“If the Marine Corps is mostly white males, why do we need to understand culture?” I was shocked by the Defense Suicide Prevention Office pushback on exploring the role of culture in military suicide. But not surprised. The study of suicide continues throttling towards the statistical and biomedical, leaving culture in the dust amid a continuing suicide epidemic. The prevention and research landscape resembles “Dragnet” – Psychiatrists, psychologists, epidemiologists, and AI-tech experts seeking ‘just the facts.’ But our ‘facts’ are incredibly incomplete.
“I think,” said researcher Craig Bryan, addressing the scarcity of cultural research, “one issue involves assumptions about the causes of suicide. I would argue that contemporary thinking about suicide is very biomedical in orientation and has become increasingly so over time. This bias almost certainly influences the availability of funds. A good portion of the research dollars have focused on developing and testing treatments and interventions to be delivered within healthcare systems. One could therefore argue that biomedical and clinical researchers have better access to resources to pursue such work.” Rajeev Ramschand at RAND echoed this sentiment in my article “Cultural Problems Require Cultural Solutions”, with three focus points for future research:
“What is the mental health culture in military settings and how does it vary? This would address questions beyond individual questions about stigma to understand how military personnel perceive mental health treatment, how leaders perceive treatment, how other support personnel (e.g., chaplains) see mental health treatment, and even how mental health providers perceive military-sponsored mental health treatment. What does the culture of mental illness look like in military settings?
“What is the culture of support in military settings? Beyond mental health, how strong and where are these deficiencies in cultures of support? Do people know when each other is struggling (relationally, alcohol use, financially) and do they offer support or ignore problems until they reach crisis points?
“How have needs changed? Does the new cohort of military recruits have norms and expectations that will require changing the ways the military “does business” and how? Is the current structure and operations across the military supportive for helping new recruits function well, thrive, and does it promote health and well-being?”
Bryan and Ramschand served on the Suicide Prevention and Response Independent Review Committee, providing 117 recommendations to DOD, duplicating many previous recommendations. Despite several mentions of culture – “greater care in the promotion and leadership selection process at all levels of the military could create a culture and environment that reduces vulnerability to suicide” – SPRIRC did not recommend shifting research from the biomedical and clinical to the cultural, which is tantamount to a trauma center treating gunshot victims while ignoring bullet holes.
“Suicide,” said Matt Miller, Executive Director of VA Suicide Prevention, during a Senate Committee hearing on Veteran suicide, “is a complex problem with a multifaceted interweaving of potential contributing factors. In addition to mental health risk factors for suicide, we must look at a broader array of other contributing factors such as sociocultural risk factors and health related social needs that are also associated with suicide ideation and attempts.” Despite acknowledgement of the complexity of suicide, academia, military leadership, and government institutions that oversee research and policy are deeply resistant to studying culture. Thomas Joiner, head of the federally funded Military Research Suicide Consortium – billed as “multidisciplinary,” despite being restricted to one profession – and editor of a top academic journal, actively prioritizes quantitative, clinical research to the detriment of less “rigorous” and therefore less valuable qualitative and cultural approaches to understanding suicide. Conventional suicidologists boil down suicide to statistically relevant risk and protective factors, seeking the “gold standard” of research – randomized control trials – to test clinical interventions. Such research removes “confounding factors” or messy aspects of behavior and environment that challenges accepted theories, making it less valid (or publishable).
The hyperfocus on clinical settings and interventions, to the exclusion of cultural perception and context, clearly explains our 20-year losing battle with military suicide. This willful blindness to cultural research is couched in academia’s culture of “publish or perish.” Obsessed with seeking grants, publishing papers in high impact factor journals, and getting tenure at major universities, most academics do not prioritize solving chronic health disparities. Like suicide itself, the burgeoning field of biomedically and risk centered suicide research shows no sign of slowing, presenting a disturbing correlation with increases in suicide.
This trend is aided by the Institutional Review Boards, oversight bodies that review research proposals in a highly complex and bureaucratic process of evaluating risks and benefits of research involving human subjects. Though refuted, DOD and VA IRB bodies make it extremely difficult to implement novel research and interventions. While the “Not Just A Number Act,” requires VA to provide “more comprehensive data regarding those who have committed suicide” and holistic picture of suicidal veterans’ interactions with the VA, this policy fails to incorporate the cultural perspective and lived experience of veterans, families, and even healthcare providers, let alone the culture of the VA itself.
While there are programs that attempt to prevent toxic climates from continuing, such as the Collaborative Assistance Team program stood up to “prevent 'Another Fort Hood',” these programs largely exclude in-depth cultural analysis and individuals with appropriate training, education, and aptitude for ethnography, the primary method for gaining in depth, contextual understanding of cultures and societies. Rather, such projects take an ‘organizational psychology’ tack and utilize SMEs with valuable, but limited awareness of ethnographic methods, confusing their results, (which can still be highly valuable), for ‘cultural research.’ It is also questionable how independently such projects and personnel operate or are seen by servicemembers.
Some leaders in the military and veteran community, however, step strongly into this cultural breach using creativity and organic resources and knowledge. Senior enlisted conduct service wide “listening sessions” and utilize social media and Reddit. Equipped with cultural experience and language, hundreds of Veteran-led nonprofits reach out directly to Veterans. Many Veterans enter government, administrative and public health roles to provide leadership from within. Such initiative, more than anything, holds suicide at bay, and highlights the bureaucratic and risk averse nature of military, healthcare, and policy arms of government. Real change in suicide prevention challenges the status quo, defies dysfunctional power structures – a missing piece of the puzzle also seen in military sexual assault.
My attempt to ‘give back’ by providing free culturally adapted Mental Health First Aid training to SOI (West) and prepare Marines to respond to mental health crises, was defeated by a risk averse climate, an excuse being that similar training exists in UMAPIT 3.0 training. Yet, MHFA is provided to civilian personnel, but not Marines, a reason being, one senior civilian personnel reviewing the proposal disclosed, “what if we talk about suicide and a Marine kill themselves?” It did not help that another leader at SOI East accused me of attempting to “experiment” on Marines. Despite support from two Chaplains, one high ranking in a nearby command, and the suicide prevention specialist, and facilitation by education and training staff, the proposal died. Yet, risk averse leadership torpedoed the training with unclear explanation. As for UMAPIT training – why would alternative training be supported on the ground if the current training were effective enough to prevent suicide? Could the answer be that required training are commonly designed and delivered as “check the box bull****” that fails to empower Marines and prevent suicide? Let the reader view a clip of UMAPIT 3.0 to see how inspirational and skills based the training is.
In 2018 I approached Joiner at a conference, a veteran speaking to someone with great influence over suicide research and advocating for more focus on servicemembers’ lived experience and perspective on mental health and suicide. His response? About a minute-long silent stare down. The need to understand culture did not register with a leading suicidologist, just as servicemembers’ and veterans’ experiences are not registered by bureaucrats or academics. Working with America’s Warrior Partnership, I learned that Veteran suicides themselves often do not register, instead chalked up as overdoses. We are seen through the sanitized lens of statistics and genetics, a walking infographic of risk and protective factors, data to be mined, not as complex, ever evolving, highly social creatures who possess strengths. Bryan described his experience with the SPRIRC changing his view of suicide and the contributing quality of life issues in the military as a “death by a thousand paper cuts.” The only force that causes death by a thousand paper cuts is culture. It is the ethical responsibility of researchers and policy makers, when their framework for understanding and solving problems is proven ineffective and the problem is out of their scope, to include new working strategies and people who do have the right tools.
As retired General Steve Salazar, president of leadership training organization 360MVP, says, we must focus on “Making the Strong Stronger.” During a visit by Senator Angus King’s staff, an airman and self-described “wrench turner,” emphasized that mental health challenges are unique to specific occupations and environments. This insight informed provisions backed by King that requires suicide reporting by branch and occupation. What a retired General and a serving “wrench turner” recognize, which we must recognize, is that lived experience, cultural context, and our strengths must be incorporated proactively to produce working solutions. As one of my teachers, Jessica Harrington, from the Health Policy Research Scholars program at Robert Wood Johnson Foundation, says, “Policy without people becomes politics.” What culturally centered and collaborative research can accomplish, and clinical approaches cannot, is realignment of suicide prevention and research with a humanistic approach that is not beholden to a risk-averse or stuck mindset.
It is past time to look into the mirror, face the ugliness of dysfunctional institutions and their cultural antecedents, become conscious of problems and our participation in them, and do the work of change, which reflects a time-honored tradition of ethical and disciplined warrior practice. I do not know if those in authority possess the courage to accomplish this task. With a legislative requirement to incorporate cultural research and collaborative partnerships with troops on the ground, and a working system to ensure that policies like “Not Just a Number” are implemented with intent and effect, we can save lives. Until then, it is up to us as the military and veteran community to save ourselves.
Seth Allard is a former Marine Infantryman (2004 - 2009, active), a PhD student of social work at Wayne State University, and a member of the Sault Ste Marie Tribe of Chippewa Indians. Seth’s focus is on both Native American and Military/Veteran suicide and mental health, and cultural approaches to understanding and preventing suicide and improving mental health. He has published with Marine Corps University Press, Marine Gazette, Routledge Press, and the Havok Journal. He is also a Health Policy Research Scholar with the Robert Wood Johnson Foundation and is continuing his education in clinical social work intern with the Veterans Justice Outreach program at the VA Ann Arbor.