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Editorials

Suicide among Falkland war veterans

BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f3204 (Published 20 May 2013) Cite this as: BMJ 2013;346:f3204

Rapid Response:

Re: Suicide among Falkland war veterans

The editorial by Holmes et al(1) on the myths surrounding Falkland veteran’s suicides concludes that we should rely on “sound statistics not misleading sound bites.” Building on this important contribution, we should recognize why misleading information and erroneous beliefs about veterans persist. We may also want to acknowledge that the minority of veterans who do have difficulties have certain distinctive behavioural features that contribute to this persistence.

Firstly then, why do misleading beliefs persist about veterans? Humans are “cognitive misers” wherever possible taking shortcuts that enables potentially complex information to be processed in a simplistic and expedient fashion.(2) A common shortcut is heuristic processing where we causally link associated memories through intuition rather than by systemically processing information to more reliably infer causation.(3) Clearly this has adaptive benefits as we do not have to assess each new piece of information on its merits. However, heuristic processing can be prone to biases in recall and highly influenced by stereotypical information.(2)

Indeed there is a longstanding stereotypical belief that military service is psychologically damaging. A letter from 1881 states “…the nation treats its soldiers like oranges, that having sucked them dry, it throws them aside.”(4) While these reports may have had some validity in the past, more recent longitudinal studies show that military service for most veterans is a positive boost to post service life.(5,6) However, negative beliefs about military service still strongly persist.(7)

Therefore, reports of high post-conflict suicide rates fit with commonly held stereotypical views of service experience (i.e., that it is psychologically damaging(8) ) and popular beliefs about the immediate causes of suicide (i.e., prompted by psychological distress (9) ), leading people to make strong intuitive connections between their beliefs about veterans ‘damaged’ in service and those veterans post-service psychological health. A further contributing influence is that events that are poignant and associated with death become easily recalled. This ease of recall, known as an availability bias, leads the reported event to be perceived as more common than it really is.(10) Furthermore, a set of perceived causal connections strongly fitting with pre-existing beliefs and stereotypes are subject to confirmation biases whereby disconfirming information (i.e., sound statistics) can often be rejected as they do not conform to the strongly held views of individuals.(2) This then would seem to be a plausible explanation for why “misleading sound bites” about veteran suicides are more influential than “sound statistics”.

Furthermore, while there is clear evidence that absolute statistical numbers of veterans who commit suicide, end up in prison or are homeless are very low, research does show that there is an veteran distinctiveness in these matters that could, arguably, also feed the confirmation biases around veterans. For example, while the rates of suicides in veterans are statistically lower than the general population(11) there are differences in the pattern of suicide. Primarily, the age of suicide of serving and veteran members is statistically lower than in the general community.(11,12) Families tend to take longer to recover from the suicides of those who are younger and tend to look to ascribe more blame for such events.(13,14) This makes for more salient and reportable cases in the press. The added emotional charge of the story strengthens accessibility of associative memories and feeds the confirmation bias further in the general public.(15)

There are also fewer veterans in prison that one would expect proportionately given the social strata of the armed forces.(16) However, those veterans that are present in prison tend to be there for more violent offences and as a group tend to be older – proportionately more than the rest of the prison population.(17) This again makes them a more salient population more readily noted by those dealing with offenders and so feeding a confirmation bias.

There are fewer homeless veterans than is commonly thought.(18) However, those veterans who are homeless tend to be older and homeless for longer compared to the rest of the homeless population.(19) This difference again makes for a more salient, more noticeable, homeless population of veterans.

Therefore, we can understand how misleading “sound bites” captures the popular imagination. The stereotype of the “damaged” veteran is entrenched because it matches intuitive individual beliefs about military service and is reinforced by the particular salience of those veterans who do suffer in terms of suicide, prison or homelessness. Thus, the salience of the suffering minority feeds the confirmation bias that keeps the old stereotype about the majority very much intact.

We agree that concern about the psychological consequences of military service should be based on sound statistics but we should also be aware why “sound bites” are much more believable for many. This may help us explain wider issues related to the military such as why many individuals in the UK hold the services in high regard but at the same time would never consider joining.(8) Despite the sound evidence that vast majority of veterans do well(5), entrenched societal beliefs and the easy “sound bite” mean that the military will continue to be judged on how it prepares veterans for post-service life for a long time to come.

1. Holmes J, Fear NT, Harrison K, Sharpley J, Wessely, S. Suicide among Falklands veterans (Editorial). BMJ 2013;346:f3204
2. Kahneman D. Thinking, fast and slow. London, UK, Allen Lane Penguin Books. 2011.
3. Chaiken S. Heuristic Versus Systematic Information Processing and the Use of Source Versus Message Cues in Persuasion. J Pers Soc Psych, 1980 39(5), 752-766.
4. Letter to Edinburgh Review dated 1881 cited in French D. Military Identities: The Regimental System, the British Army, and the British People, 1870 – 2000, Oxford, UK: Oxford University Press. 2005. p.253.
5. Iversen A, Nikolaou V, Greenberg N, Unwin C, Hull L, Hotopf M, et al. What happens to British veterans when they leave the armed forces? Eur J Public Health 2005;15:175-84.
6. Hurley S, Helping or hindering heroes? UK Armed Forces Veterans Literature Review. Ministry of Defence. 2012.
7. Gribble R, Wessley S, Klein S, Alexander DA, Dandeker C, Fear NT. Are the UK Armed Forces understood and supported by the British Public? Report for the Public Perceptions Symposium. Kings College, London, 3 October 2013. http://www.kcl.ac.uk/kcmhr/research/kcmhr/publicperceptionshandout.pdf
8. Ashcroft, M. The Armed Forces and Society: The military in Britain –through the eyes of Service personnel, employers and the public. Report published online http://lordashcroftpolls.com/wp-content/uploads/2012/05/THE-ARMED-FORCES.... 94% of 18-34 year olds thought it was common for Veterans to have some kind of physical, emotional or mental health problem as a result of service.
9. Joiner T. Myths About Suicide. Cambridge, MA: Harvard University Press; 2010.
10. Kuran, Timur and Sunstein, Cass R., Availability Cascades and Risk Regulation. Stanford Law Review 1999 51: 683-768.
11. Defence Statistics (Health). Suicide and open verdict deaths in the UK Regular Armed Forces 1984–2012, Office for National Statistics: Statistical Notice. London, UK: Defence Analytical Services Agency. 2013. http://www.dasa.mod.uk/publications/health/deaths/suicide-and-open-verdi...
12. Kapur, N., While, D., Blatchley, N., Bray, I. and Harrison, K. Suicide after leaving the UK Armed Forces: A cohort study. PLoS Med, 2009 6 e100026.
13. McIntosh, J. L., & Jordan, J. R. The impact of suicide on adults. In J. R. Jordan & J. L. McIntosh (Eds.), Grief after suicide: Understanding the consequences and caring for the survivors (pp. 43–79). New York, NY: Routledge. 2010.
14. Boelen P, van den Hout M, van den Bout J. A Cognitive-Behavioral Conceptualization of Complicated Grief. Clinical Psychology: Science & Practice. 2006;13:109-128.
15. Greifeneder, R., Bless, H. Pham, MT. When Do People Rely on Affective and Cognitive Feelings in Judgment? A Review. Pers Soc Psychol Rev 2011 15: 107-141.
16. Ministry of Defence. Estimating the proportion of prisoners in England and Wales who are ex-armed forces—further analysis. 2010. www.mod.uk/NR/rdonlyres/C7C1ADC2-8509-4D31-94B4-B07453846D2F/0/20100916_....
17. MacManus D, Dean K, Jones M, Rona RJ, Greenberg N, Hull L, et al. Violent offending by UK military personnel deployed to Iraq and Afghanistan: a data linkage cohort study. Lancet 2013; 381:907-17.
18. Rhodes, D., Pleace, N., Fitzpatrick, S. The numbers and characteristics of homeless ex-service people in London. A Review of the Existing Statistical Data, York: Centre for Housing Policy, University of York. 2006.
19. Johnsen S, Jones A, Rugg J. The experiences of homeless ex-service personnel in London. York, Centre for Housing Policy, University of York. 2008.

Competing interests: VC is employed by the Ministry of Defence on a part time basis in addition to Oxford Brookes University. The authors have not been directed by the Ministry of Defence in any way with regard to this response.

11 December 2013
Vincent Connelly
Department of Psychology, Social work & Public Health
Mark Burgess
Oxford Brookes University
Gipsy Lane, Oxford, OX3 0BP