When Dr. David Shulkin was appointed secretary of veterans affairs in February, President Donald Trump charged him with the ambitious mission of reducing the veteran suicide rate to zero. Which means that for Shulkin to truly succeed in his role as the head of an agency that on numerous occasions in recent years has been accused of fatally neglecting patients in its care, the VA will need to ensure that not a single living person who has ever served in the U.S. military dies by suicide on his watch. That’s more than 20 million people.
The veteran suicide rate isn’t what it is for lack of trying. The VA’s budget has more than quadrupled since 2001, and much of that money has been poured into suicide prevention. The agency spent $118 million on studying mental illness in 2016, making it the VA’s second most funded area of research behind “aging.” That year, the VA also expanded its Veterans Crisis Line, doubling it in size so the agency could better respond to mental-health emergencies. These efforts have been bolstered by a recent surge in national awareness of post-traumatic stress disorder and military sexual assault, as well as droves of nonprofit organizations that offer alternative forms of care for veterans suffering from service-connected mental illness. But the so-called veterans’ suicide epidemic persists.
And it will still persist until, at the very least, we figure out why it is that veterans are dying by suicide at a higher rate than their civilian counterparts. In 2014, veterans constituted 8.5% of the U.S. population, but accounted for about 18% of suicides, according to the VA’s most comprehensive report on the matter. And while veteran suicides have increased since the onset of the War on Terror, the latest data shows that seeing combat does not significantly increase the likelihood that a person will take their own life. In fact, 65% of the veterans who died by suicide in 2014 were individuals 50 years or older, most of whom had spent little or no time in Iraq or Afghanistan. Had they ever been to war, it was likely many years before they died. A lot of life happened in between.
The parents of Iraq war veteran Rusty McAlpin have not been able to bring themselves around to cleaning out the room in the basement of their home where he lived until he committed suicide in 2011.Photo by Rick Loomis/Los Angeles Times via Getty Images
Compounding the complexity of the problem is the simple fact that those who need mental-health support don’t always seek it. Since 2010, there has been a department within the VA, called the VA Center of Innovation, which, among other things, has been working to better understand why some veterans don’t use VA services. The idea is that the VA can use that information to improve access to health care so more veterans take advantage of it. After all, they earned it. Still, about 70% of the veterans who died by suicide in 2014 — at a pace of roughly 20 per day — were not regular users of VA services. Which raises an interesting question: Should veterans be doing more to help themselves?
Republican Rep. Brian Mast of Florida seems to think so. His proposal: Give all service members leaving the military the option of taking an oath to not commit suicide and also help others at risk of doing so. And while it certainly won’t drop veteran suicides to zero, Mast is confident it will help. In fact, he submitted his “Oath of Exit” proposal as a bipartisan amendment to the 2018 National Defense Authorization Act, and on July 13, itpassed the House, leaving it to the Senate to determine whether or not it will become law; although, according to Mast’s communications director, Brad Stewart, the oath would not be legally binding.
...we’re settling on a one-size-fits-all narrative to explain the veteran experience, and at the risk of imposing stifling limits on how people who have served in the military perceive themselves.
“The idea is that if a service member says they’re going to do something, they do it, because they have integrity and compassion for their fellow veterans,” Stewart said in an email to Task & Purpose.
Mast is a veteran himself. He served 12 years in the Army, and lost his legs while serving as a bomb tech in Afghanistan in 2010. Years later, in an interview with The New York Times, Mast recalled that while he was recovering from his wounds at Walter Reed Army Medical Center, he told his wife that “he could not accept that perhaps the most meaningful work of his life was behind him.” Mast was elected to Florida’s 18th Congressional District in 2016, and made addressing “the shameful treatment” veterans receive at the VA a top priority. That effort involves pushing to widen veterans’ access to health care in the private sector. “I don’t think should cease to exist,” he told NPR in January. “I think that they should up their game.” So it’s hardly surprising that while Mast’s Oath of Exit encourages veterans struggling with suicidal thoughts to seek help, it makes no mention of the VA.
Here is the oath in its entirety:
“I , recognizing that my oath to support and defend the Constitution of the United States against all enemies, foreign and domestic, has involved me and my fellow members in experiences that few persons, other than our peers, can understand, do solemnly swear (or affirm) to continue to be the keeper of my brothers-and-sisters-in-arms and protector of the United States and the Constitution; to preserve the values I have learned; to maintain my body and my mind; and to not bring harm to myself without speaking to my fellow veterans first. I take this oath freely and without purpose of evasion, so help me God.”
Mast is certainly not alone in his view that the VA doesn’t hold the magic key to ending the veterans’ suicide epidemic. Evidence of this mentality is all over the internet, most notably in the plethora of Facebook support groups that have recently sprung up with the professed goal of combating veteran suicide, some of which dispatch members to physically assist others in need of help. Even the leaders of “Marines United,” a Facebook group now famous for sparking a military-wide nude photo scandal, claimed that the page was created to help prevent veterans from taking their own lives. One need only Google “22 a day” — a reference to a dated but still widely cited study on veterans suicide — to see that there is an entire industry forming around the notion that those who’ve served are hardwired for self-destruction. At the moment, we can only guess at whether or not those efforts are alleviating the problem. And while they might be, it's important to keep in mind that lots of money is being made under the banner of keeping veterans alive.
Wreath laid at the Pacific Arch of the Memorial in honor of the 70,000 Americans who served during this historic battle of WWII.VA photo
The media has only fueled this deepening skepticism of the VA among veterans, often painting the agency as an enemy of the very people it’s supposed to help, and giving conservative politicians plenty of fodder to lambast the federal agency as an example of big government gone awry.
Mast, it’s worth mentioning, is a staunch Republican, and — at risk of sounding like a high school government teacher — I should note that his Oath of Exit is very much in keeping with his party’s core principle of self-determination. “Only we can save us from ourselves” is the message it communicates. The taker of the oath isn’t vowing to seek out professional help when they’re in the throes of a mental-health crisis, but rather his “fellow veterans.” This keep-it-in-the-family approach, while grounded in a realistic understanding of how veterans perceive their relationships with other people who have served, risks further alienating those with psychological problems from the government resources in place to assist them. What if a veteran who takes the oath finds his battle buddies unresponsive or unhelpful when he calls upon them in his time of need? He has upheld his end of the bargain, but there is nothing in the oath that obligates the veteran being approached for help to refer their battle buddy to someone actually qualified to assist them, which could prove catastrophic in an emergency.
A recent study published in the Journal of Affective Disorders compared the effectiveness of crisis-response planning — providing suicidal patients with a card “outlining steps for identifying one’s personal warning signs, using coping strategies, activating social support, and accessing professional services” — with the effectiveness of a no-suicide contract, which “outlines what not to do in a crisis (i.e., engage in suicidal behavior).” The study concluded that the crisis-response planning approach was more effective than the no-suicide contract model in “preventing suicide attempts, resolving suicide ideation, and reducing inpatient hospitalization among high-risk active duty Soldiers.” Likewise, several mental-health professionals I spoke with about the Oath of Exit told me that, while it’s possible a veteran may be more inclined than a non-veteran to adhere to an oath, among the general population, no-suicide contracts have yet to yield promising results.
“I don’t feel that an oath would lead to a significant change in suicide rates among veterans,” said Dr. Will Siu, a New York-based psychiatrist who often works with patients suffering from PTSD and other trauma-induced mood disorders. “However, I do feel that the idea of building meaningful interpersonal connections between veterans and their communities is worth pursuing going forward as a possible intervention.”
Perhaps the oath could at least be a step in the right direction. A 2008 study published in the Archives of Suicide Research found that “gatekeeper training” — teaching people “who work with veterans, families, and communities” to “identify and to refer veterans at risk for suicide” — showed “promise for increasing the capacity of VA staff to work with at risk veterans.” According to this model, which was being evaluated by the Department of Defense for use within the military as recently as 2015, gatekeepers don’t have to be VA employees. They can be anyone who “is strategically positioned to recognize someone at risk of suicide,” to include parents, friends, neighbors, and, presumably, former platoon mates. Perhaps a better version of the Oath of Exit would be one accompanied by an additional pledge to undergo training to learn how to identify warning signs of a suicide crisis and how to properly respond. In other words, a promise to take action.
And then there’s the obvious question: Do oaths hold a special meaning for veterans? So special that an oath could prevent a veteran from taking his or her own life, even five, 10, or 30 years after they’ve hung up the uniform? Mast believes so. “Integrity is more than a word to service members, so if we say we will reach to a brother or sister because we need help, then we will do it,” he told Task & Purpose.
Gold Star Mother Margie Miller attended the Spartan Pledge event and walked the grounds of the American Veterans Disabled for Life Memorial after the ceremony, May 8, 2016.Lauren Katzenberg
But of course service members break oaths. Fort Leavenworth is full of soldiers who victimized the very people they swore to protect. One of the deadliest mass shootings in our country’s history was carried out by an Army major — a doctor, at that. People are unpredictable. Our perspectives, morals, and loyalties are constantly in flux. Who we are can change dramatically over time. Change, however, isn't always a bad thing.
What I find most striking about Mast’s proposal is how it assumes that veterans’ service will remain crucial to their identity over the course of their lives. It also seems to imply that whatever relationships veterans form outside the military do not carry the same weight as the ones they forged in the proverbial trenches. What about wives, children, parents, coworkers, new friends? At some point, you have to move on. Like Mast, you have to resist the idea that the most meaningful period of your life is behind you. You have to apply the same energy, courage, and devotion to adapting back to the civilian world that you did to becoming a soldier — and for the simple fact that you are not in the military anymore.
Conventional wisdom tells us that a person can only lean on past experiences so long. Eventually the legs are going to give out. Mast understands this, which is why, as he told The New York Times, he pursued a career in politics with the hope of finding the same sense of purpose and fulfillment he experienced in uniform. But his oath instructs us to do the opposite: Cling to our military service like a lifeline. That mindset runs counter to that which gave birth to the GI Bill after World War II and helped enable an entire generation of veterans to play an instrumental role in turning the United States into the superpower it is today. Men and women came home from that war and, with some assistance from the government, threw themselves into building the next chapter of their lives and it was great for the whole country.
Of course, there was no shortage of mental-health issues among veterans then. The difference now is that we’ve come to see those issues as part of an imaginary barrier that exists between those who have and have not served — the so-called “civilian-military divide.” And it’s this potentially toxic mentality that initiatives like the Oath of Exit are feeding: The military “has involved me and my fellow members in experiences that few persons, other than our peers, can understand,” it reads. That might be true; however, in most cases, when people leave the military, they don’t take their peers with them. By fixating on the bond between brothers and sisters-in-arms, and the profound importance of the the time they spent together at war, we may be inadvertently discouraging veterans from building meaningful lives and relationships outside the military. Those networks might actually do more to protect them, especially as the years go by.
“Integrity is more than a word to service members, so if we say we will reach to a brother or sister because we need help, then we will do it.”
I think one of the most damaging byproducts of the current obsession with veteran suicide is the idea that you shouldn't let your guard down, that the demons that followed you home from war will keep stalking you until you die. There is, however, another way of thinking about military service: That it makes you a stronger and more capable member of society. This is not to say that mental illness isn’t a real and tragic side effect of war, or that veterans kill themselves out of weakness. But we’re settling on a one-size-fits-all narrative to explain the veteran experience, and at the risk of imposing stifling limits on how people who have served in the military perceive themselves. What we might be faced with now is a self-fulling prophecy. National awareness of PTSD has grown significantly since the Vietnam War, yet the veteran suicide rate has gone up. I, for one, am not surprised by these numbers. Maybe that’s because I’ve been conditioned to expect them.
Still, it’s hard to imagine that, were it widely implemented, an Oath of Exit would make the veteran suicide problem any worse. As Mast wrote to Task & Purpose, “Anything we can do to prevent one veteran from harming them self is worth it.” He’s absolutely right. I’ve lost several friends to suicide. Each time I was left racking my brain, scrambling to identify the signs that would’ve shown me it was coming had I only paid closer attention. And what I saw, in retrospect, were profoundly lonely people. Suicide is the ultimate rejection of life, but the process of severing ties with the world begins before the shotgun is loaded or the noose is sized. Perhaps, in some cases, all it takes is for someone to reach in and hold tight, before that window shuts completely.
So, yes, a pledge to look out for the people who were with us during some of the most important and formative periods of our lives is a good start. But that’s all it is: a start. If veterans are going to play a bigger role in fixing this problem — if we’re going to insist that we’re more aptly suited for the task than the VA — we need to do better.