For the past eight years, suicide is among the top 10 leading causes of death in the United States, according to data from the Centers for Disease Control and Prevention.

Despite its prevalence, suicide remains a sensitive topic often considered taboo. The effects of stigma related to suicide are of particular importance for those in the military. There is a common perception among service members that if they share their thoughts of suicide with others, they may experience negative repercussions that will affect their careers.

As mental health professionals, we too are susceptible to personal beliefs that perpetuate stigma. Without knowing it, we may bring these beliefs and fears (rooted in stigma) into the therapy room. For example, we may experience anxiety or feel uncomfortable with a suicidal patient because we lack appropriate training, are concerned about our liability, or feel hesitant to discuss the topic of suicide. In fact, work with suicidal patients can be one of the main daily stressors we face as clinicians. As a result, we may unconsciously avoid using the word suicide.

Our unconscious behavior ultimately affects those we serve and may unintentionally reinforce the stigma associated with suicide. Our uneasiness with discussing suicide may cause a patient to feel shame, guilt or reluctance to share suicidal ideation if it does arise.

Here are suggestions that we can adopt to reduce stigma related to suicide in ourselves and those we serve:

1. “Have you had thoughts of suicide since the last time we met?” We must ask about suicidal ideation at the beginning of each and every session, regardless of the patient’s presenting problem and history of suicide-related behavior. This process should become routine – just as it is for a health care provider to take a patient’s temperature at each visit. This check-in is often brief and can be as simple as asking, “Have you had thoughts of suicide since the last time we met?”

   If the answer is affirmative, we should further assess for imminent risk. If the patient has not had thoughts of suicide, the session may continue as planned. This simple act normalizes the discussion of suicide and allows the patient an easy avenue to share suicidal ideation should it arise during treatment.

2. “Have you served?” Although military members are at an elevated risk for suicide, they may not immediately disclose their status as service members. In a community mental health setting, in addition to assessing for suicidal ideation each and every session, we should also ask about the patient’s veteran status prior to beginning treatment.

   Simply asking patients “Have you ever served in the military?” and “Have you ever been deployed?” may help us gather data that we would otherwise miss. These details may inform our approach to suicide risk assessment and safety planning. For example, service members and veterans may have easy access to firearms and may be more reluctant to distance themselves from their weapons as part of their safety plan. Additionally, service members may have less fear of death and a greater sense of self-reliance that may make them less likely to disclose perceived vulnerability, such as suicidal thoughts.

3. Become comfortable talking about suicide. If patients sense that we are nervous during a discussion about suicide, they may avoid the topic so they don’t feel like a burden. We can improve our comfort and competence by taking every opportunity to attend trainings that specifically address suicidology in treatment.

   Furthermore, to address liability concerns we may consider using a standardized risk assessment and safety planning protocol when working with patients who are at high risk for suicide. We may also consider building a strong peer network to feel more supported when treating patients with suicidal ideation or behaviors. A strong professional network of support can also help with efforts if a patient ultimately dies by suicide.

4. Be mindful of our own reactions. When a patient endorses suicidal ideation, we are likely to experience some level of physiological and emotional arousal associated with anxiety. It is important to be aware of this natural reaction so we are mindful of how this influences our response to our patient. Often, we may be the first person our patient has shared these thoughts with. An exaggerated response may reinforce perceptions of stigma and lead our patients to regret sharing their ideation.

5. Balance patient safety with autonomy. It is our duty to help our patients consider ways to stay safe. We must do our best to help them maintain their autonomy if possible. Although there will be times that hospitalization is required, we must not use threats of admission to an inpatient unit as a consequence of all suicidal thoughts, this will only bolster shame and stigma. If we decide hospitalization is the best course of treatment, we must ensure that our decision is based on our patient’s best interest and not to calm our own anxiety.

Our top priority is helping our patients. Many individuals who seek treatment for suicidal ideation feel shame and guilt related to these thoughts. We can be the first line of defense in dismantling this stigma. Allowing our patients an opportunity to discuss suicide, without having to bring it up on their own, helps them feel more comfortable talking about it. When we become more comfortable with discussing suicide, we can begin to minimize the associated stigma.

Resources about suicide among service members and veterans:

Military Culture and Suicide Prevention: Resources for Providers

Air Force Guide for Suicide Risk Assessment, Management, and Treatment (PDF)

Air Force Guide for Suicide Risk Assessment, Management, and Treatment Appendices (PDF)

SAMHSA Suicide Prevention Guidelines and Resources

VA Community Provider Toolkit: Screening for Military History