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Original Articles

Gender Differences in Recovery Needs After a Suicide Attempt

A National Qualitative Study of US Military Veterans

Denneson, Lauren M. PhD*,†; Tompkins, Kyla J. MA*; McDonald, Katie L. BS*; Britton, Peter C. PhD; Hoffmire, Claire A. PhD§; Smolenski, Derek J. PhD; Carlson, Kathleen F. PhD*,¶; Dobscha, Steven K. MD*,†

Author Information
doi: 10.1097/MLR.0000000000001381
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Abstract

Suicide remains a pressing concern in the United States, as suicide rates continue to rise across most demographic and socioeconomic sectors of the population.1 Veterans are 1.5 times more likely to die by suicide than nonveterans, with age-adjusted and sex-adjusted suicide rates at 27.7 per 100,000 among veterans and 16.8 per 100,000 among nonveterans (2107).2 Unaccounted for in these numbers are the many more people who attempt suicide and live. Although exact numbers of nonfatal suicide attempts are difficult to ascertain, some estimates suggest that there are 30 times as many nonfatal suicide attempts as fatal suicide attempts in the general population, or 1.4 million people with nonfatal suicide attempts in the United States each year.3

Nonfatal suicide attempts are one of the strongest known predictors of future suicide attempts4–6 and are associated with increased risk of all-cause mortality.6 Suicide attempts also occur within the context of considerable mental, physical, and psychosocial burden7–9 that typically remains after the suicide attempt. Importantly, nonfatal suicide attempts are more common among women than men, despite dying by suicide at lower rates.1,2 Surveillance data from the Veterans Health Administration (VHA) show that women veterans are 1.3 times more likely to report nonfatal suicidal behavior than men veterans.10 Furthermore, some research suggests that risk and protective factors for suicide attempts differ by gender.8,11–13 For example, a study of homeless veterans found that harmful relationship experiences, fearfulness, and low self-esteem were more strongly associated with nonfatal suicide attempts among women than men, while substance use, aggression, low resilience, and low self-efficacy were more strongly associated with nonfatal suicide attempts among men than women.11 These gender differences in suicidal behavior patterns and risk and protective factors for suicide attempts suggest that recovery needs after an attempt may also differ by gender.

Few studies have focused on how to help patients recover from a nonfatal suicide attempt, but the available work does suggest that recovery needs after a suicide attempt may differ by demographic characteristics, such as age and country of origin.14–16 Older individuals in western cultures tend to express a loss of control over their lives, which they wish to regain,14,15 with younger individuals seeking the development of personal agency and self-responsibility.16 In a study out of Taiwan,17 middle-aged patients sought self-worth. However, no prior studies have examined gender differences in recovery needs after a suicide attempt. In this study, we interviewed a national sample of 50 US military veterans after a recent suicide attempt to compare recovery needs by gender.

METHODS

Data for this study were collected as part of a large national, mixed-methods project examining suicide risk and resilience among VHA healthcare-utilizing veterans. Detailed methods are described elsewhere.18 The study was approved by the institutional review board where the study was conducted, and all participants gave their informed consent to participate.

Setting and Sample Recruitment

The VHA is an integrated health care system that serves over 9 million patients across 1255 US facilities. Participants were recruited using the VHA’s National Patient Care Database, which contains diagnosis and health care utilization data for all patients. VHA uses Suicide Behavior Reports (SBRs) to record self-harm-related events in patients’ medical records, including suicide attempts. The records contain details of the self-harming behavior, such as the date of the reported event, a description of the behavior, and the level of suicidal intent.19 International Classification of Disease Clinical Modification—10th (ICD-10) diagnoses codes for self-directed violence are also used to document self-harming behavior. We used both SBRs and ICD-10 self-harm codes to identify patients who had engaged in self-harming behavior within the prior 6 months. Study staff then reviewed SBR details and clinical progress notes to confirm suicide attempt status. Hearing impaired, non-English speaking, and institutionalized veterans were excluded, as were veterans with dementia and a designated guardian.

We used purposive sampling to recruit a demographically, geographically, and clinically diverse sample.20 Study staff contacted potentially eligible patients’ (n=497) treating clinicians with an overview of the study and invited them to share the study information with their patients. With clinician and patient permission, we telephoned patients interested in participating, confirmed their eligibility, and invited them to be interviewed. Patients provided informed consent and self-reported demographic information over the phone before the interview was scheduled (n=52). Table 1 describes characteristics of the 50 participants who completed interviews.

TABLE 1 - Demographic and Clinical Characteristics of the Sample
n (%)
Characteristics Women (N=25) Men (N=25)
Age (mean, SD) 42 (12.1) 48 (14.8)
Race/ethnicity
 White 15 (60.0) 13 (52.0)
 Black/African American 4 (16.0) 3 (12.0)
 Multiracial 1 (4.0) 2 (8.0)
 American Indian or Alaskan Native 0 (0.0) 2 (8.0)
 Asian 0 (0.0) 2 (8.0)
 Hispanic/Latino 5 (20.0) 3 (12.0)
Mental health diagnoses
 Anxiety/panic disorder 14 (56.0) 9 (36.0)
 Depression 20 (80.0) 22 (88.0)
 Personality disorder 5 (20.0) 2 (8.0)
 Posttraumatic stress disorder 14 (56.0) 13 (52.0)
 Schizophrenia/bipolar disorder 6 (24.0) 5 (20.0)
 Substance abuse disorder 11 (44.0) 9 (36.0)
Medical diagnoses
 Chronic pain 10 (40.0) 13 (52.0)
 Sleep disorder 8 (32.0) 9 (36.0)
 Rural residence 7 (28.0) 10 (40.0)
Region
 Midwest 3 (12.0) 7 (28.0)
 Northeast 1 (4.0) 2 (8.0)
 Southeast 11 (44.0) 4 (16.0)
 Southwest 5 (20.0) 2 (8.0)
 West 5 (20.0) 10 (40.0)
Midwest=Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, Wisconsin.
Northeast=Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont.
Southeast=Alabama, Arkansas, Delaware, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, South Carolina, Tennessee, Virginia, Washington DC, West Virginia.
Southwest=Arizona, New Mexico, Oklahoma, Texas.
West=Alaska, California, Colorado, Hawaii, Idaho, Montana, Nevada, Oregon, Utah, Washington, Wyoming.

Data Collection

An initial interview guide was based on the socioecological framework and literature on gender differences in suicide risk8,11–13 and depression rates21,22 to ensure our inquiry considered the social context of participants and was informed by prior knowledge in the field. The interview guide was adjusted as new themes emerged throughout data collection. Interviews began with background information about military experiences, proceeded to explore participants’ suicidal ideation and recent suicide attempt, then concluded with health care experiences. During the section on suicide attempts, we specifically asked questions about what has been helpful or would be helpful for their recovery from their suicide attempt. The same interview guide was used with women and men. Interviews were conducted over the telephone by a qualitative analyst. The analyst documented salient narratives in field notes immediately following each interview for codebook refinement. Interviews averaged 79 minutes (range, 30–120 min). All interviews were audio recorded and transcribed. All participants were remunerated $50.

Analysis Approach

We used a thematic analysis approach for data analysis.23 Thematic analysis is a basic analysis approach that seeks to identify themes across a dataset and allows for both deductive (top-down) and indicative (bottom-up) identification of themes. Data underwent a constant comparative process24 to allow for new research and interview questions to develop while interviews were underway. As interviews were transcribed and read, 2 analysts (L.M.D. and K.J.T.) wrote analytic memos to contribute to codebook refinement and initial analysis. The analysts then coded interviews in Atlas.ti with continued discussion of coding to ensure agreement. Then, the research team generated and examined code reports by gender to refine core concepts and identify relationships among interconnected concepts.

RESULTS

Overview

We asked participants what has been helpful, as well as what would be helpful, in their recovery from their suicide attempts. In response, participants reflected on things they wished were different about themselves or their lives as well as things that were currently working for them. Although some recovery topics were similar across the group, the participants’ primary recovery needs often differed by gender. Women were focused on their connections with others as well as wanting to increase their self-knowledge and self-worth. Men were focused on trying to live up to their ideal selves by living and doing “right.” Both women and men also wanted to feel a stronger sense of purpose in their lives. We elaborate on these themes in the paragraphs below.

Women Prioritize Their Connections With Others

Women’s discussions of their paths to recovery emphasized their desire to feel connected with others. They tended to find strength in helping others, despite being over-burdened themselves. Women wished to have mutually supportive relationships, in which women could both give and receive emotional support as well as share knowledge and experiences. One woman said, “Find somebody to talk to or find somebody to help. There’s a saying that’s like, ‘the heart beats best when it’s beating for others.’ I’m at the point where it’s not beating for me. I try to make it beat for somebody else.” Yet having others to lean on in times of need was equally important, as another woman said, “A really good support system and a way for me to get help … to have somebody talk me down off that ledge.” Learning more about their own health conditions or other concerns from others going through similar things was beneficial: “Learning that now one of my friends has bipolar, learning that she has it and that I’m not alone in this, and I can talk to her.”

Women Want to Repair Their Self-worth Through Self-knowledge and Development

Relatedly, increasing their own self-knowledge—why they do, think, or feel the things they do—was an important theme among the women. For example, one woman found it helpful for her therapist to explain why she feels reactive to other people’s emotions, describing her as an “empath” and noting that she had low distress tolerance: “Anytime I go into distress, I don’t tolerate it at all … and I want to learn how to handle that.” Further, normalization of their thoughts, emotions, and behaviors was also helpful: “Some of it is the feeling that I am not damaging anybody, I need to feel like I am not hurting anybody or not saying the wrong thing or doing the wrong thing.” Another woman described this as wanting to feel normal, suggesting that she feels like something is inherently wrong with her that needs fixing: “I’ll be honest with you, I would give anything, anything in this world, I would give anything to just be normal. Have a normal relationship, have a normal life.” Many women talked generally about wanting to feel a stronger sense of self-worth: “I think what would help me is—go back to that place where I was. Had self-worth. Be a somebody.” For some, their desire to be more secure and clear in their sense of self seemed to be related to a desire to increase their sense of self-worth. As one woman put it, she was no longer feeling “whole” which was detrimental to her sense of self-worth: “I’ve got all of my limbs, but I don’t feel like a whole person either. I don’t feel like I’m a functioning person, I don’t feel like I’m whole, I don’t feel like I will ever be whole, and I would benefit also [from] … that kind of strength building, character building that gets you back to thinking that you’re worth something, that you can do something, that you can accomplish something.”

Men Try to Live and Do “Right” Toward Becoming Their Ideal Self

Men, on the other hand, very strongly focused on trying to live and do “right” when asked about their recovery process. It seemed as though the men had an idea in their mind of what living “right” meant to them personally, and they were striving toward this ideal. One man said, “Now I’m just trying to make sure I don’t get back in that pain by trying to live right. It’s hard.” They talked how, in order to do this, you had to have the right mentality, or that recovery required, “just changing my mindset.” Echoing this sentiment, one man said, “It’s like I just kind of have to make my mind up and say I want something different; I want to change. If you ever heard the saying, ‘if you want something different, you gotta do something different,’” and another said, “I’ve got my head on straight now … I believe I can make better decisions. I have a better life now.” As these quotes exemplify, the men talked about doing what is right and having the right mentality somewhat vaguely, without naming specific changes. However, a few men talked specifically about improving their overall health, avoiding using drugs, or staying away from “toxic people.” Further, some talked about being proud of who they are now, as a result of such changes, living more closely to their ideal selves than they were before: “I do a lot more physical things, a lot more—I’m lifting weights, I’m eating healthier … I’m proud of the person that I am now.” Finally, one man talked about how his suicide attempt gave him the opportunity to craft a life that he really wanted: “… you just realize you’ve got a new life because a week before that, you were ready to end your own, you tried to end your own, so you’ve got to try to think, you actually did end that life. And you’re starting up in your whole new life. So change what’s wrong. And start to do it the right way this time.”

Men Want to Feel Needed and Accountable to Others

Relationships were important for men, as they were for women, but for somewhat different reasons. A primary motivator for men in their recovery process was feeling accountable to and needed by others. As one man explained, his sense of obligation to be there for his family gave him the motivation to continue living: “You’re gonna have bad days no matter what. You have to look at it like you got people depending on you—wife, kids and everybody else that depend on you. If something happens to you, they’re all by themselves.” Others talked about contributing to something bigger, outside of themselves: “And I can see why a lot of military members and service members take their life because they just don’t have that sense of—they don’t have that sense of belonging I guess, or need. The connection has been severed and—it’s like getting out of the military. They no longer need your service. Here’s a handshake, have a great day.” Still others talked about a need to help others—similarly to how the women described it: “I was taught that if somebody helps you, they help you so you can help somebody else and there’s always somebody else worse off than you are.”

Women and Men Desire a Stronger Sense of Purpose in Life

Both women and men desired a stronger sense of purpose, or a clearer direction for their lives. They talked generally about the importance of having and achieving goals. One woman said: “A sense of purpose. Which I don’t really have right now. I don’t really know what I’m doing or what I should be doing. I kind of am just—I feel like I’m at a stalemate. Like I’m not moving. I mean I go to therapy but it doesn’t really help me figure out a goal of what I want to do.” A man described this need for goals as: “If a soldier can actually find a goal, an obtainable goal, not just a superficial goal like, ‘hey, I’m going to learn how to fly’ … but an obtainable goal would be something like, I’m going to get a job, I’m going to move someplace other than this state and have a plan of how you are doing it. I mean that’s something that you need in your life. And that actually starts the whole thought process of being positive again.” For some, this in turn provided a sense of control over their lives and a sense of stability, while others talked about movement toward achieving goals as simply a welcome distraction. One man said, “Probably just being occupied with something productive or worthwhile and not thinking too much. You know, like the job I’m doing, just keeping my mind and my hands occupied with something worthwhile and being productive.” In these conversations, many referenced the purpose they felt in the military that no longer existed in their civilian lives—wishing to regain some of that structure: “… like in the Marine Corps I always had a mission so now that I’m not in the Marine Corps I have to find little jobs for me to accomplish.”

DISCUSSION

In this study, we interviewed equal numbers of women and men veterans about their recent suicide attempts to describe gender differences in the process of recovery after a suicide attempt. We identified some similarities, but the process of recovery was described differently by women compared with men. Both women and men talked about the importance of relationships and wanting to improve themselves and their lives, but for different reasons and at different priority levels. Women’s paths to recovery focused strongly on developing mutually supportive relationships with others—something they felt they were currently lacking. Among men, who had some supportive relationships, discussions of relationships with others focused on the benefits of being accountable to others. Further, connections with others seemed less important to the men than trying to address the parts of their lives and selves that they felt were going wrong, toward becoming their best selves. Women’s discussions of self-improvement focused on learning more about themselves, feeling more “whole,” and reestablishing a sense of self-worth. Both women and men talked about needing to clarify their sense of purpose in life.

Although few other studies have specifically examined recovery after a suicide attempt, our findings are consistent with prior research suggesting that recovery needs may differ by demographic groups.14–16 A qualitative study in London examined experiences before and after a suicide attempt in the context of aging and found that loss of control over one’s life was a central theme, which contributed to helplessness and depression.14 Control over one’s life was also the key theme in a study of older adults who were interviewed decades after their last suicide attempt.15 Finally, investigators in New Zealand studied the recovery pathways of young people (aged 15–24).16 Growth of personal agency and self-responsibility was central to their recovery. The current study’s findings about women are similar to a prior study of similarly aged patients in Taiwan,17 who were mostly women. Key themes in both studies reflected a need to feel valued and develop a more positive view of one’s self.

The findings in the present study also align with the basic psychological needs proposed by self-determination theory—autonomy, competence, and relatedness—which are thought to be essential to one’s overall well-being.25,26 Essentially, we need to feel we determine our behavior (autonomy), but we also need a sense of efficacy (competence), and connection with others (relatedness). When these needs are met, we feel free to explore, make mistakes, make discoveries, and overcome obstacles. Through this process we become more psychologically integrated, discover personal meaning and purpose, and achieve greater well-being. The broader literature supports the notion that feelings of autonomy, competence, and relatedness are critical to psychological well-being and that deficits in one or more of these needs can result in negative behavior and compromised physical and mental health,25,27 as well as risk for suicidal behavior.28,29 However, to our knowledge, no studies have applied self-determination theory to understanding the needs of individuals in recovery following a suicide attempt. Among women and men trying to recover from a suicide attempt, our data suggest that women emphasize relatedness needs whereas men emphasize competence. It is possible that these preferences reflect socially acceptable gender differences (ie, deficits in both are experienced but it is socially acceptable for women to desire connection and men to desire achievement), but it is also possible that they are actual gender differences. Regardless, the data suggest that they may need to be acknowledged and addressed following a suicide attempt, and future work should further explore the role of autonomy, competence, and relatedness in suicidal behavior and recovery.

Additional work is also needed to further refine the concepts identified here and determine the best ways to apply this work to practice. However, we consider a few practical applications of this work. As women desire stronger relationships with others and want to increase their self-knowledge and sense of worth, women may be more interested in social groups and activities that connect them to other women with similar experiences. They may also benefit from group psychoeducational programs that help them better understand themselves and their behavior. Men, on the other hand, may benefit from approaches that are more goal-oriented and set them up for achieving successful experiences in their daily lives. These approaches might be individual-based or group-based, but for some men, feeling accountable to a group might be an ancillary benefit. This work also calls for further investigation of approaches that specifically enhance purpose in life among veterans, as this was a common recovery need among both genders.

This study is limited by our recruitment methods, which resulted in a VHA treatment-seeking sample of veterans and thus our findings may not generalize to veterans who do not receive VHA care, or to veterans who do not receive health care following their suicide attempt. However, we enrolled a national, clinically, and demographically diverse sample of VHA-utilizing veterans. This study is also limited by the gender identities included; our sample exclusively identified themselves as either women or men and we were unable to enroll veterans identifying as nonbinary or transgender. Future research is needed to further explicate the relative frequency and importance of the themes identified here as well as the strength of relationship to veteran recovery after a suicide attempt.

The paths to recovery after a suicide attempt may vary by gender, especially among veterans. Women may benefit from building and strengthening mutually supportive relationships, developing a better understanding of self, and increasing self-worth. Men may benefit from a process that identifies and addresses areas of their lives they wish to change toward becoming their ideal self, as well as increasing their sense of accountability to see this work through. Both women and men veterans may benefit from additional support articulating and fostering a stronger sense of purpose in life—including identifying goals to work toward and methods to achieve those goals.

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Keywords:

suicide; gender; veterans; qualitative research; behavioral health care

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