Basically they just repeatedly asked the same questions that was on the survey—just to make sure I was consistent all five hundred times. (Participant Y)
It’s hard going from doctor to doctor trying to reiterate your story all over and over again. That’s frustrating. (Participant F)
I’ve gotten used to it and know you guys are going to ask me every time…it is like sticking a needle through your eye sometimes. (Participant R)
Yeah, a lot of overlap, and she even said, ‘Why do I have the same questions?’…and it made her do the same ones over and over with the different titles, but yeah it is just template questions. (Participant J)
It’s repetitive. Annoying. It feels like I have already answered the questions for you. And you’re in the same damn office, why should I go to somebody else and answer them all over again. It is a massive waste of time,and for me, at that point when I was still working—I’m laid off right now— to have to spend seven hours at that place answering the same questions over and over again. But apparently these three people cannot talk to each other. (Participant O)
Well if you got to explain yourself every single time to a different person it gets like what’s the point. (Participant AC)
But I mean that was about the gist of it. So I just, I felt like I gained nothing. I felt like it wasn’t, there was no attempt to figure out what’s going on. It was just, ‘Uh…yep checking the box, it’s still there, see you later.’(Participant AE)
Table 3. Barriers to Suicidal Ideation Screening: Denial, Stigma and Shame
They ask you, ‘Do you need to talk to mental health?’ you say no. It does not matter if you do or not. You say no because if your commander finds out you said yes they give you shit. What, you’re a soldier. You don’t need any fluffy bunny mental health crap. (Participant J)I finally started accepting that [having suicidal thoughts] was an issue for me, but prior to that there had been several times I filled out those questionnaire, post deployment and stuff, and it was just something you had to go through to get home. You knew pretty much to say no to everything. (Participant U)
The stigma is a big deal…It’s like this stamp,you’re damaged goods. So at that point [you] are not trustable. Trust is everything in a foxhole. Food and bullets and trust and your buddy is your whole life.(Participant U)
I was embarrassed having to answer the questions the way I did, but that was the only way I was going to get any help. (Participant M)
[Feeling suicidal is] not something that you just want to reveal to everybody, somebody not in the medical field… ‘cause you don’t want to look bad. (Participant Z)
Sometimes it is a little bit or pride, little bit of stubbornness, you’re taught that, ‘Hey you can deal with things on your own.’ Then you get to that level where you can’t, you just give up and you’re like ‘fine I’m done with that.’ (Participant W)
It’s a Marine thing. I mean, if I tell somebody, ‘Well this and that’ am I weak? Have I failed the Marines? Have I failed myself? Have I not lived up to it? Me being Marine, we just don’t talk about those things. (Participant P)
I quit eating, I’d cry all the time and I just didn’t do anything. But when I was at work as a soldier, that’s when I was the soldier, I’d put on the face and nobody saw anything different. I hid everything. (Participant AB)
No. A lot of people didn’t know that I was seeing the colonel [a psychiatrist] except my NCOIC. He was a sergeant first class, twenty years in the military and he (thought that) seeing mental health is just making you weak or showing sign of weakness. He was all gung-ho. He didn’t think that—that I should have been seeking help. He thought of it as a negative thing…I think there were many soldiers that were scared to go [for mental health treatment] just because of the chain of command. (Participant H)
A lot of guys that I talk to, everybody’s always like ‘suicide is for pussies,’ ‘don’t take the easy way out,’ ‘that’s just pathetic’ because, cause technically I believe the same thing but when you actually have the thoughts and you’re not trying to have the thoughts, you don’t really want to admit that you’re having these thoughts that make you seem like less of a man for having them, so that’s another reason why people won’t say stuff because they don’t want to seem like they’re weak. (Participant E)
I think it’s the atmosphere. You don’t really see a lot of people get mental health help [in the service] and when you do its generally kind-of a looked down upon thing not necessarily like the mental health thing is bad but if you’re getting mental health help then there is something wrong with you. (Participant G)
I think the most difficult thing about being asked something like that is giving an honest answer and not being the answer you want to give. You want to give the ‘sure I’m great, no problems, keep reading on’ kind of thing, when you know you need to be honest. (Participant C)
You know, it was easy to say, you know, ‘Sure, I’ve felt suicidal but, you know, ha-ha, doesn’t everybody, and of course, I would never do anything, it’s just one of those things, no big deal’ and it was easy to brush off. (Participant C)
But I didn’t have too much issue admitting it to a mental health professional. Anybody else, not in a million years.(Participant C)
I mean, I’m sitting in a doctor’s office with a—and no offense to, you know, levels of skill or training—but even if I am sitting there with a nurse assistant and I am asked off of a—you know, as he or she is sitting there with a form and checking the block as they go, I am not going “yeah, sure” you know. It’s not going to happen. It doesn’t seem appropriate. It’s not the right timeand…so…(Participant C)
Don’t think it’s that bad, you know, thinking that I could handle it. (Participant A)
I probably would not have brought I up…only because I am a little embarrassed about it. (Participant AG)
That’s the heartache…I just try to cover it up and faking it to make it. I know I am hurting, physically and mentally, but the thought of trying to get help is a sign of weakness. (Participant F)
Table 4. Barriers to Effective Suicidal Ideation Screening: Discomfort, Distrust, Disconnection, and Discretion
Those that are nice to me and treat me with respect right away, then they will get the respect—they will get all the information that they need from me. (Participant W)I mean people don’t really want to be asked, ‘Hey are you trying to kill yourself?’ You know that like ‘Hey that none of your business,’ you know, that’s mine—that’s what I’m thinking in my head. (Participant W)
(Regarding being seen by a physician assistant instead of a physician): I mean, because she is just basically being a puppet for the doctors and she is getting the notes and then she is relaying to the person, but the person never met me so they can’t know how I am, my mannerisms from stuff off the notes…If she can take that much time in her day to read these notes to you, why couldn’t she come down here and talk to me herself personally. It’s like, cut out the middle man. (Participant S)
Sometimes just don’t want to discuss certain things [that are] kind of private, just being private and not wanting other people to know. (Participant A)
I think that I would be less likely to talk about it with a stranger…I mean you don’t want to talk to a different person every time you come to a doctor. Could you imagine your gynecologist was a different doctor every time you put your legs on the stirrups? There’s a different person entering your body. It’s kind of like that—you feel vulnerable when you talk about things, especially mental things.(Participant AC)
I really didn’t know who she was. You know, what she could do for me. At that moment it just seemed like she was just a clerk just getting information down and to me it felt like, why am I gonna tell everybody that I do. Like, I’m not gonna go around telling everybody that oh yeah, I have depression. (Participant AF)
You could say fear. Embarrassment. What she would say to her coworkers. I mean all those things go through my mind. Knowing if the individual is a professional, a doctor or a psychiatrist or something like that, you feel more comfortable telling those individuals. Whereas you come across somebody, like a clerk—I wouldn’t divulge any information to her. (Participant AF)
I’m sitting in a doctor’s office with a nurse’ assistant as he or she is sitting there with a form and checking the block as they go, I am not going ‘yeah, sure’ It’s not going to happen. It doesn’t seem appropriate. It’s not the right time… (Participant C)
If that is the first thing someone were to say to me, I would just say no because I wouldn’t want to tell them because I don’t know them. I don’t trust them, I don’t know who they are.(Participant AG)
Some people you could tell, they could care less. Whatever—yes or no. Some people are concerned….not front desk people…sometimes they even ask you like in the regional office. They are really just paperwork….they don’t care. (Participant Z)
Did you feel comfortable with how it was brought up or comfortable with him asking you? (Interviewer) Not really, because he’s not who I see every week to talk about how I am feeling.(Participant Q)
I think they were probably, obviously trying to help but the fact of the matter is, it’s not their damn business. I don’t want these people that don’t know me, don’t have any rapport with me, asking me that kind of question ‘cause I don’t believe it’s any of their business…there is no way that I am going to give them a serious answers. I don’t even barely want to talk to them. (Participant O)
I wouldn’t feel comfortable. If it was a new doctor or a new nurse, I don’t feel—it wouldn’t feel comfortable—I’d be too afraid of them. I wouldn’t know how to explain it. I’d be too uncomfortable with the strangers. (Participant H)
I don’t want to mess up my life even more by being honest with somebody. And they are strangers so I don’t really want to talk to strangers about things that are in my head ‘cause they’re my thoughts. (Participant E)
Here I have some questions, let me poke you, okay I don’t really care for your answers, I just want to poke you and make sure I check my block. (Participant AB)
Well as a medic myself, I know that there is a lot of redundancy. There’s lots of questions that you have to ask for any kind of screening—‘do you smoke,’ ‘do you drink’ and it’s all a lot of check the blocks. But something such as suicide, it very serious and checking the blocks with that is dangerous… (Participant AB)
The other [clinician] was a one way street. You ask questions, she’s writing something down, she asking other questions, she writing something down and that was it. (Participant AE)
How did you feel about that method of being asked things off a series of questions? (Interviewer) Oh (laughs). I didn’t really like it too much; I mean it just seemed too impersonal…I mean especially for how personal the process is to just have a list of real specific…I can see that—it just feels that um it doesn’t quite get to what I think they are hoping to get to. (Participant G)
The doctor I am seeing is supposed to know everything. Not ‘Oh I am only a doctor for you today’…They are doing their job, I’m just a number, expendable, I‘m a soldier, I don’t complain and stuff, I feel like a weak person being in there talking about it. (Participant F)
If a doctor for a foot come in and tried to ask me and I know he’s a doctor for a foot… (Participant F)You wouldn’t? (Interviewer) No. And trust has to come in place. (Participant F)
It was hard to talk about it. Like you guys were pushing me into it. Now I understand you are just trying to find out. At first I thought ‘why do you keep asking me that, are you trying to get me to kill myself?’ It takes some getting used to. (Participant R)
Table 5. Worries about Consequences of Admitting Suicidal Ideation: Hospitalization or Medication
You’re pretty much asked if you want to harm yourself or harm anybody else and you know the consequences of saying yes—you would end up on the sixth floor. They would immediately call the police and they will detain you and take you to the sixth floor to be restrained. So it gets to the point where you want to avoid that if you have a lot going on in your life. I don’t know if it is such a good approach, because you always know the consequences. (Participant Z)I would say the reason it’s true is because I knew, dependent on the way that I answer, I was always going to have these doctors keep trying to push medication on me. (Participant O)
It’s difficult for me, one of the reasons I was worried about talking about it is the fact that I have a girlfriend who has a child. I am thinking in the back of my mind, if I really tell this lady some of the things that I thought about doing, you know, are we going to get a court order that my girlfriend’s kid can’t live with us? Or something like that? Or is that even a possibility or is she going to try and lock me up in a straitjacket? I have no idea what the response is going to be if I talk to someone honestly. (Participant O)
Sometimes I’m afraid that they’ll keep me here, and I won’t be able to go home or something, so. And I have a lot of problems I gotta fix so being here wouldn’t help that out. I see that they’re trying to help me, and make sure that nothing happens to me, but then at the same time, it kind of makes the problems worse ‘cause I have a lot of things going on outside the walls of the hospital. (Participant D)
Dr. XX knows my situation, he knows that, about my work, my wife, my kid. And another doctor that that wouldn’t know that would automatically probably assume that ‘he needs to be on the sixth floor for a couple weeks under supervision.’ (Participant H)
You tell somebody you’re feeling suicidal and they want to put the straitjacket on you—that don’t necessarily make me feel warm and fuzzy. (Participant AC)
And to tell someone that you want to admit them, it don’t make them feel at ease. Now I’m scared to tell you something. ‘Cause you’re telling me, I’m telling you my feeling and you want to admit me to the hospital, that sometimes makes a person, especially a soldier clam up. Now we open a can of worms. Who’s going to take care of my kids? My kids is coming home from school at 5:00. I mean when you talk about admitting me you scare the shit out of me. (Participant AC)
I’ve heard these stories about people getting shock therapy and then you think about movies like a Beautiful Mind, where he got the shock therapy? A more clear idea of what goes on, meaning, I’m not going to be able to go up there and eat bonbons and watch soap operas and just unwind. Am I gonna be in the straitjacket with calm down juice going through my veins 24/7 that I don’t feel like me no more. Cause I’m slobbering at the mouth. (Participant AC)
Well, you know, sometimes you get things that go through your mind, that if you tell the wrong people they’d be like, ‘Well, you are really, seriously screwed up so you need to go somewhere for an extended period of time,’ which is something that I don’t want―would not benefit me. And would make me even worse… (Participant T)
Have there been other times that you have been asked about suicide since you received at the VA? (Interviewer) Yeah, but that was earlier on and denying the inner beast is not – I mean you don’t exactly want to tell the complete truth with issues like that because you don’t want things to go badly. You don’t want things to progress and get worse because of care or mistreated care. (Participant T)
On that day that they asked you about suicide, did you have any hesitation to talk about it or…? (Interviewer) Maybe a little, but that is only because I don’t want to be locked up in a padded cell, you know. (Participant E)
It went a lot smoother than I thought it would. I figured I’d get snatched up, put in a straitjacket, I didn’t know. My mind was running ninety miles an hour, I didn’t know what to expect really. (Participant M)
Table 6. Facilitators to Admitting Suicidal Ideation: Readiness, Trust, and Meaning
And the new lady I talked to, she, I mean it was like a fresh start. She just asked, ‘Hey what’s going on?’ and I told her. (Participant AE)Whereas when speaking with [the therapist], it’s, ‘Well, you have kids, you gotta make sure that they’re okay, though to make sure they’re okay, you have to be okay.’ So it’s a more looking down the road to, ‘help me,’ not checking the blocks, but to help me. (Participant AB)
I think that I did not really know what to expect when I went to meet with him the very first time…I did not plan on telling him everything right up front but he made me feel very comfortable, so I wasn’t going to say everything that I told him that day, but he made me free very comfortable. (Participant AG)
‘Cause I’ve seen people do that on their screen ‘Have you ever attempted suicide,’ click on the screen. He didn’t do that. He actually sat down. He talked to me. He looked at me. He didn’t take his eyes off me. He talked to me and that’s what made me feel a lot better about it…” (Participant AG)
It was very reassuring to see them take a personal interest in me, to make sure me as an individual and as a person was going to be okay. (Participant Y)
I had one consistent person for a while. That was better because when I walked in the door she knew me. You feel like she knew you and she cared about you. (Participant AC)
I know we live in a world where people have to take days off and we are all dealing with the government. But you know that show ‘Monk’? You know he always talks to the same person? Well if you got to explain yourself every single time to a different person, what’s the point?” (Participant AC)
Because it’s her, yes…I felt very comfortable. That is how she got it out of me, ‘cause in order to make someone talk you have to make them feel comfortable and then you have to form a relationship with them. That is the most important thing for the VA, for the soldiers who are coming back, to feel comfortable with the person that they are talking to. (Participant L)
Each different part of their questionnaires, they would explain to me why they would be asking these questions and I was very comfortable with everything that was said and how I even explained back to them my feelings. (Participant AI)
It seemed like she was genuinely concerned. It wasn’t somebody with their nose down and no eye contact. There was eye contact and she actually asked it like—instead of reading it. (Participant V)
Of course it was difficult. Not so much being asked, he was fairly gentle and not aggressive. But he was pretty comfortable to talk to. More than anything else I got the impression right off the bat that he was there to be supportive. (Participant C)
I talked to one guy; he was actually really on-the-ball. He seemed like he knew what was going on. He talked about the problems and some of the issues…He understood the issues that I was going through at the time. He didn’t BS me or anything either, he was straight. (Participant T)
Table 7. Consequences of Admitting Suicidal Ideation: Shock, Relief, then Progress and Healing