Military Suicides: Understanding “Moral Injury”

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.

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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.]

 

Briefing Mayor Myrick

Scott MacLeod, a donor advisor of The Sophie Fund, briefed Ithaca Mayor Svante Myrick Thursday on the fund’s newly adopted strategic plan and projects underway for 2017. The meeting was held in advance of a gathering on April 17 organized by The Sophie Fund of 30 mental health stakeholders from the greater Ithaca community and Tompkins County.

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MacLeod told the mayor that he and his wife Susan Hack set up The Sophie Fund after their daughter Sophie, a 23-year-old art student on a health leave of absence from Cornell University, took her own life in Ithaca on Easter weekend in 2016. MacLeod said Sophie’s shocking, unexpected death motivated his family to provide support and advocacy for suicide prevention and other mental health programs for young people in the Ithaca area.

The Sophie Fund Strategic Plan 2017 sets forth four goals:

To support mental health initiatives with tangible impact aiding young people in the Greater Ithaca community

To raise awareness and end the stigma around mental illness and treatment

To advance a zero suicide ethos in the community

To serve as a community advocate for young people struggling with mental illness

MacLeod also briefed Mayor Myrick on The Sophie Fund’s current projects, including: organizing the 2nd Annual Ithaca Cupcake Baking Contest; providing a grant for an author series sponsored by the Mental Health Association in Tompkins County; and developing a support system for students taking a health leave of absence from local colleges.

Mayor Myrick welcomed The Sophie Fund’s efforts and urged that strong attention be given to programs aiding struggling adolescents so that mental disorders affecting young people don’t escalate into more complicated and dangerous conditions in adulthood.

The Sophie Fund is a donor-advised fund under the umbrella of the Community Foundation of Tompkins County. As of December 31, 2016, 97 individuals and foundations had made donations to The Sophie Fund.

Post-Trump Loving-Kindness

Donald Trump’s presidential election victory reveals a deepening polarization in America. It is certain to produce even greater stress levels, whether you’re for him or against him. Let’s not let our disappointments and frustrations overwhelm us with negativity.

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Even as we hold fast and press on with our political principles, we need to take care of our mental wellness. It’s a good time to consider the therapeutic technique of “mindfulness”—specifically a practice called “Loving–Kindness.”

Here are a couple of articles on Loving-Kindness written just before Election Day but which obviously are as relevant as ever on the Day After.

Los Angeles Psychologist Deniz Ahmadinia has this blog post on the website of the National Alliance on Mental Illness:

We hold all these misconceptions about what it is to be compassionate and kind, including that it makes us weak, that it’s a form of self-pity, that it’s indulgent, and that it gets in the way of success. Our competitive, tech-driven, busy culture instead believes that being hard on one’s self is the key to achieving goals. The reality is that the great majority of us struggle with a judgmental voice when we don’t live up to our own expectations, and it is this voice that judges others as well. As a result, we may face to persistent negative emotions, doubt, feelings of worthlessness, shame and feeling disconnected from people around us.

In the Huffington Post, meditation teachers Manoj Jain and Mark Muesse advise that “meditation brings calmness, serenity, and balance in our lives during tumultuous times,” and offer this five-minute Loving-Kindness meditation.

 

An Anxious Nation Votes

Good morning, America! Are you stressed by the 2016 presidential election Tuesday? Of course you are! (Well, more than half of you are.)

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According to a survey published on October 13 by the American Psychological Association, 52 percent of American adults report that the 2016 election is a “very significant” or “somewhat significant” source of stress. The figure goes up to 56 percent among millennials.

One APA tip for managing your stress: VOTE!

The APA survey found that election-inducing stress occurred among voters of both major parties, all age groups, and across racial and ethnic lines.

Various sources cite two reasons for the anxiety ramp-up: nervousness about the two leading candidates, and constant political and cultural discussions on social media. According to a Washington Post poll, 70 percent of registered voters said that the prospect of a Donald Trump presidency made them anxious—and 51 percent said that about a Hillary Clinton victory. Let’s break that down:

In the Post poll, 28 percent reported that they were very comfortable or somewhat comfortable with a Trump presidency, while 50 percent said the idea made them “very anxious” and another 20 percent said they were “somewhat anxious”—a net 70 percent of respondents were anxious about Trump winning the White House.

In the Post poll, 47 percent reported that they were very comfortable or somewhat comfortable with a Clinton presidency, while 51 percent said they were either “very anxious” (34 percent) or “somewhat anxious” (17 percent).

An article in the Guardian attributed more of the anxiety to the Trump campaign, and to spoil any chance of relief argued that it won’t be over if Clinton wins:

Even assuming Trump loses, the relief will be superficial: Trumpism will remain, and the world will have to contend with the fact that about 40 percent of the US electorate saw little wrong with his racism and misogyny, alleged sexual assaults, business scandals, lies, misrepresentations of his wealth and charitable giving, probable failure to pay taxes, lack of impulse control, profound ignorance and tiny attention span.

The American Psychological Association offers five tips “to help people manage their stress related to the election”:

 —If the 24-hour news cycle of claims and counterclaims from the candidates is causing you stress, limit your media consumption. Read just enough to stay informed. Turn off the newsfeed or take a digital break. Take some time for yourself, go for a walk, or spend time with friends and family doing things that you enjoy.

—Avoid getting into discussions about the election if you think they have the potential to escalate to conflict. Be cognizant of the frequency with which you’re discussing the election with friends, family members or coworkers.

—Stress and anxiety about what might happen is not productive. Channel your concerns to make a positive difference on issues you care about. Consider volunteering in your community, advocating for an issue you support or joining a local group. Remember that in addition to the presidential election, there are state and local elections taking place in many parts of the country, providing more opportunities for civic involvement.

—Whatever happens on November 8, life will go on. Our political system and the three branches of government mean that we can expect a significant degree of stability immediately after a major transition of government. Avoid catastrophizing, and maintain a balanced perspective.

—Vote. In a democracy, a citizen’s voice does matter. By voting, you will hopefully feel you are taking a proactive step and participating in what for many has been a stressful election cycle. Find balanced information to learn about all the candidates and issues on your ballot (not just the presidential race), make informed decisions and wear your “I voted” sticker with pride.

Some meditation advice for when you’re “really bugging out” comes from therapist Ralph de la Rosa, in an article on refinery29.com:

—Simply make yourself aware of how you’re feeling. Whether you’re so angry you could scream or so happy you’re ready to throw it in every Facebook friend’s face, take a moment to pause and check in with your emotions. In political arguments, especially, you may not realize just how emotional you’re getting in the moment.

—Next, stop. “Excuse yourself to the restroom or get off the phone if you have to,” says de la Rosa. “The logic here is that if you’re really in an emotion, nothing you’re going to do is going to be productive.”

—Now that you know what you’re feeling and you’ve got some space, direct your attention to your breath. Start taking deep inhales and exhales (about six seconds each). Repeat this pattern for about two minutes. You can also use a mantra here if you’d like. We’re big fans of the metta meditation, which means repeating the phrase, “May I be happy, may I be healthy, may I be peaceful” a few times before moving on to repeating, “May you be happy, may you be healthy, may you be peaceful.” Then, as a final step, when you’re ready, you end on, “May all beings be happy, may all beings be healthy, may all beings be peaceful” repeated a few times. If that doesn’t feel right, de la Rosa says deep breathing alone works great, too.

—Finally, zoom out and remember the big picture, meaning who you are, what your values are, and what kind of person you want to be. Chances are, your ideal self isn’t someone who yells at her friends. And, although this election feels like it could be apocalyptic, it’s good to remind yourself that’s not actually true: “Your candidate isn’t going to necessarily accomplish everything they say they will, and neither will the other candidate,” says de la Rosa.

2016 Election Guide on Mental Health

In the first 2016 presidential debate between Donald Trump and Hillary Clinton, there wasn’t any discussion about mental health. The only time the issue came up was when Clinton mentioned the challenges faced by law enforcement officers, and said: “Mental health is one of the biggest concerns, because now police are having to handle a lot of really difficult mental health problems on the street.”

Two national mental health organizations have put together helpful guides to mental health issues in the 2016 U.S. election. Check them out below, and scroll down to the bottom and read Hillary Clinton’s Comprehensive Agenda on Mental Health.

 

Mental Health America (MHA)

MHA produced “Vote for America’s Mental Health in 2016: A Guide to Rights and Issues.”

MHA Guide’s excerpts from the Republican Party Platform

Preserving Medicare and Medicaid. “Block granting Medicaid is particularly needed to address mental health care. Mental illness affects people from all walks of life, but there has been very little success in developing effective system-wide medical models for addressing mental health. For a variety of unique reasons, government is often the first frontier for people experiencing mental health problems—from first responders who deal with crises to publicly funded mental health facilities to prisons where large numbers of inmates suffer from mental illnesses.”

Choice in Education. “We opposed school-based clinics that provide referral or counseling for abortion and contraception and believe that federal funds should not be used in mandatory or universal mental health, psychiatric, or socio-emotional screening programs.”

Ensuring Safe Neighborhoods: Criminal Justice and Prison Reform. “Along with diversion of first-time nonviolent offenders to community sentencing, accountability courts, drug courts, veterans treatment courts, and guidance by faith-based institutions with proven track records of rehabilitation, our platform emphasized restorative justice to make the victim whole and put the offender on the right path. As variants of these reforms are undertaken in many states, we urge the Congress to learn from what works. In the past, judicial discretion about sentences led to serious mistakes concerning dangerous criminals. Mandatory minimum sentencing became an important tool for keeping them off the streets. Modifications to it should be targeted toward particular categories, especially nonviolent offenders and persons with drug, alcohol, or mental health issues, and should require disclosure by the courts of any judicial departure from the state’s sentencing requirements.”

Combating Drug Abuse. “Heroin and opioid abuse touches our communities, our homes, and our families in ways that have grave effects on Americans in every community. With a quadrupling of both their sales and their overdose deaths, the opioid crisis is ravaging communities all over the country, often hitting rural areas harder than urban. Because of over-prescription of drugs is such a large part of the problem, Republican legislation now allows Medicare Part D and Medicare Advantage plans to limit patients to a single pharmacy. Congressional Republicans have also called upon the Centers for Medicare and Medicaid Services to ensure that no physician will be penalized for limiting opioid prescriptions.”

Honoring and Supporting Our Veterans: A Sacred Obligation. “Like the rest of American medicine, the VA faces a critical shortage of primary care and mental health physicians. That’s why there are long waiting times to see a doctor and why doctors are often frustrated by the limited time they have with their patients. This is especially the care with mental health care, which often amounts to prescribing drugs because there are not enough psychologists and psychiatrists to do anything else. Inadequate treatment of PTSD drives other problems like suicide, homelessness, and unemployment. This situation may not be quickly reversed, but a Republican administration will begin, on day one, to undertake the job.”

MHA Guide’s excerpts from the Democratic Party Platform:

Honoring Indigenous Tribal Nations. “We will work to fully fund the Indian Health Service, Tribal, and Urban Indian health care to ensure that all American Indians have adequate, safe, and affordable access to primary care providers, including oral health, mental health practitioners, and substance abuse treatment options.”

Supporting Community Health Centers. “We must renew our commitment to Community Health Centers, as well as community mental health centers and family planning centers. These health centers provide critically important, community-based prevention and treatment in underserved communities, prevent unnecessary and expensive trips to emergency rooms, and are essential to the successful implementation of the ACA.”

Combating Drug and Alcohol Addiction. “We must confront the epidemic of drug and alcohol addiction, specifically the opioid crisis and other drugs plaguing our communities, by vastly expanding access to prevention and treatment, supporting recovery, helping community organizations, and promoting better practices by prescribers.”

Treating Mental Health. “We must treat mental health issues with the same care and seriousness that we treat issues of physical health, support a robust mental health workforce, and promote better integration of the behavioral and general health care systems. Recognizing that maintaining good mental health is critical to all people, including young people’s health and development, we will work with health professionals to ensure that all children have access to mental health care. We must also expand community-based treatment for substance abuse disorders and mental health conditions and fully enforce our parity law. And we should create a national initiative around suicide prevention across the lifespan—to move toward to HHS-promoted Zero Suicide commitment.”

Preventing Gun Violence. “We will fight back against attempts to make it harder for the Bureau of Alcohol, Tobacco, Firearms, and Explosives to revoke federal licenses from law breaking gun dealers, and ensure guns do not fall into the hands of terrorists, intimate partner abusers, other violent criminals, and those with severe mental health issues.”

Veterans and Service Members. “We must also look for more ways to make certain the [Department of Veterans Affairs] provides veteran-centric care, such as providing women with full and equal treatment, including productive services; expanding mental health programs; continuing efforts to identify and treat invisible, latent, and toxic wounds of war; treating post-traumatic stress; and expanding the post-9/11 veteran’s caregiver program to include all veterans. We reject attempts by Republicans to sell out the needs of veterans by privatizing the VA. We believe that the VA must be fully resourced so that every veteran gets the care that he or she has earned and deserves, including those suffering from sexual assault, mental illness, and other injuries or ailments.”

 

National Alliance on Mental Illness (NAMI)

NAMI provides links to the two parties’ platforms, with some excerpts of their own:

Republican Platform

In [the Affordable Care Act’s] place we must combine what worked best in the past with changes needed for the future. We must recover the traditional patient-physician relationship based on mutual trust, informed consent, and confidentiality. To simplify the system for both patients and providers, we will reduce mandates and enable insurers and providers of care to increase healthcare options and contain costs. Our goal is to ensure that all Americans have improved access to affordable, high-quality healthcare, including those who struggle with mental illness.

Democratic Platform

 We must treat mental health issues with the same care and seriousness that we treat issues of physical health, support a robust mental health workforce, and promote better integration of the behavioral and general health care systems. Recognizing that maintaining good mental health is critical to all people, including young people’s health and development, we will work with health professionals to ensure that all children have access to mental health care. We must also expand community-based treatment for substance abuse disorders and mental health conditions and fully enforce our parity law. And we should create a national initiative around suicide prevention across the lifespan—to move toward the HHS-promoted Zero Suicide commitment.

 

Hillary Clinton’s Comprehensive Agenda on Mental Health

It’s worth noting that the Democratic campaign released a proposal on August 29, 2016 called Hillary Clinton’s Comprehensive Agenda on Mental Health (Trump has yet to issue a policy document on the topic). Excerpts from the agenda:

Today, Hillary Clinton announced her comprehensive plan to support Americans living with mental health problems and illnesses—by integrating our healthcare systems and finally putting the treatment of mental health on par with that of physical health. Nearly a fifth of all adults in the United States, more than 40 million people, are coping with a mental health problem. Close to 14 million people live with a serious mental illness such as schizophrenia or bipolar disorder. Moreover, many of these individuals have additional complicating life circumstances, such as drug or alcohol addiction, homelessness, or involvement with the criminal justice system. Veterans are in acute need of mental health care, with close to 20% of those returning from the Iraq and Afghanistan wars experiencing post-traumatic stress or depression. And the problem is not limited to adults: an estimated 17 million children in the United States experience mental health problems, as do one in four college students.

Americans with mental health conditions and their families need our support. The economic impact of mental illness is enormous –at nearly $200 billion per year nationwide in lost earnings—and the human cost is worse. Too many Americans are being left to face mental health problems on their own, and too many individuals are dying prematurely from associated health conditions. We must do better. To date in this campaign, Hillary set out policies that will direct support to individuals with mental health problems and their families—including a detailed agenda to support military service members and veterans, an initiative to end America’s epidemic of drug and alcohol addiction, and a robust caregivers’ agenda. Today, she is building on those proposals with a comprehensive agenda on mental health. Hillary’s plan will:

—Promote early diagnosis and intervention, including launching a national initiative for suicide prevention.

—Integrate our nation’s mental and physical health care systems so that health care delivery focuses on the “whole person,” and significantly enhance community-based treatment.

—Improve criminal justice outcomes by training law enforcement officers in crisis intervention, and prioritizing treatment over jail for non-violent, low-level offenders.

—Enforce mental health parity to the full extent of the law.

—Improve access to housing and job opportunities.

—Invest in brain and behavioral research and developing safe and effective treatments.

As a down-payment on this agenda, Hillary will convene a White House Conference on Mental Health during her first year as President. Her goal is that within her time in office, Americans will no longer separate mental health from physical health when it comes to access to care or quality of treatment. The next generation must grow up knowing that mental health is a key component of overall health and there is no shame, stigma, or barriers to seeking out care…

Hillary Clinton’s agenda includes the following focus on suicide prevention:

Suicides, which are usually fueled by mental illness, are rising among numerous population groups, from adolescents and college students to veterans and older adults. The overall rate of suicide increased by 24 percent between 1999 and 2014, and is now at its highest level in 30 years. Over 40,000 Americans die of suicide every year, making it the tenth-leading cause of death nationally. As the former director of NIMH, Dr. Tom Insel, often notes, suicides have 11 victims: the person who dies, and at least 10 people close to them who will never be the same. Hillary believes that suicide is a critical issue that she will prioritize as president. She will:

—Create a national initiative around suicide prevention across the lifespan that is headed by the Surgeon General: As president, Hillary will move toward the goal of “Zero Suicide” that has been promoted by the Department of Health and Human Services. She will direct all relevant federal agencies, including HHS, the VA, and the Department of Education, to research and develop plans for suicide prevention in their respective settings, and create a cross-government initiative headed by the Surgeon General to coordinate these efforts. She will also launch a citizen input and feedback mechanism, to enable outside groups to comment on agency recommendations, and explore how we can harness technology to reach out to people who need support.

—Encourage evidence-based suicide prevention and mental health programs in high schools. In 2013, a survey of high school students revealed that 17 percent considered attempting suicide in the last year, with 8 percent actually attempting it. The suicide rate among American Indian/Alaska Native adolescents is even higher, at 1.5 times the national average. There are effective ways to respond. It is critical that school districts emphasize evidence-based mental health education, so that students, teachers, and school nurses are aware of the warning signs and risk factors of mental illness and how to address them. The Model School District Policy on Suicide Prevention, released by four leading mental health organizations, includes concrete recommendations that school districts can follow. Hillary will direct the Department of Education to emphasize mental health literacy in middle and high schools and will work with regional and national PTA, school counselor associations, and associations of secondary school principals to encourage school districts to adopt this model policy.

—Provide federal support for suicide prevention on college campuses. Hillary believes that every college campus should have a comprehensive strategy to prevent suicide, including counseling, training for personnel, and policies that enable students to take leave for mental health. Such multi-layered approaches have a proven track record of decreasing suicides. For instance, the Air Force launched an initiative in 1996 that brought together multiple intervention programs and reduced the suicide rate among Air Force personnel by nearly a third in under a decade. Groups such as the Jed Foundation, American Foundation for Suicide Prevention, the Suicide Prevention Resource Center, and Active Minds have created frameworks around suicide prevention tailored for colleges and universities. Hillary will dramatically increase funding for campus suicide prevention, investing up to $50 million per year to provide a pathway for the country’s nearly 5,000 colleges – whether private or public, two-year or four-year – to implement these frameworks on behalf of students.

—Partner with colleges and researchers to ensure that students of color and LGBT students are receiving adequate mental health coverage. Evidence suggests that the psychological needs of students of color are disproportionately unmet, impeding their ability to adapt to college life. LGBT students face added burdens as well, with gay youth being four times more likely than their straight peers to attempt suicide. Hillary will direct the Departments of Education and Health and Human Services to work with universities, researchers and community programs to determine how best to meet and respond to the challenges these students face and to provide specialized counseling.