Military Spouses’ Perceptions of Suicide in the Military Spouse Community

Rebekah F. Cole, Rebecca G. Cowan, Hayley Dunn, Taryn Lincoln


Newly released data from the U.S. Department of Defense shows military spouse suicide to be an imminent concern for the U.S. military. Currently, there is an absence of research in the counseling profession related to suicide prevention and intervention for this population. Therefore, this qualitative phenomenological study explored the perceptions of military spouses regarding suicide within their community. Ten military spouses were interviewed twice and were asked to provide written responses to follow-up questions. Six main themes emerged: (a) loss of control, (b) loss of identity, (c) fear of seeking mental health services, (d) difficulty accessing mental health services, (e) the military spouse community as a protective factor, and (f) desire for better communication about available mental health resources. Implications for practicing counselors and military leadership in helping to prevent military spouse suicide as well as recommendations for future research regarding ways to support military spouse mental health and prevent suicide in this community are included.

Keywords: military spouse, suicide, prevention, intervention, phenomenological


     In 2018, there were 624,000 active-duty military spouses in the United States, 92% of whom were female (U.S. Department of Defense [DOD], 2018). Recent data also noted that the average age of a military spouse was 31.5 years and 88% of spouses had postsecondary education (U.S. Chamber of Commerce, 2017). Twenty-four percent of spouses were unemployed (DOD, 2018) and 35%–40% were underemployed (U.S. Chamber of Commerce, 2017). Further, 74% of military spouses had children under the age of 18 and often acted as single parents because of the responsibilities of the service member (Institute for Veterans and Military Families, 2016). And of particular note, the Substance Abuse and Mental Health Services Administration (SAMHSA; 2015) reported that 29.1% of military spouses have had a mental illness, with 11.8% having had at least one major depressive episode, and 6.5% having had a major depressive episode with severe impairment.

Military Lifestyle and Spousal Mental Health
     Military spouses do not serve in combat as service members do, but they are subject to many stressors brought on by the military lifestyle that may affect their mental health (Cole, 2014). One of the primary stressors of the military lifestyle is frequent moving (Tong et al., 2018). Military families move every 2–3 years to a new location (Burke & Miller, 2016), which they may not have adequate time to prepare for, adding to the stress of the relocation process (Tong et al., 2018). Military spouses may feel isolated after moving, as 70% of military families live in civilian communities rather than in military housing (Blue Star Families, 2019). Although social support has been found to be key in ameliorating mental health issues in military spouses (Ross et al., 2020), this support is lost and must be rebuilt when the family moves to a new duty station.

Because of these frequent moves, military spouses are often unable to build consistent careers or finish their education (Institute for Veterans and Military Families, 2016). Relocating spouses may experience difficulty finding a new job or utilizing their professional license or certification in their new home state or country (DOD, 2020b). As a result of these lifestyle challenges, 24% of military spouses are unemployed (DOD, 2018) and 77% of employed spouses have been underemployed at least once (Blue Star Families, 2019). These employment challenges often result in anxiety and depression among military spouses (Linn et al., 1985). In addition, the inability to find work may result in financial stress for the family and often affects spousal mental and behavioral health (Blue Star Families, 2019; Center for the Study of Traumatic Stress, 2020).

In addition to stressful relocations and career disruption, spouses also face frequent deployments of their partners (Allen et al., 2011). These deployments result in increased depression and anxiety in spouses (Baer, 2019; Eaton et al., 2008; O’Keefe, 2016), with 92% of spouses reporting increased stress during a deployment, and 85% reporting that they feel anxious or depressed during a deployment (Romo, 2019). This deployment stress may be amplified when the spouse lives overseas and is away from their friends and family in an unfamiliar culture (McNulty, 2003). When their service member is deployed, military spouses have to take on new roles and responsibilities in the home, which may contribute to these high stress levels (Eaton et al., 2008). In addition, they may live in constant fear for their service member’s physical safety, as they are unable to contact their spouse regularly, or communication may be limited to social media with inherent limits to tone or context that prove to be anxiety-inducing (Allen et al., 2011; O’Keefe, 2016).

Military Spouses and Mental Health Treatment
     Although military spouses are under constant stress in their everyday lives (Cole, 2012; Eaton et al., 2008; Mailey et al., 2018), they often resist seeking mental health treatment (Lewy et al., 2014). Past studies have revealed that spouses often do not seek therapy because they cannot locate a counselor they trust or who understands their culture, they are concerned that someone will find out they are seeking counseling, or they do not know where to find counseling services (Lewy et al., 2014). The stigma that military spouses fear regarding mental health treatment affecting their service member’s career progression mirrors that of the active-duty service member population (Britt et al., 2015). In addition, the pressure that spouses feel to take care of their families without their service member’s support and the sense that they must prioritize their families before themselves has led them to resist receiving mental health help for themselves (Mailey et al., 2018). When they do seek mental health services, spouses are likely to visit their primary care doctor at a military care facility; however, these facilities are not equipped to meet spouses’ mental health needs because of lack of personnel and resources for specialized mental health services (Eaton et al., 2008; Lewy et al., 2014).

Military Spouses and Suicide
     Although many of these studies have focused on risk factors and barriers for military spouse mental health treatment, no research has focused on the consequences of these barriers, including suicide in this population. Although much focus has been placed on researching service member and veteran suicide (Blosnich et al., 2010), statistics regarding military spouse suicide were recently tracked for the first time and released to the public in September 2019 (DOD, 2019). In 2018, 128 military spouses died by suicide, with a suicide rate of 12.1 deaths per 100,000 individuals (DOD, 2020a). Of those who committed suicide, 57.8% were female and 85.1% were under the age of 40. Given the alarming numbers of spousal suicide outlined in the DOD report, it is essential that pioneering research be done to investigate suicidality in the military spouse population. This study, therefore, explored the perceptions of military spouses related to suicide in this population by interviewing military spouses themselves, who are the experts on the military spouse lifestyle and experience (Sargeant, 2012). The purpose of this study was not to focus on the experiences of spouses who have themselves attempted suicide, but rather how members of the military spouse population made meaning of suicide within their community. Thus, a qualitative phenomenological design was appropriate for exploring this meaning making (Christensen et al., 2017; Creswell & Poth, 2017). As experts on their own community and experiences, the participants provided perceptions that proved valuable in understanding the causes and risk factors associated with suicide in this population.

Purpose Statement and Research Questions
     The purpose of this qualitative phenomenological study was to explore the perceptions of military spouses related to military spouse suicide and how these spouses made meaning of suicide within the military spouse community. Based on the perceptions and recommendations of the participants, this study makes suggestions to the civilian and military communities regarding best practices for preventing suicide in and providing mental health services for this population. This study was guided by the following research questions:

  1. What are the perceptions of military spouses of suicide in the military spouse community?
  2. What are the perceptions of military spouses regarding resources to prevent military spouse suicide?


Our research team utilized the descriptive phenomenological tradition in qualitative inquiry, in which the researcher explores the participants’ meaning-making experience and how they translate this experience into their consciousness (Christensen et al., 2017; Creswell & Poth, 2017). In order to gather information and perspective regarding suicide within the military spouse community, Rebekah F. Cole, our team’s principal investigator, interviewed 10 spouses of active-duty service members, using a semi-structured interview, to explore their experiences in-depth and to understand how they make meaning of suicide within the military spouse community. A qualitative researcher does not aim to generalize but to draw out depth of insight from participants; hence, a small sample size was appropriate and justified with the aim of collecting a wealth of information from each participant (Creswell & Poth, 2017). Cole interviewed each spouse two times for approximately 30 minutes over the course of 4 weeks and then sent each participant an email with follow-up reflection questions (e.g., “What was it like for you to participate in this study?”) and demographic questions regarding the participants’ age group, gender, race/ethnicity, military branch, years as a spouse, and spouse’s rank.

     We selected the participants based on their status as active-duty spouses as well as their willingness and availability to participate in two interviews and complete the follow-up questions. We identified and recruited participants via purposeful sampling following approval by the IRB at our university (Creswell & Poth, 2017). Cole made a posting on a military spouse Facebook page explaining the nature and purpose of the study and asking for volunteers who were married to an active-duty service member. We offered each participant a $250 Target gift card to participate in the study, given to them upon completion of the two interviews and return of the emailed follow-up questions. We selected the first 10 volunteers who responded to the Facebook post as the 10 participants in this study. Once they showed interest in participating in the study, Cole contacted each participant via email to explain the nature and goals of the study and provide the participants with the informed consent document to sign and return.

The participants in this study were all spouses of active-duty service members (see Appendix A for a demographic chart). Three of the participants were Army spouses, three were Air Force spouses, three were Navy spouses, and one was a Coast Guard spouse. Two of the spouses were in the 18–29 age range, five were in the 30–39 age range, and three were in the 40–49 age range. The time spent as a spouse ranged from 1–20 years with a mean of 9.5 years. Eight of the spouses identified as White or having a European heritage and two of the spouses identified as having Asian or Pacific Islander heritage. All of the spouses identified as female. The participants were assigned numbers (Participant 1, Participant 2, etc.) to protect their confidentiality throughout the study.

Research Team
     The research team in this study consisted of Cole and two school counseling graduate students, Hayley Dunn and Taryn Lincoln. These students had been trained in research methodology and were familiar with the qualitative data analysis process. Lincoln is a 35-year-old White female whose husband is a retired service member. Dunn is a 33-year-old White female with no military connections. Cole worked closely with Dunn and Lincoln to review the transcriptions of the interviews, develop a comprehensive codebook, and discuss the themes and patterns that emerged from the data.

Data Collection
     Cole conducted and recorded the interviews via phone. She transcribed the interviews using an automated transcription service and reviewed each transcription word-by-word to verify the accuracy and reliability of the transcription (Creswell & Creswell, 2018; Creswell & Poth, 2017). In each interview, Cole asked questions related to suicide in the spouse population (see Appendix B). She also utilized probing follow-up questions (e.g., “Can you tell me more about that?” or “Why do you think that is?”) to gather additional information throughout the interviews (Creswell & Creswell, 2018). Finally, Cole sent a follow-up email consisting of process questions related to the interview experience (see Appendix B) as well as demographic questions.

Data Analysis
     We analyzed the data in a step-by-step process: 1) organizing the data, 2) looking over all of the data, 3) coding the data, 4) generating a description of themes, and 5) presenting the description of themes (Creswell & Creswell, 2018). Cole first organized the data, sorting each participant’s file and memoing ideas that began to emerge from the data (Creswell & Creswell, 2018; Creswell & Poth, 2017). We then each reviewed the transcripts and email responses in detail. After reviewing the data, we coded the interviews and follow-up questions. Cole compiled the codes that we generated into a codebook. We then identified and defined themes and patterns that emerged from the study. This collaboration continued until we decided that no additional themes and patterns were emerging from the data. Cole then sent the codebook, as well as the themes and patterns, to the external auditor of the study, Rebecca G. Cowan, who confirmed the findings of the research team. Cole then wrote a detailed narrative of the themes, which are presented in the Findings section of this article.

Strategies to Increase Trustworthiness
     In order to increase trustworthiness of the study, Cole, the key data collector in this study, engaged in reflexivity and self-analysis throughout the study (Creswell & Creswell, 2018; Darawsheh, 2014; Meyer & Willis, 2019). As a military spouse and professional counselor, Cole inherently has her own thoughts and feelings related to spousal mental health. Thus, it was important to bracket these thoughts and feelings to prevent them from interfering with the data collection and analysis process. Cole used reflective journaling throughout the study to engage in self-reflection and to increase her self-awareness of her reactions to the participants’ perspectives (Malacrida, 2007; Meyer & Willis, 2019). She also discussed these thoughts and feelings with the research team to explore her position as the researcher in the context of this study (Barrett et al., 2020).

In addition to this reflexivity, Cole kept an audit trail throughout the study, which included the transcriptions of the interviews, the participants’ emailed responses, the codebook, reflexive journal entries, and the notes from the research team (Creswell & Creswell, 2018; Creswell & Poth, 2017). Cowan, an auditor with a PhD in counselor education who has been a counselor and counselor educator for the past 10 years, reviewed the study in full to verify the data collection and analysis process (Creswell & Creswell, 2018) as well as the rigor of the study (Patton, 2002).

To triangulate the study’s data and increase the validity of the study’s results, data were collected through two individual interviews as well as through an email questionnaire, both open-ended forms of data collection (Creswell & Creswell, 2018). Prolonged engagement assisted with the development of trust and rapport (Korstjens & Moser, 2018). Additionally, through the collection of both verbal and written data, the study’s themes gained more credibility, as they emerged from both data sources (Creswell & Creswell, 2018).

Finally, we used member checking (Creswell & Creswell, 2018) to request the participants’ feedback on the credibility of the data (Creswell & Poth, 2017). Member checking allows the study’s participants to become actively involved in and make additions to the data review process (Birt et al., 2016). Cole emailed the participants transcriptions of their interviews and asked them to review and make any additions or changes they would like to the transcriptions, allowing them ownership of their thoughts and words and increasing the trustworthiness of the data (Birt et al., 2016). In addition, Cole discussed the findings of the study with the participants as the themes and patterns emerged (Shenton, 2004).


The study’s data yielded six main themes: (a) loss of control, (b) loss of identity, (c) fear of seeking mental health services, (d) difficulty accessing mental health services, (e) the military spouse community as a protective factor, and (f) desire for better communication about available mental health resources.

Theme 1: Loss of Control
     Each of the 10 participants perceived their circumstances as a military spouse to be out of their control. For example, all of the participants mentioned deployments, especially those on short notice, to be a risk factor for suicide. One spouse described how her active-duty husband “might be home on Thursday and then he’s gone the next day. He finds out on such short notice, that’s really tricky, and a lot of my friends are constantly, you’re just so constantly anxious all the time.”

Four of the participants described how they fear for their spouse’s safety during these deployments, which impacts their mental health. One spouse, for example, described how she lives “just constantly not knowing what’s happening, but then being fearful for the significant other as well.” Another spouse explained how spouses live with a “constant fear of whether or not your spouse will return.” One participant discussed how military spouses are thus more prone to mental health issues:

[T]he stress of your life and the stress you have over your spouse’s military career, whether they’re in danger or not, worrying about their mental health . . . probably aggravates all of the mental disorders that anyone could experience, but just magnifies them if you’re a military spouse.

Participants also felt like they lacked control because of frequently relocating. All 10 participants described the stress involved with moving unpredictably. One spouse described how “you’re always worried about what’s coming next and what you can plan for and what you can’t plan for.” Another participant mirrored this same sentiment: “It’s that ‘Where are we going to be next? We just moved here, but I know in two years we’re going to move again’ type deal . . . always just kind of being on your toes and not knowing what to expect.” Another spouse expressed similar thoughts: “I hope for the best but expect the worst, which is kind of sad, but that is the kind of mentality I’ve had to live by because of how unpredictable this lifestyle is.”

As a result of these constant relocations, spouses are separated and isolated from family and friends, or their “network of support” in the words of one participant. All of the participants recognized the risk of losing this support with regard to their mental health. One spouse, for example, explained the danger of not having “long-standing relationships where you could say like, ‘Wow that person really seems like they’re going through something.’”

Theme 2: Loss of Identity
     All 10 participants struggled with a loss of their identity, especially regarding their careers. Many participants described how career struggles and finding purpose are related to spousal mental health. One spouse explained how “not having that career is part of the anxiety and depression. And not having a purpose in life.” Another spouse described the struggle to maintain a career: “Eventually, it kind of weighs on you and eventually your mind can play tricks on you and you feel like you’re not worthy.” One participant summed up these career struggles in these words: “Part of being a military spouse is sacrificing your own life . . . there’s a lot of hurt and loneliness and sacrifice.”

In addition to this struggle for career identity and purpose, five of the participants described how the military fails to recognize their value. One spouse described how spousal suicide “is definitely brushed under the rug because people are kind of like, ‘You’re not going to war, you’re not doing any of these things.’” Another participant described her own experiences: “We’ve had situations where wives were struggling, but . . . he couldn’t get off that day, he had to report in because she’s not at the hospital . . .it’s not serious.” Another explained how “the military in general, they’re so focused on their job that they kind of forget that we’re all humans and that we are people.” One participant said that “spouses get beat down and they just kind of feel like there’s the whole ‘If the military wanted you to have a family, they would have issued you one.’”

The participants also described the military spouse’s tendency to prioritize family and the military over oneself and the impact of this inclination on spouses’ mental health. “So much of the burden of the family falls onto the military spouse, I think it’s easy for the spouse to not consider their own mental health a priority, and therefore the risk factors may go undetected or untreated.” Another described how spouses “go through this constant cycle that’s always churning. You move to a new place, you try to get settled . . . then we hit the point of going, ‘Ok, now what about me?’ If we ever get to that point.” One spouse described that after each of the moves and deployments, “I feel like we lose a sense of ourselves too . . . it’s like having a new baby all of the time. . . . You kind of reach a point where you’re like, ‘Where am I? What the heck am I doing?’”

As a result of prioritizing family and the military over themselves, spouses feel unworthy of receiving mental health services and feel guilty for suffering, as described by eight of the participants. One spouse explained that “spouses can feel weak or feel like they’re not holding up their end of the bargain if they get help.” Another participant noted that spouses “consider themselves less worthy of getting treatment or that their problems [are] not as important.” Finally, a spouse explained that there is a “weird mentality, I think, in the military spouse community, where you don’t complain because someone else has it worse. . . . If you’re an Air Force spouse, maybe the Army deployments are longer, so you just don’t want to complain.”

Theme 3: Fear of Seeking Mental Health Services
     Despite these challenges that military spouses face, eight of the participants described a fear of seeking out mental health services. Five of the participants, for example, said that spouses fear appearing to be unstable or, as one spouse described, a “fear of being ostracized, or the fear of having people talk behind your back, or embarrassment.” One spouse explained how mental health issues are viewed as, “Oh, she was a crazy spouse. Oh, she got everything that she needed . . . so she was just kind of crazy.” Another participant described how a spouse was viewed after verbalizing her mental health struggles: “I’ve been told by other spouses not to go hang out with her in group settings because she’s batshit crazy.” One spouse noted that “there’s still that stigma of reaching out and being known to have the mental health issue.” Finally, spouses may fear being honest with their medical providers for this same reason. One participant described her own perception of this fear of being transparent with the doctor regarding a suicidal assessment: “If you answer it honestly, sometimes you’re like ‘They’re going to put me in a padded room if I really tell you what my last 2 weeks has been like.’”

In addition to appearing unstable, seven of the participants described how military spouses fear that seeking mental health services would negatively impact or bring “backlash” on their service member’s career. One participant noted: “People keep it quiet because they don’t want their spouse, their military member, to not get promoted or not get more responsibility and stuff like that because they’re not keeping it together.” Another participant stated that often “you run into people who are kind of skittish about going just because of the stigma.” She further explained that “you don’t want to hurt your husband’s career, and that’s what you’ve heard for a long time. He looks like he can’t handle the situations at home.’”

Theme 4: Difficulty Accessing Mental Health Services
     Spouses who do decide to seek help for their mental health may experience difficulties in securing an appointment, as described by six of the participants in this study. Each of these spouses expressed difficulties with finding a mental health provider in the community or accessing mental health treatment at a military facility. One participant explained that “the reality is they can’t guarantee that the local community and local providers will be able to provide everything we need when we need it.” Another spouse expressed frustration that “TRICARE can sometimes be a pain when you’re trying to schedule something, and it will make you schedule at 6 weeks out because that’s the first available.” One participant described her experience with trying to find a counselor covered by TRICARE. She stated, “You hope that you get an appointment and hope you can jive with whoever you called because you may have to wait another month or two to try to find someone else.” Three spouses in the study also expressed concern about the consistency of care due to frequent relocations. One participant explained the need to streamline mental health services at each duty station “so that if [spouses] are seeing a psychiatrist in one place and they go to the next place, they’re not waiting for 2 or 3 months before they can get in to see a new psychiatrist.”

Five of the study’s participants also expressed concern over not having access to a mental health specialist. For example, one spouse shared that “the person I did see, who was a social worker, I just don’t feel was very equipped to talk to me about the things I wanted to talk about.” Another spouse described her perception of military family life consultants’ work with spouses on military bases:

They just kind of give them the same spiel, like you should exercise, make sure you’re eating well, getting enough sleep, instead of saying, “You know what? This is outside of the realm of what I can handle, let’s get you in to the type of professional that you need.”

Theme 5: The Military Spouse Community as a Protective Factor
     In the midst of these mental health challenges and difficulty seeking and accessing mental health services, seven of the participants described the military spouse community as a protective factor against suicidal ideation. As one participant explained, “Anyone can try to take their own life, but if they have people around them who are looking out for them, who are with them physically and emotionally, it’s harder to do.” In addition, one participant pointed out that the spouse community can offer a sense of shared understanding: “Someone else probably very close by has gone through the same thing that you have . . . and you’re not the first person to go through this and someone might be able to help lighten your load.” The participants emphasized the need to create “a friendly, inclusive environment where spouses can network and establish relationships” as well as establish a “connection and feeling of belonging.” One participant noted that within this environment and community, it is important to normalize conversations about mental health in order to decrease the stigma attached to it. “Letting people see that while we might post pretty pictures on Facebook and someone looks all together when they’re at that unit function, we’ve all had to reach out for help, and looking at that as being strong.”

To increase this protective factor as a community, six spouses described the importance of training for spouses geared toward suicide prevention so they could recognize the signs of suicide in others. One spouse said that training in “prevention measures of how to spot suicide, signs of suicide, or who to talk to, where to go, what to say” would be helpful “because spouses are probably already witnessing all of these signs in their homes or in their neighbors or in their friend groups of depression and suicidality.” Another participant described how “spouses could be looking out for friends, if they know some warning signs or give friends resources to go to so their friend could find it if they need help.”

Theme 6: Desire for Better Communication About Available Mental Health Resources
     Each of the 10 participants expressed the need for the military to communicate more with them about mental health resources. One spouse, for example, pointed out that such “information needs to be put out there clearly at military hospitals, on military bases. . . . So I think the military could make it more clear, destigmatize it, and just make the programs more widely available and advertised.” In this proposed advertisement, the spouses would want to know “what kind of help we can get, what it costs, where we can get help, and will it matter to our spouse’s career?”

In addition to this suggested advertising, six of the participants said they would like the military leadership to communicate with them directly regarding available mental health resources specifically designed for spouses. One participant described how “it’s harder for the spouse to get that information . . . if they had information sent directly to them, I think they would be more willing to seek it out and use those resources.” Another spouse noted that “military spouses need to be presented with the resources available for their mental health directly instead of solely relying on the service member to relay the information.” As a result of receiving this information on resources available specifically for them, one participant explained that “the military spouse wouldn’t have to consider themselves less worthy of getting treatment or that their problems [were] not as important.”

Finally, six of the spouses suggested that the check-in process for each duty station could be a key opportunity to provide spouses with resources and preventative services. One spouse noted: “I think that when you move somewhere new there should be someone checking to make sure you’re okay and you’re not alone all the time. I think it’s the military’s responsibility to make sure there’s a process in place.” Another spouse proposed this check-in process as being “part of the standard procedure to make sure the spouse maybe is brought in and made aware of all of the programs that are available to them.”


     In this study, all of the military spouse participants described how spouses’ loss of control and loss of identity may contribute to their increased risk for suicide. These feelings resulted from continually moving to new duty stations (often unexpectedly), being isolated and separated from their support systems, fearing for their spouse’s safety during deployments, and struggling to maintain a sense of self and a career while making their families and the military their priority. Although they were committed to prioritizing the military lifestyle and their spouses’ career, these spouses did not feel that their needs were prioritized by the military in turn.

Each of these challenges for military spouses has been previously addressed in the professional literature (Eaton et al., 2008; Lewy et al., 2014; Mailey et al., 2018), although their direct correlation to suicidality has not yet been explored. Because increased levels of suicidality have been found in other populations when social isolation increases (Calati et al., 2019; Heuser & Howe, 2019; Pompili et al., 2007) or stressful life transitions or events occur (Oquendo et al., 2014; Paul, 2018), it is important to continue to consider how these risk factors impact military spouses’ suicidality.

Most of the participants likewise described the tendency of spouses to feel guilty for suffering, as they are not the ones on the battlefield, a new phenomenon not yet explored in the professional literature. One participant concluded that these feelings of guilt may lead to spouses feeling they are unworthy of using mental health resources intended for active-duty service members. To address these feelings of guilt, one spouse described the need to normalize the conversation about mental health among spouses, which would ameliorate these feelings of unworthiness and increase spouses’ use of resources. Finally, all of the participants felt that provision and advertisement of mental health and suicide prevention programs and services specifically for spouses would help them feel more confident in utilizing these services.

When speaking about risk factors associated with suicide, most spouses described their fears of the stigma associated with accessing mental health services and the struggles associated with finding mental health providers qualified to help them when they did decide to seek help. These fears and struggles directly correspond to results in past quantitative and mixed-methods research regarding barriers to treating military spouse mental health (Eaton et al., 2008; Lewy et al., 2014). The participants in this study likewise described their frustration with not being able to get an appointment with military or community providers. These struggles echo the results of previous research describing the challenges of spouses to access mental health services (Lewy et al., 2014), highlighting the consistency of this issue.

Although the participants’ struggles with mental health and mental health providers confirm the findings of existing studies, their suggestions for preventing suicide within the military spouse community are new ideas generated from this study. Primarily, the participants focused on the community itself as a protective factor against suicide. They described how building a strong spousal community prevents feelings of isolation, as spouses can care for each other because they share common experiences of the military lifestyle. This sense of connection is especially important, as spouses are separated from their support systems when relocating from one duty station to the next (Ross et al., 2020). In order to strengthen the protective factor of their community, the spouses discussed how they wanted more training from military leadership in the areas of suicide prevention and intervention so that they can help others around them. Interestingly, contradictory themes arose in this study’s findings regarding the spouse community shunning those who were struggling with mental health issues and the spouse community serving as a much-needed protective factor. Perhaps the participants’ suggestions of focusing on normalizing mental health support within their community would help to reduce the current tendency to shun and would increase the tendency to support.

In addition to focusing on increasing the protective factor of the spouse community itself, all of the participants stated that they desired increased communication from the military regarding mental health services and programs available specifically to them. Some of the spouses suggested that a direct line of communication from military leadership to spouses would be helpful for finding out about mental health resources available to them, as well as to their spouses. This communication would involve more strategic and widely spread advertising about suicide prevention resources and mental health services in places that spouses often frequent, such as military hospitals or on-base/on-post facilities.

Finally, several spouses suggested an innovative, structured check-in process at each duty station that would promote spousal awareness and understanding of the resources available to them. They explained that this check-in would provide an immediate sense of connection and community for the spouse and a way to formally network with other spouses in the area. This formalized check-in process carried out by the administration at the new duty station may be especially helpful for newer spouses who may not be familiar with the military’s mental health resources or health care system or who may be hesitant to reach out on their own to make connections with others, a pattern noticed by three of the most senior spouses in this study.

Implications for Future Training and Practice
     Both the military community and the mental health counseling profession are called to recognize the mental health struggles that military spouses face in order to help prevent suicide in this population. Military leadership should strategize ways to provide easier access to mental health services for spouses, including suicide prevention programs designed specifically for this population. In addition, suicide education programs for spouses may help them identify warning signs in others, ultimately strengthening the protective factor of the military spouse community. Military leadership should also work to reduce the stigma of receiving mental health services, not only for active-duty service members, but for their family members as well. Military leaders may likewise consider the participants’ suggestions regarding direct communication between military leadership and spouses, including a formalized check-in process for each duty station. Each of these suggestions offers a solution to the challenges outlined by both the professional literature and the spouse participants in this study regarding the mental health challenges faced by spouses and the risk factors of military spouse suicide.

Next, mental health counselors are called to be aware of and screen for the risk factors for suicide in the military spouse population that may be correlated to the inherent challenges that the military lifestyle brings. As prevention is a primary focus within the counseling profession (Sale et al., 2018), counselors might create preventative, psychoeducational groups for spouses to enhance their sense of connectedness and wellness. These groups would serve to identify spouses who may need additional supportive services to mitigate risk of depression and anxiety as well as other mental health issues. Additionally, when relocations occur, counselors should consider connecting their military spouse clients with mental health services in their new location and, with the permission of the client, reach out to those providers to ensure continuity of care. Finally, mental health counselors should actively seek out and build partnerships with military leadership in order to develop evidence-based resources specific to preventing suicide in the spouse population and to reduce the mental health stigma present in both active-duty service members and spouse communities.

     Several limitations to this study exist related to the nature of qualitative methodology. First, in qualitative research, the researcher is the primary source of data collection and analysis. Thus, inherent biases exist throughout this data collection and analysis process (Anderson, 2010). However, bracketing and reflexivity reduced the potential impact of this limitation. Additionally, because mental health stigma exists within the military community, it is possible that participants were guarded during their interviews. Prolonged engagement assisted with mitigating this limitation. Finally, because of the nature of qualitative research, the sample size of the study is small (Atieno, 2009). For instance, the sample in this study did not include the perspectives of any male spouses or spouses who are African American or Hispanic. Additionally, although the sample includes Army, Navy, Air Force, and Coast Guard spouses, no Space Force or Marine Corps spouses are represented. Because of these limitations in gender, ethnicity, and branches, the sample is not representative of the military spouse community as a whole.

Implications for Future Research
     Given these limitations of qualitative research, future quantitative research might focus on specific causes of suicide among military spouses. For example, studies might look at the characteristics of spouses who have committed suicide to detect any patterns or correlations that may exist. There should be particular focus on exploring any ethnic, racial, sexual minority, or gender identity disparities. Future researchers could pilot training programs in the military aimed at preventing military spouse suicide to develop best practices in this area. Finally, future qualitative studies should focus on the experiences of male military spouses. This is critical as the male military spouse suicide rate was recently found to be statistically higher than the overall male suicide rate in the U.S. population (40.9 per 100,000 and 28.4 per 100,000, respectively; DOD, 2020a).

     Overall, the military spouses’ perceptions of risk factors for suicide in this study align with previous studies regarding military spouse mental health that have been conducted throughout the past 12 years. With a new knowledge of the number of spouses that are committing suicide, it is imperative that both the counseling profession and military leadership continue to work toward solutions for spousal mental health. These stakeholders are called to recognize the inherent risk factors of the military lifestyle and provide military spouses with the resources, training, and services that they need (and want) to address and prevent suicide within their community.


Disclosure and Disclaimer Statements

This research was partially funded by a faculty research grant from Arkansas State University.

The opinions and assertions expressed herein are those of the author(s) and do not necessarily reflect the official policy or position of the Uniformed Services University or the Department of Defense.

This research protocol was reviewed and approved by the Arkansas State University Institutional Review Board (IRB) in accordance with all applicable Federal regulations governing the protection of human subjects in research.

Neither the authors nor their family members have a financial interest in any commercial product, service, or organization providing financial support for this research.



Allen, E. S., Rhoades, G. K., Stanley, S. M., & Markman, H. J. (2011). On the home front: Stress for recently deployed Army couples. Family Process, 50(2), 235–247.

Anderson, C. (2010). Presenting and evaluating qualitative research. American Journal of Pharmaceutical Education, 74(8), 141.

Atieno, O. P. (2009). An analysis of the strength and limitation of qualitative and quantitative research paradigms. Problems of Education in the 21st Century, 13, 13–18.

Baer, M. D. (2019). The experiences of spouses/partners of military RPA pilots and sensor operators: A generic qualitative study (Order No. 27666760). Available from ProQuest Dissertations & Theses Global. (2331474736).

Barrett, A., Kajamaa, A., & Johnston, J. (2020). How to . . . be reflexive when conducting qualitative research. The Clinical Teacher, 17(1), 9–12.

Birt, L., Scott, S., Cavers, D., Campbell, C., & Walter, F. (2016). Member checking: A tool to enhance trustworthiness or merely a nod to validation? Qualitative Health Research, 26(13), 1802–1811.

Blosnich, J. R., Montgomery, A. E., Dichter, M. E., Gordon, A. J., Kavalieratos, D., Taylor, L., Ketterer, B., & Bossarte, R. M. (2010). Social determinants and military veterans’ suicide ideation and attempt: A cross-sectional analysis of electronic health record data. Journal of General Internal Medicine, 35(6), 1759–1767.

Blue Star Families. (2019). 2019 Military Family Lifestyle Survey executive summary.

Britt, T. W., Jennings, K. S., Cheung, J. H., Pury, C. L. S., & Zinzow, H. M. (2015). The role of different stigma perceptions in treatment seeking and dropout among active duty military personnel. Psychiatric Rehabilitation Journal, 38(2), 142–149.

Burke, J., & Miller, A. (2016). The effect of military change-of-station moves on spousal earnings.

Calati, R., Ferrari, C., Brittner, M., Oasi, O., Olié, E., Carvalho, A. F., & Courtet, P. (2019). Suicidal thoughts and behaviors and social isolation: A narrative review of the literature. Journal of Affective Disorders, 245, 653–667.

Center for the Study of Traumatic Stress. (2020). Financial stress and behavioral health in military servicemembers report.

Christensen, M., Welch, A., & Barr, J. (2017). Husserlian descriptive phenomenology: A review of intentionality, reduction and the natural attitude. Journal of Nursing Education and Practice, 7(8), 113–118.

Cole, R. F. (2012). Professional school counselors’ role in partnering with military families during the stages of deployment. Journal of School Counseling, 10(7).

Cole, R. F. (2014). Understanding military culture: A guide for professional school counselors. The Professional Counselor, 4(5), 497–504.

Creswell, J. W., & Creswell, J. D. (2018). Research design: Qualitative, quantitative, and mixed methods. (5th ed.). SAGE.

Creswell, J. W., & Poth, C. N. (2017). Qualitative inquiry and research design: Choosing among five approaches (4th ed.). SAGE.

Darawsheh, W. (2014). Reflexivity in research: Promoting rigour, reliability and validity in qualitative research. International Journal of Therapy and Rehabilitation, 21(12), 560–568.

Eaton, K. M., Hoge, C. W., Messer, S. C., Whitt, A. A., Cabrera, O. A., McGurk, D., Cox, A., & Castro, C. A. (2008). Prevalence of mental health problems, treatment need, and barriers to care among primary care-seeking spouses of military service members involved in Iraq and Afghanistan deployments. Military Medicine, 173(11), 1051.

Heuser, C., & Howe, J. (2019). The relation between social isolation and increasing suicide rates in the elderly. Quality in Ageing and Older Adults, 20(1), 2–9.

Institute for Veterans and Military Families. (2016). The force behind the force.

Korstjens, I., & Moser, A. (2018). Series: Practical guidance to qualitative research. Part 4: Trustworthiness and publishing. European Journal of General Practice, 24(1), 120–124.

Lewy, C. S., Oliver, C. M., & McFarland, B. H. (2014). Brief report: Barriers to mental health treatment for military wives. Psychiatric Services, 65(9), 1170–1173.

Linn, M. W., Sandifer, R., & Stein, S. (1985). Effects of unemployment on mental and physical health. American Journal of Public Health, 75(5), 502–506.

Mailey, E. L., Mershon, C., Joyce, J., & Irwin, B. C. (2018). “Everything else comes first”: A mixed-methods analysis of barriers to health behaviors among military spouses. BMC Public Health, 18, 1013.

Malacrida, C. (2007). Reflexive journaling on emotional research topics: Ethical issues for team researchers. Qualitative Health Research, 17(10), 1329–1339.

McNulty, P. A. F. (2003). Does deployment impact the health care use of military families stationed in Okinawa, Japan? Military Medicine, 168(6), 465–70.

Meyer, K., & Willis, R. (2019). Looking back to move forward: The value of reflexive journaling for novice researchers. Journal of Gerontological Social Work, 62(5), 578–585.

O’Keefe, P. H. (2016). Using Facebook to communicate with husbands while deployed: A qualitative study of Army wives’ experiences (Order No. 10196383). Available from ProQuest Central; ProQuest Dissertations & Theses Global. (1853893200).

Oquendo, M. A., Perez-Rodriguez, M. M., Poh, E., Sullivan, G., Burke, A. K., Sublette, M. E., Mann, J. J., & Galfalvy, H. (2014). Life events: A complex role in the timing of suicidal behavior among depressed patients. Molecular Psychiatry, 19(8), 902–909.

Patton, M. Q. (2002). Qualitative research and evaluation methods (3rd ed.). SAGE.

Paul, E. (2018). Proximally-occurring life events and the first transition from suicidal ideation to suicide attempt in adolescents. Journal of Affective Disorders, 241, 499–504.

Pompili, M., Amador, X. F., Girardi, P., Harkavy-Friedman, J., Harrow, M., Kaplan, K., Krausz, M., Lester, D., Meltzer, H. Y., Modestin, J., Montross, L. P., Mortensen, P. B., Munk-Jørgensen, P., Nielsen, J., Nordentoft, M., Saarinen, P. I., Zisook, S., Wilson, S. T., & Tatarelli, R. (2007). Suicide risk in schizophrenia: Learning from the past to change the future. Annals of General Psychiatry, 6, 10.

Romo, V. (2019). Military families experience high stress, anxiety and unemployment, report says.

Ross, A. M., DeVoe, E. R., Steketee, G., Emmert-Aronson, B. O., Brown, T., & Muroff, J. (2020). Outcomes of a reflective parenting program among military spouses: The moderating role of social support. Journal of Family Psychology, 34(4), 402–413.

Sale, E., Hendricks, M., Weil, V., Miller, C., Perkins, S., & McCudden, S. (2018). Counseling on Access to Lethal Means (CALM): An evaluation of a suicide prevention means restriction training program for mental health providers. Community Mental Health Journal, 54(3), 293–301.

Sargeant, J. (2012). Qualitative research part II: Participants, analysis, and quality assurance. Journal of Graduate Medical Education, 4(1), 1–3.

Shenton, A. K. (2004). Strategies for ensuring trustworthiness in qualitative research projects. Education for Information, 22(2), 63–75.

Substance Abuse and Mental Health Services Administration. (2015). Spouses and children of U.S. military personnel: Substance use and mental health profile from the 2015 National Survey on Drug Use and Health.

Tong, P. K., Payne, L. A., Bond, C. A., Meadows, S. O., Lewis, J. L., Friedman, E. M., & Maksabedian Hernandez, E. J. (2018). Enhancing family stability during a permanent change of station: A review of disruptions and policies.

U.S. Chamber of Commerce. (2017). Military spouses in the workplace: Understanding the impacts of spouse unemployment on military recruitment, retention, and readiness.

U.S. Department of Defense. (2018). Military spouse demographics and employment information.

U.S. Department of Defense. (2019). Annual suicide report.

U.S. Department of Defense. (2020a). Annual suicide report.

U.S. Department of Defense. (2020b). DOD releases military spouse licensure report.


Appendix A

Participant Age Group Gender Race Military Branch Spouse’s Rank Years as Spouse
Participant 1 30–39 Female White Army Officer 10

Participant 2














Participant 3








Coast Guard






Participant 4














Participant 5








Air Force






Participant 6














Participant 7








Air Force






Participant 8








Air Force






Participant 9














Participant 10














Appendix B
Interview Protocol

First Interview

What are your perceptions of suicide in the military spouse community?

What are the risk factors for suicide in the military spouse population?

What mental health challenges do military spouses face?

What resources currently exist to help prevent military spouse suicide?

What would you like to let the civilian world know about your life as a military spouse that they might not be aware of?

Is there anything else you would like to add?

Second Interview

Do you have anything else to add from our first interview?

What do you think causes military spouses to commit suicide?

What needs to be done to prevent suicide in the military spouse community?

What might be the consequences of not addressing suicide in the military spouse community?

What type of mental health support is most needed for the military spouse community?

How would your mental health differ, if at all, if you weren’t a military spouse?

Is there anything else you would like to add?

Follow-Up Email Questions

Is there anything else you would like to add to your interview responses?

What was it like for you to participate in this study?

What is the most important resource that military spouses need to prevent future suicides?                                                             


Rebekah F. Cole, PhD, NCC, LPC, is formerly an assistant professor at Arkansas State University and is now a research associate professor at the Uniformed Services University. Rebecca G. Cowan, PhD, NCC, BC-TMH, LPC, DCMHS, is a core faculty member at Walden University. Hayley Dunn is a graduate student at Arkansas State University. Taryn Lincoln is a graduate student at Arkansas State University. Correspondence may be addressed to Rebekah Cole, Uniformed Services University of the Health Sciences, Department of Military and Emergency Medicine, 4301 Jones Bridge Rd., Bethesda, MD 20814,

School-Based Child Sexual Abuse Prevention: Implications for Professional School Counselors

Rebecca Cowan, Rebekah F. Cole, Laurie Craigen


The purpose of this qualitative collective case study was to explore the experiences of four key internal stakeholders who are involved with a school-based child sexual abuse prevention program in a southeastern state in the United States. In order to explore the experiences of participants, in-depth, semi-structured interviews were conducted. After the data were collected, transcribed, and coded by a qualified research team, three main themes emerged from this study. These themes highlighted the importance of school-based child sexual abuse prevention education, various program impacts resulting from child sexual abuse prevention and intervention within a school setting, and barriers to implementation of child sexual abuse prevention programs in school settings. Implications for professional school counselors, including how they can assist with the implementation of child sexual abuse prevention education, are discussed. Finally, inherent limitations to the research design and implications for future studies are addressed.


Keywords: sexual abuse, prevention, children, collective case study, professional school counselors



In 2017, there were 57,964 reports of child sexual abuse (CSA) in the United States (U.S. Department of Health and Human Services [DHHS], 2018). However, the incidence of CSA is likely higher, as cases of sexual abuse often go unreported (Leclerc & Wortley, 2015; Wurtele, 2009). Overall, between 7.5%–16% of males and 19.7%–25% of females report a history of CSA (Dube et al., 2005; Pereda, Guilera, Forns, & Gòmez-Benito, 2009), and approximately 39 million adults in the United States are CSA survivors (Child Molestation Research and Prevention Institute, 2015). More than 3 million children are victims of CSA, with a mean age of onset of 11.2 years of age (Broman-Fulks et al., 2007). CSA has been linked to a variety of health and mental health issues, including substance abuse, suicide attempts, sexual revictimization, high-risk sexual behavior, anxiety, depression, cognitive disturbances, post-traumatic stress disorder (PTSD), gastrointestinal issues, and chronic pain (Dube et al., 2005; Irish, Kobayashi, & Delahanty, 2010; Lalor & McElvaney, 2010; Sabella, 2016; Wurtele, 2009). Therefore, because of the high incidence and resulting consequences of CSA, prevention is paramount (Letourneau, Eaton, Bass, Berlin, & Moore, 2014).


Abel and Harlow (2001) reported that CSA perpetrators represent a variety of ethnicities and socioeconomic groups. Ninety percent of perpetrators know their victims; only 10% of perpetrators sexually abuse children unknown to them. Sixty-eight percent of CSA perpetrators sexually abuse children in their own families (e.g., biological children, stepchildren, nieces, nephews, grandchildren) and 40% sexually abuse children within their social circle (Abel and Harlow, 2001). Additionally, 5.9% of all girls and 0.3% of all boys in the United States are sexually abused by a known adult (Finkelhor, Turner, Shattuck, & Hamby, 2013). CSA perpetrators who sexually abuse boys report an average of 10.7 victims as compared to 5.2 victims of perpetrators who sexually abuse girls (Abel & Harlow, 2001). Those who sexually abuse both boys and girls report an average of 27.3 victims (Abel & Harlow, 2001).


     Professional school counselors play an important role in CSA prevention. They are federally mandated to report suspected cases of abuse (Federal Child Abuse Prevention and Treatment Act, 2010), including CSA, and also provide counseling services to victims and organize advocacy efforts (American School Counselor Association [ASCA], 2015; Sikes, 2008). Furthermore, professional school counselors are in the position to address barriers and support the implementation of CSA prevention programs within their schools. These school-based prevention efforts are imperative; despite the high incidence of children who are sexually abused, research indicates that many parents do not educate their children about CSA at home (Kenny, Capri, Thakkar-Kolar, Ryan, & Runyon, 2008). Therefore, it is vital that evidence-based CSA prevention programs are provided within the schools so that children have an opportunity to gain knowledge and personal safety skills.


In 1995, 67% of children ages 10–16 reported that they had participated in a school-based CSA prevention program (Finkelhor & Dziuba-Leatherman, 1995). However, this percentage has significantly declined in recent years because of increased focus on other topics, such as bullying prevention, standardized testing, substance use, and intimate partner violence (Morris et al., 2017; Wurtele, 2009). Despite this shift, the implementation of CSA prevention programs within school systems remains ideal because of the ability to concurrently reach multiple children in that setting (Finkelhor, 2009; National Sexual Violence Resource Center [NSVRC], 2011; Tutty, 2000; Wurtele, 2009). However, in recent years, there has been resistance to establishing CSA prevention education within the schools, as some believe that talking about sexual abuse is not appropriate in a school setting (NSVRC, 2011; Wurtele, 2009). Additionally, according to Topping and Barron (2009), CSA prevention programs might be limited because of constraints on funds and time. Some CSA prevention education critics also argue that these types of programs place an unfair burden on the child to report or prevent CSA attempts and that it may not be appropriate to expect children to defend themselves against perpetrators (Finkelhor, 2007; Rudolph & Zimmer-Gembeck, 2018). However, many opponents have “offered little evidence that support their claims of potential negative side-effects” (Kenny et al., 2008, p. 50). In fact, Walsh, Zwi, Woolfenden, and Shlonsky (2015) found in their meta-analysis of several school-based CSA prevention programs “evidence of improvements in protective behaviours and knowledge among children” (p. 2). Furthermore, this increase in knowledge and skill was seen in children regardless of the type of CSA prevention program that was implemented. A study conducted by Gibson and Leitenberg (2000) provided further evidence of the effectiveness of CSA prevention programs, as they found that 9% of participants who had participated in a school-based prevention program were sexually abused compared to 16% who had never participated in CSA prevention.


     In order to effectively implement CSA prevention programs within the schools, a better understanding of these challenges and barriers needs to be gained. Findings from this study may promote awareness, enhance programming, and contribute to prevention efforts for CSA. The purpose of this collective case study research was to explore the experiences of several key internal stakeholders who are currently involved with a CSA prevention program in a southeastern state in the United States. The primary research question answered by this study was: How do key internal stakeholders who are involved with a school-based CSA prevention program describe their experiences with program implementation?




Collective case study research (Yin, 2003) was utilized to explore the experiences of internal stakeholders and their views of a school-based CSA prevention program. The case study tradition focuses upon the constructivist paradigm in which the truth is relative and reliant on one’s unique perspective (Baxter & Jack, 2008). According to Creswell (2007), in a collective case study, “the inquirer purposefully selects multiple cases to show different perspectives on the issue” (p. 74), and this type of approach is often utilized when the unit of analysis is a program. According to Patton (2002), a case study may represent one single program or case. However, within that single program case, a researcher can conduct case studies of several participants. Utilizing the qualitative case study tradition facilitates an issue being explored through multiple lenses, rather than just one (Baxter & Jack, 2008). This approach helps “multiple facets of the phenomenon to be revealed and understood” (Baxter & Jack, 2008, p. 544).



Purposive and criterion sampling (Creswell, 2007) were utilized to recruit four key internal stakeholders for this study. Each participant had been involved with the program for at least one year (range = 1–25 years). For the purpose of this study, a stakeholder meant “people or small groups with the power to respond to, negotiate with, and change the strategic future of the organization” (Eden & Ackermann, 1998, p. 117). Two participants included in this study were current board members and two were current staff members.



This nonprofit CSA prevention organization is dedicated to preventing CSA through the education of children. Their 45-minute performance for children in kindergarten through fifth grade features a puppet who provides children with guidance on how to respond when faced with potentially dangerous situations. A safety net of professionals from Child Protective Services (CPS) and the police department, in addition to school counselors, are present at every performance so that any child who comes forward to disclose sexual abuse is properly cared for with the correct protocols in place. This CSA prevention program has resulted in the arrest and incarceration of 158 CSA perpetrators.



The principle investigator (PI) conducting this study is a Caucasian female in her thirties. She is a licensed professional counselor and has a PhD in counselor education and supervision. The PI has experience treating children who have been sexually abused and adults who were sexually abused during childhood. Two additional researchers assisted with research design and data analysis. Both researchers have doctoral degrees in counselor education and supervision and are licensed professional counselors. One of the researchers has a master’s degree in school counseling and the other researcher has an EdS in school psychology. They are knowledgeable in treating children who have been sexually abused and have experience working within school settings. Engaging a research team of three researchers helped to reduce researcher bias and generated triangulation for the research study (Creswell & Poth, 2018).


Data Collection

Individual interviews were conducted in a southeastern U.S. city. The PI met with participants in a confidential space and informed consent was reviewed and signed prior to the commencement of data collection. After informed consent was given, the PI individually interviewed participants using a semi-structured interview guide pertaining to their experiences as key internal stakeholders involved with this CSA prevention organization. These interviews were audiotaped and transcribed verbatim and lasted approximately 30–45 minutes. All participants were assigned a unique identifier (number) in order to protect confidentiality.


Data Analysis

Transcripts were initially read through by the researchers to gain an overall familiarity with them. The researchers then engaged in content analysis by open-coding the data (Patton, 2002). Through this analysis, patterns and themes were identified and overlapping data was deleted. Researchers developed coding schemes independently and then together they compared and discussed similarities and differences (Patton, 2002). Word tables were utilized to organize the data from each individual case (Yin, 2014). The analysis of these individual word tables allowed researchers to draw cross-case conclusions. Data across cases were analyzed and similarities and differences were noted (Eisenhardt, 1989; Miles & Huberman, 1984).


Strategies for Trustworthiness

In an effort to achieve trustworthiness of the data, triangulation was attained (Baxter & Jack, 2008) as multiple sources were used to collect data, including semi-structured individual interviews, demographic sheets, and program documents. Clarifying researcher bias was another strategy employed for trustworthiness as bracketing, through the use of reflexive journals, was utilized by the researchers (Tufford & Newman, 2010). Bracketing was completed prior to data collection so that the researchers were made aware of their assumptions and biases. Finally, a thick description, as defined by Patton (2002) as having “detailed description and rich quotations” (p. 438), was used as an overreaching strategy to increase the trustworthiness of this study.




A total of three themes emerged from the data analysis: (1) importance of school-based CSA prevention education, (2) program impact within a school setting, and (3) barriers to implementation of CSA prevention within school systems.


Theme 1: Importance of School-Based CSA Prevention Education

This theme includes the participants’ perspectives on the importance and value of CSA prevention education within the school setting. The following sub-themes are included in this section: (1) children and (2) parents and teachers.


Children. The majority of participants discussed the importance of child abuse education so children could implement good boundary setting and learn the language they need in order to express themselves if they feel they are at risk. When outlining the importance of educating children on this issue, one participant discussed how if children are not educated about boundaries and body safety starting at a young age, this could potentially leave a gap for this type of abuse to take place. She stated, “They groom them at a young age and so they break down their resistance and by the time they get to middle and high school, they are assimilated already into this lifestyle and so they think it is normal.” Another participant had similar thoughts and discussed the importance of empowering children to protect themselves. She stated, “We can’t protect them all the time, and I think it is important to give them the knowledge that what’s happening to them is wrong and that they can make a difference by saying no.” Likewise, another participant discussed how teaching children to protect themselves from predators is “fundamental.” She went on to ask the question, “How do you go to school and learn to become a successful adult and have good decision-making if you are carrying this around?” Another interview revealed, “At every turn around every corner, there is someone who is looking to take advantage of that child,” and that child needs to understand how to protect him- or herself. This participant went on to describe the importance of equipping children with the language they need to express what is happening to them. He stated, “What kind of language does a 6-year-old child have to be able to tell an adult that they are being sexually abused? They don’t have a way to even express what’s happening to them.”


     Parents and teachers. Many participants identified a significant need for parents and teachers to become educated on how to talk with children about these issues. One participant discussed how many parents do not know how to educate their children or how to appropriately respond if a child discloses sexual abuse. She stated, “Parents need to not just be talking about this big, bad rapist” and discussed how parents need to educate their children beyond “stranger danger.” A participant also touched on the importance of educating parents: “I do think we need to be more aggressive with the adult education piece . . . it’s an adult problem, it needs an adult solution.” Another participant shared similar thoughts and discussed how parents should be providing this type of education to their children at home. He stated, “As parents, as people in authority positions, we should be the ones answering those questions versus them hearing it from their classmate, or in the streets, or in the locker room.”


Another participant discussed how some parents might be averse to having their child participate in CSA prevention education at school. He discussed how these parents might be concerned about discussing CSA with children who have not previously been exposed to sex and how perhaps this type of discussion could pique their curiosity. This participant countered this by stating, “What better way to do it in a controlled environment and you can answer the questions that they may have.” Another participant also discussed how some parents do not believe their children should learn about CSA prevention at school, but that many of these children are simply not being educated at home. He stated, “What those parents don’t understand is that while they may be proactive in what they’re doing in educating their children about these types of things, 90% of the kids in schools today are not getting this education at home.” Another participant went on to discuss how teachers also do not get enough training on this topic. He stated, “That’s something that’s got to change. They got to get the training that surrounds this issue to be able to understand the issue and wrap their head around what’s happening in their classrooms.”


Theme 2: Program Impact Within a School Setting

Many of the participants discussed how CSA prevention programs within the schools can provide children with the courage to speak up and learn how to protect themselves from potentially dangerous situations. One participant discussed the appreciation he has for how this particular CSA prevention program creates a support system so that children may feel comfortable coming forward and disclosing sexual abuse. He highlighted how law enforcement officers, social services, and school administrators are present throughout the performance “so you have a support system that is right there that says . . . you can have the courage to share if something like that has happened.” Another participant shared similar thoughts and discussed how this particular CSA prevention program is “different” because of the safety net of professionals they have available throughout the production.


Two participants shared their personal experiences with witnessing CSA disclosures as a result of the program. One participant discussed her personal experience of watching children come forward and disclose sexual abuse after participating in the program. She stated, “I really believe the program works. In 25 years, I have seen kids come forward, you know . . . and kids learn how to prevent it from happening.” Another participant described how he had witnessed children disclose prior and current sexual abuse after participating. He stated that when children come forward and tell a teacher, “if we can . . . save one child from the horror of being sexually abused by an adult, then this program is worth its weight in gold.”


Numerous perpetrators have been prosecuted because of disclosures that occurred after children participated in this program. One participant stated, “Having 158 perpetrators prosecuted comes from when she [the director of the program] was in all the elementary schools here in the city.” However, this may be underestimated, as disclosures and prosecutions as a result of the program were difficult to track because of confidentiality and the sensitive nature of the information. Another participant also discussed prosecutions as a result of this program. He stated, “We’re seeing the prosecutions go up because there’s been more exposure of what has taken place in the dark, and so either way, it is a great success.”


Theme 3: Barriers to Implementation Within School Systems

This theme includes the participants’ perspectives on the barriers and obstacles toward implementing this CSA prevention program. The following sub-themes are included in this section: (1) funding issues, (2) a taboo topic and negative attitudes, (3) intervention is stressed, and (4) community support.


     Funding issues. Funding was identified by all participants as a major barrier to implementing CSA prevention programs, as many school systems do not have funding allocated to support this effort. One participant stated, “I’m researching grants that we can apply for and there is plenty of grant money out there for treatment, but not prevention.” Another participant believed that perhaps fundraising for this cause is difficult because the topic makes many people “feel very uncomfortable.” She further stated, “Everybody’s opening up their wallets for ALS, everybody’s opening up their wallets for autism, and those are all great causes . . . but CSA prevention is removed from them.” A third participant discussed how important it is to “champion legislative funding” and discussed how this is “key” to the implementation of CSA prevention programs within the schools in the future.


     A taboo topic and negative attitudes. Participants also discussed how sexual abuse is a “taboo” topic that is often viewed very negatively and, therefore, is often not discussed. In return, this leads to barriers to implementing CSA prevention programs. One participant discussed how many individuals seem to be in denial about the prevalence of CSA. She discussed how people need to “just open up the communication on this really disgusting tabooed subject. People don’t want to talk about it, people don’t want to hear about it. It’s so uncomfortable.” She went on to state, “Someone coined the phrase, ‘Not in My Backyard.’ It’s in every backyard.” Another participant shared similar thoughts. He discussed how some are opposed to CSA prevention programs as they believe these programs are similar to sexual education or that the topic is not “age appropriate.” However, he suggested that these individuals “would be amazed at what children already know and would be amazed at what they’re being exposed to already.”


Participants noted that attitudes about CSA prevention tend to be negative and this hinders efforts in implementing these types of programs. For instance, when one participant was asked what she would like to see changed regarding CSA prevention programs, she stated, “What would I see changed? Just people’s attitudes towards it.” Another participant explained how people working within the school systems often negatively view CSA prevention programs. He discussed how difficult it can be to get “buy-in from school administrators when school administrators know they have kids in their school who are being sexually abused and they know that if they see this program that they are going to possibly come forward.” He went on to discuss how CSA disclosures often result in a “tremendous amount of paperwork for them [school administrators], it creates huge logistical issues like dealing with parents and dealing with CPS and the police” and how this could potentially fuel resistance to implementing these programs. Another participant discussed how their senator supports CSA prevention education, but only in middle and high schools. He stated, “There is a reason for that . . . whether they believe that the elementary school students would not be an appropriate age demographic or whether they thought they would get some resistance, maybe from parents.”


     Intervention is stressed. Participants emphasized how too much focus is often placed on the intervention of CSA, whereas more attention needs to be focused on prevention. When discussing what he would tell people when explaining why CSA prevention is important, one participant said he would invite them to visit juvenile court and watch as he puts a child on the stand who must disclose CSA. He challenges people to think about how these children must find the courage to relive their experience all over again on the witness stand “in front of the judge, in front of the jury, in front of strangers . . . then you tell me how important it is that we educate our kids about child sexual abuse prevention.” Another participant said, “I think that as the general population becomes more educated about the fact that you can prevent the issue from happening, I think they could see that it’s more important to put money into prevention than treating something.” This participant went on to explain the importance of “getting people interested in prevention more than just putting the fire out once the fire starts . . . I think people wait until it’s too late and then they rather put out the fire and until it becomes a fire, they don’t want to have to deal with it.” A third participant shared similar thoughts: “It needs to be more preventive and more proactive and we need to start talking about it.”


     Community support. Community support was identified by participants as being difficult to come by but essential to the successful implementation of CSA prevention programs. One participant discussed how “there are so many fundraisers . . . and you have to pick and choose what you are passionate about,” noting that not too many people choose to support CSA prevention. Another participant discussed the importance of networking with community partners in order to gain additional support. In particular, he highlighted the importance of developing trust between the organization and community partners. He stated, “When you know a person and you have a relationship with a person, it’s easier to trust them to always do the right thing.” A third participant discussed his personal efforts related to attempting to gain additional community support: “Every opportunity I get to talk to a person about the program, I do . . . I ask them to get in touch with me if they have any questions.”




In this study, the participants emphasized that addressing the often taboo topic of sexual abuse with children is imperative. They discussed how the topic of sexual abuse is frequently avoided, especially by parents and guardians—a trend that is confirmed by the professional literature (Kenny et al., 2008). The participants noted that this avoidance hinders opportunities for both prevention and intervention in the lives of children. Notably, with education, parents and guardians are empowered to teach their children about ways to avoid sexual abuse. These discussions are crucial to preventing harm to children and providing them with the knowledge and awareness they need to protect themselves. Additionally, participants discussed how the focus on “stranger danger” by parents neglects the most common perpetrators of sexual abuse—acquaintances. Deblinger, Thakkar-Kolar, Berry, and Schroeder (2010) supported this finding, as they also found that the parents who discuss CSA with their children can erroneously focus on the dangers of interacting with strangers and not with individuals the child may already know. Additionally, Deblinger et al. found that the number of parents who stated that they desired to educate their children about CSA at home was more than those who had actually followed through with this task. Therefore, parents may lack the knowledge they need in order to adequately address this issue with their children. Professional school counselors are in an ideal position to help fill this void by developing educational opportunities for parents and guardians, so they feel better equipped to talk with their children about CSA. It would be prudent to include information about perpetrators so that parents do not solely focus on strangers when discussing safety with their children.


Professional school counselors also can play an important role in the education of teachers, administrators, and other school staff. The participants in this study discussed how there may be some resistance on behalf of school administrators to implement CSA prevention programs because of fear about the logistical issues that may result from disclosures. Therefore, as also discussed by Sikes (2008), it is important that a protocol is in place for when children disclose sexual abuse. Professional school counselors can assist with the development of this protocol and can educate school administrators and teachers about how to appropriately respond to and report disclosures of CSA. Professional school counselors should clearly define which individuals are mandated to report suspected CSA to CPS and in what timeframe the report must be made. A reporting form could be developed in order to streamline this process (see Sikes, 2008). Additionally, professional school counselors should provide educational resources to teachers and school administrators on how to identify signs of CSA.


In response to the taboo placed on discussing CSA, the participants described how their program offers stakeholders a vehicle for openly discussing CSA, as it provides a forum for creating awareness regarding the dangers of sexual abuse. In addition, the participants were proud of the community awareness that the program created, allowing for the prosecution of child sex abusers in the community. CSA prevention should not only include education of children, but also the general public, professionals, and other stakeholders (Wurtele, 2009). Professional school counselors can be an important vehicle for this type of collaboration. The participants all discussed how having social services, the police, and CPS as part of their program helped to provide a safety network for when CSA disclosures were made. According to the NSVRC (2011), “prevention programs designed for children are only one of many components of a successful community effort to prevent CSA. The burden of prevention should also be distributed across community members, organizations, and social structures” (p. 3). Participants also discussed how imperative it is to develop strong community partnerships to work together to help prevent CSA. Therefore, it could be noteworthy for professional school counselors to focus on building these partnerships so that funding and support may be bolstered for such programs to continue or be implemented within schools.


The participants also discussed how intervention is often stressed and prevention is overlooked in the treatment of CSA. This could be due to limited scholarly research that provides evidence for the effectiveness of CSA prevention programs (Rudolph & Zimmer-Gembeck, 2018). CSA prevention programs characteristically utilize a risk-reduction approach in which children are educated about sexual abuse and learn the skills necessary to avoid and report abuse (NSVRC, 2011). However, empirical support of these programs is limited (Lynas & Hawkins, 2017; Topping & Baron, 2009), as CSA prevention programs are difficult to measure (Lynas & Hawkins, 2017). In response to the lack of outcome data, the NSVRC has put forth that “additional rigorous evaluations of child sexual abuse prevention programs are needed” (2011, p. 6). Additionally, few follow-up studies have been conducted in order to determine if knowledge from these prevention programs has been retained and, more importantly, whether children can apply this knowledge to real-world scenarios. Professional school counselors can assist with the development and implementation of research and program evaluation studies in order to provide additional evidence in support of CSA prevention programs within the schools. Implementation of research within a school setting is no easy feat, as multiple approvals are necessary in order to ensure research participants are not harmed and that research is conducted in an ethical manner. Therefore, school administrators can be hesitant to approve research conducted within this setting. Professional school counselors can collaborate with administrators and make a strong case for why this type of research is absolutely necessary, so that more evidence-based CSA prevention programs are developed.


Program fidelity is another issue that has been identified within the literature when it comes to the evaluation of CSA prevention programs (Johnson, 1994; Lynas & Hawkins, 2017). Program evaluation research has indicated that when teaching about CSA, teachers can leave out content because of their own personal discomfort. This type of modification to program material could potentially impact findings of program evaluations and might minimize program effectiveness. Therefore, when educating teachers about CSA prevention, professional school counselors could discuss how sensitivities may arise while teachers deliver this type of content to their students, as well as how to ensure they are adhering to the protocol of the selected program (Lynas & Hawkins, 2017). If personal sensitivities arise because of a teacher’s own history of CSA, it may be prudent for the professional school counselor to connect these individuals with mental health providers within their community.


Limitations and Implications for Future Research


This study lays the groundwork for qualitative as well as quantitative analysis of CSA prevention programs and other similar programs that exist. The results of qualitative research designs inherently are limited in their ability to be extended to a wider population (Atieno, 2009). Our case study design was limited to four participants. In addition, as the researcher is the primary research instrument in our qualitative research design, our biases could have influenced both data collection and analysis (Anderson, 2010). Thus, the validity of the findings might be called into question.


Additional quantitative research might survey participants’ understanding of the material presented both before and after the program, measuring the knowledge that they gain. Further, a future phenomenological qualitative study might examine the experiences of the participants themselves as they process the material they encounter in a CSA prevention program. Future qualitative research studies might explore parents’ perceptions of CSA education and the ways in which they are currently addressing this issue with their children. This exploration also could highlight areas that need further parent education in order to help them prevent CSA in the lives of their children. Finally, future studies could focus on the experiences of professional school counselors as they work toward the prevention of CSA.




CSA is a major public health concern affecting thousands of children in the United States (U.S. DHHS, 2018). Although research is limited to the efficacy of CSA prevention programs, outcome data indicates that effective programs promote education and awareness, decrease stigma, and increase rates of reporting sexual abuse. Results from this collective case study yielded three central themes: the importance of school-based CSA prevention education, program impact within a school setting, and barriers to the implementation of CSA prevention within the schools. The data that emerged from the participants provide valuable perspectives on the challenges and benefits of CSA prevention programs and how professional school counselors may advocate for their implementation within the schools.


Conflict of Interest and Funding Disclosure

The authors reported no conflict of interest

or funding contributions for the development

of this manuscript.





Abel, G. G., & Harlow, N. (2001). The stop child molestation book: What ordinary people can do in their everyday lives to save three million children. Philadelphia, PA: Xlibris.

American School Counselor Association. (2015). The school counselor and child abuse and neglect prevention. Retrieved from

Anderson, C. (2010). Presenting and evaluative qualitative research. American Journal of Pharmaceutical
, 74(8), 1–7. doi:10.5688/aj7408141

Atieno, O. P. (2009). An analysis of the strengths and limitation of qualitative and quantitative research paradigms. Problems of Education in the 21st Century, 13, 13–18.

Baxter, P. E., & Jack, S. M. (2008). Qualitative case study methodology: Study design and implementation for novice researchers. The Qualitative Report, 13, 544–559.

Broman-Fulks, J. J., Ruggiero, K. J., Hanson, R. F., Smith, D. W., Resnick, H. S., Kilpatrick, D. G., & Saunders, B. E. (2007). Sexual assault disclosure in relation to adolescent mental health: Results from the National Survey of Adolescents. Journal of Clinical Child and Adolescent Psychology, 36, 260–266. doi:10.1080/15374410701279701

Child Molestation Research and Prevention Institute. (2015). Tell others the facts. Retrieved from

Creswell, J. W. (2007). Qualitative inquiry and research design: Choosing among five approaches (1st ed.). London, UK: SAGE.

Creswell, J. W., & Poth, C. N. (2018). Qualitative inquiry and research design: Choosing among five approaches (4th ed.). Thousand Oaks, CA: SAGE.

Deblinger, E., Thakkar-Kolar, R. R., Berry, E. J., & Schroeder, C. M. (2010). Caregivers’ efforts to educate their children about child sexual abuse. A replication study. Child Maltreatment, 15, 91–100. doi:10.1177/1077559509337408

Dube, S. R., Anda, R. F., Whitfield, C. L., Brown, D. W., Felitti, V. J., Dong, M., & Giles, W. H. (2005). Long-term consequences of childhood sexual abuse by gender of victim. American Journal of Preventive Medicine, 28, 430–438. doi:10.1016/j.amepre.2005.01.015

Eden, C., & Ackermann, F. (1998). Making strategy: The journey of strategic management. London, UK: SAGE.

Eisenhardt, K. M. (1989). Building theories from case study research. The Academy of Management Review, 14, 532–550. doi:10.2307/258557

Federal Child Abuse Prevention and Treatment Act of 2010, 42 U. S. C. A. § 5106g (2010).

Finkelhor, D. (2007). Prevention of sexual abuse through educational programs directed toward children. Pediatrics, 120, 640–645. doi:10.1542/peds.2007-0754

Finkelhor, D. (2009). The prevention of childhood sexual abuse. The Future of Children, 19(2), 169–194. doi:10.1353/foc.0.0035

Finkelhor, D., & Dziuba-Leatherman, J. (1995). Victimization prevention programs: A national survey of children’s exposure and reactions. Child Abuse & Neglect, 19(2), 129–139.

Finkelhor, D., Turner, H. A., Shattuck, A., & Hamby, S. L. (2013). Violence, crime, and abuse exposure in a national sample of children and youth: An update. JAMA Pediatrics, 167, 614–621.

Gibson, L. E., & Leitenberg, H. (2000). Child sexual abuse prevention programs: Do they decrease the occurrence of child sexual abuse? Child Abuse and Neglect, 24, 1115–1125.

Irish, L., Kobayashi, I., & Delahanty, D. L. (2010). Long-term physical health consequences of childhood sexual abuse: A meta-analytic review. Journal of Pediatric Psychology, 35, 450–461. doi:10.1093/jpepsy/jsp118

Johnson, B. (1994). Teachers’ role in the primary prevention of child abuse dilemmas and problems. Child Abuse Review, 3, 259–271. doi:10.1002/car.2380030405

Kenny, M. C., Capri, V., Thakkar-Kolar, R. R., Ryan, E. E., & Runyon, M. K. (2008). Child sexual abuse: From prevention to self-protection. Child Sexual Abuse Review, 17, 36–54. doi:10.1002/car.1012

Lalor, K., & McElvaney, R. (2010). Child sexual abuse, links to later sexual exploitation/high-risk sexual behavior, and prevention/treatment programs. Trauma, Violence, & Abuse, 11(4), 159–177. doi:10.1177/1524838010378299

Leclerc, B., & Wortley, R. (2015). Predictors of victim disclosure in child sexual abuse: Additional evidence from a sample of incarcerated adult sex offenders. Child Abuse & Neglect, 43, 104–111.

Letourneau, E. J., Eaton, W. W., Bass, J., Berlin, F. S., & Moore, S. G. (2014). The need for a comprehensive public health approach to preventing child sexual abuse. Public Health Reports, 129, 222–228. doi:10.1177/003335491412900303

Lynas, J., & Hawkins, R. (2017). Fidelity in school-based child sexual abuse prevention programs: A systematic review. Child Abuse & Neglect, 72, 10–21. doi:10.1016/j.chiabu.2017.07.003

Miles, M. B., & Huberman, A. M. (1984). Qualitative data analysis: A sourcebook of new methods. Thousand Oaks, CA: SAGE.

Morris, M. C., Kouros, C. D., Janecek, K., Freeman, R., Mielock, A., & Garber, J. (2017). Community-level moderators of a school-based childhood sexual assault prevention program. Child Abuse & Neglect, 63, 295–306. doi:10.1016/j.chiabu.2016.10.005

National Sexual Violence Resource Center. (2011). Child sexual abuse prevention: Programs for children. Retrieved March 9, 2015 from

Patton, M. Q. (2002). Qualitative research and evaluation methods (3rd ed.). London, UK: SAGE.

Pereda, N., Guilera, G., Forns, M., & Gòmez-Benito, J. (2009). The prevalence of child sexual abuse in community and student samples: A meta-analysis. Clinical Psychology Review, 29, 328–38.

Rudolph, J., & Zimmer-Gembeck, M. J. (2018). Reviewing the focus: A summary and critique of child-focused sexual abuse prevention. Trauma, Violence, & Abuse, 19, 543–554. doi:10.1177/1524838016675478

Sabella, D. (2016). Mental health matters: Revisiting child sexual abuse and survivor issues. American Journal of Nursing, 116(3), 48–55. doi:10.1097/01.NAJ.0000481280.22557.45

Sikes, A. (2008). A school counselor’s guide to reporting child abuse and neglect. Journal of School Counseling, 6(25).

Topping, K. J., & Barron, I. G. (2009). School-based child sexual abuse prevention programs: A review of effectiveness. Review of Educational Research, 79, 431–463. doi:10.3102/0034654308325582

Tufford, L., & Newman, P. (2010). Bracketing in qualitative research. Qualitative Social Work, 11, 80–96. doi:10.1177/1473325010368316

Tutty, L. M. (2000). What children learn from sexual abuse prevention programs: Difficult concepts and developmental issues. Research on Social Work Practice, 10, 275–300. doi:10.1177/104973150001000301

United States Department of Health and Human Services. (2018). Child maltreatment 2017. Retrieved from

Walsh, K., Zwi, K., Woolfenden, S., & Shlonsky, A. (2015). School-based education programmes for the prevention of child sexual abuse (review). The Cochrane Library, 4, 1–121.

Wurtele, S. K. (2009). Preventing sexual abuse of children in the twenty-first century: Preparing for challenges and opportunities. Journal of Child Sexual Abuse, 18, 1–18. doi:10.1080/10538710802584650

Yin, R. K. (2003). Case study research: Design and methods (3rd ed.). Thousand Oaks, CA: SAGE.

Yin, R. K. (2014). Case study research: Design and methods (5th ed.). Thousand Oaks, CA: SAGE.


Rebecca Cowan, NCC,  is a professor at Walden University. Rebekah F. Cole, NCC, is an assistant professor and Director of the School Counseling Program at Arkansas State University. Laurie Craigen, NCC, is an associate professor at Boston University School of Medicine. Correspondence can be addressed to Rebecca Cowan, School of Counseling and Human Services, Walden University, 100 Washington Avenue South, Suite 900, Minneapolis, MN 55401,