The War Inside

Maj. Gen. Mark Graham understands the tragedy of suicide firsthand. His 21-year-old son killed himself in 2003 after struggling with depression. A top ROTC cadet at the University of Kentucky, Kevin Graham wanted to be an Army doctor. He quit taking his medication because he didn’t want the Army to find out about his illness.

Eight months later, a roadside bomb in Iraq took the life of Graham’s other son, Jeff. “Both of my sons died fighting different battles,” says Graham, deputy chief of staff for U.S. Army Forces Command at Fort McPherson, Ga. “They were both heroes to us, both great young men.”

Years went by before Graham spoke publicly about what happened. Today, he is part of the Army’s intense push to reduce a historic spike in soldier suicides. He is encouraging people to talk frankly about the stigmas associated with mental health care and suicide.

“People think if you talk about suicide, you’ll cause somebody to do it,” Graham says.

“That is not the case. We’ve got to talk about it in order for people to know it’s OK to come forward and get help. We have to educate people to know it’s a sign of strength – not weakness – to get help.”

These are messages the military urgently hopes the troops will heed. More than 600 soldiers and Marines killed themselves between 2003 and 2008 – the equivalent of a battalion task force. Another 177 active-duty and inactive-duty reserve soldiers reportedly had taken their own lives by the end of September – 61 were still under investigation at the time – putting the Army on track for a record number of suicides for the fifth consecutive year.

“We have got to do better,” Army Vice Chief of Staff Gen. Peter W. Chiarelli said after the suicide data was released. “We are trying every remedy and seeking help from outside agencies that are experts in suicide prevention. There isn’t a reasonable suicide-prevention tool out there the Army won’t potentially employ.”

Mobile behavioral health teams have become a part of each brigade at Fort Carson, one of the world’s largest Army bases. That makes it routine business for a soldier to seek help. “You go see the S-1 for a personnel action, to the medical clinic to get your stuff done, or go by and see the behavioral-health guys,” Graham says. “So it’s OK. It’s accepted by the soldiers and leaders.”

The Army also has dramatically increased its suicide-prevention efforts. All 1.1 million soldiers were pulled from their normal duties over a six-week period last spring to learn ways to recognize suicidal behavior, and help fellow soldiers who are distressed or showing signs of suicide. This includes asking troubled soldiers if they are considering, or have considered, taking their own lives. “Normally, if they have, they will tell you,” Graham says. “When they do, you don’t just say, ‘Hey, you need to go get help.’ You take them to get help, right then.”

Annual suicide-prevention training will be provided Army-wide, emphasizing the common causes of suicidal behavior and the critical role Army leaders, friends, co-workers and families play in helping soldiers. In addition, the Army created a suicide-prevention task force that made dozens of improvements to programs and recruited additional psychological- and behavioral-health counselors, says Army spokesman Wayne V. Hall.

A Comprehensive Soldier Fitness program is now used throughout the Army, the National Guard and Army Reserve that places the same emphasis on mental health as physical health and fitness. A similar program is planned for family members and civilians who work for the Army. Chaplains also are leading relationship-strengthening programs, called Strong Bonds, for soldiers and families. A separate effort, Battlemind, helps troops and families prepare for the stresses of war and identify potential mental-health issues. The Navy and Marine Corps have likewise stepped up suicide-prevention efforts.

Last November, the Army contracted with the National Institutes of Mental Health to conduct a five-year, $50 million study on soldier suicides that will help guide future prevention efforts.

The Army faces the challenge, understanding that it is daunting, long-term and unpredictable.

“Suicide is one of the most complex public- health problems,” says Dr. Mark Kaplan, a professor of community health at Portland State University who served on the VA’s Blue Ribbon Work Group on Suicide Prevention last year. “With all that we’ve learned, the suicide rate has not changed that much over time. The bottom line is, there’s so much we don’t understand.”

That’s true for all suicides, military or otherwise, in part because of a lack of data. The National Center for Health Statistics estimates there are 33,000 suicides in the United States each year. “We might be underestimating suicides in the general population by 25 to 50 percent,” Kaplan says.

Because of the lack of comprehensive data, Kaplan and other researchers are wary of drawing conclusions about what’s happening in the military.

“The evidence regarding combat-related experience seems to be mixed,” he says.

“There’s often a lag time between combat exposure and post-traumatic stress disorder. Even World War II veterans, 40 years later, might experience the toll of PTSD.”

Soldier suicides over the past six years illustrate how difficult it is to find definitive answers. The Army acknowledges that repeated deployments may be contributing to the overall increase in numbers, but that’s only part of the issue. Roughly 40 percent of soldiers and 35 percent of Marines who have taken their own lives since 2003 never deployed to Iraq or Afghanistan. A recent Army study also concluded that the majority of U.S. soldiers in Iraq and Afghanistan who killed themselves did so during their first deployment. Suicides aren’t just occurring among soldiers serving in the global war on terror.

“We have other veterans trying to commit suicide – guys who served in Vietnam, Korea, World War II, the Gulf War and Panama,” says Jim Deremo, The American Legion’s department service officer in North Dakota. He helped start Courage Carries On, a suicide-prevention campaign that reaches out to veterans and servicemembers in his state. Deremo says he sees an increase in PTSD among veterans after they retire. “When you are busy working and raising a family, you don’t have time to think about it.”

Elements of the problem are often traced back to date back to the Civil War, when soldiers were first allowed to take their guns home.

“That’s when we see the rise in the number of suicides by firearms,” Kaplan says. He points to a June 1865 New York Times obituary detailing how the man who fired the first shot on Fort Sumter later turned his gun on himself.

“Ownership and possession of firearms is very high among people who successfully complete suicide,” Kaplan says. “Suicide involving guns provides a very limited window to intervene.”Pain vs. Death. Tammy Schroeder has reached for a gun many times. “The pain is so bad that death is the only alternative,” she says. The Air Force veteran has fought suicidal urges since she was raped while on active duty in 1983. “When you are sticking a gun in your mouth, you think, ‘This is utopia. The pain is going to be over.’ Unless you’ve been where I’ve been, you can’t understand it.”

Schroeder plunged into depression and started self-medicating with alcohol and over-the-counter drugs. She lost her marriage, her 2-year old and her infant. “It’s not what he did to me,” she says of the perpetrator. “It’s what he took from me.”

Two decades later, Schroeder finally told her story to a fellow veteran at the South Dakota American Legion’s Mid-Winter Conference. That woman, Terry Towns, was office manager for the Sioux Falls Vet Center and got Schroeder in touch with counselors. It saved her life.

“I got such outstanding care,” says Schroeder, who is featured in the Courage Carries On campaign as someone who benefited from seeking help. Even today, she keeps the telephone numbers for suicide-prevention hotlines on her refrigerator.

Although it took Schroeder years to seek counseling, most male soldiers never reach out. “So many people who are returning after multiple deployments are men who don’t want to talk about their problems,” says Kaplan, the Portland State University suicide expert. The stigma of mental illness remains powerful. So the question for the military is, “How do you educate young soldiers to seek help?”

“I think the way we get rid of the stigma is that we continue to educate others and talk about it, ” Graham says, “and let people know there is help, there is care for you out there. Going to behavioral health doesn’t mean someone is crazy. It means something is wrong.”

Psychological problems are not always the issue. Many military suicides involve younger soldiers with relationship or financial problems – and easy access to firearms.

“Men feel very uncomfortable when the ground shifts under them,” Kaplan says.

“They succumb to a sense of shame, a loss of control. Suicide is a way of taking control over their life.”

Financial and family issues, he says, could be dealt with by social workers instead of counselors, which would reduce the stigma associated with getting help.Lt. Col. Ross Waltemath, of the Indiana National Guard, agrees. “The majority of our folks who are in crisis have marital problems or financial problems, not psychological problems.”Transition Assistance. Kaplan says a more seamless transition from the military to VA and civilian life can reduce the stress on soldiers who are demobilizing or leaving the service. Travis Rhoads knows this territory firsthand. He re-enlisted in 2007, following a three-year break from the Army, after finding it difficult to support his wife and four children as a truck driver for a soft-drink company. Four months into his combat tour in Iraq, he tried to kill himself.

Rhoads was shipped home and enrolled in a program designed to streamline the handoff of servicemembers from DoD to VA. Instead, it took a year for him to make his way through the system, get the medical exams, and receive a disability rating so he could be placed on long-term temporary medical leave from the Army. The delays, paperwork and uncertainty exacerbated his anxiety, making it hard to find a job.

“There I am, trying to juggle so much with finances and my medical board, keep my treatment going and keep my sanity,” Rhoads says. “I don’t know how many times I had to ask, ‘Where’s my paperwork?’ I’m exhausted.”

Adele Kubein watched her daughter go through a frustrating three-year transition from the military to VA after she came home from Iraq in 2004 with a broken leg, traumatic brain injury and a battered, suicidal mind. Her daughter had served in combat for 10 months as a .50-caliber gunner and field mechanic with the Oregon Army National Guard. “She was a total wreck. I went to the barracks and there she was at the end of the hall with a cane, bent over and crying,” Kubein says.

She believes the counseling offered by the Returning Veterans Project saved her daughter’s life. The Oregon-based group, staffed by counselors who provide free services to servicemembers and families, arranged for a therapist with combat experience in Vietnam to care for her daughter.

Such concerns resonate with the people who established Courage Carries On. Despite assurances from the military, many servicemembers still believe counseling will hurt their careers, Deremo says. Some veterans, especially from the Vietnam era, refuse to go to VA because of how they were treated when they first returned home.

That’s tragic. “Don’t wait 23 years to get help like I did,” Schroeder says. “You hurt so many other people.” For her, there’s an equally pressing reason to make the call whenever she’s feeling her worst. “If I kill myself,” she says, remembering the man who assaulted her more than 20 years ago, “he’s won.” Ken Olsen is a freelance writer and frequent contributor to The American Legion Magazine.