1

Veteran Suicide Epidemic:

Through the Prism of

Contemporary Cognitive

Behavioral Theory

By: Daniel R. Gaita, MA, MSWi

May 8, y

Introduction
The objective of this paper is to investigate the theory of contemporary cognitive

behavior in order to garner and articulate a greater understanding of why veteran suicides spiked

from 2008-2012. Furthermore to discuss evidence based treatment modalities that have

demonstrated broad efficacy towards reducing suicide rates. It is the hope of this work that the

social paradigm of exalting victimhood may be enlightened through the emergence of the

presented data such that greater emphasis may be invested in the prevention of veteran suicide

through greater understanding of the actual root causes rather than perceived triggers.
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Background

Despite continuous war on two fronts following the terrorist attacks in America on

September 11th, 2001 and between the years of 2001-2007 the US Armed Forces veteran suicide

rate had been on the decline. In fact, the veteran suicide rate had not began to spike until 2008 as

detailed by the Department of Veterans Affairs (VA) in 2012 which disclosed a daily veteran

suicide rate of twenty-two (Kemp & Bossarte, 2012).

The 2012 VA publication led to a national multi-billion dollar investment into suicide

prevention programs, research and the implementation of evidenced based treatment for mental

health disorders such as Post Traumatic Stress (PTSD) , Traumatic Brain Injury (TBI) and others

thought to be the primary culprits of the rising rate of veteran suicide (Thompson, 2016). Since

then we have seen veteran suicide rates begin to drop amongst veterans utilizing VA mental

health services (VA, 2016).

However, we have also garnered much more data about veteran suicides. Specifically, the

population groups that had higher rates, key risks and precipitating factors of suicides (Bush,

Reger, Luxton, Skopp, Kinn, Smolenski, & Gahm, 2013; Friedman, 2015; JAMA, 2014; Kang,

Bullman, Smolenski, Skopp, Gahm & Reger, 2014; Leardmann, Powell, Smith, Smith, Boyko,

& Hoge, 2013; Reger, Smolenski, Skopp, Metzger-Abamukang, Kang, Bullman, Perdue, &

Gahm, 2015; Thompson, 2016; VA, 2016). Many of which have yet to be considered by

mainstream society and popular culture, until now.

The current paradigm of social thought surrounding veteran suicide continues to place

combat and repeated deployments as crucial precipitating risk factors. While this observation

may be accurate for anticipating symptomatic development of Post Traumatic Stress Disorder

(PTSD) (American Psychiatric Association, 2013), the data to date actually negatively correlates
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deployments and combat with suicide outcomes (Leardmann, Powell, Smith, Smith, Boyko, &

Hoge, 2013; Reger, Smolenski, Skopp, Metzger-Abamukang, Kang, Bullman, Perdue, & Gahm,

2015; Kang, Bullman, Smolenski, Skopp, Gahm & Reger, 2014).

In fact, those most likely to commit suicide had either attempted it prior to joining the

armed forces (Freidman, 2015), had not served out their full four year term, did not go to college,

or did not attain an honorable discharge (Reger, Smolenski, Skopp, Metzger-Abamukang, Kang,

Bullman, Perdue, & Gahm, 2015). Moreover, seventy-percent of Veteran suicides were carried

out by those that had never used VA services (Kemp & Bossarte, 2012).

Furthermore, the data cited in the above studies also suggest a stronger correlation

between PTSD and Post Traumatic Growth (PTG) than with suicide. Interesting to note, that

while fifteen to twenty percent of combat veterans develop symptoms of PTSD (Kemp &

Bossarte, 2012), an astounding seventy-five to eighty-five percent do not. Further, many combat

veterans with PTSD symptoms actually go on to thrive either as civilians or in the continued

service of their nation. Ironically, this relationship between PTSD and PTG is not a new

phenomenon, but rather one that is well studied (Tedeschi & Calhoun, 2004; Pietrzak, Goldstein,

Malley et al. 2010; Lowe, Manove & Rhodes, 2013), and explained in greater detail herein.

The convergence of these studies and their respective data sets (n >60,000,000) offers an

opportunity to better understand the above phenomenon through the prism of contemporary

cognitive behavioral theory. Since the recent study data demonstrates greater resilience amongst

combat veterans than their non-deployed counterparts we can begin to look at the issue of

veteran suicide from an angle that has not been previously charted.
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Contemporary Cognitive Behavioral Theory

With the technology of today, what was once only hypothesized can now be observed and

replicated. Such is the case with the evolution of contemporary cognitive behavioral theory. The

gradual historical shift from behaviorally dominated clinical psychology towards the

incorporation of cognition was, at first, met with skepticism due to the inability apply proper

scientific method. Earlier referred to as covert behaviors (Bandura, 1969; Mischel, 1973), and

today being a broadly accepted theory which incorporates emphasis on how individuals

cognitively structure their experiences and the resultant impact such structuring has on their

behavioral outcome (Ingram, Kendall & Chen, 1991). Research has conceptualized the

cognitive-behavioral paradigm as one in which understanding and modification of emotion takes

place. Interestingly, modern research continues to support this paradigm with growing studies

demonstrating the actual processes that occur within the various physical structures of our brains.

How this applies to veteran suicide is newly unfolding. First, we can now investigate why

those that never saw combat, never deployed, did not earn an honorable discharge and did not go

to college end up in the highest risk factor for committing suicide. Secondly we can delve deeper

into the biopsychosocial factors that may have led to the premature discharge status of the

suicidal veteran. Thirdly is in understanding how access to mezzo and macro resources is

impacted by a less than honorable discharge. Finally, how the combination of factors creates the

perfect storm of conditions precedent for suicidal ideation. In order to tie these together, we must

first understand what is happening in the brain, and why.

Neurobiology

Today we can peer into the brain, measure the volume and activity actively taking place

within various structures, and predict, with reliability, what the behavioral outcomes will be
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(Cozolino, 2010; Applegate & Shapiro, 2005; Badenoch, 2008). More importantly for mental

health practitioners, we have learned how to utilize cognitive behavioral modalities to alter

maladaptive or distorted cognitions through a wide range of various techniques that will be

covered herein. Thus, cognitive behavioral theory now finds itself at the nexus of modern

neurobiological research.

Neuroplasticity and Neurogenesis

Observed as the actual branching out and expanding of neural structures within

various association areas of our brain, particularly within the regions of the brain associated with

ongoing learning (amygdala, frontal cortex, and hippocampus) (Eriksson, Perfileva, Bjork-

Eriksson et al., 1998; Gould, Reeves, Graziano, & Gross, 1999; Gross, 2000; Cozolino, 2010;

Gould, Tanapat, Hastings & Shors, 1999) and new experiences (Purves & Voyvodic, 1987). This

active process of neural branching and expanding is demonstrative of the power of our mind to

heal itself through the reprograming of our cognitions via new associations at the

biopsychosocial level and throughout the entire lifecycle.

Neural networks. Perform functions allowing us to learn, remember, act and adapt to

different situations based on complex interactions (Cozolino, 2010).

Instantiation. Represents the symbiotic interconnects of our neural coding. Whereby our

abilities, emotions and patterns of behavior are encoded and shaped through our individual

biopsychosocial experiences (Cozolino, 2010). Effectively implemented cognitive behavioral

modalities focus on recreating new associations to previous experiences such that maladaptive

cognitions from trauma and hardships may be altered thus resulting in more healthy outcomes

based on cognitive restructuring techniques.

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Arborization. Is a process of neural pruning whereby unused neural networks die and

make room for the growth and development, referred to as long-term potentiation (LTP), of

neural networks being used thus enabling them to grow in size throughout the lifecycle

(Cozolino, 2010).

Association areas. Areas within the cortex of the brain which serve to bridge and direct

coordinating circuits to give us the ability to recall feeling, emotion, language, smell and taste

both consciously and unconsciously (Cozolino, 2010).

Glucocorticoid Receptors (GRs)

Are used in helping us process cortisol, a stress hormone which enables us to endure brief

periods of stress, restore homeostasis, mobilize energy, enhance memory and build up our future

resiliency to stress (Cozolina, 2010; Badenoch, 2008; Applegate & Shapiro, 2005)

The implications of GRs and behavioral outcomes are well studied. Normal and

sustainable doses actually enhance our capacity to endure stress and tend to result in greater

resilience throughout the lifecycle impacting our cognitive processing, affect regulation, general

sense of well-being and memory (Cozolino, 2010).

However, high levels of GRs have demonstrated negative implications on structural

brain development, which adversely impact tolerance to stress throughout the life cycle

(Cozolino, 2010).

Cortisol. Is a key stress hormone and is a (GR) present in nearly every human tissue.

Sustained high levels of stress via trauma have been shown to increase cortisol production thus

weakening the immune system via the prevention of T-cell proliferation, disruption of protein

synthesis, neural growth halting, and even neural death. Furthermore, prolonged stress is

correlated with structural deficits in brain development and reductions in amygdala and
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hippocampal volume, resulting in memory deficits, diminished sense of well-being, problems

with affect regulation, cognitive processing, and emotional bonding (Cozolino, 2010).

Mental Health

This growing area of science has had remarkable implications on the mental health

profession. It has given us hope and provided a glimpse into how nearly all psychosocial

traumas, hardships, and tragedies may be overcome and further utilized as staging for increased

resilience throughout life. Meaning that most traumatic or abusive situations can be remedied

through cognitive behavioral techniques.

Brain Structure

The result of prolonged stress from trauma is structurally witnessed by an actual

reduction in hippocampal size and volume and heightened sensitivity of the right amygdala

leading to the ineffective processing of psychological responses across the brain by limiting and

interrupting normal modulation (Badenoch, 2008). As a result, the hypersensitivity of the

amygdala and disrupted communication between integrating and regulating circuits ends up

amplifying stress related anxiety (Badenoch, 2008). This also explains why those exposed to

high stress are predictably more sensitive to even minor external events at both sympathetic and

parasympathetic levels. However, when we look at this phenomenon through the prism of

cognitive behavioral theory, other components must be considered which are worthy of further

research. One such development of growing interest is Post Traumatic Growth (PTG).

Post Traumatic Growth

The concept of strength through struggle is not new. Modern theorists have constructed

the concept of PTG as the positive psychological change experienced resulting from struggle

with highly challenging life circumstances (Jayawickreme, & Blackie, 2014). Exhaustive
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research is available to support the argument that traumatic life events can indeed result in

positive life change (Affleck & Tennen, 1996; Aldwin, 1994; Blackie, Jayawickreme,

Tsukayama, Forgeard, Roepke, & Fleeson, 2016; Calhoun, 1995; Carver 1998; Cohen & Wills,

1985; Duan, Guo, & Gan, 2015; House, House, & Umberson, 1988; Helgeson & Cohen, 1996;

Jayawickreme, & Blackie, 2014; Jin, Xu, & Liu, 2014; Park, Cohen, & Murch, 1996; Shamia,

Thabet, & Vostanis, 2015; Tedeschi & Thoits, 1986).

Ironically, the general consensus on PTG is based closely on cognitive-behavioral

principals. For example, one reason posited to explain PTG is that it enables the individual to

evolve a sense of wisdom about the world by disengaging from prior beliefs and assumptions in

order to formulate new goals, identities and beliefs. This observation of the individual

incorporating the experienced trauma(s) (Park, 2010) is a nearly identical to the evidenced based

treatment goals of Cognitive Behavioral Therapy (CBT) interventions, more specifically,

cognitive processing therapy (CPT). PTG and CPT, over time leads to greater satisfaction with

life (Jayawickreme & Blackie, 2014) such are the goals of effective CBT interventions.

PTG can also occur through emotion-focused coping or rumination as a way of actively

coming to terms with the traumatic event (Tedeschi, & Calhoun, 1995) via active coping efforts,

(Jayawickreme & Blackie, 2014) which mirrors another CBT modality referred to as Trauma

Focused Cognitive Processing Therapy (TFCPT).

Other cognitive behavioral themes that are found in PTG stem from increases in meaning

and wellbeing (Joseph & Linley, 2005) and changes in an individuals life narrative (Pals &

McAdams, 2004) both of which also occur within the cognitive behavioral realm and are treated

across a range of CBT treatment interventions that will be discussed in further detail below.
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Treatment

As discussed throughout, cognitive behavioral theories have, in large part, resulted in a

number of effective evidence based cognitive behavioral treatment modalities covering a broad

range of trauma related injuries. Below are descriptions of several CBT based treatments

currently being widely implemented throughout the VA.

Cognitive Processing Therapy

CPT is a 12-session psychotherapy for PTSD. CPT teaches you how to evaluate and

change the upsetting thoughts you have had since your trauma. By changing your thoughts, you

can change how you feel. Fifty-three percent of those who receive CPT will no longer have

PTSD (VA, 2017,1)

Prolonged Exposure Therapy

Prolonged Exposure (PE) is another specific type of CBT. PE usually takes 8-15 weekly

sessions, that are 1.5 hours each. PE teaches you to gradually approach trauma-related memories,

feelings, and situations that you have been avoiding since your trauma. By confronting these

challenges, you can actually decrease your PTSD symptoms. Fifty-three percent of those who

receive CPT will no longer have PTSD (VA, 2017,1)

Stress Inoculation Training

Stress Inoculation Training, (SIT), is another less effective type of Cognitive Behavioral

Therapy (CBT) lasting about 3 months of weekly 60-90 minute sessions. By teaching you coping

skills, SIT works to help you find new ways to deal with symptoms. SIT is often done in a group

or individually with one or two providers. However, only twenty percent of those who receive

CPT will no longer have PTSD (VA, 2017,1)

Eye Movement Desensitization & Reprocessing

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EMDR is an individual psychotherapy for PTSD covering about 1-3 months of weekly

50-90 minute sessions. EMDR has been receiving strong reviews from veterans but is not widely

accessible at VA hospitals yet. In most cases you are not asked to talk about the details of your

trauma but rather to think about your trauma during sessions. EMDR is posited to help you

process upsetting memories, thoughts, and feelings related to trauma. By processing traumatic

experiences, you may get relief from symptoms. Fifty-three percent of those who receive CPT

will no longer have PTSD (VA, 2017,1)

Diversity

Another fascinating observation, which bolsters the argument of resilience through

hardship, is reflected in the data, which shows more typically oppressed population groups have

lower rates of veteran suicide (Reger, Smolenski, Skopp, et al., 2015). Specifically, Black

veterans demonstrate the lowest suicide rate of (10.5/100,000). Conversely, the White veteran

suicide rate is doubled at (20.17/100,000). Comparably, Asian or Pacific Islanders and Hispanics

have a rate of approximately (12/100,000). However, the Native American veteran population

has the highest rate (30/100,000) (Reger, Smolenski, Skopp, et al., 2015).

With the data it becomes plausible to posit that Black, Asian, and Hispanic veterans have

a lower rate of suicide due to built up resiliencies developed both epigenetically and via the

probable hardships of their biopsychosocial development. Conversely, the White veteran

population may demonstrate a higher rate of suicide due to a shortage of resiliency possibly due

to a socially privileged predisposition. This is certainly worth further investigation in future

study.

Discussion
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When considering Cognitive Behavioral theories in association with veteran suicide we

now have that data to peer into the root causes. Most of which have little to do with combat,

trauma or PTSD and almost everything to do with status of discharge and the impact such

discharge determinations have on individual ability to access resources.

Discharge Status

The highest rate of suicide amongst the veteran population (44-48/100,000) observed by

those that served less than one through three years of active duty and never deployed (Reger, et

al., 2015). Compared with a rate of (21/100,00) for those whom served 4 years and (11/100,000)

for those that serve 20 years or more. Considering the standard enlistment contract is four years

at minimum we can infer that those whom served less than four were somehow discharged under

less than honorable conditions. Ironically the population of veterans with a less than honorable

discharge have a rate of suicide (45/100,000) which corresponds to the rate observed in those

that served less than two years as compared to the rate (22/100,000) observed by veterans with

an honorable discharge and four years of service (Reger, et al., 2015).

Discharge status is commonly not considered amongst the civilian population, yet it has

broad reaching implications across biopsychosocial spheres and impacts a veterans ability to

reintegrate effectively following armed forces service. Specifically, if a veteran is discharged

under less than honorable conditions, he or she is effectively ineligible for most of the valuable

resources, which assist in the transition from service member to civilian. Such resources include

education, health care, disability compensation and mental health services. It is this relationship

to gains in social and psychological resources (Hobfoll, Hall, Canetti-Nisim, Galea, Johnson &

Palmieri, 2007) that arguably lead to repeated examples of PTG amongst combat veterans

discharged honorably while those discharged under less than honorable conditions are unable to
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effectively adapt to the sense of isolation and shame that often accompany a failed term of

service or premature and dishonorable discharge.

Thus it is the dishonorably discharged service members whom require the most mental

health care that find themselves rejected and helpless. It is this population that kills themselves

and this population in need of cognitive behavioral solutions.

Thankfully, as of March 2017, the recently appointed VA Secretary announced intentions

to expand mental health care to former service members with other-than-honorable discharges

and in Crisis (VA, 2017, 2) Considering the benefit demonstrated by CBT treatment, this shift in

VA policy may very well begin to finally address the root cause of the veteran suicide crisis

while enabling the combat veteran population to inspire others through growing examples of

PTG such that the exaltation of victimization can cease and resilience and strength can manifest.
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