09/18/2013 11:06 am ET Updated Nov 18, 2013

Healing The Hidden Wounds of War: Treating The Combat Veteran With PTSD at Risk For Suicide

Warning: This post contains graphic information that may not be suitable for some readers.

More military personnel and combat veterans are dying by suicide than were killed in combat. Posttraumatic Stress Disorder is the condition most associated with suicide. Most military personnel and veterans with PTSD, however, are not at risk of suicide.

Persistent severe guilt over combat experiences is the major factor differentiating veterans with PTSD who had attempted suicide and those who were seriously preoccupied with suicide from those veterans who were neither. This first became a problem in the Vietnam War.
The chaotic nature of guerilla combat in Vietnam, the uncertainty about who was the enemy, the emphasis on body counts, and the Viet Cong's use of women, children, and the elderly as combatants all contributed to combat actions about which veterans felt severe guilt.
The Viet Cong for example, would strip American soldiers they had killed and hang their naked bodies from a tree with their genitals stuffed into their mouths. Such tactics, designed to frighten soldiers, tended to infuriate them and contributed to atrocities on both sides.

How the veteran experienced the combat events i.e., the meaning of the combat experience to the veteran, was the key factor in determining the nature of the guilt and the risk for suicidal behavior. "Meaning of combat" refers to the subjective, often unconscious perception of the traumatic event; it includes the affective state of the veteran before the event took place, when it took place, and the affects experienced subsequently. Recurrent nightmares are a cardinal symptom of PTSD. They are an invaluable tool in determining the meaning of the experience to the veteran and the veteran's risk of suicidal behavior.

Case Example: Throughout his combat tour Greg thought he would be killed in action. The thought was comforting to him because it would enable him to avoid having his friends, family, and fiancée discover that that the stress of combat had caused him to lose control of his anger and kill without reason in Vietnam. During the last two weeks of his tour, when he learned that he was not going to be assigned to any more combat missions, he tried to kill himself with an overdose of drugs.

He had been an artillery spotter in Vietnam. He was preoccupied with a memory of a friendly village that he and his sergeant had helped to destroy in a contest designed to see who could call in the best coordinates. Through his binoculars, Greg had watched with excitement as the shells landed. As the village was being destroyed he saw an old woman with betel nut stains on her teeth running in his direction. She was shaking her arms trying to get him to stop the shelling. As she ran toward him, she was killed by an artillery round.

After he returned to the United States, Greg was tormented by a painful recurring nightmare that expressed his intense guilt over the destruction of the village. In the dream he is captured by South Vietnamese villagers, strung on a pole like a pig carcass, and paraded around the village so that everyone can throw stones at him, hit him, spit on him, and curse him. The old woman with the betel nut-stained teeth is taunting him. The villagers hold him responsible for all the death and destruction in their village. He knows they are going to kill him.

Nightmares of most veterans with PTSD correspond closely with the combat experiences and the terror over being killed that they engender. Veterans with severe guilt over their combat experiences are likely to have punitive nightmares and are at highest risk for suicide.
Understanding the subjective, perceptive experience of combat to the veteran is a crucial step to success in treating these veterans. A core of trust between the veteran and the therapist needs to be established for this to take place. Even when that trust has been established, veterans may not be willing or able to reveal the combat experience that is most disturbing to them right away.

The veteran needs to forgive himself for the behavior that triggered his guilt that is being expressed in a self-punitive way. When the veteran feels relief at having shared the experience with a trusted therapist, the therapist is in a position to help - to give him 'permission' to forgive himself, to work with the therapist to resolve problems that have developed in the course of the illness, and to go on with his life. Guilt is a healthy human emotion that can be harmful when it is self-punitive, but it can be a powerful force for changing the direction of one's life.

Although we see many veterans with PTSD of the wars in Iraq and Afghanistan similar to the Vietnam veterans, the picture is complicated. The multiple tours of combat increase the exposure to combat stress and add significant stress to family and personal relationships. Casualties in the war in Iraq were largely due to Improvised Explosive Devices (IEDs), which were responsible for the number of Traumatic Brain Injuries (TBI's) that have resulted from that war. Veterans with TBI are also more vulnerable to suicide. Guilt over combat actions, however, is less likely to be an issue for those veterans with TBI. In often exhibiting aggressive emotional behavior that is out of control, however, they have much in common with the veterans with PTSD who are suicidal.

This post is part of a special Huffington Post series, "Invisible Casualties," in which we shine a spotlight on suicide-prevention efforts within the military. Every weekday in September, we'll feature a different blog post by someone who is either an expert in the field, who has been affected by a suicide, or who has contemplated suicide. To see all the posts in the series, as well as original reporting, audio and video, click here.

If you or someone you know would like to contribute to our series, send an email to

And please, if you or someone you know needs help, call the national crisis line for the military and veterans, 1-800-273-8255, or send a text to 838255.