Suicide, Suicide Assessment Self-Efficacy, and Workplace Anxiety: Implications for Training, Practice, and Research

Alexander T. Becnel, Lillian Range, Theodore P. Remley, Jr.

 

In a national sample of current school counselors with membership in the American School Counselor Association (N = 226), we examined the prevalence of suicide training among school counselors as well as differences in suicide assessment self-efficacy and workplace anxiety between school counselors who were exposed to student suicide and those who were not. The results indicate that 38% of school counselors were not prepared for suicide prevention during graduate training. Although school counselors’ exposure to suicide was not related to their workplace anxiety, those who were exposed to a student suicide attempt had higher suicide assessment self-efficacy scores than those who were not. This study demonstrates the impact of suicide exposure on school counselors and the need for additional suicide assessment training.

Keywords: school counselors, suicide, suicide assessment, self-efficacy, workplace anxiety

 

     Suicide continues to be a growing concern for young people in the United States. Suicide is the second leading cause of death among children between the ages of 11 and 18, claiming the lives of 2,127 middle school– and high school–aged children in 2019 alone (Centers for Disease Control and Prevention [CDC], 2021). In 2019, a nationwide survey found that 18.8% of high school students reported seriously considering attempting suicide, 15.7% reported making a plan to attempt suicide, and 8.9% reported attempting suicide (Ivey-Stephenson et al., 2019). As youth suicide rates continue to rise (National Institute of Mental Health [NIMH], 2019), it is becoming increasingly important to understand how school counselors are prepared to work with suicidal youth, as well as the impact of suicidality on them.

     Children and adolescents spend significant amounts of time at school, making school counselors the primary suicide and risk assessors for this population (American School Counselor Association [ASCA], 2020b). School counselors are more likely to assess youth for suicide risk than any other mental health professional (Schmidt, 2016). In 2002, a national study of ASCA members found that 30% of professional school counselors experienced a suicide-related crisis event while they were graduate student interns (Allen et al., 2002). In a more recent study, about two thirds of school counselors reported that they were conducting multiple suicide assessments each month (Gallo, 2018). Stickl Haugen et al. (2021) found that 79.8% of school counselors worked with a student who had previously attempted suicide and 36.7% experienced a student’s death by suicide. As school counselors become more frequently exposed to student suicide, it is important to understand their preparation for this role and the impact of these events on the school counselors themselves.

School Counselor Suicide and Crisis Training
     Although school counselors are often exposed to student suicide, many school counselors lack appropriate crisis intervention and suicide assessment training (Allen et al., 2002; Springer et al., 2020; Wachter Morris & Barrio Minton, 2012) and lack confidence in their ability to assess students for suicide risk (Gallo, 2018; Schmidt, 2016). About 20 years ago, one third of school counselors entered the field without any formal crisis intervention coursework and nearly 60% did not feel adequately prepared to handle a school crisis event (Allen et al., 2002). Ten years later, school counselors did not fare any better, with less than a quarter of school counselors reporting that they completed a course in crisis intervention and nearly two thirds reporting that a crisis intervention course was not even offered during their master’s program (Wachter Morris & Barrio Minton, 2012). Not surprisingly, therefore, school counselors feel unprepared. In a national survey, 44% of school counselors reported being unprepared for a student suicide attempt, and 57% reported being unprepared for a student’s death by suicide (Solomonson & Killam, 2013). In another national survey, Gallo (2018) found that only 50% of school counselors thought that their training adequately prepared them to assess suicidal students, and only 59% felt prepared to recognize a student who was at risk. These results are especially troubling considering that the Council for Accreditation of Counseling and Related Educational Programs (CACREP) requires school counselor education programs to provide both suicide prevention and suicide assessment training (CACREP, 2015).

Exposure to Suicide and Self-Efficacy
     Mental health professionals often question their professional judgment following an exposure to suicide (Sherba et al., 2019; Thomyangkoon & Leenars, 2008). Consequently, it is imperative to explore school counselor self-efficacy in the aftermath of a student suicide. Self-efficacy is the degree to which individuals believe that that they can achieve self-determined goals, and individuals are more likely to be successful in achieving those goals simply by belief in their success (Bandura, 1986). Counselor self-efficacy is defined as counselors’ judgment of their ability to provide counseling to their clients (Larson et al., 1992). As counselors spend more years in practice, their self-efficacy increases (Goreczny et al., 2015; Kozina et al., 2010; Lent et al., 2003). Further, counselor education faculty have significantly higher levels of suicide assessment self-efficacy than their students (Douglas & Wachter Morris, 2015). The relationship between counselor self-efficacy and work experience is well documented, so it is imperative to control for years of counseling experience as a potential covariate when studying other factors that can affect counselor self-efficacy.

     Although the literature regarding school counselors’ exposure to suicide is sparse, more studies have focused on the experiences of related professions, such as clinical counselors, social workers, psychiatrists, and psychologists. In a national survey, 23% of clinical counselors experienced a client’s death by suicide at some point in their career (McAdams & Foster, 2002). In the aftermath of their clients’ deaths by suicide, those counselors reported a loss of self-esteem and an increase of intrusive thoughts. They increased referrals for hospitalization for clients at risk, gave increased attention to signs for suicide, and increased their awareness of legal liabilities in their practices. In a study of community-based mental health professionals who experienced a client death by suicide, one third considered changing careers and about 15% considered early retirement in the aftermath of the suicide (Sherba et al., 2019). Psychologists who felt responsible for the death were more likely to experience a sense of professional incompetence (Finlayson & Graetz Simmonds, 2018). Among psychiatrists, those who experienced a patient’s suicidal death were more likely in the future to suggest hospitalization for patients who showed risk signs for suicide (Greenberg & Shefler, 2014). Additionally, 20% of the psychiatrists in Thomyangkoon and Leenars’s (2008) study considered changing professions after experiencing a patient death by suicide. Given the similarities in these professions, it is reasonable to suggest that school counselors may feel more anxious about their jobs following a suicide exposure.

     To date, there are only three published studies that explore suicide exposures among school counselors (Christianson & Everall, 2008; Gallo et al., 2021; Stickl Haugen et al., 2021). In a qualitative study, high school counselors felt a lack of personal support from their fellow staff members and noted the importance of self-care in the aftermath of a student death by suicide. Additionally, those who lost students to suicide thought that a lack of practice standards made it difficult to navigate these difficult situations (Christianson & Everall, 2008). In another qualitative study, elementary school counselors who worked with suicidal students recognized their important work in preventing suicide but also reported a lack of suicide prevention training opportunities tailored toward working with young children (Gallo et al., 2021). In a quantitative study, most school counselors thought that a student’s death by suicide left both personal and professional impacts on their lives. These school counselors most often reported low mood, a sense of guilt or responsibility, and preoccupation with the incident as personal impacts. They also identified heightened awareness of suicide risk, more professional caution around suicide, and seeking additional training as professional impacts. The researchers suggested that future studies should determine if the number of student deaths by suicide influences the impact of the suicide exposure (Stickl Haugen et al., 2021). However, this study did not examine anxiety, an important personal impact, nor did it examine self-efficacy in dealing with suicide attempts, a more likely occurrence than suicide deaths.

Research Questions
     The following research questions guided this study:

  • What is the prevalence of graduate and postgraduate training in suicide prevention, crisis intervention, and suicide postvention among current school counselors?
  • Are there differences in suicide assessment self-efficacy between school counselors exposed and not exposed to student deaths by suicide and suicide attempts, controlling for years of school counseling experience as a covariate?
  • Does the number of suicide exposures relate to school counselors’ level of suicide assessment self-efficacy when controlling for years of school counseling experience as a covariate?
  • Are there differences in workplace anxiety between school counselors exposed and not exposed to student deaths by suicide and suicide attempts, controlling for years of school counseling experience as a covariate?

Method

Procedure
     We obtained approval from our university’s Human Subjects Protection Review Committee prior to conducting this study. Using a random number generator, we randomly selected 5,000 members from the ASCA member directory to receive a link to the survey. When potential participants clicked the link, they viewed and agreed to an informed consent statement before they were permitted to view the survey. This statement also informed participants that they could stop participation or withdraw their participation at any time. Upon agreement to the informed consent statement, participants were directed to the survey. This online survey was administered via Qualtrics, which allowed them to respond anonymously.

Participants
     From the 5,000 potential participants, 422 began the survey. From these participants, 101 opened the survey and did not answer any questions, 5 did not agree to the informed consent statement, 29 reported that they were not current school counselors, and 60 did not complete the survey. Thus, 226 of the 5,000 ASCA members completed the survey (4.52%). An a priori power analysis (Cohen, 1992) with a power of .8, a medium effect size, and α = .05 determined that the required sample size for our most robust test was 175.

     Participants were 226 current school counselors (201 women, 88.9%; 25 men, 11.1%). The racial categories included 192 White (85%), nine Black or African American (4%), eight “other” races (3.5%), six Asian (2.7%), five biracial or multiracial (2.2%), three American Indian or Alaska Native (1.3%), and three not reporting race (1.3%). The ethnicity categories included 210 participants (92.9%) who were not of Hispanic or Latino or Spanish origin and 16 (7.1%) who were of Hispanic or Latino or Spanish origin. The mean age was 39 years (SD = 10.68), and the mean years of experience working as a school counselor was 7 (SD = 6.98). With regard to school setting, 52 school counselors worked in an elementary or primary school (23%), 58 worked in a middle or junior high school (25.7%), 81 worked in a high school (35.8%), 19 worked in a K–12 school (8.4%), and 16 worked in another type of school not listed (7.1%). Although ASCA does not provide demographic information about their members, this sample is similar in its demographic makeup to the sample in Gilbride et al.’s (2016) study, which sought to describe the demographic identity of ASCA’s membership.

Instrumentation
     The survey packet consisted of three instruments: the demographic questionnaire, the Counselor Suicide Assessment Efficacy Survey (CSAES; Douglas & Wachter Morris, 2015), and the Workplace Anxiety Scale (WAS; McCarthy et al., 2016).

Demographic Questionnaire
     Using a demographic questionnaire, we asked participants to identify the following information: sex, race, ethnicity, age, years of school counseling experience, and school type (e.g., high school, middle school). Additionally, we asked participants to identify the types of suicide exposures that they have encountered in their school counseling careers. If they reported exposure to either deaths by suicide or suicide attempts, the survey followed up with additional questions about the number of exposures, the amount of time since the first suicide exposure, and the amount of time since the most recent suicide exposure. We asked participants if their schools had crisis plans or crisis teams. We also asked participants if they had training in suicide prevention, crisis intervention, and suicide postvention during graduate school and the number of postgraduate training hours in each of these areas.

CSAES
     The CSAES evaluates counselors’ confidence in their ability to assess clients for suicide risk and intervene with a client at risk of suicide. It includes 25 items in four subscales: General Suicide Assessment, Assessment of Personal Characteristics, Assessment of Suicide History, and Suicide Intervention. Each item is rated on a 5-point Likert scale from 1 (not confident) to 5 (highly confident). High scores indicate high self-efficacy. Among school counselors in the original study, each subscale had good internal consistency (α = .88–.81) and acceptable goodness of fit. As suggested by Douglas and Wachter Morris (2015), we scored each subscale separately and averaged each score. This process created four comparable subscale scores.

WAS
     The WAS measures participants’ job-related anxiety. This scale asks participants to rate eight items such as “I worry that my work performance will be lower than that of others at work” on a 5-point scale from 1 (strongly disagree) to 5 (strongly agree). High scores on the WAS indicate higher levels of job-related anxiety. The WAS demonstrated good internal consistency (α = .94) and acceptable goodness of fit (McCarthy et al., 2016).

Data Analysis
     To address our first research question, we used descriptive statistics to examine the prevalence of training among the participants. We used analysis of covariance (ANCOVA) to detect differences in both suicide assessment self-efficacy (CSAES scores) and workplace anxiety (WAS scores) while controlling for years of school counseling experience between school counselors who were exposed to student suicide and those who were not. We considered exposure to deaths by suicide and exposure to suicide attempts as different types of exposure. Therefore, we performed a total of four ANCOVAs: (a) differences in CSAES scores between school counselors exposed to deaths by suicide and those not exposed, (b) differences in CSAES scores between school counselors exposed to suicide attempts and those not exposed, (c) differences in WAS scores between school counselors exposed to deaths by suicide and those not exposed, and (d) differences in WAS scores between school counselors exposed to suicide attempts and those not exposed. We also used analysis of variance (ANOVA) to determine the difference in years of school counseling experience between those exposed to suicide and those not exposed. To determine the relationship between the number of suicide exposures and counselor suicide assessment self-efficacy, we also completed two partial correlations between the number of exposures to student death by suicide and CSAES scores, and the number of exposures to student suicide attempts and CSAES scores.

Results

     A total of 64 school counselors reported that they experienced a student death by suicide during their school counseling experience (28.3%), with a mean of 2.11 deaths (SD = 2.21). On average, their first suicide death was 6.72 years ago (SD = 5.87), and the most recent suicide death was 3.84 years ago (SD = 3.88). A total of 124 participants experienced a student suicide attempt during their school counseling experience (54.9%), with a mean of 5.36 attempts (SD = 10.54). On average, the first suicide attempt was 5.91 years ago (SD = 6.07), and the most recent attempt was 1.82 years ago (SD = 2.10). Of all 226 school counselors, 195 worked in schools that have crisis plans (86.3%), and 170 worked in schools that have crisis teams (75.2%).

Suicide Training
     Regarding suicide prevention training during their graduate program, 140 (62%) received some training, but 86 (38%) received no training. Regarding crisis intervention training during their graduate program, 142 (63%) received some, but 84 (37%) received none. Regarding suicide postvention, only 87 (38.5%) received some, but 139 (61.5%) received none. The number of postgraduate training hours varied widely for each preparation type. For suicide prevention, training hours averaged 12.20 (SD = 28.61); for crisis intervention, training hours averaged 9.04 (SD = 15.51); and for suicide postvention, training hours averaged 6.45 (SD = 18.14). We removed one participant’s postgraduate training data that was more than 3 standard deviations higher than the mean. In order to better illustrate the distribution of postgraduate training hours, we grouped the number of training hours into four categories: 0 hours, 1–10 hours, 11–50 hours, and more than 50 hours of postgraduate training. Nearly a quarter of the participants (24.3%) received no postgraduate training in suicide prevention, about a third of the participants (30.5%) received no postgraduate training in crisis intervention, and half (50.4%) received no postgraduate training in suicide postvention.

     To further demonstrate the disparity of suicide training, cross-tabulation was performed between graduate training and the number of postgraduate training hours. We reported this data in Table 1. Most surprisingly, 25 school counselors (11.1%) received no graduate training in suicide prevention, nor any postgraduate hours of training in suicide prevention; another 45 (19.9%) received no graduate training and only 10 or fewer hours of postgraduate training in suicide prevention, making nearly 1 in 3 school counselors unprepared to provide suicide prevention services. Crisis intervention fared similarly with 26 school counselors (11.5%) reporting no graduate training and no postgraduate training hours and 41 school counselors (18.1%) reporting no graduate training and 10 or fewer postgraduate training hours. Again, nearly 1 in 3 school counselors were not adequately prepared to provide this important service. Crisis postvention fared the worst, with 80 school counselors (35.4%) reporting that they received no graduate training and no postgraduate training hours, and 46 school counselors (20.4%) reporting no graduate training and fewer than 10 hours of postgraduate training. More than half of the school counselors surveyed are unprepared to face the aftermath of a suicide.

 

Table 1 

Graduate Training and Postgraduate Training Hours

Number of postgraduate training hours Received graduate training Did not receive graduate training
Frequency Percentage Frequency Percentage
Suicide Prevention
   0 hours      30   13.3   25     11.1
   1–10 hours      73   32.3   45     19.9
   11–50 hours      29   12.8   15       6.6
   50 or more hours        8     3.6     1       0.4
Total    140   62.0   86     38.0
Crisis Intervention
   0 hours      43   19.0   26     11.5
   1–10 hours      69   30.5   41     18.1
   11–50 hours      26   11.5   16       7.0
   50 or more hours        4     1.8     1       0.4
Total    142   63.0   84     37.0
Suicide Postvention
   0 hours      34   15.0   80     35.4
   1–10 hours      37   16.4   46     20.4
   11–50 hours      12     5.3   11       4.8
   50 or more hours        4     1.8     2       0.9
Total      87   38.5 139     61.5

 

Suicide Exposure and Suicide Assessment Self-Efficacy
     An ANOVA indicated that school counselors exposed to a student death by suicide had significantly more years of school counseling experience (M = 11.9, SD = 7.87) than school counselors not exposed to a student death by suicide (M = 5.1, SD = 5.56): F(1, 224) = 21.512, p < .001. Controlling for years of school counseling experience as a covariate, an ANCOVA indicated that there was no significant difference between these two groups in General Suicide Assessment, F(1, 223) = .316, p = .574; Assessment of Personal Characteristics, F(1, 223) = .156, p = .694; Suicide Intervention, F(1, 223) = .028, p = .867; or Assessment of Suicide History, F(1, 223) = 1.095, p = .133.

     Similarly, results of an ANOVA indicated that school counselors exposed to student suicide attempts had significantly more years of school counseling experience (M = 8.8, SD = 7.31) than counselors not exposed (M = 4.9, SD = 5.94): F(1, 224) = 8.055, p = .005. Controlling for years of school counseling experience, an ANCOVA indicated significant differences between the two groups in General Suicide Assessment, F(1, 223) = 6.014, p = .015; Assessment of Personal Characteristics, F(1, 223) = 7.140, p = .008; and Suicide Intervention, F(1, 223) = 6.671, p = .010; but not Assessment of Suicide History, F(1, 223) = .763, p = .383. Overall, effect sizes were small.

Number of Exposures and Self-Efficacy
     A partial correlation between the number of suicide exposures and CSAES scores while controlling for years of school counseling experience was not statistically significant. There was no significant relationship between the number of death by suicide exposures and General Suicide Assessment, r(61) = .137, p = .285; Assessment of Suicide History, r(61) = .207, p = .104; Assessment of Personal Characteristics, r(61) = .170, p = .184; or Suicide Intervention, r(61) = .077, p = .551. Likewise, there was also no significant relationships between the number of suicide attempt exposures and General Suicide Assessment, r(121) = −.028, p = .762; Assessment of Suicide History, r(121) = .087, p = .336; Assessment of Personal Characteristics, r(121) = .131, p = .150; or Suicide Intervention, r(121) = .076, p = .401. We reported data regarding the frequency of suicide exposure in Table 2.

Suicide Exposure and Workplace Anxiety
     In WAS scores, an ANCOVA revealed that there were no significant differences between school counselors exposed and not exposed to a student death by suicide when controlling for years of school counseling experience: F(1, 223) = .412, p = .522. Likewise, an ANCOVA revealed that there was no significant difference in WAS scores between school counselors exposed and not exposed to student suicide attempts when controlling for years of school counseling experience: F(1, 223) = .238, p = .626. To further illustrate the relationship between years of school counseling experience and workplace anxiety, a correlation coefficient indicated that these measures were significantly related, r(224) = −.260, p < .001.

Discussion

     Among these school counselors, more than a quarter experienced a student’s death by suicide and over half experienced a student’s suicide attempt. These results are consistent with previous studies indicating that many school counselors will eventually be exposed to a student suicide during their careers (Allen et al., 2002; Gallo, 2018; Schmidt, 2016; Stickl Haugen et al., 2021). Given how common suicide experiences are, school counselors need to be trained to manage suicide-related crises.

Training
     A surprising result in our study was the overall lack of suicide and crisis training reported. As seen in Table 1, nearly 2 in 5 school counselors (38%) reported that they received no suicide prevention training during their graduate education. Additionally, a quarter of the school counselors in this study reported that they received no postgraduate training in suicide prevention, and half reported between 1 and 10 hours. Thus, a sizeable portion of these school counselors were not adequately trained to incorporate suicide prevention programs into their school counseling practice. This finding echoes Gallo (2018), who reported that only 60% of school counselors felt prepared to identify students at risk for suicide. These rates are poor considering that CACREP requires suicide assessment and suicide prevention training as a standard of all counselor education programs (CACREP, 2015). Further, ASCA states that school counselors are responsible for identifying students at risk for suicide and ensuring that suicide prevention programs are in place in schools (ASCA, 2020a). The lack of training reported in this study is particularly troubling given that all of the participants in this study were members of ASCA.

 

Table 2 

Frequency of Student Suicide Exposure

Variable Frequency Percentage
Number of student deaths by suicide (n = 64)
   1 37 57.8
   2 15 23.4
   3–5   8 12.5
   > 5   4   6.3
Years since first death by suicide (n = 64)
   Within 1 year 12 18.8
   1 and 5 years 25 39.0
   6 and 10 years 12 18.8
   More than 10 years 15 23.4
Years since most recent death by suicide (n = 64)
   Within 1 year 23 35.9
   Between 1 and 5 years 26 40.6
   Between 6 and 10 years 11 17.2
   More than 10 years   4   6.3
Number of student suicide attempts (n = 124)
   1 29 23.4
   2 29 23.4
   3–5 44 35.5
   > 5 22 17.7
Years since first student attempt (n = 124)
   Within 1 year 30 24.2
   Between 1 and 5 years 51 41.1
   Between 6 and 10 years 21 17.0
   More than 10 years 22 17.7
Years since most recent attempt (n = 124)
   Within 1 year 84 67.7
   Between 1 and 5 years 33 26.6
   Between 6 and 10 years   6   4.8
   More than 10 years   1   0.8

 

     Crisis intervention training among school counselors also was poor. Comparable to the finding on suicide prevention training, a third of these school counselors reported no graduate training in crisis intervention. Further, more than a third reported that they did not receive postgraduate training hours in crisis intervention, and nearly half received between 1 and 10 hours of postgraduate training. A significant portion of these school counselors were not adequately prepared to respond to crises in their schools. These findings are slightly worse than the findings from 20 years ago when one third of a sample of school counselors reported that they entered the field with no formal crisis intervention coursework (Allen et al., 2002). However, these findings are much better than Wachter Morris and Barrio Minton’s (2012) study in which only 20% of school counselors completed a course in crisis intervention during their master’s degree program. Although preparation has increased, crisis preparation for school counseling students must continue to improve given that school counselors regularly experience crises (Wachter, 2006) and school counseling students often experience crises while still in graduate school completing their practicum or internship (Wachter Morris & Barrio Minton, 2012). The number of school counselors who experienced a student suicide event in the current study also supports the notion that school counselors regularly experience crises.

     Most of these school counselors (61.5%) were not trained in their graduate programs for suicide postvention. Half of the surveyed school counselors reported that they received no postgraduate training hours in suicide postvention, with an additional 38% reported having received between 1 and 10 hours of postgraduate training. These results demonstrate that the vast majority of school counselors are not prepared to respond to a student’s suicidal death. This finding is distressing because school counselors play a vital role in the aftermath of a student suicide (Maples et al., 2005; Substance Abuse and Mental Health Services Administration [SAMHSA], 2016).

Suicide Assessment Self-Efficacy
     Among these counselors, exposure to suicide alone did not make a difference with their suicide assessment self-efficacy or workplace anxiety. Years of school counseling experience appears to have a much more important role in suicide assessment self-efficacy and reduced anxiety than experiencing a student’s death by suicide. This result supports previous studies that found that years of experience has a positive relationship with self-efficacy (Douglas & Wachter Morris, 2015; Kozina et al., 2010; Lent et al., 2003). It also parallels the previous finding that the impact of a client’s suicidal death on a mental health practitioner decreases as the practitioner gains years of experience (McAdams & Foster, 2002). This result is different from Stickl Haugen et al.’s (2021) finding that school counselors who were exposed to a student death had higher levels of suicide assessment self-efficacy than those not exposed. However, Stickl Haugen et al. did not control for years of school counseling experience.

     In contrast, exposure to suicide attempts did make a difference in suicide assessment self-efficacy. Even after controlling for years of experience, counselors with suicide attempt experience reported more efficacy in three of four subscales: General Suicide Assessment, Assessment of Personal Characteristics, and Suicide Intervention. One explanation for this outcome is that a student suicide attempt experience might motivate school counselors to learn about suicide and the risk factors associated. This explanation echoes Wagner et al.’s (2020) finding that counselors found additional training in the aftermath of a suicide very helpful. Many of the school counselors in the current study received no formal training, so it is possible that these experiences helped them fill in knowledge gaps, which in turn increased their self-efficacy. Training increases self-efficacy (Al-Darmaki, 2004; Mirick et al., 2016; Wachter Morris & Barrio Minton, 2012), so it is also possible that this experience worked as an in vivo training for these school counselors, increasing their self-efficacy.

Workplace Anxiety
     Although mental health clinicians often experience symptoms of anxiety in the wake of a student suicide (McAdams & Foster, 2002; Sherba et al., 2019), present results suggest that a student’s death or suicide attempt does not have an impact on school counselors’ workplace anxiety. One explanation for this finding is the relationship between self-efficacy and anxiety. Overall, these school counselors had high self-efficacy scores in each of the four subscales. Previous research indicated that as self-efficacy increases, anxiety decreases (Bodenhorn & Skaggs, 2005; Gorecnzy et al., 2015; Larson et al., 1992). The death by suicide experience might not have impacted the counselors’ anxiety in this study because of their overall high self-efficacy. Another explanation is that the school counselors in this study had on average several years of experience (M = 7.05). Workplace anxiety levels decrease as school counselors spend more time on the job.

Implications
     These results have several implications for school counselors and school counselor educators. First, school counselor educators and school counseling graduate programs should be aware of both the overall disparity of graduate-level suicide and crisis training as well as the benefits that training can provide to future school counselors. Regarding suicide prevention, crisis intervention, and suicide postvention, there are far too many untrained school counselors among the current body of school counselors. School counseling students are a vulnerable group when it comes to suicide assessment self-efficacy (Douglas & Wachter Morris, 2015), so it is imperative to support their professional development. School counseling graduate programs must increase their efforts to adequately train and prepare school counselors for suicide prevention, assessment, and intervention.

     Second, school counselors should prepare to face the probability of having to deal with student suicide attempts and student deaths by suicide. If school counselors do not receive this training during their graduate programs, then they must seek continuing education opportunities that address suicide prevention, crisis intervention, and suicide postvention. Suicide and crisis training increases counselor self-efficacy (Mirick et al., 2016; Wachter Morris & Barrio Minton, 2012), making appropriate preparation vital. Additionally, school counselors could consider clinical supervision as a supplemental layer of support. School counselors receive supervision at much lower rates than their clinical counterparts (Perera-Diltz & Mason, 2012) even though many school counselors desire more supervision (Cook et al., 2012). Given that school counseling–focused supervision can increase self-efficacy (Tang, 2019) and school counselors feel a lack of personal support in the aftermath of a suicide (Christianson & Everall, 2008), school counselors must seek clinical supervision.

     Finally, school counselor educators should consider training efforts that focus specifically on student suicide attempts. In the current study, school counselors exposed to a suicide attempt were more efficacious than school counselors not exposed to a student suicide attempt. Modeling these experiences through the use of specific role plays could help school counseling students feel more confident about their suicide assessment capabilities. Although CACREP does not require counselor education programs to provide suicide postvention training (CACREP, 2015), perhaps standards should adapt to include this important training area. Regardless, programs should also emphasize this training to best prepare school counselors.

Limitations and Suggestions for Future Research
     Some factors limited this study. Although we had a national sample, we surveyed only current members of ASCA. It is possible that school counselors who are not members of ASCA might have responded differently. The study also had a low response rate (4.64%). Those school counselors who responded may be uniquely interested in this area, so the results may not reflect all school counselors. This study also did not limit the types of school counselors who could participate. It is possible that school counselors who work with younger children, such as elementary and primary school counselors, have less familiarity with suicide assessment and intervention than those school counselors who work with older children. The inclusion of these counselors could have affected the results of this study. Finally, this study did not ask participants if they graduated from a CACREP-accredited program. Because suicide prevention and assessment training are required components of CACREP-accredited programs, it is possible that school counselors who graduated from these programs may have different levels of training and self-efficacy than those trained in unaccredited programs.

     For future studies, researchers should consider limiting their samples to specific levels of schooling such as elementary, middle, or high school. This change would help illustrate the nuanced differences among school counselors in different academic environments as well as increase focus on the school counselors who most often work with suicidal students. Future studies should also consider surveying a sample that includes all school counselors, not just ASCA members. Researchers should also differentiate between school counselors who graduated from CACREP-accredited programs and those who did not. Collecting this data would allow researchers to detect if there are any differences in suicide assessment training and self-efficacy between these two groups. Finally, future researchers should consider designing a study that seeks to identify the factors that most impact suicide assessment self-efficacy. Although this study showed that a suicide attempt experience could impact suicide assessment self-efficacy, other factors, such as self-confidence, could have a larger influence.

     Suicide continues to be understudied in school counseling. Even though this study demonstrates the high likelihood that a school counselor will experience a student suicide, school counselors continue to report a lack of preparation in suicide prevention, crisis intervention, and suicide postvention. Although school counselors who experienced a student suicide attempt appeared to gain self-efficacy from their experiences, additional training in counseling suicidal students might help school counselors feel prepared before they face such serious situations. If additional training can help school counselors save students from suicide, then efforts must be made to adequately prepare them.

 

Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.

 

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Alexander T. Becnel, PhD, NCC, LPC, is a doctoral candidate at the University of Holy Cross. Lillian Range, PhD, is a professor at the University of Holy Cross. Theodore P. Remley, Jr., JD, PhD, NCC, is a professor at the University of Holy Cross. Correspondence may be addressed to Alexander T. Becnel, 4123 Woodland Drive, New Orleans, LA 70131, abecnel2@uhcno.edu.

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?

Method

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.

Participants
     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).

Results

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.”

Discussion

     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.

Limitations
     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).

Conclusion
     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.

 

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Appendix A
Demographics

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

Participant 2

 

18–29

 

Female

 

White

 

Army

 

Officer

 

1

 

Participant 3

 

30–39

 

Female

 

White

 

Coast Guard

 

Enlisted

 

11

 

Participant 4

 

18–29

 

Female

 

White

 

Navy

 

Officer

 

3

 

Participant 5

 

30–39

 

Female

 

Asian

 

Air Force

 

Officer

 

2

 

Participant 6

 

40–49

 

Female

 

White

 

Army

 

Officer

 

20

 

Participant 7

 

40–49

 

Female

 

Asian

 

Air Force

 

Officer

 

20

 

Participant 8

 

40–49

 

Female

 

White

 

Air Force

 

Officer

 

18

 

Participant 9

 

30–39

 

Female

 

White

 

Navy

 

Enlisted

 

8

 

Participant 10

 

30–39

 

Female

 

White

 

Navy

 

Officer

 

2

 

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, rebekah.cole@usuhs.edu.

Bereavement Experience of Female Military Spousal Suicide Survivors: Utilizing Lazarus’ Cognitive Stress Theory

Lindsey Mitchell

The purpose of this study was to explore the relationship of five variables—primary appraisal, secondary appraisal, coping skills, social support and stigma—to bereavement among women whose military spouses had completed suicide. Four correlations to bereavement (primary appraisal, secondary appraisal, coping skills and stigma) were significant. Hierarchical multiple regression analysis assessed the overall relationship of bereavement (the criterion variable) to the five predictor variables, along with the unique contribution of each predictor variable. In the regression, five of six models (all except Model 4) showed significance. The dissertation on which this manuscript is based has the following practical implications: statistically significant correlations between bereavement and constructs of Lazarus’ Cognitive Model of Stress (LCMS), as well as the significance of Lazarus’ construct of primary appraisal within Model 6, indicate that LCMS holds promise for understanding symptoms of bereavement in women whose military spouses have completed suicide.

Keywords: suicide, bereavement, military, spouse, Lazarus

 

Reports indicate that suicides in the U.S. military surged to a record number of 349 in 2013. This figure far exceeds the 295 American combat deaths in Afghanistan in 2012 and compares with the 201 military suicides in 2011 (National Institute of Mental Health [NIMH], 2013). Some private experts predict that the trend will worsen this year (Miles, 2010).

From 2008–2010, the Army reported the highest number of suicides (n = 182) among active duty troops; whereas the Navy and Air Force reported 60 and 59 respectively (National Institute of Mental Health [NIMH], 2013). The Marine Corps had the largest percentage increase in suicides in a period of 2 years (Lamorie, 2011). U.S. veterans accounted for 20% of the more than 30,000 suicide deaths in the United States in 2009. Between 2003 and 2009, approximately 6,000 veterans committed suicide annually, an average of 18 suicides each day (Congressional Quarterly, 2010; Miles, 2010). During the 2009 fiscal year, 707 members of the veteran population committed suicide, and another 10,665 made unsuccessful suicide attempts (Miles, 2010). Certain experiences of military service members (e.g., exposure to violence, act of killing the enemy, risk of injury, exposure to trauma) increase suicidal tendencies (Zamorski, 2011).

For every person who completes suicide, an estimated 20 people experience trauma related to the death (NIMH, 2010). This suggests that from the 349 military suicides in 2013, approximately 7,000 people have experienced related trauma. Suicide survivors are family members and friends whose lives significantly change because of the suicide of a loved one (Andriessen, 2009; Jordan & McIntosh, 2011; McIntosh, 1993). Survivors of suicide may have higher risk for a variety of psychological complications, including elevated rates of complicated grief and even reactive suicide (Agerbo, 2005).

It is also important to note that suicide survivors might not differ significantly from other bereaved groups regarding general mental health, depression, post-traumatic stress disorder symptoms and anxiety (Sveen & Walby, 2008). Examining the impact of suicide on surviving military family members may provide important information on minimizing negative consequences, including possible survivor suicide.

Military deaths are often sudden, unexpected, traumatic and/or violent in nature, and the family is conditioned to anticipate these types of deaths. In contrast, death by suicide is not anticipated and might not be handled well among military families (Martin, Ghahramanlou-Holloway, Lou, & Tucciarone, 2009). Suicide within the military culture is a traumatic as well as a unique experience. Service members and their families struggle with the visible and invisible wounds of war and the aftermath that combat deaths leave for the survivors. When a service member’s trauma leads to suicide, the military community is less trained and conditioned to process the grief than when death occurs as a direct result of military service (Zhang & Jia, 2009).

Stress plays a role in the grief process within the military culture when it relates to suicide. The chief identifying feature of military culture is warfare, which in turn leads to the claiming of human lives (Siebrecht, 2011). Siebrecht argued that bereavement can only be overcome if people adopt a more rational attitude and grant death its natural place in life. Association with the military ensures that most families will have to experience some form of bereavement and many forms of loss during times of war (Audoin-Rouzeau & Becker, 2002). Military men and woman are less equipped than the general population when it comes to their culture’s acceptance of outward demonstration or sharing of the emotional experience of grief (Doka, 2005).

Stigma

Historically, the stigma of suicide has been present in society (Cvinar, 2005). The biggest obstacles that families with members who have completed suicide confront are acts of informal social disapproval. The surviving family may be suspected of being partly blameworthy in a suicide death and consequently may be subjected to informal isolation and shunning (Bleed, 2007). The stigma of suicide can be subtle. It can be manifested in overt actions taken against the survivors (i.e., placing blame on the family), as well as by omitted actions (i.e., not receiving life insurance), which are probably far more common. When people experience the untimely loss of a family member, there can be feelings of being offended, wounded or abandoned (Neimeyer & Jordan, 2002). The stigmatization experienced by survivors may complicate their bereavement process (Cvinar, 2005; Jordan, 2001; McIntosh, 1993). This complexity results in communication issues, social isolation, projection of guilt, blaming of others and scapegoating (Harwood, Hawton, Hope, & Jacoby, 2002; Lindemann & Greer, 1953). There is a lack of research in the professional literature addressing the grief of surviving military family members impacted by the death, including suicide, of a loved one (Lamorie, 2011).

 

Suicide and Bereavement

Jordan (2001) researched suicide bereavement and concluded that there are several underlying reasons that it differs from other types of mourning. Jordan summarized that “there is considerable evidence that suicide survivors are viewed more negatively by others and by themselves” (p. 93) and that suicide “is distinct in three significant ways: the thematic content of grief, the social processes surrounding the survivor, and the impact suicide has on family systems” (p. 91). In reviewing the social processes surrounding suicide, Jordan’s analysis supports those of Worden (1991) and Ness and Pfeffer (1990), saying that “there is considerable evidence that survivors feel more isolated and stigmatized than other mourners, and may be viewed more negatively by others in their social network” (p. 93). Most traumatic death survivors will face questions regarding their own culpability in their loved one’s decision to take his or her own life. Survivors may find themselves repeatedly pondering missed warning signs and risk factors (Parrish & Tunkle, 2005). Four primary factors that distinguish the complexities of suicide bereavement for families include stigma, questions about reasons, issues of remorse and guilt, and various logistical and legal factors unique to suicide that necessarily influence the events and processes following death (Minois,1999). The question of why often comes up given the pervasive sense that suicide is a preventable event. This line of thought can often define the grief process. Combined with factors of shock from the sudden, often violent nature of the death, these questions are virtually unavoidable. In some cases, answers to questions of why may never be forthcoming or satisfactory (Steel, Dunlavy, Stillman, & Pape, 2011). Among military families, bereavement is complex. A military death often has circumstances not normally found in the civilian world. It is most likely unexpected, potentially traumatic, occurring in another country, publicized by the media, and enveloped in the commitment to duty and country. Surviving family members of military personnel are often parents, siblings, grandparents and spouses. Military widows are young, often with young families, and are living at a duty station, far away from family and longtime friends (Katzenell, Ash, Tapia, Campino, & Glassberg, 2012).

 

Bereavement in the Military Culture

Bereavement is a part of the military culture but is often misinterpreted as a weakness that will elicit limited outside support. Military men and women in general are uninformed about the cultural acceptability of outwardly demonstrating their grief or sharing the emotional experience of the loss (Doka, 2005). Although traditional mental health treatments predominantly encourage emotional vulnerability, the military culture values emotional toughness (Kang, Natelson, Mahan, Lee, & Murphy, 2003) and stigmatizes mental illness (Doka, 2005). These attitudes can often deter service members from seeking assistance that could help them to overcome physical and mental health issues. Military culture affects the impact of suicide on families. Each spouse and family has a different bereavement process, and this process is influenced by stigma, social support and ability to cope. In the U.S. military, these issues can be a hindrance to seeking services and can lead to feelings of isolation, which in turn are a risk factor for suicide (Christensen & Yaffe, 2012).

 

Conceptual Framework

The conceptual framework of Lazarus’ Cognitive Model of Stress (LCMS) was used to frame this study. The underlying construct of this model states that times of uncertainty and difficulty may assist in understanding a person’s ability and capacity to cope with the suicide of a loved one. In general, when people encounter a difficult situation, they employ strategies for dealing with and lessening perceived stress (Groomes & Leahy, 2002).

LCMS (Lazarus & Folkman, 1984) has served as a useful lens for examining the interaction between a person and situational demands. Burton, Farley, and Rhea (2009) used LCMS to frame a study of the relationship between level of perceived stress and extent of physical symptoms of stress, or somatization, among spouses of deployed versus non-deployed servicemen. Eberhardt and associates (2006) examined Lazarus and Folkman’s 1984 stress theory regarding the ways that stress mediators and perceived social support may affect anxiety (as a stress response). The above studies show the usefulness of LCMS in depicting the impact of stress and coping on perceived anxiety, acceptance, ability to lead mentally and physically satisfactory lives, and perception of social support.

LCMS includes primary appraisal, secondary appraisal, coping and perceived social support. Stress is defined as a person’s relationship to his or her environment, specifically a relationship that the person perceives as exceeding his or her resources and endangering well-being. This model supports that the person and the environment are in a dynamic, reciprocal and multidimensional relationship. This conceptualization suggests that people’s perception of stress is related to the way they evaluate, appraise and cope with difficulties.

Stress can be measured by the way an individual appraises a specific encounter. Lazarus and Folkman (1984) presented two types of appraisal. The first is primary appraisal, defined as an individual’s expressed concern in terms of harm, loss, threat or challenge. Harm and loss appraisals refer to loss or damage that has already taken place; threat appraisal refers to harm or loss that has not yet occurred (i.e., anticipatory loss); and challenge appraisal refers to the opportunity for mastery or growth (Lazarus & Folkman, 1984). The second type is secondary appraisal, defined as the focus on what the individual can do to overcome or prevent harm. Lazarus and Folkman suggested that an appraisal of threat is associated with coping resources that can mediate the relationship between stressful events (e.g., loss of spouse to suicide) and outcomes (e.g., ability to seek mental health services).

Coping resources are the personal factors that people use to help them manage situations that are appraised as stressful (Lazarus & Folkman, 1984). Coping resources can be available to the person during the grief process or can be obtained as needed. This fact suggests that the grief process following a suicide is stressful and imposes demands on coping as the bereavement process evolves. Lazarus and Folkman (1984) defined coping as “constantly changing cognitive and behavioral efforts to manage specific external or internal demands that are appraised as exceeding the resources of the person” (p. 141). Coping is a dynamic process that is called into action whenever people are faced with a situation that requires them to engage in some special effort to manage that situation (Lazarus & Folkman, 1984). The ability to cope impacts a person’s bereavement process, and the ways and ability to cope vary with each individual. Stigma and the amount of perceived social support also influence the ability to cope (Bandura, 1997). These variables impact the bereavement process, especially with the added variable of death by suicide.

Social support can strengthen an individual’s position against the stressor and reduce the level of threat (Lazarus, 1996). Research suggests there are specific reasons why survivors do not seek out social support. McMenamy, Jordan, and Mitchell (2008) identified depression and a lack of energy as substantial barriers to obtaining social support.

People who experience a traumatic event are more likely to perceive barriers and not request medical and mental health services due to this lack of energy, lack of trust in professionals and depression (Amaya-Jackson et al., 1999). Provini, Everett, and Pfeffer (2000) stated that the stigma and social isolation that survivors experience can interfere with seeking social support and the willingness of social support networks to come to the aid of the survivor. A lack of social support can increase depression, a lack of energy to complete daily tasks and isolation. Limited social support is especially common for suicide survivors. Shame and guilt surrounding a suicide can impact survivors’ ability to seek social support; however, high social support can be linked to positive mental health.

 

Barriers to Bereavement

Many suicide survivors struggle with questions about the meaning of life and death, report feeling more isolated and stigmatized, and have greater feelings of abandonment and anger compared with other sudden death survivors (Callahan, 2000). Moreover, the feeling of relief from no longer having to worry about the deceased may distinguish survivors of suicide from survivors of other types of sudden death (Jordan, 2001). Experiencing suicide in one’s family increases risks for family members’ mental health and family relationships (Jordan, 2001). Despite the frequency of suicide, there is limited research focusing on the needs of surviving spouses (Miers, Abbott, & Springer, 2012).

The family system in which the spouses existed as a couple is destabilized by suicide, but the survivor must continue to function. Tasks that were carried out in the relationship must now be carried out by the survivor (Murray, Terry, Vance, Battistutta, & Connolly, 2000). Cerel, Jordan, and Duberstein (2008) stated that because suicide occurs within families, the focus on the aftermath of suicide within families and the impact on the spouse are important areas to investigate in order to determine exactly how to help survivors. Helping survivors to address practical, economic and legal issues, in addition to providing information and therapeutic intervention, is important (Dyregrov, 2002; Provini et al., 2000).

 

Purpose of the Study

 

Because of the frequency of suicide in the United States, the increased number of suicides within the U.S. military, and the impact of suicide on the family, the bereavement process among female spousal survivors of military suicides deserves further exploration. The purpose of this study was to explore bereavement in female spousal survivors of military suicides. Using LCMS, the study explored the relationship of bereavement and stigma, social support, primary appraisal, secondary appraisal, and coping skills among women whose military spouse had completed suicide.

 

Summary of the Study and Methodology

This study investigated the linear relationship between the dependent variable of bereavement and each of five independent variables—primary appraisal, secondary appraisal, coping skills, perceived social support and stigma—among women whose military spouses had completed suicide. The following hypotheses guided the study. Hypothesis 1 stated that there would be a relationship between bereavement and stigma; this positive relationship was significant. Hypothesis 2 stated that there would be a relationship between bereavement and social support; the relationship was not statistically significant. Hypothesis 3 stated that there would be a relationship between bereavement and primary appraisal; this positive relationship was significant. Hypothesis 4 stated that there would be a relationship between bereavement and secondary appraisal; this negative relationship was significant. Hypothesis 5 stated that there would be a relationship between bereavement and coping skills; this negative relationship was significant.

Using hierarchical regression analysis, the researcher examined the relationship of five independent variables—primary appraisal, secondary appraisal, coping skills, social support and stigma—to bereavement. The relationship was statistically significant. The model was a good fit and controlled for time since death (i.e., number of years since the person completed suicide). Therefore, for this sample, the five independent variables are components of a statistically significant model.

 

Participants and Recruitment

The participants in this study were women aged 18 and older who had lost a military spouse to suicide. Criteria for inclusion were that (a) the service member who had completed suicide had been either on active duty or of veteran status, (b) the survivor was female and 18 years of age or older, and (c) the survivor was considered a spouse. A spouse was defined as legally married to another person or living and cohabiting with another person in a marriage-like relationship, including a marriage-like relationship between persons of the same gender. Participants were chosen from seven national organizations serving veterans. The researcher recruited participants from these organizations by explaining the study and asking for volunteers. The director or assistant director of each organization distributed study information and materials through listservs and posted them on their Web sites. Once prospective participants received an e-mail, they decided whether they wanted to participate and whether they met the eligibility requirements. If the spouses decided to participate in the study, they would complete the survey through Survey Monkey.

 

Variables

Demographic variables included age, race/ethnicity, length of relationship with the deceased partner, the decedent’s military status (active or retired), the decedent’s length of service, and time elapsed since death. The survey also asked about the deceased’s rank, education level, surviving children and prior suicide attempts.

A self-report online survey was constructed using the following five instruments: the Core Bereavement Items (CBI; Holland, Futterman, Thompson, Moran, & Gallagher-Thompson, 2013), the Stigma of Suicide and Suicide Survivor Scale (STOSASS; Scocco, Castriotta, Toffol, & Preti, 2012), the Coping Self-Efficacy Scale (CSES; Chesney, Neilands, Chambers, Taylor, & Folkman, 2006), the Multidimensional Scale of Perceived Social Support (MSPSS; Zimet, 1988), and the Stress Appraisal Measure (SAM; Peacock & Wong, 1990). The SAM is one measure. However, the variables of primary stress appraisal and secondary stress appraisal within it were separated, and the questions within the SAM regarding primary stress appraisal were referred to as the primary stress appraisal measure (PSAM), and the remaining questions of the SAM were referred to as the secondary stress appraisal measure (SSAM). In addition to these assessments, participants would also answer 11 demographic questions and three open-ended questions. The survey was split into seven sections.

The first section had 11 demographic questions. The second section, comprised of the MSPSS, had 12 questions regarding social support of the participant and used a 7-point Likert scale. The third section, comprised of the CBI, had 26 questions regarding the participant’s ability to cope and used a 10-point Likert scale. The fourth section, comprised of the SAM, had 19 questions regarding participant’s stress appraisal measures and used a 4-point Likert scale. The fifth section, comprised of the STOSASS, had 17 questions regarding the participant’s perceived stigma and used a 4-point Likert scale. The sixth section, comprised of the CBI, had 17 questions regarding the participant’s bereavement process and used a 4-point Likert scale. The survey included the three following open-ended questions that were derived from the Grief Evaluation Measure (GEM) and reviewed by three licensed professional counselors working in the field of suicide bereavement: (1) What do you recall about how you responded to the death of your spouse at the time?; (2) What was the most painful part of the experience to you?; and (3) How has this experience affected your view of yourself or your view of your world? To analyze the qualitative responses, the researcher identified the most commonly recurring words or phrases used by participants for each question. Three experts in the field of grief and loss were consulted and confirmed the content and face validity of the survey.

 

Data Analysis

The Statistical Package for the Social Sciences (SPSS), a statistical software package, generated all of the statistics for this research investigation. A Pearson correlation analysis was conducted to determine whether there was a linear relationship between primary appraisal, secondary appraisal, social support, coping skills, stigma and bereavement for women whose military spouse had completed suicide. Following this analysis, a multiple regression was used to describe the relationships of the independent or predictor variables to the dependent or criterion variable (Lussier & Sonfield, 2004). Because LCMS states that it is possible to discern the order in which a person experiences each variable with regard to a particular event, the variables were entered into the regression using the following equation: Bereavement = {time since death} + {primary appraisal} + {secondary appraisal} + {coping skills} + {perceived social support} + {perceived stigma}.

 

Results

Descriptive Statistics

     Descriptive statistics provided simple summaries of the demographic characteristics of the sample, as well as descriptors such as means and standard deviations for these characteristics. The sample was a well-educated, racially diverse group of women who had lost their military spouses to suicide. The majority of participants were non-Hispanic White females who had attended at least some college. Most were affiliated with the Army and had been married to the military member who had completed suicide. The majority of the partners had committed suicide while on active duty. The mean age of respondents was 33.48 years (SD = 5.20; SE = .373); their ages ranged from 23–50 years. The mean number of children aged 17 or under that were a product of the relationship with the service member was 1.12 (SD = .79; SE = .064); the range was 0–4 children. The mean number of prior suicide attempts by the service member (known/confirmed by the surviving female spouse) was 1.31 (SD = 1.06; SE = .096); the range was 0–4 prior suicide attempts.

 

Correlation Results

Using SPSS Student Version 22.0 software, a Pearson correlation coefficient was used to measure the relationship of bereavement, primary appraisals, secondary appraisals, coping skills, social support, and stigma among women whose military spouses had completed suicide. The correlation coefficient measures the strength and direction of the relationship among variables. When conducting a correlational analysis of two co-occurring variables, the researcher can indicate whether change in one is accompanied by systematic change in the other. Examination of intercorrelations among study variables indicated statistically significant correlations between bereavement and each of four independent variables: primary appraisal, secondary appraisal, coping skill, and stigma. The results for each correlation are presented separately and summarized below as well as in Table 1.

 

     Control variable. There was a statistically significant relationship between time since death and bereavement for women whose military spouse had completed suicide, r(194) = .277, p < .01. The shorter the amount of time elapsed, the higher the bereavement scores.

 

     Independent variables. Primary stress appraisal, r(193) = -.309, p < .01: There is a weak negative linear relationship between bereavement and primary stress appraisal. Secondary stress appraisal, r(193) = -.309, p < .01: There is a weak negative linear relationship between secondary stress appraisal and bereavement. Coping skills, r(193) = -.174, p = .015: There is a weak negative linear relationship between coping skills and bereavement. Social support, r(193) = -.039, p = .594: There is no linear relationship between perceived social support and bereavement. Stigma, r(193) = .252, p < .01: There is a weak positive linear relationship between perceived stigma and bereavement.

 

Table 1

Correlations for Independent, Dependent and Control Variables

                        CBI          TSD      PSAM       SSAM      MSPSS      CSES

1. TSD             .277*

2. PSAM        -.309*      -.167

3. SSAM        -.309*      -.151       .602*

4. MSPSS      -.039          .032       .379*         .172*

5. CSES         -.174*      -.167*     .494*         .473*        .585*

6. STOSASS   .252*       .095     -.196*        -.221*        .022          -.253

Note: N = 194; CBI = Core Bereavement Items; TSD = Time Since Death (in months);

PSAM = Primary Stress Appraisal Measure; SSAM = Secondary Stress Appraisal Measure;

CSES = Coping Self-Efficacy Scale; MSPSS = Multidimensional Scale of Perceived Social Support; STOSASS = Stigma of Suicide and Suicide Survivor Scale.

*Significant at p < .05.

 

Multiple Regression

Following the correlational analysis, a multiple regression was utilized. This analysis was appropriate to describe the relationships between the independent or predictor and dependent or criterion variables in an objective manner (Lussier & Sonfield, 2004). The design was appropriate because the purpose of the study was to explain the relationships between variables.

Model 1 (TSD onto bereavement) yielded R = .277, R2 = .077, F(1, 125), p < .001. The portion of the variance explained was 7%. Model 2 (TSD and primary appraisal) yielded R = .431, R2 = .186, F(2, 124), p < .001. The portion of variance explained was 18.6%. Model 3 (TSD, primary appraisal and secondary appraisal) yielded R = .454, R2 = .206, F(3, 123), p < .001. The portion of variance explained was 20.6%. Model 4 (time since death, primary appraisal, secondary appraisal and coping skills) yielded R = .455, R2 = .207, F(4, 122), p < .001. The portion of variance explained was 20.7%. Model 5 (time since death, primary appraisal, secondary appraisal, coping skills and social support) yielded R = .471, R2 = .221, F(5, 121), p < .001. The portion of variance explained was 22.1%. Model 6 (time since death, primary appraisal, secondary appraisal, coping skills, social support, and stigma) yielded R = .482, R2 = .232, F(6, 120), p < .001. The portion of variance explained was 23.2% (see Table 2).

 

Table 2

Hierarchical Multiple Regression

Model           R           R2        t          p         B        β      R2 Change
 Model 1TSD

.277

.077

61.600

  3.228

.000

.002

.049

.277

0

Model 2TSDPSAM

.431

.186

 19.482

   2.696

  -4.074

.000

.008

.000

 .039

-.406

 .222

-.335

.109

Model 3TSDPSAMSSAM

.454

.206

19.646

  2.618

 -1.947

 -1.782

.000

.010

.054

.077

 .038

-.254

-.192

 .214

-.209

-.191

.02

Model 4TSDPSAMSSAMCSES

.455

.207

16.971

 2.622

 -1.952

 -1.788

    .266

.000

.010

.053

.076

.791

 .038

-.262

-.199

 .004

 .216

-.216

-.198

.025

.001

Model 5TSDPSAMSSAMCSESMSPSS

.471

.221

12.989

  2.307

 -2.359

 -1.111

 -0.710

  1.505

.000

.023

.020

.269

.479

.135

.034

-.335

-.132

-.012

 .091

 .192

-.276

-.132

-.083

 .167

.015

Model 6        TSDPSAMSSAMCSESMSPSSSTOSASS

.482

.232

 9.026

 2.329

-2.187

-1.105

-0.320

 1.107

 1.280

.000

.022

.031

.271

.750

.271

.203

.034

-.312

-.131

-.006

.069

.086

 .194

-.257

-.131

-.039

 .128

 .112

.010

Note: TSD = Time Since Death (in months); PSAM = Primary Stress Appraisal Measure; SSAM = Secondary Stress Appraisal Measure; CSES = Coping Self-Efficacy Scale; MSPSS = Multidimensional Scale of Perceived Social Support; STOSASS = Stigma of Suicide and Suicide Survivor Scale.

 

Qualitative Component

There is a growing interest in integrating qualitative data across quantitative studies to discover patterns and common threads within a specific topic or issue (Erwin, Brotherson, & Summers, 2011). The main aim of the qualitative questions within the survey is to gain insight into the participants’ world and capture their unique experiences (e.g., naturally occurring events and/or social or human problems) and their interpretations of these experiences (Jones, 1995; Sarantakos, 1993).

A total of 55 (28.4%) participants responded to the question, “What do you recall about how you responded to the death of your spouse at the time?” Of these, 24 stated recalling “sadness” as most frequent. Fifteen participants indicated disbelief, shock, feelings of helplessness or feelings of fear. Other participants’ responses included “trying not to think about what had happened,” crying, sobbing, physical symptoms, physical pain, collapsing, fainting, being unable to forget what happened, and being unable to recall or process the event. A total of 68 (35.1%) participants responded to the question, “What was the most painful part of the experience to you?” Of these, 50 reported physical and emotional numbness and only partial recollection of learning about the death (e.g., who told them, where they were when notified, immediate responses). These participants indicated that they could recall parts of the experience but struggled with identifying feelings or emotions directly following the event. Other responses included being hospitalized, contemplating suicide, refraining from eating, and feeling that their future had been lost. Although four reported contemplating suicide following the death of their spouse, no participants reported attempting suicide at any point. A total of 36 (18.6%) participants responded to the question, “How has this experience affected your view of yourself or your view of your world?” Of these, 15 participants indicated that they no longer feared death, while seven reported having a negative reaction to relationships. Eleven participants reported that they perceived stress as more threatening than before the suicide of their spouse and were unaware of the triggers that brought on stress during the bereavement process. Ten participants indicated that their view of love had changed since the loss of their spouse. Nine participants wrote about making an effort to enjoy life after the suicide of their spouse.

 

Discussion

This study investigated the relationships between bereavement and primary appraisal, secondary appraisal, coping skills, perceived social support and stigma among women whose military spouses had completed suicide. There are several study findings that deserve further exploration.

First, there was a statistically significant positive relationship between stigma and bereavement, suggesting that as female survivors perceive increased stigma regarding the suicide of their spouse, they present more symptoms of bereavement. Knieper (1999) suggested that bereavement following suicide is not the same as that following natural death. He reported that stigma and avoidance continue to be central issues for suicide survivors. Psychological projection of feelings of rejection and the actual social response to the survivor interact in a complicated manner. Worden (2009) also noted a difference between suicide bereavement and other forms of bereavement, suggesting that suicide is often associated with stigma and a sense of shame. Such shame can result in the complete isolation of the bereaved during the period immediately following the suicide event. Eaton and associates (2008) examined survivors’ barriers to seeking mental health treatment after the suicide of their partners and found that spouses were 70% less likely to seek treatment following a suicide, as compared to a natural death, and that stigma was a recurrent theme in the qualitative analysis. However, Eaton et al.’s study did not directly examine the impact of stigma on bereavement. It did show that stigma is an important variable that needs to be investigated further. The present study showed similar results to Eaton et al.’s (2008) research.

The qualitative comments recorded in the open-ended question section of the survey supported the study findings. For example, one participant responded, “I blamed myself for not doing more, not being there enough, or not being there when the death happened.” Another participant noted, “Suicide is one of the most difficult and painful ways to lose someone we love, because we are left with so many unanswerable questions.” One participant expressed the following:

[I felt] anger at family members for not assisting me with my husband and anger at physicians that treated my husband and were not able to see the warning signs or provide assistance in caring for them properly. I was then left with the scars after the death and had to explain to people what happened. I felt I got blamed and it was not my fault.

Several participants expressed “numbness and isolation.” Responding to stigma, people with mental health problems often internalize public attitudes and become embarrassed or ashamed. These feelings can lead them to conceal symptoms and fail to seek treatment (President’s New Freedom Commission on Mental Health, 2003). These survey responses assist in understanding the impact of stigma upon the military spouse survivors and imply that unanswered questions, as well as guilt, are important factors to explore in the grief process following a suicide.

Second, a statistically significant relationship between primary appraisal and bereavement was reported, suggesting that survivors who perceive the death of a spouse to be stressful are more likely to experience bereavement. This result is supported by the bereavement literature (Cvinar, 2005; Jordan, 2001; McIntosh, 1993). Lazarus (2005) argued that primary appraisal shows that it is not the situation, but the way a person interprets the situation, that affects the person’s experience. The way a person appraises a situation can impact the way the person reacts to it. Primary appraisal is an important step in processing the stress of bereavement, since grieving is such an individualized experience.

The qualitative comments recorded in the open-ended question portion of the survey supported the statistical relationship between primary appraisal and bereavement. For example, one participant indicated that her worldview had changed when she responded, “My world has become gray; I have made myself closed. I live in a rain cloud and now know that good people do bad things that change lives.” The participant had changed her worldview such that her world became a smaller, more restricted place. Another stated, “This death, this loss, makes small things seem insignificant. Material things are insignificant. Relationships with people are more important. I don’t have a fear of dying and in fact, feel like I will die at a young age.” This concept of primary appraisal is based on the idea that emotional processes are dependent on a person’s expectancies about the significance and outcome of a specific event. The same event within the same community (in this case, suicide within the military) can elicit responses of different quality, intensity and duration due to individuality in experiences and personality (Krohne, Pieper, Knoll, & Breimer, 2002). The different kinds of stress identified by the primary appraisal may be embedded in specific types of emotional reactions, thus illustrating the close conjunction of the fields of stress and emotion (Lazarus & Folkman, 1984).

Third, a statistically significant negative relationship was reported between secondary appraisal and bereavement, suggesting that survivors who make a negative appraisal of their ability to control the outcomes of their spouse’s death are more likely to experience bereavement. In the future, when examining outcomes of interventions that impact coping, beliefs about a person’s ability to perform specific behaviors related to coping would need to be highlighted. This concept is known as specific coping behaviors and is also pertinent to stress, coping theory and secondary appraisal (Chesney et al., 2006). Part of secondary appraisal is the judgment that an outcome is controllable through coping; another part addresses the question of whether or not the individual believes he or she can carry out the requisite coping strategy (Chesney et al., 2006; DiClemente, 1986; Hofstetter, Sallis, & Hovell, 1990).

The qualitative comments recorded in the open-ended section of the survey supported this finding. For example, one participant indicated her appraisal of the situation by stating, “Everyone must learn to face the misfortune, because life on the road will not be smooth.” Another stated that “time can dilute all and I must face life and accept my reality;” yet another wrote, “I want to work on longer range goals to give myself some structure and direction to my life and not focus on my loss. I am only interested in rebuilding my life.” However, other participants stated that it was harder to assess the loss and to move forward after the suicide. One participant stated the following:

I often find myself complaining to God about what seems senseless or unjust and unfair. I find myself bogged down in fear and even anger at myself or the person who died and “left” me. I do not accept what happen[ed] to me and my children.

Some participants reported not knowing what to do. An example of this feeling is the statement, “I perceive stress as threatening. I feel totally helpless.” Perceived self-efficacy, defined as a belief about one’s ability to perform a specific behavior, is a salient component of this theory. It highlights the importance of personal efficacy in determining the acquisition of knowledge on which skills are founded (Bandura, 1997; Chesney et al., 2006).

Fourth, a statistically significant negative relationship between coping skills and bereavement was reported, suggesting that survivors who believe they have a low ability to cope with their spouses’ death are more likely to experience bereavement. Although it is important for survivors to become familiar with the stress appraisal process, the way they assign meaning to their spouse’s death and their past experience with death also are important in their primary appraisal to the overall coping effort. One model of this process is the transactional model of coping (Lazarus & Folkman, 1984). This model of coping implies that a person’s appraisal of his or her interaction with a difficult event naturally evokes a coping response for dealing with the situation. Experiencing a suicide or living in a social environment that hinders, stigmatizes or isolates a person who has experienced a suicidal death may cause demands to exceed his or her resources for dealing with certain situations. Few studies have examined the natural coping efforts used by suicide survivors, or have identified specific problems and needs that survivors experience following the suicide of a significant other (McMenamy et al., 2008). Interventions with suicide survivors have limited effectiveness (Jordan & McMenamy, 2004). Provini et al. (2000) presented four categories of concerns for suicide survivors: concerns related to (a) family relationships, (b) psychiatric symptoms, (c) bereavement and (d) stress. Family-related problems were the most frequently mentioned type of concerns (Provini et al., 2000). Examples of family relationship concerns included inability to maintain parenting roles, inability to maintain family routines, existence of different coping styles within the family, and inability to provide appropriate emotional support to family members.

Qualitative comments recorded in the open-ended section of the survey supported this study finding. For example, one participant stated, “I often feel distracted, forgetful, irritable, disoriented, or confused. I try to remember how I got over a death in the past, sometimes it helps and sometimes it does not.” Another participant stated, “I know I need to start to form new relationships or attachments in my life but my mind [is] telling me ‘there must be some mistake,’ or ‘this can’t be true.’ ” Regarding bereavement, one participant wrote, “Grief is perhaps the most painful companion to death.” Addressing coping, one participant stated, “I must also adjust to working or returning to work after the death. I know things can’t go back to the way they were before, very difficult and painful to deal with and I better adjust to life.” These statements support the need to further explore the relationship between one’s ability to cope with the suicide of a spouse and one’s ability to experience and acknowledge feelings and move forward with everyday life activities (e.g., employment, childcare, financial obligations). Ability to cope impacts a person’s bereavement process; the ways and ability to cope vary with the individual. Stigma and amount of perceived social support have been correlated with ability to cope (Bandura, 1997). It is important to understand the individual impacts that stigma, social support, primary appraisal, secondary appraisal and coping have on bereavement. However, it is equally important to examine the relationships of these variables within the context of a model in order to establish future interventions for bereavement within the context of a suicide.

Fifth, results indicated that the model is statistically significant in predicting bereavement outcomes and provides considerable support for using the Lazarus model as a means of understanding the relationship between stress and bereavement when placed into the equation in a particular order: CBI = TSD + PSAM + SSAM + CSES + MSPSS + STOSASS.

This study suggests that the proposed model, using LCMS and assessment of stress, identifies the constructs associated with bereavement among women whose military spouses completed suicide. Future research could further explore the assessment of primary and secondary appraisal processes, coping, stigma, and social support enhancement programs and interventions to improve the bereavement process for military spouses. When survivors can identify and address their needs, the bereavement process following a suicide can begin (Christensen & Yaffe, 2012).

 

Limitations

First, the majority of the sample (54.1%) were non-Hispanic White, or Euro-American. Second, there is limited representation across military branches. Third, the study collected data from a self-administered electronic survey. Fourth, although the social support measure (i.e., MSPSS) has good reliability and measures social support as a general feeling of belonging to a social network that one can turn to for advice and assistance in times of need (Uchino, 2006), it does not delineate various types of social support. Finally, most of the sample consisted of women whose spouses had completed suicide while on active duty. Active duty members typically live on base and are well connected to the military community. When the military spouse dies, these supports are often no longer available, and the stigma of a suicide could strongly affect these women.

 

Recommendations for Future Studies

There are several practice implications from this study. The statistically significant correlations between bereavement and four other variables (primary appraisal, secondary appraisal, coping skills and stigma), as well as the significance of the LCMS construct of primary appraisal within Model 6, indicate that LCMS holds promise for understanding symptoms of bereavement in females following the suicide of a military spouse. Primary appraisal, the most significant variable within this study, could be highlighted within bereavement research on women whose military spouses have completed suicide. When conceptualizing the responses of these women, counselors and clinicians could use LCMS, examining the three components of primary appraisal (goal relevance, goal congruence and ego involvement) and exploring the ways these components present during the client’s bereavement process. The approach would focus on the role of maladaptive cognitions during times of stress (Sudak, 2009).

The reluctance of the military community to seek mental health support contributes to an inability to move through the bereavement process in a healthy way. Within the military community, it can be quite difficult to deal with the ambiguity of bereavement that is typically associated with emotional vulnerability (Lamorie, 2011). However, the current study suggests that four constructs—primary appraisal, secondary appraisal, coping and stigma—are significant when addressing the issues of bereavement in females who have lost a military spouse to suicide. Using LCMS to address cognitions, counselors might be able to assist a population whose members have been reluctant to seek mental health services in the past. Because the components of LCMS are correlated with bereavement, clinicians could use LCMS and cognitive stress research, which together seem to be a promising direction, when assisting women who have lost a military spouse to suicide.

 

Conflict of Interest and Funding Disclosure

The author reported no conflict of interest

or funding contributions for the development

of this manuscript.

 

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Lindsey Mitchell, NCC, is the recipient of the 2015 Outstanding Dissertation Award for The Professional Counselor and a licensed counselor in both Texas and Washington, D.C. Correspondence may be addressed to Lindsey Mitchell at lmitch26@gwmail.gwu.edu