To date, I have said nothing about the current crisis of suicide both within the military and within the veteran population.  With this post I enter the discussion , but with some trepidation, and I do hope that I enter it with the respect that the many dedicated clinicians and researchers across the country deserve as they grapple with this epidemic.  I simply want to add my take as of today.

As many of you probably know, this week the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury sponsored a major conference in Washington DC, bringing together the Department of Defense and the Veterans Health Administration for a Suicide Prevention Conference entitled, Back to Basics: Enhancing the Well-Being of Our Service Members, Veterans, and Their Families. 

It was a big deal, and rightly so.

Today I only want to reflect on one presentation given at the conference, as brought to my attention by the ever-vigilant, ever-informative Bobbie O’Brien in her blog Off the Base: remarks made by Dr. Craig Bryan and his co-presenter, Dr. David Rudd, in a breakout session entitled Reasons for Attempting Suicide Among Active Duty Soldiers: Clinical Implications.  The substance of the presentation was reported by Karen Parrish of the Armed Forces Press Service.

Dr. Bryan is a big deal in these circles: the guy has an eye-popping CV (even more impressive for somebody only six years out of the engraving of his doctoral sheepskin!), and currently is in the well-deserved position as the Associate Director of the National Center for Veterans Studies at the University of Utah in Salt Lake City.  I get worn out just reading the man’s accomplishments, let alone imagining how I could attempt even a third of them and not collapse in sheer ignominy.

Drs. Bryan and Rudd worked with active-duty service members who had been hospitalized for suicidal ideation/behavior.  In a study designed both to gather data and to institute prevention/treatment strategies, they tried to understand the reasons why active duty military desire to take their lives.  Using a classification system apparently well-known within suicidology circles, they came up with the following data:

1.  One hundred percent (100%) of those interviewed stated that they were seeking emotional relief, or the “desire to stop bad feelings”;

2.  Over eighty percent (82.4%) stated they were seeking avoidance and escape, with the primary goal of “get[ting] away and escap[ing] from other people”;

3.  Just over eighty percent (80.1%) stated they were seeking interpersonal influence, especially “to communicate or let others know how desperate [they] were”; and

4.  Over seventy percent (72.1%) stated that they were seeking the generation of feeling, especially to “feel something, even it was pain.”

Quite the list.

In his CV, Dr. Bryan notes that he is especially interested in developing evidence-based treatments to reduce suicide, and as presented by Ms. Parrish, he hopes that his work may be useful to “teach patients ‘how to suffer in a way that doesn’t require you to die.’”

On Teaching, Relating, and Suffering Together . . .On a Mission

Clearly Dr. Bryan and his colleagues throughout the suicide prevention community are deeply passionate about their work and deeply committed to improving the lives of all active-duty military and veterans.  I applaud them in their persistence and in their efforts to clarify what needs to be clarified and to treat what can be treated.

Today as I sit on my porch in the relative coolness of a June Sunday, far away from Lake Huron, less than twenty-four hours away from my return to the world of combat veterans desperately seeking hope somewhere, soon, I merely think again about language.  And about hierarchy.

And about mission.

As most of you know, I was not a military man.  Yet I am a man, one who grew up in the America of the Sixties and Seventies, who established himself both personally and professionally in the Eighties and Nineties, and who now looks to the twenty-first century as the place to pull all that together, offer what I can, and then leave the rest to my children’s generation and beyond.  It is true that the concept of “man” and “masculinity” has undergone, shall we say, some re-examination over my lifetime.  I acknowledge that, and I do hope that, in many ways, I am embodying the best of those re-examinations.

Still, the key word there for me is embody: I experience the world as a man whose biology has emerged within the interpersonal context of American culture, its “boy culture” and its “male culture.”  No matter whether I have wanted to or not–quite frankly, often in spite of my best, conscious efforts–the interpersonal and the physical have united to create a pattern of thought and feeling that sets the stage for my every thought and feeling long before I even realize that I’ve had either.

And I must say: as time is moving on and I am meeting men much younger than I, both in military/veteran contexts and in far different contexts, I am not finding that “twenty-first century men” experience their world much differently from how I do.

So let’s call it like it is: many of us men–maybe even most of us–are obsessed with hierarchy.

Every single thought, every single feeling we have has already come to us through a filter of “who’s first, who’s second?”; “who’s winning, who’s losing?”; “who’s up, who’s down?”; “who’s front, who’s back?”  Who else but a group of Western men, even a group of very good friends-Western-men, can turn a Domino’s pizza order into high drama over who will prevail: the pepperoni-only guys, the sausage-only guys, or the two-toppings-even-though-it’ll-cost-extra guys?

Ah, ‘tis the age-old question, is it not?  How much of a “relationship” is hierarchical and how much is mutual, the traditional-male approach to the elephant and the traditional-female approach to said creature?  As individuals, no matter what our chromosomal patterns, which is our primary experience?  How much of the alternative experience will we allow into our consciousness?

Is teaching, is therapy hierarchical or mutual?  The answer, of course, is C, i.e., both A and B.  Great, fill in the circle on the scan sheet, next question.

But really . . . really . . .

Maybe it’s because I’m a guy and a traditional one at that.  Yes, maybe that’s it.

But I’m going to have to confess in public: I don’t experience teaching as mutual.

And honestly?  I don’t naturally experience therapy as mutual.

I don’t experience it as mutual when I hear other therapists talk about it, especially in the context of psychoeducation, task performance, and review/rehearse.  And I’m constantly–constantly–having to remind myself when I’m with a patient that I’m just a guy who once hurt a great deal and who still can hurt, sitting with a man or woman who continues to hurt a great deal, still.  I ain’t above, I ain’t below.  Sometimes, I’m barely holding on with.

Or maybe it’s because I’m an old guy as well.  Yes, maybe that’s it, too.

Not only are my students (undergraduate, graduate medical) younger than I, not only are most of my combat vet patients younger than I, most are now the age of my peers’ children or, horrors, of my very own children.  I had always calmed myself by the fact that I started this parenting deal later than did most of my peers.  Good Lord, I can’t even fall back on that now.

This is not necessarily a bad thing, however, not by a long shot, this age stuff.  As I’ve noted in previous posts, I have a certain paternal relationship with many of my patients (and even many of my students) that both of us, patient/student and I, seem to enjoy a great deal.  When hierarchy is suffused with warmth, especially for us guys, it’s usually a win-win, big time.

For never forget:  not only do many of us guys first experience the world as hierarchy, many of us are consequently more comfortable within hierarchy.  As long as we’re being respected (and not humiliated) in the number-two position, the latter ain’t a bad place to be in life, let me tell you.  Let the big guy take the heat, you know what I mean?  The rest of us can just shrug our shoulders, then, with one of those classic “what’s-a-peon-like-me-to-do” looks plastered on our mugs.

From what I glean, a whole lot of military men (and women) have lived that latter life to the fullest.

What’s hard, of course, is for “Dad” to admit to “child” that he both does know a thing or two and that he doesn’t really have that much of a clue as to which way is up, at least much of the time.  It’s hard to hold on both to a position of authority, often a necessary position desired both by the one in authority and the one under authority, and a position of “I’m just a guy wanting the best for you” position of mutuality.

Which takes me back to language, and specifically to the language emotional relief, avoidance and escape, interpersonal influence, and feeling generation.

How easy it is for us as teachers and/or therapists, man or woman, to look at our students, our patients/clients, to observe them, always with the underlying desire to learn from them and to give back to them what we’ve learned so that they too can learn one, do one, and then hopefully teach one themselves.

How much harder it is for us to look at them and feel them, as one sufferer with another, as one who may have no clue as to the depth of the suffering of the other, who can therefore never suffer as (my daily experience), yet as one who is willing to sit in the presence of that other and his or her depth, who can–and will–again and again suffer with.

I have to confess: I have no way of conceptualizing emotional relief except as the most profound of interpersonal experiences, of finding relief from someone for the pain that one is enduring.  I have no way of conceptualizing avoidance and escape except as a desperate attempt on the suicidal person’s part to run away from his/her suffering precisely because there is no one, at least in his/her mind, to run to with that suffering.  I have no way of conceptualizing interpersonal influence except as a desperate attempt to find someone–dear God, anyone–to influence, please, maybe just for a few minutes of your time?  I have no way of conceptualizing feeling generation except as a desperate attempt to get something ignited within the person, given that no one seems to be able to ignite anything of any significant for him/her.

I wish in my mind’s eye I could easily conceive of a general, a colonel, an admiral, a captain looking the soldier, the Marine, the sailor, the airman, the guardsman eye to eye, a superior to an inferior, yes, but also a human being to a human being, saying with all his/her heart, “I want you to live, soldier.  I want you to live” . . .

. . .and then not have to conceive the questions that inferior, that fellow human being might ask in response:

“Really, Sir/Ma’am?  Me? 

“At the expense of the mission, even?

“Oh, yes, Sir/Ma’am, I do understand: I am the mission, an indispensable part of it, the one united with others who will make the mission succeed, bring peace, bring us all home safely. 

“But, Sir/Ma’am, you and I both know: I might end up having to be an “expectable loss” of this mission, won’t I?  Yes, I know that I will die with honor.  I know that you will honor me.  I know you will bestow honor upon my family.  I thank you for that.

“And, yes:  I know that if I die by my own hand, I will die with tragedy.  I know you will feel my tragedy.  I know I will bestow tragedy upon my family.  No, Sir/Ma’am, I don’t want that.

“But, permission to speak, Sir/Ma’am: either way, I’ll be dead, won’t I? 

“True, you’ll feel better, my family will feel better if I die with honor and not tragedy.  Yes, that is important to me.

“But either way, Sir/Ma’am, I’ll be dead.

“Correct?

“And you’ll still have your mission.

” . . .Correct?”

I don’t know what to say, really, what to think, what to feel.  I’m a civilian, after all.  My only comparison is a weak one: if one of my patients kills himself or herself, my life will go on.  I will be sadder, less whole, but I will continue.

Without the soldier, the mission will be sadder, less whole, but it will continue.

It all comes back to hierarchy, doesn’t it.  Guys get that.  In the twenty-first century, women get that too.  At least it’s an even playing field.

So there you have it . . .

If it’s between you and me, patient, yes, I’ll choose me, but I’ll wonder why it had to get to this point.

If it’s between you and the mission, soldier, though: well, you signed up for this.  That always was the point.

Dear God, I thank you, truly, that I never had to live the latter encounter.

Dear God, be with those who do.