As they engage in the reflection and soul searching that another high-profile suicide rightly demands, Americans pondering what can be done to lower the national suicide rate would do well to consider lessons from what might, at first glance, seem an unlikely source: the U.S. Army. Military suicides have been a major problem for more than a decade, and the military has developed ideas that, if applied to the general population, might help reduce the epidemic of suicides plaguing the United States.
In 2007, as President George W. Bush announced that he was dispatching an additional 30,000 troops to Iraq, newspapers across the country reported that for the first time, the suicide rate among active-duty soldiers had risen above the national average. For an institution that had spent the decades after Vietnam repairing its image and building a reputation as an organization that helped young Americans “be all that they can be,” this statistic prompted close study and a cultural reckoning.
At first glance, there seemed to be a simple explanation for the increase in suicides: Soldiers were returning from a prolonged, violent war traumatized by their experiences, and some of them took their own lives.
While logical, this explanation turned out to be oversimplified. When the Army’s Health Promotion, Risk Reduction and Suicide Prevention Task Force studied cases of suicide, it found that most soldiers who had taken their own lives had deployed only once to Iraq, or not at all, and that deployment-related mental-health troubles didn’t necessarily correlate with suicides.
Instead, the committee found that the pace of Army life, particularly during wartime, produced a hectic stream of trainings, deployments, job changes and relocations that placed soldiers under more stress than their civilian peers but that soldiers most often took their lives for the same reasons that civilians did: failed relationships; careers imperiled by legal trouble or injury; mounting debts; or unmanageable depression, anxiety or substance abuse.
As appears to have been true in Catlin’s case, each additional stressor compounded the sense that there was no escape. In its report, the task force described this as a maze: A stressor pushed someone into the maze, and compounding pressures led them deeper; some ended up at the center of the maze and could not escape.
Helping soldiers escape the maze required that the Army change not only its policies but also its culture. On the one hand, the Army sought to make behavioral health care more accessible, integrating it into primary care and placing providers in the units where soldiers worked every day. The Army also worked to rewrite regulations to ensure that soldiers’ careers would not be harmed if they sought mental-health treatment, to make it easier for the chaplains, substance abuse counselors, marriage and family therapists and others who worked with troubled soldiers to share information and provide high-quality care while maintaining patient privacy. Army leadership also worked to ensure that as soldiers changed units and posts, their records were effectively transferred and that care was continuous.
But the Army understood that better care would be meaningless without cultural changes. As in American culture as a whole, mental-health issues were often met with silence or derision inside the Army. In an environment where toughness and manliness were paramount attributes, mental-health problems were a sign of weakness and therefore something to shield from public view. This culture discouraged soldiers from seeking help.
In 2010, the task force issued a “Health Promotion, Risk Reduction, Suicide Prevention Handbook,” which argued that the frantic pace of the Iraq and Afghanistan wars had led leaders to value fighting skills over people skills, to the point that soldiers’ struggles — deteriorating relationships, substance use that was becoming abuse, maxed-out credit cards or a penchant for risky behavior — were not being noticed until too late.
Condemning what it called “the lost art of garrison leadership,” the Army determined that it needed to change its culture to cultivate leaders’ capacity to care for and mentor soldiers. “Now more than ever, our Soldiers need firm, fair and consistent leadership,” Gen. Peter Chiarelli, then-vice chief of staff, wrote in the report’s introductory letter, adding, “We must identify our Soldiers who are at-risk, mitigate their stress and, if necessary, personally intervene to assist them.”
This new understanding led the Army to embark on an aggressive and multifaceted effort to reduce the stigma surrounding mental health and to encourage and accept the practice of seeking help. Senior leaders such as Gens. Carter Ham and Mark Graham spoke about their own struggles with, and effective treatment for, mental-health issues or described the impact that suicide had had on their families. The Army also launched the Shoulder to Shoulder campaign, which sought to define seeking help and caring about another soldier’s mental health as appropriately manly soldier behaviors.
This effort included the new strategies laid out in the handbook — for example, deeming acceptable “modifying mission requirements, when feasible, to remove impediments that prevented Soldiers from participating in [wellness] programs and services,” encouraging leaders to “plan for and approach ‘stress windows’ systematically” so as to “take measures to mitigate potential stressors before they occur,” and encouraging the larger Army to “improve Soldier assessments to better identify those who may be at risk to allow early treatment and maximize the potential for full recovery.”
The Army’s suicide prevention efforts have not been a panacea. It took until 2012 to arrest the rising suicide rate, which remains unacceptably high. This leveling off is perhaps attributable to reduced stress on soldiers as the Iraq and Afghanistan wars wound down. But it also results from an increasing recognition on the part of soldiers at every level that mental health deserves attention and that troops need to be taught to care for themselves and others.
The Army has been far from perfect, of course — some leaders still dismiss mental-health trouble as a weakness, many soldiers remain unwilling to seek help, and encouragements to become more resilient can sometimes replace encouragements to seek help. Nonetheless, the Army’s efforts hold important lessons as we confront a rising suicide rate in the civilian sector.
Insurance companies and providers can seek policy changes that will make care more affordable, accessible and effective while maintaining privacy. Employers can do more to foster wellness and encourage help-seeking — including reducing pressures and demands. Everyone can follow the Army’s lessons regarding stigma reduction by talking openly about our challenges and how we benefited from treatment. And perhaps most important, we can ask how the frenetic pace of our daily lives has turned us away from being compassionate friends, family members, colleagues and mentors, and how we, too, might cultivate the lost skills that might help us lead someone out of the maze.
To grapple with our mental-health epidemic in America, which encompasses not just suicide, but also substance abuse, we must change our culture to encourage treatment, connections and a less stressful way of life.