Get "The Handle"! - Comments on 2011 RAND study "The War Within: Preventing suicide in the U.S. military"
With all due and the most sincere respect and admiration for this study (apparently the first, very serious and focused study of this kind in the new field of military suicidology) and its authors and their efforts, I have to admit, that in my very humble and personal opinion this study is unsatisfactory, inadequate, superficial and formal. Apparently it follows the general matrix of similar studies in psychiatric epidemiology but it fails to identify and to address the root problems.
Statistics indicate that the rate of suicides in the military since 2005 grew in an exponential fashion, in geometric progression, which means that it is a true psychiatric epidemic: an explosion, a raging wild fire which has not reached its apex yet by far and has a grim potential for expanding and taking more lives.
If it is a sudden and a very pronounced epidemic arising de novo, then there must be some very specific and powerful forces which fuel it and propel its pathogenetic mechanism. This RAND study fails to recognise and identify these specific forces and prefers to concentrate on nonspecific and more or less implied in the past general suicidogenic factors. Without the identification of these new specific causes and their mechanisms, it seems to be quite doubtful to me that this epidemic can be understood, addressed and stopped. In other words, if we want to get a handle on it, it must be The John Snow Handle of the specific causation, which has to be found, identified, studied and neutralised or removed.
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What makes john snows and their "handle finding and removing ability"?
Emotional, intellectual and scientific independence, open-mindedness and curiosity; search for the truth "and nothing but the truth", commitment to serve, social activism, and probably some other traits. This is an interesting subject for research also.
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Summary of the 20011 RAND study on epidemiology of suicidal behavior in the U.S. military
- "The RAND research team took an epidemiological approach to answering questions of keen interest to DoD policymakers." (p. xiii)
Comments:
This is exactly what the problem with this study is: you cannot approach this issue from epidemiological - statistical perspectives only: it is just a part, one of the facets of the whole picture. The methodological approach, as always, should be comprehensive, interdisciplinary and analytical - interpretative. "Number crunching" has to be balanced, supplemented, complemented, refined and verified by individual cases and their milieu analyses in the attempt to capture the true, integrated insights and understandings.
This is exactly what the problem with this study is: you cannot approach this issue from epidemiological - statistical perspectives only: it is just a part, one of the facets of the whole picture. The methodological approach, as always, should be comprehensive, interdisciplinary and analytical - interpretative. "Number crunching" has to be balanced, supplemented, complemented, refined and verified by individual cases and their milieu analyses in the attempt to capture the true, integrated insights and understandings.
- "The figure also indicates that the suicide rate across DoD has been climbing, rising from 10.3 in 2001 to 15.8 in 2008, which represents about a 50-percent increase. The increase in the DoD suicide rate is largely attributable to a doubling of the rate in the Army." (p.xiv)
Comments:
One of the most interesting statistical facts on this graph is the difference in rates between the services, which, apparently reflects the smarter and more effective policies, probably along with the better shape of mental health services in the Navy and Air Force (these are, apparently more of the "elite" branches) than in lagging Army and the Marines (the latter is especially telling and troubling).
- "Across services, there are significant differences in only the Army’s suicide rate over time. Specifically, the Army suicide rates for CYs 2006 and 2007 were higher than in 2001 and 2004, and the rate in CY 2008 was higher than in it was between CY 2001 and CY 2005 and higher than the average rate for CYs 2001 through 2008." (p.xiv)
- "These results show that the suicide rate in the synthetic civilian population is both fairly constant and substantially higher than that in DoD. Of concern, however, is that the gap between DoD and the general population is closing. The most pronounced increases in the DoD suicide rate occurred in 2007 and 2008, so, assuming that the national rate remains relatively stable in these years, the gap between the rate in DoD and the general population may be even narrower." (p. xv)
Comments:
It is also possible that this psychiatric epidemic just reflects the demographic and attitudinal "catching up" with the larger (and the main) community, and if it is so, the rates increase curve should plato at this point, at 20 per 100,000. The real reason to worry would be if it continues its exponential growth. The next three years will clarify the picture somewhat.
The interesting question is: can any predictions be ventured based on the characteristics of this curve? Can the possible plato or continuing growth be seen now? Apparently, more accurate, "cleaner", more natural, original, smaller community samples might be more helpful in the attempts to find the answer. And this should be a question for the statisticians and epidemiologists to entertain and seriously consider.
It is also possible that this psychiatric epidemic just reflects the demographic and attitudinal "catching up" with the larger (and the main) community, and if it is so, the rates increase curve should plato at this point, at 20 per 100,000. The real reason to worry would be if it continues its exponential growth. The next three years will clarify the picture somewhat.
The interesting question is: can any predictions be ventured based on the characteristics of this curve? Can the possible plato or continuing growth be seen now? Apparently, more accurate, "cleaner", more natural, original, smaller community samples might be more helpful in the attempts to find the answer. And this should be a question for the statisticians and epidemiologists to entertain and seriously consider.
- "In the United States, males are more likely to die by suicide than females—thus, the expected suicide rate based on this demographic characteristic alone is higher than for the country as a whole." (p.xvi)
Comments: Why? ("males are more likely to die by suicide than females")
It is, at least hypothetically conceivable that this "niche" is filled with latently homosexual males (which probably is a major suicide risk factor for males; this aspect still is very much underresearched, I think.) If it is so, then it is also possible that those of them who found their "asylum" and their solution for this intrapsychic conflict in the military, became the group which does "the catching up" with the general population when they were deprived of their convenient "cover" and this "safety net" of antigay policies and exclusions. And this brings us back to the hypothesis previously described here. It would be interesting (and valuable, if we want to understand the situation completely) to confirm or refute this hypothesis by research methods. Comparisons with other cultures and countries with different gender distribution of suicide rates might be helpful in this type of a research.
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| … sexual orientation and suicide risk: Evidence from a … - Russell - Cited by 413
Am J Public Health. 2001 August; 91(8): 1276–1281.
PMCID: PMC1446760
Adolescent Sexual Orientation and Suicide Risk: Evidence From a National Study
Abstract
Objectives. Sexual orientation has been a debated risk factor for adolescent suicidality over the past 20 years. This study examined the link between sexual orientation and suicidality, using data that are nationally representative and that include other critical youth suicide risk factors.
Methods. Data from the National Longitudinal Study of Adolescent Health were examined. Survey logistic regression was used to control for sample design effects.
Results. There is a strong link between adolescent sexual orientation and suicidal thoughts and behaviors. The strong effect of sexual orientation on suicidal thoughts is mediated by critical youth suicide risk factors, including depression, hopelessness, alcohol abuse, recent suicide attempts by a peer or a family member, and experiences of victimization.
Conclusions. The findings provide strong evidence that sexual minority youths are more likely than their peers to think about and attempt suicide.
Risk factors for suicide among gay, lesbian, and … - Proctor - Cited by 140
… and Bisexual Youths General and Specific Risk Factors - Hegna - Cited by 14
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people.ucalgary.ca/~ramsay/gender-sissy-butch/index.htmCached
The Homosexuality Factor is Associated with Higher Risk for Suicidality ... GLBTTs and Transgender Males at Greater Risk for Attempting Suicide: The ..... an indication of deviance, either latent or actual, from heterosexuality" (Phelan, 1993, p.
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Who Is at Risk?
Prior Suicide Attempts: "...a prior suicide attempt is the strongest predictor of subsequent death by suicide (Isometsa and Lonnqvist, 1998, Harris and Barraclough, 1997)."
Mental Disorders: "depression and anxiety disorders (including post traumatic stress disorder, or PTSD). The Institute of Medicine (IOM) estimates that approximately 4 percent of those with depression will die by suicide (Goldsmith et al., 2002), and, though the same figure is not yet known for those with PTSD, community-based surveys indicate that persons with PTSD are more likely than those without the disorder to report past suicide attempts and ideation (Kessler, Borges, and Walters, 1999; Sareen et al., 2005; Farberow, Kang, and Bullman, 1990)."
Substance-Use Disorders: "...approximately 20 percent of servicemembers report heavy alcohol use (drinking five or more drinks per typical drinking occasion at least once per week) (Bray and Hourani, 2007)."
Head Trauma/Traumatic Brain Injury (TBI): "persons with concussions, cranial fractures, or cerebral contusions or traumatic intracranial hemorrhages had higher rates of suicide mortality than the general population (Teasdale and Engberg, 2001; Simpson and Tate, 2002, 2005)."
Those Suffering from Hopelessness, Aggression and Impulsivity, and Problem-Solving Deficits: "Those with high levels of hopelessness are at increased risk, and there is some evidence that higher levels of aggression and impulsivity, as well as those with problem-solving deficits, are also at increased risk for suicide (McMillan et al., 2007; Mann et al., 1999; Rudd, Rajab, and Dahm, 1994)."
Life Events, Precipitating Events, and Triggers: "Most of the scientific literature suggests that it is the interaction with underlying vulnerabilities, such as behavioral health problems, that influence a suicidal response to these relatively common events (Yen et al., 2005; Joiner and Rudd, 2000)."
Firearm Access: Military personnel have access to firearms, particularly when deployed, and are more likely to own a personal gun than are members of the general population (Hepburn et al., 2007).
Suicides of Others and Reporting of Suicides: "For youth and young adults, there is evidence of contagion—that a suicide may lead to subsequent suicides (Insel and Gould, 2008)
(p. xvii)
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"The challenge in identifying best practices for suicide prevention is the lack of
data on the effectiveness of programs."
"Our assessment of these various programs indicates that promising practices exist, but much remains unknown about what constitutes a best practice."
(p. xviii) "...Comprehensive suicide-prevention program should include the following six practices:
1. Raise awareness and promote self-care...
2. Identify those at high risk...
3. Facilitate access to quality care...
4. Provide quality care...
5. Restrict access to lethal means...
6. Respond appropriately..."
(p. xix)
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"Suicide Prevention in the Army
The Army’s current approach to suicide prevention revolves around programs that encourage “soldiers to take care of soldiers” and those that offer a holistic approach to promote resiliency."
(p. xx)
Comments:
This is a very sound and practical approach. In general, "self-help" movement and strategies are, most likely, the directions of the future, in both civilian and military mental health services.
Recommendation:
Establish psychological help (not just specifically suicide prevention) hotline staffed by trained (1 week initial training, with regular additional training) soldiers. The criteria for their selection (first of all "psychological mindedness" and ability for empathy, ability to be a good listener) and the guidelines for training can be elaborated and described at a later time. Call this hot line, for example, "My Buddy". The same psychotherapists can conduct semistructured interviews and psychometric assessments.
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"Suicide Prevention in the Navy
The Navy’s approach to suicide prevention is guided by a model that sees stress on a continuum and in which suicide represents an extreme endpoint on the continuum.The model emphasizes early intervention to prevent and manage stress, particularly in the face of challenging life events (e.g., relationship or financial difficulties)."
(pp. xx-xi)
Comments:
This is also a very good and logical approach and is consistent with the line of thinking expressed earlier.
Recommendation:
This approach should be developed further, expanded and adopted by all other services.
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"Suicide Prevention in the Air Force
The Air Force approach to preventing suicide is based on initiating cultural changes in
attitudes and actions pertaining to suicide and implementing these changes through
the highest-ranking Air Force officials.
...
There is published evidence to suggest that the implementation of the Air Force Suicide Prevention Program (AFSPP) was associated with a 33-percent risk reduction in suicide (Knox et al., 2003).
It has been reviewed by the National Registry of Evidence-Based Programs and Practices, which found that research methods were strong enough to support these claims
(SAMHSA, 2010)."
(p. xxi)
Comments:
This issue here is taken very seriously, apparently not only because it might involve a significant material loss in addition to human loss, but because culturally and traditionally this is an elite service, adequately saturated with refined attitudes and technology.
Recommendation:
There is no reason why the best approaches and methods could not be combined and utilised by all services.
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"Suicide Prevention in the Marine Corps
The Marine Corps approach to suicide prevention relies primarily on programs in
which members of the USMC community are trained to identify and refer marines
at risk for suicide to available resources (e.g., a commander, chaplain, mental health
professional)."
(p. xxi)
Comments:
Apparently, this is a more formal approach and there might also be some denial of this issue and its associated complexities.
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Conclusions
"Raise Awareness and Promote Self-Care
Most of the messages conveyed focus on raising awareness, which has limited evidence of creating behavior change."
(p. xxii)
Comments: Which is not surprising at all, in the light of what was discussed earlier. It simply does not work: we cannot instruct the ill person (lack of insight of various degrees is very often the part of the problem) to understand his illness or to cure it; just like we cannot expect the dead body to revive itself.
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"Identify Those at High Risk"
(p. xxiii)
Comments:
This is a very important key point. The best identification is the direct one: 1) via the computerised self-reports and 2) standardised semistructured (checklists) assessments by not only and necessarily "gatekeepers" but those who know the subject more or less well: from family and friends to hotline therapists; with further central processing and referral.
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"Access to and delivery of "quality care"
(p. xxiii)
Comments:
"Quality" of care is difficult to define and to measure, and the question will always remain: by what margin the results of this "quality" care might exceed the less expensive and more "mass" options, such as group therapy led by trained therapists selected from soldiers. My hunch is that the latter will be all in all more efficacious and preferable mode of intervention, with "quality" care reserved for serious, severe or treatment resistant cases. In other words, the so called "quality" care is not necessarily the guarantee of "quality results".
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"Restricting access to lethal means"
(p. xxiv)
Comments:
This does not appear to be very practical, especially when the "means", if not some, then the others, could always be found.
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"Appropriate response"
(p. xxiv)
Comments:
This depends on training and the structure of the programs. The best response is always preventive and automatic.
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General Comments to "Conclusions":
There is a very "clear and convincing" evidence that the services which pay the greatest attention to this issue and which utilise the best: most thought out and systematic programs and their implementations are the most successful in controlling the problem.
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Notes
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Ep-st an-s
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Psychotic Suicides
Nonpsychotic suicides
should be viewed as first of all and most of all the manifestations of the disorders of (psycho)social integration. Suicides are practically nonexistent in the animal kingdom. This indicates that the epiphenomenon of suicide is a part and parcel of social nature of man. It is the end result of deep and irreconcilable conflict (as it appears to be to the victim of suicidal behavior) between the individual and his social milieu. It is a wreckage of the ship which has not been able to negotiate with the sea and to become a part of it.
If it is so, then all the corrective and preventive measures directed at the individual only are the palliative half-measures and will ultimately fail. The underlying conflict between the individual and his group has to be addressed, explored, diagnosed properly and objectively and the preventive treatment should be directed at the social reintegration, including, if needed, the transfer and reassignment.
The best measurements of suicide as a psychosocial pathology are not only their nominal numbers (it is just the number of completed shipwrecks), but the measurements of the state and capacity for the adequate and healthy psychosocial integration in a given military community, which should take into account all possible relevant factors: subculture, attitudes, circumstances, complex knots of interrelationships, etc. No service would be better positioned and equipped to handle this task than the military intelligence, with the additional training in psychology, mental health, sociology and philosophy. We have to understand what lead to a shipwreck, what was wrong with the ship's engine, what kind of weather was there at the moment, why the catastrophe happened and what we should do to help the other ships to avoid it.
Psychometric and sociometric instruments have to be developed and used for the assessment of suicidogenic situations and environments and for the overall state of psychosocial health in a military community and for measurements of effectiveness of corrective and preventive interventions. These measurements have to be pooled statistically and epidemiologically, they have to be studied carefully, common threads should be discerned, causal connections should be traced and analysed; conceptual organisation and understanding of this data should be attempted and better, more effective interventions should be sought. This should be ongoing routine activity, especially since the social environments and attitudes always change; almost imperceptibly but most definitely.
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Situational Suicides
Altruistic Suicides
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should be viewed as first of all and most of all the manifestations of the disorders of (psycho)social integration. Suicides are practically nonexistent in the animal kingdom. This indicates that the epiphenomenon of suicide is a part and parcel of social nature of man. It is the end result of deep and irreconcilable conflict (as it appears to be to the victim of suicidal behavior) between the individual and his social milieu. It is a wreckage of the ship which has not been able to negotiate with the sea and to become a part of it.
If it is so, then all the corrective and preventive measures directed at the individual only are the palliative half-measures and will ultimately fail. The underlying conflict between the individual and his group has to be addressed, explored, diagnosed properly and objectively and the preventive treatment should be directed at the social reintegration, including, if needed, the transfer and reassignment.
The best measurements of suicide as a psychosocial pathology are not only their nominal numbers (it is just the number of completed shipwrecks), but the measurements of the state and capacity for the adequate and healthy psychosocial integration in a given military community, which should take into account all possible relevant factors: subculture, attitudes, circumstances, complex knots of interrelationships, etc. No service would be better positioned and equipped to handle this task than the military intelligence, with the additional training in psychology, mental health, sociology and philosophy. We have to understand what lead to a shipwreck, what was wrong with the ship's engine, what kind of weather was there at the moment, why the catastrophe happened and what we should do to help the other ships to avoid it.
Psychometric and sociometric instruments have to be developed and used for the assessment of suicidogenic situations and environments and for the overall state of psychosocial health in a military community and for measurements of effectiveness of corrective and preventive interventions. These measurements have to be pooled statistically and epidemiologically, they have to be studied carefully, common threads should be discerned, causal connections should be traced and analysed; conceptual organisation and understanding of this data should be attempted and better, more effective interventions should be sought. This should be ongoing routine activity, especially since the social environments and attitudes always change; almost imperceptibly but most definitely.
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Situational Suicides
Altruistic Suicides
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Suicide as a form of ultimate social protest
Suicide from philosophical perspectives
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Stoicism (Stanford Encyclopedia of Philosophy)
plato.stanford.edu/entries/stoicism/Similar
15 Apr 1996 – The Stoic view on modality is supposed to make the world safe for ..... however, a choice, for example, to end our lives by suicide can be in ...
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Suicide as "pathological" acclamation of freedom and autonomy
Evolution of social perceptions and views on Suicide
Religious views on Suicide
Suicide across cultures
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Recommendations
I would like to respectfully submit the following set of recommendations to DoD:
- Organise Conference on Military Suicidology in PR.
- Attitudes and Policies:
Family model
Sexual attitudes: freedom, equality, no violence, no coercion and no sexual exploitation.
Psychosexual health is one of the most important components of general mental health.
Family model
Sexual attitudes: freedom, equality, no violence, no coercion and no sexual exploitation.
Psychosexual health is one of the most important components of general mental health.
Zero tolerance policies re: homophobia, heterophobia, or any other phobias.
- Issue an order directly prohibiting the self-injurious, aggressive (towards members of the MC) and suicidal behaviors: it would be justified ethically, medically and militarily. Sounds ridiculous but will definitely bring some benefits: soldiers do trust their collective parent: The DOD.
- Train the specialists in Military Mental Health field:
Task:
To create an institute of military philosophers-psychotherapists who will be in charge of all issues pertinent to individual and overall MC (Military Community) mental health, recruited primarily from the interested and psychologically minded officers of military intelligence services.
To create an institute of military philosophers-psychotherapists who will be in charge of all issues pertinent to individual and overall MC (Military Community) mental health, recruited primarily from the interested and psychologically minded officers of military intelligence services.
Rationale:
The need for the therapeutic element in the services is apparent. Interpersonal relationship (nonspecific, eclectic, atheoretical, and, for the purposes of this discussion, task oriented) is the basis of any psychotherapy curative mechanism. Therapeutic relationship is a silver cup which "argentifies": charges, purifies, enables, makes therapeutically efficient any psychotherapy theory that is contained in it. It also might become one of the major factors in this "war within" for one of the most valuable, powerful, unique and irreplaceable weapons in any armed forces arsenal: the soldier's soul, mind and his/her mindset. This is not the issue of crude propaganda which does not work anyway. This is the issue of mental and spiritual health and mutual "goodness of fit".
The need for the therapeutic element in the services is apparent. Interpersonal relationship (nonspecific, eclectic, atheoretical, and, for the purposes of this discussion, task oriented) is the basis of any psychotherapy curative mechanism. Therapeutic relationship is a silver cup which "argentifies": charges, purifies, enables, makes therapeutically efficient any psychotherapy theory that is contained in it. It also might become one of the major factors in this "war within" for one of the most valuable, powerful, unique and irreplaceable weapons in any armed forces arsenal: the soldier's soul, mind and his/her mindset. This is not the issue of crude propaganda which does not work anyway. This is the issue of mental and spiritual health and mutual "goodness of fit".
Psychoanalytic theory and methods are not the best choice in these circumstances: they are excessively, emptily (the core of the onion), stressfully and unnecessarily "deep", foster dependence and loss of autonomy in a "transferrential therapeutic relationship", whatever this term means; and might be even detrimental and harmful to troops morale and military readiness. Stoicism as a theory of psychotherapy, based on philosophical teaching, might be much better suited for these purposes and much more therapeutically efficient.
- Therapeutic military philosophy:
Stoicism: to elaborate and develop for practical implementation.
- Continuous Data Collections,
more refined and sophisticated, down to platoon levels, with broader and at the same time more focused scope, with an effort to trace the connections between suicide rates and chronological changes in attitudes and policies on various levels and across all services and demographic groupings.
- Development of psychometric instruments: scales, computerised interviews and diagnostic-therapeutic video games.
-Use EEG ( Electroencephalography - From Wikipedia ), preferably its computerised option, as a part of routine medical checkup and screening, especially in persons with history of head trauma, somewhat inadequate and puzzling (although not necessarily overtly "abnormal") behavior ( I realise that great many of us might fit into this vague "category", probably including your humble servant); especially with excessive and obsessive religious preoccupations, with the follow-up (or even routine screening, if it can be afforded) by sleep deprivation EEG and neurological consultation. Temporal Lobe Pathology ( Temporal lobe epilepsy - From Wikipedia ), with or without seizure activity, can present with various and protean psychiatric manifestations and be a source of latent psychoticism and various ("not otherwise specified") affective (e.g. "epileptoid disphorias" of various intensities, also as the possible precipitants of suicidal behaviors) and complex behavioral disturbances. This pathological phenomenon is poorly understood conceptually and diagnostically, is mis - and underdiagnosed frequently (if not all of the time), is inadequately researched and can be a frequent and unrecognised source of self-injurious and suicidal behaviors. There is a need for the development of more precise and accurate, and, hopefully, more predictive electrodiagnostic methods and instruments. For example (very grim, shocking and tragic one), major Hasan looks very much "organic" to me; for me (again) it is literally "written on his face"; and his inflexible, overvalued, dysfunctional religiosity (or hyperreligiosity, for that matter), also appears to be quite telling and possibly "symptomatic".
Generally speaking, the biological, medical, neurological aspects and pathological underpinnings of various suicidal behaviors should not be overlooked in our "easy" and very tempting rush to "psychologising".
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References and Links
military philosophy - Google Search
therapeutic military philosophy - Google Search
stoicism - Google Search
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