Elsevier

Social Science & Medicine

Volume 236, September 2019, 112341
Social Science & Medicine

U.S. combat veterans’ responses to suicide and combat deaths: A mixed-methods study

https://doi.org/10.1016/j.socscimed.2019.05.046Get rights and content

Highlights

  • Responses to combat and suicide loss were examined among recent U.S. combat veterans.

  • Veterans report combat deaths are expected and easier to accept than suicide losses.

  • Degree of combat exposure was associated with veterans' level of grief.

  • Grief is a long-overlooked toll of war. .

Abstract

Rationale

Limited research has examined how combat veterans experience deaths of comrades to combat or suicide. We sought to investigate the process and identify factors that predict the level of grief among post-9/11 U.S. veterans.

Methods

Using a mixed-methods study design during 2016–2017, U.S. combat veterans of the Iraq and Afghanistan conflicts who lost comrades to both combat and suicide (N = 28) participated in semi-structured interviews, and veterans who lost a comrade in combat or to suicide (N = 178) completed online surveys that assessed grief, combat exposure, unit cohesion, anger, posttraumatic stress symptoms (PTSS), and past diagnoses of PTSD and depression.

Results

Text analyses of interview transcripts revealed seven themes: 1) Suicide death is unexpected and can make acceptance of loss harder; 2) Combat death is expected and can ease acceptance of loss; 3) Combat death is heroic and can make acceptance of loss easier; 4) Brotherhood forged in combat intensifies the emotional response; 5) Guilt over the inability to prevent a comrade's death makes acceptance harder; 6) Attribution of blame for a death creates anger; and 7) Detachment from the civilian world may make it more difficult to cope with comrades' deaths. Regression analyses of survey data indicated: 1) suicide loss predicted non-acceptance of the loss; 2) mode of death moderated the association between unit cohesion and grief; 3) combat exposure, anger, closeness to the deceased, and having a past diagnosis of depression predicted the level of grief; and 4) combat exposure is a similarly strong predictor of grief and PTSS. Results highlight how veterans' grief further delineates war's toll.

Conclusion

The mixed-methods design tells a rich story about a previously unexplored consequence of war. These findings have important public health implications because outcomes impact not only veterans but also their families and communities.

Introduction

More than 5400 U.S. troops have been killed serving in Afghanistan and Iraq since the wars began in 2001 and 2003, respectively (Department of Defense, 2018). As the number of troops killed in action has declined, the military suicide rate has at times surpassed the rate of casualties (Williams, 2012). A military combat career carries a fundamental risk of injury or death, as well as the loss of comrades in battle. However, U.S. troops have borne the additional toll of losing comrades to suicide, which most often has occurred off the battlefield post-deployment (Bush et al., 2013). Until 2008, the U.S. military suicide rate was below that of the general population, yet it presently exceeds the civilian rate, and the military suicide rate is also greater than the combat casualty rate (Nock et al., 2013). A 2017 Iraq and Afghanistan Veterans of America (IAVA) survey found that 58% of post-9/11 veterans know a veteran who died by suicide and 65% know a veteran who has attempted suicide (Iraq and Afghanistan Veterans of America, 2017).

While there has been abundant research quantifying war's psychological impact, much of it has focused on posttraumatic stress disorder (PTSD), depression, and substance use or abuse associated with combat exposure (Lubens and Bruckner, 2018). The few grief studies in the military community have focused primarily on military families. For example, while studying the experiences of military children, Kaplow et al. (2013) used a framework that included the role of combat deployments, post-deployment reintegration of the service member, and the aftermath of combat death. The authors did not apply the same framework to the losses experienced by service members or veterans themselves.

Scant research has focused specifically on grief responses in military personnel, explored how troops feel if they have lost members of their units in battle or to suicide, or considered whether grief is a distinct outcome from PTSD. A few studies have focused on long-term grief in veterans (Cerel et al., 2015; Pivar and Field, 2004; Shatan, 1974). For example, in a study of veterans who experienced a suicide loss at some point in their lifetime, Cerel et al. (2015) found that perceived closeness to the deceased predicted prolonged grief. Highlighting the saliency of the issue, a study of U.S. Vietnam veterans decades after the conflict ended found that 68.1% reported losing a close friend in combat and their prolonged grief was associated with adverse physical and mental health and poor family relationships (Currier and Holland, 2012). Only one study has focused on grief in U.S. veterans who served in Afghanistan and Iraq — Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF), respectively — and the researchers measured grief with a single item and examined its association with physical health problems (Toblin et al., 2012). Thus, although past research has elucidated grief in military families and has explored protracted grief over battle deaths in Vietnam veterans, we still know very little about how OIF/OEF veterans have experienced the loss of comrades and if their responses to combat and suicide deaths differ.

Despite the fact that there is limited grief research focusing on service personnel or veterans, research in the civilian community suggests that grief responses are highly variable (Wortman and Silver, 1989) and may depend on the circumstances and mode of death. Some literature highlights the differences between expected and unexpected deaths, and it attributes differential grief response to the unanticipated or sudden nature of a death (e.g., Bailley et al., 1999; Stroebe et al., 2012). Other research in the civilian community has drawn distinctions between suicide loss versus other forms of death in terms of survivors searching for the death's meaning, as well as differential emotions the losses engender, including guilt, shame, and anger (e.g., Jordan, 2001; Miles and Demi, 1992).

Additional literature focuses on unique responses to suicide. For example, Jordan (2001) described three primary differences between grief responses to suicide and grief over other causes of death: the “thematic content” of the grief, the social dynamics, and how grief may upset a family system. Moreover, other researchers have found a greater sense of rejection, a higher feeling of shame and level of grief (Bailley et al., 1999), or greater self-blame (Miles and Demi, 1992) in response to suicide death compared to other causes of death. Additionally, the confluence of negative social attitudes and poor social support following suicide loss (Cvinar, 2005) can complicate responses to suicide, largely due to the stigma associated with suicide itself (Ginsburg, 1971; Pitman et al., 2018), or to stigmatization of friends and loved ones of people who die by suicide (Doka, 2008; Jordan, 2001).

In addition to exploring grief responses to different circumstances or modes of death, civilian bereavement research also suggests that social support and a social network's quality are predictors of grief (e.g., Hibberd et al., 2010; Walker et al., 1977). Findings about the protective role of social support in bereavement suggest that military unit cohesion might influence the level of grief in service members or veterans. Unit cohesion in the military, which is an attachment akin to family ties or close social networks (Siebold, 2007), is comparable to civilian social cohesion and may play a similar socially-supportive role (Currier et al., 2018). This cohesion and familial-like attachment may predict the same sort of guilt in the military over suicide that has been seen in the civilian community. Furthermore, we might wonder if this familial-like bond among service members might also create guilt over failure to prevent the death of a comrade in battle, whereas the civilian response to a homicide death is less likely to evoke the same sort of guilt.

Although grief research in the civilian community raises important questions about grief in service members over the loss of comrades, there are substantial differences between civilian and military losses. For example, while studies in the civilian community typically classify both suicide and violent deaths as unexpected (e.g., Bailley et al., 1999), combat deaths — which are inherently violent — may be expected because death is intrinsic to war. On the other hand, military suicide deaths, particularly those that occur after troops have returned home, are likely to be unexpected. In addition, the societal stigmatization of suicide in the civilian community may also carry over to the military. In the military context, we might wonder if suicide is stigmatized as a sign of weakness, or if a person who dies by suicide is regarded as having been cowardly compared to the person who dies in combat, who may be regarded as a hero. Consequently, veterans might feel more grief over a combat death than a suicide death.

The uniqueness of military service and its duties may also distinguish predictors of grief among veterans from predictors of grief among civilians. Although combat exposure and combat trauma have been associated with deleterious psychological outcomes such as depression and PTSD (Lubens and Bruckner, 2018), given that combat exposure and loss of comrades in battle are likely to be inextricably linked, combat exposure may also be a risk factor for grief. Moreover, because we know that the suicide rate is higher in the military than in the civilian community (Nock et al., 2013), combat duty may not only be a greater risk for suicide, but also for suicide grief in comrades of the deceased. In addition to combat exposure, other factors that have been found to be associated with poor psychological responses to subsequent traumatic events, such as a history of mental health problems or prior adverse life events (Breslau et al., 2008; Seery et al., 2010), may also be relevant to understanding grief in combat veterans.

Section snippets

The present study

The purpose of this mixed methods study of U.S. OEF/OIF combat veterans was to delineate adverse outcomes in veterans by addressing a long-overlooked toll of combat service: grief. Using grief research conducted in the civilian community as a guide, our goal was to better understand how combat veterans experience the deaths of their military comrades to combat or suicide and what factors predict the nature and level of their grief. Through qualitative methods using semi-structured interviews,

Methods

All methods for the study were approved by the Institutional Review Board of the University of California, Irvine. Both components of this study were conducted simultaneously.

Sample

Interview participants. The participants in the qualitative component (N = 28) were residents of ten U.S. states. They had a mean age of 33 (ranging from 25 to 42). Most were in the Army (42.9%) or Marines (42.9%). They were ethnically diverse: Hispanic (38.5%), White (30.8%), multi-ethnic or multi-racial (16%), African American (4%), Asian (4%), Native American or Alaskan Native (4%), and Arab (4%). Almost 30% had some college education, and 59.2% had graduated from a university or had a

Discussion

The interviews and survey results tell a different story than grief research in the civilian community, which has classified both violent and suicide deaths as unexpected (Bailley et al., 1999). Our finding that the mode of death moderated the association between unit cohesion and grief (Fig. 2) was complemented by the qualitative theme describing the depth of bonding, the “brotherhood” forged in combat--a form of unit cohesion in the case of the all-male participants in our study's qualitative

Conclusions

Grief in veterans appears to have been largely overlooked by researchers studying the aftermath of war (Lubens and Silver, 2019). Our study tells an important story about veteran grief in light of research that has found deleterious prolonged mental and physical health effects of grief (e.g., Hibberd et al., 2010; Prigerson et al., 1997; Stroebe et al., 2007; Toblin et al., 2012). Results of the few studies that have explored grief in Vietnam-era combat veterans — conducted decades after they

Acknowledgements

This research was funded by the University of California, Irvine Program in Public Health Dissertation Research Fellowship, and the University of California, Irvine Center for Global Peace and Conflict Studies.

We thank Joanna Fagan for her assistance with transcription of the interview recordings, for her insight that contributed to the revision of the combat exposure measure, and for her recruitment of veterans to preview the survey.

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