A Culture Without Suicide

                The self-destructive behavior presented by Homer in the character Odysseus of The Odyssey, hints at the nature of combat veterans and their increased risk of suicide since ancient times (Shay, 2002). Shortly after I returned home from three combat deployments to Iraq and Afghanistan, I was having a conversation with a Navy SEAL veteran who served in Vietnam. “A lot of those guys ended up killing themselves”, he said. That comment and the way he said it touched my nerves and sticks with me to this day. At the time, no one from my unit had suicided, but I made a commitment to myself and to the 41 men we lost on the battlefield to pursue an education and a career that would help prevent suicides. It is now nearly eight years later, and at least 16 men from my battalion have killed themselves.

                A handful of those men I knew quite well during my time in service, the rest I only knew in passing or after reading their obituaries. It is impossible to say with absolute certainty what might have influenced their decisions to end their lives, but after completing Applied Suicide Intervention and Skills Training (ASIST), I’ve realized that speculation isn’t all that important. What’s important is that when someone is in a suicidal frame of mind, they have tunnel vision and are quite literally unable to weigh the implications of their decision. If you come across someone who is suicidal, the two primary goals should be to ensure the individual can keep themselves safe, and to help them open up that tunnel vision and remember all that they have to live for… but I digress.

Setting the Context

                In 2012, the Department of Veterans Affairs (VA) issued a study which found for nearly 12 years running, there was an average of 18-22 veteran suicides per day (Kemp & Bossarte, 2012). The study concluded that a majority of suicides occurred among veterans over the age of 50, which is pretty similar to the civilian population. That being said, they found that risk factors for veterans of all eras remained the same. Additionally, the report made note that Washington State, the state which is home to the veterans I serve, had the most reliable state suicide data and was tied with Idaho for having the highest rate of veteran suicides by state in the United States: 25.11%-26.82%. This means of all suicides in Washington State, over one quarter of them are military veterans.

                Another study looked at suicide among the Post-9/11 veteran population and found that they have a 41-61% higher risk of suicide than the general populace (Kang, 2015). The rate is around 28 suicides for every 100,000 people; again, roughly double the general population. The 2012 VA report also concluded that enlisted veterans suicided at nearly twice the rate of veterans who served as officers. The study showed that 83% of all suicides were males, making them over three times more likely to kill themselves than females. That said, female veterans were found to suicide at twice the rate of their civilian counterparts, which is a notably larger gap than what occurs between veteran and civilian males (Zarembo, 2016).

                When it comes to diversity, veterans who are white, middle-aged males are suiciding at higher rates than most other ethnic groups. In fact, a full 92% of veteran suicides in the primary study were white males (Kemp & Bossarte, 2012). One could speculate as to what the reasons for this phenomenon might be. Perhaps individuals of other ethnic backgrounds have adopted coping strategies, or have more supportive communities of family and friends that they can lean on. More study and evaluation of the ethnic and cultural factors that contribute to, or prevent suicide, is absolutely needed.

Stigma

Stigma in regard to suicide, seems to have two primary layers.

On the first layer, there is the general negative stigma that exists around mental health care. In mainstream American culture, and particularly in the military culture, seeking mental health care or “admitting weakness”, has a very negative stigma. This stigma seems to be one of the largest barriers that exists for veterans who could be accessing the very helpful services they’ve earned through the VA. “Pain is weakness leaving the body”, is a military t-shirt slogan that comes to mind. Rather than face their pain and address it with the support of professionals, many veterans will let it bottle up until there is no more room for the pain inside them. I’ve been there, it is awful.

The negative stigma around seeking mental health care has also been perpetuated by high ranking military officials and public figures, but my observation is this appears to be getting better. Additionally, for veterans who want to pursue a career in the military or law enforcement, having mental health treatment in their records can actually become a barrier to their career goals. This point in itself is a great example of something wrong with this system.

If military and law enforcement personnel are afraid to seek mental health treatment because it could impact a career in those fields, we’re probably doing something wrong as a society. I would much rather have a policeman or woman on patrol in my neighborhood who has processed their traumas and been taught coping skills and grounding techniques by a professional, than one who has bottled things up out of fear of losing their career but is placed in regular high-stress situations. Mental health care should be encouraged, rather than stigmatized.

                The second layer to stigma in this discussion is the stigma that exists around suicide itself. I am on a private Facebook group for the Marines who served in our battalion. When the first few suicides occurred, there were emotional and lengthy arguments about the individual who suicided. Words like “selfish”, “coward”, and “weak”, were used often. If tomorrow another veteran from our unit is contemplating suicide and remembers those words used by their peers, it’s probably a safe assumption that they are not going to reach out for help. In fact, it seems that most of the individuals from my unit who have suicided, did not give much warning or notice at all. Stigma may be a major factor.

What’s being done about it?

                It is no question that suicide among the veteran population is a major issue in our society. In 2015, congress passed what’s known as the Clay Hunt SAV Act (H.R. 203, 2015). Clay Hunt was one of the first Marines from my unit to kill himself. The SAV Act created some positive steps forward for the VA to bring on additional support for suicide prevention and to collaborate more with NGO’s and outside agencies in that goal. That said, it is yet to be determined how successful the SAV Act will be.

                In recent years, the Department of Defense has contracted with Living Works, the creators of ASIST, to provide suicide intervention trainings to individuals and leaders at the unit level. I was fortunate to witness this first hand and participate in one of the ASIST certification trainings with a few members of Growing Veterans, a non-profit with a mission to empower military veterans to grow food, communities, and each other. I was very impressed with the ASIST model and have used it a handful of times over the past year. Once learned, it is quite intuitive and easy to remember during the high stress situation of holding space for someone else’s pain, as they grapple with thoughts of ending their life.

                There are also countless non-profit and community agencies that exist throughout the country that have trainings and missions to help end veteran suicide. All of these agencies are helpful, but most remind me of the analogy of babies floating down a river in baskets before a waterfall. Many of these agencies are catching those floating babies. Rather than wading in the river and saving each baby that floats by, I would rather run upstream and take out the person tossing babies in. Particularly when there are too many babies floating by that I'm not able to save. While it is useful to know suicide intervention strategies, I believe that a true suicide prevention approach will need to address and change some deep rooted cultural norms and practices. However, before I discuss these cultural components, we will first look at the idea of identity.

What about identity?

                While taking courses in higher education, social justice conversations always seem to emphasize identity. This has forced me to think for countless hours about my identity as a veteran and the identity experienced by my veteran peers. The typical Post-9/11 combat veteran entered the military shortly after high school, spent a few months to a year in training, and then went off to war. Due to our lack of a military draft, many Post-9/11 veterans will have served on multiple combat deployments. After 4-8 years of service and multiple deployments, most veterans will get out and pursue a career or higher education. But the moment they leave base, something happens to their identity.

                Having spent the past few years in a military culture, surrounded by peers that can relate to their war experiences, the warrior who re-enters civilian life is suddenly surrounded by people and places that they struggle to relate to. They are surrounded by people who make problems out of what may seem to a combat veteran minuscule, at best. They talk with people who seem to only care about themselves and feel entitled to anything they desire. But perhaps most importantly, they are surrounded by people who fail to recognize many good people have lost life and limb fighting in our longest wars to date. Wars that are still ongoing and that we as a society are largely ignoring.

To the warrior, however, those wars have shaped their identity. War has shown them the highs and lows of humanity. It has introduced them to the side of life that most people fear, or worse, pretend does not exist. They have learned lessons in leadership, teamwork, community, sacrifice, perseverance, endurance, and many other intangible characteristics that make up their new identity as a warrior. Some veterans have learned new levels of patriotism. Others have learned that patriotism can be a double-edged sword. All have formed a new identity as a warrior.

While in the military, surrounded by other warriors, this identity is comfortable for most. It is not until a warrior is surrounded by civilians do they truly recognize how much different they’ve become. It can be especially challenging if the warrior is cognizant they are surrounded by civilians who do not recognize the society we live in- is a warrior culture. Albeit, the most na?ve warrior culture to ever exist.

Our society was founded on war. Our biggest economic advances have been fueled by war. Our mainstream culture is infatuated by Hollywood depictions of war. Even our children’s playground big toys resemble military obstacle courses. Imagine being a warrior who has lost friends in battle, living in a society fueled by war, but being surrounded by an entire community who fails to recognize you, the friends you’ve lost, and the wars you’ve fought in. What might happen to your identity?

A common outcome of this identity struggle and inability to fit with civilian community, is isolation. Not only is isolation a primary symptom of PTSD, it is something we do as humans when we do not feel like we belong in a group. I have worked with hundreds of veterans over the past few years and the ones who isolate the most are the ones who don’t feel like they belong. They isolate from friends, family, and their broader community.

All warriors return with a new identity. The nature of war teaches warriors incredibly useful lessons about humanity and culture; about individuals and groups; and about life in general. The way our society welcomes warriors home, or lack thereof, is failing to help warriors embrace this new identity and invite them to share the incredible lessons that they have learned from war. It is time we start to recognize ourselves as a warrior culture and empower our warriors to teach us what they have learned. If for no other reason than because we lose warriors every day to suicide.

A culture without suicide

                As I suggested earlier in this paper, I believe that a true suicide prevention approach will need to address and change some of our deep rooted cultural norms and practices. Judging by mainstream media, our current culture seems to care more about what happens in Hollywood than what happens in the Middle East.

By definition, our individualist mainstream culture means the majority of individuals care more about themselves than the communities they live in. We are socialized since birth this way, so it is hard to place blame on anyone, but the reality seems to create some blatant difficulties- and makes it very easy to isolate ourselves.

Our military is one of the more collective sub-cultures that exists in the United States. It emphasizes group cohesion and mission accomplishment over any one individual. Veterans learn how to embrace and rely on a community while in the military, and this is especially true in combat where survival depends on it. As Sebastian Junger has pointed out in Tribe, living in and belonging to a strong community is likely the key to not only our survival as humans, but our psychological well-being (2016).

This may be why a majority of warriors tend to have a harder time integrating outside of the military community, than inside of it; and why they isolate as a result. It is also probably why warriors struggle with their new warrior identity, when they leave the group of warriors they fought next to.

Combining the notion that communal culture is helpful for survival and psychological well-being, with best practices that already exist for effective military veteran reintegration; I believe suicide could disappear from our culture if we adopted a culture of peer-support. At the very least, we would see a drastic decline. As outlined by the Defense Centers of Excellence, peer-support has the benefit of reducing stigma, improving quality of life, promoting wellness, improving coping skills, and more (Money et al, 2011). Best practices have already been identified by thorough analysis of military veteran peer-support programs around the country (Money et al, 2011).

If taken to a cultural level, these best practices in peer-support could change the way our society welcomes veterans home and even interacts with each other. Negative stigma would disappear, isolation would become nearly impossible, veterans would be able to identify and embrace their new warrior identities, and they would be empowered to share their lessons learned with the civilians around them.

Up until this point, peer-support has primarily been used in the medical “recovery” model to address post-traumatic stress and substance abuse, but it can also be found in aspects of Alcoholics Anonymous and similar peer-focused support groups. What I am proposing however, is a peer-support model that would challenge our entire culture to embrace peer-support and their role as peer-supporters to each other. Rather than only being accountable to ourselves, we should all be accountable to each other. In a sentence, I am proposing that everyone in our society, veterans and civilians alike, be trained as peer-supporters and adopt peer-support best practices as cultural norms.

An example of creating a culture of peer-support is already beginning to unfold through the non-profit organization, Growing Veterans (Brown et al, 2016).  Based out of Washington State, Growing Veterans has created a peer-support training that emphasizes facilitating a culture of peer-support among their staff, volunteers, and stakeholders. The training was created by veteran peers themselves and has been tested and refined by feedback from those same veteran peers, as well as educators and mental health professionals (Brown et al, 2016). It was formed using best practices identified by the Defense Centers of Excellence (Money et al, 2011).

Still in its infancy, the training is continuing to evolve. There have only been two formal training cycles as of this writing, but each training gathers comprehensive feedback from participants (peers) and Growing Veterans incorporates the feedback into the next iteration of the training. That said, individuals who have taken the training report having a new confidence in communicating with and supporting their peers.

In a 3-month follow-up, the first 12 trainees reported providing peer-support to an estimated total of 90 veterans, and 154 people including veterans and civilians. Yes, veterans who go through Growing Veterans' Peer Support Training are providing support to veterans and civilians. They are embracing a culture of peer-support.

Combat veterans and civilians have taken the training offered by Growing Veterans, and the positive reports are the same from both groups. It is of note that the combat veterans and civilians took the training in the same cohort. One civilian participant even went so far as to say, “This stuff could change the world”.

My biased opinion (I am the co-founder of Growing Veterans and serve on the Board of Directors), is that individual's observation is accurate: this could change the world… for the better. If everyone embraced peer-support roles to the point of making it a new cultural norm, we would have new standards for communicating with each other and for addressing difficult issues.

Civilians entering military service would already have peer-support in their mindset and it would be part of their identity, helping themselves and their comrades be more resilient to combat before, during, and after combat experiences. Upon returning home from war, civilians who embraced their roles as peer-supporters would be able to reach out to warriors, articulate their gratitude, and create open space for them to share the lessons they learned from overcoming adversity in combat.

Our culture would be able to hold sacred space and absorb the warrior lessons and characteristics I listed earlier like leadership, teamwork, community, sacrifice, perseverance, and endurance through hardship. Through a culture of peer-support, we might be able move from a na?ve warrior culture that hasn’t learned from our warrior history; to a warrior culture that embraces and honors the warriors who maintain it and strives for peace with knowledge of every lesson learned through our collective wisdom.

These are obviously ambitious ideas and there is very real room for improvement in the evolving culture of peer-support training that is offered at Growing Veterans, but it is one example that we ought to be taking a close look at. Indeed, researchers in and outside of the VA have begun to inquire about the Growing Veterans peer-support model and there may be some long-term evaluation done to learn from their training. At this point one can be hopeful, and as an individual I remain focused on the good that has already been done in shifting cultural norms among the individuals who have taken the training and embraced their roles as peer-supporters.

I, for one, will remain a peer-supporter as a professional counselor for combat veterans throughout my career. After all, it is peer-support from my father and a counselor he encouraged me to see, that I thank for allowing me to be here and write this message to you. It is peer-support that has allowed me to connect with hundreds of veterans around me and share these observations with the civilian community around me as well. Most importantly, it is through peer-support that we have the opportunity to grow closer to each other and create a culture where suicide does not exist.

References

Brown, C; Besterman-Dahan, K.; Chavez, M.; Njoh, E.; Smith, B. 2016. "It gave me an excuse to get out into society again": Decreasing Veteran Isolation through a Community Agricultural Peer Support Model. Under submission with Journal of Veterans Studies.

H.R. 203: Clay Hunt SAV Act. (2015). Library of Congress Summary. Retrieved from https://www.govtrack.us/congress/bills/114/hr203#summary

Kang H.K., et al. (2015). Suicide risk among 1.3 million veterans who were on active duty during the Iraq and Afghanistan wars. Annals of Epidemiology. Retrieved from https://dx.doi.org/10.1016/j.annepidem.2014.11.020

Kemp, J. & Bossarte, R.. (2012). Dept of Veterans Affairs Suicide Data Report. Mental Health Services. Suicide Prevention Program.

Junger, S. (2016) Tribe: On homecoming and belonging. Hachette: New York, NY.

Phillips, D. (2015). A unit stalked by suicide, trying to save itself. NY Times. Retrieved from https://www.nytimes.com/2015/09/20/us/marine-battalion-veterans-scarred-by-suicides-turn-to-one-another-for-help.html?action=click&pgtype=Homepage&module=photo-spot-region&region=top-news&WT.nav=top-news&_r=0

Shay, J. (2002). Odysseus in America: combat trauma and the trials of homecoming. Scribner: New York, NY.

Veterans Health Administration. (2012). Suicide Data Report: VHA Response and Executive Summary. Signed by Robert A Petzel, M.D., Under Secretary for Health.

Zarembo, A. (2016). Detailed study confirms high suicide rate among recent veterans. Los Angeles Times. Retrieved from https://www.latimes.com/nation/la-na-veteran-suicide-20150115-story.html.