Update to last week’s post on suicide and combat guilt

 

I received a good number of emails, as well as a couple of comments asking for references on last week’s post. I’ll summarize my response here, as well as post an email I sent to the author of an essay in Task and Purpose, a military focused blog, on the relationship of PTSD and combat veterans. That letter, which was more than 600 words and documented, was not even acknowledged, let alone responded to or published…so it goes 😉

As I noted in last week’s post I am dealing with traumatic brain injury (TBI). I also have a diagnosed neuro-cognitive disorder. For the purposes of this blog and the work I try to take part in, this is causing tremendous problems. I suffer from constant headaches, migraines and fatigues, as well as difficulty with concentration, thought and cognitive tasks. Since I published that post last Tuesday, today is the first day,  the Tuesday before last, it’s now taken me more than ten days to have had the mental clarity, ability and energy to work on my computer, write and finish this post. I’ve had at least six migraines, lasting from four to sixteen hours, and the constant headaches and fog in my head have kept me just not off my computer, but away from reading books, essays and articles, as well as watching movies, documentaries and tv shows, walking my dogs and spending time with my partner. It should be noted that these cognitive and migraine problems can also be related to PTSD, depression, and alcohol abuse, but my doctors, both in NC and now here in DC, believe it to be rooted in brain injury. Most likely I believe this brain injury comes from the hundreds of explosive blasts I was exposed to during my time in the Marines, both in training and in Iraq, and as a government official in Iraq – live by the sword, die by sword. This type of brain injury may be similar to what football players and boxers experience later in life. I say all of this to explain why I have not responded sooner to requests for more information, as well as why I am not generally traveling, writing, commenting, appearing on media, etc these days.

However, back to the post from last week: When I speak of guilt, I am speaking of the guilt that comes from being ashamed of one’s actions, whether one engaged directly or indirectly in those actions, or whether one was trying to act morally as individual in otherwise immoral circumstances; eg. an individual takes part in the Iraq War, acts in a manner that an outsider would regard as moral, but because he/she has taken part in an event with ill aims and purposes he/she assumes a greater responsibility and role and feels as if he/she has transgressed his/her own morality. This form of guilt is known as moral injury and is becoming well understood to be one of the three signature invisible wounds of war alongside PTSD and TBI.

While different than PTSD and TBI, moral injury often co-exists and overlaps with either one or both. Often moral injury/guilt, PTSD and TBI reinforce and exacerbate one another and where one wound ends another may begin. However, it is important to remember that although the three wounds manifest symptoms in the same manner and are often closely linked, moral injury/guilt, PTSD and TBI are different from one another in their causes and treatment. Simply put PTSD is the body and mind’s reaction to a traumatic or series of traumatic events, TBI is actual damage done to the brain as the result of an external force, whether it be a physical blow or explosion, and moral injury/guilt is a psychological wound caused by the betrayal of an individual’s own values, ethics, morality etc. For further definitions please see here for PTSD, here for TBI and here moral injury/guilt.

With regards to guilt and moral injury, many people recognize that it can take the form of guilt that is widely known as survivor’s guilt. This is the guilt one feels from being left alive or unhurt when others were killed or injured. In veterans survivor’s guilt can be very pronounced as those that are killed or wounded are often friends or subordinates for whom the service member feels a parental like responsibility. I dealt with this in a very awful manner from a helicopter accident that I survived in 2006, but from which four others did not, including a man I consider a friend. In this case, my guilt was not because I solely survived and they died, but because I did not save them. This aspect, of not doing more to help or save others, is also seen often in veterans, as young men and women are recruited into the military and then conditioned to see themselves as heroes in the waiting.

There is another aspect of guilt and moral injury that comes with combat veterans and this is the guilt that comes from taking part in killing. Studies tell us the guilt that comes from this killing can come from either directly or indirectly taking part in the killing, e.g. you don’t have to have been the one who pulled the trigger, and that this guilt can come from not just the killing of civilians and innocents, but also from killing the “enemy”. This guilt over killing the enemy is particularly understandable if the veteran recognizes the enemy as human and as someone who is simply fighting occupation, ie. acting justly, such as the Afghans, Iraqis and Vietnamese fighting against occupation. In this enemy they recognize actions they would do themselves if the situation was reversed. For example, I used to say of the 153 Marines and Sailors I commanded in Iraq in 2006, that if they were young sunni males living in Anbar Province, 51 would be fighting us, 51 would be in Abu Ghraib and 51 would be dead. It is not a very long or difficult path for many veterans to reach this empathy for the enemy, particularly once they leave the bubble and cocoon of group-think that dominates military life and they are able to freely and independently examine both the micro and macro aspects of the war in which they took part.

In the video I shared last week, when I spoke of veterans killing themselves from guilt, I was referring to this guilt or moral injury: that of taking part in something criminal, unjust, and wrong and/or of having done something that violated spiritual, religious, professional or self-held values, principles, beliefs, etc. See the video I posted above for description of how the US Armed Forces mentally condition young men and women to see themselves as heroes and then what happens when they realize they are more a pawn or villain than a hero. For many this is the crux of moral injury and it is a soul crushing and existential crisis that I believe leads to a great many suicides.

In my case, my personal foundation, my very essence and being was ripped from me; to say my world was turned upside down is not just a minimalist description, but a trite one, as the experience, lasting years and managed now because of the great help of psychologists at the VA Medical Center in Durham, reached such depths as are only encountered in the most intense spiritual or awakened moments. Coupled with traumatic brain injury, depression, PTSD and alcohol abuse, it is easy to understand how with no ability to make amends and the constant hero worship of the American public this guilt could only be assuaged with thoughts of suicide. As my life crumbled and I believed in nothing, I was already an atheist, believing neither in the gods of Abraham or deism, despair and despondency became exaggerated and resounded in my head and soul with every little failure and misstep. Alcohol self medicated me for awhile, but the only escape from the sheer distress at the very base of my being was to end it.

Guilt driving someone to suicide should not be a striking idea, it is common in the literature and religion that we are first introduced to as children and teenagers: think of Judas in the Gospels or Lady Macbeth shouting: “Out, out damn spot!”. Guilt, however, has not been something men and women returning home from war have traditionally been screened for or asked about, more than likely I believe as any guilt associated and announced with the wars of the United States is politically and patriotically unacceptable (in that spirit RootsAction and myself received several angry and righteous emails denouncing the linking of suicide in veterans to feeling guilty about what they took part in during the war or killing the enemy).

As mentioned above, I will paste a letter I sent to the military blog Task and Purpose, but first I would like to list a number of references I use to support my conclusions that it is guilt that is the chief driver of suicides in combat veterans. Additionally, I have a pdf that contains links and abstracts to 25 separate studies that exam the relationship of guilt/moral injury, TBI, and PTSD to suicide in veterans. Please send me an email at matthew_hoh@riseup.net if you would like a pdf copy of that.

Data on veterans suicides can be found in the 2017 suicide data report published by the VA.

For information on suicide rates of veterans with PTSD compared to other mental health populations, please see Figure 3, page 9 in the report.

For information on suicide rates for veterans, broken out by age group and sex and compared to the US population, see Table 4, page 18

For information on suicide rate of Iraq and Afghan war veterans see Table 5, page 19 and Figure 22, page 33. By comparing these tables and utilizing the information available from the CDC in figure 2 of its suicide data on the general US population, you’ll see for example that the youngest male veterans of the Iraq and Afghan wars have suicide rates nearly 6 times that of other young men their age. By looking at other tables and figures in the suicide report and comparing them to the rate of civilian suicides you’ll note that veterans in the age groups where the United States was in major and lengthy wars (WWII, Korea, Vietnam, Iraq and Afghanistan) have significantly higher rates of suicide than non-veterans. During periods of time when the United States was not in these large wars veteran suicide rates are on par or below civilian suicide rates.

Of course, being in war doesn’t mean that a service member sees combat or takes part in the killing experience that may lead him/her to later take their own life. However, there have been a number of studies that have shown that veterans who have been in combat have a higher rate of suicide than veterans who have also deployed to war but not seen combat (and incidentally, despite common perception, Iraq and Afghan veterans have been more likely to be in combat than veterans of any previous war, see my letter below to Task and Purpose).

The linking of combat and suicide has also been reported through journalism, such as this NY Times story which tracked a battalion of infantry Marines after their return home and to civilian life after their time in Afghanistan. At the time of the reporting, this unit of approximately 1,000 men who had been engaged in heavy fighting in Helmand Province, had a suicide rate 14 times higher than their civilian male counter-parts. As I know Marines who were in this unit, nothing makes me suspect that the rate of suicide has lessened for these men.  Another news story detailed how WWII veterans kill themselves at 4 times the rate of non-veterans of the same age, which demolishes the myth that such a problem with mental health and suicidality didn’t exist for previous generations of war veterans or goes away with time and age. From the Washington Post linked in the previous sentence:

The reality was that of the 16 million Americans who served in the armed forces during World War II, fewer than half saw combat. Of those who did, more than 1 million were discharged for combat-related neuroses, according to military statistics. In the summer of 1945, Newsweek reported that “10,000 returning veterans per month . . . develop some kind of psychoneurotic disorder. Last year there were more than 300,000 of them — and with fewer than 3,000 American psychiatrists and only 30 VA neuropsychiatric hospitals to attend to their painful needs.”

One of those hospitals was the subject of John Huston’s 1946 documentary, “Let There Be Light,” which said that “20% of all battle casualties in the American Army during World War II were of a neuropsychiatric nature.” The film followed the treatment, mostly with talk therapy, drugs and hypnosis, of “men who tremble, men who cannot sleep, men with pains that are no less real because they are of a mental origin.” Huston’s movie was confiscated by the Army just minutes before its premiere in 1946 and was not allowed to be shown in public until 1981. The government rationale at the time was protecting the privacy of the soldiers depicted, though Huston maintained all had signed waivers..

and

“Most of the World War II men that I worked with came to me in their 70s or 80s, after retirement or the death of a spouse,” said Joan Cook, a professor of psychiatry at Yale and a PTSD researcher for Veterans Affairs. “Their symptoms seemed to be increasing, and those events seemed to act as a floodgate.”

For so many veterans, that was when they finally learned they were not crazy or weak. “Pretty much to a person, for them, learning about PTSD and understanding that people were researching it in World War II veterans was a real relief,” Schnurr said. “Many people felt isolated and crazy, and they thought it was just them. And they didn’t talk about it.”

For studies on the relationship of combat to suicide, please start with this meta-analysis of 22 studies on this topic done by the Center for Veterans Studies at the University of Utah in 2015. The conclusion was that there is a significant link between killing, combat and suicide:

“Across all suicide-related outcomes (i.e., suicide ideation, suicide attempt, and death by suicide), the relation of specific combat exposure with suicide-related out- comes was twice as large (r = .12) as the relation of general deployment across all suicide-related outcomes” and

“the difference between the relation of combat-specific experience and general deployment history with suicide- related outcomes was significant”.

The report goes on to say that being involved in combat increases the likelihood of suicide in veterans by 43%.

You can also watch a short video summarizing this report here.

The VA on its site dedicated to moral injury also includes a list of studies.

In the video from RootsAction I mention that as early as 1991 researchers had determined combat related guilt to be the most significant predictor of suicide in Vietnam veterans. That study can be found here. Its conclusion reads: “In this study, PTSD among Vietnam combat veterans emerged as a psychiatric disorder with considerable risk for suicide, and intensive combat-related guilt was found to be the most significant explanatory factor. These findings point to the need for greater clinical attention to the role of guilt in the evaluation and treatment of suicidal veterans with PTSD.”

Take note that the current checklist for screening veterans at the VA does not include specific questions about or references to guilt and a 2012 VA study noted:“Killing experiences are NOT routinely examined when assessing suicide risk. Our findings have important implications for conducting suicide risk assessments in veterans of war.” (emphasis mine)

As mentioned above I have links, citations and abstracts for 25 studies I have reviewed that are available online, primarily through NIH, that explore the connection of suicide, combat, guilt, PTSD and TBI. As it it 12 pages long I will not paste it here, but if you would like a PDF, please let me know by comment or by email (matthew_hoh@riseup.net).

As I noted in my original post last week, there is also a very real connection between TBI and suicides, and with so many Iraq and Afghan veterans living now with TBI many of the suicides that are occurring would likely be connected to TBI. More information on TBI and veterans is found in the letter below.

Please do not hesitate to contact me with any questions.

Peace to you.

Matt

Below is a letter I sent to the military blog Task and Purpose, which went unacknowledged, regarding many of the common misperceptions of PTSD and veterans.

  • From: Matthew Hoh
    Date: February 5, 2018 at 2:28:11 PM EST
    To: james….
    Subject: Your article on PTSD

    Dear James,

    Thank you for your recent article on PTSD and the effects of transition on veterans. I believe the broad outlines of the study and its conclusions are correct. It reminds me of what I heard said about American soldiers returning from WWI: “how are you going to keep them on the farm when they have seen Paris?” There are a few things that the study’s authors, however, did not take into account and that can lead to misunderstanding about veterans by the public, particular the effects of combat.
    First, the study’s authors do not differentiate between the veteran population as a whole, those who deployed, and those who saw combat. This is crucial for understanding the stresses and challenges veterans face and why they face them. For example,  a meta-study from the National Center for PTSD by Brett Litz and William Schlenger, examined 14 published PTSD studies of Afghan and Iraq war veterans, and found that troops who had seen combat had PTSD rates of 10-18% but for troops that had not seen combat the rate was only 1.5%. An important differentiation.
    The authors also do not make the correlation or connection to the symptoms that they identify in veterans due to transition stress to the same symptoms that occur in unemployed civilians. There is a vast body of literature on unemployment related symptoms that has come out of the Great Recession, particularly in men. These symptoms include depression, anger, listlessness/apathy, mood impairment, sexual dysfunction, relationship problems and other issues that are similar to the symptoms that veterans experience upon separating from the military.
    Secondly, the authors do not discuss the role of TBI in OIF/OEF veterans. Rates of TBI among all OIF/OEF era veterans range from 10-20% according to the VA. The Rand Corporation and the Congressional
    Research Service put the rate as high as 23%. So, more OIF/OEF veterans suffer from TBI than PTSD, and as you most likely know, TBI can have a latent development and is often under reported (as is PTSD).
    Among combat troops the rates of TBI are much higher. One study of over 1,000 Marines and Sailors that deployed to Afghanistan had a TBI rate of 57% prior to deployment and during that deployment nearly 20% of those deployed sustained a TBI. https://www.ncbi.nlm.nih.gov/m/pubmed/24337530/?i=4&from=/23129059/related
    Another study’s authors said this:
    “The soldiers in Iraq and Afghanistan are having a very unique experience both because they have very good body armor now and because of the way in which insurgents use a lot of explosives. The soldiers are exposed to a lot of explosions, so they get hit over and over again, but they’re protected from all but the worst cases of secondary and tertiary effects. Whereas had it been the Vietnam War, for example, they [the soldiers] would have been much more grievously injured and would have been evacuated.”
    And the study’s co-author said this:

    “Probably the only war that is comparable to the wars in Iraq and Afghanistan is World War I, the trench and artillery warfare. The term “shell shock” came from that war and that really refers to the effects of these post-concussive symptoms.

    In the group of veteran participants in this study, the average number of blast exposures that were severe enough to cause acute symptoms consistent with the diagnosis of mild traumatic brain injury was 20. It was more common to have been exposed to between 50 to 100 blasts than to have a single one.”

    That leads to my third point, which I think would make an excellent article for you. The notion as advanced terribly by Sebastian Junger that these wars have been safer is demonstrably false and there is no evidence to demonstrate such, rather OIF/OEF (not just combat arms but all veterans) have had higher exposure rates to combat, violence, death and injury than any previous generation of veterans. Looking at a broad range of studies and surveys we see that OIF and OEF veterans experience combat at rates of 50% or higher, again a higher rate than any previous generation of American veterans.
    I have pasted below summaries I have written from various studies on OIF/OEF combat exposure, please note that some of the studies, such as the last study I reference, include veterans who did not deploy, so the rate of combat exposure is much higher than stated for deployed veterans:

    Studies and surveys have shown that veterans from OIF and OEF have experienced greater or equal rates of combat/trauma exposure of veterans of other wars. For example, the 2010 National Veterans Survey reported that the overall veteran populatiohas experienced combat at a rate of 34%. However, among veterans who deployed to Afghanistan and Iraq 63% of veterans had combat exposure. For veterans who went to war zones prior to WWII the rate was 55.4%, for those who went to war zones during WWII it was 44.9%, in Korea it was 26%, in Vietnam it was 44% and in the Gulf War it was 41%. That information comes from a study done by Ryan Edwards of Queens College, City University of New York in 2014.

    Additional sources debunking Junger’s and others unsupported and undocumented notion that only 10% of American troops saw combat or experienced danger/trauma in Afghanistan and Iraq, include:

    a 2004 study by Walter Reed Army Institute of Research that found 77-87% of American troops discharged their weapons in Iraq and more than 90% reported coming under small arms fire 

    a 2009 study from the Rand Corporation, by the same authors from a Rand study that Junger cites in his book, reports that only 10-15% of Afghan and Iraq veterans report no combat trauma experienced at all during deployment and close to 75% report multiple exposures to combat trauma

    a 2011 study from the National Center for Veterans’ Studies at the University of Utah reported 58-60% of Afghan and Iraq veterans had experienced combat

    a 2014 study published by the British Journal of Psychiatry found that contrary to Junger’s claims on p87 of his book that British troops had half the rate of PTSD than the American troops that “were in combat with them”, both British and American troops that experienced comparable levels of combat exposure had comparable rates of PTSD. The authors of the 2004 Walter Reed report referenced above also shared this finding. In the 2014 study of the American veterans of Afghanistan and Iraq nearly 70% reported receiving small arms fire; 85% experienced artillery, rocket or mortar fire; 43% handled human remains; 62% experienced dead/injured US forces; 24% had a friend injured near them; 28% gave aid to the wounded; 42% experienced sniper fire; 50% cleared and searched buildings; 51% experienced hostile civilians; and 45% reported a threatening situation to which they could not respond

    a 2014 survey of studies by the Walter Reed Army Institute of Research and published in the Journal of Clinical Psychiatry found that among veterans and service-members the greatest predictors of PTSD were high combat exposure rates and sexual abuse as an adult, and not events that occurred prior to service in the military as is often alleged. This is confirmed by many other studies, including a study by the VA from 1991 that found the best predictor of suicide in Vietnam veterans was combat related guilt. 

    a 2016 study by Texas Tech University of student servicemembers and veterans found that 44% of those surveyed had experienced combat. This study included veterans and active duty/reserve service members, both those that deployed to Afghanistan and Iraq and those that did not.

    Suicide is another factor the authors do not address. According to the VA, among the youngest male veterans of OIF/OEF, ages 18-29, the suicide rate is almost 6x higher for them than for their civilian male peers. For veterans in their 30s it is 3-4x higher. Among combat units that have been tracked the suicide rate is as high as 14x that of their civilian peers. This high and exaggerated rate of suicide holds true for all generations of American veterans who served during a war era. WWII veterans have a rate 4x higher than their non veteran peers. The link between combat and suicide is undeniable and has been well documented (a meta-study by the National Center for Veterans Studies in 2015 found a significant and clear link between combat and suicide in 21 of 22 studies examined). For veterans who did not serve in a war era, the rate of suicide is comparable or less than the civilian peer population. Veteran suicide is very troubling and not something to be disregarded when talking about veterans issues, particularly mental health.

    https://www.mentalhealth.va.gov/docs/2016suicidedatareport.pdf

    https://mobile.nytimes.com/2015/09/20/us/marine-battalion-veterans-scarred-by-suicides-turn-to-one-another-for-help.amp.html

    https://psychcentral.com/news/2015/04/13/key-factors-predict-military-suicide-risk/83462.html

    https://www.google.com/amp/s/www.commondreams.org/news/2010/11/11/suicide-rates-soaring-among-wwii-vets%3famp

    One final note, and thank you for indulging this long correspondence, but the source in the study you write about, that cites less than a 10% PTSD rate in veterans comes from a survey of 700 Danish soldiers. The Danes faced very hard fighting in Helmand, at one point I believe they had the most casualties per capita of the nations in ISAF (they had one deployed battalion on infantry), but I think it is disingenuous and unwise of the study’s authors to use a study of Danish troops, to make a broad statement about American veterans.
    For your reference, I was a Marine combat engineer officer for ten years. I have PTSD, TBI and neuro-cognitive disorder diagnosis  from my time at war.
    Let me know if you’d like more information. Again, thank you for indulging this long email (I thought this a better format than leaving a comment), and please consider writing an article on the documented level of combat in OIF and OEF veterans to dispel the myth that only 10% see combat, that these wars were safe, OIF/OEF vets had it easy, etc.
    Peace brother,
    Matthew Hoh

 

 

 

7 thoughts on “Update to last week’s post on suicide and combat guilt

  1. Many thanks for this Matt.

    I will be terminating my program WORLD FOCUS.

    Too much time away from my other projects.

    If you would like to apply for this program let me know

    and I will recommend you to the managers of KPFK.

    Peace,

    Blase

    Blase Bonpane, Ph.D. Director, Office of the Americas

    Phone: (310) 450-1185 FAX: (310) 452-4841 E/Mail: ooa@igc.org http://www.officeoftheamericas.org

    >

    Like

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