And the Armies That Remained Suffer'd: Veterans, Moral Injury and Suicide

Think now of young men or women home from Iraq or Afghanistan, Somalia or Panama, Vietnam or Korea, the woods of Europe or the islands of the Pacific, what they have done cannot be undone, all the words of assurance that their actions were not murder cannot be justified, and nothing can clean the haunting blood from their hands. (Photo: U.S. Marine Corps/Lance Cpl. Robert Reeves)

And the Armies That Remained Suffer'd: Veterans, Moral Injury and Suicide

The only way to prevent veterans from killing themselves is to prevent them from going to war.

I was very pleased to see the New YorkTimes editorial on November 1, 2019, Suicide Has Been Deadlier than Combat for the Military. As a combat veteran myself and someone who has struggled with suicidality since the Iraq war I am grateful for such public attention to the issue of veteran suicides, particularly as I know many who have been lost to it. However, the Times editorial board made a serious error when it stated "Military officials note that the suicide rates for service members and veterans are comparable to the general population after adjusting for the military's demographics, predominantly young and male." By incorrectly stating veteran suicide rates* are comparable to civilian suicide rates the Times makes the consequences of war seem tragic yet statistically insignificant. The reality is that deaths by suicide often kill veterans at a level greater than combat, while the primary reason for these deaths lie in the immoral and ghastly nature of war itself.

To the Times' discredit annual suicide data provided by the Veterans Administration (VA) since 2012 clearly notes that veteran suicide rates when compared with the civilian population are adjusted for age and sex. In the 2019 National Veteran Suicide Prevention Annual Report on pages 10 and 11 the VA reports that adjusted for age and sex the suicide rate for the veteran population is 1.5 times that of the civilian population; military veterans make up 8% of the US adult population, but account for 13.5% of the adult suicides in the US (page 5).

VA data shows among veterans that had deployed to Iraq and Afghanistan, those in the youngest cohort, i.e. those most likely to have seen combat, had suicide rates, again adjusted for age and sex, 4-10 times higher than their civilian peers.

As one notes the differences in populations of veterans, specifically, between veterans who have seen combat and those that have not seen combat, one sees a much higher likelihood of suicide among veterans with combat exposure. VA data shows among veterans that had deployed to Iraq and Afghanistan, those in the youngest cohort, i.e. those most likely to have seen combat, had suicide rates, again adjusted for age and sex, 4-10 times higher than their civilian peers. Studies outside the VA that focus on veterans who have seen combat, because not all veterans who deploy to a war zone are engaged in combat, confirm higher rates of suicide. In a 2015 New York Times story a Marine Corps infantry unit that was tracked after coming home from war saw suicide rates among its young men 4 times greater than other young male veterans and 14 times that of civilians. This increased risk of suicide for veterans who served during war holds true for all generations of veterans, including the Greatest Generation. A study in 2010 by The Bay Citizen and New America Media, as reported by Aaron Glantz, found the current suicide rate for WWII veterans to be 4 times higher than for their civilian peers, while VA data, released since 2015, show rates for WWII veterans well elevated above their civilian peers. A 2012 VA study found that Vietnam veterans with killing experiences had twice the odds of suicidal ideation than those with lower or no killing experiences, even after adjusting for post-traumatic stress disorder (PTSD), substance abuse and depression.

The VA's Veterans Crisis Line (VCL), one of many programs of support unavailable to previous generations of veterans, is a good measure of how intense the current struggle with veteran suicide is for the VA and caregivers. Since its opening in 2007 through the end of 2018, VCL responders "have answered more than 3.9 million calls, conducted more than 467,000 online chats and responded to more than 123,000 texts. Their efforts have resulted in the dispatch of emergency services nearly 119,000 times to Veterans in need." Putting that last statistic into context more than 30 times a day VCL responders call police, fire or EMS to intervene in a suicide situation, again a service that was not available prior to 2007. The VCL is just one part of a larger support system for suicidal veterans and there are undoubtedly many more than 30 needed emergency interventions for veterans each day, just note the oft mentioned number of 20 veteran suicides a day. That number of men and women who die by suicide each day, without end, brings the true costs of war: bodies buried, families and friends destroyed, resources expended, back to a nation that has always thought itself protected from war by its two protecting oceans. How tragic do Abraham Lincoln's words now sound when the thought of the consequences of the wars the US has brought to others return home to us:

Shall we expect some transatlantic military giant to step the ocean and crush us at a blow? Never! All the armies of Europe, Asia, and Africa combined, with all the treasure of the earth (our own excepted) in their military chest, with a Bonaparte for a commander, could not by force take a drink from the Ohio or make a track on the Blue Ridge in a trial of a thousand years. At what point then is the approach of danger to be expected? I answer. If it ever reach us it must spring up amongst us; it cannot come from abroad. If destruction be our lot we must ourselves be its author and finisher. As a nation of freemen we must live through all time or die by suicide.

This high rate of suicide in veterans leads to a total number of deaths of combat troops at home that surpasses the totals killed in war. In 2011, Glantz and The Bay Citizen "using public health records, reported that 1,000 California veterans under 35 died from 2005 to 2008--three times the number killed in Iraq and Afghanistan during the same period." The VA data tells us that close to two Afghan and Iraq veterans die by suicide each day on average, meaning the estimated 7,300 veterans who have killed themselves since just 2009, after coming home from Afghanistan and Iraq, are greater in number than the 7,012 service members killed in those wars since 2001. To visually understand this concept that the killing in war does not end when the soldiers come home, think of the Vietnam Veterans Memorial in Washington, DC, The Wall, with its 58,000 names. Now visualize The Wall but lengthen it by some 1,000-2,000 feet to include the 100,000 to 200,000 plus Vietnam veterans who are estimated to have been lost to suicide, while keeping space available to continue to add names for as long as Vietnam veterans survive, because the suicides will never stop. (Include the victims of Agent Orange, another example of how wars never end, and The Wall extends past the Washington Monument).

The mental, emotional and spiritual injuries that come with surviving war are not unique to the United States or the modern age. Disparate historical sources, such as Roman and Native American accounts, tell of the psychological and psychiatric wounds of war, and what was done for returning soldiers, while in both Homer and Shakespeare we find clear references to the lasting invisible wounds of war. Contemporary literature and newspapers of the post Civil War era chronicled the consequences of that war on the minds, emotions and health of Civil War veterans by documenting the prevalence of afflicted veterans in cities and towns all across the United States. Estimates are that hundreds of thousands of men died in the decades after the Civil War from suicide, alcoholism , drug overdoses and the effects of homelessness induced by what they had done and seen in the war. Walt Whitman's "When Lilacs Last in the Dooryard Bloom'd", primarily an elegy to Abraham Lincoln, pays tribute to all who suffered after the war was over on the battlefields, but not in minds or memories:

And I saw askant the armies,
I saw as in noiseless dreams hundreds of battle-flags,
Borne through the smoke of the battles and pierc'd with missiles I saw them,
And carried hither and yon through the smoke, and torn and bloody,
And at last but a few shreds left on the staffs, (and all in silence,)
And the staffs all splinter'd and broken.
I saw battle-corpses, myriads of them,
And the white skeletons of young men, I saw them,
I saw the debris and debris of all the slain soldiers of the war,
But I saw they were not as was thought,
They themselves were fully at rest, they suffer'd not,
The living remain'd and suffer'd, the mother suffer'd,
And the wife and the child and the musing comrade suffer'd,
And the armies that remain'd suffer'd.

Digging further into the data on veterans suicide provided by the VA one finds still another chilling statistic. It is difficult to truly ascertain an exact ratio of suicide attempts to death by suicide. Among US adults the CDC and other sources report that there are roughly 25-30 attempts for each death. Looking at information from the VA it appears that this ratio is much lower, perhaps in the single digits, perhaps as low as 5 or 6 attempts for each death. The primary explanation for this seems to be that veterans are much more likely to use a firearm for suicide than civilians; it's not hard to understand how using a gun is a much more likely way to kill oneself than by other methods. Data shows the lethality of using a firearm for suicide is above 85%, while other methods of death by suicide have only a 5% success rate. This does not satisfy the question though as to why veterans have a stronger intention of killing themselves than civilians; why do veterans reach a place of distress and despair in their suicidality that initiates such a serious determination to end their lives?

Multiple answers have been offered to this question. Some suggest veterans struggle to reintegrate into society, while others believe the culture of the military dissuades veterans from asking for help. Other thoughts extend to the idea that because veterans are trained in violence they are more likely to turn to violence as a solution, while another line of thinking is that because a high number of veterans own guns the solution to their problems is in their immediate possession. There are studies that show of predispositions to suicide or the relationship between opiates and suicide. In all these suggested answers there are elements that are partiality true or complement a larger reason, but they are incomplete and are ultimately belied, because if these were the reasons for elevated veteran suicides then the entire veteran population should respond in a similar manner. However, as noted above, veterans who have been to war and who have seen combat have higher rates of suicide than veterans who did not go to war or experience combat.

The answer to this question of veteran suicide is simply there is a clear link between combat and suicide. This link has been confirmed over and over again in peer reviewed research by the VA and US universities. In a 2015 meta-analyis by the University of Utah National Center for Veteran Studies researchers found 21 of 22 previously conducted peer reviewed studies investigating the link between combat and suicide confirmed a clear relationship between the two.** Titled "Combat Exposure and Risk for Suicidal Thoughts and Behaviors Among Military Personnel and Veterans: A Systematic Review and Meta-Analysis", the researchers concluded: "The study found a 43 percent increased suicide risk when people were exposed to killing and atrocity compared to just 25 percent when looking at deployment [to a war zone] in general."

There are very real connections between PTSD and traumatic brain injury and suicide, both conditions often being the result of combat. Additionally, combat veterans experience high levels of depression, substance abuse and homelessness. However, the primary cause of suicidality in combat veterans I believe is not something biological, physical or psychiatric, but rather something that in recent times has come to be known as moral injury. Moral injury is a wounding of the soul and spirit caused when a person transgress against her or his values, beliefs, expectations, etc. Very often moral injury occurs when someone does something or fails to do something, eg. I shot and killed that lady or I failed to save my friend from dying because I saved myself. Moral injury can also occur when a person is betrayed by others or by an institution, such as when one is sent to a war based on lies or is raped by their fellow soldiers and then denied justice by their commanders.

An equivalent for moral injury is guilt, but such an equivalence is too simple, as the severity of moral injury transmits to not just a blackness of the soul and spirit, but also to a deconstruction of one's own self. In my own case it was as if the foundations of my life, my existence, were cut out from underneath me. This is what drove me to suicidality. My conversations with fellow veterans inflicted with moral injury attest to the same.

For decades the importance of moral injury, whether or not this exact term has been utilized, has been understood in literature examining suicide among veterans. As early as 1991 the VA identified the best predictor of suicide in Vietnam veterans as being "intensive combat related guilt". In the aforementioned meta-analysis of studies examining the relationship of combat and suicide by the University of Utah, multiple studies speak to the importance of "guilt, shame, regret, and negative self-perceptions" in the suicidal ideation of combat veterans.

Killing in war does not come natural to young men and women. They have to be conditioned to do so and the US government has spent tens of billions of dollars, if not more, perfecting the process of conditioning young men and women to kill.

Killing in war does not come natural to young men and women. They have to be conditioned to do so and the US government has spent tens of billions of dollars, if not more, perfecting the process of conditioning young men and women to kill. When a young man enters the Marine Corps to become a rifleman he will go through 13 weeks of recruit training. He will then go for six to eight weeks of additional weapons and tactics training. During all these months he will be conditioned to kill. When receiving an order he will not say "yes, sir" or "aye, sir" but will respond with the yell "Kill!" This will last for months of his life in an environment where the self is replaced with unquestioning group think in a training environment perfected over centuries to create disciplined and aggressive killers. After his initial training as a rifleman, this young man will report to his unit where he will spend the rest of his enlistment, approximately 3 1/2 years, doing only one thing: training to kill. All of this is necessary to ensure the Marine will engage and kill his enemy with certainty and without hesitation. It is a non-stop, academically and scientifically proven process unmatched within anything in the civilian world. Without such conditioning men and women will not pull the trigger, at least not as many of them as the generals want; studies of past wars showed the majority of soldiers did not fire their weapons in battle unless they were conditioned to do so.

Upon release from the military, upon returning from war, the conditioning to kill no longer serves a purpose outside of combat and the bubble of military life. Conditioning is not brain washing and like physical conditioning such mental, emotional and spiritual conditioning can and will atrophy. Faced with himself in society, allowed to view the world, life and humans as he once knew them a dissonance between what he was conditioned to in the Marine Corps and what he once knew of himself now exists. Values he was taught by his family, his teachers or coaches, his church, synagogue or mosque; things he learned from the books he read and the movies he watched; and the good person he always thought he was to be return, and that dissonance between what he did in war and what and who he believed himself to be results in moral injury.

Although there are many reasons people join the military, such as the economic draft, the majority of young men and women who join the US Armed Forces do so with the intention of helping others, they view themselves, rightly or wrongly, as being someone with a white hat on. This role of hero is further inculcated through military training, as well as through our society's near-deification of the military; witness the continued and unquestioning reverence of soldiers whether it be at sporting events, in movies, or on the political campaign trail. However, the experience of veterans at war is often that the people who were occupied and to whom the war was brought didn't view US soldiers as wearing white hats, but rather black ones. Here, again, a dissonance exists within a veteran's mind and soul, between what society and the military tells him and what he has truly experienced. The moral injury sets in and leads to a despair and distress to which, in the end, only suicide seems to provides relief.

I mentioned Shakespeare before and it is to him I often return when I speak of moral injury and death by suicide in veterans. Remember Lady MacBeth and her words in Act 5, Scene 1 of MacBeth:

Out, damned spot! Out, I say!--One, two. Why, then, 'tis time to do 't. Hell is murky!--Fie, my lord, fie! A soldier, and afeard? What need we fear who knows it, when none can call our power to account?--Yet who would have thought the old man to have had so much blood in him...

The thane of Fife had a wife. Where is she now?--What, will these hands ne'er be clean?--No more o' that, my lord, no more o' that. You mar all with this starting...

Here's the smell of the blood still. All the perfumes of Arabia will not sweeten this little hand. Oh, Oh, Oh!

Think now of young men or women home from Iraq or Afghanistan, Somalia or Panama, Vietnam or Korea, the woods of Europe or the islands of the Pacific, what they have done cannot be undone, all the words of assurance that their actions were not murder cannot be justified, and nothing can clean the haunting blood from their hands. That in essence is moral injury, the reason why warriors throughout history have killed themselves long after coming home from war. And that is why the only way to prevent veterans from killing themselves is to prevent them from going to war.


*With regards to active duty military suicides, active duty suicide rates are comparable to civilian rates of suicide, when adjusted for age and sex, however, it is important to note that prior to the post 9/11 years suicide rates were as little as half that of the civilian population among active duty service members (the Pentagon did not start tracking suicides until 1980 so data on previous wars in incomplete or non-existent for active duty forces).

**The study that did not confirm a link between suicide and combat was inconclusive due to methodology issues.

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