On Contact: High rates of suicide among combat veterans

CM: Military veterans make up 8% of the U.S. adult population but account for 13.5% of the adult suicides in the United States. Data from Veterans Affairs shows, among veterans that had deployed to Iraq and Afghanistan, suicide rates are 4 to 10 times higher than their civilian peers, but even these statistics may be understating suicide rates among combat veterans. In a 2015 story, a Marine Corps infantry unit that was tracked after coming home from war saw suicide rates among its young men 4 times greater than other young, male veterans and 14 that of civilians. This high rate of suicide in veterans leads to a total number of deaths of combat troops at home that surpasses the totals killed in war. In 2011, an investigative piece in the "Bay Citizen" that examined public health records found that 1,000 Californian veterans under the age of 35 died from 2005 to 2008. That is 3 times the number killed in Iraq and Afghanistan during the same period. Close to two Afghan and Iraq veterans die by suicide each day on average, meaning the estimated 7,300 veterans who have killed themselves since just 2009 after coming home from Afghanistan and Iraq are greater in number than the 7,012 servicemembers killed in those wars since 2001. Why is suicide such an epidemic among combat veterans from our wars in the Middle East? Joining me to discuss veteran suicides is Matthew Hoh, who served as a Marine Corps company commander in Iraq and later as a State Department official in Afghanistan, resigned in protest over the escalation of the war, so, Matthew--and I spent 20 years covering war; I didn't carry a weapon, and that's an important distinction, but certainly dealt with PTSD, as I know you have--let's first just explain what PTSD does to you, and I know you've fought this battle, too.

MH: Yeah, absolutely, Chris, and thank you for having me on, and I think that point you made is something, you know, we'll get into about the difference as a perpetrator or war--and, say, I was--as opposed to somebody who has taken part in the war, as you were, but was not a perpetrator of the violence, and that's an important distinction.

CH: And I want to throw in, that's a very important distinction which I've always felt...

MH: It's there. Yes.

CH: makes my struggle with PTSD far easier than yours.

MH: Yeah, but I don't think that's fair, though. I don't think that's truly fair because I think when it comes down to when you're talking about veteran suicides, you don't see post-traumatic stress disorder, per se, as the reason for veteran suicides, so post-traumatic stress disorder is what occurs when somebody-- You know, and it doesn't have to just be a military member. Certainly, PTSD affects people in all aspects of life--people who were in car accidents, people who were victims of abuse, people who were victims of physical violence. You know, PTSD is that the body has been triggered into a state of survival, that all those survival chemicals in you--so whether it's the seroto--you know, the cortisols, the adrenalines that are produced by the body in order for the body to escape, in order for the body to survive, and in order for you to persevere through a life-threatening event--are continually triggered over and over again in instances where it is not necessary. Now, for someone like yourself, Chris, or someone like me or other veterans of war or people who participated in it, one of the real struggles with PTSD is that, say, for someone who goes to Iraq or Afghanistan--and, of course, this is--you know, we can get also to how this affects the people in these countries, but let's just talk about how it affects veterans for the moment--so when you're in Iraq of Afghanistan--you're a Marine, or you're a soldier or sailor or an airman--and every day, you're leaving your base, and you are hunting for other people, and other people are hunting for you, and you do that for 7 or 8 months, 9 or 10 months, 11 or 12 months, when you come home, that survival mechanism in you is not turned off, and so you're constantly in a state of hyperawareness, hypervigilance. All those survival chemicals are continually being kicked through your system, and that then turns into secondary effects where you have issues with, say, nightmares. You have issues with sleeping. You have issues with personality problems, irritability, you know, as well, then, too, that then turns into other issues, such as depression, relationship issues, problems at work, you know, and so you can understand how that spiraled, and it turns into mental health disorders, substance abuse, et cetera, and can ultimately lead towards suicide. However, I believe and what many other believe is, the main driver in veteran suicide is not PTSD, per se. However, it's something called moral injury, and moral injury is-- You know, it's kind of a fancy term for guilt, but it goes much deeper than that. Moral injury occurs when you transgress, when a person transgresses against his or her belief system, against their fundamental values, against what they believe, you know, whether it be based from a higher power; whether it be because what they are raised as, the values taught to them by their families, you know, by their communities; or whether it's just basically something they have come to on their own, but you've transgressed that. You've committed an act so vile, so abhorrent to your own senses that you are no longer the person you once were or the person that you thought you would be, and I can't emphasize enough how deep and how destructive that is. For me, going through those periods where I realized I had done this, I had this moral injury, it was a period of blackness. It was an undercutting of the very foundations of who I was, and you see this in study after study that's been conducted by the U.S. Veterans Administration, by American universities, by various researchers, also in international organizations in countries--including, say, in Vietnam or Israel--where veterans who have taken part in killing, that guilt, that moral injury has come home, and it subsumes them. It takes over their lives. These ghosts, as you will, take over their lives, and ultimately, the stress is to great that the only way to get out of that distress, the only relief from it, seems to be through suicide, and this is not something that is new. This is something that has occurred for as long as there's recorded history of warfare. There has been-- Whether there's recorded instances--but certainly, you're not gonna have statistics going back to the Romans, say--but certainly, we have anecdotal evidence in recorded history, as well, that as far back as the Romans, suicide among veterans was very common.

CH: I want to talk because there are different types of war, all of which I covered. I covered the civil wars in Central America. I covered the first Gulf War, which was largely mechanized warfare in the desert between Saudi Arabia and Kuwait, but the war that you fought in in Iraq and Afghanistan is much like the Israeli occupation, so as soon as you left the wire, soon as you went beyond the perimeter of wherever your base was, you were in hostile territory. In those kinds of wars, the enemy is often elusive. There are IEDs. You don't actually see them. You are taking casualties. It's very difficult to strike back because it's not a conventional war situation, and Robert Jay Lifton calls it "atrocity-producing situations." This is what happened in Vietnam when he was writing about Vietnam where suddenly, especially if you start losing people in your unit, everyone becomes the enemy and everyone becomes a legitimate target, and those kinds of wars are always very dirty. I mean, when I talked about the difference between my PTSD, which was quite severe after the war in Yugoslavia, I do think there is a distinction in that I never harmed anyone. I never shot anyone.

MH: Yeah.

CH: You call it moral injury. That's a very good term, and, anecdotally from having been around a lot of combat veterans, I think the worst PTSD--or the worst struggle, if you want to call it that, moral injury--comes from what you did. I had all the...

MH: Yes.

CH: you know, adrenaline and endorphins, everything else kicking in and had the nightmares, and I think we just want to say about PTSD, because I think a lot of people who haven't gone through it don't get it, what it does is, it renders you, at least in my case, numb. I couldn't sleep. I didn't tend to have nightmares in the war zone, but I'd always have them when I got out. I don't know what your experience was...

MH: Yeah.

CH: and sometimes you don't remember them. Sometimes you do, but over a period of nights, you don't sleep, and you're exhausted. You stumble into bed at 9:00. Then by 11:00 or 12:00, you're up. Your heart is racing. You just sit there until, you know, the light comes through the window, and what that does is--I can remember in my worst case--just to get up and shower and shave was almost a Herculean effort. You feel like you're crawling up, you know--and you have no energy--from the bottom of this dark, black hole, and, I mean, I managed to crawl out--you managed to crawl out--but I certainly, through that experience, understood that, you know, the psychological and physical distress is so debilitating, so crippling, and so frustrating, I got why people kill themselves.

MH: Yeah, and it is. I think it's appropriate. Like many other forms of mental health experiences, you know--whether, say, it's an eating disorder or whatever--unless you've experienced it yourself, it's really difficult to understand what the person is going through. In my case, exactly as you described, Chris, I dealt with the inability to sleep by drinking myself to the point where I was able to sleep, and then certainly, yeah, the nightmares, night terrors. You know, I hurt women who were sharing my bed with me, you know, because, you know, you act out those night terrors. Whether you're flailing out or actually punching, you know, I mean, you are a danger to others, and so, exactly, you know, as you were describing, you have this spiral with PTSD that ultimately leads to, you know, you lose your relationships, whether they be with a significant other. You know, another aspect of PTSD that is hardly ever spoken about is sexual dysfunction. One, you lose intimacy, but then, two, you also do have an inability to be intimate, and then if you're on a lot of the drugs that they give you for these types of problems, that often has an effect on your ability to have sex, and so you can imagine, you know, being a young couple and being unable to be intimate, being unable to have sex. It's just one more major problem that ends up destroying relationships, as well then, too, you're unable to work, as you say. You end up causing issues with friends and family, so you end up becoming a real burden on your community, you know, on your neighbors, on your family, et cetera, so this ripples out and affects people in such a great degree, and then, of course, you know, when a suicide occurs, the effect that that has, that has an effect on-- Directly, it has an effect on-- The numbers I've seen from one of the larger suicide-prevention networks in the United States is that approximately 165 people are directly affected by each suicide, so you can imagine how this ripples out and how it affects so many people who have been connected to this person, so it is not just-- While it is an invisible wound and it is occurring within somebody, it is affecting, you know, mass amounts of life, mass amounts of people, and entire, you know, relationships, work structures, neighborhoods, et cetera.

CH: And you wrote a very fine piece, "And the Armies That Remained Suffer'd: Veterans, Moral Injury and Suicide," but in the piece, you make a strong argument, in fact, the numbers, the official data that we have on veteran suicide is probably way too low.

MH: Correct, absolutely. It's hard to, one-- One of the problems is that about 70% of the veterans who are now killing themselves are not in veterans health services, are not receiving care from the V.A.

CH: When we come back, we'll continue our conversation about veteran suicides with former Marine Corps commander Matthew Hoh.

CH: Welcome back to "On Contact." We continue our conversation about veteran suicides with Matthew Hoh, so, Matthew, before the break, we were talking about the difference between being under care and not being under care, and you said that if people are being monitored by the V.A., their suicide rate is lower.

MH: That's correct. That's correct. The V.A. is criticized, and rightly criticized, for a number of different issues. In my opinion, those criticisms basically fall into the fact it's not resourced well enough. For example, there are roughly about 50,000 vacancies in V.A. staffing right now. However, if a veteran is under veterans health care and is receiving care from mental health specialists at the V.A., that veteran has a much lower chance of killing themselves than if they are not under care, but this goes back to your previous question, Chris, about how the numbers that we do know, you know, according to V.A. data--and this data is almost a year old already--but 7,300 veterans from the Iraq and Afghan wars have killed themselves just since 2009. You know, how do you-- There are oftentimes an undercounting, so if a veteran is in despair and he or she ODs, if a veteran is drink and crashes his car into a tree and dies, you know, that does not count as a suicide.

CH: Right.

MH: However, very much what occurred, the events that led to that death are all the same events, all the same stressors, all the same type of distress that a veteran who puts a gun in his mouth and pulls the trigger...

CH: Right.

MH: is going through.

CH: No. That's an important point. I mean, my uncle fought in the South Pacific in World War II and never recovered--he was wounded--both physically and psychologically. He came home to a small town in Maine and drank himself to death...

MH: Absolutely.

CH: and we didn't know the term "PTSD" at the time. I want to talk about the kind of existential crisis that veterans go through because, you know, especially in elite combat units, you often find very idealistic, young men and women who believe that, you know, they're going over to a place like Iraq and Afghanistan to help, that they are bringing liberty and democracy. They believe all the lies they are told by the government and church and Hollywood that we are a virtuous people, et cetera, and they run right into a reality that is very disquieting and one that the wider public back home just refuses to recognize, that we, in fact, can perpetuate evil as ruthlessly as terrorist groups like Al-Qaeda, that, you know, people in Iraq and Afghanistan don't want us there. The military itself, which is kind of deified in American society, is like any totalitarian, hierarchical institution, one that, you know--I watched it--I mean, senior officers, colonels, and on up in particular were sending kids off to combat missions which they weren't going on so they could get their combat infantry badge sewed onto their uniform as fast as they could.

MH: Mm-hmm.

CH: All of this is quite shattering, and so veterans such as yourself will come back and speak this truth, but it's a truth that the wider society not only doesn't recognize, but doesn't want to hear, and that creates, I think, an existential crisis that goes along with moral injury and goes along with PTSD.

MH: Yeah, absolutely. You know, just jump back one quick moment. It's important for people to remember that PTSD wasn't a recognized diagnosis in the American medical community until 1980. As well, then, to you point about your uncle drinking himself to death, you know, that certainly was my way to do it, as well, until it just got so bad, that I wanted to put a gun in my mouth, so certainly, yeah, there are all these other aspects about this that makes this very nuanced and very complicated but certainly, too, when you go overseas, and I should say, with moral injury, it doesn't just have to be something that you do. It can be something that you neglect to do...

CH: Mm.

MH: so if you see--right, I mean, or it can be something that is done to you, so if you deploy to the Iraq War and you think you're going over there, right, Chris, because you're going over to help liberate the Iraqi people because you've been told that Iraq is connected to Al-Qaeda, et cetera, and then when you found out you were lied to and you're seeing your friends killed for this, you've taken part in killing, that's another form of moral injury, that betrayal, as well as, two--and this is something that is becoming more understood--you know, between one in 4 and one in 3 women in the military will be sexually assaulted or raped, and that itself is a form of moral injury because most of the time, they're being raped or sexually assaulted by their superiors, so that's a betrayal of trust that turns into a moral injury, but then when you go to these wars, it's that you, for lack of a better term, feel that you have a white hat on, that you're going there to help people, and because of whether these wars are based on lies, whether because what occurred is out of your control, you know, I mean, 90% of the casualties in these wars, you know, depending upon how you count them, are civilians, so even--you know, you could be in a unit--and I like to say this, actually--you yourself could be over there trying to do--trying to be as moral as possible, but when you're in an immoral situation, that's not gonna work out. You're gonna take part in things that are inherently immoral because of the nature of war, because of the nature of these war in particular with the killing of civilians or the fact that they're based--built on lies, you know, and so when you come home and you leave that protective bubble of the military and you leave behind all the conditioning the military did to try and make--the military did to turn you into a killer and you come home and that conditioning starts to fade away and evaporate and you're now face to face with what you did over there, what you took part in over there, as well as who you used to be and who you believed yourself to be, that dissonance causes this moral injury, cause this incredible distress, and I also want to bring up, too, that, you know, everything we know about all American wars is that suicide rates have been exceptionally high for veterans, that we only have data in the last couple decades on our current veterans, whether they're from the World War II generation, they're from Vietnam or from the Iraq and Afghan wars, and we know statistically that all veterans have seen elevated rates of suicide as early as--I'm sorry--as late as 2010, World War II veterans, and so many of them are dying off because they're now mostly in their late 80s and early 90s, but World War II veterans had suicide rates in 2010 4 times higher than their civilian peers, and that was the good war, right? We know from literature. We know from newspaper accounts. We know from jail records. We know from different forms of media dating in the decades after the Civil War--the other good war in American history, right--that hundreds of thousands of Civil War veterans, including veterans of the North, ended up drinking themselves to death, ended up killing themselves, ended up homeless, ended up destitute. Many of them, literally hundreds of thousands of them, the prime killer of them was opium overdoses because of what they were going through, and, again, that was another good war...

CH: Right.

MH: so this idea that somehow that either this generation, my generation, of veterans are somehow mentally or emotionally weaker than past generations or that past generations didn't have these episodes and actually are still enduring these episodes of suicide is just completely false and is based completely on ignorance.

CH: I want to talk about the hypermasculine culture. You're a Marine. I went into Kuwait with First Battalion, First Marines--a very fine unit, actually--but one of the things that-- I like the Marines better than the Army. There's a more egalitarian quality to it, but what I did see in the Marine Corps was a lot of hazing, and that hypermasculine culture which was always part of the Marines really became exacerbated in combat zone, and there are suicides in combat zones, but oftentimes, those suicides are people who are being hazed by the unit either because they're overweight or they're different or whatever reason, and they go in a Porta Potty and take the--you know, put the barrel, a long-barreled weapon to their chin and blow their brains out.

MH: That's right.

CH: I want to talk about that hypermasculine culture because that's also a contributor, I think, to the psychological distress that veterans have to cope with.

MH: Yeah. It is. It is, you know, and it's pronouncing itself in other ways. You know, when you recruit for the Marine Corps and the same thing for the Army infantry, whereas other aspects of the military stress college tuition, stress gaining job skills, right, you know, education, seeing the world, you know, what have you, when it comes to recruiting for, say, the Marine Corps and the Army infantry and then, of course, the Special Operations, it's about being a warrior. It's about protecting your country. It is about proving yourself physically, and that is found throughout, you know, the entire life cycle or career cycle of someone who does that line of work,. Whether it's just for 3 1/2, 4 years or whether it's for 20 or 30 years, that type of machismo, for lack of a better term, is prevalent, and it pervades everything, you know, and it falls into line with, you know, their high rates of substance abuse. You know, it's really alcohol, but there's also some drug use, you know, that go hand in hand, this glorification of masculinity, this glorification of alcohol use, as well as, too, this glorification of violence, you know, and so it's something that is stuck with you. It is something that is a part of you. You are conditioned to kill because it's not in human nature to kill. It's human nature to protect, right, but it's not in human nature to kill, and that's why the Marine Corps and the Army have spent so much money studying on how to train to kill and how, if you join the Army infantry or the Marine Corps infantry, you spend months being taught how to kill, and then the remainder of your time in the--

CH: Well, just let me interrupt. Having read the studies, it's called operant conditioning, and it's exactly the same way you train a dog...

MH: That's exactly right.

CH: repeated response under stress. I think that hypermasculinity is also crippling in terms of intimacy in relationships, and a lot of veterans will come and cling to it, but it's very self-destructive. I want to-- Because we're almost done, I want to ask you a question which I, you know, have thought a lot about. Do you believe in heroism?

MH: Yeah. Wow. That's a good question. One quick trip back to the hypermasculinity...

CH: Yeah.

MH: you see this in really high rates of domestic violence...

CH: Yeah.

MH: in the military community and in veterans communities. There's very high rates of domestic violence, well above what the rate should be when compared to civilian rates, but in terms of heroism, you know, Chris, yeah. I do, and it's not in the heroism that you get from, you know, the television advertisements. You know, I think back to Stanley Kubrick's great film "Full Metal Jacket" and when the hero of that film, if you will, goes to Marine Corps boot camp. He calls Parris Island the home of the fake tough and the phony brave, and here's--

CH: I have to stop you there, Matthew, because it's the end, but what you're talking about is moral courage, as opposed to physical courage, and on a battlefield...

MH: That's right.

CH: you can often see a lot of physical courage, but not much moral courage, and you're right, and for me, that is heroism, as opposed to physical courage. All right. Thanks, Matthew. That was great. Thanks for being on the show.

MH: You bet, Chris.

CH: That was Matthew Hoh, former Marine Corps company commander in Iraq, now an activist on combat veteran suicides.