As America commemorates Memorial Day honoring those who gave their lives for their country, let us recognize the tragedy of military suicides among active duty soldiers and veterans.

In 2014, 273 U.S. servicemen died by suicide compared to 58 killed in action in Afghanistan (55) and Iraq (3). And 7,403 vets took their own lives in 2014—18 percent of all adult suicides in the United States—according to the Veteran’s Administration. A factor receiving increasing attention in military suicides is known as moral injury.

Military service by definition is fraught with moral quandaries, from whether a particular war is “just” or an individual action within a “just” war is morally right. Psychiatrist Jonathan Shay, a specialist in combat trauma who has studied Vietnam veterans, says moral injury “is present when there has been a betrayal of “what’s right,” either by a person in legitimate authority or by one’s self, in a high stakes situation.” Both forms of moral injury impair the capacity for trust and elevate despair, suicidality, and interpersonal violence, Shay says.

Laura Greenstein of the National Alliance on Mental Illness (NAMI) illustrates the dilemma:

Imagine you are a young soldier leading your unit on a foot patrol in an Afghan village. One moment your environment is peaceful, the next your unit hears a loud explosion and you realize you are taking fire from the enemy. You find a secure position to radio your overhead observer, to determine where the threat is originating. It’s your job to take out the enemy before any soldiers or innocent civilians are harmed. Your overhead observer gives you the location and describes the enemy for you: an 11-year-old Afghan boy who is firing at your unit with a machine gun. At this point, you are ordered to take out the enemy. You follow the orders to save your soldiers and the innocent civilians in the village.

Six months later, you finished your deployment and are welcomed home by your friends and family. You begin to remember many of the experiences from your deployment, several you wish you could forget—including the day with the 11-year-old boy. This experience has made you question who you are, the morality you believe you had and causes you to worry that people may view you differently.

Writing in The Conversation, Holly Arrow and William M. Schumacher explain how mental health treatment and positive social interactions can help the healing:

Preliminary evidence suggests that cognitive-behavioral therapy (CBT) modified to treat issues related to moral injury can reduce depression as well as guilt- and shame-related thoughts. Treatment can come in other forms, as well. Psychotherapist Edward Tick, for example, organizes trips to Vietnam for U.S. veterans to meet their Vietnamese counterparts, for the healing of decades-long wounds.

However, we don’t need to be trained therapists to make a difference. Everyday social connections can also help the morally injured heal. In his dissertation, the second author of this article conducted a series of interviews with veterans exposed to potentially morally injurious events and found consistent differences between those with higher levels of depression and suicidal thoughts and those with fewer symptoms. Veterans who weren’t doing so well felt isolated and lacked support by friends, by family and by peers. Veterans with few symptoms felt supported by family, friends, peers and by their community. That’s the rest of us.

When we discover that someone has a military background, replacing the perfunctory “Thank you for your service” (which rarely leads to a meaningful exchange) with questions that start a conversation can create a new connection. The hopes, dreams, insecurities and mistakes of those who have served may be somewhat different based on their military background; many won’t be different at all.

Photo: Airmen of the 374th Security Forces Squadron, Yokota Air Base, Japan, May 15, 2017. Airman 1st Class Donald Hudson/U.S. Air Force
[If you or someone you know feels the need to speak with a mental health professional, you can contact the National Suicide Prevention Lifeline at 1-800-273-8255 or contact the Crisis Text Line by texting HOME to 741-741.]

[Veterans Crisis Line connects Veterans in crisis and their families and friends with Department of Veterans Affairs responders through a confidential toll-free hotline, online chat, or text. Veterans and their loved ones can call 1-800-273-8255 and Press 1, chat online, or send a text message to 838255 to receive confidential support 24 hours a day, 7 days a week, 365 days a year.]

[Visit the NAMI Veterans and Active Duty page for treatment resources, disclosure, and staying healthy during the transition to civilian life.]