Military Suicide: Impact on Families and Survivor Support

Introduction: Military Suicide and Its Effects on Survivors

As the number of suicides among U.S. Armed Service members has steadily increased over the past decade, so has the rate of survivors affected by military suicide. Whenever a loved one dies as a result of suicide, the resulting trauma and shock can compromise the survivors' physical and mental health, leaving them more susceptible to a more agonizing and complex grief process. Individuals bereaved by suicide face an increased risk of eventually taking their own lives. Peer encouragement, a recognized recovery method associated with addictions and illness, has been clinically observed to be broadly used among suicide loss survivors. Researchers have given relatively little attention to effective interventions for suicide loss survivors in the general U.S. population; even less is known regarding the effectiveness of peer support among survivors of U.S. military suicide loss (Harrington-LaMorie, 2011).

Lasting effects are imposed by military suicides on survivors whose lives are permanently changed (Shneidman, 1972, p. xi). For every individual who dies by suicide, conservative estimates suggest that six people with close relationships to the deceased are directly impacted (American Association of Suicidology, 2010). Regardless of whether death results from direct or indirect acts of self-destruction, suicide is typically experienced as a sudden, traumatic loss. With every suicide death of a service member, allies, military families, and significant others are greatly affected spiritually, socially, emotionally, and physically. The abruptness of the loss frequently intersects with stigmatizing grief, making the suicide survivors' mourning more susceptible to a distressing, isolated, and complex process. The literature suggests that survivors impacted by suicide loss struggle with more intense and prominent "thematic issues" (Jordan, 2008, p. 680) such as social isolation, shame, guilt, traumatic symptoms, perceived rejection, complex grief, and their own suicidality—all of which contribute to the survivor's vulnerability to prolonged distress and psychiatric disorders (Cerel, Padgett, Conwell, & Reed, 2009).

Military personnel have lost their lives to suicide both in wartime and in peacetime (Harrington-LaMorie & Ruocco, 2010). Suicide in the military has existed since the formation of standing armies (Defense Health Board, 2010, p. 11). Historically, peacetime suicide rates in the military were 50% to 55% and 20% to 30% lower, respectively, than the U.S. civilian suicide rate (Kang & Bullman, 2008). Today, with suicide rates rising across all branches of the U.S. Armed Forces, the need to expand suicide prevention, intervention, and post-intervention efforts has become a critical mental health crisis for the Department of Defense (DoD). Since the onset of conflicts in Iraq (2003) and Afghanistan (2001), there has been a disturbing increase in suicide rates among active-duty service members (Harrington-LaMorie & Ruocco, 2010). Rates began climbing in 2002, with self-inflicted gunshot wounds being the most common method of death; 41% of these deaths were documented as involving non-military-issued firearms (Defense Health Board, 2010).

The U.S. Army and Marine Corps have experienced the most deployments and the greatest exposure to combat in Afghanistan and Iraq since those conflicts began, and both branches have seen the highest and most sustained increases in suicide rates. How best to assist suicide survivors remains a pressing question (American Foundation for Suicide Prevention, 2010, p. 2), and even less is known about treatment and prevention strategies specifically designed for this population.

Related Theoretical Frameworks

Although considerable research has been conducted on suicidal behavior within theoretical contexts, theories of suicide spanning diverse perspectives have been proposed. Biological theories hold that suicidal behavior results from the simultaneous presence of a biologically grounded diathesis and an activating personal stressor. Psychodynamic theories suggest that suicide stems from unconscious forces, intense affective states, a desire to escape psychological pain, existential drives for meaning, and disrupted attachment. Cognitive-behavioral theories emphasize the causal roles of hopelessness, the suicidal cognitive mode, deficits in autobiographical memory, perceptions of entrapment, and emotional dysregulation. Systems and developmental theories highlight disrupted family systems and social forces as contributing factors (Orden et al., 2011).

Suicidal behavior is a leading global concern that has received relatively limited empirical attention, in part because of a relative lack of theoretical development in the field. According to the Interpersonal Theory of Suicide, the most dangerous form of suicidal desire arises from the simultaneous presence of two interpersonal constructs—perceived burdensomeness and thwarted belongingness—and that the acquired capacity to engage in suicidal behavior is distinct from the desire to do so. The theory holds that this capacity develops through habituation and opponent processes arising from repeated exposure to physically painful or fear-provoking experiences. The fundamental premise is that individuals die by suicide because they are both able and willing to do so. Three constructs are central within the theory's framework: two are primarily associated with suicidal desire (perceived burdensomeness and thwarted belongingness), and one is primarily associated with capability (acquired capability for suicide). The theory also specifies a causal pathway for the development of both the desire for suicide and the ability to engage in serious suicidal behavior (Orden et al., 2011).

This theory is grounded in a developmentally informed, multidimensional understanding of grief. Its content areas encompass and extend beyond existing models of both normative and pathological grief, including the then-proposed DSM-5 Persistent Complex Bereavement Disorder criteria (American Psychiatric Association, 2012). The three content areas are: Separation Distress, Distress over the consequences of death, and Identity/Existential-Related Distress. The theory rests on several assumptions: that both positive adjustment and maladjustment may be evident within each content area; that different content areas may be differentially related to varying causal precursors (such as the nature of the death and mediating factors), causal consequences (such as functional impairment and developmental disruption), and moderators (such as developmental phase and cultural context); and that positive and negative adjustment processes can—and often do—co-occur within and across content areas (Kaplow, Layne, Saltzman, Cozza, & Pynoos, 2013).

Policy Responses and Treatment Advocacy

President Barack Obama addressed the American Legion's 96th Annual Conference and outlined five priorities for restructuring the U.S. Department of Veterans Affairs (VA). Among those priorities was the mental health of service members, veterans, and their families. The new mental health executive initiatives aimed to improve the transition from the DoD to VA and private healthcare providers; enhance both the quality and accessibility of mental health care at the DoD and the VA; improve treatment for conditions such as Traumatic Brain Injury and Post-Traumatic Stress Disorder (PTSD); reduce stigma around mental health and encourage help-seeking; improve patient safety and suicide prevention; and strengthen community resources.

The Department of Defense announced it would automatically enroll every service member receiving care for a mental health condition into the Department's Transition Program upon separation from military service. Previously, the program had only been available to service members referred by their DoD provider or who independently sought it out. The VA also introduced a new policy ensuring that newly discharged service members could access mental health medications prescribed by an authorized DoD provider, regardless of whether those medications appeared on the VA formulary.

To improve access to and quality of mental health care, the VA announced an expansion of mental health peer support services to veterans receiving treatment in primary care settings. The DoD committed to working with Congress to bring TRICARE into full parity with mental health and substance use disorder coverage requirements.

To reduce stigma and encourage help-seeking, the DoD and VA expanded suicide prevention and mental health education for healthcare providers, chaplains, and staff working directly with veterans. Both agencies also sought to improve suicide prevention and patient safety by offering new opportunities for service members, veterans, and their families to return unwanted medications and voluntarily secure their firearms. Additionally, the DoD and VA planned to provide military cultural competency training to 3,000 community mental health providers within the following year (AFSP, 2014).