Author and former marine Anthony Swofford gets to the bottom of an epidemic.
I was sitting next to Melissa, a call responder at the VA Crisis Hotline in Canandaigua, N.Y., when she looked at me and whispered, 'He just said he thinks he should walk out into traffic on Interstate 5 and end it all, that life is not worth living.'
On the other end of the line was a young man who'd been out of the Marines for four months. He was unemployed and broke and hadn't eaten all day. He'd driven his father's truck from the middle of the country to Southern California to be near Marine Corps Base Camp Pendleton and his buddies. But most of them were either overseas again or separated from the Marine Corps. He'd taken to drinking and occasionally smoking pot. After four years of military service and two combat tours in Iraq, he couldn't find a steady job. Now he sat at a rest area near Camp Pendleton, contemplating suicide.
Melissa had about her the endearing charm of a kindergarten teacher coupled with the steely nerves of a nose tackle and the all-American looks of a blonde-haired, blue-eyed beauty queen.
She smiled and nodded at her computer screen as she spoke to the young Marine. Her voice radiated goodness. Her screen indicated that he'd called twice earlier in the afternoon and had had brief conversations with two other responders.
"You'll learn from reaching out and making this call. It's a brave call."
She IM'd a colleague on the crisis-hotline floor, a health technician, and told her that she thought this kid was in need of a rescue.
The tech had no idea where Interstate 5 and Camp Pendleton were. I told her Southern California, North County San Diego. I'd flown to Rochester from San Diego that morning.
"You have a long time to figure this out. You can't figure it out in four months," Melissa said to the young man.
The technician got to work initiating the rescue with a 911 center in California. I thought about calling my wife in San Diego and telling her to go find the kid.
About 18 veterans kill themselves each day. Thousands from the current wars have already done so. In fact, the number of U.S. soldiers who have died by their own hand is now estimated to be greater than the number (6,460) who have died in combat in Afghanistan and Iraq. Eleven years of war in two operating theaters have taken a severe toll on America's military. An estimated 2.3 million Americans have served in Iraq or Afghanistan, and 800,000 of those service members have been deployed multiple times.
Pull up your local newspaper online and search "veteran suicide," and you're likely to come up with at least one link to a story. Based on data from the National Violent Death Reporting System, Mark Kaplan of Portland State University asserts that male veterans have a twofold increase in death by suicide over their civilian counterparts and that female veterans are three times as likely to kill themselves as their civilian counterparts. Veterans are 60 percent more likely to use a firearm in an attempted suicide than civilians, and firearms are the most effective way of taking one's own life.
So why are these young veterans killing themselves at such high rates?
In 1992 I was in danger of becoming such a statistic, just released from the Marines after four years of service and combat action in Kuwait during the Gulf War. I know the suicidal temptation that can accompany the isolation and loneliness veterans experience after the high of combat and the brotherhood of arms fade in the rearview mirror. I skulked around college campuses with a watch cap pulled tight to my ears, looking for a threat, knowing that when it appeared, I could extinguish it. I took a swing-shift warehouse job that required very little human interaction. I became a writer, which also required very little human interaction. It took nearly two decades to find my way free of the morass.
While there is no one reason for any person's suicide, the Department of Veterans Affairs and the military shy away from placing blame directly on the psychological and social costs of killing during combat.
No one within the VA will use the word "epidemic" when talking about suicide, but it can't be denied that the rate of suicide among current-war veterans is drawing attention and concern. Before these current wars, the rigorous training and intense discipline of military service were considered a defense against suicide.
Even Peter Gutierrez of the Denver VA, codirector of the Military Suicide Research Consortium, concedes this fact. "The stresses of multiple deployments and the amount of time that troops have to reset between deployment probably is more a unique factor," Gutierrez says. "It's not necessarily increasing risk of suicide, but it is certainly having an impact ... Perhaps the protective influence of training is no longer enough. But we don't have the data to back that up."
Researchers and practitioners are unwilling to overtly connect the trauma of combat with suicidal tendencies. But why? They assert there is no evidence to support this link. However, when you teach a kid how to kill and send him to combat a few times, he will come home mightily changed, with a dependence on weaponry and a tendency to treat violence as a perfectly acceptable way of solving a problem.
What we do know is that something has clearly changed. "Up until the last 10 years, being in the military, including serving in combat, seemed to be a protective factor against suicide," says Gutierrez. "[But now] in certain cohorts of active-duty personnel, the suicide rates are actually higher than in their civilian counterparts."
Despite the reluctance of many within the military medical establishment to discuss the subject, I spoke with two doctors who have extensive experience working with Vietnam veterans and were willing to offer straight answers.
Dr. Jonathan Shay, who has written books about soldiers at war and coming home, was the central proponent of the "unit cohesion" model of deployment back in the Vietnam era. He recognized isolation and despair in the veterans he treated and linked this directly to the way they had been deployed. During Vietnam, new troops filled the ranks of combat units when others died or rotated home. This lack of unit cohesion corrupted trust, and trust is one of the main protective factors against mental injury in combat. Because of Shay's advocacy, unit cohesion is a significant consideration in arranging standard deployments these days.
But today, Shay says, soldiers face a different set of challenges flowing from multiple deployments. When they are sent on repeated combat tours, soldiers run a much higher risk of suffering what Shay describes as a "moral injury." A moral injury occurs when a soldier's concepts of trust and right and wrong do not survive the heat of battle. This breakdown can result from a soldier's real or perceived failure under fireâ€”or from the failure of a commander to properly lead. As a result of this moral injury, the soldier brings home the psychological habits he developed for coping with the intense stresses of combat. In other words, he returns to civilian life hypervigilant and trusting no oneâ€”a difficult way to live.
Another doctor who has examined the state of veterans today is Dr. David Spiegel of the Stanford Center on Stress and Health, who believes that the country is so checked out from the realities of the war on the ground, with assistance from the government, that "the troops come home with questions, and they don't feel understood." He points to the policy during the Bush administration that forbade the publication of images of returning soldier coffins at Dover Air Force Base. As a society we didn't have to turn away from those images, since they were never even presented to us.
Spiegel notes that during Vietnam, the war became a central part of American culture. Whether you'd fought there, whether you were for or against the war, you cared about it deeply. It might have been better for the psyche of a soldier to be the object of protest than to be simply ignored. As Spiegel says, "Now we pretend the vets don't even exist."
Spiegel is unwilling to dismiss the violence of warfare as a contributing factor in suicide. "When the line of violence has been crossed once, it's easier to cross again. Homicide and suicide differ greatly, but they are both [forms of] killing."
Many veterans and their families have taken matters into their own hands rather than rely on the VA. Dan West admits that he had been "avoiding the mental-health question for many years."
West served as the public-affairs noncommissioned officer with the Army's 214th Fires Brigade in Al Kut, Iraq, in 2009. Within a week of being deployed, his public-affairs unit was on a medical mission to a nearby villageâ€”the Hearts and Minds aspect of American counterinsurgency operations. He'd been snapping photos for a few minutes and watching the docs do their good deeds when a woman appeared holding a 2-year-old baby boy with burns covering nearly his entire body.
He had to step away from the scene and collect himself. But it didn't take long for him to habituate to the gore of the battlefield. A week later he snapped a photo of an old man carrying a severely malnourished boy of about 12. He took the photo and moved on quickly to the next task. A copy of that photo hangs on West's refrigerator today to remind him of what he saw while at war.
"Our post-deployment mental-health screening took place with the entire unit sitting down with the chaplain, and the chaplain asking if we had any problems, and the commanding officer saying that no one had any problems," West says.
When West returned home to Missoula, Mont., he noticed that the world just didn't feel the same as before he'd deployed. "I still reacted to situations like I was in combat," says West. So the military offered to send him to three post-deployment reintegration Yellow Ribbon weekends in Las Vegas. "I called that death by PowerPoint," he says. "I don't want to denigrate the Yellow Ribbon system. But I lived a thousand miles away from my command unit. They didn't direct me to services in Missoula."
A single, never-married soldier without children, he was forced to sit through sessions on marriage counseling and other family-health matters.
West faced the same perplexing experience that greets many Reserve and National Guard members when their units disperse after deployment: when a reservist returns from combat, within weeks he's sitting back in the civilian office chair he vacated for the battlefield.
West had been back in the civilian world for three years when he finally found a group of local veterans through a group called XSports4Vets that helped him to realize he had mental-health problems. The groupâ€”founded by Jesse Scollin, an Iraq War veteran, and Janna Sherrill, an occupational therapistâ€”gets combat veterans together for high-adrenaline extreme sports that foster camaraderie and esprit de corps that are unavailable in the daily grind of job, school, and family. "Extreme sports force veterans to achieve levels of concentration that daily civilian life does not require," Sherrill explains. "By improving their ability to pay attention, the sports also help veterans engage in meaningful interactions."
West says that his involvement with XSports4Vets helped save his life.
The Military Wakes Up
The VA has finally begun to screen for posttraumatic stress disorder and suicidal tendencies, even if a guy walks into the ER with nothing more than a broken thumb. Caregivers from social workers to physicians are supposed to be asking the right questions and listening for the answers that indicate significant psychological problems. If a veteran is drinking excessively or using drugs, not sleeping, out of a job, and isolating himself, those are pretty good indicators that he's in trouble. Matt Kuntz, a mental-health advocate in Helena, considers the shame attached to mental illness for soldiers and veterans the major hurdle to individuals seeking care. As Kuntz, a West Point graduate, puts it, "In the infantry there's a stigma against blisters. You think a combat vet is going to reach out for help? The soldiers need to be aggressively screened. Repeatedly."
Groups like Disabled American Veterans and Veterans for Common Sense are constantly pushing (sometimes via lawsuits) the VA to improve and adapt its services for a plugged-in and media-savvy veteran population. Finding troubled veterans through outreach is an essential part of the VA's task. And there seems always to be room for improvement.
But the question remains: once veterans are in the system, do they get any better? A multipronged approach seems necessary. Dr. Jessie Lu, a current psychiatry resident at the UCLA Medical Center who did rotations at the West Los Angeles VA hospital in its PTSD clinic, is a proponent of prolonged-exposure therapy. In this form of treatment, a patient recounts into a tape recorder the most intense traumatic event he suffered. He's asked to talk about how the day started and to use all of his five senses. The therapist might ask a question along the way to guide the patient. The idea is that the patient walks out of the room having narrated the trauma with as much clarity and intensity as possible. The patient is then asked to listen to a recording of the session every day for a week. This is repeated for three months.
Lu admits that it is not an easy therapy to undertake, because its point is to force the patient to confront what stresses him most in daily life. "It's effective for the people who can stick with it," she says.
I asked Lu why some soldiers return from combat damaged and others don't. "Oh, God," she said. "If I knew the answer to that ..." And she trailed off. "When you sit down with a patient for the first time and give him a PTSD diagnosis, it's like sitting with a patient you've just diagnosed with schizophrenia. Nothing will ever be the same. They went off to do something idealistic for their country, and they came back shattered."
Ninety minutes had passed, and Melissa was still on the phone with the young Marine who was thinking about killing himself on Interstate 5. The rush-hour traffic was heavy, and the highway patrol had gone to the wrong rest area. Now I seriously considered calling my wife and telling her to go find the Marine. Take him for a walk along the beach, I thought.
"Selling hope" is how Stacey, another responder and an Air Force veteran, describes the work they do. One hundred sixty-four thousand calls received last year; 6,760 rescues; 2,300 calls from active-duty personnel; 12,000 calls from friends and family of veterans.
Finally, Melissa looks up at the health technician with a smile and a thumbs-up, saying into her headset, "Oh great. OK? It's MPs from Camp Pendleton? That's OK. Put me on with them."
"Thank you for showing up," she says to the MP. "This young Marine needs some help."
Anthony Swofford is the author of Jarhead and Exit A.