Do unit and post-deployment social support influence the association between deployment sexual trauma and suicidal ideation?
Introduction
Approximately 2.7 million service members have deployed in support of Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) (Defense Manpower Data Center, 2015). Those who deployed are at risk for a variety of stressful and traumatic exposures (Street et al., 2009, Vasterling et al., 2010). Yet research on deployment-related experiences among OEF/OIF/OND veterans has traditionally focused on combat-related experiences among men. Fewer studies have examined sexual harassment and sexual assault during deployment, and those that have typically have focused on women. This is concerning considering that 41.1% of women and 3.7% of men who deployed following 9/11 report experiencing military sexual trauma (Barth et al., 2016) – which is defined as psychological trauma due to sexual assault or sexual harassment while on active duty, active duty for training, or inactive duty training (U.S. Government, 2014). Although military sexual trauma can occur at any point during one's military service, approximately 12% to 42% of women and 0.5% to 12.5% of men who served in OEF/OIF/OND have reported that they experienced military sexual trauma while deployed (i.e., deployment sexual trauma; Katz et al., 2012, Maguen et al., 2012).
Research with OEF/OIF/OND veterans has found that deployment sexual trauma is associated with post-deployment suicidal ideation (Gradus et al., 2013) and recent suicidal ideation (Monteith et al., 2015). Studies examining sexual trauma more broadly have also found that veterans who experience military sexual trauma are at heightened risk for suicide attempts and suicide (Kimerling et al., 2007, Kimerling et al., 2016). However, the reasons for the elevated suicide risk among veteran survivors of sexual trauma are not well-understood. Although deployment sexual trauma is associated with various psychiatric sequelae (e.g., posttraumatic stress disorder [PTSD], depression; Katz et al., 2012, Maguen et al., 2012), psychiatric symptoms do not fully explain the association between deployment sexual trauma and suicidal ideation among women (Gradus et al., 2013). Similarly, other traumatic experiences during deployment (e.g., combat) do not account for this association (Monteith et al., 2015). Therefore, knowledge remains limited regarding factors that potentially explain the association between deployment sexual trauma and suicidal ideation (i.e., mediation). Information is also lacking regarding factors that alter the strength of the association between deployment sexual trauma and suicidal ideation (i.e., moderation).
One potentially important factor to consider is social support – namely, support from other service members and leaders while deployed, as well as support from family members and friends after returning from deployment. Military sexual trauma is associated with lower perceived unit support and poorer social functioning (Laws et al., 2016, Surís et al., 2007). Isolation and negative interpersonal responses are also common sequelae of military sexual trauma (Burns et al., 2014). Survivors of military sexual trauma often endorse perceptions of betrayal by other service members and leaders after experiencing military sexual trauma (Monteith et al., 2016a) and may, in turn, withdraw from interpersonal relationships (including potential support systems) as a means of protecting themselves in the presence of distrust and fear of revictimization. Of note, in a recent qualitative study, men who attempted suicide following military sexual trauma described experiencing negative reactions from other service members, encountered victim-blaming, and reported perceived betrayal by the military institution (Monteith et al., 2018). Such experiences may be particularly harmful considering their potential effects on the extent to which survivors of sexual trauma feel supported by, or disconnected from, others. Research with women who experienced military sexual trauma has demonstrated that a sense of thwarted belongingness (i.e., feeling disconnected from others) and perceived burdensomeness are associated with suicidal ideation, above and beyond the effects of psychiatric symptoms and prior suicide attempts (Monteith et al., 2017).
Despite evidence of the adverse effects of experiencing sexual trauma on interpersonal relationships, initial research suggests that experiencing social support after sexual trauma may be protective. Veterans and civilians who perceive support from others following sexual trauma report less severe outcomes and better recovery (Monteith et al., 2018, Ullman and Najdowski, 2009). Although prior research describing the role of social support as it pertains to suicidality among survivors of military sexual trauma has primarily been qualitative, findings from the broader mental health literature with veterans and service members underscore the importance of examining the role of social support in the association between deployment sexual trauma and suicidal ideation.
Perceived unit support and post-deployment support have been found to be inversely associated with suicidal ideation among OEF/OIF/OND veterans (Lemaire and Graham, 2011, Pietrzak et al., 2010). Two studies have also found that perceived social support may moderate the effect of potential suicide risk factors (e.g., PTSD/depression symptoms, combat exposure) on suicidal ideation (DeBeer et al., 2014, Mitchell et al., 2012). DeBeer et al., (2014) tested whether perceived post-deployment support moderated the relationship between PTSD/depression symptoms (a composite) and suicidal ideation among OEF/OIF veterans; indeed, the association between PTSD/depression symptoms and suicidal ideation was significant only in the context of low post-deployment social support. Mitchell et al., (2012) examined a sample of U.S. soldiers and also found that perceptions of unit cohesion (a construct related to unit support) moderated the effect of combat exposure on suicidal ideation among recently deployed men. In addition, there is evidence that unit support may act as a mediator of the association between deployment sexual trauma and PTSD symptoms (Laws et al., 2016). Laws et al., (2016) found that perceived unit support partially mediated the association between deployment sexual trauma and PTSD symptoms in a sample of previously deployed OEF/OIF/OND veterans. Furthermore, although prior research (described above) focused exclusively on men or included gender as a covariate, Laws et al., (2016) examined if there were potential gender differences and found that perceived unit support acted as a mediator for both men and women.
In sum, unit and post-deployment social support appear to be important in post-deployment mental health. While there is evidence that unit cohesion and post-deployment support may buffer against experiencing suicidal ideation in the presence of adverse deployment experiences (i.e., combat exposure; Mitchell et al., 2012) and mental health symptoms (i.e., PTSD/depression; DeBeer et al., 2014), it is unknown whether this applies to the experience of deployment sexual trauma. That is, no studies have examined whether unit or post-deployment support moderate the association between deployment sexual trauma and suicidal ideation. In addition, there is research to suggest that social support may mediate the relationship between deployment sexual trauma and post-deployment mental health (i.e., PTSD symptoms; Laws et al., 2016); however, no studies have examined whether that applies to suicidal ideation specifically.
Understanding more about whether perceptions of unit and post-deployment support play a role in the relationship between deployment sexual trauma and suicidal ideation, in addition to the specific type of effects (i.e., moderation vs. mediation) of these constructs, would be valuable. Although moderation and mediation offer inherently different explanations of the relationship between variables (MacKinnon, 2011), each offers important yet distinct clinical implications for informing suicide prevention efforts for veterans who experienced sexual trauma during deployment. For example, evidence of moderation would suggest subpopulations of deployment sexual trauma survivors who might benefit from more intensive or targeted suicide prevention efforts. A significant moderating effect of unit support may suggest that efforts are warranted to assess and intervene through evidence-based treatment in survivors of deployment sexual trauma describing lower support from other service members or military leaders within their unit. By contrast, a significant mediating effect of perceived unit support may underscore the possibility that efforts to decrease suicidal ideation (e.g., within the Department of Defense) following deployment sexual trauma should attempt to increase perceived unit support, as unit support may be a variable that explains risk for suicidal ideation. While differing in their mechanistic approach, in both instances, significance could indicate important factors in need of further investigation at various levels (e.g., psychological, biological).
In consideration of these factors, the primary aims of the present study were to examine if perceived unit support and post-deployment support moderated the effect of deployment sexual trauma on suicidal ideation among previously deployed OEF/OIF/OND veterans. Considering prior research (e.g., DeBeer et al., 2014, Mitchell et al., 2012), we hypothesized that unit support and post-deployment support would moderate the relationship between deployment sexual trauma and suicidal ideation, such that this association would be strongest in the presence of low perceived social support. However, as prior research has also found that social support mediates the association between deployment sexual trauma and post-deployment mental health (Laws et al., 2016), an exploratory aim was to examine if perceived unit support or post-deployment support mediated the association between deployment sexual trauma and suicidal ideation. We sought to test this aim only in the absence of significant moderation, as a means of informing extant research. Lastly, we sought to address these aims separately in both women and men to see if there would be gender differences in the pattern of results. As previous research in this area has been limited and mixed with respect to the presence of gender differences (e.g., Benda et al., 2005; Laws et al., 2016), we did not generate hypotheses regarding a specific pattern of gender differences.
Section snippets
Sample and procedures
The present study was a secondary analysis of data from the Survey of Experiences of Returning Veterans (SERV; Smith et al., 2014), a longitudinal cohort study of previously deployed OEF/OIF/OND veterans. The current analysis was cross-sectional and used baseline interview data only. Participants were recruited through several sources, including social media, listservs, and word of mouth. Eligibility criteria were: (1) separated (discharged) from the United States military, (2) served in
Participant characteristics
Less than one-fifth of participants (n = 142, 17.2%) reported experiencing any suicidal ideation in the past three months, and 11.5% (n = 95) reported experiencing active suicidal ideation specifically. No significant differences were identified in the presence or distribution of suicidal ideation severity between men and women (p > 0.05). Years since separation from military service varied considerably within the sample (mean = 3.2, SD = 2.5, range = 0.0 to 11.9). Sample characteristics and
Discussion
Although studies have implicated deployment sexual trauma as a correlate of suicidal ideation (Gradus et al., 2013, Monteith et al., 2015), research aimed at understanding factors that influence or explain this association has been limited. The present study advances knowledge regarding this relationship by elucidating the role of different types of perceived social support in this association. While perceived social support was relevant to understanding the association between deployment
Acknowledgments
This material is based upon work supported in part by the Department of Veterans Affairs (VA) CSR&D ZDA1 (PI: Hoff) and the Rocky Mountain Mental Illness Research, Education and Clinical Center (MIRECC) for Suicide Prevention. The views expressed are those of the authors and do not necessarily represent the views or policy of the VA or the United States Government. For Dr. Holliday, writing of this manuscript was supported by the VA Office of Academic Affiliations, Advanced Fellowship Program
Declarations of interest
None.
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