Long Campaign to Change

There has been a long standing campaign to get the President to change the previous policy, led by families who had soldiers die by suicide. Various veteran groups, members of Congress and  mental health professions, including myself have been publicly advocating that the President change the policy.

The Keesling  Family

I first wrote about this issue in my blog (Psychiatry Talk.com in December 2009) after reading a NY Times piece the previous month about the tragic loss which the Keesling family suffered when their 25 year old son Chance killed himself in Iraq in June of that year. He was in his second tour of duty when the stresses of combat combined with an argument with his girl friend over the phone led to hopelessness and suicide. Hours before his self-inflicted fatal gunshot wound the Keesling family received a rambling despondent email message from their son.

Chance Keesling (Photo from the Keesling family)

His father Gregg commented on my blog and we began a correspondence about this issue. He and his wife had decided to share some of their grief with the public in order to try to bring about a change in the Presidential policy, which was so hurtful to his, and other families who suffered similar losses.  They would receive a folded flag, a letter from the Army praising their son, a rifle salute at his burial and financial death benefits. But the letter of condolence from the President of the United States, which is the symbol of the voice of the people of our country, which is sent to every other fallen soldier in war since the presidency of Abraham Lincoln, was conspicuously absent. There was an increasing frequency of articles touching on this subject in the media. I wrote about it again in my blog and in the Huffington Post and received more comments than any other pieces that I have written. The House of Representatives voted in May 2010 to add an amendment sponsored by Representatives Burton and Napolitano to the Defense Authorization (HR 5136) that urged that the policy be overturned. The only response from the President was that this policy was being evaluated.

Why There Was Resistance to Change ?

It was difficult to say exactly why there was resistance to changing this policy. It appeared to come from certain factions within the military who had the misguided idea that such recognition would encourage suicide or would be rewarding those who were “weak” and couldn’t deal with stresses compared to those who did. These ideas were antithetical to the fact that there were so many accounts of the comrades of these soldiers who did die from suicide who were quite devastated by these losses and very supportive to the families of their fallen comrades and to their memories. There also was no psychological basis for such theories. I could not help but feel this was another example of the stigmatization of mental illness.

American Psychiatric Association Weighs In

As a Past Speaker of the Assembly of the American Psychiatric Association (APA) I believed that it was important that American Psychiatry speak out on this issue. I wrote an Action Paper (a resolution) with Dr. Roger Peele of Washington D.C. which was also co-authored by Drs. Catherine May, Eliot Sorel, Hind Benjelloun and Joseph Napoli which was voted upon and approved by the APA Assembly in May of 2010. The Board of Trustees of the American Psychiatric Association then approved it. In July 2010 James H. Scully Jr. M.D., CEO and Medical Director of the American Psychiatric Association wrote to President Obama representing the 37,000 psychiatric physicians. He called upon the President to eliminate the stigma and shame associated with suicide for families and survivors by reversing current policy and forwarding Presidential condolence messages to families of individuals who complete suicide while in military service. In October of 2010  the APA issued a public statement urging President Obama to reverse the policy of barring such letters. A number of other mental health groups including the American Foundation for Suicide Prevention and the Mental Health America had officially come out in favor of this policy change. APA President Carol Bernstein, M.D. issued a statement in which she noted, “ The contributions of these men and women to their country are not less for having suffered a mental illness. A reversal of this policy to allow condolence letters to family members will not only help to honor the contributions and lives of the service men of women, but will also send a message that discriminating against those with mental illness is not acceptable.”

The Long Awaited Change

The number of suicides in the military continued to go up either approaching or in some analyses exceeding the number of combat deaths. The problem of PTSD and the mental health of our combat troops became a high priority of the military but there was still no change in the Presidential policy.

Last month (June 2010) I met with Gregg Keesling for breakfast as he was in Los Angeles for a business meeting. He had received some indication that the President was reconsidering his policy but nothing had come down yet. Senator Barbara Boxer had just sent a letter to the President, which was made public.  We reflected in our discussion whether this issue might come to a head sooner if fate had led to a high profile family to lose a military family member to suicide rather than unknown but valiant people such as Gregg and his wife. It was clear that he and others like them in memory of their lost loved ones were not giving up the fight and were continuing to push for a change in the Presidential policy.

The Keeslings were notified in advance of the official announcement that henceforth the families of soldiers who die in a combat zone by suicide will receive a Presidential letter of Condolence. They understood that this would not be retroactive but were nevertheless overjoyed that the battle that they had fought in memory of their son was won. While there is nothing that relieves the pain of the loss of a child, hopefully the significance of this accomplishment will help in a small way.

I certainly am very pleased that the President has seen fit to make this change in his policy. I imagine that it was not an easy thing to do since there apparently was strong resistance in the military.

Still Unfair Discrimination

Coming Home (Photo from the Keesling family)

However, it should also be pointed out that there is still something inherently unfair and discriminatory about the new policy. As I understand it, letters of condolence will only be sent to families of troops who have killed themselves in a war zone. I am certain that if a soldier is critically injured by an explosive device but does not die until he or she is back in the United States receiving treatment, his family would not be denied a letter of condolence from the President. Similarly what if a soldier develops a mental disorder related to the stresses which he or she is experiencing in a combat zone and is transferred to the US to be treated but unfortunately succumbs to this condition and commits suicide? Shouldn’t this soldier also be considered to be a combat victim and shouldn’t his or her family also receive a letter of condolence.  Sometimes changes come in small increments and perhaps this important step and the attention to this issue will help the destigmatization of all mental disorders.

If an American soldier is wounded and then dies or is killed immediately in Iraq or Afghanistan,  the President of the United States and The Secretary of Defense write a condolence letter to the family. However, if an American soldier is wounded physically and /or psychologically during his action in Iraq or Afghanistan and then commits suicide there is no letter of condolence written to his or her family by the President and the Secretary of Defense.

There are now more suicides among our combat troops than all those killed by enemy fire in Iraq and Afghanistan together according to a recent CNN Report on this topic. There have been 354 suicides thus far in the year 2009 which is more than the 335 total of combat deaths which occurred in Iraq and Afghanistan combined . While most of the suicides don’t occur until the soldiers have returned to the states at least one third have taken place in Iraq and Afghanistan. The US Army and the National Institute of Mental Health are partnering to assess risk and resilience in service members in an epidemiologic study of mental health, psychological resilience, suicide risk, suicide-related behaviors, and suicide deaths. While this is quite important, it does not address the failure of our leaders to knowledge the sacrifice of those psychologically injured soldiers who commit  suicide. This is a serious defect in our moral fabric.

While Presidents since Lincoln have been writing letters of condolence to families, there is apparently unwritten policy that this does not include families of soldiers who have committed suicide. It is easy to imagine how hurtful that must be to a family who is burying a son or daughter who came back from war with psychological problems and then committed suicide or perhaps killed themselves while still overseas. The New York Times recently wrote a story about one such family. After Gregg and Janet Keesling’s son, Chancellor, killed himself in Iraq in June, the family received a folded flag, a letter from the Army praising their son, a 21-gun salute at his burial and financial death benefits, but not a letter of condolence from President Obama.

A spokesperson for President Obama said that the policy in regard to who should receive a letter of condolence is currently undergoing a review.

What is Going on Here?

I heard one report state that many soldiers would feel that their comrades combat death would be somehow demeaned if the families of soldiers who suicided were given an equal letter of condolence. Another view is that treating suicide the same as other war deaths might encourage mentally frail soldiers to take their lives by making the act seem honorable. These ideas may be influencing the thinking of some our military leaders and perhaps the President. I hope not.

If this is the case it is misguided thinking which resurrects the stigmatization of mental illness. These conditions are not something that anyone chooses to have. This includes depression, post traumatic stress disorder and traumatic brain injury all of which can be secondary to combat experiences. Soldiers cannot will themselves to avoid these conditions anymore than a soldier can avoid a bullet aimed at their head or an explosive device that goes off under their vehicle.  While training and good support can reduce the odds somewhat but once you are in a combat zone you are vulnerable to injury. I also know of no evidence that people on the verge of suicide would be driven to do it because their family would get a letter of condolence.

There is a famous cartoon which shows a therapist giving a patient a large slap in the face while saying “Snap out of it”  and the title of the cartoon is “One Session Therapy”. If there is humor in this, it is because some people have the phantasy that it is that easy to put aside psychological injury. Anyone with knowledge about mental illness and clinical experience knows that it is not true.

A soldier who suffers to the point of  ending his or her own life, has to be recognized as someone who has suffered as much as anyone can imagine.

As far as the idea that some deaths deserve a letter of condolence and some don’t, consider this. If a soldier in Iraq is working in the kitchen and the stove catches fire leading to his demise, would this death be any less deserving of a letter of condolence than a soldier who was caught in an enemy ambush? Would the loss be any less deserving of the latter soldier if it turned out that he made a foolish tactical error leading to his being killed as compared to someone who was brave enough to fall on a grenade to save others lives? Of course not. Similarly, would you compare a soldier who faced many horrific combat situations and developed PTSD with another soldier who became severely depressed shortly after his  plane just  touched down in the combat zone if both ended up having intolerable suicidal feelings which led to their death? Would one family be deserving of a letter of condolence and another not? I don’t believe that we judge some soldiers deaths as being more worthy than others.

Yes, we do give out special medals and recognition  for unusual acts of bravery but these in no way diminish the sacrifice that others have made.

They Are All Heroes

All of the soldiers that we have discussed above would have volunteered to serve in the military and today everyone knows that this most likely could mean exposure to combat. For this they deserve our thanks and when they and their families have made the supreme sacrifice they deserve at least a letter of condolence.

Action to Fix This Situation

What can we do to see that the families of soldiers who have suicided be given the same letter of condolence as families of other soldiers who have died in the military?

We can a write a letter to the President of the United States, Secretary of Defense and our Congressperson and US Senator. Those of you who are mental health professionals should clearly state this in such correspondence and explain how you feel about this situation especially based on your understanding of mental illness. The email address to write to the President is :       president@whitehouse.gov       There is every indication your email would be read by his staff and a sample of them are often shown to the President.  If many of the readers of this blog were to write him a note it is bound to make an impression as this issue is under consideration by the President at present. If you would like some tips on how to write to the President I found this brief article .

We should also ask our professional organizations if they have not done so already to weigh in on this matter. I am writing a letter to my colleague Dr. Alan Schatzberg, President of the American Psychiatric Association (APA), requesting him to consider asking the Board of Trustees to pass such a resolution if this has already not been done. This last November I finished my term as Past Speaker of the Assembly of the American Psychiatric Association and left the Assembly. So while I cannot sponsor such a resolution myself anymore,  I will ask my former colleagues there to also consider doing so . Both the Board of Trustees and the Assembly must approve position statements in the APA. I would hope that once this organization takes it on they will be able enlist the support of our colleagues in the American Medical Association as well as other professional groups.

By all indications President Obama is a compassionate person and I believe that once he has the facts and has heard from the public including mental health professionals, he will do the right thing.

I welcome your comments on this issue.