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The Truth is in the Middle

Updated: Aug 4, 2023

The following was taken from a speech by our Clinical Director, Jennifer Schouman, regarding Veteran suicide, moral injury, the impact a dog can make to save a life.

How many veteran suicides are there a day? That number depends on who you ask. In 2016 the Department of Veteran Affairs said it was 22 a day. Then they said it dropped to 20 and now, in 2023, they report 17 a day. Meanwhile in 2022, Duke University and the University of Alabama released a joint study that indicated the number of veteran suicides is closer to 44 per day. Why the big discrepancy? Some human error in counting and the VA doesn’t usually consider deaths caused by self-injury as suicide, but rather accidental or undetermined. It’s fair to say that for some of those, considering them accidental or undetermined is appropriate. But not all of them. What kinds of actions fall under self-injury? Drug overdose. Asphyxiation. Gunshot wounds. Suicide by Law Enforcement. High speed, single-driver accidents.

The joint study argues that if deaths were properly categorized and reported, the daily veteran suicide rate would jump from 17 a day to 44. 44 A DAY. I must emphasize that the VA is not to blame. They get their numbers from state and local levels. The truth must lie somewhere in the middle and the middle of 17 and 44 is about 31 suicides per day.

There is no such thing as a checklist of things that must be completed for a death to be considered suicide. There doesn’t have to be note. The person doesn’t have to verbalize their intent. A lot of times, suicide is a very impulsive decision. Recently, I had a Veteran client brought to me who had just attempted suicide. They had been struggling with substance abuse issues, had an argument with their partner and decided it wasn’t worth it. They got their gun and as they were putting it to their head, they fired the gun. The bullet went into a wall and not their head. This was a very impulsive suicide attempt.

What about the Veteran who tells me they were driving 120 mph down the interstate at midnight last night. Is this a suicide attempt? Maybe. I have clients who report to me that they always have thoughts of suicide but don’t have a plan of how to carry it out. They also say, “If I got killed in a car accident, that would be ok.” Does this mean they aren’t going to be as careful driving? Does this mean they are going to put themselves in harm’s way? And is that not just another form of passive suicidality?

What the VA terms as “deaths caused by self-injury,” I call passive suicide completion. Not all of them, but a significant amount. So how do our Veterans get to this point? What causes them to become so angry, so sad, so disillusioned? Let me give you an example. This is a snippet of a session I had with another Veteran recently:

He walks into my office, trying to appear confident and strong. But he’s not. I see the anxiety, the frustration. He’s exhausted. He sits on my couch, back to the wall, so he can see everything: the room, the door, me.

After the usual pleasantries, he tells me, “I’ve been having a lot of nightmares lately.”

“What’s that about?” I ask.

“Well, it’s an anniversary time for an incident that took place over there.”

I stay silent while he decides whether he wants to share, and if so, how much. Finally, he states, “We were in a hostile area. Lots of locals who we never knew whether they’re friendlies or not. We had been engaged in multiple conflicts all day and we were feeling pretty good, since we hadn’t lost anyone. We were coming out of a building we had just cleared. A local boy was walking towards us. He was probably 11 or 12 years old.”

At this point, my client’s dog gets up from where he had been laying and nudges my client’s knee. Unconsciously, I believe, the Veteran reaches down and starts stroking his dog’s head and scratching his ears. He continues, “I said hello to the boy, but he didn’t respond. I tried again, this time waving, and the boy still didn’t respond. It was scary because locals in that area had been known to make the children suicide bombers. Crazy. I don’t get it.”

I continue with my silence, just holding space for my client to experience his thoughts and feelings. After a few moments, he whispers, “I shot him.” He looks up at me with his eyes filled with tears. “I shot him! I shot a little kid!” He looks back down to his dog and continues petting him, shoulders slumped with despair. At this point, my eyes are filled with tears which I rapidly try to blink away. My client continues, “If I hadn’t killed that kid, he was going to kill all of us. It was a choice between killing that kid or that kid killing all of us, him included.”

I respond, “It sounds like you made the only choice you could. An impossible choice in an impossible situation.”

“Yeah,” he says, “but it still sucks, and I still killed a kid. It’s so messed up. I have kids at home his age. I can barely stand to be around them cuz I’m afraid I’ll have a flashback and end up hurting them.”

After assessing for suicide, we review his Safety Plan and schedule a follow up appointment for two days later. He agrees to have his wife hold the bullets to his gun and agrees to call 988 if he is in crisis.

Our Veterans not only view all the atrocities of war, but they must make choices that go against their own moral compass. While they are able to justify the decision at the time, they struggle to reconcile the decision when they come home. This is what we call moral injury and it’s not something that is frequently talked about.

Moral injury, like PTSD, is an invisible wound. Oftentimes, Veterans don’t even realize that this is an injury. They mistakenly assume that they are “bad” for the decisions they have made. In combat, they are called upon to make these impossible decisions. And what might be the right decision in battle, would rarely be the right decision outside of battle. This is a difficult concept to wrap our heads around. It’s often not talked about by the veteran because of the immense shame and self-loathing they feel. They become convinced that because of the decisions they made in battle means they are less than human, not worthy of happiness; not worthy of love.

Happily, this is where our dogs come in. With their persistent non-judgmental affection and attention, they can slowly help the veteran realize they are worthy of happiness and love. I have had many veterans tell me that they tell their dogs EVERYTHING. Without fail, their dogs simply give the veteran love and affection, unconditionally. “My dog never judges me.” What a gift. The dog is re-teaching our clients their value in combination with providing mental health therapy with a qualified and compassionate counselor. Paws and Stripes clients can reclaim their place in society and get rid of, or at the very least, decrease the shame and self-loathing. They can become more attentive mothers, fathers, daughters, sons, sisters, brothers, and friends. They will never be rid of the memories and hopefully, those memories will lose the strong hold they have on our clients. Like my client who struggled to be around his own children because of the choice he had to make in battle: the time he spent training his dog to be a service dog and allowing space for the dog to teach him that he is worthy of happiness and love, combined with mental health therapy, he was able to become again a good father to his children and a loving husband to his wife.


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