance abuse, and difficulties with anger management

In their report, Harrell and Berglass propose three protective factors that can help a traumatized individual resist the lure of suicide.  They suggest that people who experience both belongingness and usefulness, and have an aversion to pain or death are less likely to take their own life in response to overwhelming emotions or circumstances.  They believe that, in the past, military service included these protective qualities, but now see the changing nature of military service in Iraq and Afghanistan as having actually weakened these three factors.

Military personnel have long felt a strong sense of belonging within their units.  The close-knit camaraderie and team spirit, the code of leaving no one behind, went a long way toward strengthening service members emotionally and psychologically.  Our current wars don’t stick with this pattern, in that units are formed, deployed, and then quickly dissolved after returning from deployment.  Returning Guardsmen and Reservists disband directly back into their communities.  Vital supportive relationships with peers and superiors are lost.

Usefulness in traditional military service included the regular assignment of significant responsibilities and important tasks to relatively junior personnel.  High levels of responsibility and interaction among unit members gave a sense of value and purpose to each member’s contributions.  “In contrast”, Harrell and Berglass report, “the experience of living in a garrison environment or returning to a civilian job, or worse, unemployment, can introduce feelings of uselessness.”  Individual accounts and interviews “show that individuals withdrew, felt disconnected from their units and their families, and perceived themselves as a burden.”  My experience in treating veterans confirms these experiences and perceptions are common and widespread.

Aversion to pain and death – the third protective factor – has always been problematic for military suicide because “military service is one of the few experiences that can override this factor”.  Repeated exposure to the trauma of combat, repeated deployments, witnessing violence and death 24/7 in country in Iraq and Afghanistan, has greatly intensified the traumatic experiences of our military personnel.  To cope and remain effective, many say, they must go numb and consider themselves “already dead”.  This mindset, while it may seem necessary for survival, purposefully and completely erodes any aversion to death.

I’ve taken a lot of space today to share with you the findings of the CNAS report.  I think this information is extremely important and vital for all of us to know.  It disturbs me that the only coverage of this report that I’m aware of occurred in the Huffington Post.  All our local newspapers and media outlets should have reported this.

I agree with CNAS that all aspects of military personnel wellness are vital to our national security.  If you’ve been reading my recent blogs, you know I think it’s also a responsibility and obligation for our government and for each one of us as American citizens.  We must all commit to restoring our returning OEF and OIF forces to health and wholeness.

Next week: vital and on-target recommendations from “Losing the Battle: The Challenge of Military Suicide”.

I recognize that this is a heavy subject.  Please stay with me on this one.  I’m going to primarily focus on suicides among combat troops of Iraq (OIF) and Afghanistan (OEF).  I firmly believe this topic must be addressed.  The men and women serving our country in our armed forces deserve to be heard before they use suicide to blast their way to our attention.

First, let me say that suicide attempts and completions are a symptom.  This ultimate act of self-destruction is a symptom of emotional trauma, or what has come to be called “invisible wounds” in our post-9/11 world.  As symptoms, suicide completions and attempts usually happen only after the development of other symptoms or warning signs, such as depression, reckless behavior, or substance abuse.  I’ll go into this later in more detail.  For now, I want you to understand that to effectively treat the symptom of suicide, we’ll need to comprehensibly address and heal our military’s invisible wounds.

The suicide statistics for veterans are truly alarming.  I’m going to start with data from a Department of Veterans Affairs study completed in 2010.  In his article for the Army Times, staff writer Rick Maze reported the following:

• 18 veterans of all wars and conflicts commit suicide every day (that’s one suicide every 80 minutes)
• 950 veterans in treatment with the VA attempt suicide every month (that’s 31 suicide attempts per day)
• 98 veterans of OIF and OEF committed suicide between October 2008 and September 2009 (that’s one suicide every four days)
• 1,868 OIF/OEF veterans attempted suicide during that same time period (that’s five attempts every day)

Let me tell you why I think these numbers don’t fully represent the magnitude of our veteran suicide problems.

First, this study is limited to information about veteran suicides that the VA knows about.  These statistics cover veterans receiving some type of treatment within the VA system combined with statistics the VA has been able to collect from other sources about veterans outside the system.  The VA’s internal data may be accurate, but many veterans outside the system can “fly under the radar” and their suicides and suicide attempts may not be measureable in any truly precise way.  For this reason, I would bet the VA numbers are low.

Second, I firmly believe that many suicides don’t end up looking like suicides or being reported as suicides.  An example of this that’s been in the news lately is the phenomenon of “suicide by cop”.  In suicide by cop, an individual acts in such a way as to present a flagrant danger to himself or others, in an effort to be shot and killed by peace officers.  Police responding to a scene of domestic violence, or burglary, or assault may find themselves face-to-face with a veteran desperate to end his suffering but unable to complete the act of taking his own life.  The veteran acts in an aggressive, threatening way to the officers, who necessarily shoot in defense of themselves and/or innocent bystanders.

Another example of disguised suicides and suicide attempts are deaths from reckless behavior.  A veteran feeling there’s “no way out” climbs on his motorcycle and speeds past control into a fatal crash on a winding country road.  Another veteran combines prescription medication with alcohol and no one really knows whether he slipped away by mistake or design.  Many incidents like these are masked suicides and not all of them will find their way into our statistics and awareness.

I’ve treated many OIF/OEF veterans and I’ve seen that they don’t want to draw attention to themselves.  When I ask the veterans I’ve been able to help how I can find and reach out to other hurting veterans in the community, they all say, “They don’t want to be found.”  This tells me the magnitude of our veteran suicide problem is probably significantly greater than we know, even with the most careful and conscientious reporting efforts.

What we do know is alarming enough.  Next week, in Part 2 of this series, I’ll present the results of another, recent military suicide report by the Center for a New American Security.

Ten-Step Action Plan for Combatting Stress

1.  Slow down, don’t panic

In a difficult, stressful, or traumatic situation, the first thing to do – always – is to slow down.  Racing thoughts and a racing heartbeat can speed you across the finish line into panic, where nothing constructive can take place.  None of the steps that follow this one will help you if you panic.  Slowing down to find some calm in your storm is absolutely essential to prevent unavoidable difficulties from turning into avoidable trauma.

2.  Remember you’re not alone

After panic, the second-greatest threat to successfully coping with stress is self-deception.  Believing you are the only person experiencing distress leads to believing there is something wrong with you, that what’s happening to you is somehow your fault and you deserve it.  On the contrary.  You are not alone.  Many, many people today are struggling and suffering with problems similar to yours.

3.  Think through your options

When you steer clear of panic and self-condemnation, you will be able to think clearly.  You’ll be able to use your rational, creative abilities to identify good ways to respond to problems and crises, rather that reacting impulsively and thoughtlessly.  You’ll recognize the best choices for how to deal with the situation in front of you, and come up with a plan of action for moving forward in a positive way.

4.  Ask for help, don’t isolate yourself

Along with panic and self-deception, isolation is your enemy in the war on trauma.  Alone, our energy and personal resources are limited.  When we reach out to others – family, friends, loved ones – we gain strength and valuable perspectives unavailable to us on our own.  I can’t emphasize this enough; reach out and share your burdens.  Let people help you.

5.  Take good care of yourself physically and emotionally

Wars can be fought with exhausted troops, but victory is more sure when warriors are rested, well-fed, and in good physical condition.  You may not think you have time to take care of yourself physically and emotionally when you’re battling stress, but letting yourself get run down will cost more time and trouble in the long run.  Make self-care a high priority.

6.  Don’t blame yourself for things beyond your control

You are human.  Let me say that again: You are human.  You are not perfect, and are not supposed to be.  There are things beyond your control, beyond any one person’s control.  You may have gotten behind on your mortgage payments, but our enormous financial downturn – which no one could have fully anticipated – is not your fault.  Take responsibility for your part, and let the rest go.  Guilt and blame will drain your spirit and keep you stuck and traumatized.

7.  Reduce the pressure on yourself in every way possible

Get very clear on what is essential to deal with in the present, and leave everything else alone.  Simplify your priorities and commitments.  Examine your “rules” – such as “I have to pay all my bills on time, no matter what”, or “I’ve got to always keep my house clean and organized”, or something else from your own personal list.  What truly matters right now?  Choose taking care of the people you love (including yourself, see #5), over taking care of things every time you can.

8.  Keep your perspective

Our Great Recession has been going on for so long it can be hard to remember when times weren’t tight and difficult.  Hard times are here for now and for the near future, but better days will return.  When they do, we won’t be the same people we were before.  We have the opportunity to grow from our experiences, or become devastated by them.  It’s your choice.  Look forward.

9.  Look for ways to help others, give back to those who’ve helped you

The quickest way I know to move out of a fog of discouragement is to lift my head and look for someone else who’s hurting too.  Mobilizing ourselves to help others can give us the energy to not only make a difference in their lives, but in our own, as well.  Being able to give fellow sufferers support and encouragement (and a helping hand to move furniture or make a meal) gives meaning and purpose to these dark, distressing times.

10.  Don’t lose hope

Never, ever give up.  If you lose heart and collapse, get back up again.  Accepting defeat is never the answer.  Remember the hard times you’ve been through before and believe that you can survive this one, as well – even if this time is the hardest time yet.  Surrender the things it’s time to let go of, and fight to the end to save the things that really matter.  Feed your spirit and keep hope alive.

As I said last week, these ten steps are fairly simple, but I know personally that they are not easy.  Some of them can, in fact, be very challenging to conquer.  But they’re worth the attempt.  Like all of life’s “basics”, these ideas are worth studying, putting into action as best you can, and then coming back to think about some more.  I wish you much success as we journey together through the challenging days to come.