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An Innovative Approach to Treating Combat Veterans with PTSD at Risk for Suicide
HERBERT HENDIN, MD
Suicide rates among military personnel had a significant drop in 2013, but there is no evidence of a drop among veterans. The problem of suicide among combat veterans with posttraumatic stress disorder (PTSD) remains a source of concern. The Department of Defense and the Department of Veterans Affairs are now calling for innovative treatment approaches to the problem. A short-term psychodynamic therapy presented here may be able to fill that need by dissipating the guilt from veterans’ combat-related actions that leads to suicidal behavior. The treatment showed promise of success with veterans of the war in Vietnam. Preliminary work with combat veterans of the wars in Iraq and Afghanistan indicates that it may be equally successful in treating them. Basic aspects of the psychodynamic approach could be incorporated into current therapies and should improve their ability to treat veterans with PTSD at risk for suicide. Post traumatic Disorder.
A 7-year research and treatment project with combat veterans of the Vietnam War with posttraumatic stress disorder (PTSD) and at risk for suicide at a Veterans Administration (VA) Medical Center laid the groundwork for the material in this article (Hendin & Pollinger Haas, 1984a,b). Comparable research being performed at the Michael E. DeBakey VA Medical Center in Houston, Texas, which includes veterans of the wars in Iraq and Afghanistan as well as Vietnam, is building on this work (Hendin, Al Jurdi, Houck, Hughes, & Turner, 2010).
PTSD AND THE RISK FOR SUICIDE
Vietnam veterans with PTSD are four times more likely to die by suicide than veterans without PTSD (Bullman & Kang,
1994). Although PTSD is the disorder most associated with suicide among veterans, most veterans with PTSD are not at risk for suicide. Veterans at risk for suicide who do not have PTSD have very different problems than veterans at risk for suicide who do. This study only addresses the problems of veterans with PTSD. The study of Vietnam combat veterans with PTSD provided insight into the factors associated with suicide among them. Persistent severe guilt over combat experiences was found to be the major factor differentiating veterans who had attempted suicide and those who were seriously preoccupied with suicide from those veterans who were neither (Hendin & Pollinger Haas, 1991). Nineteen of 100 combat veterans with PTSD had attempted suicide at least once since returning from Vietnam. Guilt related to combat actions was significantly marked in all 19 of the suicide attempters, but in only 32 of the 66 nonsuicidal veterans (v2 = 14.24, df = 1, p < .001). Fifteen had been seriously preoccupied with suicide since they left the service. Guilt was also marked in 12 of these 15 veterans compared to the 66 nonsuicidal
HERBERT HENDIN, Suicide Prevention Initiatives, New York, NY, USA and New York Medical College, Valhalla, New York. Address correspondence to Herbert Hendin, Suicide Prevention Initiatives, 1045 Park Avenue, New York, NY 10028; E-mail: hhendin@ spiorg.org
582 Suicide and Life-Threatening Behavior 44(5) October 2014 © 2014 The American Association of Suicidology DOI: 10.1111/sltb.12135
veterans (v2 = 3.71; df = 1, p = .05). Although anxiety, survivor guilt, and depression marked those at risk for suicide, combat guilt outperformed the other three predictors, including depression, when all four were entered into a logistic regression simultaneously. The combat experiences of the suicidal veterans were examined for possible determinants of their guilt. The chaotic nature of guerilla warfare in Vietnam, the uncertainty about who was the enemy, the emphasis on body counts, and the Viet Cong’s use of women, children, and the elderly as combatants contributed to combat actions about which veterans felt severe guilt. The Viet Cong would strip American soldiers they had killed and hang their naked bodies from a tree with their genitals stuffed into their mouths. Such tactics, designed to frighten soldiers, also tended to infuriate them and contributed to atrocities on both sides. A more common provocation was rage precipitated by experiencing the death of close comrades (Hendin & Pollinger Haas, 1991; Shay, 1995). Post traumatic Disorder.
MEANING OF COMBAT
How each veteran experienced combat events; that is, the meaning of the combat experience to the veteran, was integral in determining the nature of the guilt and the risk for suicidal behavior. The term meaning of combat refers to the subjective, often unconscious perception of the traumatic event, and includes the affective state of the veteran before the event took place, when it took place, and the affects experienced subsequently. Nightmares and other re-experiencing symptoms are cardinal symptoms of PTSD. Both are valuable tools in determining the meaning of the experience to the veteran. The following case example is illustrative (Hendin & Pollinger Haas, 1984a). (Informed consent was obtained from all project participants and some cloaking was performed with case presented).
Throughout his tour, Greg L. thought he would be killed in action. The thought was comforting to him because it would enable him to avoid having his friends, family, and fiancee discover that he had lost control of his anger and killed without reason in Vietnam. During the last two weeks of his tour, when he learned that he was not going to be assigned to any more combat missions, he tried to kill himself with an overdose of drugs. He had been an artillery spotter in Vietnam. He was preoccupied with a memory of a friendly village that he and his sergeant had helped to destroy in a contest designed to see who could call in the best coordinates. Through his binoculars, Greg had watched with excitement as the shells landed. As the village was being destroyed, he saw an old woman with betel nut stains on her teeth running in his direction. She was shaking her arms trying to get him to stop the shelling. As she ran toward him, she was killed by an artillery round. After he returned to the United States, Greg was tormented by a painful recurring nightmare that expressed his intense guilt over the destruction of the village. In the dream, he is captured by South Vietnamese villagers, strung on a pole like a pig carcass, and paraded around the village so that everyone could throw stones at him, hit him, spit on him, and curse him. The old woman with the betel nut stained teeth is taunting him. The villagers hold him responsible for all the death and destruction in their village. He knows they are going to kill him. Greg made a second suicide attempt during a re-experiencing event in which he thought he saw the villagers covered in blood. He cut his wrists and described feeling a sense of relief as the blood spurted out. Both the nightmare and the reliving experience express his sense of guilt and need for punishment. The nightmares of most veterans with PTSD correspond closely with the combat experiences, and the terror over being killed that they engender. Veterans who have severe guilt over their actions in
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combat are more likely to experience nightmares that reflect their guilt and are often punitive in nature. They are at high risk for suicide. Greg’s experience of feeling out of control while in Vietnam was usual among the suicide attempters. Sixteen of 19 suicide attempters (82%) in the study had felt out of control as a result of excessive fear or rage during their tours of duty, including situations in which their anger led to their killing noncombatant civilians (Hendin & Pollinger Haas, 1991). Veterans like Greg, who feel out of control while in combat, and remain so in civilian life, are the most difficult to involve in the treatment. It was not surprising that Greg turned down the offer of short-term psychotherapy that was available to participants in the research project. During the course of study, three of the veterans who also felt out of control, and did not accept the offer of treatment, did kill themselves.
RECOGNIZING THE VETERAN AT RISK FOR SUICIDE
Treating the veteran at risk for suicide requires identifying correctly those veterans who are at risk. In a previous study with patients who were civilians, detailed data were obtained from therapists of patients who died by suicide while in treatment with them. Written responses to questionnaires and subsequent personal interviews with the therapist were used to determine what patients were feeling and experiencing in their lives immediately before their suicides (Hendin, Maltsberger, Lipschitz, Haas, & Kyle, 2001). The data were contrasted with data from the same therapists on comparably depressed patients in treatment with them who were not suicidal. We found that the suicides were preceded by a time-limited state of suicide crisis that was marked by three factors that usually occurred in combinations of two or three in a single patient: a precipitating event, behavioral changes, and intense affective states.
Intense affective states that were intolerable and uncontrollable proved to be the factor most related to suicide (Hendin, Maltsberger, & Szanto, 2007). The uncontrollable nature of the affects engendered fear on the part of the patients that they were fragmenting; that is, “falling apart.” Nine affects were examined: anxiety, rage, desperation, abandonment, loneliness, hopelessness, self-hatred, guilt, and humiliation. A striking contrast was observed in the patients who went on to suicide and the comparably depressed patients who were not suicidal. Just before death, the suicides averaged more than three times the number of intense affects than comparably depressed nonsuicidal patients. These differences remained when controlled for severity of depression, comorbid Axis 1 diagnosis, and borderline personality disorder. That work made it possible to develop the Affective States Questionnaire, which was tested prospectively and successfully for its ability to predict short-term risk for suicidal behavior (3 months) among a general population of 240 outpatient and inpatient veterans not selected for the presence of PTSD or the risk for suicide. Recognizing the intense, overwhelming emotional states that leave veterans feeling out of control in a crisis period immediately preceding the suicidal behavior is critical in this process (Hendin et al., 2010).
TREATING THE VETERAN WITH PTSD AT RISK FOR SUICIDE
The treatment employed is based on the ability to address the subjective, often unconscious meaning of a traumatic event. Even slight differences in the recurrent nightmares and the actual experience can be helpful in understanding the meaning of the experience and making treatment possible. Tom B. is an example. Troubled by violent impulses toward his family as well as suicidal thoughts, Tom’s entire postcombat life had been per
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vaded by PTSD. For years, he had suppressed the symptoms with drugs that he had been using since he returned from Vietnam. He stopped because he felt they were destroying his body, but he then became aware of his preoccupation with Vietnam and the disturbing nature of his nightmares. Tom had one recurrent nightmare that he said “scares the hell out of me. It’s so real but I don’t know if it actually happened.” In the dream, he is carrying the dead body of a young woman and trying to bury it so no one can find it. Upon waking from this dream, he would sense that he had some involvement in the young woman’s death, but would be unable to recall what it was. When asked whether he had ever raped any Vietnamese women, Tom replied that he had not. When asked whether he had ever witnessed a rape, he said that he had. His squad had been assigned to secure the entrance to a tunnel complex, while four men from another squad went underground to explore the tunnels. His squad was in radio contact with the other squad and learned that they had found a Viet Cong hospital base. A short while later, Tom heard shouting and the sounds of grenades exploding. The four men came out of the tunnel dragging a French nurse who was bleeding from arm wounds. Each of the four raped the nurse while Tom’s squad watched. When the last man was finished, he pulled out his knife and killed the woman. When this happened Tom and his squad departed; he never knew how the men disposed of the nurse’s body. He did know that when the four soldiers reported the incident, they made no mention of taking anyone alive. Tom claimed to have had no particular reaction to the event. He admitted that he had been sexually excited while watching what had happened, but he had never connected the episode with his nightmare. Tom was seen for several months of short-term psychotherapy during which time he was helped to explore and feel the emotions connected with his experience. Just as in the dream where he was carrying Post traumatic Disorder.
and trying to find a place to bury a woman’s dead body, he had tried for years to bury the entire experience. Although he had succeeded on a conscious level, the burden of guilt he was nonetheless carrying is evident in his dream. In therapy, he was able to connect it with the rape and killing of the nurse he had witnessed, to recognize that he was a “participant” in her rape, and to experience the emotions connected with it. He stopped having the nightmares, became less angry with his family, no longer had thoughts of suicide, and had remained so on follow-up a year later. Tom had been referred to our research and treatment program as having been treated with behavioral therapy and medication without any improvement. His nightmare, however, had been treated only as a symptom to be suppressed with sleeping medication rather than an opening to unconscious feelings that were troubling him. Although understanding the subjective, perceptive experience of combat to the veteran is a crucial step in treatment, a core of trust between the veteran and the therapist needs to be established for this to take place. Even when that trust has been established, veterans may not be able or willing to reveal the combat experience that is most disturbing to them right away. Supervising the treatment of veterans, one finds that therapy often flounders when the veteran has shared at least some of the disturbing specifics of his combat tour. The therapist may inadvertently respond with revulsion, anger, or fear. More frequently, the therapist’s discomfort is communicated in the need to convey understanding or acceptance before he or she is in a position to do so. When this happens, it is the therapist’s discomfort, rather than what is specifically said, that the veteran responds to, only increasing his distress. It is better for the therapist to accept and respect the veteran’s guilt, to acknowledge the pain of the experience, to indicate that he has already punished himself enough, and to work to help him not let
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that event continue to define his life. Telling a veteran who appropriately feels guilty over his behavior in combat, “These things happen in war,” is counterproductive. The relationship between the veteran and the therapist plays a key role in the healing process of veterans who have PTSD, and this is particularly true for those who have severe combat guilt and are at risk for suicide. The veteran needs to forgive himself for the behavior that triggered his guilt and the self-punitive way it is expressed. When the veteran feels relief at having shared the experience with a trusted therapist, the therapist is in a position to give him “permission” to forgive himself, to resolve problems that have developed in the course of the illness, and to go on with his life. Guilt is an emotion that can be harmful when it is self-punitive, but it can be a powerful force for changing the direction of one’s life. A dozen of the 27 veterans at high risk for suicide were successfully treated in the course of the study of 100 Vietnam veterans with PTSD, most of whom had been referred to us with a history of having been treated unsuccessfully with behavioral therapy and medication. In establishing the role of guilt in the suicidal behavior of veterans, or in predicting suicidal behavior among them, the research had built in controls and could be validated. That was not true for the treatment aspects of the work. As a consequence, we have no knowledge of the quality of the behavioral therapy employed in the previous treatment of the veterans. Little rigorous, controlled research has been performed on preventing suicide among combat veterans with PTSD who are at risk for suicide. Cognitive behavior therapy (CBT) and dialectical behavior therapy (DBT) are two significant exceptions. Researchers in both are being funded by the Department of Defense. Although these therapies have shown ability to reduce some PTSD symptoms, so far they have not shown the ability to prevent suicidal behavior in this population; they are still being tested so it is too early to come to
any conclusions about them. Prolonged exposure therapy is being used to treat civilian and military personnel with PTSD, but it has not been tested for its ability to prevent suicide among military personnel or veterans. The need for testing is even more evident with therapies that have demonstrated success in treating PTSD in civilian populations, but have not been tested with a veteran population such as Interpersonal Therapy and Cognitive Processing Therapy (CPT), which utilizes components of CBT and exposure therapy in its successful treatment of female victims of sexual assault (Resick & Schnicke, 1992). Several factors are likely to explain why the current treatments used by the military and the VA are so far not proving effective in preventing suicide among those with PTSD who are at risk. Not determining the often unconscious, subjective, emotional meaning of traumatic combat experiences of the veterans is only part of the problem. Of equal importance is not adequately recognizing the ways in which the relationship between the veteran and the therapist can be used to enable the veterans to give up selfdestructive behavior. Earlier concepts of the unconscious that are outdated have been rejected by modern psychodynamics that has recognized its underlying, enduring contributions to our understanding and ability to treat mental illness and, in particular, the role of the unconscious in influencing behavior, the value of dreams in that process, and the nature of the relationship with therapists doing the treatment. The concept that human behavior can be understood without reference to unconscious processes runs counter to advances in neuroscience that see the mind as operating largely by unconscious processes taking place in the brain (Kandel, 2013). Clinicians are often trained in one form of therapy and practice that with minimal variation with all of their patients. Many clinical researchers believe that a multifaceted approach is more effective, but
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since demonstrating its effectiveness is more challenging and harder to fund, it reinforces the tendency to specialize in and utilize only one particular approach. Granting agencies are beginning to recognize this and to fund “integrative projects.” A less constrictive approach has been incorporated in a short-term psychodynamic therapy (12 sessions) that also utilizes techniques of established behavioral psychotherapies. There is reason to believe that these therapies would improve their ability to treat combat veterans with PTSD at risk for suicide if the therapists employing them received training in some basic psychodynamic principles. For clinicians wanting to incorporate the psychodynamic approach into their clinical practices, there are many ways to get this training. In a research project, the situation is more complicated. The didactic training of both therapists and supervisors is carried out by an expert and involves use of a guideline describing the treatment protocol; case examples; weekly supervision of the first cases treated; less frequent subsequent supervision throughout the treatment; the use of an adherence protocol to be completed by the supervisor; and the employment of an adequate control group with which to compare the results.
COMBAT DIFFERENCES
There is a difference in the population that served in the Vietnam War and the wars in Iraq and Afghanistan. The veterans of the wars in Vietnam were drafted, their average age was 20, and they rarely had a history of suicidal behavior prior to the war. Veterans of the wars in Iraq and Afghanistan were volunteers, their average age was 28, and they frequently had histories of precombat mental illness including suicidal behavior prior to combat (Leardmann et al., 2013). In cases we have seen, their enlistment was often a way of trying to provide structure to their lives which left them vulnerable when it did not work.
The combat experiences of Vietnam veterans differed significantly from the experiences of veterans of the wars in Iraq and Afghanistan, where improvised explosive devices were a principal cause of traumatic brain injury (TBI). Veterans with TBI are also more likely to die by suicide than those without TBI (Brenner, Ignacio, & Blow, 2011). Guilt over the killing of noncombatants is less likely to play a role in their suicide than it is with Vietnam veterans who experienced the chaotic combat firefights and sustained guerilla warfare of the war in Vietnam. Iraq veterans with experiences roughly comparable to those of Vietnam veterans usually fought in battles, like those in Fallujah and Ramadi, in which sustained firefights (over months and years) in cities and within buildings led to actions in which women and children were killed and situations where soldiers felt guilt afterward. Multiple deployments, however, that characterized the wars in Iraq and Afghanistan have been shown to contribute to veterans’ physical and mental health problems (Kline et al., 2010) and may also be contributing to suicide independent of combat exposure. Vietnam veterans remain responsible for a significant part of the increase in suicide among veterans with PTSD seeking help at VA medical centers. Many of them have an exacerbation of their symptoms when confronted with aging, retirement, and the death of friends and relatives. Sixtyeight percent of male veterans who die by suicide are between 65 and 74 years of age (Kemp & Bossarte, 2012). A large number of them are Vietnam veterans. They can be treated and should be included in any treatment research program. Post traumatic Disorder.

GUILT, SURVIVOR GUILT, AND DEPRESSION
Although logistic regression analysis did not identify survivor guilt as a significant predictor of suicide attempts, additional one-way analysis provided some evidence
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of the importance of the concurrent presence of the two types of guilt. Forty of the 100 veterans studied, for example, showed both marked guilt about combat actions and marked survivor guilt. Among this group, 14 (35%) had made a suicide attempt. In contrast, none of 30 veterans who showed neither marked combat guilt or survivor guilt had attempted suicide (v2 = 13.3, df = 1, p < .001). Moreover, among the 17 veterans who had killed civilians while feeling out of control and felt guilty about such actions but were not suicidal, only two had survivor guilt. By contrast, 9 of the 12 suicide attempters who had killed civilians while feeling out of control experienced marked survivor guilt in addition to guilt over their combat actions (v = 12.21, df = 1, p < .001). The findings suggest that the combination of these two types of guilt plays a significant role in determining suicide risk among veterans. For most of the suicidal veterans, the clinical data obtained through the interviews elaborated the linkages between combat incidents about which a veteran felt guilty and the loss that led to survivor guilt. Sometimes the loss of a combat buddy came first and contributed to a state of rage which, in turn, led to a loss of control over combat behavior. In other cases, loss of control as a result of extreme fear or rage led to actions about which the individual felt guilty, which was reinforced when a friend was killed. In either case, the veteran was apt to feel that a friend who did not deserve to die had died, while he, who did not deserve to live, was alive. When survivor guilt was particularly strong and persistent, it led to a state of perpetual mourning and depression. These veterans often felt that they had already died and a number had dreams of dead bodies which they related to themselves. To understand and help the veterans with survivor guilt, the therapist needs to inquire about who and what they are mourning and their relationships and interactions with those with whom they served. Their depres
sion needs to be addressed, with medication when indicated. In most of the suicidal cases, like Greg’s, the actions that had been committed were of a nature that made the postservice guilt and nightmares of punishment seem understandable and almost inevitable. In other cases, the combat actions were not as unequivocal. In the war in Iraq, American soldiers would enter buildings that were occupied by insurgents who were firing at them. They would enter a room and start firing at what were presumed to all be insurgents. It frequently turned out that they had also killed or left wounded noncombatant women and children. Guilt in such cases was often severe and was compounded with survivor guilt when they subsequently lost comrades in battle. The suicidal veterans varied considerably in the degree to which they were conscious of their combat-related guilt and its relation to their self-destructive behavior. One veteran who killed prisoners of war stated that everyone had done it and that he was not troubled by his behavior. However, he dreamed repeatedly of being killed in the same way that he had killed the prisoners. Substance abuse and/or difficulty functioning—at work, and in family and social relations—increase the risk for suicide (Hendin et al., 2010). For substance abusing veterans with PTSD at risk for suicide, enrollment in a substance abuse program needs to be a requirement for participation in the treatment. Another factor increasing the need for punishment and complicating treatment occurs when veterans who have lost emotional control during combat, remain emotionally out of control in civilian life, and see themselves as transformed by the combat experience (Hendin & Pollinger Haas, 1991; Shay, 1995). This condition can be the result of neurochemical or physical changes in the brain or epigenetic changes caused by the stress of combat. To what degree psychological treatments can result in beneficial epigenetic changes in such cases has yet to be determined.
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SUMMARY AND CONCLUSION
A unique short-term (12 sessions) psychodynamic treatment approach has been presented that targets the guilt from combat-related experiences that underlies suicidal behavior in combat veterans with PTSD who are most at risk, a risk that is intensified if they also have survivor guilt. It has shown promise of being able to prevent suicidal behavior with veterans of the wars in Vietnam and Iraq and Afghanistan who have experienced chaotic firefights resulting in out-of-control behavior that aroused guilt. This is a significant segment of the Vietnam veteran population and a smaller segment of the veterans of the wars in Iraq and Afghanistan. The treatment’s essential components define the meaning of combat to the veteran with the aid of the veteran’s nightmares and address the relief of guilt. The next step is to test the treatment with a control group large enough to determine its effectiveness. We are hopeful that practitioners of other therapies, and particularly those working with veterans with PTSD at risk for suicide, will incorporate psychodynamic techniques into their practice and research. Their doing so might increase the possibility that more veterans would be getting the treatment they need.
The quality of care provided by the VA has improved dramatically in the past 30 years, but the VA is underfunded and understaffed in relation to the increased need and demand for its services. The VA and the DoD have been criticized for failing to implement properly and evaluate treatments used with combat veterans at risk for suicide; they are now working together to change that. Reducing suicide among military personnel and veterans remains a challenge that needs to be met. Although the large majority of patients with PTSD are not suicidal, those who are suffering from guilt over combat experiences are an important subgroup responsible for a disproportionate percentage of suicides. Mental health professionals in the VA are ready to learn, develop, and test treatment approaches to PTSD that will work. The public and Congress are currently in a mood to support their treatment. That support tends to weaken as the years after veterans return go by. There will need to be an ongoing effort to sustain public awareness of the problem so that Congress provides adequate funding. The need for help does not fade, nor does the danger of suicide abate, in a disorder that is rightly described as “posttraumatic