Back in March, Quaker House in Fayetteville, NC, the home of America's largest military base, Fort Bragg, hosted me to discuss my recovery from post traumatic stress disorder (PTSD) and moral injury.
During my talk I am not very clear about the correlation, and, yes, I would also say causation, between combat and suicide. However, there is a very clear link between combat veterans and suicide, a link that is obviously very dangerous to cherished American myths of war, with all too familiar, prevalent and false motifs of justice, honor and redemption. To illustrate the connection between war, violence and suicide, a connection that manifests in veterans through PTSD, depression, substance abuse, and moral injury, I have included, at the end of this essay, 15 fairly easy to find studies of the last few decades documenting the prevalence of suicide in combat veterans.
Among the below studies, and among the most recent, dealing with my fellow veterans of the Afghan and Iraq Wars, researchers at the National Center for Veterans Studies have found that veterans who were exposed to killing and atrocity had a 43 percent greater risk of suicide, while 70 percent of those Afghan and Iraq veterans who participated in heavy combat had attempted suicide. We spends millions of dollars and thousands of hours to physically, mentally and morally condition each young man and woman who volunteers to serve in the military to travel abroad and kill, but upon their return, in reality, effective and thorough programs to decondition our veterans, help them reenter and reintegrate into society, and regain emotional, moral and spiritual balance and health are nonexistent, while care for developed wounds, both physical and mental is underfunded.
What underlies my words in the video, and the studies below, is a very tangible, unrelenting and unforgivable sense of shame and guilt, that coupled with a brain professionally and artfully conditioned for war and violence, is causing many of America's combat veterans to seek relief, atonement and peace by ending their own lives.
The LA Times recently published an op-ed on moral injury. In her essay, the author does not enter what I will describe as the holy sanctuary of moral injury nor does she provide an explanation for how moral injury should be addressed and treated. Fear of crossing a forbidden threshold, of insulting the sacred idol of the American people, the soldier, limits her discussion of moral injury and ends with effusions of praise and gratitude, quite possibly the very thing that is most harming to veterans suffering from the guilt and shame of what they did, or did not do, in war.
In Sergeant Panyagua's case, in the LA Times story, he seems to suffer from issues of guilt, because of actions he may not have taken. Often issues like this can be addressed through PTSD treatment by reaffirming a sense of security and trust in oneself, something the sergeant's wife seems to be doing effectively (bless her, by the way, for her compassion and strength in her care for her husband).
However, what the author of the essay identifies, correctly, as moral injury at the essay's opening and in the essay's title, does not seem to be present in the sergeant's story. Sergeant Panyagua's story seems to be more PTSD related, i.e. the after effects of surviving a traumatic experience, rather than a thematic experience, i.e. I violated "thou shall not kill", my government lied to me, my Marines died for nothing, etc. Most of the moral injury I am familiar with has to do with betrayal, as the author describes; whether the veteran committed the betrayal to another person, to personal values, to an institution, etc, or was betrayed by another person, by faith, by an institution, etc, seems to not to matter in terms of how damaging and damning the moral injury can be.
What so many people struggle with having the courage to say when talking about moral injury, that holy sanctuary they are afraid to enter and violate, the sacred idol they are terrified to defame or reject, is the very same aspect of moral injury that is torturing veterans of our most recent wars, as it has for veterans of previous wars. Simply, what we did in Afghanistan and Iraq was wrong. Invading and occupying Iraq was wrong. Supporting a corrupt and illegitimate government in Afghanistan in order to protect their poppy fields was wrong. Killing children, women and innocent men, even if accidental, was wrong, particularly when our reasons for being in both those countries was founded on lies or we found ourselves doing nothing more than supporting one side against the other in a civil war. It is the denial of these very real truths within veterans that causes the moral injury. In my own life, I have found that only through accepting the wrongness of my actions, forgiving myself and then acting on that forgiveness, can relief be found from the guilt and shame of the moral injury from the things I did and did not do in war.
As we do everyday in the United States, telling veterans they are heroes, when they view themselves as villains, makes the matter worse. Should I go to jail for what I did in Iraq? There are times I believe I should, maybe then my guilt would be assuaged, my shame reduced. Should I be called a hero, endlessly thanked for my service, and then given free tickets to a baseball game? No. Somewhere in between castigation and lionization, somewhere people understand that I did things that violated the morals, ethics and values I was raised with and that we, the US, were, and are, the villains to many people in those countries, is the understanding and acceptance veterans suffering with moral injury require to heal in order to move forward in our lives with the same conviction, confidence and love we once possessed.
I am not sure if anyone I joined the Marines with joined with one singular purpose in mind. Lots of reasons were present, but among those reasons was a desire to be a good guy, a hero. As recruits and officer candidates we thought we were, and we wanted to be, the type of men our country tells us Marines are. Fight the bad guys, defend the weak, protect the innocent, do what is right... Well, when you realize that is not what occurred, those fundamental principles that define you are ripped away; the spine of your soul, of your existence, that which makes you, has been not just broken, but is gone. You are spiritual, ethical, moral, and existential jelly. Without such fundamentals, without such principles, your life is gone. Anger, rage, sorrow, grief, nightmares and regret are constant. Alienation and isolation become a survival mechanism. Substance abuse becomes your crutch and, when that fails to keep you upright, suicide becomes a very real choice.
As a nation we are mortally afraid to insult, afraid to judge, afraid to affirm the moral injury that inflicts veterans. We are afraid to say the wars were wrong, what we were doing there had no purpose, that young Soldiers, Sailors, Airmen and Marines died scared and barbarically thousands of miles from home without reason.
If we are serious as a nation in our platitudes and compassion for veterans and if we want to stop veterans from driving their cars into trees, overdosing on medications, hanging themselves in their backyards, bleeding out in their bathtubs, and putting the barrels of their pistols in their mouths, then we must adhere to our nationally self-professed and loudly proclaimed values of justice, honor and courage and speak honestly with our veterans. What it takes is someone to say to us, yes, you are right, you did wrong. Someone to offer us forgiveness and compassion and to say let's get you better and be the person you once believed you were.
Studies demonstrating a link between combat, suicide, PTSD and moral injury:
In 1991, a Veterans Affairs and National Institute of Health study found:
"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."
In 1997, a Duke University study on Vietnam Veterans found:
"These results suggest that combat veterans with PTSD exhibit greater interpersonal violence than combat veterans without PTSD"
Then, in 1998, Duke University reported:
"PTSD symptom severity, guilt and interpersonal violence rates were similar to previously reported studies that examined treatment seeking combat veterans with PTSD.".
In 2009, a VA and University of San Francisco study of Vietnam veterans found:
"Controlling for demographic variables and exposure to general combat experiences, the authors found that killing was associated with posttraumatic stress disorder symptoms, dissociation, functional impairment, and violent behaviors."
In 2010, UC San Francisco and San Francisco VA reported:
"The impact of reported direct and indirect killing on mental health symptoms in Iraq war veterans.
Military personnel returning from modern deployments are at risk of adverse mental health conditions and related psychosocial functioning related to killing in war. Mental health assessment and treatment should address reactions to killing to optimize readjustment following deployment."
A Florida State study in 2010:
"This theory proposes that three necessary factors are needed to complete suicide: feelings that one does not belong with other people, feelings that one is a burden on others or society, and an acquired capability to overcome the fear and pain associated with suicide...Findings suggest that although there are many important factors in military suicide, the acquired capability may be the most impacted by military experience because combat exposure and training may cause habituation to fear of painful experiences, including suicide."
A 2011 study by Catholic University:
"U.S. soldiers who likely killed enemy soldiers in combat reported elevated levels of PTSD symptoms."
In 2011, the University of Utah, funded by the Department of Defense, reported:
"Researchers with the National Center for Veterans' Studies at the University of Utah looked at survey results gathered in 2011 from 525 veterans....Ninety-eight percent had been deployed in the wars in Iraq or Afghanistan and 58 percent to 60 percent reported they had experienced combat... findings were startling: 46 percent of respondents indicated suicidal thinking at some point during their lifetime; 20 percent reported suicidal thoughts with a plan; 10.4 percent reported thinking of suicide very often; 7.7 percent reported a suicide attempt; and 3.8 percent reported a suicide attempt was either likely or very likely."
Following up the next year, the University of Utah found:
"For those in his study who saw heavy combat, the findings are stark: 93 percent qualified for a diagnosis of post traumatic stress disorder and nearly 70 percent had attempted suicide."
A 2011 study by UC San Francisco and San Francisco VA:
The Impact of Killing on Mental Health Symptoms in Gulf War Veterans - ResearchGate. Available from: http://www.researchgate.net/publication/232573899_The_Impact_of_Killing_on_Mental_Health_Symptoms_in_Gulf_War_Veterans [accessed Jul 7, 2015]
Also in 2011, UC San Francisco and San Francisco VA reported:
"Killing in combat, mental health symptoms, and suicidal ideation in Iraq war veterans.
These results provide preliminary evidence that suicidal thinking and the desire for self-harm are associated with different mental health predictors, and that the impact of killing on suicidal ideation may be important to consider in the evaluation and care of our newly returning veterans."
Also, in 2012, a NIH study reported:
"Veterans who had higher killing experiences had twice the odds of suicidal ideation, compared to those with lower or no killing experiences "
A 2013 study on multiple traumatic brain injuries, a signature injury of the war in Afghanistan and Iraq:
"Suicide risk is higher among military personnel with more lifetime TBIs, even after controlling for clinical symptom severity. Results suggest that multiple TBIs, which are common among military personnel, may contribute to increased risk for suicide."
This year, in 2015, the University of Utah reported:
"Researchers found a 43 percent increased suicide risk when people were exposed to killing and atrocity compared to just 25 percent when looking at deployment in general."
Interestingly, the lead author of this report had this to say regarding the confusion between deployment and combat by researchers:
"As he gathered all the studies he could find on the topic, the pattern began to emerge, and he realized that the mistake had been the assumption that deployment equaled exposure to killing and death."
A 2015 study by the VA and the National Institute of Mental Health found that those veterans with the highest risk of suicide were those suffering from sleep disorders, pain and traumatic brain injuries. While the study didn't make the connection, those three factors are well known, signature veteran issues stemming from combat.