ORIGINAL ARTICLE
“We're Afraid to Say Suicide”
Stigma as a Barrier to Implementing a Community-Based Suicide Prevention
Program for Rural Veterans
Lindsey L. Monteith, PhD,*† Noelle B. Smith, PhD,‡§ Ryan Holliday, PhD,*†
Brooke A. Dorsey Holliman, PhD,*|| Carl T. LoFaro, MSW,*|| and Nathaniel V. Mohatt, PhD*§¶
Abstract: Suicide is a significant public health concern for veterans residing in
rural communities. Although various initiatives have been implemented to pre-
vent suicide among veterans, efforts specific to rural veterans remain limited.
To aid such efforts, we examined stigma as a potential barrier to community readiness
in the implementation of a community-based suicide prevention program for rural
veterans. In this qualitative study, community readiness interviews were conducted
with 13 participants in a rural community. Themes included lack of awareness regard-
ing veteran suicide, rare discussions of veteran suicide, and suicide-related stigma
within the community. Results suggest that prioritizing destigmatization may be par-
ticularly important to implementing community-based suicide prevention program-
ming in rural communities. In particular, addressing community misconceptions
regarding veteran suicide, while increasing knowledge of the extent to which vet-
eran suicide occurs locally may facilitate increased awareness and thus community
readiness to prevent suicide among rural veterans.
Key Words: Veteran, suicide prevention, rural, stigma, community readiness
(J Nerv Ment Dis 2020;208: 371–376)
S uicide continues to present a major public health concern (Centers
for Disease Control and Prevention, 2018), particularly for rural
communities (Hirsch, 2006). Although suicide rates in the broader vet-
eran population remain significantly elevated in comparison to the gen-
eral adult population (Department of Veterans Affairs, 2018), rurality
seems to exacerbate this risk. Veterans who reside in rural areas are sig-
nificantly more likely to die by suicide, compared with their urban
counterparts, even when accounting for age, sex, region, and psychiat-
ric diagnoses (McCarthy et al., 2012).
Suicide in rural communities is likely influenced by multiple fac-
tors, including lower mental health care access and utilization (Hirsch,
2006; Hirsch and Cukrowicz, 2014). Despite high rates of mental health
concerns in rural populations, residents of rural communities consis-
tently access mental health services at lower rates (Smalley et al.,
2010). Although several contextual factors may explain decreased utili-
zation of mental health care (e.g., lower availability of services) in rural
communities, stigma seems to be salient in deterring rural individuals
from utilizing mental health care (Hirsch, 2006; Smalley et al., 2010).
Rural communities have higher levels of stigma regarding mental
health, as well as more severe public and self-stigma regarding using
mental health care, compared with urban communities (Jones et al.,
2011; Stewart et al., 2015). In addition, within rural communities, there
*Rocky Mountain Mental Illness Research, Education and Clinical Center for Suicide
Prevention; †Department of Psychiatry, University of Colorado Anschutz Medical
Campus, Aurora, Colorado; ‡VA Northeast Program Evaluation Center; §Depart-
ment of Psychiatry, Yale University School of Medicine, New Haven, Connecticut;
||Colorado School of Public Health; and ¶Department of Physical Medicine and Re-
habilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado.
Send reprint requests to Lindsey L. Monteith, PhD, Rocky Mountain Regional VA
Medical Center, MIRECC, 1700 North Wheeling, Aurora, CO 80045. E‐mail:
lindsey.monteith@va.gov.
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0022-3018/20/20805–0371
DOI: 10.1097/NMD.0000000000001139
The Journal of Nervous and Mental Disease • Volume 208, Number 5, May 2020
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
is more negative labeling of individuals who seek mental health care,
which is associated with being less likely to have personally sought
mental health care (Rost et al., 1993).
Stigma related to mental health and suicide has thus been posited
as a potential contributing factor in suicide (Pompili et al., 2003). More-
over, in a model of rural suicide by Stark et al. (2011), the authors postu-
lated that stigma is paramount in increasing risk for suicide. In particular,
they theorized that, in the presence of mounting psychosocial stressors
(e.g., social isolation) concurrent to perceptions of helplessness, stigma
regarding seeking mental health care decreases one's potential to escape
such factors, thereby increasing risk for suicide.
Indeed, studies have demonstrated the detriment of stigma across
various socioecological levels on mental health outcomes and risk for
suicide, albeit not in rural samples specifically. For example, structural
stigma (e.g., institutional and systemic policies and practices that re-
strict the rights of stigmatized individuals) and public stigma (e.g., be-
liefs or stereotypes held by the larger group) are associated with lower
social acceptance of individuals with mental health conditions, poten-
tially impacting openness to seeking help for risk factors (e.g., depres-
sion) associated with suicide (Schomerus et al., 2015). Internalized
stigma (i.e., when individuals internalize stereotypes and feel devalued;
Livingston and Boyd, 2010) is also associated with a host of negative
outcomes, including disempowerment, decreased hope, lower treatment
adherence, and suicidal ideation (Livingston and Boyd, 2010; Oexle
et al., 2017; Vrbova et al., 2018).
These factors may be further exacerbated within the veteran popula-
tion. Research has consistently found stigma to be a significant barrier to
mental health care among veterans, despite access and availability of
high-quality, evidence-based care (Vogt, 2011). A review by Vogt (2011)
identified stigma as particularly salient to military personnel and veterans.
In particular, the author discussed a myriad of beliefs that may underlie
perceptions of stigma and serve as particular deterrents to using mental
health care. These may include beliefs about oneself (e.g., being “unfit”
for duty), those with mental health diagnoses (e.g., that others will dis-
tance themselves from the veteran if they perceive him or her to have a
“psychological problem”), and those who seek mental health treatment.
As such, Vogt stressed the import of understanding stigma-related beliefs
in targeted populations to tailor interventions accordingly.
Unfortunately, suicide prevention programming that specifically
seeks to address stigma in rural veterans has been limited (Mohatt et al.,
2018). One intervention developed to address this gap is Together with Vet-
erans (TWV), a community-based suicide prevention program for vet-
erans residing in rural communities that encompasses stigma reduction.
Rural communities are provided with suicide-specific psychoeducation, re-
sources, facilitation, and training based on a public health model. These
components support rural communities in implementing local suicide pre-
vention efforts to reduce suicide risk factors, increase protective factors, and
promote health across multiple socioecological levels (Brenner et al., 2018;
Caine et al., 2017).
However, a critical aspect of understanding the extent to which
community-based suicide prevention interventions, such as TWV, can be
successfully implemented in rural communities is community readiness
www.jonmd.com 371
Monteith et al. The Journal of Nervous and Mental Disease • Volume 208, Number 5, May 2020
(i.e., the level of readiness within a community to participate in an interven-
tion; Allen et al., 2009; Edwards et al., 2000). The community readiness
model conceptualizes a community's readiness as being at one of nine
stages of change (i.e., no awareness, denial, vague awareness, preplanning,
preparation, initiation, stabilization, confirmation/expansion, professionali-
zation; Edwards et al., 2000). A community's level of readiness has direct
implications as to whether an intervention can be implemented (Edwards
et al., 2000) and for understanding what initial intervention components
should entail. For example, higher levels of preintervention community
readiness are associated with stronger postimplementation community
health impacts (Kostadinov et al., 2015). Thus, identifying factors that im-
pede community readiness is essential for determining which initiatives
may be necessary prerequisites to facilitate the success of subsequent
interventional efforts (Donnermeyer et al., 1997; Edwards et al.,
2000). Although a number of factors can impact community readiness
(e.g., awareness that a problem exists, understanding of how to address
a problem), stigma has not been examined explicitly with respect to
community readiness among rural veterans.
Thus, knowledge regarding the role of stigma in community read-
iness for rural veteran suicide prevention programming is needed. The
overarching aim of this manuscript was to explore the role of stigma in
community readiness for the implementation of a community-based sui-
cide prevention program for rural veterans (i.e., TWV).
METHODS
Participants
Community leaders running a TWV demonstration program in a
rural community identified and recruited participants following the
guidelines of the Community Readiness for Community Change manual
(Stanley, 2014). Community readiness interviews were conducted with
13 individuals in a US community who were identified by community
leaders as representing essential perspectives regarding veteran suicide pre-
vention within the community. These included individuals representing
veterans service organizations, healthcare, public health, government, law
enforcement, the judicial system, emergency response, media, religious
and spiritual leaders, and local businesses. This is consistent with recom-
mendations for assessing community readiness (Stanley, 2014), which
suggest interviewing a broad range of individuals who have knowledge
of the community.
In terms of the community itself, data were obtained from multi-
ple sources, including state- and county-level public health depart-
ments, as well as the VA (e.g., National Center for Veterans Analysis
and Statistics) to characterize the community. These data sources re-
vealed that the community is highly rural, ethnically diverse, and situ-
ated in a sparsely populated region characterized by persistent poverty
and poor health outcomes. Furthermore, veterans comprised a higher
proportion of the community's population compared with both the state
and national averages. In addition, the suicide rate within the commu-
nity exceeded the national suicide rate. To protect the identity of both
participants and the community, further details are being withheld.
Procedures
Individuals suggested by community leaders as being knowledge-
able regarding the community were contacted by our team to invite them
to participate in the interview and to facilitate scheduling. The majority of
individuals identified participated, with the exception of one individual,
who could not participate due to scheduling difficulties. All interviews
were conducted within the community by individuals on our team.
For this manuscript, we relied upon secondary data analysis of
qualitative data collected during the TWV needs assessment phase. Spe-
cifically, community readiness interviews were conducted to assess the
community's level of readiness (Stanley, 2014). Following guidelines
for conducting community readiness assessments, which recommend
372 www.jonmd.com
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
clearly defining the issue and the community (Stanley, 2014), the inter-
view guide was modified to assess veteran suicide prevention in this rural
community. Interview questions assessed community knowledge of local
efforts to address veteran suicide and of the issue of veteran suicide, lead-
ership, and the community climate, as well as resources related to veteran
suicide prevention within the community. Example questions included
the following: “Using a scale from 1 to 10, how much of a concern is vet-
eran suicide in [the community]… please explain; What are the primary
obstacles to efforts addressing veteran suicide in [this community]? How
knowledgeable are [community] citizens about veteran suicide?” Com-
munity readiness interviews were audiorecorded and transcribed. Inter-
views were subsequently scored by two or more reviewers, who met to
achieve consensus on their community readiness scores. All participants
provided verbal consent to participate in this project, which was approved
by the local institutional review board.
Qualitative Analysis
An abductive approach, composed of both inductive and deduc-
tive processes, was used to analyze interview transcripts for the pres-
ence and manifestation of stigma. Analysis was deductive in that
transcripts were examined for mentions of stigma specifically, while
also inductive because we did not have predetermined or a priori codes.
Patterns and themes within the interviews were identified through thematic
analysis (Braun and Clarke, 2006). Two or more coders independently
coded each transcript, using descriptive and in vivo coding methods. De-
scriptive coding assigns labels to data to summarize in a word or short
phrase the basic topic discussed, while in vivo coding uses words or short
phrases from participants' own language as codes (Saldaña, 2016). The
team met to achieve consensus regarding themes that emerged from the in-
terviews. During consensus meetings, codes and categories were carefully
examined, and overarching themes were identified. Results were then orga-
nized around the broader themes that described stigma surrounding veteran
suicide in the community. The main themes that emerged are presented be-
low, with individual quotes provided for additional context. Identifying in-
formation has been removed.
RESULTS
Overall, results revealed a low level of community readiness. Re-
sults also indicated both direct and indirect mention of stigma. Overall,
there was a lack of awareness of the issue of veteran suicide and wide-
spread lack of knowledge surrounding resources and efforts to address
veteran suicide within the community. The broad themes that emerged
were as follows: 1) lack of community awareness of veteran suicide;
2) lack of discussion related to suicide; and 3) stigma about suicide.
These are described below.
Theme 1: Lack of Community Awareness of
Veteran Suicide
Lack of Knowledge and Prioritization
Many participants described a general lack of awareness that sui-
cide among veterans was an issue in their community. Relatedly, com-
munity members described a lack of community awareness of local
suicide prevention efforts for veterans. For example, one participant
stated the following regarding suicide prevention efforts for veterans
within the community: “My guess is that most people just don't know
that much. But I don't know that most people are very much aware…
possibly veterans are, veterans and their families….” When asked about
community members' knowledge of veteran suicide, another participant
stated: “I don't think too many people would know or even have an
idea.” This individual described several other issues community mem-
bers considered to be local concerns for veterans, but questioned the ex-
tent to which the community prioritized suicide as a concern: “I don't
know if specifically suicide is really considered a concern or an issue.
© 2019 Wolters Kluwer Health, Inc. All rights reserved.
The Journal of Nervous and Mental Disease • Volume 208, Number 5, May 2020
I think it's how do we help [veterans] integrate, get them a job, do the
housing part. If someone comes back without an arm, how do you help
them with that, that kind of thing. I just don't know if suicide… I'm sure
it's there, but I don't know if that is the primary for most people.”
Awareness Limited to Subsets of the Population
Participants also suggested that community members generally
would not be as supportive or knowledgeable about community efforts
to prevent veteran suicide unless they personally had been affected by
suicide and/or knew veterans or were veterans themselves. “I would
say, unless it has affected them, particularly in their family, they are
probably not aware of those services.” Another respondent suggested
that this also applied to gatekeeper training (i.e., training nonspecialists
to recognize, respond to, and refer individuals at risk for suicide to ap-
propriate care; Yonemoto et al., 2018): “Other times the people who are
attending [gatekeeper trainings] have had suicide affect them in one
way or another—they either know somebody, a family member.” Sim-
ilarly, another interviewee indicated that community members would
likely be more knowledgeable about veteran suicide and efforts to ad-
dress it within the community if they personally had family or friends
who were veterans: “…people who have more veterans in their families
and in their immediate circle of friends, I would imagine would have a
much higher level of awareness and therefore concern about it.” Results
indicated that personal knowledge or connection to veterans increased
awareness and prioritization of this issue.
Theme 2: Suicide Is Not Discussed
Not Talked About Within the Community
The general lack of awareness of veteran suicide within the
broader community seemed to relate to the lack of discussions taking
place within the community about veteran suicide. “It's not something
that I hear people talk about very often in my particular circles.” An-
other participant described: “It's not that people don't care, but at least
from my perspective, it's not anything I hear about.” An implication
of community members not talking about veteran suicide was a lack
of recognition that veteran suicide was an important problem within
the community, as described by another individual: “I don't think the av-
erage citizen here would recognize [veteran suicide] as being a big
problem… because it's not put in the forefront…a lot of this stuff is
put on the back burner and if you don't see it, you don't want to
acknowledge it.”
Rarely in the Local Media
In addition to not hearing community members talk about vet-
eran suicide, the majority of participants specifically noted that they
were not reading or hearing through local media outlets about veteran
suicide within their community. “I don't see anything in the newspaper.
I don't see a lot. I almost have the impression that some veterans are
aware. But I don't see it out there, like there's nothing. There's no flyers,
there's nothing in the newspaper. There are small events here or there.
But I'm not seeing it.” Another community stakeholder described the
dearth of local media coverage on veteran suicide within the commu-
nity: “You hear things once in a while, but it's not a constant message.”
This was considered a major factor contributing to the lack of awareness
in the community about the issue of veteran suicide. “I am not hearing
about it from my standpoint. I am unaware there are veterans commit-
ting suicide in [this community] or attempting to.”
Some participants acknowledged hearing about veteran suicide
nationally, but described the limitations of only hearing about it on a na-
tional level: “There's a problem, but it's happening outside of [this com-
munity]…we don't know if we have any here in [town], but I haven't
heard of anybody…we hear about it on TV from happening in other
states or maybe in the big cities, but in these small rural communities,
© 2019 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Suicide Stigma in Rural Communities
unless you know the family or you know because you have lived in
[the community] a long time and you know what has happened, no
one else knows…like I said, word is not out that this is a problem that needs
to be fixed.” This individual further elaborated on the need for local efforts
focused on recognizing veteran suicide as an issue within the community:
“We need something here in [this community], but we need something that
is out there that puts it out in the forefront, not just something on the na-
tional TV that is ‘oh this war veteran commits suicide…’ That is detached
from [the community]. That's nothing, but when [the community] knows
there are people here that are suffering, that they need help and we have this
group here, we can get them to…then it's personal and we gotta [sic] make
this veteran's problem personal to [the community].”
Theme 3: Stigma About Suicide
Preference Not Talk to About It
A few participants suggested that, rather than there being a lack
of community awareness of veteran suicide, community members sim-
ply preferred not to talk about suicide: “So there is awareness, but there
is also the knowledge that we don't talk about it. So we may know about
that, that there are a lot of people that commit suicide, and veterans are
at higher risk, but…we don't talk about it…. It goes back to ‘we know
about it, we just don't want to talk about it.’” Others also made state-
ments suggesting that stigma about suicide existed within their commu-
nity and that it posed a barrier to discussing and preventing veteran
suicide. Participants' statements suggested that there was an overall
sense of discomfort within the community in talking about suicide,
such that people did not want to talk about suicide or were uncomfort-
able doing so. One participant described suicide as “kind of a new
word…it's been around. It's been a concern for a while or historically,
but I think recently, I don't think it's been a whole lot.” For these partic-
ipants, a community-wide preference to avoid the topic contributed to
lack of discourse and minimal local efforts to address veteran suicide.
Fear
Relatedly, fear of talking about suicide was described as a major
reason that people within the community were not talking about veteran
suicide. “Suicide is one of those more… we're afraid to say suicide
[whispers]. You know, it's the ‘S’ word. And people are afraid. If I say
‘suicide,’ someone is going to kill themselves, you know? Or if we talk
about it, it's going to bring that into people's minds, and if we just leave
it alone, they won't think about it.” Fear of talking about suicide was
identified as a major barrier to preventing veteran suicide in the com-
munity. When asked about barriers to implementing suicide prevention
programming in the community, one participant stated: “The fear. The
people are afraid to, you know, suicide… ‘We shouldn't talk about sui-
cide.’ It's not something that people talk about, especially with veterans,
and it's just the opposite. We should absolutely be talking with veterans
about suicide all the time and making sure that they are supported and
that they have the resources that they need.” Another individual de-
scribed the pervasiveness of stigma within the community: “There's al-
ways a stigma…there's a stigma around mental health or seeking care or
being depressed or suicidal…so when we get away from having that
conversation about stigma to saying it's a norm, I'd say we got there.
But it's still there for sure.”
Suicide as More Stigmatized Than Other Mental
Health Conditions
Another potential indication of the stigma associated with suicide
within the community was that suicide was considered more stigmatizing
than other mental health conditions. One interviewee suggested that com-
munity members would be more open to seek treatment for depression
than suicide. “I think depression is one of those things where, I don't
know if it's more, I want to say it's more common…but there is more
www.jonmd.com 373
Monteith et al. The Journal of Nervous and Mental Disease • Volume 208, Number 5, May 2020
awareness maybe to it right now. There is more openness to seek help for
depression versus suicide.”
Preference to Seek Help Through Family and Friends
Rather Than Mental Health Professionals
Relatedly, participants conveyed the belief that veterans in their
community would be reluctant to seek help from mental health profes-
sionals if they became suicidal, believing that they would be more likely
to seek care for other mental health concerns. Participants stated that
family and friends would be the first people that veterans seeking help
for suicidal thoughts would likely turn to within their community.
“Family…because I think historically when people have had trou-
ble…their first reaction is to go to family.” Similarly, another individual
speculated: “Maybe they would keep [suicide] more internal and talk to
their family or friends…. They rely a lot on their family and friends.”
Alternately, one participant stated: “You'd think they'd turn to family
and sometimes they just don't ‘cause they are afraid to show that weak-
ness. Some will turn to family, some will turn to your VA…most won't
turn to anybody.” Consequently, informal sources of support were gen-
erally considered the first lines of support that veterans in the commu-
nity would reach out to if suicidal and seeking help. This seemed to be
due to general help-seeking norms and suicide-related stigma within
the community.
Privacy
The perceived reluctance to seek professional help when suicidal
may have also derived from a general wariness of mental health care,
due to concerns about privacy and mistrust. In this way, the preference
to seek help from family and friends, combined with the emphasis on
privacy, seemed to be an indication of stigma. “Trying to get people
to want to discuss their issues with someone they don't know… I would
characterize it as a deep-seated desire for privacy.” This participant elab-
orated further regarding “the privacy concerns of the veterans. It's rare
for veterans to identify themselves as veterans in any context. I don't
think they see much advantage to it…. You may know who is a veteran,
but you may not know whether or not they are having any repercussions
as a result.” The closeness of the small rural community seemed to exac-
erbate the desire for privacy: “Close-knit family community, and that has
its strength and weaknesses. The weaknesses being that everybody
knows everything about everything and everyone.” Another participant
indicated that, “Also, it's really hard building trust out there because there
is a little paranoia …they are really leery of people going out there.”
DISCUSSION
Qualitative analysis of community readiness interviews yielded a
number of themes indicating significant barriers to implementing com-
munity-based suicide prevention programming for rural veterans. In
particular, lack of knowledge and awareness, combined with stigma,
emerged through interviews with community members. In some cases,
suicide was not recognized as a local issue warranting concern within
the community, which may relate to underestimation in the prevalence
of mental health concerns common in rural communities (Bartlett
et al., 2006). Conversely, suicide was minimized in comparison to other
problems. Although many participants readily stated the community's
interest in implementing a suicide prevention program for veterans, further
questioning revealed significant barriers to community readiness. These re-
sults extend prior research regarding stigma and suicide (Schomerus et al.,
2015) by suggesting that stigma may play a key role in rural communities'
level of readiness to engage in suicide prevention programming.
Given the lack of knowledge and awareness regarding suicide
and suicide prevention efforts in the community, the recommended
course of action is increasing awareness of the issue of veteran suicide
within the broader community. Suicide literacy campaigns may help to
374 www.jonmd.com
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
increase knowledge regarding suicide among individuals who have not
had exposure to suicide (Batterham et al., 2013).
Furthermore, there was a culture of not talking about suicide,
even when there was awareness of the issue. Community members
feared that speaking of suicide increased its acceptability and could lead
to more suicides, despite evidence that asking and talking about suicide
may actually prevent suicidal self-directed violence (Dazzi et al., 2014).
This finding is consistent with the literature at large, which suggests
that, although mental health stigma has steadily decreased, stigma sur-
rounding suicide has remained relatively stable (Sudak et al., 2008), in-
cluding among rural veterans (Stotzer et al., 2011). Moreover, it seems
that help-seeking for mental health concerns (e.g., depression) was per-
ceived to be more likely and acceptable than seeking help when suicidal.
This is also consistent with prior research suggesting that suicide-related
stigma may be more severe and persistent than mental health-related
stigma (Sheehan et al., 2017; Sudak et al., 2008). As stigma can deter
help-seeking (Corrigan, 2004) and is associated with increased rates of
suicide (Schomerus et al., 2015), determining the most effective means
of decreasing suicide-related stigma in rural communities is essential.
Reducing stigma through public awareness and education, as well
as gatekeeper training, may be important suicide prevention strategies in
rural communities (Mann et al., 2005). Multilevel suicide prevention ap-
proaches that incorporate destigmatization have demonstrated effective-
ness in decreasing stigma and increasing mental health help-seeking
behavior (Knox et al., 2003, 2010), although initiatives specific to rural
veterans warrant further evaluation. Mass media campaigns can reduce
stigma regarding mental health and treatment-seeking, while increa-
sing knowledge regarding seeking help (Clement et al., 2013;
Niederkrotenthaler et al., 2014; Wakefield et al., 2010). In addi-
tion, stigma can be further reduced when individuals perceive there to
be more relevance or similarity with the individuals depicted (Caputo
and Rouner, 2011). Thus, given the reluctance and fear of talking about
suicide within this rural community, mass media could help to combat
suicide-specific stigma, address erroneous stereotypes and assumptions,
and improve knowledge within communities. Destigmatization efforts
through mass media could be further reinforced at an individual-level
by healthcare providers, who could provide education regarding suicide
and ways to prevent it. Stigma can also be reduced by increasing contact
with stigmatized individuals (Corrigan and Kosyluk, 2013) and utilizing
strategies to deflect biases (Schmader et al., 2013). These multipronged
efforts could help to reduce stigma, increase knowledge of suicide risk,
and ultimately increase help-seeking (Niederkrotenthaler et al., 2014).
There were also concerns regarding privacy, which centered
around the belief that individuals would lose privacy and that others
would find out about their problems if they were to seek professional
mental health care when suicidal. Such concerns may be exacerbated
in small rural communities where maintaining privacy and confidential-
ity can prove more difficult (e.g., being recognized or seen at a mental
health provider's office; Stotzer et al., 2011). One strategy to mitigate
this concern is to emphasize the importance of developing trust when
discussing suicide, particularly with veterans (Ganzini et al., 2013).
For example, healthcare providers could ensure that their patients un-
derstand that disclosure of suicidal ideation will be held confidential
and will not in itself necessitate hospitalization, except in imminently
life-threatening circumstances.
Such an approach may be particularly pragmatic for addressing
underlying, erroneous beliefs regarding mental health treatment that are
common among rural and veteran populations (Stark et al., 2011; Vogt,
2011). Erroneous perceptions of the consequences of disclosing suicidal
thoughts and behaviors may serve as barriers to suicide prevention in the
community. For example, as problems are kept private and isolated from
general awareness, individuals and the system itself may only acknowl-
edge and recognize veteran suicide as a national issue. This may dampen
a community's readiness to address veteran suicide, as the problem may
seem to be less prominent or locally widespread.
© 2019 Wolters Kluwer Health, Inc. All rights reserved.
The Journal of Nervous and Mental Disease • Volume 208, Number 5, May 2020
Leading theories of suicide underscore thwarted belongingness
as a hallmark driver of suicidal thoughts (Van Orden et al., 2010); fur-
ther, family and friends may be part of a core system necessary to the
successful implementation of rural veteran suicide prevention program-
ming (e.g., TWV). Indeed, rural community members were perceived to
be more willing to seek help from family and close friends. Although a
preference for seeking help from friends has been reported in other pop-
ulations (e.g., Ciarrochi and Deane, 2001), this may be particularly rel-
evant in rural communities, in which there is often a strong sense of
collectivistic family structures (Hirsch, 2006). Similarly, veteran cul-
ture, which is rooted in a cohesive nature during one's military service,
also often has a collectivistic culture that can impact openness to help-
seeking outside of family or the community (Weiss and Coll, 2011).
This highlights the importance of family, friends, and peers in mental
health and suicide prevention specific to these populations. However,
considering that individuals with a history of suicidal behavior are more
likely to experience stigma from individuals within their social net-
works, relative to other sources (e.g., mental health providers), and that
perceived stigma from individuals in one's social network is associated
with depressive symptom severity (Frey et al., 2016), it may be partic-
ularly important to ensure that stigma reduction efforts include individ-
uals in rural veterans' social networks. As noted by Hom et al. (2015),
encouragement from close individuals to seek help, increasing positive
perceptions of mental health services, and increased understanding of
mental health may be particularly impactful. However, given the overall
limited awareness of veteran suicide at the community level, increasing
awareness of the issue may be a particularly integral first step.
It is important to acknowledge the limitations of the present study.
Data were obtained from a single rural community, and it is possible that
the generalizability of these findings to other rural communities may be
limited based on a number of factors (e.g., geographic region). In addi-
tion, although participants were selected in a manner consistent with
guidelines for assessing community readiness (Stanley, 2014), it is possi-
ble that participants' perspectives were not consistent with those of other
community members. It is also possible that a more open-ended qualita-
tive interview designed specifically to explore stigma would have yielded
different results than this secondary analysis of community readiness in-
terviews. For example, it is possible that we missed important manifesta-
tions or nuances of stigma, suggesting the need for replication of these
findings in other rural communities.
CONCLUSIONS
Findings from the present study suggest a number of general and
stigma-related barriers potentially impacting community readiness for a
rural veteran suicide prevention program. Such stigma may manifest in
various ways—through preventing discussions of veteran suicide
among community members, preclusion of local media efforts focused
on veteran suicide, strong preferences to seek help from close trusted in-
dividuals (e.g., family or friends), and a reticence to seek care from
mental health professionals. Our findings suggest that these manifesta-
tions of stigma toward suicide may inhibit community readiness, in par-
ticular, via diminished knowledge and awareness of veteran suicide as a
local issue. This, in turn, has direct implications for the types of inter-
vention strategies that can be successfully implemented to address vet-
eran suicide within such communities, as well as for the sustainability
and effectiveness of suicide prevention efforts that fail to attend to
stigma early in the implementation process. A multipronged approach
to reducing community stigma and growing broad awareness and sup-
port, as described by the community readiness model, may be an essen-
tial prerequisite to facilitating motivation for action needed for effective
implementation of community-based suicide prevention programming
for rural veterans.
© 2019 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Suicide Stigma in Rural Communities
DISCLOSURE
This material is based upon work supported in part by the US Depart-
ment of Veterans Affairs (VA), the Veterans Health Administration Office of
Rural Health, the Rocky Mountain MIRECC, and the VA Office of Aca-
demic Affiliations, Advanced Fellowship Program in Mental Illness Re-
search and Treatment. In the 3 years preceding submission of this
manuscript, Dr. Monteith received grant funding from the VA Office of Ru-
ral Health, VA Office of Mental Health and Suicide Prevention, VA National
Center for Patient Safety, VA Health Services Research and Development
(in kind), Military Suicide Research Consortium, and Colorado Depart-
ment of Human Services; Dr. Holliday received research funding from
the Jerry M. Lewis M.D. Mental Health Foundation and fellowship funding
from the VA Office of Academic Affiliations, Advanced Fellowship Program
in Mental Illness Research and Treatment; Dr. Dorsey Holliman received
grant funding from the VA Office of Rural Health and the VA Rehabilitation
Research and Development Service; Dr. Mohatt received grant funding
from the VA Office of Rural Health, VA Office of Mental Health and Suicide
Prevention, the Military Operational Medicine Research Program, the
Patient-Centered Outcomes Research Institute, and VA National Center
for Patient Safety. The authors declare no conflict of interest.
The views expressed are those of the authors and do not necessar-
ily represent the views or policy of the Department of Veterans Affairs or
the US Government.
REFERENCES
Allen J, Mohatt G, Fok CC, Henry D, People Awakening Team (2009) Suicide preven-
tion as a community development process: Understanding circumpolar youth sui-
cide prevention through community level outcomes. Int J Circumpolar Health.
68:274–291.
Bartlett H, Travers C, Cartwright C, Smith N (2006) Mental health literacy in rural
Queensland: Results of a community survey. Aust N Z J Psychiatry. 40:783–789.
Batterham PJ, Calear AL, Christensen H (2013) Correlates of suicide stigma and sui-
cide literacy in the community. Suicide Life Threat Behav. 43:406–417.
Braun V, Clarke V (2006) Using thematic analysis in psychology. Qual Res Psychol. 3:
77–101.
Brenner LA, Hoffmire C, Mohatt N, Forster JE (2018) Preventing suicide among vet-
erans will require clinicians and researchers to adopt a public health approach.
Available at: https://www.hsrd.research.va.gov/publications/forum/spring18/.
Caine E, Reed J, Hindman J, Quinlan K (2017) Comprehensive, integrated approaches
to suicide prevention: Practical guidance. Inj Prev. 24:i38–i45.
Caputo NM, Rouner D (2011) Narrative processing of entertainment media and men-
tal illness stigma. Health Commun. 26:595–604.
Centers for Disease Control and Prevention (2018) Suicides Rising Across the US:
More than a Mental Health Concern. Available at: https://www.cdc.gov/
vitalsigns/suicide/index.html.
Ciarrochi JV, Deane FP (2001) Emotional competence and willingness to seek help
from professional and nonprofessional sources. Br J Guid Counc. 29:233–246.
Clement S, Lassman F, Barley E, Evans-Lacko S, Williams P, Yamaguchi S, Slade M,
Rüsch N, Thornicroft G (2013) Mass media interventions for reducing mental
health-related stigma. Cochrane Database Syst Rev. 2013:CD009453.
Corrigan PW (2004) How stigma interferes with mental health care. Am Psychol. 59:
614–625.
Corrigan P, Kosyluk K (2013) Erasing the stigma: Where science meets advocacy. Basic
Appl Soc Psych. 35:131–140.
Dazzi T, Gribble R, Wessely S, Fear NT (2014) Does asking about suicide and related be-
haviours induce suicidal ideation? What is the evidence? Psychol Med. 44:3361–3363.
Department of Veterans Affairs (2018) VA National Suicide Data Report: 2005–2015.
Available at: https://www.mentalhealth.va.gov/docs/data-sheets/OMHSP_
National_Suicide_Data_Report_2005-2015_06-14-18_508-compliant.pdf.
Donnermeyer J, Plested B, Edwards R, Oetting G, Littlethunder L (1997) Community
readiness and prevention programs. J Community Development Society. 28:65–83.
www.jonmd.com 375
Monteith et al. The Journal of Nervous and Mental Disease • Volume 208, Number 5, May 2020
Edwards RW, Jumper-Thurman P, Plested BA, Oetting ER, Swanson L (2000) Com-
munity readiness: Research to practice. J Community Psychol. 28:291–307.
Frey LM, Hans JD, Cerel J (2016) Perceptions of suicide stigma. Crisis. 37:95–103.
Ganzini L, Denneson LM, Press N, Bair MJ, Helmer DA, Poat J, Dobscha SK (2013)
Trust is the basis for effective suicide risk screening and assessment in veterans.
J Gen Intern Med. 28:1215–1221.
Hirsch JK (2006) A review of the literature on rural suicide. Crisis. 27:189–199.
Hirsch JK, Cukrowicz KC (2014) Suicide in rural areas: An updated review of the lit-
erature. J Rural Ment Heal. 38:65–78.
Hom MA, Stanley IH, Joiner TE (2015) Evaluating factors and interventions that in-
fluence help-seeking and mental health service utilization among suicidal individ-
uals: A review of the literature. Clin Psychol Rev. 40:28–39.
Jones AR, Cook TM, Wang J (2011) Rural–urban differences in stigma against depression
and agreement with health professionals about treatment. J Affect Disord. 134:145–150.
Kostadinov I, Daniel M, Stanley L, Gancia A, Cargo M (2015) A systematic review of
community readiness tool applications: Implications for reporting. Int J Environ
Res Public Health. 12:3453–3468.
Knox KL, Litts DA, Talcott GW, Feig JC, Caine ED (2003) Risk of suicide and related
adverse outcomes after exposure to a suicide prevention programme in the US Air
Force: Cohort study. BMJ. 327:1376–1378.
Knox KL, Pflanz S, Talcott GW, Campise RL, Lavigne JE, Bajorska A, Tu X, Caine
ED (2010) The US Air Force suicide prevention program: Implications for public
health policy. Am J Public Health. 100:2457–2463.
Livingston JD, Boyd JE (2010) Correlates and consequences of internalized stigma for
people living with mental illness: A systematic review and meta-analysis. Soc Sci
Med. 71:2150–2161.
Mann J, Apter A, Bertolote J, Beautrais A, Currier D, Haas A, Hegerl U, Lonnqvist J,
Malone K, Marusic A, Mehlum L, Patton G, Phillips M, Rutz W, Rihmer Z, Schmidtke
A, Shaffer D, Silverman M, Takahashi Y, Varnik A, Wasserman D, Yip P, Hendin H
(2005) Suicide prevention strategies: A systematic review. JAMA. 294:2064–2074.
McCarthy JF, Blow FC, Ignacio RV, Ilgen MA, Austin KL, Valenstein M (2012) Sui-
cide among patients in the Veterans Affairs health system: Rural–urban differ-
ences in rates, risks, and methods. Am J Public Health. 102:S111–S117.
Mohatt NV, Billera M, Demers N, Monteith LL, Bahraini NH (2018) A menu of options: Re-
sources for preventing veteran suicide in rural communities. Psychol Serv. 5:262–269.
Niederkrotenthaler T, Reidenberg DJ, Till B, Gould MS (2014) Increasing help-seek-
ing and referrals for individuals at risk for suicide by decreasing stigma: The role
of mass media. Am J Prev Med. 47:S235–S243.
Oexle N, Rüsch N, Viering S, Wyss C, Seifritz E, Xu Z, Kawohl W (2017) Self-stigma and
suicidality: A longitudinal study. Eur Arch Psychiatry Clin Neurosci. 267:359–361.
Pompili M, Mancinelli I, Tatarelli R (2003) Stigma as a cause of suicide. Br J Psychi-
atry. 183:173–174.
376 www.jonmd.com
Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
Rost K, Smith GR, Taylor JL (1993) Rural-urban differences in stigma and the use of
care for depressive disorders. J Rural Health. 9:57–62.
Saldaña J (2016) The coding manual for qualitative researchers. Los Angeles: SAGE
Publications.
Schmader T, Croft A, Whitehead J, Stone J (2013) A peek inside the targets' toolbox:
How stigmatized targets deflect discrimination by invoking a common identity.
Basic Appl Soc Psych. 35:141–149.
Schomerus G, Evans-Lacko S, Rüsch N, Mojtabai R, Angermeyer MC, Thornicroft G
(2015) Collective levels of stigma and national suicide rates in 25 European coun-
tries. Epidemiol Psychiatr Sci. 24:166–171.
Sheehan L, Dubke R, Corrigan PW (2017) The specificity of public stigma: A compar-
ison of suicide and depression-related stigma. Psych Res. 256:40–45.
Smalley KB, Yancey CT, Warren JC, Naufel K, Ryan R, Pugh JL (2010) Rural mental
health and psychological treatment: A review for practitioners. J Clin Psychol. 66:
479–489.
Stanley LR (2014) Community readiness for community change (2nd ed). Fort Collins,
CO: Tri-Ethnic Center for Prevention Research, Colorado State University.
Stark CR, Riordan V, O'Connor R (2011) A conceptual model of suicide in rural areas.
Rural Remote Health. 11:1622.
Stewart H, Jameson JP, Curtin L (2015) The relationship between stigma and self-
reported willingness to use mental health services among rural and urban older
adults. Psychol Serv. 12:141–148.
Stotzer RL, Whealin JM, Darden D (2011) Social work with veterans in rural commu-
nities: Perceptions of stigma as a barrier to accessing mental health care. Adv Soc
Work. 13:1–16.
Sudak H, Maxim K, Carpenter M (2008) Suicide and stigma: A review of the literature
and personal reflections. Acad Psychiatry. 32:136–142.
Van Orden KA, Witte TK, Cukrowicz KC, Braithwaite SR, Selby EA, Joiner TE Jr.
(2010) The interpersonal theory of suicide. Psychol Rev. 117:575–600.
Vogt D (2011) Mental health-related beliefs as a barrier to service use for military per-
sonnel and veterans: A review. Psychiatr Serv. 62:135–142.
Vrbova K, Prasko J, Ociskova M, Holubova M, Kantor K, Kolek A, Grambal A,
Slepecky M (2018) Suicidality, self-stigma, social anxiety and personality traits
in stabilized schizophrenia patients – a cross-sectional study. Neuropsychiatr Dis
Treat. 14:1415–1424.
Wakefield MA, Loken B, Hornik RC (2010) Use of mass media campaigns to change
health behaviour. Lancet. 376:1261–1271.
Weiss E, Coll JE (2011) The influence of military culture and veteran worldviews on
mental health treatment: Practice implications for combat veteran help-seeking
and wellness. Int J Health Wellness Soc. 1:75–86.
Yonemoto N, Kawashima Y, Endo K, Yamada M (2018) Gatekeeper training for sui-
cidal behaviors: A systematic review. J Affect Disord. 246:506–514.
© 2019 Wolters Kluwer Health, Inc. All rights reserved.