The Senate is considering a defense funding bill that proposes an "oath of exit" aimed at decreasing self-harm and suicide among America's veterans. But while acknowledging the idea is well-intentioned, many experts who deal with suicide and mental health among veterans say asking exiting service members to take the voluntary pledge could actually do harm.
Those experts are calling on the Senate not to include the oath in its version of the 2018 National Defense Authorization Act, which has passed the House. They say crisis response planning is much more effective in helping veterans.
"The concern is it's basically a 'no-suicide' or a 'no-harm' contract and those have been discouraged for at least 10 years," says psychologist Craig Bryan, a suicide expert and associate professor at the University of Utah and executive director of the National Center for Veterans Studies. "It's a bad idea, there's no data to support its effectiveness, and if anything, the data suggests it's not helpful and is maybe even harmful."
Bryan and other critics of the oath, including Heather O'Beirne Kelly, director of military and veterans health policy practice for the American Psychological Association, warn veterans might choose not reach out for help in the midst of crisis, embarrassed by their struggles to keep their promises.
"The version that passed the House could potentially backfire lethally," Kelly said. "No suicide compact in crisis is effective. It sounds great but it's ineffective at best and potentially quite dangerous for veterans."
The oath was proposed by Army veteran Rep. Brian Mast, R-Florida, who was severely wounded in Afghanistan in a roadside bombing that cost him both legs. In proposing the oath, he noted that "integrity is more than a word to a service member. If we commit that we will reach out … then we will do it."
But Kelly worries that the oath might be a feel-good "solution" that deters policymakers and providers from pursuing measures that have actual impact. Even the time spent on the oath during the transition out of active service could be better spent on proven suicide prevention efforts.
"Especially for federal programs that are engaging with service members, we want the very best evidence-based programs to be used to prevent suicide, both to prevent suffering, but also, why on earth would we be working with initiatives that aren't evidence-based and could be potentially dangerous?" Kelly asks.
There appears to be no support in the medical community for the "oath of exit" proposal. Bryan says that no-suicide contracts have been discouraged for years and are no longer supported by experts who deal with suicide.
Research published in January 2017 in the Journal of Affective Disorders looked at the effectiveness of different suicide prevention efforts among U.S. Army soldiers. The study, led by Bryan, randomly assigned active-duty soldiers at Fort Carson, Colorado, to receive a safety contract similar to the proposed oath, a crisis response plan or an enhanced crisis response plan.
A crisis response plan is an intervention that starts with listening to the soldier and then asking questions, Bryan says. Soldiers are asked to recount their crisis and how they reached the point of trying to harm themselves. "It allows us to piece together the things that led up to the suicidal crisis," says Bryan, "and helps to foster a strong relationship between the suicidal individual and the clinician. We have been able to show that it helps to create a strong sense of empathy and strengthens the feeling a person has been understood and heard."
Next, the clinician produces an index card and the soldier helps identify personal warning signs to help him spot crisis as it emerges. They look at self-management strategies that have helped the soldier in the past. They talk about personal reasons to want to stay alive: "That piece is extremely important," Bryan notes.
They also identify people who can help them if they need support, including family, friends and other soldiers. They list professional assistance, including a therapist's phone number, a crisis hotline and other round-the-clock crisis resources.
"It's designed to start with how do you know you're heading down this road, recognize it and do something. It's an empowerment-oriented intervention. They recognize their own strength and capacity, then as backup, professional support," Bryan says.
When researchers checked back in with the soldiers in the study after six months, they found that the soldiers who had received a crisis response plan were 76 percent less likely to try to kill themselves. Crisis response planning was associated with a significantly faster decline in suicide ideation, as well as with fewer days in the hospital. They found no difference in results between standard and enhanced crisis response plans.
The proposed oath arises from the popularity of "The Spartan Pledge," in which a soldier promises not to take his or her life without first talking to a "battle buddy."
According to Military.com, it started with a conversation between an Iraq veteran, Boone Cutler, and his friend "Nacho," discussing the death by suicide of one of their friends.
According to the article: "I said to him, 'Have you ever thought about it?'" Cutler said during an interview with NPR reporter Quil Lawrence. "And he said, 'Yeah, I think about it every day.' And it blew me away. We'd never discussed that — and we were tight. We covered each other."
The two made a promise that experts say is a good one: to support and help each other. A crisis response plan includes a similar aspect as a soldier identifies his or her social support network, which could include veteran buddies, Bryan notes.
"It's one thing in a circle of close friends and comrades to say let's make sure we reach out to each other when we need help. It's very different to raise your right hand and make a general, unspecified oath," he said. "On the one hand, it's well-intentioned and has some elements that might work for some people … but when you legislate this on a national level, any potential benefit associated with it is sort of stripped."
Caitlin Thompson, former director of suicide prevention at the Department of Veteran Affairs and now a vice president of Cohen Veterans Network, was more direct in an interview for Stars and Stripes: "It isn't just that (use of a no-harm or no-suicide contract) it didn't work. It actually had the opposite effect. It made it so that the person who signed it wouldn't talk to their provider about feeling suicidal because of this fear of 'I signed this promise'."
Joshua Hansen, who retired from the U.S. Army as a sergeant, is founder of Continue Mission, a nonprofit that serves veterans from any era who have mental, physical and emotional injuries from their time in the service. He sees great value in veterans' camaraderie. That's why he started the group, which gets veterans together, often with their families, to ride bikes, climb mountains, paddle board or a host of other activities that keep them up and moving. Activity and exercise, he says, are powerful against depression. They're also great for veterans who don't suffer depression.
His group welcomes any injured veterans and their families who want to participate, not just those who struggle.
But he doesn't think signing an oath as one leaves active duty is apt to do much to prevent suicide. And he says he knows a fair amount about depression.
Hansen, 46, of Woods Cross, Utah, served two tours with the Army in Iraq. His job was to find bombs on the road. He was severely injured in Fallujah and was hospitalized for three months. In war, he lost six of his buddies. Since returning home, he's lost nearly as many — five — to suicide.
"I went down that deep, dark road where I felt I was more of a burden on the family. I didn't have a purpose after serving the country and it was really hard to find out where my place was. As you go deeper in that depression, it is very difficult to come out," he says. "Those that don't suffer from depression and PTSD (post-traumatic stress disorder) don't understand how hard it is, how hard to just get off the couch and walk around the block. In our organization, we try to motivate" through activities, close personal friendships and fun with family.
He's pretty sure, he says, that in his deepest depression, signing a piece of paper would not have an impact. "With the depression I've been through and still have issues with today, that would be the last thing on my mind, that piece of paper I signed. What helps me is being with other veterans and physical activities and having good resources and professional help."