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Reframing suicide in the military.

Since 2001, the suicide rate among members of our military has increased dramatically. This increase occurred despite improving behavioral health conditions for American forces serving in Iraq and Afghanistan. (1) The public response to this alarming and paradoxical trend largely has been to blame the usual suspects when bad things happen in our military: stress, the strain of intense operations and repetitive deployments, and the hardships of military life. Proposals to address the problem of suicide have also trod familiar ground: more money, more programs, more chaplains, expansion of mental health resources, more research on Post-Traumatic Stress Disorder (PTSD) and Traumatic Brain Injury (TBI), new training modules, increased awareness, and better screening and treatment for those we think are at risk. Nevertheless, suicides continue to occur at unusually high rates in the military. We will argue that our current understanding of this problem is incomplete, and that, as a nation, our approach to suicide in the military needs to be refrained.

Scope of the Problem

The suicide rate in the United States in 2001 was about 10.7 per 100,000 and in 2006 was virtually unchanged at 11.1 per 100,000, translating into approximately 30,000 deaths by suicide each year. In contrast to this stability, the suicide rate in the Army was 9.0 per 100,000 in 2001 but rose sharply to 19.3 per 100,000 in 2008. Rates in the Marine Corps were 16.7 in 2001 and 19.9 per 100,000 in 2008. (2) In fiscal year 2009, the Army lost more soldiers to suicide and accidental death than to combat fatalities? Meanwhile, during this same period, rates in the Navy and Air Force remained relatively steady (10.0 to 11.7 for the Navy and 10.1 to 12.6 for the Air Force). In sum, virtually all of the increase in the DOD suicide rate has taken place in the two ground services that have borne the brunt of the deployment burden in Iraq and Afghanistan. This would seem to provide an initial clue about where to start and what to consider in accounting for the overall increase in military suicides.

Current Approaches

The RAND Corporation recently issued a report on suicide in the military that begins with the assumption that the increase in suicide rates is attributable to stress, particularly stress associated with repetitive deployments. For example, the opening paragraph of the RAND report's summary observes:
   Since late 2001, U.S. military forces have been engaged in
   conflicts around the globe, most notably in Iraq and Afghanistan.
   These conflicts have exacted a substantial toll on soldiers,
   marines, sailors, and airmen, and this toll goes beyond the
   well-publicized casualty figures. It extends to the stress that
   repetitive deployments can have on the individual service member
   and his or her family. This stress can manifest itself in different
   ways--increased divorce rates, spouse and child abuse, mental
   distress, substance abuse--but one of the most troubling
   manifestations is suicides, which are increasing across the
   Department of Defense (DoD). (4)


Given the RAND report's strong emphasis on repetitive deployments as a stressor associated with increased suicides, it is perhaps surprising to discover that the 2009 Department of Defense Suicide Evaluation Report finds only 7 percent of military suicides occurred among servicemembers with multiple deployments. (5) According to the same DOD report, while 51 percent of military suicides had been deployed at some time to Iraq or Afghanistan, only 17 percent had experienced combat. Many suicides happen among junior enlisted soldiers; repetitive deployments are more common among senior noncommissioned officers.

In 2010, the Army released its own comprehensive Health Promotion, Risk Reduction, Suicide Prevention Report (Army HP/RR/SP Report). (6) Carefully reviewing a wealth of data, the report emphasizes two factors: (1) lapses in garrison leadership supervision and control, and (2) the lowering of recruitment standards (through increased use of waivers) during the years of high operational tempo, thereby admitting more recruits given to "high risk behavior" (alcohol or drug abuse and brushes with the law). The report focuses on this "troubling subset of our [the Army's] population" as a"subculture" prone to high-risk behavior which drives the Army's suicide rate higher. According to the report:
   [This section] will demonstrate that we are creating and sustaining
   a high risk population that is a subset of the Army population.
   Several factors including an increase in enlistment waivers (e.g.,
   misconduct) combined with a decrease in separations have led to a
   small cohort that may be more likely to abuse drugs and alcohol
   while engaging in increased levels of high risk and criminal
   activity. (7)


The Army HP/RR/SP Report focuses on misconduct and "high-risk behavior," but the 2009 Department of Defense Suicide Event Report (DODSER) shows that relatively few servicemembers who committed suicide during calendar year 2009 had a history of Absent Without Leave (AWOL) (10 percent), Articles 15 (15 percent), or civilian legal problems (12 percent). (8) Fewer than one third (27 percent) had been experiencing job-related difficulties.

Theoretical Approaches to Suicide

Durkheim on Suicide

Suicide is simultaneously an individual and a social act. Many of us intuitively view suicide primarily in individual terms and might find it ironic that a classic treatise on suicide was written by a sociologist. French sociologist Emile Durkheim (9) chose it as his subject matter in the latter years of the nineteenth century for that very reason. (10) At the time, the field of sociology was struggling with its substantive and scientific identity. Durkheim sought to set the record straight. If society was nothing more than the sum of its individuals and their psyches, he argued, sociology had no unique subject matter. But when individuals connect to form a society, society itself becomes a thing with a life and properties of its own. He sought to demonstrate this point by studying fluctuations in the incidence of suicide.

France in those years already had a long history of collecting vital statistics, especially birth and death records. During the early nineteenth century, French statistician Andre-Michel Querry developed techniques for presenting these and other kinds of data in maps to illustrate their temporal regularities and covariation with "causal" variables. (11) This enabled Durkheim to draw upon reams of statistical data in presenting and testing his ideas. He sought to show that, in order for a society to sustain itself over time, it must meet certain "needs," most centrally those of "regulation" and "integration." These terms have slightly different meanings in English than in French, but in Durkheim's thinking they referred respectively to the necessity for well-defined norms and customs that regulate the interactions and lives of societal members (regulation), and for sufficiently strong commitments to these collective rules generated through immersion in group life (integration).

Integration--Egoistic and Altruistic Suicide

By Durkheim's reasoning, the health of a society should be reflected in the incidence of suicide and other social ills. Specifically, Durkheim argued that suicide rates should increase when levels of integration and regulation are either too low or too high. In other words, a healthy society is one whose members are sufficiently immersed in group life, whether at home, at work, or in voluntary associations (such as religious faith and practice), and thus are influenced by collectively shared ideas of what is appropriate and inappropriate. Where integration is weak, one can expect to see higher rates of social ills because societal groupings do not adequately sustain and constrain their members. Central among the ills resulting from erosions in group life, Durkheim contended, is a rise in a type of suicide he termed "egoistic" to capture the sense of individuals operating outside sufficient group control. For example, Durkheim noted that in nineteenth century Europe the suicide rate among Protestants (then, primarily Lutherans and Calvinists) was higher than among Catholics. The difference, he believed, was not because Protestants were more accepting of suicide--they were not--but rather because Catholicism at the time more effectively integrated its adherents into a collective community. (12)

Increases in the level of integration reduce the incidence of suicide, but not in a linear fashion. There is a point beyond which optimal gains in societal health are achieved. As the intensity of group bonds exceeds this point, there occurs another spike in the observed incidence of suicide. Durkheim described the type of suicide associated with this second increase as "altruistic." Egoistic suicide, he observed, was rare in "lower" societies. In contrast, altruistic suicides historically are those understood to be required by custom, particularly among the elderly (when they can no longer constructively contribute to societal life), among women upon the death of their husbands, or among followers upon the death of their chiefs. Durkheim compared the two in this manner: "Now, when a person kills himself, ... it is not because he assumes the right to do so but, on the contrary, because it is his duty. We thus confront a type of suicide differing by incisive qualities from the preceding one.... One occurs because society allows the individual to escape it ...; the other, because society holds him in too strict tutelage." (13)

Regulation--Anomic and Fatalistic Suicide

Variations in regulation--the extent to which norms and customs are well-defined and effectively enforced--produce similar fluctuations in suicide rates. Durkheim observed that suicide rates increase during both economic busts and booms. Why should economic booms and busts both produce more suicides? Durkheim's explanation begins with the supposition that human needs and desires are not curbed by what is required physically to survive but, rather, are potentially infinite and therefore must be constrained by some force external to the individual. Social norms and customs serve this purpose and, once in place and widely accepted by members of a society, provide equilibrium between individual desires and socially-accepted means to satisfy them. Economic booms and busts disrupt this equilibrium, albeit in different ways:
   In normal conditions, the collective order is regarded as just by
   the great majority of persons....Since this regulation is meant to
   restrain individual passions, it must come from a power that
   dominates individuals; but this power must also be obeyed through
   respect, not fear. ... But when society is disturbed by some
   painful crisis or by beneficent but abrupt transitions, it is
   momentarily incapable of exercising this influence; thus comes the
   sudden rises in the curves of suicide. (14)


While the conditions producing this type of suicide are drawn from fluctuations in economic cycles, the description points more generally to the effect of disequilibrium resulting from any violation of established rules and the resultant breakdown of binding expectations. "Anomic" suicides occur when "the scale is upset" and "results from man's activities lacking [sufficient] regulation and his consequent sufferings." Durkheim concludes: "This and egoistic suicide have kindred ties. Both spring from society's insufficient presence in individuals. In egoistic suicide [society] is deficient in truly collective activity. ... In anomic suicide, society's influence is lacking in the basically individual passions, thus leaving them without a check-rein." (15)

Durkheim devotes much less attention to "fatalistic" suicide, which he expects to occur where regulation becomes intensely suffocating. As an example, he suggests the conditions experienced by those held in slavery. Perhaps he neglected this type of suicide because he did not find many instances of it in his nineteenth century French data. Nonetheless, what is common to all four types of suicide is the importance of the relative levels of "integration" and "regulation"--low levels result in "egoistic" and "anomic" suicides, respectively, while high levels produce "altruistic" and "fatalistic" suicides.

Somewhere in the middle range exists the sweet spot for a healthy society, and reciprocally for the health of its individual members. This theory worked well for Durkheim in demonstrating the study of society as an entity itself. (16) We believe that this same framework can help us to better understand the problem of military suicide.

A Modern Perspective

Durkheim's analysis of suicide illustrates that there are clear associations between structural variables and rates of suicide, but it does not explain why some individuals who are exposed to distressing societal conditions choose to end their lives, while others do not. Psychologist Thomas Joiner's theory of suicide is far more than an extension or restatement of Durkheim's view, but does share some common ground (see Figure 1). (17) Joiner emphasizes three factors as contributing to suicidal potential: (1) failed belongingness, (2) perceived burdensomeness, and (3) habituation to self-injury. Failed belongingness corresponds to Durkheim's category of low social integration, which can lead to egoistic suicide in Durkheim's scheme. Perceived burdensomeness, where a person comes to feel he or she is a burden to others, resembles the effect of excessively high integration Durkheim associated with altruistic suicide.

Joiner postulates that suicide occurs when the desire for suicide (resulting from failed belongingness or perceived burdensomeness) coexists with the capacity to commit self-injury. He posits that this capacity is acquired through the process of habituation. Because our natural desire for self-preservation is so strong, it is difficult for most people to accomplish suicide. Individuals can habituate, or gradually decrease their response and resistance to self-inflicted injury by successively approximating fatal behavior. This habituation may be accomplished by nonfatally injuring oneself physically; by rehearsing such acts mentally; or even by observing such acts by others. Certain groups with elevated suicide rates (physicians, for example) may be occupationally exposed to experiences which habituate their response to injury and death, and which also provide them with ready access to potentially fatal instruments and pharmaceuticals.

[FIGURE 1 OMITTED]

This formulation addresses one of the central mysteries of suicide-why is it so difficult to predict who is at risk for suicide? Some risk factors are more prevalent among people who commit suicide. For example, alcohol abuse, substance abuse, and failed relationships occur at much higher rates among those who commit suicide than among others. There are genetic and biological factors also known to be associated with suicide, and social and cultural variables do play an important role. (18) Even so, only a very small fraction of people who possess one or more of these other risk factors actually go on to commit suicide. Joiner's theory suggests that habituation to self-injury is one moderating variable in suicide risk; among those with a desire for suicide, only some have the capacity to attempt or complete the act, and that capacity is derived in part from habituation to the aversive consequences of self-injury.

In sum, we consider that the desire for suicide arises from failed belongingness or perceived burdensomeness and that it may be acted on by individuals who have practiced or thought realistically about ending their lives. Because similar life experiences are not interpreted, understood, and felt in the same way by all individuals, exposure to similar circumstances and situations might lead only some individuals to suicidal thoughts or behavior. This moderating variable in suicide is the cognitive or mental process by which we construe, or understand and make sense of, our experiences and feelings. Internal attribution of negative circumstances, difficulty relating to and communicating with others, emotional dysregulation, and learned helplessness are individual variables which may affect how a person thinks about his or her life and its value. (19) Distorted thinking of this sort can lead a person to the conclusion "others would be better off without me." This is what Roy Baumeister describes as cognitive deconstruction. (20) Baumeister sees this condition as a state in which people numbly and mechanically go about their lives, and in which impulsive and self-destructive behavior becomes more likely.

Limits of Current Approaches

Attempts to explain, predict, and prevent suicide run aground on the shoals of statistical rarity--suicide is exceedingly rare in comparison to its various associated risk factors. While simple measures of combat exposure and amount of time deployed do not correlate especially well with suicide risk, there are some variables (such as alcohol and drug abuse) which clearly do occur at a higher rate among those who commit suicide. There are a great many people, however, who abuse alcohol and drugs, the majority of whom do not commit suicide.

If we wish to understand suicide in the military more clearly, one possible approach is to look for factors identified by the theoretical perspectives of Durkheim and Joiner, as discussed earlier in this article. Durkheim's framework points to disruptions in integration and regulation, and Joiner's to failed belongingness and perceived burdensomeness. Here, we consider trends, conditions, or events in military and in civilian society over the last several years that might fit these theoretical perspectives to suggest a different understanding of, and approach to, suicide in the military.

A Fresh Look at the Problem

Egoistic Suicide Revisited

The Army 2010 HP/RR/SP Report presents clear and dramatic evidence that the Army has failed to sustain an appropriate level of social integration in some garrison environments. One tragic incident described in the report seems to illustrate exactly the circumstances Durkheim might describe as an egoistic suicide. (21) A Sergeant First Class, depressed in part by the loss of friends from his unit after return from deployment, committed suicide while transitioning to Drill Sergeant School. Incredibly, his absence went unnoticed and his demise was not discovered by his unit for nearly five weeks until his landlord called the Army post to inquire why he had not paid his rent. Soldiers today commonly report that they form close relationships with their comrades in the military. Indeed, personnel policies in the all-volunteer force seem intended to foster exactly the kind of intense bonding that often occurs among unit members. Insofar as these policies are successful, they, along with the homogeneity of the military and the differences between military and civil society, may serve to accentuate and emphasize the decline in social integration that occurs when bonds between unit members are disrupted. Disruptions may occur when deployments end, when soldiers are moved or transferred, or when particular individuals come and go from a unit.

Such disruptions are less common, and perhaps also less consequential, in civilian life. Soldiers who experience them without adequate support from the military may find it difficult to regain a sense of belongingness among civilians with whom they may no longer feel they share much in common. Reserve Component and National Guard soldiers may be especially vulnerable to this kind of disruption: they are more likely to return to an environment in which opportunities to participate in military culture are fewer and less intense than active component soldiers. On the other hand, reintegration into a preexisting network of social and family bonds may mitigate the effect for some.

An increased emphasis on compliance with existing rules and regulations pertaining to conduct in garrison and in transit might serve to enhance the detection of soldiers who display particular risk factors for suicide, such as alcohol, substance abuse, or family difficulties. The root cause of some symptoms may be related to a loss of connectedness and integration. If so, the HS/RR/SP Report's suggestion to promote social and administrative relationships more consistent with an optimal level of what Durkheim called "social integration" could have a beneficial effect on suicide rates over the long term.

Altruistic Suicide Revisited

Military life places significant strain on family members. The demands made by military service are such that spouses and children must necessarily learn to cope with the challenges of daily life on their own. As family members become more independent and self-reliant, soldiers may feel less and less needed. Reunion after separation can bring complex and difficult emotional challenges--joy on the one hand, but consternation on the other that neither the soldier nor his or her family members are the same person they were before. The challenges associated with personal reintegration thus may occur in a context in which family members seem not just less dependent upon or needful of the soldier, but perhaps be able to cope more effectively without him/her.

Anomic Suicide Revisited

Anomie occurs when regulation is disrupted. Durkheim offered examples such as disruptions in the business cycle that suddenly alter a person's economic and social status, either positively or negatively. More broadly, we understand anomie as a possible result when there is a disjunction between expectations and reality, especially when commonly held ideas, values, and norms seem no longer to hold. It seems to us that the current state of the military and of civilian-military relations are rich with potential for changing circumstances that could lead to anomic responses in some servicemembers.

The HS/RR/SP Report indicts garrison leadership as inadequate, but asserts confidence in combat leadership: "While our commanders and subordinate leaders are phenomenal warriors, they are unaccustomed to taking care of Soldiers in a garrison environment." (22) Perhaps this compartmentalization of dysfunction overlooks a broader impact on military leadership culture over the last decade. Several high-profile incidents in both Iraq and Afghanistan have identified failures of leadership as important contributory factors.

The earliest such incident to attract widespread attention was the detainee abuse that took place in 2003 at Abu Ghraib in Iraq. While soldiers and NCOs were convicted of crimes, several company- and field-grade officers were reprimanded, fined, and disciplined for their leadership failures in this case. (23) In 2004, the death of Pat Tillman due to friendly fire in Afghanistan was followed by revelations of the Army's subsequent cover-up and deception concerning the true nature of the incident, which came to light only after lengthy outside investigations. (24) In 2005, several Marines were tried in the killings of 24 Iraqi civilians near Haditha, Iraq. The initial investigation was hampered by leadership lapses in the chain of command. (25) In 2006, a group of soldiers from the 101st Airborne Division raped a young girl and murdered her family in Iraq. Leadership issues surfaced again during the investigation of this incident. (26) In October of 2009, eight American soldiers were killed at an observation post (OP Keating) in Afghanistan. Eighteen months later, several officers were disciplined for related leadership failures. (27) In early 2010, soldiers from a Stryker unit murdered Afghan civilians for sport over a period of months. It is thought by some that the command climate in that unit played a role in these events. (28) Running through these incidents is a common thread of ineffective supervision or poor leadership in the zone of combat.

Although these and incidents like them are exceptional, they receive a great deal of notoriety. Little may be heard about the countless instances of exemplary leadership that happen every day in the course of military combat. Nonetheless, failures such as Abu Ghraib and others should give us pause as we consider the plausibility of the assertion that garrison leadership in the Army is in crisis but leadership elsewhere is "phenomenal." In each of the above-mentioned incidents, it was military leaders who deceived, stonewalled, or outright failed in their duties. The results of such errors may have an adverse effect on soldiers' perceptions of the military more generally. In an earlier paper, we explicitly addressed this very issue: under certain circumstances, violations of "psychological contracts"--expectations servicemembers develop, both formally and informally, of the military itself in exchange for their commitment and service--may lead to disenchantment with the institution, its mission, and their role within it. (29)

The ground services have been severely challenged in Iraq and Afghanistan, not only by the scale and duration of these conflicts, but also by their nature. Our military forces began these wars organized for conventional warfare, but were soon forced to adapt to a role which is both unfamiliar and, for some, unwelcome. Counterinsurgency is a mode of warfare in which difficult-to-resolve tensions permeate every aspect of the conflict. Force protection at times is pitted against mission effectiveness: the use of violence must be carefully titrated with positive engagement of the populace to accomplish the mission. The need to achieve and maintain this balance may well require that otherwise correctable vulnerabilities be accepted in service of the larger goal. (30) Many soldiers enter combat with expectations and training best adapted to the use of lethal methods on a known enemy. In the context of recent conflicts, highly trained soldiers had to learn to operate more flexibly against an enemy whose members can hide among the very people the military is trying to protect.

This tension may not yet be fully resolved. Over a period of several years, the Army conducted a series of surveys of soldiers in Iraq, and later Afghanistan, to assess soldiers' behavioral health while deployed. Mental Health Advisory Teams (MHATs) visited the combat zones and conducted interviews and focus groups with soldiers and behavioral health personnel. (31) In 2006, MHAT IV queried soldiers and Marines about "battlefield ethics" and, while relatively few respondents reported actually witnessing the abuse or killing of Iraqi civilians or detainees, a majority said that if they were to witness such an event, they would report it. Only a minority of those surveyed felt that noncombatants should be treated with dignity and respect. Large majorities of soldiers and Marines reported that they received ethics training, but substantial numbers (a third of Marines, a quarter of soldiers) said that they had not received clear guidance from NCOs and officers that they should not mistreat noncombatants. The subsequent (MHAT V) report showed a rate of commission of such acts comparable to that seen in MHAT IV, but presented no results on the issue of reporting such events. Battlefield ethics questions were eliminated in MHAT VI. (32) While there are surely contextual factors that demand caution from anyone who might wish to judge the behavior of those whose lives are at risk in combat, it is nonetheless reasonable to consider how soldiers' attitudes might reflect the quality of leadership under which they serve in combat. Relatedly, it is important to consider whether those attitudes are consistent with American military training and values, and with the expectations of American society.

Recent political and military history has supported what may be an historically unprecedented deference to military leaders. Cultural differences persist, however, between military and civilian society. These differences may be most apparent in the realm of social policy or so-called "values" issues. A few months ago, when then-Secretary of Defense Robert Gates visited Afghanistan, he was asked by a Marine sergeant if Marines would be given an opportunity to "opt out" of their enlistments if they disagreed with the repeal of "Don't Ask, Don't Tell (DADT)." The sergeant reasoned:
   Sir, we joined the Marine Corps because the Marine Corps has a set
   of standards and values that is better than that of the civilian
   sector. And we have gone and changed those values and repealed the
   "Don't Ask Don't Tell Policy." (33)


Interestingly, polls show that most Americans, and for that matter, most servicemembers, (35) disagree with the Marine sergeant's resistance to the repeal of DADT as a manifestation of superior values. Conservative political and religious beliefs may be overrepresented in the military in comparison to society as a whole but there are in fact some strong differences of opinion between segments within the military and civilian society and within the military as well. (35)

Polls have shown that for the last several years a majority of Americans has opposed continuation of the wars in Iraq and Afghanistan (see Figure 2 below). Figure 2 is not presented to suggest that public opinion about current conflicts has a causal relationship to the military suicide rate, or vice versa. Rather, it is intended to illustrate the changes in both factors over time, which may be the result of unintended, unforeseen consequences over a decade of conflicts that have affected servicemembers as well as civilians. (36)

[FIGURE 2 OMITTED]

Such changes may not be inconsequential. Compared to their historical predecessors, soldiers today are more easily connected to and keenly aware of American social and political trends. They have access to television, the internet, and telephonic communication. The juxtaposition and manifold differences between military and civilian life, and between military personnel and civilians themselves, can now be observed even in the theater of combat with unprecedented vividness and immediacy.

The foregoing considerations suggest that some of the difficulties soldiers encounter may arise from perceived conflicts between their own beliefs and expectations concerning military life and leadership on the one hand, and the ever-changing realities to which they are exposed in their work and via news and electronic media. Anomie occurs when a familiar and predictable web of rules and regulations begins to unravel. Some soldiers may experience the many changes and tensions within and around their reality as just such an unraveling of the understanding and expectations that would otherwise bestow a secure and predictable sense of belonging and purpose.

Fatalistic Suicide Revived

Durkheim identified fatalistic suicides as those caused by an excess of regulation. Unfortunately, he allocated only a few paragraphs to his discussion of this phenomenon. He may have considered fatalistic suicide the least likely to occur, or perhaps he included it simply to round out the logic of his larger theory. In any event, we would like to make the case for a bit more emphasis on this category, and suggest that perhaps there is an element of the same sort of fatalism involved in at least some military suicides.

For example, there are anecdotal reports of soldiers already in the combat zone who for whatever reason find themselves unable to tolerate it any longer. Lacking an honorable exit, these individuals commit an act of seemingly reckless heroism which results predictably in their own death. It seems possible to us that in a climate of military, social, or personal stress, some soldiers might feel trapped by the choices they have made, unable to find an honorable way out.

The US military is an institution highly esteemed by society. Those who volunteer for military service often gain new status and respect from friends and family, and receive expressions of immediate respect and gratitude, even from total strangers. As noted previously, many in the military regard military culture as superior to that of civilian society. For someone whose sense of identity and value accrues from military service, it may be all but impossible to depart or dissent from core military beliefs, values, or behavioral norms. In a context of perceived insurmountable stress, suicide may seem to be the only solution for a soldier who can no longer tolerate combat.

Although military service in America is voluntary, many servicemembers are attracted to the profession by pay, benefits, and increasingly generous enlistment and reenlistment bonuses. Legal professionals sometimes describe lavish, irresistible compensation packages as the "golden handcuffs" binding individuals to highly demanding jobs which eventually cause burnout. In the military, compensation and other incentives need to increase as service becomes less attractive; service incentives have increased during the last several years and waivers (37) have sometimes been used to meet force structure goals. Perhaps the faltering economy has made military service a more attractive option, but economic pressure exerts yet another source of pressure. There may be people serving in the armed forces in part because they cannot afford to do otherwise.

The New Frame

The Army and Marine Corps, the services that have been most directly and heavily engaged in our current wars, are the services with the most dramatic increases in suicide rates. Neither repetitive deployment nor intensity and duration of combat experience can completely explain these rising suicide rates. Insofar as failed belongingness and perceived burdensomeness represent a kind of final common pathway to suicide, the factors we have identified here might be seen as contributing to the development of social isolation and loss of connection. These, we know, are common features of many suicides. We think that understanding suicide requires more than the measurement of stress-related suffering, more than a focus on resilience, training, and preparation. Rather, it should encompass consideration of the capacity of soldiers to meaningfully interpret their experiences in military service.

The meaning an individual can make of his or her individual experience in service of a society is conditioned by the collective interpretation of the larger events of which those experiences are a part. Civilian control of the military means that each of us is ultimately responsible for what happens to our military members, whether or not we ourselves have served, and whether or not we feel qualified or comfortable to have that responsibility. That responsibility includes the obligation to publicly examine our wars, the military asked to fight them, and those doing the asking in the fullest and fairest way possible, following the facts wherever they may lead.

Framing a problem is an essential step toward its eventual solution. It is the step that narrows our attention to a critical subset of potential solutions. By reframing the problem of military suicide more comprehensively to include the considerations outlined above, we are forced to confront the consequences of choices we have made more generally as a society. We have chosen to maintain an all-volunteer military force; that choice affects not only the composition and character of the military itself, but also the relationship of its members to cultural expectations from within and without.

We have chosen to ask and allow a few to shoulder voluntarily the burden once shared by all. We have chosen to permit our leaders to involve us in wars the majority of citizens do not support. These choices have consequences that may include the creation of a constellation of social, cultural, and political conditions which conspire to elevate the rate of suicide in the Army and Marine Corps.

When rhetoric and reality are in conflict, cynicism flourishes. Americans are now fiercely and unconditionally supportive of a military in which they are no longer required to serve. Neither our military institutions nor the individuals of which they are comprised can possibly live up to the standards of service, sacrifice, and success ascribed to them in public discourse. Some soldiers may see a reality which diverges from the public's sanitized version. Elizabeth Samet, Professor of English at the US Military Academy, recently noted the "street theater" of many interactions between civilians and members of the armed forces, culminating in the trite expression of gratitude, "Thank you for your service." Of this ritualized exchange, one officer she quotes remarked,

"People thank me for my service, but they really don't know what I've done." (38) Insofar as that is so, the soldier and his comrades are left to struggle alone with whatever contradictions they may perceive, for the public seemingly has little patience for anyone wishing to disturb the comfortable arrangement that now exists between society and the military, an arrangement facilitated by the lack of honest, thoughtful, and open dialogue.

Our dealings with and treatment of the citizens of Iraq and Afghanistan may be one example of a topic that should merit more discussion. Counterinsurgency is a costly form of warfare: costly in blood and treasure, but psychologically costly, as well. The early Mental Health Advisory Team (MHAT) studies contain the suggestion that many soldiers serving in the wars in Iraq and Afghanistan may have adopted or tolerated a set of ethical standards that deviate from those endorsed by the institutions of which they are a part, both military and civil. If so, this clearly represents a failure of leadership in the combat zone. If there is conflict between the beliefs and values we grow up with and those seemingly forced upon us by the situations into which we are thrust, then this in itself a potential source of social isolation. Questions pertaining to such matters were dropped from the later MHAT studies, for legitimate reasons. Finding a way to address these issues consistent with existing regulatory and legal frameworks, and to include these in pre- and post-deployment discussions, may be essential steps in helping soldiers to process their attitudes, experiences, and actions in a positive way.

Efforts at prevention of suicide in the military will be most effective when they are rooted in as complete and accurate an understanding of the factors leading to suicide as possible. Examining military suicide through a social and cultural frame demands that we ask questions about ourselves, our military institutions and servicemembers, and our policies that may yield uncomfortable answers. To shrink from that duty would indeed be to break faith with those who have sacrificed incomparably more in our name.

NOTES

(1.) This generalization is taken from the MHAT IV--VII studies. The Mental Health Advisory Teams have conducted surveys of soldiers and marines in both Iraq and Afghanistan on behavioral health issues: acute stress problems, morale and cohesion, barriers to receiving care, and many other indices of overall behavioral health. In both Iraq and Afghanistan, reports of low morale were associated with perceptions of poor leadership. The MHAT reports are available on at www.armymedicine. army.mil.

(2.) Rajeev Ramchand et al, The War Within: Preventing Suicide in the U.S. Military (Santa Monica, CA: RAND Center for Military Health Policy Research, 2011), 10. All suicide rate estimates in this paragraph are taken from this report.

(3.) Army Health Promotion Risk Reduction Suicide Prevention Report 2010 (Washington, DC: Department of the Army, July 2010), 11.

(4.) Ramchand et al, The War Within, iii.

(5.) Luxton, David D. et al, Department of Defense Suicide Event Report (DODSER), Calendar Year 2009 (Washington, DC: National Center for Telehealth and Technology [T2], Defense Centers of Excellence for Psychological Health & TBI [DCOE], 2010). Referred hereafter as DODSER Report CY 2009.

(6.) Army, Health Promotion Risk Reduction Suicide Prevention Report 2010 (Washington, DC: Department of the Army, 2010). Referred to hereafter as Army HP/RR/SP Report.

(7.) Army HP/RR/SP Report, 40.

(8.) DODSER Report CY 2009.

(9.) Emile Durkheim, Suicide: A Study in Sociology, George Simpson, ed, trans. John A. Spaulding (New York: The Free Press, 1979), Kindle e-book.

(10.) The Army HP/RP/SP Report does refer to Durkheim's study in passing, but does not devote any space to an explication of Durkheim's theory or its potential application to the problem at hand.

(11.) Michael Friendly, "A.-M.Guerry's Moral Statistics of France: Challenges for Multivariable Spatial Analysis," Statistical Science 22, no. 3 (2007): 368-399.

(12.) Durkheim, Suicide: A Study in Sociology, 3192.

(13.) Ibid., 4255, emphasis in the original text.

(14.) Ibid., 4918.

(15.) Ibid., 5044.

(16.) For a discussion of Durkheim's functionalism in comparison with other sociological theories, see Jonathon H. Turner, The Structure of Sociological Theory (Belmont, CA: Wadsworth/Thompson, 2003), 23-29, 457-460.

(17.) Thomas E. Joiner, Why People Die by Suicide (Cambridge, MA.: Harvard University Press, 2005).

(18.) Both Joiner's book, Why People Die by Suicide, and a report published by the Institute of Medicine, S.K. Goldsmith, T.C. Pellmar, A.M. Kleinman, W.E. Bunney, eds., Reducing Suicide: A National Imperative (Washington, DC: The National Academies Press, 2002) contain more comprehensive discussions of the risk factors for suicidal behavior.

(19.) Joiner, Why People Die by Suicide.

(20.) Ibid., 40-41.

(21.) Army HR/RP/SP Report, 37.

(22.) Army HS/RP/SP Report, 37.

(23.) Christopher Graveline and Michael Clemens, The Secrets of Abu Ghraib Revealed: American Soldiers on Trial (Dulles, VA: Potomac Books, 2010).

(24.) Jon Krakauer, Where Men Win Glory (New York: Anchor Books, 2009).

(25.) The Times published the result of the first investigation under US Army Major General Eldon Bargewell, along with interviews of eyewitnesses. It noted that the "official investigation has already resulted in the removal of Lieutenant Colonel Jeffrey Chessani, the commanding officer, and Captain Luke McConnell and Captain James Kimber, two company commanders, from their duties. Bargewell's investigation found that: "Statements made by the chain of command during interviews for this investigation, taken as a whole, suggest that Iraqi civilian lives are not as important as U.S. lives, their deaths are just the cost of doing business, and that the Marines need to get 'the job done' no matter what it takes. These comments had the potential to desensitize the Marines to concern for the Iraqi populace and portray them all as the enemy even if they are noncombatants." This excerpt is from Army Major General Eldon A. Bargewell's report, "'Simple Failures' and 'Disastrous Results'," Washington Post, April 21, 2007, http://www.washingtonpost.com/wpdyn/content/article/2007/04/ 20/AR2007042002309.html linked from http://en.wikipedia.org/wiki/ Haditha_killings#cite_note-32 (accessed June 21, 2011).

(26.) Jim Frederick, Black Hearts:" One Platoon's Descent into Madness in Iraq's Triangle of Death (New York: Broadway Books, 2011).

(27.) Lardner, Richard, "Probe: Keating was 'tactically indefensible,' Army Times, June 10, 2011, http://www.armytimes.com/news/2011/06/ ap-keating-probe-troops-exposed-deadly_attack_061011/ (accessed June 21, 2011).

(28.) Anna Mulrine, "Pentagon had red flags about command climate in 'kill team' Stryker brigade," The Christian Science Monitor, October 28, 2010, http://www.csmonitor.com/USA/Military/2010/1028/ Pentagon-had-red-flags-about-command_climate_in_kill_team_ Stryker_brigade (accessed June 21, 2011).

(29.) Wilbur J. Scott, David R. McCone, and George R. Mastroianni, "Psychological Contracts in Two U.S. Units in Iraq: What Happens When Expectations and Realities Diverge?" Sociological Focus 39, no. 4 (November 2006): 301-318.

(30.) Wilbur J. Scott, David R. McCone, and George R. Mastroianni, "The Deployment Experiences of Ft. Carson's Soldiers in Iraq: Thinking About and Training for Full-Spectrum Warfare," Armed Forces & Society 35, no. 3 (April 2009): 460-476.

(31.) MHAT reports may be accessed at http://www.armymedicine.army.mil/reports/mhat/mhat. html.

(32.) The reports point out that these ethics questions were eliminated from MHATs after MHAT V based on input from the Defense Manpower Data Center (DMDC) and "human use" committees concerning the potential ethical issues associated with revelations about committing or witnessing war crimes. Such concerns would not seemingly apply to some of the "Battlefield Ethics" questions, such as those referring to attitudes regarding the treatment of noncombatants with dignity and respect, or whether or not torture ought to be allowed, as such attitudes are not in themselves war crimes.

(33.) David Alexander, "No opt-out for opponents of gays in military: Gates," Reuters, June 5, 2011, http://www.reuters.com/article/2011/ 06/05/us-usa-military-gays-idUSTRE7541VD20110605 (accessed June 29, 2011). As the title of the article suggests, Secretary Gates's response to the question was that the servicemember may not opt out in protest of the change in policy.

(34.) U.S. Department of Defense, Report of the Comprehensive Review of the Issues Associated with the Repeal of "Don't Ask, Don't Tell, "(Washington, DC: Department of Defense, 30 November 2010), 3.

(35.) Although there are signs that this may be changing--a recent Military Times poll showed fewer military members self-identifying as Republican, and more as independents, but no increase in Democratic affiliation. See Brendan McGarry, "Survey: Troops Shift Political Parties," Navy Times, April 11, 2010, http://www.navytimes.com/news/2010/04/military-poll_advance_041110w/ (accessed August 8, 2010). The same survey also shows increasing pessimism about the war in Afghanistan.

(36.) Data used to construct this chart were obtained from the following sources: military suicide rates were obtained from the RAND report through 2008, and supplemented with the 2009 rate from the Army HP/RR/SP report; the opinion data for Afghanistan were obtained from a Gallup poll question "Thinking now about U.S. military action in Afghanistan that began in October 2001, do you think the United States made a mistake in sending military forces to Afghanistan, or not?" Readers should note that this question was apparently not asked each year, and so the results depicted on the graph for the years 2004-2007 represent the last available data. Interested readers can find the source we used from Jeffrey M. Jones, "Americans More Positive on Afghanistan After Bin Laden Death," Gallup, August 29, 2011, http://www.gallup.com/poll/147488/Americans- PositiveAfghanistan-Bin-Laden-Death.aspx (accessed September 1, 2011). The Iraq data were taken from a 2008 Pew summary of survey results asking whether the decision to use military force in Iraq was right or wrong, Pew Research Center for the People & the Press, "Public Attitudes Toward the War in Iraq: 2003-2008," March 19, 2008, http://pewresearch.org/pubs/770/iraq-war-five-year-anniversary (accessed September 1, 2011).

(37.) Incentives and waivers (waivers are temporary suspensions of disqualifying histories, such as criminal convictions or drug use) have been used to help meet enlistment needs in some services during particularly difficult periods over the last several years.

(38.) Elizabeth Samet, "War, guilt, and 'Thank you for your Service,'" Washington Monthly, August 2, 2011, http://www.washingtonmonthly.com/ten- miles-square/2011/08/war_guilt_and_ thank_you_for_yo031250.php (accessed August 25, 2011).

George Mastroianni and Wilbur Scott are professors in the Department of Behavioral Sciences & Leadership at the US Air Force Academy in Colorado Springs.
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Date:Jun 22, 2011
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