Handbook of Military and Veteran Suicide Assessment,
Treatment, and Prevention, 1st Edition
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v
Contents
Acknowledgments vii 5. Combat Experience and the Acquired
About the Editors ix Capability for Suicide 53
Contributors xi Craig J. Bryan
Tracy A. Clemans
1. Introduction to Military Suicide 1 Ann Marie Hernandez
Elvin Sheykhani
Lori Holleran 6. Combat-Related Killing and the
Kasie Hummel Interpersonal-Psychological Theory
Bruce Bongar of Suicide 64
Lindsey L. Monteith
2. Why Suicide? 10 Shira Maguen
Victoria Kendrick
Lori Holleran 7. Suicide Risk Assessment with Combat
David Hart Veterans—Part I: Contextual Factors 79
Dana Lockwood Christopher G. AhnAllen
Tracy Vargo Abby Adler
Bruce Bongar Phillip M. Kleespies
3. Suicide and the American Military’s 8. Suicide Risk Assessment with Combat
Experience in Iraq and Afghanistan 23 Veterans—Part II: Assessment and
Joseph Tomlins Management 89
Whitney Bliss Phillip M. Kleespies
Larry James Abby Adler
Bruce Bongar Christopher G. AhnAllen
4. Suicide in the Army National 9. Driving Themselves to Death: Covert
Guard: Findings, Interpretations, and and Subintentioned Suicide among
Implications for Prevention 39 Veterans 103
James Griffith Glenn Sullivan
Phillip C. Kroke
Timothy B. Hostler
vi
vi Contents
10. Identifying MMPI-2 Risk Factors 16. The Problem of Suicide in the United
for Suicide 114 States Special Operations Forces 190
John J. Barreto Bruce Bongar
Roger L. Greene Kate Maslowski
Catherine Hausman
11. Ethical Issues in the Treatment of Suicidal Danielle Spangler
Military Personnel and Veterans 121 Tracy Vargo
W. Brad Johnson
Gerald P. Koocher 17. Managing Suicide in the Older
Veteran 201
12. Evidence-Based Treatments for Bavna B. Vyas
PTSD: Clinical Considerations for PTSD Lisa M. Brown
and Comorbid Suicidality 131 David Dosa
Afsoon Eftekhari Diane L. Elmore
Sara J. Landes
Katherine C. Bailey 18. Person-Centered Suicide Prevention
Hana J. Shin in Primary Care Settings 213
Josef I. Ruzek Paul R. Duberstein
Marsha Wittink
13. The Collaborative Assessment and Wilfred R. Pigeon
Management of Suicidality with Suicidal
Service Members 147 19. Caring Letters for Military Suicide
David A. Jobes Prevention 240
Blaire C. Schembari David D. Luxton
Keith W. Jennings
Index 255
14. Healing the Hidden Wounds of
War: Treating the Combat Veteran with
PTSD at Risk for Suicide 166
Herbert Hendin
15. Understanding Traumatic Brain Injury and
Suicide Through the Lens of Executive
Dysfunction 178
Beeta Y. Homaifar
Melodi Billera
Sean M. Barnes
Nazanin Bahraini
Lisa A. Brenner
vi
Acknowledgments
This book is dedicated to all of our active duty mili- to my summer research students, from whom I have
tary and veterans. I would also like to acknowledge learned much: Dave Shaw, Bobby Morris, Hope
the contributions of the graduate students in my Hackemeyer, Hannah Granger, Ethan Betts, Phillip
Clinical Crises and Emergencies Research group -in Kroke, Nicole Harding, Tim Hostler, and Rachel
particular the incredible hard work of our lead gradu- Kroner.
ate students for this book, Danielle Spangler and Glenn Sullivan
Catherine Hausman.
Bruce Bongar I would like to acknowledge and thank all the military
personnel and veterans we have lost along the way in
In sincere appreciation of my VMI departmental col- service to this great nation.
leagues who proudly wore their country’s uniform in Larry James
time of war: Thomas N. Meriwether, PhD, Colonel,
US Army, Vietnam, and Dave I. Cotting, PhD,
Captain, US Army, Operation Iraqi Freedom. And
vi
ix
About the Editors
Bruce Bongar, Ph.D., ABPP, FAPM, CPsychol, Medical Center in Salem, Virginia. Dr. Sullivan is
CSci, is the Calvin Distinguished Professor of an associate professor of psychology at the Virginia
Psychology at Palo Alto University, and served as Military Institute, where he received the Thomas
Consulting Professor of Psychiatry and Behavioral Jefferson Teaching Award, which is presented annu-
Sciences at Stanford University’s School of Medicine— ally to a faculty member “deemed especially talented
as well as Co-Chair and Director of Training for the at inspiring students in the development of their in-
PGSP-Stanford doctor of psychology program. For tellect and character.” In addition to his numerous
over three decades, Professor Bongar’s research and publications and presentations, Dr. Sullivan main-
published work has focused on the wide-ranging com- tains an active private practice in Lexington, Virginia.
plexities of therapeutic interventions with difficult His clinical specializations include psychological as-
patients in general, and on suicide and life-threaten- sessment, forensic evaluation, and the treatment of
ing behaviors in particular. Dr. Bongar received his combat veterans.
Ph.D. from the University of Southern California
and served his internship in clinical community psy- Larry C. James, Ph.D., ABPP, retired as a colo-
chology with the Los Angeles County Department of nel from the United States Army, and served as the
Mental Health. Professor Bongar has consulted and Chair, Department of Psychology at Walter Reed
published on the topic of suicide risk management Army Medical Center, and the Chair, Department of
and prevention among both active duty military per- Psychology at Tripler Army Medical Center. Colonel
sonnel and veteran populations (most recently on the James was awarded the Bronze Star and the Defense
issue of suicide among special operations personnel). Superior Service Medal. He is currently the President
& CEO of the Wright Behavioral Health Group,
Glenn Sullivan, Ph.D., earned his Ph.D. in clini- LLC and a professor at Wright State University.
cal psychology at the Pacific Graduate School of Previously he served as the Associate Vice President
Psychology, Palo Alto, California. He completed his for Military Affairs at Wright State University in
clinical internship at the San Francisco Veterans Dayton, Ohio. Prior to that assignment, he served
Affairs Medical Center and a postdoctoral residency in as the Dean, School of Professional Psychology,
postdeployment mental health at the Veterans Affairs Wright State University from 2008 to 2013. He
x
x About the Editors
received his Ph.D. in Counseling Psychology at the psychopharmacology and clinical health psychology.
University of Iowa and completed a Post- Doctoral He has lectured internationally on these topics, has
Fellowship in Behavioral Medicine at Tripler Army published six books (with several others in press),
Medical Center. Dr. James is a recognized expert in and has over 100 professional papers and conference
psychology, national security, defense issues, clinical presentations.
xi
Contributors
Abby Adler, Ph.D. John J. Barreto, Ph.D.
VA Boston Healthcare System Palo Alto University
Boston University School of Medicine
Harvard Medical School Melodi Billera, LCSW
University of Denver Graduate School of
Christopher G. AhnAllen, Ph.D. Social Work
VA Boston Healthcare System Rocky Mountain Mental Illness, Research,
Harvard Medical School Education, and Clinical Center (MIRECC)
Denver VA Medical Center
Nazanin Bahraini, Ph.D.
Rocky Mountain Mental Illness, Research, Whitney Bliss, M.S.
Education, and Clinical Center (MIRECC) Palo Alto University
VA Eastern Colorado Health Care System
VA Salt Lake City Health Care System Bruce Bongar, Ph.D., ABPP, FAPM, CPsychol, CSci
Palo Alto University
Katherine C. Bailey, Ph.D.
National Center for PTSD, Dissemination and Lisa A. Brenner, Ph.D.
Training Division University of Colorado Denver School of Medicine
VA Palo Alto Health Care System Rocky Mountain Mental Illness, Research,
Education, and Clinical Center (MIRECC)
Sean M. Barnes, Ph.D. VA Eastern Colorado Health Care System
Rocky Mountain Mental Illness, Research, VA Salt Lake City Health Care System
Education, and Clinical Center (MIRECC)
VA Eastern Colorado Health Care System Lisa M. Brown, Ph.D., ABPP
VA Salt Lake City Health Care System Palo Alto University
xi
xii Contributors
Craig J. Bryan, Psy.D., ABPP Beeta Y. Homaifar, Ph.D.
National Center for Veteran’s Studies Rocky Mountain Mental Illness, Research,
University of Utah Education, and Clinical Center (MIRECC)
VA Eastern Colorado Health Care System
Tracy A. Clemans, Psy.D. VA Salt Lake City Health Care System
National Center for Veteran’s Studies
University of Utah Timothy B. Hostler, B.S.
United States Air Force
David Dosa, M.D.
Providence VA Medical Center Kasie Hummel, M.A.
Brown University Palo Alto University
Paul R. Duberstein, Ph.D. Larry James, Ph.D., ABPP
University of Rochester School of Medicine Wright State University
and Dentistry
Rochester Health Care Decision Making Group Keith W. Jennings, Ph.D.
The Catholic University of America
Afsoon Eftekhari, Ph.D.
National Center for PTSD, Dissemination and David A. Jobes, Ph.D., ABPP
Training Division The Catholic University of America
VA Palo Alto Health Care System
W. Brad Johnson, Ph.D.
Diane L. Elmore, Ph.D., M.P.H. United States Naval Academy
UCLA–Duke University National Center for Child
Traumatic Stress Victoria Kendrick, M.S.
Palo Alto University
Roger L. Greene, Ph.D.
Palo Alto University Phillip M. Kleespies, Ph.D., ABPP
VA Boston Healthcare System
James Griffith, Ph.D. Boston University School of Medicine
National Center for Veterans Studies
University of Utah Gerald P. Koocher, Ph.D., ABPP
DePaul University
David Hart, M.S.
Palo Alto University Phillip C. Kroke, B.S.
United States Army
Catherine Hausman, B.A.
Palo Alto University Sara J. Landes, Ph.D.
National Center for PTSD, Dissemination and
Herbert Hendin, M.D. Training Division
Suicide Prevention Initiatives VA Palo Alto Health Care System
Ann Marie Hernandez, Ph.D. Dana Lockwood, M.S.
University of Texas Health Science Center at Palo Alto University
San Antonio
David D. Luxton, Ph.D.
Lori Holleran, M.S. University of Washington School of Medicine
Palo Alto University National Center for Telehealth & Technology
xi
Contributors xiii
Shira Maguen, Ph.D. Hana J. Shin, Ph.D.
San Francisco VA Medical Center National Center for PTSD, Dissemination and
University of California, San Francisco Training Division
VA Palo Alto Health Care System
Kate Maslowski, M.A.
Palo Alto University Danielle Spangler, M.A., M.S.
Palo Alto University
Lindsey L. Monteith, Ph.D.
Rocky Mountain Mental Illness Research Glenn Sullivan, Ph.D.
Education and Clinical Center Virginia Military Institute
and
University of Colorado School of Medicine Joseph Tomlins, Ph.D.
Palo Alto University
Wilfred R. Pigeon, Ph.D.
University of Rochester School of Medicine Tracy Vargo, M.S.
and Dentistry Palo Alto University
Canandaiguia VA Medical Center
Bavna B. Vyas, M.D.
Josef I. Ruzek, Ph.D. Bay Pines VA Healthcare System
National Center for PTSD, Dissemination
and Training Division Marsha Wittink, M.D, M.B.E.
VA Palo Alto Health Care System University of Rochester School of Medicine
and Dentistry
Blaire C. Schembari, M.A. Rochester Health Care Decision Making Group
The Catholic University of America
Elvin Sheykhani, M.S.
Palo Alto University
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HANDBOOK OF MILITARY AND VETERAN SUICIDE
xvi
1
Introduction to Military Suicide
Elvin Sheykhani
Lori Holleran
Kasie Hummel
Bruce Bongar
“The solider above all prays for peace, as the soldier must suffer and bear the deepest wounds
and scars of war.” (MacArthur, 1962, p. 3)
S U I C I D E S TAT I S T I C S jointly by the Department of Defense and the
Department of Veteran’s Affairs found that 90% of all
Each year in the United States more than 30,000 service members who completed suicide had been
people die by suicide. Over 20% of those decedents diagnosed with a mental health condition. Of those,
are believed to be veterans or current service mem- 50% to 75% are thought to have received inadequate
bers (Department of Veterans Affairs, 2012). On av- treatment (Department of Defense & Department of
erage, 22 American veterans die by suicide each day Veterans Affairs, 2013).
(Department of Veterans Affairs, 2012). In 2008, the
suicide rate among active duty personnel exceeded
that of the civilian population for the first time in P R E VA L E N C E O F M E N TA L H E A LT H
history. The largest increases in completed suicides C O N D I T I O N S I N O E F / O I F V E T E R A N S
from 2001 to 2010 within the armed forces were seen
in the U.S. Army and Marine Corps (Department There are currently over 1.6 million veterans of
of the Army, 2010). Due to the Army and Marine Operation Iraqi Freedom (OIF) and Operation
Corps’ roles in ground combat, it was postulated that Enduring Freedom (OEF). The majority of these
the extended wars in Afghanistan and Iraq may have individuals have assimilated back into civilian life
a disproportionate effect upon suicide rates within with few difficulties, but a sizable minority report
these two branches (Hoge, McGurk, Thomas, Cox, adjustment and deployment- related difficulties
Engel, & Castro, 2008). When comparing active (Department of Defense Task Force on the Prevention
duty and reserve components, active duty person- of Suicide by Members of the Armed Forces, 2010;
nel complete suicide at a disproportionate rate: 57% Schell & Marshall, 2008). A recent study conducted
of all suicide deaths within the U.S. Army involve of returning OEF and OIF veterans (n = 1965) found
active duty personnel although they make up less that 14% screened positive for difficulties associ-
than 49% of the overall force (Greene-Shortridge, ated with posttraumatic stress disorder (PTSD), 14%
Britt, & Castro, 2007; Rusch, Corrigan, Todd, & screened positive for major depressive disorder, and
Bodenhausen, 2010). A recent study conducted 19% reported probable traumatic brain injury (TBI)
1
2
2 Handbook of Military and Veteran Suicide
related to deployment injuries (Hosek, Kavanagh, & 40% who seek services regarding their condition,
Miller, 2008). It is estimated that over 300,000 OEF/ only half are thought to be provided with adequate
OIF veterans suffer from PTSD, and that 320,000 vet- and appropriate treatment (Balesco, 2007; Institute of
erans suffer from TBI. Roughly one-third of all return- Medicine, 2007). The Institute of Medicine reported
ing veterans report difficulties associated with at least that the proportion of veterans and active duty person-
one of these conditions, and 5% report symptoms of nel who receive “quality care” is expected to be even
both (Hosek et al., 2008; Schell & Marshall, 2008). smaller than that.
Of those reporting probable TBI, 57% report not OEF/OIF service members and veterans report
being evaluated by a physician regarding their symp- that the largest hurdle to receiving behavioral health
toms. Of service members experiencing difficulties treatment is often perceived stigma (Hoge et al., 2004;
with major depression disorder or PTSD, 53% report Hoge et al., 2008; Kim et al., 2010). In a study of active
seeking services from a physician or mental health duty personnel in the U.S. Army, Warner et al. (2011)
professional (Department of Veterans Affairs, 2012; found that 51% of the service members believed that
Hosek et al., 2008; Schell & Marshall, 2008). Of those seeking mental health treatment would negatively
who seek treatment, it is estimated that only half re- impact their careers. Concerns about appearing weak
ceive adequate treatment. These deficits in treatment have historically been a barrier to seeking and receiv-
are thought to be due to a multitude of factors known ing care within the military culture (Hoge et al. 2004;
as barriers to care (Schell & Marshall, 2008). Jones, 2002; Jones, 2006; Kim et al., 2010).
BA R R I E R S T O C A R E HISTORICAL CONTEXT OF
M I L I TA R Y S U I C I D E
Current research suggests that veterans seek mental
health services at a rate similar to that of civilians. War syndromes, which refers to symptoms experi-
Forty percent of veterans report feeling comfortable enced by servicemen during combat, have been doc-
seeking mental health services versus 41% of the umented for centuries but occurred without being
general population (Brown, Creel, Engel, Herrell, formally acknowledged by the military (Jones 2002;
& Hoge, 2011). Kim, Thomas, Wilke, Castro, and Jones, 2006; Soetekouw et al., 2000). Numerous
Hoge (2010) conducted a study in which they ex- plausible sources for this lack of military recognition
amined healthcare behaviors of 15,918 active duty exist, including the broad spectrum of symptoms ex-
and National Guard soldiers. Of these service mem- perienced by servicemen, the subjectivity related to
bers, 10,386 reported being deployed to either Iraq the diagnosis of these symptoms, cultural factors that
or Afghanistan. The study focused on healthcare may impact symptomatic conceptualization, and the
utilization and attitudes associated with perceived ambivalence demonstrated by the military toward
stigma, access to care, service use, and financial con- psychiatry in general (Jones, 2006; Soetekouw et al.,
straints. Kim and colleagues found that 28% of vet- 2000). Here we consider some of the war syndromes
erans thought that “it would be too embarrassing” to experienced during the 1900s and the military’s re-
seek mental health services, 40% reported fear that sponse to these occurrences.
those within their units would have less confidence
in their abilities, 45% reported fear of reprisals and
The First World War
consequences from leadership, and 44% feared that
they would be seen as weak. Twenty-eight percent While psychological distress associated with war has
of those sampled reported either having difficulty been documented throughout history, increased rec-
scheduling an appointment or not knowing the ap- ognition of these experiences began during World
propriate means of contacting a healthcare agency. War I. In the early stages of the fighting, war-related
Furthermore, 20% believed that the financial burden psychological distress, characterized by nervous ex-
to seek services was too great. haustion, sleep disturbance, and movement difficul-
Access to appropriate services remains an obstacle ties, was dubbed “shell shock” and was presumed
as reported throughout the armed services. Of the to have an organic etiology (e.g., microscopic brain
3
Introduction to Military Suicide 3
lesions caused by concussive shock; Jones, 2006; I (Pols & Oak, 2007). When servicemen experienced
Wessely, 2006). severe symptoms, they were regarded as mentally ill
More psychologically attuned physicians, such as and as such were to be repatriated according to policy
American psychiatrist Thomas Salmon, viewed these (Pols, 2011; Pols & Oak, 2007).
same symptoms as responses to combat stress and the In response to the shocking attrition of manpower
result of the mental conflict between self-preservation caused by psychogical injuries, new treatment ap-
and the demands of duty (Pols, 2011; Pols & Oak, proaches were implemented. Roy Grinker and John
2007). Nevertheless, other physicians and military Speigel treated soldiers on the front lines in align-
leaders persisted in characterizing these experiences ment with ideas first proposed by Salmon during
as either malingering or as indicators of weakness World War I (Pols & Oak, 2007). They injected sol-
(Jones, 2006; Wessely, 2006). Shell shock was often diers with sodium pentothal, inducing a twilight sleep
viewed as an attempt to escape military duty (Jones, within which the soldiers were encouraged to re-
2006; Wessely, 2006). At best, it was presumed that experience and process their trauma in a supportive
only the psychologically weakest and most “unfit” environment (Pols, 2011; Pols & Oak, 2007). While
men were disposed to “crack” under the pressure of Grinker and Speigel reported a success rate greater
battle. than 70%, military authorities were disappointed that
fewer than 2% of the treated soldiers ever returned to
combat (Pols, 2011).
The Second World War
Additionally, American psychiatrist Fredrick
The belief that weakness in an individual’s morals or Hanson delivered a treatment focused on addressing
constitution contributed to the risk of psychological fatigue (Pols, 2011). Soldiers suffering from battle ex-
disability in war carried into World War II (Jones, haustion would receive “a sedative, warm food, and
2006; Pols, 2011; Wessely, 2006). Roy Halloran, the blankets, and … be allowed to sleep” (Pols, 2011,
chief of psychiatry of the U.S. Army Medical Corps. p. 317). Psychiatrist Herbert Spiegel considered the
held the belief that battle revealed one’s true self, and impact of group cohesion on soldier morale (Pols
only those with compromised mental health suffered & Oak, 2007). This research informed the work of
symptoms during war (Pols, 2011). The United States social scientist Samuel Stouffer and his team, which
attempted to avoid sending men into World War II confirmed that soldier morale was significantly re-
who would not be able to tolerate the intensity of war lated to aspects of the relationships between sol-
by implementing psychiatric screening for enlistees diers, including emotional support, as well as to the
(Eagan Chamberlin, 2012). This strategy was sup- relationships between soldiers and their respective
ported by the American Psychiatric Association and commanders (Eagan Chamberlin, 2012; Pols, 2011;
served as a focus for its annual meetings between 1940 Pols & Oak, 2007). Research during World War II
and 1942 (Pols, 2011). Based on this approach, nearly contributed to the understanding of psychological
2.5 million men, or 12% of the men examined, were responses to war by examining the relationship be-
rejected from enlisting due to emotional or mental tween physical and psychological symptoms and by
defects (Pols, 2011; Pols & Oak, 2007). However, the demonstrating a positive relationship between these
United States’ effort to identify men who were imper- two factors. Additionally, those suffering from psy-
vious to psychological illness was unsuccessful, with chological difficulties stemming from their service in
psychological symptoms presenting in more than a World War II were asked to consider the source of
third of wounded soldiers in some areas of combat their symptoms, with 41% indicating their symptoms
(Pols, 2011). arose from psychological stress related to their mili-
Soldiers continued to experience psychological tary service (Jones & Wessely, 2005). The research
and physical symptoms (including fatigue, memory conducted during this period contributed to psycho-
and concentration issues, somatic pains, and sleep logical understanding in two significant ways. First,
disturbances), and these were eventually recognized it shifted “the attention from problems of the abnor-
as the result of “battle exhaustion” or “combat neu- mal mind in normal times to problems of the normal
rosis” (Jones, 2006). During the Second World War, mind in abnormal times” (Farrell & Appel, 1944,
the prevalence rate for combat-related psychological p. 12). Second, the emotional bonds between sol-
injuries was more than double the rate in World War diers and the presence of group cohesion was found
