Dr. Craig Bryan is the director of the Division of Recovery and Resilience and also heads trauma and suicide prevention programs at Ohio State University. He is an American Board of Professional Psychology (ABPP) certified clinical psychologist with a Doctorate in Psychology (PsyD) with expertise in behavioural treatments (CBT) for individuals experiencing suicidal thoughts and post-traumatic stress disorder (PTSD).
As a military veteran he was deployed to Iraq in 2009 and has since had extensive experience and expertise working with military personnel, veterans and first responders. Dr. Bryan in collaboration with his colleagues, developed and demonstrated the effectiveness of brief cognitive behavioural therapy (BCBT) for suicidal military personnel.
He is a recipient of the prestigious Edwin S. Shneidman award by the American Association of Suicidology in 2016, the Peter J.N. Linnerooth National Service Award by the American Psychological Association in 2013 and published more than 200 peer-reviewed scientific studies.
Dr. Craig Bryan spoke to MVI on military suicide and potential remedial measures. Excerpts from the conversation...
A view presented by US Military Psychologist Richard Doss is that there is no correlation between ‘Combat Deployment’ and ‘Suicide’, that the suppression of emotions, “tough it up” attitude and lack of emotional outlets are the key stressors leading up to troop suicides. This view has its supporters while others dispute the observation. Keeping the aforementioned in mind,
Q: Do you see an observable correlation between combat deployments and suicide amongst military personnel?
Ans: This question has driven a lot of research here in the US, and what we’ve learned is that the answer isn’t quite as simple or straightforward as we initially thought. We conducted a meta-analysis a few years ago in an attempt to answer this question and found that there is not a correlation between deployments and suicide, but there is a correlation between exposure to death/violence while deployed and suicide risk. I’ve attached a copy of that study here.
A combination of ‘operational and non-operational’ factors have been identified as factors responsible. According to the findings in a 2007 internal report by Colonel PK "Royal" Mehershi (Retd) on ‘suicides and fratricides’ commissioned by former Chief of Army Staff General JJ Singh, more than 90% of suicides were committed by Personnel Below Officer Ranks (PBOR).
The 2007 study and subsequent studies on the subject found the following:
Employing jawans (enlisted men) for unsoldierly tasks, poor accommodation and sanitary facilities, administrative and cultural issues in the multi-arm Rashtriya Rifles (counter-insurgency) units, subpar clothing and rations, and poor grievance redressal mechanisms for junior personnel, inadequacies in the quality of leadership, overburdened commitments, inadequate resources, frequent dislocations, lack of fairness and transparency in postings and promotions, insufficient accommodation, and non-grant of leaves, are some service-related issues resulting in chronic stress and suicides among the enlisted ranks.
Furthermore, issues like marital discord, children’s education, unwanted parenthood, illness of parents/spouse/children, financial problems and other difficulties arising out of prolonged absence of their families as causes of stress. It has also been suggested that "abusive language" by seniors and "unauthorised punishments" have been named as the triggers.
Q: What in your professional opinion is the primary factor leading to the stark contrast between the suicide rates among the enlisted ranks and Commissioned Officers?
Ans: One thing I’ve learned is that there typically is not a “primary factor.” Suicide tends to be very complex, and part of the reason we are not better at suicide prevention is because we try to find one or two key factors to target rather than taking a more comprehensive approach to understanding and preventing suicide.
Q: Would you agree with the view that the Indian Army’s Officer shortage is a major compounding factor affecting the stress levels of junior/mid-level Officers, in turn trickling down to PBORs? Could you elaborate with some observations or anecdotes from your time in service?
Ans: We do have some data from military studies indicating that occupational stressors are correlated with suicidal ideation, such as burnout, ambiguity in job roles, long work hours, etc. We’ve also done some research indicating that these everyday stressors probably play a bigger contributory role to suicide than trauma and other major stressors. This seems to be because everyday stressors wear a person down gradually over time.
Q: How do you see the acute shortage of officers affect the overall psychological stress in a military organisation; from the subunit level all the way up to the senior leadership?
Ans: Related to the previous question, increased work strain and pressure on service members can increase stress as a whole. This stress is often compounded by organizational uncertainty. When no one really knows how long these conditions will last, that can facilitate a sense of hopelessness.
Q: How would you propose to address stress related issues in military organisations in general?
Ans: We typically recommend addressing and changing organizational factors that increase strain for everyone. Things that can improve well-being and morale include expressions of gratitude and appreciation, treating people (especially subordinates) with respect, and seeking to reduce uncertainty and ambiguity in the workplace.
Q: Do you feel that there is a need to streamline/review the ‘tenure policy’ (deployment duration) of military personnel, especially those serving in insurgency environs? What do you feel such a review would find?
Ans: The US military has done some research showing that longer deployments are associated with increased mental health problems and suicide. There seems to be a “tipping point” of sorts around the 9-month mark, wherein military personnel seem to do okay up until then but then after the 9-month mark, mental health problems tend to increase.
There is a perception that the ‘appellate system’ is inefficient, in the sense that it is time consuming, with several cases stuck in the back burner in the various Armed Forces Tribunals (AFT), thus the ‘non availability of a quicker appellate mechanism’ only adds to a service-members pre-existing stress levels.
Q: Would you agree with this observation?
Ans: Yes, I would agree with the observation.
Low-Intensity Conflict Operations (LICO) have been an evolving trend in armed conflicts, with military organisations increasingly engaged in combat environs amongst the civilian populace. Such types of operations have often been criticised for their perceived lack of aim, lack of visible success, as often cited in the case in Afghanistan in the United States context, and in Jammu and Kashmir (J&K) and the North East in the Indian context.
Counter-insurgency operations are often marked with significantly high casualty rates, operational and moral ambiguity, intense battle fatigue, all of these resulting in lowered troop morale and high levels of stress during, and after deployments in hostile areas.
Q: Would you say that combating non-state actors, operating within the civilian population, pose a significantly higher military mental health risk than other types of more conventional combat operations such as with an opposing conventional military force?
Ans: Yes, because it contributes to uncertainty and also increases the likelihood for moral injury (e.g., killing/harming civilians instead of enemy combatants).
Social Apathy: the lack of acknowledgement of military service by the civilian population has been another identified factor leading to stress/depression amongst servicemembers.
Q: Do you see a correlation between social apathy and troop suicide?
Ans: I have not seen any research data, but that doesn’t mean they don’t exist. I have wondered about it, though, and I do think it’s a possible factor.
A service member's helplessness in resolving property disputes back home is a major point of contention, in the Indian context. A soldier’s long duration of absence has often aided in the unfair acquisition of the servicemembers land by family members/villagers. This long-standing issue has been identified as one the most significant identified stressors, leading to troop suicides.
Q: Do you see this as a uniquely Indian problem or something that affects the US Military as well?
Ans: I think these issues affect all militaries to some degree, although different cultural contexts may magnify or reduce the impact of these issues.
The abstract to your study states: ‘Brief cognitive behavioral therapy for suicide prevention (BCBT) has demonstrated preliminary efficacy as a psychotherapeutic intervention that reduces suicide attempts among U.S. Army Soldiers. The generalizability of BCBT's effects in other military groups and its underlying mechanisms of action remain unknown,’
Q: Could you explain to our readers what BCBT is and how it may be an effective tool in countering troop suicide? What are some other alternative and/or allied tools of therapy to address the issue at hand? What edge does BCBT offer other tools of therapy?
Ans: See attached article by David Rudd.
Q: How do you feel that your study will be able to help tackle the issue at hand? Do you feel that it can be replicated in other military organisations as well?
Q: Given the view that BCBT's offer a key advantage over the usual PCT which is also in practice for civilians going through depressive episodes is an individualised ‘Crisis Response Plan’, would you recommend it be mandatory to include BCBT preemptively during the training of the recruits/officer cadets?
Ans: I don’t think I would go that far. The vast majority of military personnel will not become suicidal and/or attempt suicide. Requiring them to go through a specialized treatment would not make sense and would not be a good use of resources. Consider, for example, that we do not require everyone to receive chemotherapy simply because some people get cancer, and we do not require everyone to undergo surgical procedures because some people will later acquire a fatal medical condition.
Q: Your study depends on self-reporting on the part of Marines about suicidal thoughts/attempts or recommendations by the mental health facility as a part of the outpatient procedure. For a senior officer commanding troops, what tools or methods can they apply to adjudge recommending mental health consultation to their subordinates?
Ans: We’ve been doing a lot of research on how suicide risk can emerge or become manifest without explicit expressions of suicidal ideation. For instance, our research with the Suicide Cognitions Scales shows us that certain types of thoughts and statements very clearly signal increased risk for suicide even though these thoughts and statements do not include explicit thoughts about suicide.
We’ve also found that these types of thoughts are better indicators of suicide risk than our traditional assumptions like depression, hopelessness, and thoughts about death and suicide. We are therefore teaching/training non clinicians to become aware of these “coded” indicators of suicide risk that would prompt referrals for help.
Q: In your study, to establish prevalence of suicidal thought as a baseline, there was the use of computer-based tests such as CFI, S-IAT and dot probe test, specifically aiming at bias towards suicide and death. While for the latter of the two, HRV was also used, can simply administering these tests to the entirety of at-risk force reduce the efficacy of the results? Do you advise normalising these tests at regular intervals and/or in special circumstances?
Ans: I don’t think we have enough data yet to know how effective these computerized and physiological methods could be relative to our traditional self-report methods. It’s possible that these methods would be better, but it’s also possible that they would be worse and/or have other unintended consequences (e.g., lots of false positives that lead to unnecessary and costly treatment).
Q: For Emotional Regulation, the tests used were self-reported measures. How does an attempt in isolation at such self-reported measures compare to an environment like a test centre? What would be an ideal policy to preemptively reach out to those in need?
Ans: It’s likely that people will be more honest and forthright in responding if they take the tests in a private area. If you are setting up a large testing center, you would therefore want to make sure that you set up barriers between people, so they don’t feel watched by others. You would also want to make sure that their responses are protected. We do have research showing that military personnel underreport problems, suicidal ideation, and other sensitive topics on screening tools when they’re names and identities are linked to their responses, so maximizing opportunities for privacy will be key.
Q: Do you see evidence in the current military working environment of stigmatisation of mental health related consultations? What can one do, both policy wise and individually, to mitigate the breeding of such issues?
Ans: Yes, although research suggests that stigmatizing attitudes are not as strongly correlated with help-seeking as we often think. Perceptions of treatment efficacy and convenience of treatment are much stronger correlates. In my opinion, the best way to overcome stigma is to emphasize that treatment works and make the consultations very easy to access: low cost, close proximity, hours/times that do not conflict with work demands, etc.
Q: The study focuses on active-duty officers. How does one fare beyond active duty, whether early discharge or change in operational responsibilities?
Ans: The treatments seem to work for those who have been discharged, too. We are currently conducting studies to show this scientifically, but our own experience in clinical practice is that BCBT works for a wide range of people.
Q: Is there anything about your study which you would like to add or highlight?
Ans: This is just the next step in our research program. We have many studies underway designed to understand why and for whom these treatments work, so I would say that the current research is not the end of the story; it’s just the beginning.
- Also Read: Interview: Addressing Stress Related Issues in the Indian Army with Brig. Rajiv Williams, YSM (Retd)
- Also Read: Suicides & Fratricides: The Army’s Need for a Comprehensive Psychological Approach
- Also Read: Military Mental Health: A War Within
(Views expressed are the interviewees own and do not reflect the editorial policy of Mission Victory India)