Staff Perspective: WHY…WHY…WHY? - Why Are Rates of Suicide in the National Guard So High?
As parents of a toddler, we are on the precipice of big things in the realm of language development. My little girl points to items, motions for what she wants, and has a few words that she says. We have been blessed with a curious, adventurous child that I anticipate will very soon be asking a lot of whys, like “Why do I have to brush my teeth? Why can’t I wear my swimsuit in the winter? Why do I need to eat broccoli?” From an early age, people learn to be curious about the happenings of the world by asking “why.” However, in some cases the “why” becomes a question about tragic life events such as, “Why did this happen?” When I recently read the newly released 2016 Department of Defense Suicide Event Report (DoDSER), one particular tragic finding had me asking a curious, Why?
According to the CY2016 DoDSER report, while the suicide rates for active duty and reserve Service members were found to be similar to those of the US adult population (same age and sex), a major finding was that the rates for members of the National Guard (NG) were elevated. Multiple studies have reported that NG members are considered especially high-risk for suicide (Baucom et al., 2017; Bryan et al., 2017; Rynders, 2013). My goal in this blog is to explore some of the reasons WHY that is and identify some steps that behavioral health providers and the military community can take to help address this issue.
There are some standard suicide risk factors specific to the military population that are present for NG members. In general, Service members are more likely to own personal firearms, engage in alcohol and drug use, and report interpersonal relationship problems. Additionally, National Guard members face some unique stressors as compared to civilians and their active duty counterparts. Let’s take a look at some of these now.
What is happening?
Service Commitment
Some members of the Guard entered service in a time of peace and now are faced with a much different service commitment than they had anticipated. According to Rynders (2013), members of the National Guard have dealt with extraordinarily high stress levels because of multiple combat deployments, national disasters, and peacekeeping missions since 9/11. When NG members return to home and work after deploying, they may face challenges reintegrating and feel isolated. These unique stressors of the NG service commitment may lead to an increased risk for suicide.
Employment
The dual role of Guard members being both citizens and Service members places significant stress on them (Griffith, 2016). This can be seen especially in the employment arena. NG members have to balance their Service commitments, while also juggling the needs of their civilian jobs. In many instances, this can lead to interrupted employment and underemployment. As might be expected, employment issues may also then contribute to relationship and financial stressors. All of these issues serve as stressors which can contribute to suicidality for NG Service members.
Relationship Issues
Relationship problems are not unique to NG members, but the unpredictable lifestyle of NG members may contribute to higher discord in intimate relationships. For instance, NG families make frequent adjustments while on weekend drill or deployments. These disruptions can lead to tension and communication difficulties. When there are chronic problems, such as persistent criticism or perceived rejection in a relationship, it can cause elevation of suicidality for Service members.
Suicide Contagion
Many researchers have been looking closely at suicide exposure, which is commonly referred to as suicide contagion. Bryan and colleagues (2017) reported that 65.4% of National Guard members indicated knowing someone who died by suicide. When there is a perceived closeness to someone who has died by suicide, those around that individual will be at a heightened risk for suicide. The first year after exposure to suicide is an especially high-risk time for National Guard members (Bryan et al., 2017).
Lack of or Insufficient Suicide Prevention Programs
While all branches of Service have been developing and refining suicide prevention programs, these are lacking or insufficient within the NG. Suicide prevention screening is widely implemented. However, this screening may not always identify high-risk Service members in the NG because the timing of the screening may not correspond with a suicidal episode or because members may be motivated to minimize risk to preserve their service record (Baucom et al., 2017). Service members who are at chronic risk of suicide may go undetected when the military system has sporadic, limited contact with those serving in the NG.
Command Limitations
When commanders of active duty Service members are concerned about the safety or well-being of their members, they can order a commander-directed evaluation. However, within the NG, commanders can only direct a mental health evaluation when a NG member is on duty (i.e., drill weekends, annual training, or while deployed/mobilized). Further, if a NG member seeks behavioral health treatment on his/her own, there is no obligation to report this treatment to chain of command as there is for active duty Service members.
Poor Access to Healthcare
NG members report significant concerns about mental health stigma and service utilization on military records as a primary barrier to seeking care (Gorman et al., 2011). An additional common barrier includes cost. Members of the NG and their families are not eligible for military healthcare programs unless they are mobilized or they choose to pay large premiums to acquire their healthcare through the military. Also, many NG members live far away from a military treatment facility and may have trouble locating civilian providers with military experience.
What can be done?
- After a suicide occurs, behavioral health and other supports should explore the perceived closeness of Service members to the member who died. In the first year following exposure to a suicide, the intervention used for Service members should include a focus on the psychological effects of the suicide loss (Bryan et al., 2017).
- Helping NG members identify sources of stress, providing support to reduce their stress, and increasing capacity to deal with stress will aid in reducing suicidality (Kim et al., 2017).
- Behavioral health clinics and providers should ensure their screening/intake paperwork includes inquiry about total suicide exposure over an individual’s lifetime, as opposed to a simple yes or no question about exposure to suicide. Sample questions might include: Do you know anyone who has died by suicide? How many people have you known who have died by suicide? Rate your perceived closeness to the person or people who died by suicide. (Bryan et al., 2017).
- Military and community leaders should encourage utilization of behavioral health professionals as a routine response to suicide. This support will increase NG member access to these services and decrease stigma.
- Military treatment facilities and the military community should perform post-deployment health assessments and can encourage openness about any difficulties NG service members are experiencing while reintegrating, so that these can be addressed.
- Case management services can be essential to NG Service members. For members at risk for suicide, these services can ensure that the members get connected to community behavioral health services, attend appointments, and assist in addressing other issues that may be impacting well-being.
- Means Safety counseling should be enacted to ensure NG members who are at elevated risk for suicide do not have access to the means they plan on using to kill themselves (Griffith, 2016).
- Behavioral health providers and NG leadership should also be regularly talking with NG members about familial issues and employment concerns, as these are often a source of stress that can contribute to suicidality.
This blog explored the problem of suicide within the NG community and examined a variety of the reasons why NG Service members may be at higher risk for suicide. One possible resource to help address this problem within the NG community is the Star Behavioral Health Providers (SBHP) program. SBHP is a resource for Veterans, Service members and their families. SBHP has a registry of civilian providers who have completed trainings that are intended to make them better able to understand, assess and counsel members of the military and their families. SBHP is currently offered in the following states: Indiana, Michigan, Ohio, Oregon, California, Georgia, South Carolina, Utah, and New York. Click here to learn more about SBHP and the trainings being offered. As behavioral health professionals and a military community, we must continue asking why this is happening and seek out appropriate responses to this alarming problem.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Erin Frick, Psy.D., is a Military Internship Behavioral Health Psychologist at the Center for Deployment Psychology (CDP) at Uniformed Services University of the Health Sciences in Bethesda, Maryland.
Resources
Baucom, B. R. W., Georgiou, P., Bryan, C. J., Garland, E. L., Leifker, F., May, A.,…Narayanan, S. S. (2017).The promise and the challenge of technology-facilitated methods for assessing behavioral and cognitive markers of risk for suicide among U. S. Army National Guard Personnel. International Journal of Environmental Research and Public Health, 14(361), 1-18. doi:10.3390/ijerph14040361
Bryan, C. J., Cerel, J., & Bryan, A. O. (2017). Exposure to suicide is associated with increased risk for suicidal thoughts and behaviors among National Guard military personnel. Comprehensive Psychiatry, 77, 12-19. doi.org/10.1016/j.comppsych.2017.05.006
Gorman, L. A., Blow, A. J., Ames, B. D., & Reed, P. L. (2011). National Guard families after combat: Mental health, use of mental health services, and perceived treatment barriers. Psychiatric Services, 62(1), 28-34.
Griffith, J. (2016). A description of suicides in the Army National Guard during 2007-2014 and associated risk factors. Suicide and Life-Threatening Behavior, 47, 266-281. doi:10.1111/sltb.12275
Kim, H. M., Levine, D. S., Pfeiffer, P. N., Blow, A. J., Marchiondo, C., Walters, H., & Valenstein, M. (2017). Postdeployment suicide risk increases over a 6-month period: Predictors of increased risk among Midwestern Army National Guard soldiers. Suicide and Life-Threatening Behavior 47(4), 421-435. doi:10.1111/sltb.12303
Martin, R. L., Houtsma, C., Green, B. A., & Anestis, M. D. (2016). Support systems: How post-deployment support impacts suicide risk factors in the United States Army National Guard. Cognitive Therapy and Research, 40, 14-21. doi:10.1007/s10608-015-9719-z
Rynders, T. G. (2013). Suicide prevention in the Army National Guard: Modeling effective strategies. U.S. Army War College Fellowship.
Pruitt, L.D., Smolenski, D.J., Bush, N.E., Skopp, N.A., Edwards-Stewart, A., & Hoyt, T. V. (2017). Department of Defense Suicide Event Report Calendar Year 2016 Annual Report. National Center for Telehealth & Technology and Defense Centers of Excellence for Psychological Health & Traumatic Brain Injury.
As parents of a toddler, we are on the precipice of big things in the realm of language development. My little girl points to items, motions for what she wants, and has a few words that she says. We have been blessed with a curious, adventurous child that I anticipate will very soon be asking a lot of whys, like “Why do I have to brush my teeth? Why can’t I wear my swimsuit in the winter? Why do I need to eat broccoli?” From an early age, people learn to be curious about the happenings of the world by asking “why.” However, in some cases the “why” becomes a question about tragic life events such as, “Why did this happen?” When I recently read the newly released 2016 Department of Defense Suicide Event Report (DoDSER), one particular tragic finding had me asking a curious, Why?
According to the CY2016 DoDSER report, while the suicide rates for active duty and reserve Service members were found to be similar to those of the US adult population (same age and sex), a major finding was that the rates for members of the National Guard (NG) were elevated. Multiple studies have reported that NG members are considered especially high-risk for suicide (Baucom et al., 2017; Bryan et al., 2017; Rynders, 2013). My goal in this blog is to explore some of the reasons WHY that is and identify some steps that behavioral health providers and the military community can take to help address this issue.
There are some standard suicide risk factors specific to the military population that are present for NG members. In general, Service members are more likely to own personal firearms, engage in alcohol and drug use, and report interpersonal relationship problems. Additionally, National Guard members face some unique stressors as compared to civilians and their active duty counterparts. Let’s take a look at some of these now.
What is happening?
Service Commitment
Some members of the Guard entered service in a time of peace and now are faced with a much different service commitment than they had anticipated. According to Rynders (2013), members of the National Guard have dealt with extraordinarily high stress levels because of multiple combat deployments, national disasters, and peacekeeping missions since 9/11. When NG members return to home and work after deploying, they may face challenges reintegrating and feel isolated. These unique stressors of the NG service commitment may lead to an increased risk for suicide.
Employment
The dual role of Guard members being both citizens and Service members places significant stress on them (Griffith, 2016). This can be seen especially in the employment arena. NG members have to balance their Service commitments, while also juggling the needs of their civilian jobs. In many instances, this can lead to interrupted employment and underemployment. As might be expected, employment issues may also then contribute to relationship and financial stressors. All of these issues serve as stressors which can contribute to suicidality for NG Service members.
Relationship Issues
Relationship problems are not unique to NG members, but the unpredictable lifestyle of NG members may contribute to higher discord in intimate relationships. For instance, NG families make frequent adjustments while on weekend drill or deployments. These disruptions can lead to tension and communication difficulties. When there are chronic problems, such as persistent criticism or perceived rejection in a relationship, it can cause elevation of suicidality for Service members.
Suicide Contagion
Many researchers have been looking closely at suicide exposure, which is commonly referred to as suicide contagion. Bryan and colleagues (2017) reported that 65.4% of National Guard members indicated knowing someone who died by suicide. When there is a perceived closeness to someone who has died by suicide, those around that individual will be at a heightened risk for suicide. The first year after exposure to suicide is an especially high-risk time for National Guard members (Bryan et al., 2017).
Lack of or Insufficient Suicide Prevention Programs
While all branches of Service have been developing and refining suicide prevention programs, these are lacking or insufficient within the NG. Suicide prevention screening is widely implemented. However, this screening may not always identify high-risk Service members in the NG because the timing of the screening may not correspond with a suicidal episode or because members may be motivated to minimize risk to preserve their service record (Baucom et al., 2017). Service members who are at chronic risk of suicide may go undetected when the military system has sporadic, limited contact with those serving in the NG.
Command Limitations
When commanders of active duty Service members are concerned about the safety or well-being of their members, they can order a commander-directed evaluation. However, within the NG, commanders can only direct a mental health evaluation when a NG member is on duty (i.e., drill weekends, annual training, or while deployed/mobilized). Further, if a NG member seeks behavioral health treatment on his/her own, there is no obligation to report this treatment to chain of command as there is for active duty Service members.
Poor Access to Healthcare
NG members report significant concerns about mental health stigma and service utilization on military records as a primary barrier to seeking care (Gorman et al., 2011). An additional common barrier includes cost. Members of the NG and their families are not eligible for military healthcare programs unless they are mobilized or they choose to pay large premiums to acquire their healthcare through the military. Also, many NG members live far away from a military treatment facility and may have trouble locating civilian providers with military experience.
What can be done?
- After a suicide occurs, behavioral health and other supports should explore the perceived closeness of Service members to the member who died. In the first year following exposure to a suicide, the intervention used for Service members should include a focus on the psychological effects of the suicide loss (Bryan et al., 2017).
- Helping NG members identify sources of stress, providing support to reduce their stress, and increasing capacity to deal with stress will aid in reducing suicidality (Kim et al., 2017).
- Behavioral health clinics and providers should ensure their screening/intake paperwork includes inquiry about total suicide exposure over an individual’s lifetime, as opposed to a simple yes or no question about exposure to suicide. Sample questions might include: Do you know anyone who has died by suicide? How many people have you known who have died by suicide? Rate your perceived closeness to the person or people who died by suicide. (Bryan et al., 2017).
- Military and community leaders should encourage utilization of behavioral health professionals as a routine response to suicide. This support will increase NG member access to these services and decrease stigma.
- Military treatment facilities and the military community should perform post-deployment health assessments and can encourage openness about any difficulties NG service members are experiencing while reintegrating, so that these can be addressed.
- Case management services can be essential to NG Service members. For members at risk for suicide, these services can ensure that the members get connected to community behavioral health services, attend appointments, and assist in addressing other issues that may be impacting well-being.
- Means Safety counseling should be enacted to ensure NG members who are at elevated risk for suicide do not have access to the means they plan on using to kill themselves (Griffith, 2016).
- Behavioral health providers and NG leadership should also be regularly talking with NG members about familial issues and employment concerns, as these are often a source of stress that can contribute to suicidality.
This blog explored the problem of suicide within the NG community and examined a variety of the reasons why NG Service members may be at higher risk for suicide. One possible resource to help address this problem within the NG community is the Star Behavioral Health Providers (SBHP) program. SBHP is a resource for Veterans, Service members and their families. SBHP has a registry of civilian providers who have completed trainings that are intended to make them better able to understand, assess and counsel members of the military and their families. SBHP is currently offered in the following states: Indiana, Michigan, Ohio, Oregon, California, Georgia, South Carolina, Utah, and New York. Click here to learn more about SBHP and the trainings being offered. As behavioral health professionals and a military community, we must continue asking why this is happening and seek out appropriate responses to this alarming problem.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Erin Frick, Psy.D., is a Military Internship Behavioral Health Psychologist at the Center for Deployment Psychology (CDP) at Uniformed Services University of the Health Sciences in Bethesda, Maryland.
Resources
Baucom, B. R. W., Georgiou, P., Bryan, C. J., Garland, E. L., Leifker, F., May, A.,…Narayanan, S. S. (2017).The promise and the challenge of technology-facilitated methods for assessing behavioral and cognitive markers of risk for suicide among U. S. Army National Guard Personnel. International Journal of Environmental Research and Public Health, 14(361), 1-18. doi:10.3390/ijerph14040361
Bryan, C. J., Cerel, J., & Bryan, A. O. (2017). Exposure to suicide is associated with increased risk for suicidal thoughts and behaviors among National Guard military personnel. Comprehensive Psychiatry, 77, 12-19. doi.org/10.1016/j.comppsych.2017.05.006
Gorman, L. A., Blow, A. J., Ames, B. D., & Reed, P. L. (2011). National Guard families after combat: Mental health, use of mental health services, and perceived treatment barriers. Psychiatric Services, 62(1), 28-34.
Griffith, J. (2016). A description of suicides in the Army National Guard during 2007-2014 and associated risk factors. Suicide and Life-Threatening Behavior, 47, 266-281. doi:10.1111/sltb.12275
Kim, H. M., Levine, D. S., Pfeiffer, P. N., Blow, A. J., Marchiondo, C., Walters, H., & Valenstein, M. (2017). Postdeployment suicide risk increases over a 6-month period: Predictors of increased risk among Midwestern Army National Guard soldiers. Suicide and Life-Threatening Behavior 47(4), 421-435. doi:10.1111/sltb.12303
Martin, R. L., Houtsma, C., Green, B. A., & Anestis, M. D. (2016). Support systems: How post-deployment support impacts suicide risk factors in the United States Army National Guard. Cognitive Therapy and Research, 40, 14-21. doi:10.1007/s10608-015-9719-z
Rynders, T. G. (2013). Suicide prevention in the Army National Guard: Modeling effective strategies. U.S. Army War College Fellowship.
Pruitt, L.D., Smolenski, D.J., Bush, N.E., Skopp, N.A., Edwards-Stewart, A., & Hoyt, T. V. (2017). Department of Defense Suicide Event Report Calendar Year 2016 Annual Report. National Center for Telehealth & Technology and Defense Centers of Excellence for Psychological Health & Traumatic Brain Injury.