He was remote and suspicious, and I could feel how depressed he was.
A heavy set Iraq veteran, he came with his wife, who stayed close at all times. But he was not emotionally responsive to her, or to anyone for that matter. On the third evening of the retreat, he chose to watch a film called the Gifts of Grief, one of several programs that were offered.
Two thirds of the way in, I saw him emerge from his deep freeze. First his eyes began to water, then a few tears ran down his cheeks. When the film ended, he got up. The color had returned to his face. His arm was around his wife. A few more tears trickled down. He made no effort to conceal or wipe them away. As I approached him, he began to talk about his losses during the war, how unbearable they had been, how he hadn't told anyone. There were more hugs with his wife, conversation, and, during the large group, he leaned over and gave her a kiss.
He began talking with his fellow vets. He was alive again. In a small group meeting he described how desperate he'd felt and revealed how he'd tried unsuccessfully to kill himself to end it. During the large closing circle he surprised everyone by speaking and expressing his gratitude to all gathered. It was visible that the depression had lifted, at least for the moment. He'd come back from the dead. Then he said something that stopped me: he looked forward to seeing everyone again next year, if he was still here.
This veteran was already in psychological treatment, and on all kinds of medications. After the retreat, a fellow spouse whom his wife had befriended contacted me and let me know that his house was being foreclosed on. It had brought him spiraling back down, and he'd become suicidal again. The support and resources he and his wife received from fellow vets and spouses they'd connected with at the retreat helped him make it through intact.
There are other examples of vets expressing suicidal feelings and even revealing attempts, past and planned, that they've never told anyone, sometimes even their therapist.
A new Department of Defense report brings into sharp focus just how elusive a solution to the continuing alarming rise in suicides among active duty service members is. In 2012, there have been 154 military suicides in 155 days, a rate of one per day, more than the number of combat deaths during the same period. And suicides have also eclipsed car crashes as the top "non-combat" cause of US troop deaths. It is truly alarming that these numbers do not include National Guard and Reservists and Veterans. Paul Rieckhoff, Executive Director of Iraq and Afghanistan Veterans of America, reports that 37 percent of the Iraq and Afghanistan veterans among their approximately 160,000 members know another veteran who has committed suicide.
But when at-risk veterans are in a safe environment with fellow vets they trust, and with whom they can stay connected -- that's what can begin to make a huge difference.
At the Coming Home Project, we call it the power of community. In the military, it goes by the name unit cohesion. In the research world, social support. Although not a panacea, it heals and prevents, strengthens and inoculates, all at the same time. Unit cohesion correlated, in one study, with lower suicide rates.
Feeling safe, understood, and accepted without judgment are pivotal elements of community. Another key is a sense of belonging. Dr. David Kahn, an authority on suicide prevention, wrote in 2008 about studies with students, "Connection and a feeling of social belonging is, I think, the most important initial step in preventing suicide," he said. "Once the person feels that sense of trust in belonging to the community, they may be more receptive to suggestions that they seek help, if they haven't sought it already." This was confirmed at every turn at Coming Home's recent student veterans' retreat near Yosemite.
Jackie Garrick, head of the newly established Defense Suicide Prevention Office at the Pentagon, expressed concern in an interview about the increase in the military suicide rate, "Experts are still struggling to understand suicidal behavior," she said. "What makes one person become suicidal and another not is truly an unknown." I admire her honesty; a good leader is honest. Not knowing is a good place to start. Here is what I've seen and learned:
- Even people in therapy and on medications commit suicide.
- Not every one of the couple thousand service members, veterans and their families and care providers who've attended Coming Home retreats want or need therapy. Those who do should receive the best care - no question.
- Big top-down programs and public relations campaigns, while useful, only go so far.
- Massive trickle-down train-the-trainer approaches, likewise, do not necessarily suffice to change a culture.
- Attention to practical needs of veterans - jobs, housing, education, health care - makes a huge difference, but likewise is not sufficient.
- Peer-based counseling programs are useful but still require the person to self-identify as having a problem. They are not what I am referring to in this blog as social support or peer support.
- Online support communities are critically important and useful but need to be complemented with in-person opportunities to stay connected. Some prefer online, others don't. In-person and virtual together are the wave of the future.
- Military culture is tough to change and we should be realistic about how much stigma reduction to expect. I think the transition home from the war zone and the transition out of the military are critical periods to intervene with community-building approaches.
- Active Duty Service Members and Guard and Reservists can benefit mightily from genuine community-building peer-support based programs facilitated by trained therapists, chaplains and other veterans and family members, outside of military settings.
- Stigma vanishes (perhaps temporarily) in these optimal settings, and vets become more open to follow-up services.
Although the need for psychological treatment will continue, and top notch psychological services must be made more accessible, I think the future of suicide prevention and resilience programs (as well as reintegration, transition assistance, and mental health programs) lies in integrative community-based public health approaches that are interdisciplinary, community-building and educational. These will be psychiatry-friendly but not based on compartmentalized, medical models of mental disorder and mental health. They will acknowledge the thirst for spirituality-friendly venues where the moral and spiritual injuries of war that I and others, including Shay, Tick and Dewey, have written about. These wounds are what keep veterans up at night, for decades, and contribute to despair and hopelessness so profound that they often lead to suicide. It takes a community to welcome, weather and help transform such unbearable experiences and feelings. To enable veterans to feel that they belong, they matter, are accepted, and understood.
These optimal settings, based in the community and working in concert with the military and the VA, will cultivate durable, ongoing social support opportunities for veterans and their families. Service members, veterans and their families benefit from such approaches. We should make them part and parcel of reintegration and mental health programming and provide the resources necessary for them to grow.