Healing Combat Trauma

Comparing Risk of Suicide in Veterans to Non-Veterans

Periodically I wish we were doing a section on this site called "What We Knew, When" because the unfortunate tendency in the world at large, for whatever reason, is to suggest that so little is known about PTSD and combat veterans that we can keep re-discovering it, at great expense and to the detriment of the veterans affected themselves (and their family members, who also have to cope with this).

One case in point that I ran across the other day is this. Back in 1986, before some of the servicemembers in the current war climate were even born, the New England Journal of Medicine reported in a study that veterans were "65% more likely to die from suicide and 49% more likely to die in a motor vehicle accident than non-vets of the same age."

The article's authors affirmed, "We conclude that the most likely explanation for these findings is that military service during the Vietnam War caused an increase in subsequent deaths from suicide and motor-vehicle accidents." (N Engl J Med 1986; 314:620–4.)

I bring this up because even the other day, a civilian wondered -- on hearing the statistics of how many suicides are being reported in the Army -- how the rate of suicide in those who've served compares to the civilian rate. The short answer? It's much higher. The current figures for servicemember suicides are one every 36 hours; for veterans, an also-shocking 18 every day -- and those figures have been valid for a while. (If you want to learn about civilian suicide rates, you'll have to do your own homework here, but the NIMH is a good place to start. The figures are a bit old but periodically update.) As a general point of reference, in 2007 it was known to be twice that of the civilian population.

Periodically new studies arise that make different claims -- a recent one says there's no difference at all, but perhaps their window of "in the past year" was too small -- but as a general rule of thumb, it's higher than civilians and the NEJM reference cited above is an interesting metric about how much higher. It also makes mention of motor vehicle accidents, which have a certain overlap with suicide in terms of method. 

Another recent study which seems to have gotten no traction in the news is that suicide is also higher for veterans who've suffered traumatic brain injuries ("TBI"). (The figure they mentioned is 1.55% the rate of non-veterans.) And of course TBI and PTSD frequently go together in recent veterans. This isn't to impugn the current veterans' sturdiness level in some manner, but rather to remind us all perhaps of the higher costs of serving. Let's all keep an eye on this issue, and exercise both compassion and interest as it develops over time.

Editor's note: Over the years, we've written quite extensively on suicide on this site, so there's lots of good information if you want to delve into it further -- from personal essays to suicide maps across the U.S. to even what seems to help forestall or prevent suicide. And of course this section also includes some worthwhile wisdom from the acknowledged "father of suicidology," Edwin Shneidman, M.D., whose words are well worth knowing and remembering.

"The Greatest Generation" Also Struggled, Silently -- with Suicide

Aaron Glantz, the author of The War Comes Home is one of a handful of reporters uniformly worth reading when it comes to war and veterans issues. Lately Glantz has particularly been on a roll, with his new gig at The Bay Citizen, which produces the San Francisco/Bay Area content for the New York Times. Three stories in particular stand out, and they're all California-related because that's where the Bay Citizen is based -- but if the same investigations were done in other states, the results might very well be similar.

Glantz' investigations lean heavily on Freedom of Information data, since the VA apparently doesn't keep all the statistics it could on the matter. The three stories of particular note:

• "After Service, Veterans' Deaths Surge": An in-depth investigation of deaths of California's OIF/OEF vets after they get home, which shows they're dying at three times the rate they've died in combat. From suicide, motor vehicle accidents, and the like. (Link.)
• "Veteran Suicides: See Data in Your County": A county-by-county examination, resulting in a chart, of how many vets in which age ranges die of suicide, which yields some very surprising data. (Link.)
• "Suicides Soar among World War II Vets, Records Show": (Link.)

The last two stories are somewhat linked, because the data by county shows a preponderance of older veterans taking their own lives, which we sometimes mistakenly believe does not happen.

The "Suicides Soar among World War II Vets, Records Show" story examines this problem in greater depth, and finally gives the lie to the suspicion or prejudice of so many that the so-called "Greatest Generation" managed to emerge from horrific combat somehow psychologically unscathed. We assume that, unfortunately, because they rarely share their internal struggles with others; but that doesn't mean that they don't have them.

Writes Glantz:

"In the popular mythology, they’re practically invincible, rarely complaining about the trauma of war. But an investigation by The Bay Citizen and New America Media shows there’s a massive amount of pain behind that taciturn exterior: In California, World War II-era veterans are killing themselves at a rate that’s nearly four times higher than that of people the same age with no military service."

Wow.

Since there's a fascinating "legacy" passed down from soldier dads to soldier sons -- where the older generation's reticence about truly talking about the war, and resulting emotional distance as fathers often creates a hunger in the younger generation to experience what dad can't manage to talk about -- I think about how today's Iraq and Afghanistan veterans often have Vietnam veterans as their dads and uncles. Those Vietnam veterans, in turn, often had World War II veterans as their distant, uncommunicative fathers. As one Vietnam veteran joked with me the other day, it wasn't hard for him and his buddies to find liquor in their underage drinking days: every family's home was outfitted with a wet bar, for the World War II veteran dads when they retreated to "their" bunkers.

Now we find that they weren't just self-medicating with alcohol -- no judgment implied, it's understandable why -- but also struggling, especially in their later years, with suicide. The only silver lining from this otherwise-tragic revelation about a generation of warriors universally admired is that it somehow puts all warriors from recent wars on the same level playing field when it comes to PTSD.

There is so much stigma still around the concept of psychological wounding from combat experience, and a reluctance of many to come forward and admit that they have a problem. Among older generations, there can be the sense that young servicemembers are somehow "softer" than, say, the World War II veterans, who never are heard to complain. But as it turns out, the pain is still there, and it's real, and it's prevalent. It just expresses itself differently; but it's the same cause, and it's the same effect. If anything, as we've seen from documentaries like HBO's "Wartorn," the cost of combat is psychological injury to many that's difficult to overcome, not that it can be easily avoided. One piece of progress is realizing that the veterans of every generation have this painful experience in common.

It effectively "normalizes" the experience of PTSD, across the generations: from "the Greatest" to "the Latest." If you read the other articles in our World War II series, especially those about Eddie, the World War II POW and longtime PTSD sufferer, whose thoughts are chronicled in the "An American Veteran" series, you can see how difficult their lives were, after combat. May veterans of every era find the peace and healing they need, while they're still alive -- regardless of their age.

© 2010 by Lily Casura / Healing Combat Trauma. All rights reserved. Use with attribution.

 

Quotable Quotes -- A Marine Sniper on True Combat Age

Someone asks the former Marine sniper, pictured at left, how old he is.

"How old am I?" he replies.

"I am 2 combat deployments, 47 dead friends, a handful of confirmed kills, one year of college and 24 years old." "You'll have to add all of that stuff up," he continues.

Then he adds as a postscript, "Unfortunately now I'm 52 dead friends and 26 years old."

-- Sgt. Richard V. Gilbert, USMC Retired, Scout/Sniper

(Quote and photo used with permission.)

Editor's note: Happy Marine Corps Birthday. 235th today.

 

The Toll of Veteran Suicide: Those Unnecessary Deaths

The poet T.S. Eliot called April "the cruelest month," but you know, this time of year, heading into the holidays, isn't that great either -- especially for those who are suffering from post-traumatic stress, when numbers of those who take their own lives actually climb. The numbers are already bad enough; and 'tis the season, so to speak, when they actually get worse.

Currently, 18 veterans a day(!!!) kill themselves; and one active duty servicemember every 36 hours(!!!).

Those are TERRIBLE numbers, because each one represents a life that can never come back, and plunges a family and a community into an often never-ending ordeal.

According to the website FierceGoodbye, material for survivors put together by the Mennonites, something we already know, but it's painful to hear the statistics again, and contemplate how far indeed the trauma reaches. They say: "Over four million people in the U.S. mourn the tragic suicides of family members. Suicide devastates family members for many years; family survivors are at greater risk of suicide themselves, and the pain ripples out to the entire community."

That's why optimizing mental health is so important. An unusual quote that a colleague just shared with me, from a writer who knows:

"Looking at suicide—the sheer numbers, the pain leading up to it, and the suffering left behind—is harrowing. For every moment of exuberance in the science, or in the success of governments, there is a matching and terrible reality of the deaths themselves: the young deaths, the violent deaths, the unnecessary deaths." -- Kay Redfield Jamison, mental illness sufferer, psychotherapist and author of "Night Falls Fast: Understanding Suicide."

For those of you who work with veterans, thank YOU for your service. Ideally, it honors the veterans' lives, loves, and their commitments to stay in the game, and helps get them the tools to do so.

Editor's note: If you're a veteran in trouble, please contact the hotline numbers linked here, or if you're truly in crisis, call 9-1-1. If you're someone who wants to learn more about suicide and veterans, there's a series of articles on the topic, linked here. And if you want to learn about a veteran overcoming his own struggle with suicide, click here.

Additionally, "Fierce Goodbye: Living in the Shadow of Suicide,' is a book, a website, and a DVD. It's also a video-on-demand at Amazon to rent (inexpensive) or to purchase.

PTSD and MST Affect Men, Women Servicemembers and Veterans Alike

A few months ago, I attended the week-long clinical training program in post-traumatic stress disorder (“PTSD”) at the National Center for PTSD in Menlo Park (Veterans Administration) as well as the “Brain at War” conference in San Francisco, put on by the Department of Defense. Both made clear how much money is being spent on research ($500 million) but as for success stories, they can be hard to find. PTSD affects veterans, their families and communities; it can also lead to suicide.

Current statistics show an active duty suicide every 36 hours, and that 18 veterans a day die by their own hand. Suicides are on the rise in every branch of the military that’s seen heavy combat in the current wars -– Marines, Army, National Guard -- and so far this year, there have been more suicides than combat deaths. 

The problem extends to women veterans as well. According to the American Psychiatric Association, “Women veterans are two to three times more likely to commit suicide than nonveteran women” -- and also die at a younger age, “between 18 and 34.” 

Clearly the problem is serious and troubling. But suicide is also the final step on a journey of misery, pain and despair that can potentially be halted earlier, by intervention that increases a veteran’s chances of survival and success.

Five years ago, after writing about integrative medicine for years, I created the nonprofit Healing Combat Trauma, a website devoted to therapeutic resources for veterans with combat-based PTSD. Today, that’s becoming an actual program to lead combat vets with PTSD through, using integrative medicine -- “the best of East and West” -- to help them recover from the scars of war. 

Two years ago last week, a combat vet, Marine, who’d served in Vietnam, and suffered TBI from explosions and a head wound, as well as 40 years of severe, chronic PTSD, flew out to meet me, and together we went around the country, experiencing specific therapeutic modalities in the hands of experienced practitioners that were targeted to address his PTSD. (Watch "A Veteran's Healing Journey," here, for more of his story.)

Initially actively suicidal, once his symptoms receded, so did his threats of suicide. He had gotten his life back, and was eager to stay involved in it. And the cost of helping him reverse his symptoms, and improve his quality of life? Under $10,000, including travel, lodging, and practitioner visits.

As much attention as PTSD receives in the media, military sexual trauma (“MST”) – which frequently leads to PTSD – receives even less. A more taboo subject, MST affects roughly the same number of men and women, approximately 60,000 each, between 2002-2008, despite their disproportional numbers in the services. 

According to the VA, “Approximately 1 in 5 female patients … reports MST,” and MST is associated with “increased risk for mental health conditions including PTSD, depression and substance abuse disorders.” VA reports the prevalence of MST among OEF/OIF veterans is 15.1% among females, but anecdotally the figures are much, much higher, typically under-reported because of shame and fear of reprisal.  And MST leads strongly to PTSD. Among Gulf War veterans, for example, women who suffered MST were at 5x higher risk of contracting PTSD.

But for a sense of the human toll, read how one young woman soldier expressed her misery, after multiple sexual assaults in a single deployment in Iraq, followed by a suicide attempt: 

“I remember so many things I want to forget. I remember once upon a time I was a real person. Then I was a soldier. Now I am a ghost.”

Earlier this summer, another young woman combat veteran, Angela, with whom I’ve become friends, spent time staying out here, around our both attending a local retreat for veterans and their families. Angela has MST and PTSD, and a service dog to help her manage her PTSD symptoms. 

Even in the brief time she visited, taking her to practitioners chosen to help her recovery, she was able to reduce her smoking by half, and said she couldn’t remember when she’d felt so relaxed – certainly not since she’d experienced combat. (A former Army sergeant, she’d been in Baghdad during the surge in 2003.)

A few years earlier, Angela had attended the VA’s “cutting-edge” program for women vets with MST. The program housed the women vets –- all of whom had experienced sexual assault -- in a men’s homeless shelter(!). The stress of that experience was so great, Angela said, that her fellow attendees all relapsed into substance abuse. She credited her own experiences with integrative medicine as what kept her, barely, on the path. Out here this summer, she was able to expand those options further, in positive ways that continued to help her heal. 

Now we want to offer that opportunity to more women veterans (and later, men) in a pilot program. Please help us do that.

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© 2010 by Lily Casura / Healing Combat Trauma. All rights reserved. Use with attribution.

 

Stop Just Talking about Suicide Awareness and Prevention...Find and Fund Programs That Work!

The numbers continue to get more shocking. First more suicides than combat deaths; then suicides on the rise in each branch that sees heavy combat (Marines, Army and the National Guard), despite millions spent/wasted in suicide prevention campaigns; now, finally, a figure to wrap our collection brains around: one military or veteran suicide every 36 hours. Ouch.

They cite the usual suspects for the shockingly high numbers -- operational tempo, not enough dwell time between deployments, etc., etc., etc. And in the same news cycle comes the idea that really what we need is a "Suicide Prevention Office." Really. Good place to stack all the posters, videos, CDs, DVDs, promotional materials, etc., about NOT killing yourself. In addition to all the pep=talks. Sure...suicide awareness and prevention programs help...some...but clearly, not nearly ENOUGH, or the statistics wouldn't continue to climb despite the best efforts thrown at it. And every suicide devastates the family who's left behind. Read just one tragic story to get a sense of that, linked here.

Let's take a different look at the same problem. Let's stop telling people under stress, hey, don't KILL yourself! It's a bad idea! (Don't you think they know that? But when the pressure gets too great, all the wonderful advice in the world goes out the window...however true it might be). Let's instead start looking at...veterans and servicemembers who struggled at one time, recently, WITH wanting to kill themselves, but who broke free of the grip. How did they do it? To what do they attribute their success? And let's replicate THAT, if it's reproducible. 

There's a whole concept called body psychology, where trauma is stored in the body, not "just" in the mind. The theory is "controversial," which means it has its adherents and its detractors (many things do). But if the theory is correct, it opens up ways for removing trauma from the body, other than the "gold standard" (aka, only thing practiced) of talk therapy and psychopharmaceuticals. Even VA admits that what they offer doesn't work for everyone; and that's of those who sign up to be treated, which isn't remotely all who need the help. And it doesn't even count those who are still serving. Trauma takes its toll. Let's be increasingly more open-minded about how to remove it from the body AND the mind. 

Clearly, the status quo isn't working. If it were, the numbers of servicemembers and veterans who kill themselves wouldn't continue to climb. All the awareness and prevention in the world doesn't help clear trauma from the body. Let's start exploring the ways that actually do. Talk therapy and drug therapy already have their place. Let's enlarge the conversation to include other modalities. We don't have much to lose; lives are already being lost, and the status quo clearly isn't working. A few more pep talks, a few more videos, an office of suicide prevention: NO. Let's find and fund things that WORK. Start here.

Trust Betrayed: Sexual Assault in the Military Gives Rise to Increased Levels of PTSD

"Military sexual trauma ("MST") is the term that the Department of Veterans Affairs uses to refer to sexual assault or repeated, unsolicited, threating acts of sexual harassment -- that occurred while the veteran was in the military."

Some comments to orient you, the reader, to what MST survivors go through/think like:

• "While in (the Middle East) I was gang-raped by fellow soldiers. They told me if I talked they would kill me, and they would always know where to find me. I went to the MP anyway. They asked me what I expected being a female in combat..."
• "I never told anyone about the rape until I started therapy..."
• "I was very aggressive in trying to prove my 'manhood.' I tried in all ways to prove I was not weak and I that I was not homosexual. I did not feel like I was a real man. I carried the shame and guilt with me always. I felt I was at fault. I was weak."
• "I have attempted suicide six times because of the rape."
• "I spent two years attempting to track my perpetrator so I could kill him."

Some facts and figures about Military Sexual Assault, which affects roughly equal numbers of male and female servicemembers (despite the differing percentages of those who serve.)

From a just-released Army report (August, 2010): "One of the more disturbing trends from FY 2001 – FY 2009 is a clear and steady rise in the number of sexual offenses, which have essentially tripled since FY 2003."

From the 2006 Department of Defense Survey of Active Military: Annual incidence rates of sexual harassment: 34% of women; 6% of men; for unwanted sexual contact: 6.8% of women; 1.8% of men. (Of course, anecdotally, the figures are MUCH higher.)

Other statistics from VA: "Approximately 1 in 5 female patients and 1 in 100 male patients report MST." (Source: MST Screening Report, FY 2005.)

Total number of veterans who have reported MST in VA (2002-2008): 61,126 men and 59,690 women. (Source: HEC Eligibility Center National MST Report.)

Consequences, according to VA: "More readjustment problems after discharge; more physical health problems; more anxiety, depression and PTSD; more substance abuse; can exacerbate stress reactions to war-zone exposure." 

MST "is associated with increased risk for mental health conditions including, PTSD, depression, substance abuse disorders." The prevalence of MST among OEF/OIF veterans is 15.1% among females;l 0.7% among males. (These statistics are typically under-reported because of shame and fear of reprisal.)

MST Consequences and PTSD:

Male Gulf War veterans: MST = 6x risk for PTSD; combat = 4x risk for PTSD;

Female Gulf War veterans: MST = 5x risk for PTSD; combat = 4x risk for PTSD;

(Source: Kang, Dalager, Mahan & Ishii, 2005.)

Among VA patients who report MST: 28.1% of women and 18.4% of men report PTSD; 45.6% of women and 28.2% men report depression; 5.9% of women and 9.5% of men report alcohol disorders; 5.2% of women and 7.3% of men report drug disorders." (Source: Kimerling, R., Gima, K., Smith, M.W. et al., 2007.)

VA Rules:

A veteran does NOT need to be "service-connected" nor have previously reported a sexually traumatic event to be eligible for MST services through the VA. Even veterans who do not meet general eligibility requirements for VA health care are treated for health and mental health consequences of MST (coded 'ineligible' or 'humanitarian'). The veteran with a dishonorable discharge may want to consult with the local MST Coordinator.

The VA uses two questions to screen for military sexual assault:

• While you were in the military, did you receive unwanted sexual attention, such as touching, cornering, pressuring for sexual favors or verbal remarks? 
• While you were in the military, did someone ever use force or threats of force or punishment to have sexual contact with you when you did not want to? 

If you have been assaulted while serving, please educate yourself about the problem and go to the VA and get help. Maybe bring a trusted friend with you because the process can be difficult to navigate (VA bureaucracy not specifically MST care) "even for healthy people," according to one veterans' advocate.

Provider Burnout among Combat Stress Healthcare Practitioners

It's been interesting to follow the Tweets from the conference at Mass. General Hospital this Friday and Saturday, on the "Complexities and Challenges of PTSD and TBI." It sounds like it was a great conference. One of the items that stood out to me was the statistics being shared about provider burnout. Check these out:

"Not enough social workers, therapists, etc. to help all the people who need help."

"146,000 mental health providers in U.S. Medical Command (MEDCOM),...a huge centralized training that's re-assessed annually for improvements...now (with) significant training resources in place to help providers manage stress." 

Studies that MEDCOM has done indicate that provider "burnout" is approximately "35% among deployed psychiatrists," "20% in deployed psychologists," "15% in deployed social workers," and "26% in non-deployed." (Source: LTC Graeme C. Bicknell, PhD, LISW, LTC, MS, Deputy Chief, Behavioral Health Division US Medical Command.)

We've written about "Caring for the Caregivers" frequently on this website, most recently here, in a post entitled, "Too Long a Sacrifice Can Make a Stone of the Heart:The Tao of Self-Care." Acknowledging provider burnout is another aspect OF "caring for the caregivers." The takeaway? Combat stress injures troops AND mental health providers; servicemembers and practitioners alike need stronger support. 

(There's a great article by Charles Figley on the topic, "The Art and Science of Caring for Others without Forgetting Self-Care, linked here, suggested by one of the readers on the Facebook site for this website, which is linked here.)

Editor's note: You can follow the PTSD Conference, now over, on Twitter, @PTSDConference; and you can follow this website on Twitter @HealingPTSD.

Veterans, PTSD and Suicide: The Overlooked Element of Contagion

This is an article I'd first started writing two years ago now. I did the research, and located the main, most often-cited study's principal investigator, long since retired, and asked him to confirm whether the trend is still true, though he first published it back in the 1970s. He affirmed that it was. What it is is an important and often-overlooked "connection" that will make more sense when we start describing it. It also fits into the category of things where the information is out there, but for some reason is also strangely ignored. Another instance was a few years ago, when the military kept saying, "We don't know what PTSD is tied to"; essentially, "we have no idea." Yet at the time, and this goes back several years now, I was able to read through the existing literature and learn, PTSD is tied to combat exposure. In other words, the more combat, the greater the chances of developing PTSD. And I wrote about it, here, at the time the military was saying, in essence, we don't know what it's linked to.

So it isn't that that wasn't known...it's that no one was paying attention to what was out there. (And these days, several  years later, they ARE admitting publicly that more exposure = greater chance of developing PTSD. But it does make me laugh a little bit to hear that now, thinking, we were talking about it here well before that was being said publicly. And not because of some strange prophetic abilities on our part; just from reading the available literature, and drawing what seemed like obvious conclusions.)

There's the old saying that "those who refuse to learn from history are condemned to repeat it." Well, much of what's known about PTSD has been known for decades now, with another fair part of the knowledge base has been increasing exponentially. I read an article the other day about a Harvard-trained psychiatrist who worked at the V.A. in Boston during the Vietnam war, and was "shocked" to learn that there wasn't a single book on war trauma in the library there. Today, one would hope, that situation has changed quite a bit. 

But to the point at hand...

As I read through my Twitter feed today (you can follow us @HealingPTSD on Twitter), I noticed several suicides being Tweeted by various sources. One was that of Mel Turpin, a former All-American basketball player and NBA star, dead at 49; and then the troubling news, especially to us in the veterans community, of a Marine Corps veteran, James F. Popkowski, 37, who apparently died in a "suicide-by-cop" or armed confrontation outside the V.A. in Bangor, Maine. (See those stories linked here and here, as well as a longer quasi-obituary of Popkowski, here.) At first the headline said only "an armed man" had died in a confrontation with police near a local VA -- and as soon as I read that, I hoped -- but yet somehow knew -- that it would be a veteran, with a painful story of his own. Later the news matured to show that in fact he was a veteran, who was struggling with this illness (cancer) and its treatment. But the fact he was a veteran and committed suicide reminded me instantly of the news from the last few days, where the Seattle Times did such a good job covering the suicide of a veteran with PTSD from Whidbey Island, Orrin McClellan. (I wrote about Orrin's life and death here and here.) So many suicides in the media, and superstitious types tend to think those run in threes -- though technically McClellan's death was in mid-May, with the coverage of it in the media happening over the last few days.

I need to branch off in two different directions here, to cover this material. 

One is to talk about the V.A. suicide's statements about his own condition, because veterans with PTSD and their family members may recognize their own veterans in those words. And the other is to introduce something very different, which is the effect that media coverage of suicides has on "successful" suicide attempts by others during the same general news cycle, especially young men (who are, after all, the majority of those who serve.) 

On that second point, as the military has generally speaking tried and failed to lower the suicide rate lately, I haven't seen much recognition (OK, any) of the idea that suicides are to some degree contagious. There's quite a bit of medical literature on the subject...and it's been documented in studies around the world, starting in the 1970s, that suicides reported in the news will have a demonstrated effect on increasing suicide attempts from specific populations who hear the news. Since suicide is a broad category -- many single-car or single-motorcycle accidents are also suicides -- and the military attempts periodically to crack down on motorcycle safety, etc., it would also be wise to enlarge the conversation to not only what other methods qualify as suicides, but also to take a look at how one suicide making the news can, depending on how it's portrayed, have an effect on increasing the number of other suicides that take place in the same general time frame, especially among those prone to committing suicide, because of depression and other factors. And we haven't even mentioned yet here the effect that some prescribed pharmaceutical medications can have on increasing suicidal thoughts.

(While it's somewhat unlikely that Popkowski, in Maine, was reading the Seattle Times' coverage of Orrin McClellan's death -- one, we never know; and two, in the age of the Internet, geographical barriers have disappeared and the news is instantaneous -- especially if you include other social media, like Facebook and Twitter, which can serve as additional sources of the same news. We're so much more wired now than when these studies first started being done, so we can't assume Popkowski didn't read the Seattle Times coverage, even though it's most likely that he didn't. For the sake of this argument -- because if it didn't happen with this case, it surely does with others, let's pretend that Popkowski did spend some time over the last few days reading the coverage of McClellan's suicide on the Internet.)

There's enough material to cover here that I need to go as far as I can with it now and then circle back around to it again soon. We'll introduce the science (below) but also cover what Popkowski said about his failing health, because his words will resonate with other veterans, who struggle not with cancer but with PTSD.

According to the article in the Portland, Maine Press Herald today, Popkowski, who had undergone a stem cell transplant for his cancer back in 2003 at the National Institutes of Health, struggled valiantly with the effects of the cancer and its treatment (both difficult), as well as sleep problems, depression and the like. In a letter to the editor of the magazine "New Scientist" back in 2008 he wrote,

"Suicide is like a little devil, always on my shoulder and always tempting me. Concern for the care of my three dogs after I am gone, my dogs being the only things I feel anything resembling passion for, is the only thing I think that has kept me from pulling the trigger on the loaded pistol, which rests next to my pillow."

He continued,

"The best way to describe the mental and emotional issue is that I am numb and passionless. Nothing brings joy or pleasure. I graduated magna cum laude with a (Bachelor of Science degree) in computer info systems and business management in just three years. Now, I cannot mentally focus enough to read a newspaper."

He added,

"I have lost count of the number of sleep aids NIH and my local VA have tried. Like the anti-depressants, none have worked."

And he described leaving his bunker, in terms that a veteran with PTSD would understand, only for brief forays out to re-provision with groceries and return, if his health even allowed him that. He wrote:

"For weeks at a time I will only leave my house once, and only briefly at night, to buy groceries and other supplies. Most of the time, the only time I drag myself into the shower, is when I have to go into town to buy groceries."

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Now, we hope that no veteran ever crosses the bridge to suicide in his or her lifetime, and especially is not discouraged enough reading news of how another distressed veteran felt to contemplate it. Please use the resources at your disposal, including hotlines, buddies, and compassionate others as lifelines to not give up hope, because there IS hope, and you can get better. But for the rest of us, we need to keep pushing on with this narrative because there's something to learn here, including for decisionmakers who wonder about how better to educate about suicide prevention. This is where the element about the notoriety/publicity level of a suicide influences other at-risk populations.

To the science on this.

• Back in 1977, in the journal Science, DP Philips showed that "motor vehicle fatalities" (including "suicides by motor vehicle") increase in the time frame "just after publicized suicide stories." From the abstract: "The average increase in motor vehicle fatalities is 9.12 percent in the week after a suicide story. The more publicity given to the story, the greater the rise in motor vehicle deaths thereafter. This rise apparently occurs because suicide stories stimulate a wave of imitative suicides, some of which are disguised as motor vehicle accidents."
• In 2006, an Australian journal, Social Science Medicine, published a similar study, further demonstrating the "relationship between media reporting of suicide and actual suicide." They studied data on "4,635 suicide-related items appearing in Australian newspapers and on radio and television news and current affairs shows between March 2000 and February 2001. The study found that 39% of media items were followed by an increase in male suicides, and 31% by an increase in female suicides. Media items were more likely to be associated with increases in both male and female suicides if they occurred in the context of multiple other reports on suicide (versus occurring in isolation), if they were broadcast on television (versus other media), and if they were about completed suicide (versus attempted suicide or suicidal ideation). Different item content appeared to be influential for males and females, with an increase in male suicides being associated with items about an individual's experience of suicide and opinion pieces, and an increase in female suicides being associated with items about mass- or murder-suicide." They concluded, "Further research on this topic is required, but in the meantime there is a need to remain vigilant about how suicide news is reported. Mental health professionals and suicide experts should collaborate with media professionals to try to balance 'public interest' against the risk of harm."
  
• Versions of the original study were repeated over and over in the intervening years, and 30 years later, in 2007, the International Journal of Epidemiology published a study which showed "the influence of media reporting of the suicide of a celebrity on suicide rates," where a male television celebrity in Taiwan committed suicide, followed by a wave of somewhat "copy-cat" suicides among young men. (The "celebrity" element may initially confuse, but think of it this way -- it's a well-publicized suicide when it happens, which means it reaches most of the target audience. It also happens, according to other studies, when non-celebrities commit suicide. The distinguishing factor is how well publicized the suicide is/how much media attention or coverage is given to it. The more coverage, the more people know about it, including those in somewhat fragile populations.) Back to the study's results: "After controlling for seasonal variation, calendar year, temperature, humidity and unemployment rate, there was a marked increase in the number of suicides during the 4-week period after media reporting (relative risk = 1.17, 95% CI 1.04-1.31). The increase was in men (relative risk = 1.30, 95% CI 1.14-1.50) and for the individuals using the same highly lethal method (hanging) as the TV  actor did (relative risk = 1.51, 95% CI 1.25-1.83). However, the age groups in which the increase occurred were younger than the age of the celebrity. CONCLUSIONS: The extensive media reporting of the celebrity suicide was followed by an increase in suicides with a strong implication of a modelling effect. The results provide further support for the need for more restrained reporting of suicides as part of suicide prevention strategies to decrease the imitation effect."
• Also in 2007, a study was conducted in Taiwan around the fact pattern of the same television celebrity's suicide and published in the Journal of Affective Disorders. It attempted to define the "influence of media reporting of a celebrity suicide on suicidal behavior in patients with a history of depressive disorder," and what it found was "Among 438 depressive patients exposed to the media report, 38.8% reported an influence on subsequent suicidal behaviors, including 24 (5.5%) with a suicide attempt. The risk of such influence was highest among patients in a severe depressive state just prior to the media report (adjusted OR 7.81, 95% CI 3.28-18.59). Such influence on a subsequent suicide attempt was highest in patients with a most recent suicide attempt within one month prior to the media reports (adjusted hazard ratio 11.91, 95% CI 3.76-37.72)." The authors concluded, "This study has provided more convincing evidence suggesting negative influences of media reporting of a celebrity suicide on subsequent suicidal behaviors among depressive patients. Particular attention in terms of potential negative media influences should be paid to patients who are younger and currently depressed and have made a recent suicide attempt."
• This year (2010), another Taiwanese study took a look at suicide rates after media reporting of another celebrity suicide, this time a female singing star. Their premise was that "Suicide attempters are known to be vulnerable to the influence of media reporting of suicide events. This study investigates possible influences of media reporting of a celebrity suicide on subsequent suicide attempts and associated risk factors among suicide attempters." In their study, "Sixty-three suicide attempters registered in a surveillance system of Taipei City Suicide Prevention Center were assessed using a structured interview soon after media reporting of the suicide of a young female singing star." Their results? "Forty-three (68%) respondents had encountered with the suicide news. Among them, 37% reported being influenced by the media reporting on their subsequent suicide attempts." Most hard-hit by the news? "Men (adjusted OR 6.36, 95% CI 1.29-31.44) and younger age groups (adjusted OR 4.93, 95% CI 1.04-23.45) were more susceptible to the media reporting." And the authors concluded, "This study has provided further evidence for suicide imitation among vulnerable people encountered with media reporting of celebrity suicide, and for the need to actively restrain reporting of suicides to decrease the imitation effect."

It's also true that young men -- the dominant demographic of who the all-volunteer military is these days, though approximately 11% are women -- are more prone to suicide than other age groups. Back to the science:

• According to statistics from a fact sheet on youth and violence provided by the CDC, "In 2005, 17% of high school students seriously considered attempting suicide, and 13% made a plan about how they would attempt suicide during the 12 months preceding the survey." (The reference cited is CDC. Youth Risk Behavior Surveillance - United States, 2005.  Morbidity and Mortality Weekly Report 2006; 55 (SS-5): 1-112.)
• Similarly, according to the CDC, "approximately 14% of all deaths among children and adolescents aged 5-19 years result from suicides."  The numbers climb according to age ranges, with younger children having the fewest, and older children the most.  Suicided ages 10-14: 283.  Suicides ages 15-19: 1,700.  (The reference cited is CDC, National Center for Injury Prevention and Control, Office of Statistics and Programming. Web-based Injury Statistics Query and Reporting System (WISQARS). Online at http://www.cdc.gov/ncipc/wisqars/. Accessed September 6, 2007.)

There's more that we could talk about here -- responsible reporting guidelines about suicide, when disseminated and implemented, seem to have the effect of reducing the number of copycat suicide attempts after a successful publicized suicide (a study in Austria shows that) -- but the intended effect here, which we can elaborate on in future posts, is to introduce the idea that one publicized suicide by, say, a veteran, can also most likely encourage an increased number of suicide attempts, some of them successful, by members of at-risk populations, such as young/depressed/men. Do any of those words correlate with anyone who might be suffering from PTSD, or taking medications that might also increase suicidal thoughts? And we haven't even added into the mix the effects of alcohol, which many PTSD sufferers self-medicate with, and how that would affect suicidal thinking. There's much, much, much more to talk about on this topic -- not just here on this site but nationally -- but we hope this dense, rather convoluted post has at least gotten you thinking about not so much that we need to protect veterans with PTSD from seeing or reading the news, which might contain an item about another veteran's suicide -- but that suicides can almost go in waves (read the literature on prison populations, etc. for this), where one suicide spurs others in the same population -- because publicity surrounding a suicide has the unintended consequence of increasing suicidal tendencies in other affected people. Since many, many veterans with PTSD are to a degree on edge already...it might be good to realize the effect that reading about another veteran's demise could have on an already depressed, stressed or demoralized individual.

And since the larger goal for all of should be preventing suicides among PTSD-injured veterans, it's highly worth having this conversation.

Anatomy of a Suicide: OEF Veteran Orrin McClellan, RIP from PTSD

The Seattle Times has an article in yesterday's paper about a young Whidbey Island OEF veteran who unfortunately killed himself in May of this year. Orrin Gorman McClellan served with the 173rd Airborne Brigade Combat Team in Afghanistan in 2005-2006. He took a lot of photos of his experience in Afghanistan, and he also wrote, poignantly, about his experiences as a soldier in an online journal, where he wrote every day. (The article doesn't reveal the location of that journal.) In what's known in the journalism biz as a "package," the article also has two multimedia presentations included with it: a video of his parents leafing through a book they're putting together of poems Orrin wrote, linked here, and a video narrated by his parents of some of his photography from Afghanistan, linked here. "I've become numb," McClellan writes, "but not comfortably so."

It's wrenching watching his parents in the videos sit side-by-side on the couch, in a tableau no doubt repeated across America, as the parents of the approximately 18 veterans a day who kill themselves must do, trying to make sense of why Orrin had to go, and still actively grieving, trying to come to terms with their own loss. In Orrin's case, his mother is a social worker, who the article says specializes "in the treatment of traumatized individuals." Of course, not even a mother with this background can necessarily save her son, which only adds to the tragedy. It says his mother even "took a counseling job with the Whidbey Island NAS and helped her son navigate through the VA system." He was retired with a 100% disability due to PTSD. The article quotes the mom as saying that as a community, we all need to listen better to our vets. And practice "deep listening" to their stories of what they've gone through.

What makes the article good, from this reader's perspective, is that it positions Orrin McClellan's death against the backdrop of the statistics of veterans suicides across the country, and then projects how those statistics affect Washington state, where the Seattle Times is based, and where Orrin lived. Eighteen deaths of veterans a day, the number of suicides approximating deaths in combat this year -- these are shocking statistics, but like so many others, we become numb to them over time. Bringing it closer to home, those same statistics mean of the almost 36,000 OIF and OEF veterans from Washington state, a dozen would be lost to suicide. In 2010, Orrin McClellan was sadly one of that number.

(Army veteran Chris Loverro, who served with the Stryker brigade from Fort Lewis, Washington, did a poignant video of his own about PTSD and suicide in the life of a veteran. We've shown it in a recent article, linked here.)

McClellan's mother, Judith Gorman, says that her son never really came all the way back home, because of his PTSD. Retired Army General Eric Shinseki, now head of the VA, is also quoted in the article, as ruminating -- perhaps not about McClellan's death in particular but about veterans' suicides in general -- that he often asks himself, "Why do we know so much about suicides, but so little about how to prevent them?" That's a fabulous quote, but it's also quite a profound question.

Edwin Shneidman, the so-called "father of suicidology" -- who ironically got his start leafing through files at the VA, reading suicide notes of veterans -- is someone we've written about a fair amount on this site. He's also known as the originator of the concept of a "psychological autopsy," where someone, reasoning backwards from the fact of the a person's death, tries to reconstruct the extent and timing of the stressors in that person's life, to determine how and why it became too much for them (the "when" having already been determined.)

I'm not sure, but I would hazard a guess that, other than the families of veterans who commit suicide, who are directly involved, there isn't much of an effort made on a larger level to reconstruct what stressors became unbearable in the lives of those who kill themselves, during or after military service. Perhaps a broader study into this, a la Shneidman's methods, would produce important or helpful conclusions.

McClellan's story is in many ways all too typical...except for the social worker mother, and the wonderful legacy he left behind in the poems he wrote and photographs he took. He struggled, as many veterans with PTSD do, with drugs and alcohol, with trying to fit back into his life, with impulse control, with hypervigilance, with nightmares, with combining alcohol with prescription medications, with grief and perhaps blaming himself over the deaths of two close friends. And he struggled with long drives to the VA, which was located quite a distance from his home.

His parents sound like amazing people, who tried so hard. They even established a Veterans Resource Center, on the island where they lived, "to offer referrals, networking and other assistance," to help other veterans in addition to their son. In the wake of his son's death, they may also publish a book of his writings, to raise awareness about PTSD.

Digging around on the Web, especially within social media, it wasn't hard to find some of McClellan's thoughts. He had two journals where he kept his writings, one on MySpace and one on LiveJournal. I've chosen not to link to them, to protect his privacy in case that's an issue. But in one he quotes from T.S. Eliot's famous poem, "The Hollow Men," which closes with the memorable lines about "this is how the world ends, not with a bang but a whimper."

It also contains an entry from September of 2008, while McClellan was actively struggling with PTSD, but a full year and a half before he ended his life. In an entry called "What the hell happened to me?" he writes:

"I read some entries in my journal from two years ago" 

[2006, the end of his Afghanistan deployment and beyond]

I love who I was.

Why did I do this to myself?

Was it war?

Did I implode from all the shit I saw?

Or was it something else?"

Questions really with no answer. He goes on for a bit more, and then concludes with the poignant question:

Why did I let myself

Get so lost?

RIP Orrin McClellan, gone too soon, and comfort to your family and your friends.

Editor's note: The photo is of a point on Whidbey Island, a thoroughly beautiful place in Washington state.

Quotable Quotes -- Former U.S. Senator Bill Bradley on PTSD

Former U.S. senator Bill Bradley (D-NJ), NBA Hall of Famer, and Rhodes Scholar, had this to say in a commentary published in Vanity Fair today about PTSD. The occasion was the premiere of the Tom Hanks/Steven Spielberg/HBO miniseries, "The Pacific," about U.S. Marines in the Pacific during World War II, also getting screened privately at the White House today.

Bradley thinks there are several things that the president and the first lady should be thinking about while they watch the miniseries. One of those topics is PTSD. Says Bradley:

"Both The Pacific and Band of Brothers focus on the horrors of the war and the emotional trauma that a soldier or Marine can endure. P.T.S.D. should be treated with as much seriousness as a gunshot wound. If the president is going to send tens of thousands more troops [into combat], he also needs to consider the emotional payload. With suicide rates up among veterans -- accounting for 20 percent* of all suicides among Americans -- the government must dedicate more money to support programs for our returning troops."

Editor's note: If 8,000 veterans kill themselves every year, conservatively, and the national suicide rate is close to 34,000, according to the NIMH, the percentage of suicides who are veterans is closer to *25%. They also represent almost 50% of the homeless population. So yes, please, let's do that...and sooner rather than later...

(The full commentary is linked here.)

More Numbers to Remember: 3 Then, 7 Now

A newspaper article reports today, "In the Vietnam war, for every soldier killed, three came home wounded. In Iraq, for every soldier killed, seven come home wounded." Those are some substantial numbers...and I wonder if they're even accounting for PTSD in them, which is often considered an "invisible wound," and one which shows up usually after the fact.  The numbers could be even that much higher...

Roughly 5,000 killed to date -- 35,000 wounded (by that estimate) -- and for every veteran, another 50 people who he or she affects (see Fred Gusman comment about that, which we blogged about earlier -- linked here).  If we add the number killed and the number wounded together, then multiply the 50 each veteran affects directly in his or her life, that's 2 million Americans affected by veterans' sacrifices.

Let's Hope This Isn't More "Blame the Victim" Thinking on Combat Veterans with PTSD, But...

A recent medical study, published in the British Medical Journal and reported on Friday, suggests that "the risk of combat-related post-traumatic stress disorder (PTSD) increased by two- to threefold in military personnel who had significant mental or physical problems before deployment, according to a study of 5,400 veterans."  In other words, those who were vulnerable beforehand, were even more susceptible to PTSD than their peers.  Hmmmn.

It's always interesting, and is going to stay interesting, to contemplate what, if any, predictive or predisposing factors there are for who develops later develops combat-based PTSD and why.  At the very least, this study throws yet more analysis into the mix, in a story that will continue developing for years.

According to the BMJ, the conclusion of the study was that:

"Low mental or physical health status before combat exposure significantly increases the risk of symptoms or diagnosis of post-traumatic stress disorder after deployment. More vulnerable members of a population could be identified and benefit from interventions targeted to prevent new onset post-traumatic stress disorder."

The study, which was supported by the U.S. Department of Defense, reported that:

"More than half of post-combat PTSD diagnoses involved veterans who ranked below the 15th percentile in mental or physical health at baseline, Cynthia LeardMann, of the Naval Health Research Center in San Diego, and colleagues reported online in BMJ.

"We have identified an at-risk population whose functional health seems to predict vulnerability to PTSD after combat deployment," the authors said. "In theory, such a population could be targeted for PTSD prevention programs, early intervention after exposures to stress, or even protection from stressful exposures, when possible."

The findings came from the Millennium Cohort Study, which has accumulated data on military personnel since 2001, before the wars in Afghanistan and Iraq. Investigators collected follow-up data from June 2004 to February 2006.

A previous report based on the study suggested that combat exposure -- as opposed to deployment -- significantly increased the risk of new-onset PTSD. Building on that observation, the authors examined the association between baseline mental and physical health and the risk of new symptoms or a diagnosis of PTSD.

The current analysis involved 5,410 combat veterans who completed baseline and follow-up questionnaires. The questionnaire includes a 17-item self-report measure of PTSD symptoms.

Baseline health status was determined by participants' scores on the mental and physical summaries of the SF-36V (veterans) health survey. A new PTSD diagnosis was based on DSM-IV criteria (derived from the questionnaires) or self-reported physician diagnosis.

The analysis showed that 7.3% of the participants had new-onset symptoms or a diagnosis of PTSD at follow-up by DSM-IV criteria. When self-reported physician diagnosis was included, the rate increased to 8.6%.

The authors stratified the participants into three groups according to mental and health status scores: below the 15th percentile, 15th to 85th percentile, and above the 85th percentile.

Combat veterans who scored below the 15th percentile of the mental summary had a relative risk of PTSD of 3.51 compared with those in the 15th to 85th percentile.

A score below the 15th percentile of the physical summary more than doubled the risk of PTSD (RR 2.22).

Overall, 58% of new PTSD diagnoses involved combat veterans who were below the 15th percentile for either summary.

Subgroups at increased risk for new PTSD symptoms or diagnosis included:

• ≥3 combat exposures during deployment, 2.60
• Women, 2.33
• Current smokers, 1.56
• Non-officers, 1.77
• Reserve/National Guard members, 1.85
• Army veterans, 2.04"

Editor's Note: The full reference is: LeardMann CA, et al "Baseline self reported functional health and vulnerability to post-traumatic stress disorder after combat deployment: Prospective U.S. military cohort study."  The full citation is: BMJ 2009; 339: DOI:10.1136/bmj.b1273. For the link to the full article, click here.

A Look in "The Mirror" -- Great Britain Seeing War Trauma Now in 3 Years, Not 13 As Before

Because Americans are notorious for paying little attention to things that happen elsewhere, even among other English language-speaking countries, here's some news from Great Britain's tabloid-esque "The Sunday Mirror" today about their soldiers' battles with PTSD on the homefront -- soldiers who served in Iraq and Afghanistan.  For the link to the article, called "War's Silent Victims," by Rupert Hamer, click here. (The tabloid nature of the newspaper explains the fairly breathless writing style, but let's hope the facts and the reporting are accurate nonetheless.)

Points worth mentioning from the article include:

"Alarmingly, the charity [Combat Stress, see below] say[s] the figures are just the "tip of the iceberg" and add that the rate at which soldiers are developing the condition has accelerated. Usually it takes 13 years for cases of post-traumatic stress disorder to develop in veterans.

But psychiatrists at Combat Stress's pioneering centre say the men and women now being treated have come forward after just THREE years.

Also:

Dr Walter Busuttil, a consultant psychiatrist at Combat Stress, said: "What we are seeing now is just the tip of the iceberg.

"Because there has been no proper study of post-traumatic stress disorder among troops in this country we have no idea of the true scale of the problem.

"The same thing happened in the US after Vietnam. The Government tried to dismiss the disorder as a myth - then the whole thing exploded. Now when I speak to my colleagues in America they tell me: 'You are going through your Vietnam'."

And finally:

Dr Busuttil, 49, a psychiatrist in the RAF for 16 years, says the Government has covered up the severity of the conflicts from the public.

"The worst thing for a serviceman or woman is to come back from a war and for people not to have any idea what they have been through.

Editor's note: For a link to Great Britain's charity, Combat Stress, click here.  To find them on Facebook, click here. We've written about them before on this blog, but according to their website, "Combat Stress is the leading charity specialising in the care of British Veterans who have been profoundly traumatised by harrowing experiences during their Service career and who are suffering from poor mental health as a result."

"It Was Loyalty to Your Buddies That Kept Men Going" -- The Wet Bond of Blood, Civil War Style

A few months ago we blogged about an interesting, little-known WWI-era poem, written by Robert Graves for Siegfried Sassoon, called "The Wet Bond of Blood," about the brotherhood men forge in combat. (That post is linked here.)

From the news this past week comes a related story in the L.A. Times, talking about the work of Dora Costa and Matthew Kahn, a husband-and-wife research team at UCLA, who have been delving into 41,000 Civil War records of the Union Army to find out what makes some soldiers "stay and fight on a brutal battlefield," and others "desert and flee." Their new book is called "Heroes and Cowards: The Social Face of War."

According to the L.A. Times,

"The book's thesis is that serving in a homogenous Army company, particularly one of volunteers recruited from the same region, reduced desertion rates in the 1860s. Patriotism played a role in keeping soldiers at the front lines, according to the book, but more important factors were sticking with buddies of similar backgrounds and avoiding a bad reputation back home.

"Loyalty to comrades trumped cause, morale and leadership. But loyalty to comrades extended only to men like themselves -- in ethnicity, social status and age," the authors wrote."

For example,

"Through statistical analysis, the authors developed a formula in which group loyalty in those Union regiments was found to have counted twice as much in preventing desertion as a soldier's ideology, and six times as much as their unit leaders' popularity. For example, Company D of the 36th Regiment contained neighbors and relatives from Worcester County, Mass. The men, mainly mechanics and artisans, saw heavy action and no desertions.

In contrast, Company B of the 47th Regiment from New York was a more diverse lot, including men from cities and farms, along with laborers who were paid to substitute for conscripts. Its desertion rate was 16 percent."

"Cohesion" in military units is a topic even experts like Jonathan Shay, M.D., Ph.D. have spoken about as vital and essential for morale, and for the prospect of some form of healing taking place also in community.  As the article's author remarks, "Unlike the Civil War army, American units today are ethnically and geographically diverse. Yet the military has learned to reinforce the bonds gained in training, and usually rotates entire units in and out of war zones rather than fill in for casualties with new soldiers as it did during the Vietnam War, the professors said."

Interestingly, the book's authors are economists, not sociologists. The data they surveyed, and the ways they worked with the source material might also be useful for others to evaluate as well.  One of the recent, though debated, conclusions of PTSD research is that ethnic minorities are at risk for suffering from PTSD at greater rates than the general population.  There are various hypotheses proposed as to why, and no general agreement as yet about why this might be.  (See "PTSD among ethnic minority veterans," from the National Center for PTSD Research, linked here, for more on this subject. Also Professor Hedley Peach's research with the Australian Vietnam veterans studies as well, previously discussed on this blog.)

(Here's a look at the source material and their techniques for analyzing it, from the same L.A. Times article:)

"They used Internet databases as well as copies of antique paper documents written in the elegant penmanship of 19th-century government clerks. They applied the statistical tools of economic analysis to history, a cross-disciplinary technique increasingly popular in academia. Through those archives, the authors examined service records, ages, birthplaces, prewar occupations, battlefield deaths and prisoner-of-war interments among 35,000 white and 6,000 black Union soldiers. They also tracked census and pension information going back in some cases to 1850 and as far forward as 1910. Similar Confederate records were not available, they said. And to estimate pro-Union sentiment among the troops they studied, the researchers examined support for President Abraham Lincoln¹s elections in the soldiers' home counties."

Dora Costa, one of the book's authors called the source material they used, the Union Army's war records, "a fantastic laboratory for studying how do men behave under extreme stress." For that very reason, I hope other authors and scientists will mine this same trove of information.  The book's authors come up somewhat blank on one of the most fascinating themes of all.  During the Civil War, "the most ideological of U.S. wars," Costa remarked, "it was loyalty to your buddies that kept men going.id. "But we don't know why there was this loyalty."

Answering that question, we might want to turn to Graves' poem for Sassoon, mentioned above, or the thoughts of America's premier wartime journalist, Ernie Pyle, who we've also talked about at length on this blog.  From last summer -- the author of "Ernie Pyle's War," describing Pyle's authentic empathy for the soldier beside him, so well-conveyed in print:

"He knew, too, that it was neither God nor Flag nor Mother that impelled a pimply faced kid to risk, to lose his life in an obscene adventure.  He did it for the kid next to him; he couldn't let him down.  They needed one another so bad."

In "Heroes and Cowards," Costa and Kahn were surprised to learn that the average Union desertion rate was only about 10%, on average.  Says the L.A. Times, "Given the horrific conditions, it is surprising there was so little desertion," Costa said. That was especially true since fewer than one-half of those who deserted were caught, punishment often was not very harsh and execution extremely rare."

In the absence of any other, better sociological explanation, it just goes to underscore the "wet bond of blood" -- or what Pyle referred to as "the powerful fraternalism of the ghastly brotherhood of war."

What Would Hope Regained Do for Combat Veterans?

I was in a conversation the other day with a Vietnam era psychologist, who I respect and admire a great deal, but who was nonetheless giving me static for the way I talked about "hope" in a previous blog post, as it concerned combat veterans.  "You talk about it as though it's an abstract, but then immediately move into talking about its RESULTS," he said (I'm paraphrasing.)  Rrrright.  And that would be exactly the point.  Hope is a great and a necessary thing -- but our goal here is to find ways to get over combat trauma, to the extent possible -- at least to reduce its effects on veterans -- and in that regard, yes, we're all about the results.  Are there any?  And what can those be?  Because if they're legitimate at all, in the vacuum of hope-lessness and despair created by a complete lack of reasonable solutions, let's figure out what those are, and let's try them out.  Are combat veterans game?  Many are.

Here's something I ran across the other day, in the middle of a [draft] journal article.  The author was talking about a type of therapy he used -- a therapy he's famous for developing, and which has been around and in use for decades -- on combat veterans, mostly from the Vietnam era, and the results he was able to achieve with them.  I have some inside knowledge of his program, but this was the first time I'd read something in print about it.  In the middle of quite an extensive article, charting this result and that, he happened to mention the results of one of the tests he did on the 22 vets, both before and after the two weeks of treatment.  This is what he wrote:

"Scores on the Beck Hopelessness Scale fell from an average of 11 before treatment to 3 following treatment.  In clinical practice, scores of 9 or more are used to indicate serious hopelessness.  A score of 4 is expected in the general population.  The veterans went from having pre-test scores characteristic of hopelessness, suicidal ideation and predictive of suicide attempts, to having scores typical of the general population.  Thirteen veterans had scores above 9 before treatment, one had a score above 9 after treatment. (That individual's score had dropped from 17 to 10.)  Nineteen out of 22 scores dropped; two remained the same (scores of 1 and 2); and one score increased [negligibly] (from 4 5o 5).  Marked decreases in pessimism are indicated, and it seems safe to conclude that the treatment group felt considerably more hopeful at the program's conclusion."

Do you see what's embedded in that, if true?  In two weeks of treatment, combat veterans with PTSD that went back decades started feeling better to a degree, on average, better than the general population?  That's remarkable...

---

So I ask you, what would HOPE do for veterans today, and their families?  It's pretty clear that when it comes to suicide, people are able to go forward with the act because they've given UP hope.  (That's why the Beck test, for example, is able to link the two: hopelessness and suicide, both ideation and attempts.)  We've seen in previous blog posts how the "focus" of a suicidal person becomes narrower -- it's not that they "don't love their family" or "aren't thinking about the consequences to others," they simply have narrowed their focus down to an either/or choice, and the rest of the considerations, no matter how otherwise dear, are simply "not in the picture." 

---

Now it's entirely possible that the veterans in the above-mentioned program didn't functionally "stay" that perky and optimistic, and that's why more follow-up studies, such as retests at longer intervals, would have contributed more information worth knowing.  Many times, at the end of a program, irrespective of what type of program it is, participants feel most buoyed and optimistic about future performance, lighter about their burdens, and more likely to discount the negative effect of future obstacles they may encounter.  However, even so it's significant to note how good those scores seemed to be, given the great degree of difficulty the same participants had having hope beforehand.

It's not just veterans -- it's also their families.  How often do family members say things like, "But you were only in the war for two years...how can you let it affect you for the whole rest of your life?"

If combat veterans are able to access health care that adequately deals with their symptoms, and reduces their symptom load to a manageable extent, and gives them back HOPE -- they will have the ability to resume their lives with some degree of normality, and prevent any number of negative consequences that come from NOT having hope, from having given up.  The tremendous societal costs from combat trauma we have to start understanding not only affect the veterans involved -- they affect their families, the communities in which they live, future generations, etc.  Veterans with hope -- who get their hope back -- will be functional and integrated into all aspects of their lives, and actively participate in their various roles as spouses, parents, employees, citizens, etc.  Veterans who lose hope, and who we do not help to regain hope, will lose out.  And this loss will affect them first, and then like the ripple effect of a pebble thrown into a pond, concentric circles of effect will spread out from them to others in their lives: their immediate families, their workplaces, their schools, their communities, even future generations in their families.

Far from being an abstraction, I believe HOPE is pretty central to the whole concept of "healing combat trauma."  We've got to help combat veterans to hang on and have some, and they themselves have to believe it's possible to get better.  Then we have to make sure we're connecting them with the very resources that can deliver the results.

In the News: Two Articles Worth Reading Recently

Two articles worth reading that have been in the news recently:

"How the VA Abandons Our Vets," by Joshua Kors, in The Nation, linked here; and the poorly-headlined but otherwise worthwhile"Military Town Newspaper Challenges U.S. Military on Murder of Military Women," by Ann Wright, in TruthOut.org on the Web, linked here. 

Kors' article talks about the recent veterans' class-action lawsuit against the VA, fought in Federal court, and WHY it was necessary -- and there are some interesting and unexpected points, which didn't show up elsewhere in enough detail.  The biggest one is about the "fuzzy math" the VA employs to calculate claim times, and how this uniformly works against veterans (no pun intended on the "uniformly" thing.) It also confirms a longheld impression on my part that a veteran who struggles intensely with the mammoth difficulty of being his or her own advocate in the process, and ends up committing suicide, is actually counted as a "victory" for the VA, who calls their claim "resolved" in the time it took them to kill themselves.  In other words, fellow veterans killing themselves while waiting for their claims to be resolved actually makes the VA look "better and faster" at resolving claims, if you can believe that.  Yikes.  Talk about a system that needs to be overhauled and addressed...

Another great point Kors makes is that "someone" already attempted -- but was fired for her efforts.  That "someone" is Frances Murphy, M.D., who in 2004, according to Kors, "helped draft the Mental Health Strategic Plan, a blueprint for overhauling the VA.  The plan called for 256 changes to the organization, among them: installing a tracking system to stay in touch with suicidal veterans, creating rehabilitation programs that involved veterans' families, and streamlining the benefits process to resolve wounded veterans' immediate needs."  However, after expressing her frustration in public (to mental health providers) about the barriers the VA erects to veterans' speedy care, and how this causes veterans to suffer additionally and unnecessarily -- she was summarily fired.

Read the Kors piece to understand what wounded veterans have to go through, and how unfair it is; and to get a better picture on the fuzzy math that's employed to make things seem much better than they are.

The Ann Wright piece talks about military wives and women servicemembers murdered recently by other servicemembers, and mainly serves to remind us of how this is a problem that isn't going away.  The "news peg" for her article is a recent editorial in the Fayetteville, NC Observer -- Fayetteville is close to huge Army and Marine bases -- called "Our View: Military Domestic Violence Needs More Aggressive Prevention" (speaking of odd word choices).  That editorial is linked here.  The editorial references a recent vigil to memorialize the murdered women locally.

In conjunction with the Helen Benedict material and the other writings on Military Sexual Trauma, blogged about recently, here -- this is a topic worth keeping in the forefront of our minds.  Collateral damage from combat trauma? Or just crimes committed by otherwise sick individuals who happen to be in the military?  Either way, "more" needs to be done about this terrible problem.  (A similar and related topic is the "non-combat deaths" one we discuss from time to time, which can sadly be what's used to describe what more actually is a victim's suicide or a "domestic violence" type murder, of one servicemember by another.) We're just about to add a series of blog posts about domestic violence, and why it's important to leave when you're at risk, but ideally how to do so in a way that preserves your life.  Look for that shortly.

About the authors:

Joshua Kors is an investigative reporter for The Nation, where he covers military and veterans' issues. He is the winner of the National Magazine Award, George Polk Award, IRE Award, National Headliner Award, Casey Medal, Mental Health Media Award, and the Military Reporters and Editors Award.  He was also a finalist for the Michael Kelly Award, Tom Renner Award, Harvard's Goldsmith Prize for Investigative Reporting, and the American Bar Association's Silver Gavel Award.

Ann Wright is a retired US Army Reserves colonel with 29 years of military service. She also was a US diplomat who served in Nicaragua, Grenada, Somalia, Uzbekistan, Kyrgyzstan, Sierra Leone, Micronesia and Mongolia. She is the co-author of "Dissent: Voices of Conscience," profiles of government insiders who have spoken and acted on their concerns of their governments' policies.

Getting the Better Picture: Major Causes of Death and Injury for Vietnam Veterans from the War

(Well, other than suicide, that is...which certainly became more prevalent later on, after their return from the war; and still, unfortunately, goes on to this day.)

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It's true that my hero, Mark Twain, once said that "there are only three kinds of lies: lies, damned lies, and statistics."  A very funny line, but statistics still do have their place.  For one thing, even if they're slightly in error, they still manage to paint us a "bigger picture" of what's really going on.  War statistics are no different.

If you want some great current ones, by someone who loves statistics, check out my friend Ilona's blog, and in particular, this recent post.  However, what I'm hoping to do here is contribute to the "bigger picture" on injury in the Vietnam war.  I came across this passage earlier today, and it's remarkable in its ability to demonstrate who was killed by what, and who was injured by what, on the American side.  There's going to be a different distribution from the OEF/OIF conflicts in Afghanistan and Iraq -- and we already know what the signature wounds of those wars are: TBI, PTSD, and eardrum damage from the blasts.  But if you want to look back and better understand what Vietnam was like for our veterans, check this out.  I don't think I've ever seen a better list to give us a "picture" of what combatants went through and suffered, albeit externally:

"There were three major causes of American combat deaths during the Vietnam war.  Fifty-one percent were killed by small-arms fire; thirty-six percent by fragments from artillery fire; and eleven percent by booby traps and mines.  The percentage killed by small arms during Vietnam fighting was a substantial increase over that of earlier U.S. wars.  During both the Second World War, and the Korean War, only thirty-three percent were killed by small arms. 

The Vietnam percentage was much greater, because of both the fact that ambush was a major tactic of the Vietnamese Communists, and the Communists’ use of a Russian-supplied rifle, which was high-velocity, rapid-fire, light and extremely effective.  American soldiers suffered wounds from four major sources: sixty-five percent from artillery fire; sixteen percent from small-arms fire; fifteen percent from booby traps and mines; and two percent from punji sticks.

Of those soldiers killed in action, thirty-nine percent were hit in the head; nineteen percent in the chest; eighteen percent in the stomach or groin area; seventeen percent in the legs; and one percent in the shoulder or arms; with sixteen percent suffering multiple location wounds.  The percentage that died due to head wounds is considered high, and is attributed to the reluctance of many GIs to wear a helmet because of the heat; quite a large number wore floppy cloth hats instead.

 

Americans who survived their wounds were hit in the following locations: thirty-six percent in the legs, eighteen percent in the arms or shoulders, fourteen percent in the head, seven percent in the chest, and five percent in the stomach or groin; twenty percent suffered multilocation wounds.

 

Many who were wounded during Vietnam fighting survived because of both the helicopter and improvements in medical treatment.  In Vietnam, only 2.6 of those who survived long enough to reach field hospitals died; during the Second World War, almost twice that many died on hospital tables – 4.5 percent."

-- Source: Vietnam: The Valor and the Sorrow, by Thomas D. Boettcher.

Editor's note: Hope you don't mind the sick humor of the beef diagram, above, but it comes from years of working in law firms, where personal injuries are graded according to worth of the body part harmed, and the age (and therefore future life expectancy/earning power) of the injured.  Speaking of lists that need to be revised...

Understanding the Veteran: Amount of Combat Experienced

Here's an interesting quote that helps to define the Vietnam experience, although the principle involved is the same irrespective of the war.  More combat = more chances to develop PTSD, as we've already covered in an earlier post, linked here.  It's important to learn from the combat veterans in your life just how much they actually experienced, even if they and you don't want to share the actual details.

"During World War II, the Sixth Marine Regiment served four years in the Pacific but only engaged the enemy for about four weeks. In Vietnam, the combat soldier typically served a 12-month tour of duty but was exposed to hostile fire almost every day of his tour."

Source: Article called "Vietnam Veterans, U.S. Crime and Prison," by John J. O'Connor in the New York Times, July 15, 1982.  The quotation is from the narration of a movie called "Vietnam Requiem."