Understanding Service Members Perceptions of Stigma and Help-Seeking: Findings and Implications DOD/VA Suicide Prevention Conference, Denver, CO Henry Griffis, Ph.D. & Neil Carey, Ph.D. Center for Naval Analyses Laura Neely, Psy.D. Defense Suicide Prevention Office Study Findings Henry Griffis, Ph.D. & Neil Carey, Ph.D. Center for Naval Analyses Outline and Approach Study overview Vignette development and overview Number of focus groups and participants Drawing conclusions from focus groups Findings and implementation ideas Training and resources Perceptions Leadership Summary of possible implementation steps
3 DoD Policy Review Key tensions exist between privacy of service members and commanders need to assess fitness RAND identified 97 policies that prohibit the actions of persons with mental health disorders (PWMHDs)most prohibit service members from serving in certain positions Ambiguities occur in the language of DoD policies Wording makes it unclear whether exclusions concern having had a mental health disorder in the past, currently having a diagnosis, or currently having a diagnosis that is managed adequately with treatment Policies do not yet address stigma of those in mental health treatment Consider policies to protect those in treatment or to help cope with stigmatizing and discriminatory behavior from others Families of service members, unit members are critical influences over whether service members seek carebut rarely addressed Interventions should explore stigma reduction among unit and family 4 Purpose of study and background
OSD and services have had stigma reduction campaigns* to encourage help-seeking Important role of staff members and gate-keepers needs exploration Information sharing Need to document beliefs of service members about consequences of sharing information about at-risk individuals What happens to the information, and how do commanders respond? Potential recommendations Strategies for direct acquaintances, indirect acquaintances and support staff members to more appropriately respond to at-risk service members Ways to modify processes to reduce stigma and encourage at-risk service members to seek help *Earlier efforts included Military Crisis Line, Life is Worth Living campaign 5 Observations from SMEs Despite progress in policies to combat stigma and facilitate help seeking, problems still exist Story of a service members seeking mental health treatment led to commanders order of a search of house for weapons and drugs Access barriers, norms, and peer support should be addressed in vignettes
There are medical, community health, and readiness approaches to suicide prevention but the various approaches sometimes conflict, e.g.: Readiness approaches, maximizing a commanders need to know about fitness for combat can compromise service member privacy Community health approaches can delay a service member seeking treatment Medical approaches can make a minor adjustment difficulty appear to be a larger problem than it really is Discretion/ Privacy Conflicting legitimate goals Commanders need to know 6 Vignettes Why use vignettes? To focus discussion of character actions rather than personal experiences To challenge participants to think on their feet rather than repeat training To leverage as potential future training material Vignette overview We developed 40 vignettes, 10 per service
Vignette language is specific to service but overall storylines are parallel 3 Categories (to coincide with focus group rank groupings); junior, mid-level, leadership At least 4 Characters in each vignette troubled servicemember, direct acquaintance (personally knows the candidate), indirect acquaintance (anyone who incidentally learns of important information), supervisor Focus group questions We ask participants to answer questions from different character points of view 7 Our vignettes feature possible factors associated with suicide Poor financial decisions "On an impulse, he buys a new truck at one of the dealers near base, borrowing the down payment from a payday loan a couple blocks away." Insomnia She told Liz that PFC Johnson has also been having terrible nightmares and trouble sleeping.
Hints at self harm I wont let people down anymore. A falling star ends fast. Panic attack experiencing chest pains, cold sweats, and heart palpitations that seemed to come on whenever she had thoughts and fears of losing her child. Change in appearance; demeanor slumped over with her head down on her desk saying that she feels like the weight of the world has lifted from her shoulders. 8 Possible factors associated with suicide (cont.) Unexpected anger Gretta noticed that he was frequently short tempered and irritable. Substance abuse found unconscious in his barracks from drinking whiskey. There is also an empty bottle of sleeping pills by the bedside.
Extramarital affair said she had a fight with her boyfriend. I didnt even realize that you had a boyfriend. Victim of abuse/rape disclosedthat she had been abused as a child by her father. a man with a mask over his head attacked her last night and that she barely escaped after hitting him with a rock. Dialogue that suggests possible depression, anger, frantic thinking I cant take this anymore. Im broken beyond repair. 9 Urgency/criticality of the problem Vignette Story Flows (general outline with example) Initial problem Escalation 1 Background Initial concerns
Building tension Further tension/critical Further concerns decision/suicide aftermath seeking/help-offering? PFC Jones is a wheeled vehicle mechanic. He is very outgoing and wellliked. He is a skilled marksman . He likes to work hard and play hard, and in the past he has made decisions that come back to haunt him. Question set one Escalation 2 Impulsively buys a new truck which angers his wife. He struggles to make the payment, is noticeably distracted and late to work, starts spending evenings at the bar and buys a new pistol. Continues to arrive
late at work, is very distracted and possibly drunk. Begins to make selfdepreciating comments. He has an angry conversation on the phone with his wife and speeds away from work in his truck, citing a family emergency. Question set two Question set three Final Questions Further thoughts? Ways to increase helpWays reduce stigma? Changes to policy/ procedures/customs? Time flow 6 Overview of Vignette Questions Help offering What are the signs of someone needing help? (identification) Thoughts about best ways to offer help, words to use? Thought about what resources are available for help, which are best, pros
and cons? (information gathering) Reasons to offer help and reasons not to offer help? (overcoming barriers) Help seeking What would you do to get someone to talk or seek help? When should somebody seek help? (overcoming stigma) Programs, policies, and barriers Perceptions of programs and policies Perceptions of possible initiatives; e.g., caring outreach--dental hygienist, financial planning teacher, etc. 11 Number of focus groups Number of Focus Groups 12 10 10 10 10 9 8
8 8 7 7 6 6 Air Force Army Marine Corps 4 2 0 E1 to E4 E5 to E6 E7 to E9 & O3 to O5 Rank of focus group members 12
Number of focus group participants 120 Focus group participants 100 80 97 94 78 76 78 70 66 65 65 E-1 to E-4 E-5 to E-6 E-7 to E-9 & O-3 to O-5 60 40
20 0 Air Force Army Marines 13 Drawing conclusions from focus group responses We collected over 4,000 statements from our 620+ respondents They told us how vignette characters should respond, in their opinion This allowed us to discuss suicide with precautions for human subjects concerns, and more context than a questionnaire could provide Purpose of focus groups different from statistical analysis Uncover viewpoints/opinions about emerging issues Pay attention to how people use words to describe thoughts/opinions Invite differing opinions We drew conclusions about direction of opinion after triangulation
Asked for reasons for opinion, how strongly believed Asked whether others in the group had different reactions or beliefs about what the characters should do Asked later groups whether they agreed with what other groups said We concluded that an opinion was widely held when: Expressed in three or more groups Reasons were given for an opinion 14 Availability of training and resources Finding There is a perception that suicide prevention training is "check the box" with briefing slides and is not well presented or well received. Scenario-based training (like the vignettes from the focus groups) is more effective and better liked. Implication There should be more scenario-based training and less didactic training. Training should have more active participation, with a "debrief" discussion at the end. Possible translation steps Scenario-based training.
Senior enlisted and officers would like to see A successful communications strategy would Tabletop game for more specialized training at the level of E7- focus separately on senior enlisted and E7-E9s and officers. E9s and officers. officers to leverage their role in suicide prevention. Resources that fall outside the chain of A better training and communications command are important for discretion and to strategy should make servicemembers more maintain privacy. aware of outside resources and how to use them. A new mental health app focused on getting people to appropriately offer and seek help using outside resources. 15 Perceptions of help-seeking, help-offering, & stigma Finding Implication Possible translation steps Servicemembers prefer chaplain or family More training in suicide prevention for Suicide-prevention tabletop game
counselor as first-line helper. chaplains and family counselors might be for chaplains and family counselors. needed. Participants would rather see a troubled A communications theme might be "your Develop a communications servicemember seek help than have others friends want you to be healthy." Our focus campaign based on this insight. require him/her to get help. groups documented many statements supporting help-seeking. Junior focus groups believe that, if someone A communications campaign might be Develop a communication campaign seeks help, they might be labeled as crazy, effective showing examples of people who based on this insighte.g., getting weak, or trying to get out of work (the have successfully sought help. help is strong. worst!). Servicemembers are more likely to help a good performer get back on track than a poor performer. Commands might need to be more vigilant A tabletop game for leadership that for potential suicides with poor performers addresses this issue. who do not have support within the unit. Unit members might not recognize that someone is stressed until their performance worsens. Intervention might be delayed by overlooking behavior issues just because
the individual is a good performer. A tabletop game for leadership that addresses this issue. 16 Perceptions of help-seeking, help-offering, & stigma (2) Finding Junior focus groups believe that one of the biggest obstacles to seeking help is fear of losing security clearance or access to firearms to do job. Implication Possible translation steps This again points to the importance of the A communications campaign might chaplain and family counselor, where include clarifications of rules problems are not documented in a way regarding mental health, including that could hurt careers. Servicemembers are trained in what to look Warning signs manifest themselves as for so they know what to hide. weak signals and are often missed or misinterpreted. the change in Question 21 that people who seek help for combatrelated issues or who receive
marital counseling dont have to answer yes to mental health treatment. Training on cognitive biases could help with the interpretation of weak signals. The network or peers and direct-line supervisors needs to be empowered to pay attention to weak signals every do to create a vital safety net. 17 Leadership Possible translation steps An app for suicide prevention would focus on reducing selfstigma by emphasizing successful examples of getting help. Finding Leadership focus groups believe that the stigma reduction message is getting through. Implications The message is being heard but not necessarily believed because of stories of past actions. Unit cohesiveness if compromised when stigma is present.
Units should openly discuss the Scenario-based training. consequences of action or inaction, perhaps as part of their scenario-based training. Leaders often learn of risky behaviors when it is too late. Servicemembers need to be able to approach Develop a communications their NCOs or other command leaders for campaign based on this insight, advice and guidance and not just later on for e.g., Talk before it gets worse. problem solving. Personal leadership is required to speak up when someone is perceived to be at risk. A culture of silence often exists because of the fear of the unknown about the consequences of speaking up. Accountability rests in each person individually, not just in the chain of command. Scenario-based training or a tabletop game that emphasizes how to offer help in an appropriate way. If personal accountability rests only in the Scenario-based training or a
chain of command and not within each tabletop game that emphasizes person individually (whether it is the person individual and chain-of-command at risk, or the one in a position to offer help), responsibilities. if will be difficult to intervene. 18 Summary of possible translation steps Combining what we learned from the literature review and the focus groups, there are several promising ways forward: 1. Tabletop games for leadership or help-givers 2. Scenario-based training for all levels 3. Mental health app to help bridge the gap between troubled Service members and potential resources 4. Communications campaign messages based on themes from the focus groups 19 Implications: Translation of Study Findings Laura Neely, Psy.D. Defense Suicide Prevention Office Defense Strategy for Suicide Prevention Goal 2: Implement research-informed communication efforts within the Department of Defense that prevent suicide by changing knowledge, attitudes, and behaviors Objective 2.1: Develop, implement, and evaluate
research-informed communication efforts to reach defined segments of the Military Community regarding suicide prevention 21 DEOCS Help Seeking Given Suicidal Thoughts Intimate partners, friends, parents/parental figures, and mental health professionals are most likely to be sought for support by members experiencing suicidal thoughts 20% of this sample indicate they would not seek help from anyone if they were experiencing suicidal thoughts If you were experiencing suicidal thoughts, how likely is it that you would seek help from the following people? (n = 7,703); Q10 Likely Extremely Likely Intimate partner (e.g., girlfriend, boyfriend, husband, wife) % of Sample 1145 Friend (not related to you)
4504 1911 Parent or parental figure 3057 1271 Mental health professional (e.g. psychologist, social worker, counselor) 73% 64% 3167 1687 58% 2550 55% Minister or religious leader (e.g. Chaplain, Pastor, Priest, Rabbi) 1459 2487 51%
Other relative/family member 1419 2514 51% Doctor (General Practitioner) 1352 Phone helpline (e.g. Military Crisis Line, Vets4Warriors, Lifeline) 2000 1190 I would seek help from another not listed here 656 I would not seek help from anyone 536 0 1899 1327 984 1000
44% 40% 26% 20% 2000 3000 4000 5000 6000 22 DEOCS Barriers to Care Commanders and suicide researchers are interested in eliminating barriers that prevent service members from seeking care Being perceived as broken, privacy and negative career implications will most likely prevent this sample from seeking care Individuals who need mental health care (depression, suicidality, addiction, etc.) would not seek help because of: (n = 7,810); Q5 Agree Strongly Agree % of Sample Fear of being perceived as
2386 Loss of privacy/confidentiality 2417 Negative impact to my career or progress 1389 1141 2210 Lack of confidence in the resources available to solve their problems 1185 1980 Lack of confidence in the chain of command 911 1837 Not knowing who to turn to 1944 0 1000
2000 48% 46% 43% 37% 1049 37% 910 37% 3000 4000 23 SOFS-A Barriers to Care Being perceived as broken and negative career implications most often prevent members from seeking care 792 active duty members provided write-in comments addressing other reasons why individuals who need mental health care would not seek help Key themes are consistent with literature on help-seeking barriers: Pride,
Embarrassment, Stigma, Impact on Career, Trust Individuals who need mental health care (e.g., for depression, suicidal thoughts, addiction) would not seek help because of % of Reporting Agree or Strongly Agree Fear of being perceived as 60% Negative impact to my career or progress 59% Loss of privacy/confidentiality 54% Lack of confidence in the chain of command 45% Lack of confidence in the resources available to solve their problems 41% Not knowing who to turn to 37% Other 16% 0%
24 100% Communications Campaign A Service member has suicide ideation A. Seeks help, receives treatment, and fully recovers. B. Loses his clearance and separates from the military, but still has a successful civilian career C. But refuses to seek help, deteriorates to the point of command directed evaluation. D. Seeks help, is supported by his command and unit, and returns to full duty status E. And goes through the Med Board process Communications Campaign Decrease Fear of the Unknown Educate Service members on actual (not perceived) consequences Promote Problem-Solving Instill Hope Decrease Dichotomous Thinking If I dont have my military career, I have nothing Evaluating Communications
Campaigns Principles of Effective Health Communications 1. Strategic Planning 2. Analysis and Goal Setting 3. Target Audiences and Behaviors 4. Audience Research 5. Creative Brief and Evaluation Plan 6. Design and Delivery of Messages and Materials 7. Pretesting at Each Stage 27 Evaluating Communications Campaigns Communication Strategy (Independent Variables) Psychosocial attributes of the receiver Source or spokesperson Settings/ channels/ activities/ materials used to disseminate the message Message itself Dependent Variables (sample categories): Exposure Attention Comprehension Yielding Attitude Change
Behavior 28 Types of Evaluation Formative Evaluation Assists in development to effective strategies to decrease problems (pilot) Process Evaluation how well it is delivered as planned Summative Evaluation evaluating if your message reached intended audience, achieved impact & objectives 29 Conclusion DSPO funded a research study, conducted by CNA, to understand further Service members beliefs about stigma and help-seeking DSPO & CNA will translate these results into a communications campaign 30
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