FInal Essay_Suicide Among Female Veterans

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1 The Suicidal Female Veteran STUDENT School of Behavioral Sciences, Liberty University CCOU304: Christian Counseling for Women (D01) Dr. Kristin Kellen August 4, 2023

2 Introduction When God first created man and woman, they lived in harmony with their Creator and the world around them. However, this peace did not last forever, and in Genesis 3, Adam and Eve committed the original sin. Since sin entered the world, mankind has been living in sin’s shadow, fighting demons of all sorts. Living under the curse of sin and fighting Satan’s influence every day can be a heavy burden to carry, and, unfortunately, the burden becomes too heavy for them to carry. Exhausted and with feelings of hopelessness and helplessness, and not knowing who to ask for help, some decide to give up the fight and turn to suicide. For the purposes of this essay, it is critical to provide operational definitions for different terms related to suicide. First, suicide is defined as “taking one’s own life” (Kellen, 2022, p. 133). Suicidal ideations are the thoughts, ideas, or wishes surrounding suicide. And a suicide attempt simply means that a person has made an attempt, whether or not the attempt was successful (Kellen, 2022, p. 133). In 2021, 12.3 million adults had serious suicidal ideations; 1.7 million adults attempted suicide, and 48,183 people completed suicide (CDC.gov: Facts About Suicide, 2023). That means that approximately 1 of God’s people, created in His image, dies by suicide every 11 minutes (CDC.gov: Facts About Suicide, 2023). Suicide is a scary topic, one that is often considered taboo. However, it is a subject that must be addressed and examined further because is the tenth leading cause of death in the United States as of 2020 (Kellen, 2022, p. 133). Female Veteran Suicide One special population that garners much attention when it comes to the topic of suicide is United States veterans. They are our nation’s heroes, working around the clock to protect their fellow Americans, often under tremendous levels of stress and danger. These heroes include

3 women, which is the fastest-growing demographic in the veteran population, accounting for about 9% of all veterans, a number that is expected to reach more than 15% by 2035 (Women veterans report, 2017). And worrying trends among the female (or woman) veteran population that warrant further examination and discussion, especially for those who wish to counsel women. Unfortunately, the topics of mental health and suicide remains incredibly stigmatized despite the Department of Defense (DOD) and the Department of Veterans Affairs (VA) having their respective suicide prevention initiatives. While the suicide rate among veterans has declined since 2018, the average number of daily veteran suicides has increased overall from 6,001 in 2001 to 6,146 suicide deaths annually as of 2020; a net total of 145 more veteran lives lost every year (2022 National Veteran Suicide Prevention Annual Report). Statistics Department of Veterans Affairs (VA) 2022 National Veteran Suicide Prevention Annual Report discusses the most recent suicide trends in the veteran community. Current statistics suggest that, on average, 16.8 veterans died by suicide per day in the year 2020, making the suicide rate 57.3% higher than their non-veteran counterparts (2022 National Veteran Suicide Prevention Annual Report). Further, among veterans ages 18 to 44 years, suicide is the second leading cause of death, compared to being the tenth leading cause among the total U.S. population (2022 National Veteran Suicide Prevention Annual Report). While male veterans are more likely to die from suicide, female veterans are more than twice as likely to die by suicide than civilian women. Moreover, between the years 2005 and 2017, the suicide rate among veteran women increased 60% (Denneson et al., 2020, p. 1). It is still the second leading cause of death for female veterans 18 to 34 years old and the third

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4 leading cause of death for those between 35 and 44 years old (2022 National Veteran Suicide Prevention Annual Report). One reason for the difference in the rate of suicides between veteran and non-veteran women is likely that veteran women are 15% more likely to use firearms in their suicide attempts than non-veteran women (48.2% versus 33.3%). The second most used method for female veterans is poisoning, including overdose in almost 27% of suicide attempts (2022 National Veteran Suicide Prevention Annual Report). Possible Reasons for Suicide Attempts What They Have in Common Counselors need to be aware that suicide is complex and there is never one single cause of suicidal ideations. (Houston, 2017, p. 64). There are several reasons a woman may consider committing suicide and many of them are non-discriminatory. In a study published by Denneson et al., researchers interviewed a sample of 50 veterans about the circumstances surrounding their suicide attempts (2020, p. 3). Women reported feelings of worthlessness, shame, and emptiness stemming from feelings of powerlessness and poor interpersonal relationships and a subpar support system. When they would ask for help, these veteran women were met with rejection. Additionally, many women indicated that they were victims of sexual abuse and trauma (pp. 4- 5). Moreover, women may consider suicide out of bitterness and contempt toward another person for having hurt them; their wish is to “hurt them back” (Kellen, 2022, p. 135). Again, none of these reasons are unique to veterans or non-veterans. Unique Considerations Veteran women and non-veteran women are more alike than they are different. Female veterans are still humans, image-bearers of their Creator with their own unique roles and

5 functions. Yet there are several factors unique to veteran women that must be accounted for in the counseling process in order to better understand their symptoms and assist in treatment planning (Ross et al., 2015, p. 521). Military culture is unique and complex; each branch has its own traditions, ways of socializing, values, terminology and behavioral norms (Ross et al., 2015, p. 521). Not only do veteran women carry the burdens associated with family, relationships, their role as women, and as human beings living under the curse of sin, they bring additional stressors like recent transitions from military to civilian life, chronic stress related to lengthy deployments, and the horrors of combat (Houston, 2017, p. 173). Also, the female veteran may have been the victim of military sexual trauma (MST), in which she was harassed or assaulted in the line of duty, which research has linked to increased suicide risk (p. 176). Another concern for female veterans, especially in the context of suicide, is that many do not enjoy the same amounts of camaraderie and belongingness as their male counterparts, leaving them especially vulnerable to feelings of loneliness and isolation (p. 175). Finally, research suggests that men and women who join the military are more likely than their civilian counterparts to have experienced difficult childhoods, including higher instances of all types of abuse (Houston, 2017, p. 175). It is hypothesized that military-related stressors may trigger or aggravate such wounds, leaving servicemembers and veterans more susceptible to mental illness and suicidal ideations or behaviors (p. 175). A Biblical Perspective of Suicide Because humanity dwells in the shadow of sin, all are vulnerable to suicidal ideations and Christians are no exception. There are conflicting perspectives on the topic of suicide within the Christian community, so it is critical that counselors rely on scripture to guide them in counseling

6 those at risk for suicide. While the Bible does not provide any prescriptive teachings on suicide, there are several core beliefs in Christianity regarding why suicide is wrong. Suicide is Sinful God’s Commandments The best place to begin is with the definition of what suicide is: it is self-murder (Potter, 2021, p. 3). Committing murder of any kind, whether it is homicidal or suicidal in nature, is a violation of God’s sixth commandment, “you shall not murder,” given to Moses in the book of Exodus (20:13, New International Version). Furthermore, sin is willful disobedience against God; suicide is willful and therefore, a sin. Second, if God forbids taking the life of any image- bearer, the sixth commandment extends to one’s own life (Potter, 2021, p. 2). In the same passages regarding creation, it is made clear that God is the Ultimate Authority when it comes to the creation of life and when life ends. If someone other than God ends a life, they are attempting to impose their will on God, rather than submitting to his will (Potter, 2021, p. 2). She is Precious Another reason Christians believe that suicide is wrong is because our lives are not our own; God owns our bodies, not us (Potter, 2021, p. 5). In 1 Corinthians 6:19-20, Paul says that the human body is a temple of the Holy Spirit and was bought for the high price of Christ’s blood on the cross. Therefore, we should honor God by caring for our bodies. Moreover, one of the very first lessons Christians learn from the Bible is that God created man and woman in his image, Imago Dei. And, when God saw all that he had made, it was very good (Genesis 1:31, New International Version). Like every woman that came before her, the counselee is just that, very good. She is beautiful, has a purpose and has potential, whether she sees it or not (Kellen, 2022, p. 10). Therefore, to Christians, when someone harms their body in

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7 any way, especially through intentional death, they destroy a vessel of the Holy Spirit, something that is precious to God, the Father (Potter, 2021, p. 6). Suicide Hurts Everyone Satan has multiple talents; they may be nefarious in nature, but the enemy is still good at them. One thing Satan is good at is convincing us that lies are truth, even the lies we tell ourselves in moments of weakness. In Genesis 3, Satan convinced Eve that God was fearful of others being like him, which we know is a lie if God truly made humans in his image. In convincing Eve of this lie, Satan sowed the seeds of doubt regarding God’s power and goodness; Eve questioned her Father’s love for her. Because of original sin, those seeds of doubt remain. One of the biggest lies a woman may tell herself is that she is a burden and others would be better off if she died. First, research suggests that when someone commits suicide, they drastically increase the risk of suicide among their friends and family who are grieving their loss (Pitman et al., 2016, p. 8). Second, suicide hurts God; Jesus grieves for everyone in pain and is also left to grieve the loss of another precious life. The pain a woman’s suicide would cause is the antithesis of Jesus’ teaching that we are to love the Lord, heart, mind, and soul; and that we are to love our neighbors as we love ourselves (Matthew 22:37-39, New International Version). While suicide is a very serious sin, according to Counseling women: Biblical wisdom for life’s battles , the wise counselor knows how to balance the sinfulness of suicide with the biblical message of hope and God’s grace (Kellen, 2022, p. 137). Counseling a Suicidal Veteran Suicide is a heavy and intimidating topic, but counselors should not be afraid to ask questions regarding suicidal ideations, intent, planning, or attempts. Sometimes counselees will offer the information voluntarily and without prompting. Conversely, there are clients who may

8 not offer such information for multiple reasons. For example, many veterans are accustomed to the stigma in military culture surrounding mental illness and asking for help. Such situations require the counselor to remain aware of any signs that it may be appropriate to screen for suicidal ideations, such as in times of distress (Houston, 2017, p. 63). At the very least, counselors should screen for and discuss suicide and suicidal risk during initial counseling sessions and then more often, if needed (Kellen, 2022, p. 137). Initial Steps Risk Assessments Not every suicide can be predicted or avoided. Nevertheless, suicide risk assessments are the first step in ensuring client safety. During a risk assessment, the counselor gathers information on the counselee’s personal history; for veterans, the counselor should ask questions related to her military career. Any deployments, combat experience, and environmental stressors may increase the likelihood of developing several mental health conditions; counselors should also ask if the counselee has a history of mental illness because such conditions increase the risk for suicide (Houston, 2017, pp. 35-56). It is also crucial for the counselor to ask questions related to any past suicidal ideations, self-harm behaviors, or suicide attempts. Research has found that 34% of people who entertain suicidal ideations will develop a plan, 72% of whom will make an attempt (p. 63). Furthermore, previous suicide attempts are typically the most reliable predictor of future attempts and completed suicides; nearly one-quarter of those who previously attempted suicide will make a subsequent attempt within 1 to 4 years and approximately 10% will eventually die by suicide (Houston, 2017, pp. 63-64).

9 Finally, risk assessments should also assess for protective factors, such as support network, the health of their spiritual relationship with God, insight, and help-seeking behaviors. For example, marital status, the presence of children, and cultural beliefs are all possible protective factors that may help the counselee overcome suicidal ideations (p. 71). Safety Planning If the counselee indicates she is experiencing suicidal thoughts or intent, the counselee and counselor should immediately complete a suicidal ideation action plan, sometimes also called a safety plan (Kellen, 2022, p. 137). In this plan, or contract, the counselee should agree to be open and honest and to notify their counselor should any relevant thoughts or events occur. Also, the counselee should define the severity of an event or her thoughts; is she feeling hopeless? Is she experiencing suicidal ideations without intent, or is she planning? Finally, in the contract portion, the counselor should get the counselee to agree to speak up if she is ever feeling unsafe. Most importantly, the safety plan should clearly and simply outline prioritized coping strategies for use in preventing or in the event of a suicidal crisis (U.S. Department of Veterans Affairs, n.d.). The safety plan includes people and resources the veteran can contact should she experience suicidal ideations or an acute suicidal situation (Kellen, 2022, p. 138). Included in the list of contact information should be the phone number for the Department of Veterans Affairs Veterans Crisis Line and the full-time suicide prevention coordinator at her local Veterans Affairs Medical Clinic (Carroll, 2018). Counseling Techniques The Department of Veterans Affairs website cites several evidenced-based therapies that they suggest their mental health professionals use in the process of suicide prevention. Three

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10 commonly used methods are acceptance and commitment therapy for depression (ACT-D), cognitive behavioral therapy (CBT) and dialectical behavior therapy (DBT). Acceptance and Commitment Therapy for Depression (ACT-D) Acceptance and commitment therapy for depression (ACT-D) is a therapeutic approach aimed at improving the lives of people, in this case veterans, who are experiencing depression. Over the course of 12 to 16 psychotherapy sessions, ACT-D aims to reduce experiential avoidance, which is any desire or action taken to eliminate painful or undesirable thoughts and emotions (Walser et al., 2015, p. 26). Researchers theorize that, in instances of suicidal ideations or suicide attempts, veterans view suicide as an effective method to avoiding problematic emotional experiences (p. 26). Research suggests that veterans who completed the ACT-D treatment protocol exhibited increased experiential acceptance and mindfulness, which resulted in reductions in depression symptoms and an improvement in their quality of life (p. 26). Cognitive Behavioral Therapy (CBT) Another popular treatment used in suicide prevention is cognitive behavioral therapy (CBT). Cognitive behavioral therapy focuses on the relationships between a person’s thoughts, feelings, behaviors, and situations; CBT aims to assist veterans with changing undesired behaviors through skill building and goal-setting (U.S. Department of Veterans Affairs, n.d.). A 2022 article by Vesco et al. examines three common CBT techniques that may be useful in suicide prevention. First, the counselor and veteran work together to work on building hope and examining reasons for living, typically through the completion of a “hope box,” which is a container that contains items that remind the veteran of their reasons for living (Vesco et al., 2022, p. 674). The second technique involves working with the counselee to build social skills, forming a strong support network and strengthening existing positive relationships (p. 675). The

11 third technique is lethal means counseling, which focuses on the importance of avoiding access to lethal means such as firearms or pills (p. 676). Lastly, Vesco et al. cite research indicating that using cognitive behavioral techniques is effective in reducing suicide attempt recurrence by 50% to 60% (p. 672). Dialectical Behavior Therapy (DBT) Dialectical Behavior Therapy (DBT) is an evidence-based treatment often used at the Veterans Affairs Medical Clinics with individuals who are at risk for suicide. DBT was originally developed for use with individuals diagnosed with borderline personality disorder but has since been adapted for use among other mental health patients, including veterans experiencing suicidal thoughts, attempts, and self-harm behaviors (Bentley, 2021). DBT treatment protocol includes several cognitive behavioral therapy techniques as well as teaching emotion regulation, distress tolerance and interpersonal effectiveness skills (Bentley, 2021). To achieve these goals, counselees learn mindfulness techniques, which allows counselees to observe and process their current suicidal thoughts and any associated emotions, absent of the burden of guilt, shame and judgment (Bentley, 2021). Conclusion On June 12, 1948, President Truman signed the Women’s Armed Services Integration Act into law, which gave women the right to permanently serve in the United States armed forces. Since then, millions of women have served their country honorably in various roles. However, along with this honorable service comes a distinctive set of challenges each woman brings with her into counseling. Not only is she struggling with the roles assigned to her by the Creator, but she also carries the burdens inherent to military service, including various types of traumas,

12 weakened interpersonal relationships and eventually the difficulties of transitioning to civilian life. While many female veterans share certain experiences, the wise counselor must remember that each veteran is still a woman, an individual with unique needs and characteristics. Further, counselors should also remember that any woman who is considering suicide is suffering from a great deal of pain and one single stressor did not lead her to this particular moment. The counselor must be compassionate and patient, walking along side the counselee one day at a time while leading her back to her Heavenly Father who says, “come to me, all you who are weary and burdened, and I will give you rest. Take my yoke upon you and learn from me, for I am gentle and humble in heart, and you will find rest for your souls. For my yoke is easy and my burden is light” (Matthew 11:28-30, New International Version).

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13 References Bentley, O. (2021, November 18). Dialectical behavior therapy: An evidence-based treatment for suicide risk . Health.mil. https://www.health.mil/Military-Health-Topics/Centers-of- Excellence/Psychological-Health-Center-of-Excellence/Clinicians-Corner- Blog/Dialectical-Behavior-Therapy-An-Evidence-Based-Treatment-for-Suicide- Risk#:~:text=DBT%20is%20recommended%20in%20the,%2C%20and%20self%2Dhar m%20behaviors. Bible Gateway: New International Version . BibleGateway.com: A searchable online Bible in over 150 versions and 50 languages. (n.d.). https://www.biblegateway.com/ Carroll, D. (2018). Facts About Suicide Among Women Veterans . U.S. Department of Veterans Affairs Office of Mental Health and Suicide Prevention. https://www.mentalhealth.va.gov/suicide_prevention/docs/Final_Facts_About_Suicide_A mong_Women_Veterans_508.pdf Centers for Disease Control and Prevention. (2023, May 8). Facts About Suicide . CDC: Preventing Suicide. https://www.cdc.gov/suicide/facts/index.html Denneson, L. M., Tompkins, K. J., McDonald, K. L., Hoffmire, C. A., Britton, P. C., Carlson, K. F., Smolenski, D. J., & Dobscha, S. K. (2020). Gender differences in the development of suicidal behavior among United States Military Veterans: A national qualitative study. Social Science & Medicine , 260 . https://doi.org/10.1016/j.socscimed.2020.113178 Department of Veterans Affairs. (2017, February). Women veterans report: The past, present and future of women veterans . National Center for Veterans Analysis and Statistics. https://www.va.gov/vetdata/docs/SpecialReports/Women_Veterans_2015_Final.pdf

14 Houston, M. N. (2017). Treating suicidal clients & self-harm behaviors: Assessments, worksheets & guides for interventions and long-term care . Proquest: E-book Central . PESI Publishing & Media. Retrieved from https://ebookcentral.proquest.com/lib/liberty/reader.action?docID=6260908. Kellen, K. (2022). Counseling women: Biblical wisdom for life's battles. Nashville, TN: B&H Academic. Pitman, A. L., Osborn, D. P., Rantell, K., & King, M. B. (2016). Bereavement by suicide as a risk factor for suicide attempt: A cross-sectional national UK-wide study of 3432 young bereaved adults. BMJ Open , 6 (1). https://doi.org/10.1136/bmjopen-2015-009948 Potter, J. (2021). Is suicide the unforgivable sin? Understanding suicide, stigma, and salvation through two Christian perspectives. Religions , 12 (11). https://doi.org/10.3390/rel12110987 Ross, P. T., Ravindranath, D., Clay, M., & Lypson, M. L. (2015, December). A greater mission: Understanding military culture as a tool for serving those who have served . Journal of graduate medical education. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4675404/ U.S. Department of Health and Human Services. (2022, July). 2020 National Survey on Drug Use and Health: Veteran Adults . Substance Abuse and Mental Health Services Administration. https://www.datafiles.samhsa.gov/ U.S. Department of Veterans Affairs. (2022, September). Department of Veterans Affairs (VA) 2022 National Veteran Suicide Prevention Annual Report . Office of Mental Health and Suicide Prevention. https://www.mentalhealth.va.gov/docs/data-sheets/2022/2022- National-Veteran-Suicide-Prevention-Annual-Report-FINAL-508.pdf

15 U.S. Department of Veterans Affairs. (n.d.). Mental health: Evidence-based therapy . Evidence- Based Treatment. https://www.mentalhealth.va.gov/get-help/treatment/ebt.asp Vesco, K. M., LaCroix, J. M., Bond, A., Fox, A., Ribeiro, S., Darmour, C., & Ghahramanlou- Holloway, M. (2022). Three clinical techniques from cognitive behavior therapy for suicide prevention. Social Work in Mental Health , 20 (6), 672–681. https://doi.org/10.1080/15332985.2022.2050878 Walser, R. D., Garvert, D. W., Karlin, B. E., Trockel, M., Ryu, D. M., & Taylor, C. B. (2015). Effectiveness of acceptance and commitment therapy in treating depression and suicidal ideation in veterans. Behaviour Research and Therapy , 74 , 25–31. https://doi.org/10.1016/j.brat.2015.08.012

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