Putting Suicide Policy through the Wringer: Perspectives of Military Members Who Attempted to Kill Themselves.

In response to the Air Force Surgeon General, Lieutenant General Mark Ediger's call for medical services to be guided by service members' values, preferences, and experiences within the medical system, we conducted an interpretive phenomenological analysis of transcripts in which service members shared their experiences of military mental health policy and practices after being identified as suicidal. Themes of their experiences underscore nuances as it relates to intersectionality of policy when faced with unique military contextual factors and power differentials; both of which were missing in available research literature. Their experiences also illuminate further the innate "Catch 22" which happens when accessing help. Catch 22 basically means if you know you need help than you are rational; but if you actually seek help, then you are crazy and not trustworthy to do your job. Themes presented center on the lack of confidentiality of Service Members in the Workplace, effects of Unit Members' Surveillance and Command Directed Evaluations, and experiences of Military Mental Health Services. Critical discussions of policy and taken for granted assumptions that often drive narrow responses to suicide, treatment, prevention, and stigma are presented. Particular attention is given to the lived experiences of service members when placed under the demands of circumstances created by policy that may inadvertently lead in some cases to further suffering. The paper closes with recommendations from participants and the authors for policy makers and future directions in research.

Go ahead and throw money

You don’t hear me

You have all the answers, you see

But still you don’t hear me

You know it all booksmarts of society

Professionals are real good at talking, but not hearing me

As long as you can change my identity….

You label me with anxiety, depression, PTSD

This lifelong cycle by society is not capable of hearing me….

You’ll wonder why then you didn’t listen to me…[1].

1. Introduction

Suicide is viewed as caused by mental illness [2,3]. This understanding then creates a context for military policy and the way service members are treated to evolve from a hierarchical expert position of mental health researchers and mental health providers without input from the members seeking help [4,5,6,7,8]. The goal of our research was to take a different approach, agreeing with and responding to the Air Force Surgeon General’s call [9] that for continued transformation of military medical policy and services, it is vital and critical to ensure that the perspectives of those with experiences in our medical system are legitimized and considered in ongoing production of knowledge informing policy transformations. The perspectives of individuals formerly suicidal as applied to the creation of policy was spearheaded by several large civilian health organizations recently to good effect. Adopting the practice in 2016, the Air Force Surgeon General agreed and urged in a directive memorandum to medical leaders to create medical practices and polices responsive to the values, needs, and experiences of those we serve [9]. This perspective places participants in our military medical system in the role of key collaborators integral in the production of knowledge to inform policy transformation. This study included service members who experienced challenges created by the existing mental health policy and practices when they were identified as considering suicide. The exploration of their lived experiences is a critical means to broader based suicide prevention in military policy transformation efforts. Our work was completed to understand ways military mental health policy leaders can respond better to individuals and apply insider knowledges to the ongoing transformation of mental health policy and its practices, now lacking in their internal practices. To this end, secondary information—historical transcripts of individual interviews with service members who shared their experiences when identified as experiencing suicidality from prior research completed by Tirzah [7] were revisited for further analysis.

1.1. Evolution of Suicide Prevention Policy: Staking a Claim in Pathology

To illuminate why suicide has only been understood largely through a medical perspective in the United States, below is a brief summary of the historical evolution of suicide prevention policy efforts in the United States.

The first policy initiated for suicide prevention in the United States was created in 1999 by the leading medical authority, the United States Surgeon General. The United States Surgeon General’s call for action to end suicide helped cement the idea that suicide is a health condition requiring problem solving and action by mental health researchers and mental health providers. In response to the 1999 United States Surgeon General’s call for action, in 2001, mental health leaders in the U.S. Department of Health and Human Services, in collaboration with the Air Force Medical Service, and other health systems across the United States, published the first ever National Strategy for Suicide Prevention [4]. The report was updated in 2012 and continues the idea that suicide is a health problem that can be solved by improved surveillance of and identifying populations deemed at risk so that individuals who are perceived as mentally ill could be funneled to mental health services earlier. The 2012 national strategy will continue to guide the United States suicide prevention efforts for the next decade [6]. The Department of Defense 2015 Strategy for Suicide Prevention uses the framework outlined in the 2012 national strategy ([6], p. i.).

1.2. Implications of Suicide Staking a Claim in Pathology

The assumption that suicide is evidence of a mental health disorder, or is an inherent marker of pathology for individuals considering suicide has fueled mental health research and treatment geared toward identifying demographic information and characteristics of people who commit suicide [10,11,12,13]; predictors of suicidality, and detection of suicidality [14,15,16,17,18,19,20]. While understanding suicide from the medical perspective has no doubt saved lives, it has inadvertently created a circular loop in the continued national and military policy responses of suicide as being largely understood in the context of mental health pathology controlled and privileged by mental health professionals requiring continued mental health problem solving [4,5,6,8], overlooking other perspectives, in this case service members’ perspectives of military mental health policy and suicide prevention efforts. Military leaders recognizing the lack of voices of those who have lived experience and are most able to inform what would be helpful in our internal military policy transformations, asked us to collect their experiences as an initial step to resolve this [7].

As individuals who practice narrative therapy, we agree with White’s view [21] that by switching from an internalized focus of the problem to an externalized focus, people may start to find different ways of addressing the effects of the problem in community. In this case, viewing service members’ insider knowledges that speak to the broader, external demands placed on them within the military context that are embedded in their experiences to inform our policy efforts. This research is our attempt in using our privilege as researchers, to stand in solidarity with those effected by the system and practices we are a part of, the research viewed as a critical platform for descriptions of lived experiences as a legitimate source to the ongoing transformation of military mental health policy and practices by inviting them to be a part of the conversation.

2. Methods

Our work was completed to identify other ways military mental health policy leaders can respond to individuals and apply insider knowledges to the ongoing transformation of mental health policy and its practices, lacking in their internal practices. The core of our research centered on the investigation of secondary information from existing transcripts capturing the collaboration with seven military service members who offered accounts of their lived experience centered upon what was helpful in moving toward wanting to choose life after being identified as suicidal in the military system [7]. The participants included seven individuals, three women and four men ranging in active duty service from two years to over 20 years. The occupational services varied as well as the military branch in which they served. Age ranges for those who reported were between early twenties and late forties.

In this new endeavor, in an iterative process, using Interpretative Phenomenological Analysis (IPA) [22] the transcripts were revisited, pulling out descriptions of lived experiences specifically related to military practices from policy. The phenomenologists’ focus on a first-person perspective matches the research interests in legitimizing insider’s local knowledge in hopes to transform future policy. From a phenomenological perspective, service members’ worlds presented themselves in dialogue involving their stories, the transcripts—the mechanism in which this process was recorded—we revisited to further investigate the descriptions related to experiences with policy and practices. According to Smith et al., Interpretative Phenomenological Analysis (IPA) attempts to “capture particular experiences as experienced by particular people” ([22], p. 16). In other words, there is a focus on personal meaning-making within a particular context. Their experiences are legitimized, not because they must be experienced by a statistically significant majority, but because they are insiders to the experience of existing policy, what we want to hear about and learn from. IPA serves as the framework to approach service members’ unique experiences with military policy when identified as being suicidal. In a double hermeneutic interpretation, their experiences were understood as a response to the demands of the world entangled with the meanings that they attributed in which our understandings added to their meanings. In interpreting the stories, IPA enabled a strong commitment to understand the individual’s point of view, and we analyzed the transcripts by keeping closely to the language and perspectives provided.

While IPA is mindful to obtain robust descriptions of lived experiences, it also aims to move to an interpretation of the experiences. In other words, IPA not only seeks to describe, but also to understand meanings and interpret the accounts gathered. In interpreting the stories by connecting them with military policy and practices, IPA held a strong commitment to understanding differing points of view. This was important so as not to treat their stories as data to be funneled and regurgitated through our professional language or privileged only through our methodical mechanisms.

Meaning Interpretations: Analysis

IPA emphasizes that the research exercise is a dynamic process with an active role for the researcher in that process. Access to individuals’ meanings depends on the researchers’ own conceptions to make sense of through interpretative activity [22]. IPA served to respect individual’s stories, considering their experiences as life stories versus research data. IPA processes allowed for the analysis of the transcripts to remain centered on the meanings captured in their stories without dismissing the fact that it did so in relation to our interpretations from our subsequent meaning making and interpreting their words in relation to military policy.

In the current research analysis, drawing from IPA’s ideographic approach, an in-depth analysis of each of the participants’ stories within the context of military specific mental health policy and practices was completed. We followed the below steps, congruent with IPA processes outlined by Smith et al. [22]:

Each transcript was read individually twice with a focused interest of pulling out the descriptions and experiences related to the military workplace and services, with emergent themes created in the margins for each transcript

Placed together in an excel, one tab for each person, all the experiences related to policy were captured with emergent themes with beginning dialogue of what is common and not so common among the group

The development of moving from individual analysis to group analysis, placing themes and looking across the group, connecting experiences to policy mandates.

Organization of a paper trail, from initial review and comments of transcripts, emergent themes, and quotes, tracing from individual to group analysis

Development of full narratives, drawing heavily on participant descriptions

Tirzah completed the themes, with Bernadette’s guidance along the way borrowing from Morrow and Smith’s processes of rigor [23]. Tirzah included mechanisms such as the creation of audit trails for categories of meanings, and creation of themes for Bernadette to follow. We are also visible in our writing to allow, as much as possible, the perspectives of the service members, alerting the reader to form their own judgments. This work does not claim knowledge authority and we realize that other readers may, based on their lived experiences and perspectives, find new fantastic things to explore or to bring forth new knowledge from engaging in reading this work.

3. Collaborators’ Lived Experiences Categorized into Themes

Within the themes (Table 1) are descriptions of service members in bold that attracted our attention, thereby drawing your attention, being visible in our focus of creation of themes and subsequent analysis through this writing.

Table 1

Themes and Subordinate Themes.

Theme One: Lack of Confidentiality of Service Members in the Workplace

Subordinate Theme A: Ripples of I’m tired of being told I can’t do something when I’m more than capable of doing it.

Subordinate Theme B: Units Being Super Supportive and/or Not

Theme Two: Unit Members Surveillance and Command Directed Evaluations

Theme Three: Military Mental Health Services: Diagnosis and De-Contextualization of Experiences.

Subordinate Theme A: Loss of Ability to Articulate Humanity to the Authority of Pathology Language.

Subordinate Theme B: I am your textbook and theory, study me

Embedded in the themes we underscore the policy, congruent with the aim of the research endeavor, for policy makers to understand insider experiences of policy to transform future policy.

3.1. Theme One: Lack of Confidentiality of Service Members in the Workplace

One of the themes described is related to the loss of confidentiality in the workplace. There are several differences in military policy compared to civilian policy related to confidentiality. In accordance with the mandates outlined in Department of Defense Issuance (DODI) 6490.08, military health providers must disclose, under specified notification standards, health information to service members’ commanding officers/supervisors and include “the diagnosis, a description of the treatment prescribed or planned, impact on duty or mission, recommended duty restrictions, the prognosis, any applicable duty limitations, and implications for the safety of self or others” [24] (p. 6). The experiences described below are circumstances created under mechanisms outlined in Department of Defense Issuance 6490.08.

Trish: So, I was kind of labeled, like when you’re in high school and you’re labeled as the kid that can’t do anything, put in the corner. That was me. Everybody treated me like I was some fragile victim that they couldn’t trust to do anything because they didn’t know when I was going to fall apart. When I had proven to everyone that I didn’t have panic attacks at work,

Gummo: To take it even further as a part of pararescue men,

3.1.1. Subordinate Theme A: Ripples of I’m Tired of Being Told I Can’t Do Something When I’m More than Capable of Doing It

Hoppi shares how being taken off the team leads to not exposing one’s suffering:

Most important is on a team, a Special Forces team, a Green Beret team, whatever. Any form of mental weakness, especially, when I was serving in these rotations and stuff, number one, your security clearance was at risk and folks still even feel that way, even though that taboo is supposed to be gone

In Hoppi’s experience, hiding included: Dr.:

As a matter of fact, when I went to the ER…and I was having all of these physical things going on, one of the Flight Surgeon doctors called me and he said,

Aria also described people wanting to hide so they can be perceived as normal:

…But I do understand why people don’t seek help. Especially military soldiers, because I’ve seen sometimes people treat the military as their sole career and it is probably their last option or choice and they don’t want to screw it up.

John:My sister is a psychiatrist, so we would joke about it for years. “As soon as I’m done with the Air Force, my first appointment is going to be with a psychiatrist so I can get on pills.” We would laugh about it, but that’s really how I felt. (imagine writing awards and decorations for other members in the unit to progress in their careers, as your career is diminished). That’s the harsh stigma of being in.

Trish describes how viewing what happens negatively to others undergoing mental health services sustains the stigma:

The stigma is service wide. I think it’s less than it used to be because there has been a lot of success with it but at the same time when

Gummo and Hoppi describe how stigma may change when considering the intersections of age, family, warrior ethos, and phase of career contexts:

Gummo:

Hoppi also underscores military contextual features that influence the performance of hiding from others when considering the intersections of age, the Alpha male ethos, and power differential inherent to his higher rank:

…If you think that I’m embarrassed (for taking psychiatric medication), you’re out of your mind, but it was a taboo and a stigma.

McKenzie highlights that military messaging to dispel stigma may inadvertently create it due to actions not matching the messaging. She also highlights the nuances created with the idea of being honest.

I would love to see that change because you can’t persist and say, “Hey we’re here to help you, we care about you, you’re a member of our family” if you will but then turn around and completely disregard everything you just said. That’s my two huge things is that as long as we’re still able to do what we’re supposed to be doing we shouldn’t be judged any differently.

3.1.2. Subordinate Theme B: Units Being Super Supportive and/or Not

Another subordinate theme related to loss of confidentiality in the workplace in accordance with Department of Defense Issuance (DODI) 6490.08 [24], illuminates the impact of the service member beings supported and/or not in their units after their unit is notified, they are considering suicide. Trish discerns how she is treated differently in her old unit being a victim in one and not in the other:

…

Trish discusses how a supportive work environment and honoring her privacy is an important contextual feature in lowering stress and anxiety:

…

….

McKenzie highlights below that the loss of confidentiality in her workplace led to being isolated, losing social support, and being treated differently in the unit. These risk factors are known to place individuals further at risk for possible issues with mental and/or physical health [25,26].

McKenzie: Things were at their worst; my command went from super supportive to non-existent and my first shirt (sergeant) and the other co-worker have been really the only two who’ve not abandoned me in the whole process….Take for instance the first time I was in-patient my command visited every week, like older colonels visiting driving two hours each way. They visit every week; they called every week and

…Okay,

John describes his different experience in the context of power differentials when working directly for the commander and thereby getting a slap on the wrist:

….It wasn’t as negative as I thought it was going to be. I was expecting I was going to get out of that detox ward, I’d have letters of reprimand, article 15s for dereliction of duty, all of this stuff. I was very paranoid that the bender I went on…I called off sick for two days while I was going through this bender. I was paranoid about that.

…It was a real good wing-man concept. In a way, it was a success story for the leadership. I felt that’s why they praised it. Here’s a guy who’s struggling. Here’s somebody who intervened. Self-admitted, got treatment.

We are curious who is getting crushed the first time, not having the power and privilege that John carried.

3.2. Theme Two: Unit Members Surveillance and Command Directed Evaluations

Another theme centered upon the culture of surveillance within the workplace and being placed under demands to undergo a mental health evaluation by those who have authority over the service member. In the military, supervisors and commanders in the workplace have the authority to order subordinate service members to be mentally assessed “for a variety of concerns, including fitness for duty, occupational requirements, safety issues, significant changes in performance, or behavior changes that may be attributable to possible mental status changes” [27] (para c, p. 2). In addition, in accordance with DoDI 6490.04, all service members are educated through annual training “regarding the recognition of personnel who may require Mental Health Evaluations for imminent dangerousness, based on the individual’s behavior or apparent mental state” [27] (para g., p. 3).

Aria underscores the difference between an old commander and a new commander’s actions. She also describes how the command-directed evaluations can be initiated (or not) as a means of social control for desired behaviors. This suggests that psychological or psychiatric diagnoses and treatments can be used as punishment from higher ranking service members as a means of maintaining social control over subordinates:

My previous commander gave me a set of initiating protocol, like the

Trish shared the tension she has experienced with power differentials and how her low rank situated suggestions from those higher ranking as a threat that if she didn’t heed the suggestion, negative outcomes may have followed:

The day that I went to see mental health had been a really tough week for me and then my supervisor, flight commander and flight chief ganged up on me unexpectedly and were like, “You need to see somebody either the chaplain or mental health”…not forced me to go but basically said, “Hey we’re telling you to go kind of thing.” Once I was there, I’m like, ‘I might as well just be honest and say everything that’s been going on kind of thing.’

Aria, in the same vein, when confronted with gossip about her and others, was educated that standing up for herself to her peers meant they could raise alarms about her to her leadership.

“They also got involved…what really set it off is

I told them the reason I was always going about, running about, was because I guess that I could trust them, like I could involve that information because I could trust them. I told them the reason why I’m gone so much and the reason why leadership…although they know about it, it’s okay with them, you don’t have a right to be doing this because you really don’t know what all is going on. The reason I’m doing this is because I’m on a high interest list which is for people that are on suicidal watch because they are thinking of attempting suicide or have suicidal thoughts and I guess what rung into his mind was, “Oh, suicide, suicide, suicide,” you know?”

Hoppi shared his experience as unit leader, using his power to educate others on ways to help without exposing the service member and exacerbating the situation:

At that time, it was an education piece for me, as the leader of the company, was I brought them all in there I said, “It pains me to be on the lookout for this. Yeah, there’s nothing wrong with drinking a beer after work or whatever, that is still a normal thing, but when you see a guy walking around with a cup all day…You need to realize that we have been at war for 15 years and maybe he’s doing exactly that. Maybe he is self-medicating.

Hoppi further explains why, in his units’ unique contexts, surveillance of members for possible issues and if suspected, being told to report for a mental health evaluation would not work in his unit:

Unique to Hoppi’s experience was the intersectionality [28] of his leadership role, his unit’s warrior ethos, and how these factors played out in the interaction between him and his commander:

When I came back from the ER,

3.3. Theme Three: Military Mental Health Services: Diagnosis and De-Contextualization of Experiences

3.3.1. Subordinate Theme A: Loss of Ability to Articulate Humanity to the Authority of Pathology Language

Another theme described the experiences of being limited to the words to describe life through the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). That is, having their lives reduced to only words pathologically focused, funneled through the disordered dictionary used by mental health providers to language lived experiences of those that are mandated to seek services due to the idea they are mentally ill for considering suicide. In the military, if you are identified as being suicidal, you must report for mental health services for fitness of duty considerations.

McKenzie:

Then the paperwork dropped for the discharge and I filed a congressional…and I filed a congressional complaint. After that, she (the military mental health provider) was like, ‘We can’t work together anymore’ because it was like me attacking her license and decisions, which is the exact same thing they were doing to me…

Aria:

Aria describes the assessment process she was ordered to undergo by a new commander and supervisor after learning she was considering suicide and seeking mental health services:

Aria’s words speak to assessments locating the service member as being forever static, stuck in time in their worst moments, and having it used in present moment as ammunition that she is lying for improving from before. It is also another example of the tunnel vision that can happen when a diagnosis has been given and no one is taking into consideration the person and not the label.

…

3.3.2. Subordinate Theme B: I Am Your Textbook and Theory, Study Me

Another theme centered upon hearing the same theory from multiple providers and group sessions and consequently services were not being helpful. The VA/DoD Clinical Practice Guideline for Assessment and Management of Patients at Risk for Suicide recommend only treatment options that fall under the Cognitive Behavioral therapy conceptualization using a structured framework, or medication [8]. The VA/DoD Clinical Practice Guideline for Assessment and Management of Patients at Risk for Suicide was updated and released in 2019, after the interviews were completed. It proposes the continuation of utilizing only CBT conceptualization and interventions in psychotherapy for individuals with self-directed suicidal behaviors.

Charles:

…All textbook, it’s all, you go to school, and it’s all textbook. It’s an ongoing training for doctors and psychiatrists, and psychologists, but the true professional can get into my head. The true professionals can get in there, and help me, just Google in the word help is, it’s not going to be there.

Hoppi:

I would say this,

I would say do the homework on the patient, and in the military case of this, the organization in which they come from.

In my personal opinion, a psychologist or psychiatrist should be an extremely intelligent person, and if they are, which I’m sure they are, they should do that homework and figure out, ‘How do I get into this guy’s brain a little bit to get him into the box that I want him at so I can help him?’

Gummo describes how he was trying to articulate his experiences in session, and the wrong fit led to him desperation and consequently, considering suicide.

Again, I felt like talking to the therapist despite their good intentions and their dedication to the profession, I truly felt that it was fruitless…I immediately felt like I was barking up the wrong tree because whenever I went to see a counselor and not to minimize this person’s qualification or their experience or who they are as a human being but it was a really bad fit…

…I wanted to feel as if someone understood what I had gone through and what I was going through and I did not feel that that was adequate and a lot of the providers themselves they were like ‘Holy smokes, this is surreal.’ In a very real way for us to even hear what you’re saying that you’ve been through let alone us attempt to help guide you through your emotions on this.

…Again, it’s all about finding that right fit obviously but it’s very hard when no one else has experienced the things that you’ve experienced and so now they’re just applying theory to you.

McKenzie describes how being vulnerable and sharing information to the military mental health provider limits her ability to articulate due to the lack of confidentiality and its effects:

…

Aria found the services helpful but stopped treatment because she heard it before:

4. Researcher’s Conclusions and Responses to Participant’s Descriptions

The insider knowledges were extremely useful to identify issues we had no idea were occurring in mandates from policy and clinical practice guidelines. What we appreciated about the descriptions from the stories of the service members were the nuances they highlight of the performances of policy. How policy played out was different in their unique contexts. Performance of policy was effected when entangled with power differentials prevalent in the makeup of the military ranking system, effected by the role they and others occupy, effected by the mission of their unit, where they are in their career (i.e., nearing retirement), developmental stages of life and differences in age; and what characteristics and social norms are preferred in the military (i.e., strength, honesty, integrity, and the warrior ethos) [29,30,31]. Such rich descriptions of insiders’ experiences within military policy and mental health services is missing in the available research and internal military policy transformation mechanisms.

Their experiences also illuminate further the innate “Catch 22” which happens when accessing help. Catch 22 basically means if you know you need help than you are rational; but if you actually seek help, then you are crazy and not trustworthy to do your job [32]. This located the service members as unstable, with policy that also mandates them viewed and treated as such through placing them in menial job roles, unable to perform their mission or job duties, negatively effecting relationships with peers and others in the unit, and fear of being discharged and the ripples it would have to their families. There are also descriptions of abuses of power related to the command directed evaluation and allowing for supervisors and others of higher rank to direct subordinate members to present for mental health services or psychological assessment based on perceived wrong doings, which situates psychological assessment and services as a form of punishment. The descriptions of service members highlight military unique sociocultural features arising from DoD policy that contribute to the creation of stigma distinctive from that described and understood outside military contexts.

4.1. Criticality of the Language of Suicide with Pathology and Narrow Specificity of How to Help

The participants underscore unhelpful experiences when providers designate life problems only understood through the framework of mental disorders, disordered thinking, and narrowly locating issues of suicide living within the skull of the individual. They describe no curiosity of their life contexts nor looking outward to the social practices that create human suffering [33,34]. This idea contributes to the ongoing restrictive perspective of suicide and its prevention, to include stigma as being due to irrational thoughts and behaviors from disordered service members, thereby solutions are provided accordingly, (i.e., people experience suicide because they have undiagnosed mental health disorders, identify them so they can go to treatment, ending the problem of suicide). While the dominant medical perspective and pathological conceptualization of suicide have no doubt saved lives, it is apparent there are ramifications and inadvertent ripples to the lives of service members when being mandated by policy to be understood in these perspectives only.

The service members’ descriptions speak to being dehumanized, with lack of control and power over who to share their stories of suffering with due to unique military specific requirements that mandate those identified as experiencing suicidality to be exposed to leaders in the workplace. They describe losing authorship to their stories to the authority of mental health providers, commanders and supervisors, who often through their practices, deem suicidality as evidence of a disorder, locating the issue inherent to the pathology of the individual. The service members storytelling is silenced, not legitimate, dead from an act of storycide [35] killed by the mental illness story.

The service members also speak to the same theory and textbook like mental health services they are mandated to use to help, as unhelpful. In the VA/DoD Clinical Practice Guideline for Assessment and Management of Patients at Risk for Suicide, CBT therapies, which are often manualized and scripted, is suggested for providers to use with the intention to “Reduce current unwarranted practice variation and provide facilities with a structured framework to help improve patient outcomes (prevent suicide and other forms of suicidal self-directed violent behavior” ([8], p. 2). What this language does is locate the person’s unique articulation in their own preferences to describe ways of living in their own contexts as not fitting in with the session’s “structured framework”. Consequently, the session is not helpful to the individual, seemingly helpful instead for the researcher interested in standardization of processes, helpful to mental health provider’s mandated by clinical guidelines to conceptualize problems in the CBT framework coupled with disordered language to understand the person’s suicidality. This seemingly creates services, and processes thereby tone deaf to learn the many changes and nuances of power differentials and intersectionality of unique sociocultural contexts of suffering illuminated in the service members stories. The service members are not allowed to articulate their experiences but are rather placed under the linguistic demands of how to speak about their lives through our own conceptualizations, “structured frameworks”, and DSM-5 disorders. When you look at it from the perspective of our participants it becomes an issue of social justice because they are being reduced to their labels, told what they need to do to get better, “replace thoughts with more realistic and useful ones” while ignoring the outward causes of suffering in addition their goodness of fit for the process. Reynolds illustrated how medicalized language “seduces us to abdicate our social and collective obligations to change the contexts in which these kinds of deaths occur—violence, poverty, (military unique social experiences) and homelessness, none of which are natural. This can also direct all research and resources towards a corporate medicalized response to what are primarily social issues” [36] (p. 176).

In response, we share the service members’ own stories, in their words and life theories of understanding their consideration of suicide. This is what seems to have been lacking in their experiences in military mental health services:

Aria: Aria shared that she joined the military looking for help “because I didn’t have any health insurance or medical benefits, and I couldn’t afford it”. She described her role in the Air Force as “customer service”. She underscored her religious belief as a contextual feature to “when it comes to suicide, with God and suicide, it’s because you get angry at your creator sometimes. Something…you know, life throws you lemons, and just get angry at your creator, and it’s so unfair…It’s like, you want control in your life, and you hate being not in control. You get angry.”

Trish: Trish shared that she had served the prior six years in the Air Force in the medical field. She shared contextual features that contributed to her considering suicide: “My family is like very, very big on military history. My grandad was in, my dad was in and now I was in and I had been sexually assaulted and raped four times (by men with authority in the military) in a three-year period and by that time I had contemplated suicide…I was in the middle of the situation and I had told my mom about what was going on. She didn’t know about everything, but she knew about parts of things and she was disappointed that I had turned one of the guys in because she has a history of also, of sexual assault and stuff like that and she never turned any of the guys in so she didn’t understand why I was, in her words, ”Making a big deal out of nothing. “ I felt like I was letting her down because I was standing up for myself which was a dilemma in and of itself. Then when I finally was like, “I can’t live with myself and I can’t do this anymore. ”

McKenzie: McKenzie shared that she had joined the Air Force because “when I was in high school, I started the Reserve Officers’ Training Corps (ROTC). And it was then that I knew that serving was for me. Before that, it’s been a thought that hadn’t been that driving force. And going through high school in ROTC and meeting the instructors that I did and the people that I did, I was able to find, I guess, the closest thing that I had to a family. Like that sense of belonging. And the more I delved into the military and how they live and what their job is and how what they do makes such a huge difference, I knew that that was where I was supposed to be. That was where I was supposed to be headed in doing. Before that, it was always I knew medical, but the military added to that medical interest in helping and making such a difference. It was what gave me purpose in life.” McKenzie shared that contextual features in contemplating suicide was when she was in a new location and unit and having a lot of stress in her unit.

Gummo: Gummo shared that he served as a Marine for 12 years in special operations and with the Air Force as a pararescue man where he is in the “two or three percent” of the Air Force members whose daily job “is normally filled with the worst day of someone’s life”. One military experience of significance during his deployment to Afghanistan led to unanticipated hand-to-hand combat and deaths. Immediately after this significant event, through “serendipity”, Gummo was met coming off the helicopter when he returned to his overseas military location by three individuals from the “media” that were interested in learning about his unit’s experiences during deployment. One of the men was a tattoo artist that offered Gummo a tattoo. Gummo found the processes of receiving a tattoo as helpful by “riding into catharsis”. He shared there is limited time to process grief as there is little time now from being in battle and then chatting with his family back home in the United States.

John: John shared that he is an Air Force pilot. “…For about six years…We were flying…in ground support missions.” John shared that he, in the past, suspected he may have benefited from mental health services; he was interested particularly in medication following his family connections to psychiatry, but policy dictates he would have been grounded and not allowed to fly. Rather than go to mental health and be taken off the mission and not fly, John shared he used alcohol to calm down. “I think I was lucky in that I was in a detox ward at the time. I had just come off of a four-day bender with alcohol. Over a four-day period I think I consumed probably five or six bottles of vodka. I was pretty much a wreck and out of sorts. I was in this detox ward. I was supposed to get out of there in four days. The counselors that were in the detox ward got ahold of my wife. She basically said we’re done, it’s time for a divorce, and some really other harsh language; but basically, you can sit in there and rot. At the time my daughter was getting up to 18 months, so I had a little baby at home. That was really tough for me”.

Charles: Charles shared that he was serving the past 23 years in special operations as a Green Beret. Circumstances he shared of what contributed to the consideration of suicide was “survivor’s guilt, it goes back to that family, that person to your left and right, you’ve been with for so long, friend with for so long, and you’re wondering, you’re asking yourself why? Why, why him and not me. Having to relive it year after year”.

Hoppi: “I’ve been a Green Beret and a special operator for many, many years… I come from the Northeast, coal mining country, where everybody worked hard, took pride in their work”. Hoppi shared that his consideration of suicide “Is not necessarily from shooting the enemy at all or seeing horrible things. A lot of it is stress compounded for so many years, because you’re trying to balance so many things, and you look at it as no fail. You cannot fail”. Hoppi also described the experience of being at peace in war and returning home as frustrating. “I was at peace over there because when something confronted me, I could kill it. Over here, you’ve got to deal with it. You can’t just grab somebody by the neck or bring in a B-1 bomber to end the problem. You have to listen to all of this madness, and it gets a little bit frustrating for when your normal is dealing with everything with extreme violence or force”.

4.2. Effects of Saturation of Literature Pushing “Evidence Based” Structured Frameworks

There is another dangerous idea that may be assumed in the language in the VA/DOD clinical practices that providers should use the same scripts to “Reduce current unwarranted practice variation and provide facilities with a structured framework to help improve patient outcomes (prevent suicide and other forms of suicidal self-directed violent behavior)” ([8], p. 3). The language in the quote locates suicide or bad outcomes as being caused by providers who don’t adhere to CBT or a step by step technician style manualized approach. This is an erroneous claim considering there are many theoretical practices, methods of diagnosis and assessment, and treatments that have historically produced successful outcomes too often disparaged and ignored by promoters of the dominant approach to mental health care [37,38,39]. Consequently, the saturation of CBT in the United States military training and research literature provides many privileges. CBT being economically advantaged in research is arguably the most widely studied form of psychotherapy [40] and produces more than 1000 research articles [41]. Mental health research is fueled by government funding, the government is historically the creator of the most research activities in the United States, spending billions annually [42]. Conversely, this saturation continues the controlling of the production of knowledge channels to continue the rhetoric of CBT as the few “evidence-based” practices and all other perspectives as located as illegitimate excluded from consideration on the grounds that they are not sufficiently scientific in the name of randomized controlled trials [37,38,43,44,45]. The suggested VA/DOD guidelines are created seemingly through this myth, thus other perspectives are made invisible and less privileged.

Also embedded in the service members’ descriptions are the absences of a positive therapeutic relationship or meaningful therapeutic alliance with military mental health providers when confronted with unhelpful practices. The critical importance of the therapeutic alliance and relationship as primary mechanisms to improving outcomes in mental health services, regardless of the theoretical basis used by the mental health provider is well established [39,46,47,48,49,50,51,52,53]. The fact that members describe experiences related to policy that directly effects the ability for individuals and providers to engage in therapeutic relationships and to form meaningful alliances, one service member, Gummo, shared this was what led him to consider suicide is alarming.

4.3. Stigma Created by DoD Policy

The descriptions of service members highlight military unique sociocultural features arising from DoD policy that contribute to the creation of stigma distinctive from that described and understood outside military contexts. Acosta et al. through their content analysis of DoD policies “identified policies that allow nonprofessionals to determine mental health fitness that support the use of mandated mental health screening for specific individuals or groups…these practices could put some service members at risk for stigma and discrimination” ([54], p. xix). They also state that “mental health screening and evaluation programs may be used inappropriately…” (p. xix). The descriptions of service members highlight military unique sociocultural features arising from DoD policy that contribute to the creation of stigma distinctive from that described and understood outside military contexts. Stigma attached to keeping people from seeking mental health services is not a new concept in the United States military. However, few military programs or policies currently target the nuances of the military institutional contexts [54], or other sociocultural factors described and illuminated by the participants’ experiences. This is most likely due to scarcity in the available literature describing stigma from the lens of intersectionality [28] or other perspectives to include the relational and contextual features arising from unique military circumstances that effect stigma over time. Of the available research literature, most researchers focus narrowly on the idea that service members are not presenting for mental health services due to misperceptions they have of mental health care, misperceptions of treatment, and misperceptions of career effects [29,55,56,57,58,59,60,61,62,63,64]. This locates the person as the creator of stigma in their head, thereby stigma is traditionally problem solved from this perspective. In the Department of Defense, this has led to funding programs and service wide messaging socializing that members who seek treatment early before it is a problem identifiable to others in their workplace have less career impact, and that seeking help is a sign of strength [5,6,29,31]. This fuels the idea that service members should engage in help seeking behaviors before it is a problem, which begs the question, why would people seek treatment if the problem is not a problem?

Interestingly, there is a higher prevalence of stigma reported among service members in treatment, most likely due to (DODI) 6490.08 that mandates the lack of confidentiality in their workplaces through the process of seeking mental health services [54]. There seems to be the taken for granted idea in military research and messaging that service members’ misperceptions about treatment or misperceptions of career impact is what keeps people from seeking help, overlooking the policy nuances that occur when seeking mental health in the military also keeps people from being helped due to discriminatory social practices and policies as illuminated in the descriptions from the participants. Inadvertently, service members are trusting the messaging that seeking help comes with no strings attached without negative consequences; only that is not always the case. Acosta et al., in a study of mental health stigma in the United States military, warned of such dangers to service members after completing a content review of Department of Defense policies:

“A large number of the policies we reviewed prohibited specific job opportunities or actions if a service member had a Mental Health Disorder (MHD) or sought mental health treatment. For many of these policies, the language is unclear, stating only that a service member is prohibited if he or she has a mental health issue…In 12% of policies, we identified language that was pejorative and characterized MHDs and treatment in a negative light.”

Agreeing with Reavley and Jorm [65] that stigmatizing attitudes lead to negative feelings, stereotyping, and discriminatory behaviors; these mechanisms play out regarding service members in that they are treated differently as dictated by policy. Department of Defense policies unjustly blankets those seeking mental health services with sanctions [54], locating the service member as seemingly incompetent and untrustworthy, one who cannot manage successfully their lives and unable to manage their work duties. They are placed under circumstances of having to prove themselves capable, set up for failure as the policy mechanism demands them treated incapable, thereby they become incapable; their lives and personhood in essence being taken away. Regarding suicide prevention, this creates further suffering in those identified as suffering and wanting help, causing them to be discriminated against in the process. Policy inadvertently creates circumstances known to increase suicide risk to include isolation, loss of social support, loss of team membership, loss of purpose, and loss of hope and meaning [8,66,67].

5. Conclusions

5.1. Possible Ways Forward

Congruent with the aim of our study and the preferences of military policy leaders, to legitimize insider perspectives and knowledges to guide in transformations of policy, below are the recommendations in their own words, followed by ours. We also, considering the participant experiences of their stories being re-languaged, consequently regurgitated through other’s perspectives, with very real ramifications to their lives, we are intentionally leaving their recommendations as they uttered them. Future research and projects inspired by this work may take unlimited shapes and forms, and we hope to hear what projects are inspired from this manuscript.

Aria: Confidentiality needs to change. I think it’s a benefit of having a mental health clinic on base, it’s just better to have it off honestly. I have recommended seeking help outside of a base, rather than on a base, so that everybody is not able to stick their nose into your business.

Charles: I see all these different classes…Suicidal trainings, two or three times a year. Online training, two or three times a year. I don’t see that’s heavy here. That when I say heavy here, a person is standing up in front of the audience, telling that Soldier, Airmen, Seamen, Marine, look to the people on your left and right. Is there a person who you grew up with? These are the people you trained with, is it a people you fought with, these are the people you don’t let down. Not only that, but imagine. Put in your head who you love most and on this world. You love your mother the most, your father, your sister, your brother, your wife, your children, your grandchildren. Go ahead and pull that trigger. Imagine, the after effect is going to happen. Yes, sit there to think about. Contemplate that just for five minutes. Everything that’s going to happen, what are you initialized, what is for every action there’s a reaction. You pull that trigger, what are the reactions. Mentally what is it going to do, to that loved one. Mentally what is it going to do to your buddy, to your left and right. You might just be setting off something yourself, for the chain reaction of a lot more death that you don’t want to see.

Trish: At my first duty station I tried really hard to get with the Top Three and the First Sergeant organizations and start a mentoring program due to the center that I was heading up because I really wanted to start pairing people with people who outranked them and had all this life experience in the military and expertise and knowledge that they had to offer to these young airmen who this was their first duty station and it was a terrible station and I had got orders and left in the middle of the process of getting all of that taken care of so I don’t actually know if it took off or not, but I did express the need for it because I knew my rank drastically changed once I got a mentor because I knew that no matter what happened, I could always call her, but I’m out of the military and I still call her.

Hoppi: Educate first-line supervisors to offer help interventions. The reason I say that is, it’s got to be the guy that’s with these individuals from morning to night. When you’re talking second, third, and fourth level up there, you will never be able to see it because the person is going to walk by you and say, ‘Good morning, Sergeant Major,’ and go about their day. It’s got to be the person that’s right beside him, that first-line supervisor that’s up in their rooms and with them every day. Yeah, they should be able to identify this. That self-medication is a huge indicator, when a guy starts drinking too much, it needs to be looked at because that’s normally one of the first things that starts happening. If you go to that first-line supervisor, in most cases, the soldier trusts that first-line supervisor with his wife and his life, he would be a little bit more open to taking recommendations or advice or just open dialogue with that first-line supervisor. When you get beyond that, now there’s a wall going up.

McKenzie: I shouldn’t be judged any differently as long as I can do what I’m supposed to be doing I shouldn’t be judged any differently. I know that there are some diagnoses that are unsuiting for a lot of things but there’s a lot of gray in the mental health focus as far as the military is concerned. They keep harping on the whole wingman concept and get help, be there for your people and I feel that it’s very fake in a lot of ways because from just my experience itself it’s been everything that they say it’s not. I would love to see that change because you can’t persist and say, “Hey we’re here to help you, we care about you, you’re a member of our family” if you will but then turn around and completely disregard everything you just said. That’s my two huge things is that as long as we’re still able to do what we’re supposed to be doing we shouldn’t be judged any differently. The fact that the whole air force philosophy of being honest and open and seeking help and being a wingman that needs to be followed. It’s not one of those things that you can just say because it sounds good. That’s why there’s a stigma is because people are concerned that they’re going to be just treated differently, that they’re going to risk their careers.

John: Advertise success stories. Advertise people that are on medication that are still in and it’s not damaging their career. I would try to advertise that. I think that would be helpful. Say if I read an article ten years ago that said, “Hey, this guy’s a pilot. He takes Lexapro. This guy’s a psychiatrist. He takes Prozac. This guy’s a brain surgeon. He’s on Zoloft. They’re all functioning and their careers are great. Oh, by the way, they feel great, too. They don’t have anxiety. They don’t have depression.” I think that would be huge. I still think the culture is very against it. It’s like, “Ew, you’re going to mental health? What’s wrong with you. Why do you have depression? What’s wrong with your life that your so depressed? Jeez, maybe I shouldn’t give this guy the job.”

Tirzah and Bernadette (researchers/authors of the manuscript):

Military policy organizations revamp their internal mechanisms to include speaking with service members in each military specific mission as a critical means to inform policy efforts. Each mission is different in the effects of certain policy and unit contexts as the participants’ experience highlighted.

In suicide prevention efforts, include service members at the local level to participate in the national level conversation and vice versa. Annually or every few years, we suggest employing a three- or five-day solution finding event at local units, not specifically focused on suicide per se, but to better understand local occupational and/or other cultural stressors (pay, housing, deployment schedules, work and family balance, and other base specific nuances), thereby providing local solutions to these nuances. This information could be useful to collect for policy makers to also utilize to make decisions that are mission and unit specific.

DoD add to their local and national measures individuals’ experiences of therapy, and services provided to inform ongoing policy and services transformations. This is to compliment already existing outcome measures captured by the military.

Consider removing the command and supervisor directed mental health evaluation mandates in DoD policy.

Consider updating the DoD policy related to confidentiality, particularly in the workplace requirements.

Consider rethinking the narrow specificity of utilizing CBT therapies outlined in the VA/DoD Clinical Practice Guideline for Assessment and Management of Patients at Risk for Suicide. As the clinical guidelines indicate, there is no interventions more useful than others in stopping one from committing suicide [12]. In addition, all therapies work for some people and not others [37,38,39,43,44], the diversity in theoretical ideas and interventions could be celebrated in clinical practice guidelines.

5.2. Limitations of the Study

The seven service members who participated did so to work alongside military mental health policy makers. Readers should be mindful that the sociocultural factors and polices of the military are not static and are ever changing. In addition, in our criticality of policy and the services provided does not negate that some people find the policy and services as helpful. Our intent is not to have the reader assume we are advocating, through our situating ourselves in the critical and questioning stances, that we wish to categorically subscribe to naming things “good” or “bad”, “right” or “wrong”, or other words to the same effect. It is our position rather to raise up the unintended consequences of helpful items not helpful through the experiences of insiders to the process to inform policy. It is our moral and ethical obligation to keep an eye on the inadvertent ripples to the lives our policy and practices touch.