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Mitigating veteran suicide: exploring connectedness in veterans repatriating into society as a means of increasing resiliency

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Content Mitigating Veteran Suicide: Exploring Connectedness in Veterans Repatriating into
Society as a Means of Increasing Resiliency
by
Robin Paul Vanderberry
Rossier School of Education
University of Southern California
A dissertation submitted to the faculty
in partial fulfillment of the requirements for the degree of
Doctor of Education
May 2023

© Copyright by Robin Paul Vanderberry 2023
All Rights Reserved

The Committee for Robin Paul Vanderberry certifies the approval of this Dissertation

Susanne Foulk
Helena Seli
Jennifer Phillips, Committee Chair

Rossier School of Education
University of Southern California
2023

iv
Abstract
Following separation from the military, service members face challenges transitioning to a post-
military civilian life. Evidence indicates these transitioning Veterans are at higher risk for suicide
compared with both the broader Veteran population and the United States public. This research
project focused on advancing the understanding of veteran service provider perceptions of the
association between connectedness and resilience in veterans repatriating into society. The
resulting data analysis offers an improved understanding of how individuals and groups assisting
veteran repatriation leverage connectedness to increase veteran resiliency and ultimately mitigate
veteran suicidal ideation. It explores the interaction between veterans and their environment
using a bio-ecological approach to culture and context. Finally, it incorporates veteran service
provider identified connectedness practices to recommend improvements in veteran transition
assistance that can increase resiliency and mitigate veteran suicidal ideation.
Keywords: Veteran suicide, bio-ecological theory, Interpersonal theory of suicide, Transition
Assistance Program.

v
Dedication
To all those who supported me throughout this evolution – Thank You.

vi
Acknowledgements
I thank and acknowledge my dissertation committee: Dr Jennifer Phillips (Chair), Dr.
Susanne Foulk; and Dr. Helena Seli.
I am grateful to the faculty and staff of the USC Rossier School of Education, and to my
classmates and friends in the USC Organizational Change and Leadership Cohort Thirteen.
Special thanks and a tremendous debt of gratitude to Dr. Jennifer Phillips; your mentorship,
empathy, focus, and motivation are the reason this evolution could be deemed mission
accomplished.

vii
Table of Contents
Abstract .......................................................................................................................................... iv
Dedication ....................................................................................................................................... v
Acknowledgements ........................................................................................................................ vi
List of Tables .................................................................................................................................. x
List of Figures ................................................................................................................................ xi
Chapter One: Introduction to the Problem of Practice.................................................................... 1
Background of the Problem ...................................................................................................... 1
Field Context ........................................................................................................................... 10
Overview of Theoretical Framework and Methodology ........................................................ 12
Purpose of the Study and Research Questions ........................................................................ 16
Importance of the Study .......................................................................................................... 17
Definitions............................................................................................................................... 20
Organization of the Dissertation ............................................................................................. 22
Chapter Two: Literature Review .................................................................................................. 23
Current Data on Veteran Suicide ............................................................................................ 23
Data on Age and Gender ................................................................................................... 25
Data on Deployment History ............................................................................................ 27
Mental Health Challenges Faced by Repatriating Veterans ................................................... 29
Suicide-Related Mental Health Transition Challenges for Veterans: Homelessness ....... 32
Suicide-Related Mental Health Transition Challenges for Veterans: PTSD .................... 33
Suicide-Related Mental Health Transition Challenges for Veterans: Substance Use
Disorders ........................................................................................................................... 36
Connectedness as a Protective Factor in Veteran Suicide ...................................................... 36
Theoretical Framework ........................................................................................................... 38

viii
Conceptual Framework ........................................................................................................... 39
Chapter Three: Methodology ........................................................................................................ 42
Research Questions ................................................................................................................. 42
Overview of Methodology ...................................................................................................... 43
The Researcher........................................................................................................................ 44
Data Sources ........................................................................................................................... 46
Method 1: Document and Artifact Analysis ..................................................................... 46
Method 2: Interviews ........................................................................................................ 50
Ethics....................................................................................................................................... 55
Chapter Four: Findings ................................................................................................................. 58
Document and Artifacts .......................................................................................................... 59
Participants .............................................................................................................................. 62
Findings................................................................................................................................... 68
Theme 1: Connectedness Perceived as Critical to Repatriation and Mitigating Suicidal
Ideation ............................................................................................................................. 70
Theme 2: Connectedness Considered in Program Structures and Individual Engagement
Activities ........................................................................................................................... 72
Theme 3: Service Providers' Perspective on The Influence of Veteran’s Duration of
Service............................................................................................................................... 75
Theme 4: Discomfort With Acknowledging Weakness or Shortcomings, Particularly
Regarding Mental Health .................................................................................................. 79
Theme 5: Service Providers Critical of DOD TAP Programs Content and Implementation
........................................................................................................................................... 82
Summary ................................................................................................................................. 85
Chapter Five: Recommendations and Discussion......................................................................... 88
Discussion of Findings ............................................................................................................ 88

ix
Recommendations for Practice ............................................................................................... 94
Recommendation 1: DoD TAP Team to Formalize an Engagement Strategy that
Incorporates Civilian Veteran Service Providers at the Local Level ................................ 95
Recommendation 2: Incorporation of Connectedness as a Foundational Element in
Veteran Repatriation Programs ......................................................................................... 99
Limitations and Delimitations ............................................................................................... 102
Recommendations for Future Research ................................................................................ 104
Conclusion ............................................................................................................................ 105
References ................................................................................................................................... 107
Appendix A: Nonprofit and Community-Based Organizations Focused on Providing Assistance
to Veterans at Risk of Suicide ..................................................................................................... 129
Appendix B: Recruitment Questionnaire Protocol for Veteran Service Providers ..................... 130
Appendix C: Interview Protocol ................................................................................................. 132
Appendix D: Information Sheet for Exempt Research ............................................................... 134

x
List of Tables
Table 1: Military Ethos and Strength Vulnerabilities 31
Table 2: Interviewee Prioritization Schema 51
Table 3: Research Questions and Associated Themes Matrix 52
Table 4: Interviewee Responses on Connectedness As Critical to Repatriation 70
Table 5: Interviewee Responses on Connectedness Considerations in Program Structures and
Individual Engagement Activities 73
Table 6: Interviewee Responses on Service Providers' Perspective on Influence of Veteran’s
Duration of Service 77
Table 7: Interviewee Responses on Stigma of Acknowledging Weakness or Shortcomings,
Particularly in Regard to Mental Health 80
Table 8: Interviewee Responses on Service Providers' Considerations on DOD TAP Programs
Content and Implementation 83

xi
List of Figures
Figure 1: Study Conceptual Framework 3
Figure 2: Bronfenbenner's BioEcological Framework Model 14
Figure 3: Suicidal Veterans Under VA Care 18
Figure 4: Number of Suicides Comparing U.S. Adult and Veteran Populations 24
Figure 5: Veteran Suicide Rate by Age Group and Sex 25
Figure 6: WTTA Mental Health Card: Front and Back 62
Figure 7: Participant Experience and Time Supporting Suicide Prevention Programs 63
Figure 8: Participant Experience and Time Supporting Veteran Repatriation Programs 64
Figure 9: Participant Experience and Time Supporting Veteran Suicide Prevention Programs 64
Figure 10: Participant Experience as a Service Member 65
Figure 11: DOD Transition Assistance Program Timeline 97
Figure 12: Post-Transition Timeline 99

1

Chapter One: Introduction to the Problem of Practice
Suicide among U.S. military veterans is a significant public health concern (Kemp &
Bossarte, 2012) and a leading cause of death among U.S. military veterans (Weiner et al., 2011).
Despite representing less than 8% of the U.S. population, veterans account for more than 14% of
all suicide deaths of U.S. adults (Department of Veterans Affairs, 2020). In 2017, the Centers
for Disease Control and Prevention (CDC) highlighted suicide as the 10th leading cause of death
in the United States based on a rate of suicide that grew by 43.6% between 2005 and 2017
(Murphy et al., 2018; Department of Veterans Affairs, 2020). Data from the 2020 Department of
Veterans Affairs report indicated that the age and sex-adjusted suicide rate among U.S. veterans
grew by 30% in that same period, is continuing to rise, and is at the highest documented level in
U.S. history (Department of Veterans Affairs, 2020). The purpose of this study is to explore
veteran service providers’ perceptions of the association between connectedness and resilience in
veterans repatriating into society. The intent is to discover potential recommendations for
individuals and groups assisting veteran repatriation to support the CDC and VA strategies by
leveraging connectedness as a means of increasing veteran resiliency to mitigate veteran suicidal
ideation.
Background of the Problem
Veterans have a long history of difficulty repatriating into civilian life following the
completion of their military service and often struggle with the instability of emotional
challenges during the repatriation process (Pew Research Center, 2019). Death by suicide is the
gravest outcome of an inability to cope with these challenges. The CDC ascertained that the
average number of American suicides per day rose from 86.6 in 2005 to 124.4 in 2017, including
15.9 veterans per day in 2005 and 16.8 in 2017 (Department of Veterans Affairs, 2020). In this

2
same time frame, veteran suicide rates both increased and exceeded non-veteran suicide rates
(Department of Veterans Affairs, 2020). Compared to civilians, veterans were 1.5 to 2.4 times as
likely to die by suicide than their non-veteran counterparts, dependent on the year assessed, age,
and sex (Department of Veterans Affairs, 2018b; Gibbons et al., 2012; Kaplan et al., 2012).
Veterans accounted for 13.5% of all deaths by suicide among U.S. adults in 2017 while
constituting only 7.9% of the adult population (Department of Veterans Affairs, 2020).
Twenty-first-century veterans are unique compared to past generations of veterans in that
they are products of a nation that has been continuously engaged in conflict for more than 18
years: Operation Enduring Freedom (OEF; October 2001 – December 2014), Operation Iraqi
Freedom (OIF; March 2003 - November 2011), Operation New Dawn (OND; September 2010 -
December 2011), Operation Inherent Resolve (OIR, October 15, 2014 – Present) (Torreon,
2012). There are fewer African-Americans, more Latinx, and more women serving in the armed
forces than in previous eras (Olenick et al., 2015). These recent veterans are younger, less likely
to be married, less likely to have been incarcerated, more likely to be gainfully employed, more
socially integrated, less likely to be diagnosed with substance abuse disorders, and require less
Veterans Affairs (V.A.) disability compensation for posttraumatic stress disorders (PTSD) than
their predecessors (Olenick et al., 2015). Upon release from service, these 21st-century veterans
face a loss of connectedness—the challenge of re-engaging or repatriating into relationships,
families, communities, and society (Demers, 2011; Kelley et al., 2011; Pease et al., 2015). The
following sections will map the connections between the veteran repatriation experience and the
loss of connectedness experienced by veterans, the role of resilience in diminishing the risk for
suicide, and connectedness as a key element of building resilience for this population.

3
On Becoming a Veteran
The term "veteran" means a person who served in the active military, naval, or air service
and who was discharged or released under conditions other than dishonorable (CFR 38, p. 153,
2022), but the making of a veteran is a far more detailed process. The conceptual framework
outlined in Figure 1 illustrates the journey individuals undertake when transitioning from a
position in civilian life to one of life as a servicemember; Figure 1 also captures the
servicemember’s subsequent departure from service and repatriation back to civilian life. It is at
this point of transition that one becomes a veteran.

Figure 1
Study Conceptual Framework

4
When transitioning from active service in the U.S. military to becoming a veteran,
individuals separate from the culture of the military environment in which they accepted
allegiance. They transition into civilian status, which requires them to reacclimate to the culture
and environment they left behind when joining the military. They are no longer servicemembers;
they are civilian citizens attempting to reintegrate into a society they once knew. As detailed in
Figure 1, many of the influences, attributes, and behaviors of veterans that they held as civilians
prior to joining the military were modified upon their entry into service. When leaving the
service and returning to civilian life, the veteran must again modify many of their influences,
attributes, and behaviors to effectively restore their identity as a citizen in civilian life. A person
who has returned to their country of origin or whose citizenship has been restored is considered
repatriated (Dictionary of Military and Associated Terms, 2005); this construct of repatriation is
applied in the context of this study to veterans returning to civilian life. The veteran is returning
to civilian life, and their status as a non-military citizen of society is being restored —they are
again a civilian; the veteran is repatriating into the society they left when they joined the
military. This idea of repatriation is important to acknowledge, according to Beier and Sienrukos
(2013), because of the unique nature of this challenge for veterans:
Many assume that returning back home for veterans is easy because they are
already familiar with the language and culture. However, repatriation is not as simple as
it sounds for veterans. The challenges inherent to living in a different cultural context for
a significant period of time do not end with re-entry to the prior culture; they continue
through the process of returning home and readjusting to what was left behind. In fact, it
is often those who have adjusted most successfully abroad who have the most difficulty
returning home. (p. 3)

5
Transition to veteran status occurs upon separation, as does the repatriation effort. While
separation is discreet and finite, reintegration is an ongoing effort, and timing has been identified
as a relevant factor in reintegration. A 2016 analysis of 3,795,823 U.S. service members who
served between 2001 and 2011 found an approximate doubling of suicide risk in the first year of
separating from the military (Shen et al., 2016). Given this information, many current Veteran
suicide prevention initiatives focus on reducing risk, particularly during the first year following
the transition from military service to civilian life (Kang et al., 2015; Shen et al., 2016).
The VA has devoted significant effort in the past two decades to helping veterans
repatriate into society. A common theme identified in the research is that veterans engaged in
repatriation may not seek this help due to not knowing the services available to them or the
stigma related to mental health issues among veterans. Many veterans identify asking for help as
being weak and a burden on their environment and relationships (Pietrzak et al., 2009b).
Common challenges identified by individuals leaving the military are feelings of separateness;
lack of a sufficient social support system or shared experiences with those systems;
disconnection from families; deployment-related psychological or physical injuries; and
financial, educational, and employment barriers (Pease et al., 2015).
Individual veterans face unique challenges during repatriation, and these challenges cover
a broad spectrum of issues. Veterans face mental health and substance use disorders (epartment
odf Veterans Affairs, 2018b); interpersonal and military trauma exposures that can manifest as
PTSD (Schiraldi, 2009); increased risk for chronic homelessness (Macia et al., 2020); and among
OEF and OIF veterans experiencing PTSD, 80% also have comorbid conditions of substance
abuse, major depression, and anxiety (Tanielian & Jaycox, 2008). These elements are commonly
identified as core catalysts for suicidal ideation (Department od Veterans Affairs, 2018b).

6
Suicide is but one of the consequences of the challenges identified above, but it is the gravest and
thus the focus of this study.
Building Resilience Against Suicide Among Veterans During Repatriation
The significant loss of life in the veteran community due to suicide has driven a plethora
of research into why repatriation challenges lead to suicidal ideation among veterans (Chen et al.,
2019; Committee on the Initial Assessment of Readjustment Needs of Military Personnel,
Veterans, and Their Families, n.d.; Eber et al., 2013; Logan et al., 2016). The concepts of social
integration, social support, peer support, community involvement, and personal relationships
have been frequently identified as potential sources of resiliency during the repatriation process
(as identified in Figure 1), as well as being identified as potential triggers for suicidal ideation
when they are absent or negative in character (Mavandadi et al., 2019; Olenick et al., 2015;
Pietrzak et al., 2009a). The American Psychological Association defines resilience as “the
process and outcome of successfully adapting to difficult or challenging life experiences,
especially through mental, emotional, and behavioral flexibility and adjustment to external and
internal demands” (American Psychological Association, 2022, para.1).
In repatriating veterans, resilience can be seen as the capacity for and dynamic process of
adaptively overcoming stress and adversity while maintaining normal psychological and physical
functioning (Southwick & Charney, 2012; Wu et al., 2013). Decades of suicide research have
primarily focused on risk factors for suicidal ideation and behavior while overlooking protective
factors that increase resilience and may help to address this critical public health issue (Sher,
2019; Shrivastava et al., 2012). Understanding what promotes resilience to prevent suicidal
ideation is essential to inform both prevention and intervention efforts among veterans and the
research.

7
To date, research on veteran resilience has identified two common classes of factors that
may help bolster resilience: social support and protective psychological factors (Kumar et al.,
2021). Protective psychological factors reflect internal characteristics that help promote
adjustment and adaptation (Peterson & Seligman, 2004); social support reflects greater social
connectedness and social engagement (House et al., 1988 & Pietrzak et al., 2009a). The
relationship between connectedness and resilience established in prior research guides the focus
of this study on connectedness as an element of programming within veteran support
organizations.
The Relationship Between Resilience and Connectedness
Recent research efforts highlight the importance of resilience supported by social
connectedness as a protective factor when examining suicidal ideation in general veteran samples
(Pietrzak et al., 2017; Smith et al., 2016). Veterans experiencing better connectedness, such as
social integration, social support, peer support, community involvement, and personal
relationships, exhibit greater resiliency and have more positive mental health outcomes,
including lower rates of suicidal ideation (Adams et al., 2017; Mavandadi et al., 2019; Olenick et
al., 2015; Pietrzak et al., 2009a). How an individual integrates with their surrounding ecosystems
is commonly referred to as connectedness, defined by the CDC (2005) as:
The degree to which a person or group is socially close, interrelated, or shares resources
with other persons or groups. This definition encompasses the nature and quality of
connections both within and between multiple levels of the social ecology, including
connectedness between individuals, connectedness of individuals and their families to
community organizations, and connectedness among community organizations and social
institutions. (p. 3)

8
In 2018, the Suicide Prevention Resource Center published findings that social support
and connectedness are key protective factors against suicide, enhancing resiliency and mitigating
risk factors present in an individual's life (Peterson & Bourne, 2018). The critical value of the
relationship between resiliency and connectedness was further emphasized in the U.S.
Government’s public messaging during National Suicide Prevention Month when the
Department of Defense focused on connectedness, highlighting how social connections and a
sense of belonging can be protective factors against suicide: “Resiliency as a protective factor is
the goal and connectedness is a primary means to achieving that goal.” (Army Resilience
Directorate, 2020). Research focused on veterans referred for a behavioral health assessment
identified three indices of social connections (perceived social support, frequency of negative
social exchanges, and degree of social integration) as central to effective repatriation and
uniquely associated with suicidal ideation (Mavandadi et al., 2019). Expanding on this point,
Olenick et al. (2015) found that a veteran's successful reintegration into civilian life outcomes
and interprofessional solutions evolve from community involvement, access to resources, and
support from peers.
Utilizing connectedness to facilitate resiliency is central to the CDC’s 2020-2022 Suicide
Prevention Strategic Plan, where continued emphasis on suicide prevention is targeted through a
comprehensive public health approach to suicide prevention that relies on data, science, and
action, grounded in a strong foundation of collaboration for maximum impact. One of the
primary aims is to promote opportunities and settings to enhance connectedness, identifying
connectedness as a common thread that weaves together many of the influences of suicidal
behavior and has direct relevance for prevention (CDC, 2020). This approach recognizes that
theory and research addressing the association between connectedness and suicidal behavior

9
dates back to Durkheim (1951). Current evidence continues to support the association (CDC,
2017, Stone et al., 2017).
Adopting Connectedness in Veterans Affairs Programs
Following the lead of the CDC, the VA has embraced a comprehensive public health
approach to reduce Veteran suicide rates, one that looks beyond the individual to involve peers,
family members, and the community. The VA published this approach in the National Strategy
for Preventing Veteran Suicide 2018–2028. The VA highlighted its commitment to
connectedness with three of the four strategic directions outlined in this national strategy
focusing on connectedness (Department of Veterans Affairs, 2018b).
The Department of Veterans Affairs acknowledged the role of connectedness in their
response to the continuing veteran suicide crisis when they crafted a National Strategy for
Preventing Veteran Suicide in 2018. There are four strategic directions outlined in this national
strategy (Department of Veterans Affairs, 2018b):
● Strategic Direction 1: Healthy and Empowered Veterans, Families, and Communities
● Strategic Direction 2: Clinical and Community Preventive Services
● Strategic Direction 3: Treatment and Support Services
● Strategic Direction 4: Surveillance, Research, and Evaluation
All but Strategic Direction 4 identify connectedness as a critical component in the
strategy to mitigate veteran suicide (Department of Veterans Affairs, 2018b). Understanding the
role of connectedness as a tool in veteran suicide mitigation is a critical component of the
campaign. Facilitating successful veteran repatriation is an essential step in mitigating senseless
loss of life and recovering the significant personal and fiscal investment made in veterans by the
United States (Lacroix et al., 2018).

10
Field Context
The recognition of veteran suicide as a significant national problem has catalyzed action
in both U.S. government and non-government components. Year over year, the V.A. dedicates
increasingly more resources to suicide prevention, but suicide numbers are not decreasing
(Peterson & Bourne, 2018). In addition to the Veterans' Administration, several other
government organizations are engaged in suicide prevention. Organizations such as the
Department of Defense, the Department of Health and Human Service's Substance Abuse and
Mental Health Services Administration or SAMHSA (http://www.samhsa.org), the National
Institute of Mental Health or NIMH (http://www.nimh.nih.gov/health/topics/suicide-
prevention/index.shtml), the Center for Disease Control's National Center for Injury Prevention
and Control or NCIPC (http://www.cdc.gov/ViolencePrevention/suicide/index.html), and the
Indian Health Services or IHS (http://www.ihs.gov/suicideprevention/). Accompanying this
group of government organizations is an entropic list of nonprofit and community-based
organizations focused on assisting veterans at risk of suicide (Appendix A).
The Veterans Administration acknowledged the veteran suicide challenge in the National
Suicide Prevention Annual Report, where it calls for an updated model for suicide prevention
called Suicide Prevention 2.0 or SP 2.0 (Office of Mental Health and Suicide Prevention,
Department of Veterans Affairs, 2020). SP 2.0 outlines a U.S. Department of Veterans Affairs'
public health strategy that leverages a combination of community and clinically based
approaches to implement tailored, local prevention plans while also focusing on evidence-based
clinical intervention strategies. This strategy looks beyond individuals and leverages peers,
individuals, and communities. In Executive Order No. 13861 (2019), the President further
codified the challenge and laid out a strategy in his National Roadmap to Empower Veterans and

11
End Suicide addressing both mental and physical concerns. The Order calls for the following
approach to address these concerns:
An aspirational, innovative, all-hands-on-deck approach to public health—not
government as usual. The Federal Government alone cannot achieve effective or lasting
reductions in the veteran suicide rate. This is not because of a lack of resources. It is, in
fact, due substantially to a lack of coordination: Nearly 70% of veterans who end their
lives by suicide have not recently received healthcare services from the Department of
Veterans Affairs (Executive Order No. 13861, 2019).
This Order established the President's Roadmap to Empower Veterans and End a National
Tragedy of Suicide (PREVENTS) Task Force. The Cabinet-level task force engages federal,
state, and local governments, along with non-governmental organizations and the veteran
community, creating a broad-based national public health effort to prevent veteran suicide
(Executive Order No. 13861, 2019).
Pursuing this integrating public health approach to veteran suicide, SAMHSA is
partnering with the V.A. to bring the Governor's and Mayor's Challenges to Prevent Suicide
Among Service Members, Veterans, and their Families to states and communities across the
nation. These efforts will bring together state (Governor's Challenge) or community (Mayor's
Challenge) interagency military and civilian team leaders to develop an implementation plan for
mitigating suicide among service members, veterans, and their families (SMVF). The stated
goals (Department of Health & Human Services, 2020) in both activities are to:
● Implement promising, best, and evidence-based practices to prevent and reduce suicide.
● Engage with city, county, and state stakeholders to enhance and align local and state-
wide suicide prevention efforts.
● Understand the issues surrounding suicide prevention for SMVF.

12
● Increase knowledge about the challenges and lessons learned in implementing best
policies and practices by using state-to-state and community-to-community sharing.
● Employ promising, best, and evidence-based practices to prevent and reduce suicide at
the local level.
● Define and measure success, including defining assignments, deadlines, and measurable
outcomes to be reported
The state of Nevada and the City of Las Vegas are participants in their respective
challenge teams (Nevada Department of Veterans Services, n.d.). This study focuses on those
individuals supporting the successful implementation of the challenge goals in the Las Vegas and
greater Nevada area. Particular emphasis will be placed on individuals who work with state,
local, and nonprofit organizations that are not part of the V.A. enterprise, are veterans themselves
and are not direct recipients of the support vectors identified in the challenge objectives explored
in this study.
Overview of Theoretical Framework and Methodology
In the literature, two primary theories currently serve as frameworks for suicide study and
prevention efforts—the Joiner interpersonal-psychological theory of suicide and
Bronfenbrenner's Bioecological Framework. In Joiner's (2005) interpersonal-psychological
theory of suicide, the author asserts there are three required factors to complete suicide: a
thwarted sense of belongingness, perceived burdensomeness to society, and an acquired
capability to overcome the pain and fear of suicide (Joiner, 2005). The training and experience
veterans are subject to, particularly deployment and combat, can increase suicide risk by
increasing the veteran's capacity to accept pain while concurrently increasing fear tolerance.
Gutierrez et al. (2013) conducted a qualitative study among female Veterans from recent
conflicts to explore the women's experiences and potential suicide risk factors according to

13
Joiner’s Interpersonal Psychological Theory of Suicide. The study identified support for
perceived burdensomeness, failed belongingness, acquired capability to accept pain and tolerate
fear, along with loss of identity/self-worth as potential risk factors for suicide among female
Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) veterans (Gutierrez et al.,
2013). The Joiner considerations were also recognized in a study by Denneson et al. (2015),
where they identified three contributors to suicidal thoughts among OEF/OIF veterans: military
culture (including insensitivity to suicide and emphasis on keeping silent regarding mental health
concerns), difficult deployment experiences (including combat experiences, stressors at home,
responsibilities, and leadership), and post-deployment adjustment challenges (including adjusting
to civilian life, lacking purpose, feeling overwhelmed, and changes to one’s sense of self).
Multiple studies have identified that challenges during repatriation can result in an increased
perception of being a burden based on the veteran's sense of belonging to partners, family,
friends, and society (Adler et al., 2020; Chen et al., 2019; Eber et al., 2013; Logan et al., 2016).
These studies acknowledge the potential value of applying Joiner’s theory to the veteran suicide
problem. Still, significant research applying the Joiner theory to veteran suicide is in its infancy
(Langhinrichsen-Rohling et al., 2011), and there have been relatively few longitudinal studies of
the interpersonal theory of suicide in the veteran population (Chu et al., 2020). In contrast,
applying the ecological model to veteran suicide research, the second theory integrated in this
study’s framework, is a common strategy.
Bronfenbrenner's Bioecological Framework provides an appropriate theoretical lens
through which to view the nature of a veteran’s relationship with their environment (their
connectedness) and how changes in that environment, both contextually and over time, can
impact the veteran’s ability to thrive. A graphic illustration of the Bronfenbrenner model is
provided in Figure 2.

14

Figure 2
Bronfenbrenner's BioEcological Framework Model

Note. Figure adopted from Bronfenbrenner, U., & Ceci, S. J. (1994). Nature-Nurture
Reconceptualized in Developmental Perspective: A Bioecological Model. Psychological Review,
101(4), 568–586. https://doi.org/10.1037/0033-295X.101.4.568

This framework emphasizes the role of bidirectional influences between individuals'
development and their surrounding environmental contexts (Bronfenbrenner & Morris, 2007).
The temporal component (the chronosystem) in the bioecological framework is especially

15
relevant to this effort because it highlights the impact of time on changing ideas, attitudes, and
behaviors.
The framework is appropriate because Veterans adapt when they transition from the
civilian to the military environment. The macrosystem values are different from civilian life
(code of conduct, dress, language, etc.); exosystem elements become tied to the military lifestyle
(mission drives interaction, priorities, access to family, friends, and neighbors); microsystem
processes shape the individual (boot camp, unit level, combat); and all of these interactions help
shape the individual. The formal process of induction into military services facilitates these
changes (Jackson et al., 2012). There is no formal process to realign the systems when leaving
military service. Consequently, fractures between and within the systems can occur upon
separation from military service. These fractures can become contributors to suicidal ideation
(Holyfield, 2011).
From a conceptual framework perspective, individuals join the military and undertake a
rigorous program to rebuild themselves and their ideas to fit the service's social and ideological
construct. Bronfenbrenner's micro, exo, and macro system makeup are redefined in this process.
The servicemember exists within a structured environment with known boundaries, expectations,
and connectedness. Upon separation from the service, there is inadequate investment in
transitioning from the service construct to the civilian societal construct (Jackson et al., 2012).
The processes and resources to rebuild constructive micro, exo, and macro systems are
inadequate, if present at all, leaving the veteran without a means of connecting in their new
world. Providing the necessary tools and resources to rebuild those connections in the non-
military environment better positions the veteran to successfully reintegrate into society.
Understanding and implementing practices to instantiate the needed connectedness can be a
strong tool for mitigating suicidal ideation.

16
This study will leverage a qualitative research design consisting of participant interviews
augmented by document and artifact analysis. This approach was chosen to enable the use of an
evolving set of questions and responsive tactics rather than executing a fixed plan that one sees
in a quantitative approach (Golden-Biddle & Locke, 2007). A phenomenological approach to
research attempts to describe the essence of the targeted phenomenon by exploring it from the
perspective of those who have experienced it so as to understand the meaning the participants
ascribe to that phenomenon (Teherani et al., 2015). Because the research pursues an
understanding of a social phenomenon in natural settings using a small purposeful sample of
face-to-face interactions, it is both exploratory and inductive, making it well suited to a
qualitative approach. The targeted participant pool is comprised of individuals who are engaged,
either individually or as a member of an organization, in veteran support services aimed at
helping veterans successfully reintegrate into civilian society. Participants for interviews will be
recruited from individuals and organizations participating in the Substance Abuse and Mental
Health Services Administration/Veterans Administration (SAMHSA/VA) Mayor's & Governor's
Challenge Team program in Nevada. Details of the study methodology will be elaborated on in
Chapter 3.
Purpose of the Study and Research Questions
The purpose of the study is to explore veteran service providers’ perceptions of the
association between connectedness and resilience in veterans repatriating into society. The study
acknowledges the role and significance of the veteran’s perceptions, but is specifically targeted
at the role of veteran service providers and their organizations’ role in repatriation with an
intentional focus on connectedness in the veteran service providers programs and actions. As the
existing research has already established the relationship between connectedness and resilience
and resilience as a mediator for suicidal ideation, this study explores connectedness specifically.

17
The intent is to discover potential recommendations for individuals and groups assisting veteran
repatriation to leverage connectedness to increase veteran resiliency and ultimately mitigate
veteran suicidal ideation. By identifying how connectedness is currently understood and utilized
compared to how it could be understood and utilized according to research evidence, the results
may inform strategies to better achieve goals and better understand the role of connectedness in
mitigating repatriation problems that have the potential to lead to suicidal ideation. Gathering as
much contextual and programmatic understanding as possible will better facilitate transfer
between localities and benchmarking within a national strategy. The following questions guide
this study:
1. What role, if any, do veteran service providers perceive connectedness plays in the
repatriation of veterans into civilian life following separation from military service?
2. How, if at all, do veteran support service providers consider connectedness in their
veteran repatriation programming decisions?
3. How do veteran service providers perceive a veteran’s service as influencing the
veteran’s ability to establish connectedness following separation from military service?
4. What recommendations are there for improving connectedness with the community for
the veterans transitioning from military service?
Importance of the Study
It is important to study this problem because suicide is the 10th leading cause of death in
the United States (CDC, 2016), and the veteran suicide rate is 1.4 times that of their non-veteran
counterparts (Department of Veterans Affairs, 2018b). Executive Order No. 13861 (2019) noted
that the failure to drive down the veteran suicide rate is not a resource or prioritization problem;
it is a collaboration and coordination problem. Department of Defense and VA efforts are

18
improving at a rapid pace, but by the very definition of veteran, the veteran population is no
longer under DoD purview once separated from service (CFR 38, 2022).

Figure 3
Suicidal Veterans Under VA Care

Note. From U.S. Department of Veterans Affairs, National Center for PTSD. (2018). Fiscal Year
2018 annual report: National center for PTSD [PDF].
https://www.ptsd.va.gov/about/work/docs/annual_reports/2018/NCPTSD_2018_Annual_Report
_AllAppendices.pdf

19
The VA continues to make positive strides to improve its veteran support efforts, but they
can only be effective if the veterans pursue support through the VA and as reported in the
National center for PTSD’s 2018 annual report, 70% of veterans who commit suicide have not
engaged the Veterans Health Administration (VHA) for care. The clinical tools available through
the DoD and V.A. can and are being shared in the effort to address veteran suicide. It is the
social component of the public health umbrella that lacks leadership, coherence, and
commonality across all of the stakeholders (Farmer et al., 2020). The United States invests
heavily in military members, spending over $15K per person per year on recruiting (Buddin,
2005), another $16K per person per year in training, and an average of $60K per person per year
in compensation (Dahlman, 2007), which equates to a minimum of $90K per year to field a
service member. This investment provides service members the training, education, and
capabilities they need to contribute to the national defense of the United States while serving and
their communities after separation. The PREVENTS Task Force has instantiated an
organizational construct to provide leadership, coherence, and commonality to public, private,
and government entities, but many repatriating veterans still face a shortage of tools and skills to
readily make the transition.
For many veterans, the loss of structure, connections, common language, and common
objectives is exacerbated by their unfamiliarity with the world they left when joining the service.
They find it difficult to connect in relationships, integrate into families, or feel "at home" in the
community (Sayer et al., 2010; Sayer et al., 2011; Sayer et al., 2014; Wade, 2016). Finding a
way to reconnect becomes the primary mission for the reintegrating veteran. Connectedness can
provide the connective tissue between the fragmented components of the repatriating veterans'
world (Aherne et al., 2017; Besterman-Dahan et al., 2018; Kintzle et al., 2018; Worthen &

20
Ahern, 2012). Understanding and implementing veteran connectedness through the broad
support mechanism is a key component in attaining the goals targeted in the national strategies.
It is important to optimize these prevention strategies because any life lost to suicide is an
avoidable tragedy, and the compounded personal and fiscal investment made in veterans by the
United States exacerbates the loss (Lacroix et al., 2018). Studying how connectedness is
currently understood and utilized by veteran service providers in facilitating veteran repatriation
programming provides the opportunity to advance understanding of the interaction between
repatriation, connectedness, and resiliency in practice. Exploring the integration of
connectedness in veteran repatriation programming can also provide a foundation for leveraging
potential increases in resiliency associated with connectedness in the effort to mitigate suicidal
ideation.
Definitions
To better facilitate a common frame of reference, key words and concepts will be
presented here:
● Connectedness is:
The degree to which a person or group is socially close, interrelated, or shares
resources with other persons or groups. This definition encompasses the nature
and quality of connections both within and between multiple levels of the social
ecology, including connectedness between individuals, connectedness of
individuals and their families to community organizations, and connectedness
among community organizations and social institutions (National Center for
Injury Prevention and Control, 2013).

21
● Repatriate is:
A person who has returned to their country of origin or whose citizenship has
been restored is considered repatriated. When transitioning from active service in
the United States military to being a veteran, one’s status as a civilian citizen is
being restored. That veteran is returning to civilian life, and their status as a non-
military citizen is being restored; the veteran is repatriating into the society they
left when joining the military. (Dictionary of Military and Associated Terms,
2005).
● Resilience is:
○ Clinical: The process and outcome of successfully adapting to difficult or
challenging life experiences, especially through mental, emotional, and
behavioral flexibility and adjustment to external and internal demands.
Several factors contribute to how well people adapt to adversities;
predominant among them are (a) how individuals view and engage with the
world, (b) the availability and quality of social resources, and (c) specific
coping strategies. Psychological research demonstrates that the resources and
skills associated with more positive adaptation (i.e., greater resilience) can be
cultivated and practiced (American Psychological Association, 2022)
○ Operational: A stable trajectory of healthy functioning after a highly adverse
event. As it applies to people, it involves a reintegration of self that includes a
conscious effort to move forward in an insightful integrated positive manner
as a result of lessons learned from an adverse experience (Yehuda et al.,
2013).

22
● Veteran is:
Defined by Title 38 of the Code of Federal Regulations as "a person who served
in the active military, naval, or air service and who was discharged or released
under conditions other than dishonorable" (CFR 38, p. 153, 2022)
Organization of the Dissertation
This study is organized into five chapters. Chapter One provided an introduction to the
problem of practice, field context, research questions, theoretical framework, methodology, and
key concepts and terminology addressing the concept of connectedness as it relates to the
mitigation of veteran suicidal ideation. Chapter Two provides a review of the current literature
surrounding the suicide problem, suicide theory, ecological theory, and specific challenges of
veteran suicidal ideation. Chapter Three describes the methodology used to derive and define
the participants, target data, and data collection protocols. Chapter Four details data assessment
and analysis. Chapter Five proffers a discussion resulting in conclusions.

23
Chapter Two: Literature Review
The purpose of the study is to explore veteran service providers’ perceptions of the
association between connectedness and resilience in veterans repatriating into society. The
specific problem addressed in this study is veteran suicide following separation from military
service, a focused subset of the much broader problem of suicide. Specifically, this chapter
reviews current trends in veteran suicide and mental health challenges facing veterans, as well as
the role of connectedness in the transition from military service. The chapter closes by analyzing
the Bronfenbrenner Ecological Model as a framework for viewing the connectedness during the
veteran's repatriation into civilian society.
Current Data on Veteran Suicide
This review of current trends in veteran suicide considers literature under three topic
areas that emerged from the review process. These topic areas are age, gender, and deployment
history. Figure 4 illustrates the rising suicide rate in the United States from 2005 to 2018 as both
a national and veteran challenge. In 2018, when compared to civilians, veterans were 1.5 to 2.4
times more likely to die by suicide than their non-veteran counterparts, dependent on the year
assessed, age, and sex (Department of Veterans Affairs, 2018b; Gibbons et al., 2012; Kaplan et
al., 2012). In 2017 Veterans accounted for 13.5% of all deaths by suicide among U.S. adults
while constituting only 7.9% of the adult population (Department of Veterans Affairs, 2020).

24
Figure 4
Number of Suicides Comparing U.S. Adult and Veteran Populations (2005-2018)

Note. Adapted from the National veteran suicide prevention annual report. September 2019.
Office of Mental Health and Suicide Prevention, U.S. Department of Veterans Affairs.

Figure 5 provides more detailed evidence of the disproportionately higher risk of suicide in the
veteran community compared to the civilian community regarding both gender and age
(Department of Veterans Affairs, 2020).

25
Figure 5
Veteran Suicide Rate by Age Group and Sex, 2018

Note. Adapted from the National veteran suicide prevention annual report. September 2019.
Office of Mental Health and Suicide Prevention, U.S. Department of Veterans Affairs.

The following sections look at how age and gender, deployment history, and mental health
outreach are reflected in the veteran suicide discussion.
Data on Age and Gender
Age and gender play a significant role in characterizing suicide rates in both veteran and
non-veteran populations. Suicide is a significantly growing problem in the United States; it is
the 10th leading cause of death (CDC, 2016). Suicide affects all ages and is a problem across the
life span. In 2016, the CDC reported suicide was the second leading cause of death for the 10–
34-year age group. The report also highlighted veterans as being disproportionately impacted by
suicide. The Department of Veterans Affairs conducted an extensive study in 2018 based on

26
National Death Index mortality data through 2016 for all 50 states and the District of Columbia
to better understand this disproportionality. The study provided data on age and gender
comparisons between veterans and non-veterans.
This V.A.-sponsored study revealed that while suicide rates for the total male populations
were similar, among veterans in the most densely populated age group (18-34 years old), the
suicide rate was 1.4 times greater than their non-veteran counterparts (Department of Veterans
Affairs, 2018b). The study further highlighted suicide rates for female veterans were 1.8 times
greater than their non-veteran counterparts. However, a 2015 study of U.S. Army veterans
attempted to better understand gender differences in suicide and suicide attempts among soldiers.
The study determined that while male and female veterans were subject to the same influences
and risk factors, gender was not a driving factor in suicidal ideation among Army veterans
(Maguen et al., 2015). The research only identified one gender-based difference, workplace
difficulties, being more strongly associated with suicide for female soldiers. In their 2014 article
A Gendered Perspective on Military Deployment (Kelly et al., 2014) identified workplace
difficulties as a general environment of stress, heterogeneous job responsibilities, home issues
impinging on duties, and gender-related stress. As women increase in the percentage of veterans
and take on more combat roles, there will be more female deployments to both combat and non-
combat areas of operation, making understanding potential gender differences critical to mental
health outcomes and mortality (Maguen et al., 2015). Age and gender data highlight differences
between veteran and non-veteran populations, but these factors do not address veteran-specific
influences on suicide. Therefore, it is critical to examine deployment history in addition to age
and gender as factors contributing to veteran suicide.

27
Data on Deployment History
Pursuant to suicide rates escalating following the 1991 Gulf War, researchers have
attempted to establish a causal relationship between deployment history and suicide. The
preponderance of research does not assert a strong correlation between military deployment and
suicide (Bryan & Cukrowicz, 2011; Bryan et al., 2015; Reger et al., 2018)
In 2013 the Millennium Cohort Study (MCS), known as 'Child of the New Century' to
cohort members and their families, was established to follow the lives of around 19,000 young
people born across England, Scotland, Wales, and Northern Ireland in 2000-02. The study began
with an original sample of 18,818 cohort members. One line of effort in the Millennium Cohort
Study examined risk factors for suicide in over 150,000 combat veterans. It concluded that for
the suicides studied, "No aspect of deployment (duration, number of deployments, or combat
experience) was related to suicide" (Roy-Byrne, 2013, p. 1). Expanding on these findings,
researchers sought to measure the effect of military separation on suicide rates. They "did not
find increased suicide risk associated with any deployment-related factors such as combat
experience, number of days deployed, or number of deployments” (Reger et al., 2015, p. 565),
but they did observe a "substantial increase in the hazard of suicide as a function of separation
from service” (Reger et al., 2015, p. 563).
A 2011 study by Thomsen et al. highlighted behavioral attributes of individual veterans
as being significant contributing factors to suicidal ideation. The study addressed the effects of
combat deployment on risky and self-destructive behavior among active-duty military personnel.
The participants were asked to describe their deployment experiences and participation in risky
recreational activities, unprotected sex, illegal drug use, self-injurious behavior, and suicide
attempts during three time frames (civilian, military pre-deployment, and military post-
deployment). The analysis highlighted that the strongest predictor of engagement in each type of

28
risky behavior was having previously engaged in that type of behavior. Controlling for previous
behavior did not alter the pattern of differences between deployers and non-deployers in current
risky behavior; deployment was associated with increased rates of risky recreational activity,
illegal drug use, and self-harm but was unrelated to rates of unprotected sex and attempted
suicide. In fact, as regards the five risky behaviors examined, deployment did not have a
significant effect among individuals with no prior history of engaging in that type of risky
behavior. In contrast, deployment significantly increased four of the five risky behaviors (all but
suicide attempts) among individuals who had previously engaged in that behavior. The study
concludes that deployment does not appear to introduce new risk-taking behaviors among those
who had not engaged in them previously, but rather it increases engagement in risky behaviors
among those who had already engaged in them (Thomsen et al., 2011).
In 2020, Miller et al. conducted a study on mental health considerations analyzed through
post-deployment debrief data and follow-up interviews. The research summarized data by
comparing At-Risk Veterans to Low-Risk Veterans. They determined 34% of the overall sample
met their criteria for being at risk. They further identified this “at-risk” subset as being younger,
less educated, and less likely to be married or living with a partner. “At-risk” veterans also
reported fewer years of service, fewer deployments, were more likely to have served in the
Army, and were more likely to be combat veterans (as defined by exposure to combat, blast, or
trauma). In all of these instances, the variable differences were small in magnitude (Miller et al.,
2020). These studies recognize deployments as contributors to overall mental health status but
not specifically suicide. Several studies have identified veterans' separation from the military as
a significant challenge.
Researchers identified separation from the military as a period of elevated risk, regardless
of deployment history (Magruder & Yeager, 2009; Pease et al., 2015). These same researchers

29
identified Operation Enduring Freedom and Operation Iraqi Freedom combat veterans as having
a particularly difficult time leaving the service, but this was based more on the transition to
civilian life than their deployment experience (Pease et al., 2015). In their 2012 study, Mitchell
et al. identified the transition out of the military as particularly difficult among those who
experienced the greatest stress from high combat exposure because of the emphasis on and
importance of unit cohesion to these individuals. The study highlighted that combat exposure
could be a substantial risk factor for adverse outcomes such as suicide-related ideation. However,
they still asserted that unit cohesion reduces this risk (Mitchell et al., 2012). Having just left the
social structure of the military (familiar sounds and surroundings, familiar rhythms, familiar
friends, and comfortable routines), many veterans struggle to re-enter their old social context.
The research indicates that "some veterans retreat into their former military culture for
protection, some embrace their new surroundings, and some fall through the cracks and become
isolated" (Garland, 2018, p. 84). Those that do not adapt well to the separation and embrace
their new environment find themselves at risk of adopting risky behaviors and embracing self-
harm. These behavior patterns are markers highlighting the need for support through mental
health outreach. The literature does not support a correlation between deployment history and
veteran suicide (Bryan et al., 2015; Bryan & Cukrowicz, 2011; Reger et al., 2018); but instead
points to mental health issues associated with reintegration into society as increasing the risk of
suicide (Reger et al., 2015). Consequently, the focus must also consider mental health outreach
when addressing veteran suicide.
Mental Health Challenges Faced by Repatriating Veterans
Mental health outreach programs provide a means to positively address growing veteran
suicide rates. Research shows that prevention and treatments for mental health and substance
use disorders, commonly identified as core catalysts for suicidal ideation, are effective and that

30
recovery is possible (Department of Veterans Affairs, 2018a). Unfortunately, the military's
warrior culture discourages soldiers from speaking openly about their psychological and
emotional fragility (Lacroix et al., 2018). An example of warrior culture is when military ethos
instills a belief that seeking help is a sign of weakness; this perception of weakness results in
veterans viewing themselves as a liability or burden to their families and communities, with as
few as 23% of those with mental illness seeking care (Eber et al., 2013). Table 1 highlights
several correlations between a veteran’s military ethos and the associated strengths and
vulnerabilities as reported in an Online Journal of Issues in Nursing article addressing military
culture implications (Westphal & Convoy, 2015).

31
Table 1
Military Ethos and Strength Vulnerabilities
Strength Trait Vulnerability
Placing the welfare of others above
one’s own welfare
Selflessness Not seeking help for health problems
because personal health is not a priority
Commitment to accomplishing missions
and protecting comrades in arms
Loyalty Survivor guilt and complicated
bereavement after losing friends
Toughness and ability to endure
hardships without complaint
Stoicism Not acknowledging significant symptoms
and suffering after returning home
Following an internal moral compass to
choose “right” over “wrong”
Moral Code Feeling frustrated and betrayed when
others fail to follow a moral code
Meaning and purpose when defending
societal values
Social Order Loss of meaning or betrayal when rejected
by society
Becoming the best and most effective
professional possible
Excellence Feeling ashamed of (or not
acknowledging) imperfections

Overcoming this barrier is the seminal challenge in getting troubled veterans the mental health
help they need.
In response to this challenge, the V.A. has laid out a strategy for clinicians and laypeople
to penetrate the military ethos and open a portal to facilitate healing (Department of Veterans
Affairs, 2018a). This strategy relies on communication campaigns and social marketing
interventions to help change knowledge, attitudes, and behaviors that limit access to services that
prevent veteran suicide. Enabling safe and positive messaging addressing mental illness,
substance abuse, and suicide can help overcome the stigma and encourage outreach. The
strategy's objective is to create supportive environments where veterans feel comfortable seeking
help and where families and communities feel empowered to connect a person with care before,
during, or after a crisis to assist the person in regaining a meaningful life (Department of

32
Veterans Affairs, 2018a). The connections between demographics and military experience pale
compared to mental health outreach in addressing veteran suicide. The research indicates the
disproportionately high rates of veteran suicide are most often a result of mental health
challenges and that addressing mental health and associated comorbidities is key to solving the
problem. This study looks specifically at mental health challenges in homelessness, PTSD, and
substance use disorders.
Suicide-Related Mental Health Transition Challenges for Veterans: Homelessness
The concept of veteran homelessness is often seen as puzzling because homeless veterans
are consistently older, better educated, more likely to have married, and more likely to have
health coverage than other homeless adults (Baumohl, 1996). Research addressing this concern
points to mental health problems and a history of interpersonal and military trauma exposure as
central to a veteran's increased risk for chronic homelessness (Macia et al., 2020). The research
highlights specific trauma‐related factors as being particularly relevant to episodic patterns of
homelessness as well as interfering with efforts to remain housed (Macia et al., 2020).
Current epidemiological data suggest that military service itself does not substantially
increase the risk of homelessness among veterans (Mares & Rosenheck, 2004). A study
conducted among 631 homeless veterans enrolled in the V.A. Therapeutic Employment
Placement and Support Program from January 2001 through September 2003 indicated that less
than 31% of those studied reported military service increased their risk for homelessness (18%
somewhat, 13% very much). Within the 31%, three aspects of military service were most
commonly identified: (a) substance abuse problems that began in the military (75%); (b)
inadequate preparation for civilian employment (68%); and (c) loss of a structured lifestyle
(Mares & Rosenheck, 2004). Challenges associated with veteran homeless can lead to additional
concerns.

33
Veteran homelessness is often an indicator of unresolved challenges facing veterans.
These challenges are often a result of, or contributor to, detrimental behaviors, such as substance
abuse, violence, and social separation. A 2015 nationally representative survey of U.S. veterans
identified that veterans with a history of homelessness attempted suicide at a rate more than five
times higher (6.9% vs. 1.2%) compared to veterans without a history of homelessness in the
previous two years (Tsai et al., 2018). Additionally, their rates of two-week suicidal ideation
were 2.5 times higher (19.8% versus 7.4%). The U.S. Department of Veterans Affairs (V.A.)
asserts that services provided to assist veterans’ homelessness can help mitigate homelessness
and may also assist in veteran suicide prevention (Annual Homeless Assessment Report (AHAR)
to Congress, 2016). Being homeless is often a result of challenges veterans face while
attempting to reintegrate into society, but challenges can also arise from veterans' interactions
with themselves; their memories and perceptions of past events manifest as Post Traumatic
Stress Disorder or PTSD.
Suicide-Related Mental Health Transition Challenges for Veterans: PTSD
For many of the more than two million U.S. service members who have served in Iraq
and Afghanistan since 2001, the trip home is only the beginning of a long journey. Many
undergo an awkward period of readjustment to civilian life after long deployments. Some
veterans may find themselves drinking too much, unable to sleep or waking from unspeakable
dreams, lashing out at friends and loved ones (Finley, 2019). Over time, some will struggle so
profoundly that they eventually are diagnosed with posttraumatic stress disorder (PTSD). The
Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR), the publication that defines
the criteria used to diagnose mental disorders, classifies PTSD as an anxiety disorder that arises
from exposure to a traumatic event involving actual or threatened death or serious injury (DSM-
5_TR, 2022). Some professionals consider PTSD to be a normal response by a normal person to

34
an abnormal situation (Schiraldi, 2009). This perspective asserts that the development of PTSD
is both understandable and predictable when people are exposed to abnormal traumatic
circumstances. PTSD can develop in stages over time; some individuals experience singular
symptoms and some multiple symptoms. There is no set schedule, some individuals experience
symptoms immediately following a traumatic event, and for others, it may take years (Marvasti,
2012). These variations in severity and time are thought to contribute to less than 50% of
veterans exposed to trauma being diagnosed with PTSD (Marvasti, 2012).
PTSD symptoms vary significantly from one veteran to another but generally develop in
three categories as outlined by Jamshid Marvasti in his description of PTSD signs and symptoms
(Marvasti, 2012):
• Re-experiencing: The most disruptive symptoms involve re-experiencing the trauma
(nightmares, flashbacks, or intrusive thoughts). The veteran may experience nightmares
or intrusive memories of traumatic events and be overcome by horrifying images, sounds,
and recollections. The symptoms can appear at any time, without stimulus, or they can
be triggered by a memory of the traumatic event: a noise, image, word, or smell.
• Avoidance/Numbing: Veterans with PTSD may avoid thoughts or activities that remind
them of a traumatic event. They may lose their ability to experience pleasure, seem cold
and nonresponsive, and feel detached or estranged from others.
• Hyperarousal/Hypervigilance: Veterans with PTSD may experience autonomic arousal,
also called hyperarousal. They may become hypervigilant, feeling and acting as if they
are constantly in danger. This hypervigilance can disrupt sleep, contribute to irritability
and anger, impair concentration, and coexist with an exaggerated startle response.
Medical research shows a biological basis for PTSD is reflected in chemical changes in
the body's hormonal system, immune system, and autonomic nervous system. The research also

35
identifies intense bursts of brain activity during traumatic experiences that can create new neural
pathways in the brain (Johnson, 2005). Response to traumatic experiences occurs along a
continuum and commonly includes sudden increased arousal and vigilance. A normal stress
response to danger generally dissipates with time. In veterans with PTSD, the symptoms may
intensify, become chronic, and interfere with their ability to function (Davidson et al., 2004).
Veteran views on PTSD may be complex and contradictory, shading from stigma to
acceptance and back again as the veteran moves from military service to engagement in the post-
military community. Acknowledging the military's efforts to address PTSD have been
prodigious, there have been times when affected individuals are confronted by opposing
messages deeply rooted in military culture and wartime necessity. The military depends on a
social construct that instructs service members to adopt values of toughness, stamina, and
invincibility and then rewards those who maintain composure in the most difficult environments
(Finley, 2019). This mentality is part and parcel of the relationships between service members.
These values are exacerbated under the pressures of combat when every unit member is
encouraged to believe that the team's survival depends upon living up to these values and
obligations (Finley, 2019). Unit cohesion and mission focus provide service members both
motivation and support in pursuit of these values and obligations, providing a protective factor
and enhancing resiliency while immersed in a tight-knit community with shared expectations and
insight. Even in this cultural construct, the military's best efforts can prove inadequate to
overcome the stigma of perceiving PTSD as a weakness, often distancing veterans with PTSD
from the help they need (Finley, 2019). Veterans who are no longer immersed in that tight-knit
community with shared expectations and insights find themselves even more challenged and less
likely to pursue the help they need.

36
Suicide-Related Mental Health Transition Challenges for Veterans: Substance Use
Disorders
Among those OEF and OIF veterans experiencing PTSD, 80% also have comorbid
conditions of substance abuse, major depression, and anxiety (Tanielian & Jaycox, 2008). These
findings are not new. Psychiatric epidemiology studies have consistently found veterans to have
higher rates of substance-related disorders when compared to the general population (Eisen et al.,
2004; Kulka, 1990; Thomas et al., 2010), and PTSD usually predates the onset of the substance
abuse (Kessler et al., 1995; Najavits et al., 2018). PTSD severity has also been found to be
positively correlated with substance use severity (Brown & Gannon-Rowley, 1998; McFall et al.,
1992), and veterans diagnosed with PTSD have been estimated to be more than two times as
likely to abuse alcohol as veterans without PTSD (Jakupcak et al., 2010). Neither is PTSD
unique in conferring risk for substance-related disorders. In fact, studies have identified links
between drug and alcohol abuse and a wide range of mood and anxiety disorders (Conway et al.,
2006; Wolitzky-Taylor et al., 2012). Specifically, alcohol abuse and dependence have been
linked to a wide array of comorbidities spanning both the internalizing and externalizing spectra
(Cloninger, 1987; Eaton et al., 2011).
Connectedness as a Protective Factor in Veteran Suicide
In recent years, there has been a significant amount of research and reporting on Veterans
and the transition from military to civilian life (Jenkins, 2014; Junger, 2010, 2016; Rose, 2017).
Kintzle et al. (2018) conducted a study whose findings demonstrate facilitating connectedness
may serve as a protective factor in the development of PTSD symptoms. The study also found
that connectedness can be particularly valuable to repatriating veterans who have experienced
combat as well as veterans with a non-honorable discharge status. Advancing a repatriating
veteran’s connections to family, friends, and society at large enhances resiliency as it can serve

37
as a protective factor when facing repatriation challenges. This resiliency also helps mitigate the
severity of PTSD by providing needed support. Connectedness as a protective factor to enhance
resiliency has proven valuable in moderating veteran suicidal ideation (Kintzle et al., 2018).
While PTSD is often cited in the veteran suicide discussion (Finley, 2019), PTSD
typically occurs in a relatively small population of returning veterans; in the recent conflicts in
Afghanistan and Iraq (OIF/OEF), the estimated range of PTSD prevalence has been as low as
4.7% among the returning population (Magruder & Yeager, 2009). Another challenge, transition
stress, has been found to predict treatment-seeking and the later development of veterans' mental
and physical health problems, including suicidal ideation (Interian et al., 2014). The challenge of
transition stress is supported by data indicating that most first suicide attempts by veterans
typically occur not long after military separation (Villatte et al., 2015). Connectedness is
fundamental to the repatriation process and has been identified as a valid consideration in
mitigating veteran suicidal ideation by both the CDC and V.A. (CDC, 2005 & Department of
Veterans Affairs, 2018b).
The Department of Veterans Affairs produced a National Strategy for Preventing Veteran
Suicide in 2018. In that strategy, three of the four strategic directions outlined emphasized
connectedness as a critical component in addressing veteran suicide (Department of Veterans
Affairs, 2018b). Successful veteran repatriation is a critical step in mitigating the senseless loss
of veteran life as well as recovering and leveraging the significant investment made in those
veterans (Lacroix et al., 2018). Mobbs and Bonanno's 2018 study on the crucial role of transition
stress in the lives of military veterans identified a compelling need for greater knowledge about
how different aspects of transition stress might influence veterans' long-term adjustment. In the
conclusion of their study, Mobbs and Bonanno stated the following on this need:

38
The lack of theoretical framework and empirical support to more precisely identify
salient factors before, during, and after the transition, has impeded the development of
new forms of transition programming. And as a result, at present, almost no resources are
available to address the cognitive, emotional, behavioral, or psychological impacts of the
soldier-to-civilian transition.
This study integrates two theoretical frameworks into a conceptual framework that serves as the
lens to better explore and address veterans' challenges in the military to civilian transition.
Theoretical Framework
As stated in Chapter 1, the Bronfenbrenner bioecological model is a common strategy for
analyzing suicidal ideation and was established as the cornerstone for violence prevention
activities advocated by the Centers for Disease Control and Prevention (CDC, 2022; Krug,
Dahlberg, & Mercy, 2001). The CDC depicts a four-level prevention model where the individual
is nested within relationships, community, and society. The framework has also been termed the
multiple risk factor model (Langhinrichsen-Rohling et al., 2011). Langhinrichsen-Rohling et al.
(2011) identified that suicidal members of the U.S. military often fail to disclose their suicidal
urges and behaviors and recognized the ecological model as a framework to address this
challenge better. Their study simultaneously examined four ecological levels (individual, family,
workplace, and community) of factors associated with increased or decreased risk for suicidal
ideation. Their Bronfenbrenner-framed study generated results suggesting specific risk factors at
various ecological levels of influence—individual, family, workplace, and community—were
separate from overt suicide ideation and yet may be valuable targets for suicide prevention
efforts in the U.S. military. This indicated military suicide prevention efforts could benefit from
targeting less stigmatized psychosocial factors to decrease suicidality risk (Langhinrichsen-
Rohling et al., 2011).

39
The nested relationship concept in Bronfenbrenner's Bioecological Framework provides
an excellent lens through which to view the veteran suicide problem and, specifically, veteran
repatriation efforts. Bronfenbrenner's framework emphasizes the role of bidirectional influences
between individuals' development and their surrounding environmental contexts
(Bronfenbrenner & Morris, 2007). Bronfenbrenner and Ceci (1994) updated the original
Bronfenbrenner Ecological model, adding a bioecological element that emphasized the
developmental perspective of the nature-nurture concept. Incorporation of the temporal
component (the chronosystem) in the bioecological framework (portrayed in Figure 2) further
emphasizes the developmental aspect of the model and describes time as an element that exerts
influence over a lifespan or even generations: reflected in the changing of ideas, attitudes, and
behaviors (Bronfenbrenner & Morris, 2007).
Conceptual Framework
The conceptual framework for this study acknowledges the concepts of Joiner’s
Interpersonal Theory of Suicide as described in chapter 1, but consistent with the greater
acceptance of Bronfenbrenner’s Bioecological Theory and the CDC’s endorsement of
Bronfenbrenner leverages the Bronfenbrenner (2006) model to facilitate a conceptual framework
that explores how veterans interact with external influences. The Bronfenbrenner framework is
appropriate because veterans adapt to their military environment: macrosystem values are
different from civilian life (code of conduct, dress, language, etc.); exosystem elements become
tied to the military lifestyle (mission drives interaction, priorities, access to family, friends, and
neighbors); microsystem processes shape the individual (boot camp, unit level, combat); and
these interactions define the individual. The formal process of induction into military services
facilitates these changes. The model addresses both coming into and departing military service,
but this study is focused on veterans leaving the service and rejoining civil society. Individuals

40
join the military and undertake a rigorous program to rebuild themselves and their ideas to fit the
service's social and ideological construct (Britt et al., 2006; Lieberman et al., 2014).
Bronfenbrenner's micro, exo, and macro system definitions help to conceptualize these
processes. The servicemember thrives in a structured environment with known boundaries,
expectations, and connectedness. There is no formal process to realign the systems upon
separation from military service. Fractures between and within the systems can occur upon
separation from military service. These fractures can become contributors to suicidal ideation
(Demers, 2011). Upon separation from the service, there is inadequate investment in
transitioning from the service construct to the civilian societal construct (Demers, 2011; Pease et
al., 2015). Figure 1 in Chapter 1 depicted the conceptual framework for this study that illustrates
changes associated with joining and exiting military service, highlighting potential repatriation
challenges. A review of the literature suggests, the processes and resources to rebuild the micro,
exo, and macro systems are inadequate, if present at all, often leaving the veteran without a
means of connecting themselves in their new world. Providing the necessary tools and resources
to rebuild those connections in the non-military environment better positions the veteran to
reintegrate into society successfully. The resultant connectedness can be a strong tool for
mitigating suicidal ideation. In addition to V.A. and DoD efforts, many organizations are
engaged in assisting veterans in returning to civilian society (Appendix A provides an exemplary
list). This study focuses on the nationwide SAMHSA/VA Mayor's & Governor's Challenge
Team program aimed at accelerating community involvement in facilitating effective veteran
repatriation as a means to mitigate veteran suicide concerns.
Summary
This chapter provided an overview of the relevant literature, focusing on trends in veteran
suicide regarding age, gender, and deployment history. In addition, the literature relating to

41
mental health considerations focusing on homelessness, PTSD, and substance abuse disorders
was reviewed. Lastly, an overview of the theoretical and conceptual framework for the study was
provided.

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Chapter Three: Methodology
The purpose of the study is to explore veteran service providers’ perceptions of the
association between connectedness and resilience in veterans repatriating into society. The
intent is to discover potential recommendations for individuals and groups assisting veteran
repatriation to leverage connectedness to increase veteran resiliency and ultimately mitigate
veteran suicidal ideation. Chapter 2 established a frame of reference by reviewing previous
research on trends, challenges, and mitigation considerations associated with veterans
repatriating into civil society. The conceptual framework illustrated in Figure 1 of Chapter 1
highlights veterans' changes and challenges when leaving military service and re-entering civil
society. Figure 2 in Chapter 1 depicted how the Bronfenbrenner bioecological model
(Bronfenbrenner & Morris, 2007) reflects the many types and levels of connectedness that are in
play during veteran repatriation. This chapter includes a restatement of the research questions to
provide depth of context to the connectedness concept during veteran repatriation. Next, this
chapter contains descriptions of the researcher, data collection, and data analysis procedures.
Lastly, the ethics of the study will be described as well as the limitations and delimitations of the
study design and conceptual framework.
Research Questions
This study attempted to answer four research questions using a qualitative method
supported by a demographic survey.
RQ1: What role, if any, do veteran service providers perceive connectedness plays in the
repatriation of veterans into civilian life following separation from military service?
RQ2: How, if at all, do veteran support service providers consider connectedness in their
veteran repatriation programming decisions?

43
RQ3: How do veteran service providers perceive a veteran’s service as influencing the
veteran’s ability to establish connectedness following separation from military
service?
RQ4: What recommendations are there for improving connectedness with the community for
the veterans transitioning from military service?
Overview of Methodology
The research includes non-probability, purposeful sampling targeted to recruit and then
interview participants. Interviews allow for collecting richer, more nuanced, and detailed
qualitative data but often incorporate fewer respondents due to the time required to interview,
code, and conduct analysis (Robinson & Leonard, 2018). These interviews provide in-depth and
detailed information about the role of connectedness in veteran suicide mitigation through
purposeful sampling. Purposeful sampling involves identifying and selecting individuals or
groups that are especially knowledgeable about or experienced with a phenomenon of interest,
making purposeful sampling a sound approach (Palinkas et al., 2013). To meet the purposeful
sampling objective, four attributes were identified for participants recruited from among
individuals and organizations participating in the Substance Abuse and Mental Health Services
Administration/Veterans Administration (SAMHSA/VA) Mayor's & Governor's Challenge Team
program in Nevada. Attributes one and two are required; attributes three and four are desired:
1. Service provider in suicide prevention programs.
2. Service provider in veteran support programs.
3. Service provider in veteran suicide prevention programs.
4. Experience as a service member (veteran).

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Veteran participation was desired but not required. It was desired because interviewing veterans
involved in supporting veteran repatriation programs provided enhanced insight into the
experiences, emotions, perceptions, fears, and aspirations of veterans involved in the repatriation
process. The qualitative interviews adopted a phenomenological approach to maximize the
potential for meeting the study objective. A phenomenological approach to research attempts to
describe the essence of the targeted phenomenon by exploring it from the perspective of those
who have experienced it so as to understand the meaning the participants ascribe to that
phenomenon (Teherani et al., 2015).
Document and artifact analysis was conducted prior to the interviews but after the
interviewees were identified based on the recruitment strategy. Document and artifact analysis
focused on those organizations with which the participating interviewees were affiliated.
The Researcher
I am an independent consultant whose spheres of action and influence regularly
incorporate academia, industry, and government – including the military. I am also a veteran of
more than 30 years in uniform. I have served in enlisted and officer capacities, combat and
noncombat positions, subordinate and command positions, and successfully navigated the
transition from active military to veteran status. I did not emphasize my military experience
during the data collection process; however, military members were quite adept at recognizing
the mannerisms, linguistics, and affect of someone who has served in the military. So as not to
present as hiding these facts, I openly shared that I am a veteran and provided details of my
service only when asked or to demonstrate understanding of the interviewee’s testimony.
If addressed during an interview, my experience of successful repatriation could have
been perceived negatively by the interviewee and could have resulted in social desirability bias.
Social desirability bias is a type of response bias in which people tend to answer questions

45
according to how others view their answers instead of answering truthfully (Charles & Dattalo,
2018). This type of bias may be more prevalent in an interview construct because the respondent
may be uncomfortable revealing their true attitudes or behaviors. Respondents may provide
answers that are more favorable or more in line with popular opinion or positive outcomes.
Recommended strategies to mitigate this bias are to avoid biased questions and word one’s
questions carefully and accurately (Charles & Dattalo, 2018). To comply with this strategy, I
avoided language that infers or implies any type of success or failure perspective regarding
repatriation—emphasizing that the inquiry is about the individual’s journey and not the outcome.
My service in multiple command billets in small and large unit capacities could have also
presented a positionality challenge. Individuals in senior leadership positions are often perceived
as insensitive to the impact of the orders and directives they issue (Contreras, 2017; Einarsen et
al., 2007). Veterans in transition may feel they have left the structure, hierarchy, and directive
nature of military service behind; they may be uncomfortable engaging with individuals
perceived to represent those very attributes. It was incumbent upon me to remove myself from
that persona in body language, mannerism, attitude, and language to avoid being perceived based
on past positionality in accordance with recommendations by Bartow (2012). The SAGE
Encyclopedia of Action Research (Coghlan & Brydon-Miller, 2014) defined positionality as “the
stance or positioning of the researcher in relation to the social and political context of the
study—the community, the organization or the participant group” (Rowe, 2014, pp. 627–628).
Positionalities may shift over the course of the project, and the nature of each
positionality may not always be compatible with one another (Thurairajah, 2019). Effective
engagement in reflexivity best enabled me to address the potential bias of each positionality. To
be reflexive, I learned how to recognize my positionalities and the influence of these
positionalities. Intentionally targeting each positionality’s motivations ensured I was conducting

46
the research effectively while acknowledging and balancing all positionalities, making me better
able to ensure I carried out the research project effectively without sacrificing the intentions of
my other positionalities (Thurairajah, 2019). A sound reflexive approach incorporates a robust
self-critique to examine how one’s own experiences might or might not have influenced the
research process (Dowling, 2006).
Data Sources
This research effort collected qualitative data incorporating a review of documents and
artifacts as well as interviews of the targeted population. The document and artifact collection
focused on gathering items addressing existing strategies, policies, procedures, and techniques
implemented as part of the veteran transition programs in which the selected interview
participants work. The focus of document and artifact data collection was on products
incorporating the connectedness aspects of repatriating into civilian life. The participants
selected to participate in the interview process were individuals involved in supporting suicide
prevention and veteran repatriation programs. The interviews adopted a phenomenological
approach to provide enhanced insight into the experiences, emotions, perceptions, fears, and
aspirations of veterans involved in the repatriation process as perceived by the interviewee’s
experience providing support to suicide prevention and veteran support service. The document
and artifact review was initiated before the interviews commenced and continued through the
duration of the study.
Method 1: Document and Artifact Analysis
The initial data analysis effort focused on document and artifact analysis. Merriam and
Tisdell (2019) broadly define documents as an assortment of written records, physical traces, and
visual images. Merriam and Tisdell also define artifacts as essentially three-dimensional
physical objects in the environment that represent some form of communication that is

47
meaningful to participants or the setting. Documents and artifacts addressing repatriation
syllabus development, training, and implementation were collected from sponsor organizations
of interviewees throughout the research effort, starting with a scheduled review of organizational
veteran repatriation program documentation and continuing through the interview phase. This
furthered the objective of using multiple methods of collecting data (methods triangulation) and
assisted in obtaining consistent and dependable data to enhance credibility (Merriam & Tisdell,
2019). The analytic objective assessed the organizational documents and artifacts employed to
provide guidance, education, and assessment in support of the organization’s repatriation
operations. The analysis was utilized to ground and enrich the qualitative data collected in the
interviews, furthering understanding of how the organizations’ practices impact veteran
repatriation activities.
Data Collection Procedures
The literature review and conceptual framework shaped the documents and artifacts I
collected. Document and artifact collection focused on gathering items addressing existing
strategy, policies, procedures, and techniques implemented as part of the veteran transition
programs, with emphasis on products incorporating the connectedness aspects of repatriating into
civilian life. The collection was conducted throughout the study process. The focus for initial
document collection was to conduct open access internet searches on the organizational websites
of the interview participant’s respective organizations once the interview participants were
confirmed. Additionally, participants were asked to refer documents and/or artifacts during
individual interviews that they believed addressed questions discussed during the interview
process. Items were categorized, collected, and documented via a data collection log to ensure
accurate provenance. Collecting a variety of documents and artifacts assisted in the attempt to
triangulate data and substantiating findings (Carter et al., 2014).

48
Data Analysis
Huberman and Miles (2002) summarized qualitative data analysis as being essentially
about “detection, and the tasks of defining, categorizing, theorizing, explaining, exploring and
mapping as fundamental to the analyst's role” (p. 5). In facilitating such detection, the analysis
targeted three relevant considerations: context, process, and emergence (Altheide, 1996).
Context acknowledges the social situation and significance of the document or artifact being
addressed, attempting to understand the nature and cultural meaning of the item; process
acknowledges how the item is actually created and put together; and emergence refers to the
gradual shaping of meaning through understanding and interpretation (Altheide, 1996). The
analysis process enabled placing an item’s symbolic meaning in context, grasping the role of the
item’s creation and influence, and merging understanding through detailed investigation
(Altheide, 1996). Throughout this study, analysis was conducted using a six-step process
designed to leverage modern collection technology and transcription capabilities (Rädiker &
Kuckartz, 2020):
1. Prepare, organize, and explore data
2. Develop categories for analysis
3. Create broad coding for interview transcripts
4. Refine coding to include systematic subcategories as required
5. Analysis plan that leverages the coding approach
6. Document the analytic process and results in the Appendix for codes
Coding was the underpinning of the analytic effort. This project utilized a combined
approach to coding. Initial reliance on a priori code constructs leveraged a collection of pre-
conceived codes. Appendix D contains the a priori codes used at the start of data analysis. The
codes were derived from past research, the research questions, and the methodologies used in the

49
study. This deductive approach helped establish a framework from which to initiate analysis
(Qualitative Research Practice: A Guide for Social Science Students and Researchers, 2014). As
data was collected, it was possible to inductively evolve new codes and iterate on existing codes,
developing codes based on what was presented in the data. Maturing the coding to an inductive
approach is particularly useful when conducting qualitative research using semi-structured, open-
ended interviews (as used in this project) because the researcher does not know which direction
the conversations may turn (Corbin & Strauss, 2014; Gibbs, 2018)
Credibility and Trustworthiness
In 1985, Lincoln and Guba established the trustworthiness criteria as a foundational
means for evaluating qualitative research. The authors identified several key elements to
establishing trustworthiness but emphasized credibility as the root of quality (Lincoln & Guba,
1985). Credibility refers to the truth of the data or participant and their representation by the
researcher. It is enhanced by the researcher genuinely describing their findings and verifying
those findings with the contributors (Polit-O’Hara & Beck, 2012).
Qualitative research can be viewed as credible if the researcher’s description of the
phenomena of interest is immediately and distinctly recognized as shared experiences by the
participants (Sandelowski, 1986). In addition to leveraging the triangulation strategy (Merriam
& Tisdell, 2019) presented in the document and artifact analysis section, using triangulation was
further supported by the participation of different participants. My recruitment strategy sought
individuals involved in veteran programs who were ideally veterans themselves, but my
participants also included non-veterans involved in veteran programs. The perspectives of both
types of participants provided multiple perspectives on the research questions. The research
approach employed used engagement, methods of observation, and audit trails, all of which are
strategies suggested by Cope (2013) as effective to enhance credibility and trustworthiness.

50
Method 2: Interviews
Interviews were conducted to provide in-depth and detailed information about the role of
connectedness in veteran suicide mitigation through purposeful sampling. Purposeful sampling
was used to identify and select individuals that were especially knowledgeable about or
experienced with the veteran repatriation programming. The interviews were conducted using an
integrated, semi-structured, open-ended question format. Interviews were conducted using IT-
based technology (ZOOM or WebEx) to accommodate scheduling or environmental challenges.
In-person interviews were considered as a backup as requested by the participants.
Participants
The participants in this study were recruited from among those individuals and
organizations participating in the Substance Abuse and Mental Health Services Administration /
Veterans Administration (SAMHSA/VA) Mayor's & Governor's Challenge Team program in
Nevada. The Governor’s and Mayor’s respective team leads were briefed on the study concept
in advance and authorized engagement with their team members. However, individual
participants were not contacted until Institutional Review Board approval was received. The
group membership included 26 organizations comprising a total of 44 individuals. The objective
was to solicit a minimum of six and a maximum of 12 interviewees. Recruitment survey
responses were used to target interviewees based on meeting the purposeful criteria and a
willingness to participate. The criteria to meet the purposeful sampling objective are identified
in the following four attributes:
1. Service provider in suicide prevention programs.
2. Service provider in veteran support programs.
3. Service provider in veteran suicide prevention programs.
4. Experience as a service member (veteran).

51
Attributes one and two were required, and attributes three and four were desired. Table 2
incorporates these attributes in a hierarchical schema established to prioritize volunteers to be
interviewed depending upon the number of positive responses received from the request for
study participants.

Table 2
Interviewee Prioritization Schema
Metric Criteria Response Value Scaler Priority value
YES=1, NO=0 Response x Scaler
Service provider in suicide prevention programs 1 1 1
Service provider in veteran support programs 1 1.1 1.1
Service provider Engaged in veteran suicide
prevention programs
1 1.2 1.2
Experience as a service member 1 1.3 1.3
Total prioritization value 4.6

Note. Methodology adopted from Naderifar et al., 2017.

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The criteria focus on candidate experience with veteran support, suicide prevention, veteran
suicide prevention, and as a service member. Experience was recorded in a binary fashion; a
value of 1 if yes and zero if no. These results were multiplied by the scaler values identified in
the table to yield a priority value. The recruitment survey was used to populate the table and
provide a priority value for each respondent. The 12 highest priority value respondents were
identified as priority interview candidates.
The prioritization schema was designed to discriminate between candidates sufficiently to
identify 12 candidate interviewees effectively, the study was further designed to adapt to
incorporate a minimum of six interviewees. Had the approach failed to identify six interviewees,
a snowball sampling approach was planned to identify additional candidate interviewees.
Snowball sampling is a convenience sampling method. This method is applied when it is difficult
to access subjects with the target characteristics. In this method, the existing study subjects
recruit future subjects among their acquaintances (Naderifar et al., 2017). A combination of the
prioritization schema and snowball sampling was ultimately used to identify nine interview
participants. Participants were not incentivized to participate in the study.
Instrumentation
A recruitment questionnaire consisting of questions designed to identify individuals who
meet the study criteria was emailed to the 44 individuals involved in the Department of Health
and Human Service's Substance Abuse and Mental Health Services Administration and Veterans
Administration (SAMHSA/VA) Mayor’s and Governor’s Challenge Team program.
Questionnaire data were used to select participants and refine interview questions; the responses
are not reported in the findings. A copy of the recruitment questionnaire is included in Appendix
B.

53
The interview protocol is structured to support a phenomenological approach that
provided insight into the respondents' experiences, emotions, perceptions, fears, and aspirations
regarding their work repatriating veterans. The protocol included semi-structured questions
designed to stimulate increased dialogue between the interviewer and interviewee and allow for
open-ended exchanges. Semi-structured protocols made interviewing multiple people more
systematic and comprehensive by shaping the issues to be explored while offering flexibility,
spontaneity, and responsiveness because questions were able to be personalized to deepen
communication (Patton, 2002). Open-ended questions allowed respondents to respond in their
own words and, in doing so, to be more expressive (Patton, 2002). A copy of the interview
protocol is included in Appendix C.
Data Collection Procedures
Data collection consisted of several phases. I was invited to audit the Mayor’s and
Governor’s Challenge teams from the program's inception. Being an auditor of the activity
assisted in my initial study framing by providing access to meetings, presentation materials, and
participant lists (including participant contact information). An opening email to the 44
individuals participating in the SAMHSA/VA Mayor’s and Governor’s Challenge Team program
initiated the data collection process. In the opening email, prospective participants were briefed
on the scope and purpose of the study. Three days following this initial informational email, a
second email was sent inviting the recipients to participate in the recruitment questionnaire
(Appendix B) via a hyperlink embedded in the email. The recruitment questionnaire was
administered using Qualtrics. The time required to complete the questionnaire was estimated at
less than 10 minutes. Respondents were asked to complete the survey within 14 days and be
given reminders on the fifth and tenth days. The reminders were included in a brief review of
the project objectives and a statement addressing the importance of their contribution, as well as

54
the responses being both anonymous and voluntary. The link remained active for 21 days to
catch late responders.
The interviews were guided by the interview protocol in Appendix C and conducted in
private settings. The preferred collection method was virtual (Zoom or WebEx) calls with the
camera off and recordings tracked via the subject’s assigned pseudonym. Telephone calls were
the primary backup. Interviews were recorded (system audio with video off if using Zoom or
WebEx and telephone recording software). Recordings were then be transcribed, coded,
analyzed, and archived to support the study. Interviews were targeted for 60 minutes or less, but
additional time was available if needed. Transcription was accomplished using third-party
software, and a data log was used to record interview characterization data (location, time,
participants, any additional pertinent data).
Data Analysis
Data analysis began following interview completion. To support effective analysis, I
needed to establish a rubric for assessing transcript quality and a protocol for managing
transcripts: assuring consistency of format, metadata insertion, anonymization, and file labeling
conventions (Clark et al., 2017). I followed these guidelines to ensure accurate data storage and
expedient data recovery to support the six-step process outlined in the data analysis section while
supporting the data protection strategies outlined in the ethics section. The analysis was
conducted using the same six-step Rädiker and Kuckartz (2020) process described in the
document and artifact analysis section. The previously described coding strategy was applied
here as well.
Credibility and Trustworthiness
As previously noted, credibility refers to the truth of the data or participants and their
representation by the researcher (Lincoln & Guba, 1985). Accurate transcriptions, well coded to

55
enable the researcher to describe findings and verify those findings with the contributors
genuinely, enhances credibility (Polit-O’Hara & Beck, 2012). Ensuring the data and analysis
presented are readily recognized as a shared experience or perception by the participants further
advances credibility (Sandelowski, 1986). Reducing, interpreting, and making sense of a broad
spectrum of data collected during a study combined with demonstrated engagement, sound
observation strategies, audit trails, and member checking are essential practices for effective
triangulation, enhancing credibility, and furthering trustworthiness (Cope, 2013; Merriam &
Tisdell, 2019).
Ethics
It is incumbent upon all researchers to understand that “the emergent, dynamic and
interactional nature of most qualitative research" involves complex ethical responsibilities
(Iphofen & Tolich, 2018, p.1). It is also the researcher's responsibility to accept that how the
data and participants in a study are presented directly reflects the researcher’s acumen and effort
(Merriam & Tisdell, 2019). When conducting research, the researcher must understand that
ethical concerns can arise at any time in the research process, making ethical reflexivity a
fundamental feature of qualitative research (Von Unger, 2021). Ethical reflexivity requires the
researcher to be cognizant of the risks of coercion and unrealistic expectations often experienced
in analytic design and implementation (Iphofen, 2011). Since most research is conducted in the
real world, it is improbable that all values could be realistically addressed. To combat this
dilemma, a realistic approach should focus on my primary responsibility – to produce
meaningful knowledge. In this pursuit, social research ethics have tended to focus on a smaller
subset of ethical values that are judged to have central importance in the research context:
minimizing harm, protecting privacy, and respecting autonomy (Hammersley, 2018). I must

56
embrace the fact that research ethics is simply a version of professional ethics not dissimilar to
those in other professions.
Gibbs (2018) asserted there are additional elements of concern regarding ethics when
conducting data analysis. Informed consent is important because it gives the participants
information about the research relevant to their decisions. Transcription itself is of concern
because it is critical to ensure the transcribed data is as authentic as possible. Anonymity of
transcription is required to ensure confidentiality and is particularly important in qualitative
interviews because of the richness of the data. Long-term disposal or protected preservation is
not only an ethical consideration, but if done correctly, it mitigates future concerns about
confidentiality and anonymity. To facilitate confidentiality, ensure anonymity, and mitigate
future concerns about data access, this project pursued the following strategies:
● Replace PPII (such as names) with identification codes
● Remove PPII from all cover documents
● Destroy contact lists and recruitment records when no longer required
● When transferred or transported, all electronic data files were password protected and
encrypted
● Physical data records were secured in locked rooms or cabinets
● Electronic data are stored in password-protected files or computers
● Computers hosting electronic data files were closed and locked when left unattended
● Code lists and passwords were securely stored separately from the data
● Data, code lists, and passwords were destroyed as soon as practical
As a researcher, I made every effort to observe, acknowledge, and understand the behavior of
study participants to minimize harm, protect privacy, and respect autonomy to the maximum
extent possible. This started with ensuring that all potential participants were fully informed as

57
to the voluntary nature of their participation, that their participation is defined by their informed
consent, and that their confidentiality will be respected and protected in perpetuity. This
protection was codified by garnering specific permission to record research data, anonymizing
collected data, and safely and securely storing said data.

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Chapter Four: Findings
The purpose of this qualitative inquiry was to explore veteran service providers’
perceptions of the association between connectedness and resilience in veterans repatriating into
society. Connectedness was defined as the degree to which a person or group is socially close,
interrelated, or shares resources with other persons or groups, including connectedness between
individuals, the connectedness of individuals and their families to community organizations, and
connectedness among community organizations and social institutions (National Center for
Injury Prevention and Control, 2013). The problem of practice was addressing the
disproportionately high rates of veteran suicide through a better understanding of how veteran
service providers’ perceptions of the association between connectedness and resilience in
veterans repatriating into society can facilitate resilience and, in doing so, mitigate veteran
suicide. The following four research questions were developed to guide the study:
1. What role, if any, do veteran service providers perceive connectedness plays in the
repatriation of veterans into civilian life following separation from military service?
2. How, if at all, do veteran support service providers consider connectedness in their
veteran repatriation programming decisions?
3. How do veteran service providers perceive a veteran’s service as influencing the
veteran’s ability to establish connectedness following separation from military service?
4. What recommendations are there for improving connectedness with the community for
the veterans transitioning from military service?
The purpose of this chapter is to present the findings from the study. The presentation of the
findings is organized by themes that were identified during interviews based on questions
derived from the research question.

59
The data collection effort gathered qualitative data incorporating a review of documents
and artifacts as well as interviews with the participant population. The document and artifact
collection focused on gathering items addressing existing strategies, policies, procedures, and
techniques implemented as part of the veteran transition programs in which the selected
interview participants work. The focus of document and artifact data collection was on products
incorporating the connectedness and suicide prevention aspects of repatriating into civilian life
for veterans. The participants selected to participate in the interview process were individuals
involved in supporting suicide prevention and veteran repatriation programs. The interviews
adopted a phenomenological approach to provide enhanced insight into the experiences,
emotions, perceptions, fears, and aspirations of veterans involved in the repatriation process as
perceived by the interviewee’s experience providing support to suicide prevention and veteran
support service. The document and artifact review were initiated before the interviews
commenced and continued throughout the duration of the study.
Document and Artifacts
Document and artifact analysis conducted before and after the interviews highlighted a
dearth of local (created and used by onsite personnel) products originally created by veteran
supporting organizations other than media used to communicate activity location and meeting
times. The preponderance of documents used by the local organizations were products created
by national-level organizations, such as the Centers for Disease Control and Prevention (CDC),
the Department of Health and Human Service’s Substance Abuse and Mental Health Services
Administration (SAMHSA), and the Veterans Administration. Engagement plans, prevention
plans, annual reports, and research reports are broadly shared and utilized as foundational
documents by the individuals interviewed and their organizations.

60
The documents created at these higher levels have been referenced in previous chapters,
were excluded from the document and artifact analysis, and will not be discussed here. One
artifact was identified outside these higher-level products. This product is a tool used by a group
known as Walk the Talk America (WTTA) that is focused on bridging the gap between mental
health and responsible firearm ownership by connecting the second amendment supporting
community and the mental heal practitioner community by establishing a common framework
where productive dialogue, understanding, and acceptance are provided to all who participate. In
an interview with Michael Sodini (President of WTTA), he stated, "by improving the quality and
availability of mental health resources to gun owners, we can reduce suicide by firearm. We are
paving the way by educating mental health professionals about gun culture and breaking
negative stigmas around mental health for gun owners. We are saving lives” (M. Sodini, personal
communication, June 13, 2023). As a non-profit, WTTA is engaged in various outreach
activities. One specific artifact is noteworthy in that it assists gun owners in becoming more
aware of potential mental health concerns and mitigation tools is a 4.5” by 6.5” card inserted into
firearms packaging by gun shop owners who support WTTA. Support Groups and Mental Health
concerns can insert locale-specific contact or reference information in the open space on the back
of the card. The card provides information to assist gun owners in acknowledging and accepting
mental health concerns while concurrently providing them information to assist in making the
connection with mental health professionals.

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Figure 6
WTTA Mental Health Card: Front and Back (2022)

A 2017 cross-sectional, web-based study of firearms found nearly half of all veterans
(45% of veterans as compared to only 20% of non-veterans) own one or more firearms, with
most owning both handguns and long guns (Cleveland et al., 2017). This exceptionally strong
correlation between gun ownership and being a veteran validates using firearms associations as a
viable means to connect to veterans. The artifact in Figure 6 is designed to provide an option for
veteran gun owners to connect with a mental health professional free of governmental
involvement or oversight and, in doing so, provides a connection that can assist the veteran in
addressing mental health concerns, potentially enhancing resiliency and mitigating suicidal

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ideation. Aside from this WTTA card, no other documents or artifacts were identified, and no
additional data from documents and artifacts were incorporated into the study findings.
Participants
The study sought participants in the national and local SAMHSA/VA Mayor's &
Governor's Challenge activity to characterize the larger population of veteran service providers
considered in the problem of practice. Focusing on this group provided a concentrated cohort of
individuals and organizations who were invested in addressing successful veteran repatriation as
a means of mitigating veteran suicide. The recruitment process identified in Chapter Three was
followed. The interview candidates were identified from the Recruitment Survey responses and
prioritized based on criteria focused on candidate experience with veteran support, suicide
prevention, veteran suicide prevention, and as a service member. Of the 52 candidates invited to
participate in the recruitment survey, only thirteen (25%) responded to the survey, and eight
(62%) followed through with an interview. Figures 7 through 10 identify how participants
characterized themselves in response to the recruitment questions.

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Figure 7
Participant Experience and Time Supporting Suicide Prevention Programs

Note. N = 9.

Figure 8
Participant Experience and Time Supporting Veteran Repatriation Programs

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Figure 9
Participant Experience and Time Supporting Veteran Suicide Prevention Programs

Figure 10
Participant Experience as a Service Member

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While 100% of the participants had experience with service provider support to suicide
prevention as well as service provider support to veteran suicide prevention, the expertise the
participants brought to their engagements varied. Multiple participants had experience in
providing counseling to transitioning veterans concerning transition coping skills, job
preparation or placement, finding shelter, and connecting to groups and individual environments
where they could engage others who had similar experiences. Multiple participants supported
non-profit activities focused on bringing the veteran and mental health communities together in
informal constructs, free from reporting requirements or structured sharing events. One
participant reported leading the integration of neurofeedback as a means to create cognitive
pathways for veterans to recognize and resolve ways to address their own challenges. All of the
participants acknowledged their primary role as enabling individuals facing mental health
challenges generally and veteran repatriation challenges, in particular, to recognize, accept, and
embrace the idea that pursuing or receiving help was as one participant put it “not a bad thing.”
Rather, these activities are foundational in successfully pursuing the next chapter in their lives.
The respondents who were interviewed are referred to as P-1 through P-8. All of the
interviewees are actively involved in activities to assist individuals in effectively transitioning
from one situation in their life to another. While not 100% of all the individuals being supported
by the interviewees were veterans going through repatriation, all the interviewees had experience
with and are currently working with repatriating veterans in the participants’ support roles. The
services provided in these support roles encompassed a broad spectrum of activities:
• Connection to, or delivery of, mental health support
• Connection to and assistance with skills development and job placement
• Connection to and assistance with living arrangements (mitigating homelessness)

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• Connection to and assistance with facilitating government services (Veterans
Administration and Medicare/Medicaid)
• Connection to people, programs, and organizations focused on advancing repatriation
through personal engagement and safety net development in the form of involvement
and engagement with others who understand and acknowledge the challenges being
faced without judgment or recrimination.
One aspect of repatriation that all respondents acknowledged is the role of the military program
designed to prepare service members for their transition after separation. The program, known
as the Transition Assistance Program (TAP), is a service-wide construct that is managed and
executed locally. The DoD TAP program is an outcome-based statutory program (10 USC, Ch.
58) that bolsters opportunities, services, and training for transitioning Service members in their
preparation to meet post-military goals. The program applies to all Service members with at
least 180 continuous days or more on active duty, including the National Guard and Reserve.
The program's goal is to provide information, tools, and training to ensure service members and
their spouses are prepared for the next step in civilian life (DoD Transition Assistance Program,
n.d.).
Identification of Themes
During the data gathering process, I gathered data with a focus on how the activities of the
service providers impacted the recipients’ interactions through the lens of the layers of the
Bronfenbrenner-described bioecological construct:
• Microsystem: Services provided focus on the microsystem level: those institutions and
groups that most immediately and directly impact the veteran during repatriation, such as
family, school, religious institutions, neighborhood, and peers.

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• Mesosystem: Services provided focus on the mesosystem level: those elements of
interconnection between the microsystems: between the veteran and the service they
separated from or the veteran or between the individual veteran and the greater veteran
community.
• Exosystem: Services provided focus on the exosystem level, those links between social
settings that do not involve the individual veteran, such as changes in the services’
approach to deployment, standards, or separation practices.
• Macrosystem: Services provided focus on the macrosystem level, the overarching
culture that influences the veteran, as well as the microsystems and mesosystems
embedded in those cultures. These cultural contexts can differ based on geographic
location, socioeconomic status, poverty, ethnicity, and time. Being part of a cultural
group often implies a common identity, heritage, and values. As macrosystems evolve
over time, veterans of different eras are seen and see themselves differently; World War
Two veterans, Korean Conflict veterans, Vietnam veterans, Gulf War veterans, and
Afghanistan veterans experience different individual perceptions as well as different
societal perceptions.
To further focus on elements that could rise to the level of a theme, the Research Questions were
used to align the interviewee responses and connectedness. Elements addressed by 50% or more
interviewees related to a specific research question were identified as themes. Themes are
cataloged under the specific Research Question where they most frequently presented themselves
in the subsequent sub-sections. A summary of findings associated with each specific theme is
followed by a table recounting respondents' comments focused on that theme.

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Findings
This study answers the four research questions using interview data. The interview data
were analyzed to identify common elements within the data that rose to the level of a theme. The
findings are organized and presented here based on these resultant themes rather than being
organized by research question. Table 3 shows the correlation between research questions and
themes.

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Table 3
Research Questions and Associated Themes Matrix
Research Question Associated Theme
What role, if any, do veteran service providers perceive
connectedness plays in the repatriation of veterans into
civilian life following separation from military service?
Connectedness Perceived as Critical to Repatriation and
Mitigating Suicidal Ideation
How, if at all, do veteran support service providers consider
connectedness in their veteran repatriation programming
decisions?
Connectedness Considered in Program Structures and
Individual Engagement Activities
Discomfort With Acknowledging Weakness or Shortcomings,
Particularly Regarding Mental Health
How do veteran service providers perceive a veteran’s service
as influencing the veteran’s ability to establish
connectedness following separation from military service?
Service Providers' Perspective on The Influence of Veteran’s
Duration of Service
What recommendations are there for improving connectedness
with the community for the veterans transitioning from
military service?
Service Providers Critical of DOD TAP Programs Content and
Implementation

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Theme 1: Connectedness Perceived as Critical to Repatriation and Mitigating Suicidal
Ideation
All of the individuals interviewed identified connectedness as a recognizable component
of the veteran repatriation process. Several identified connectedness as “the biggest,” “huge,”
“vital, “large part,” “priority,” “important, “or “critical” (their words) element in successfully
supporting veterans repatriating post-military service. The participants consistently tied the
connecting of people to others as a valuable tool in successful repatriation. As such, they
described connectedness as a means of enhancing resiliency. According to P8, “the more
connected they are, the less likely they are to have suicidal ideation.”
The repeated idea expressed by participants that elevating one’s connectedness is a
valuable tool in successful participation in society, followed by the participants’ repeated
assertions that such involvement can mitigate suicidal ideation, fits the concept of a theme as it
identifies a specific and distinctive quality and characteristic, or concern. Table 4 illustrates
interviewee responses that support the theme of connectedness as it relates to repatriation and
suicidal ideation mitigation.

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Table 4
Interviewee Responses on Connectedness as Critical to Repatriation
Respondent Response on the criticality of connectedness
P3 “But getting a vet out of their chair and out into the community is the hardest
thing about the whole problem.”
“When we get out, there's no aftercare, there's no transition programs. If you don't
know that, you're not prepared for that. It's a shock, it's a shock for our young
guys and gals that are getting out.”
“We found that the groups that are able to keep our soldiers, our veterans alive,
keep them from, from committing suicide, are those that reach out and assist the
veteran where they are with what their needs are, right. Whether it's a recreational
need or whether it's a housing need.”

P4 “I think that it’s a huge thing, connecting people; it, you know plays a huge role.”

P5 “A large part of my work is connectedness and connecting people and
reconnecting people, which is a hot topic now.”
“However we connect, it's all done through that emotional functioning lens, and
then from there we can work on building better, more distant connections.”

P6 “The least connected are the most vulnerable and the ones that you need to reach
the most.”
‘I absolutely believe that it (connectedness) is a lever. It is a factor. It is a variable
that one could tease to make a difference.”

P7 “I think connectedness and purpose are two of the biggest driving factors for
humans.”
“Our organization as a whole would view connectedness as a priority.”

P8 “Well, it's vital . It, it really is the foundation.”
“We acknowledge that relationships are really important and we go out of our
way to actually create a lot of it with our outreach specialists.”
“I think the more connected they are, the less likely they are to have suicidal
ideation.”

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Two interviewees (P1 and P8) emphasized the internet and social media's role as
evolving contributors to veterans repatriating into civilian life. Specifically, it was noted by
these participants that, in some cases, social media replaces human engagement and becomes a
new or evolutionary form of connectedness. Both interviewees made the point to emphasize that
they believed the term connectiveness was more appropriate than “connectedness “when
describing the interactions incorporating these “online” interactions because the term
connectiveness conveys the transitory or ongoing nature of the interaction. P1 further stated that
connectedness implied an incrementally achieved state that advances in fixed states, whereas
connectiveness was a dynamic, continuously changing state. While the connectiveness
discussion emphasized by these two participants did not rise to the level of a theme, it does
present a segregable perspective potentially worthy of additional research.
Connectedness was viewed as a fundamental, if not foundational, component of support
to veterans repatriating post-military service by the participants. Additionally, all respondents
identified numerous non-profit and government entities that attempt to provide opportunities for
veterans to engage with other veterans, community support groups, and physical and mental
health providers. According to the participants in this study, making connections to these entities
provides the first step in facilitating the veteran’s connection with personal, social, and medical
entities that provide a foundation for meaningful and beneficial relationship development. These
connections can lead to successful repatriation.
Theme 2: Connectedness Considered in Program Structures and Individual Engagement
Activities
As previously noted, all of the individuals interviewed identified connectedness
considerations as a recognizable component of the veteran repatriation process as reflected in the

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design, development, and implementation of their support activities. They identified it as an
essential component in the development and structure of their support programs. Several
identified a need to support veterans in ways the military services themselves and the Veterans
Administration could not or would not do. All eight respondents acknowledged a necessity to
incorporate integration of government, private party, and community (to include profit and not-
for-profit) efforts in their program designs leveraging “collaborative relationships.”
Consistent with the positions reflected in Table 4 above, the participants acknowledged to
varying degrees that their programs needed to “get contact” with veterans; establish “stable
relationships;” and “create support” in the form of connections with “people,” “resources,” and
“community engagements and activities.” P7 emphasized that the environment and their
response to it was “constantly evolving.” All participants shared this idea of responsiveness,
along with endorsing the fundamental importance of relating to their clients, as expressed by P8,
“we have to start with a relationship. And you know, that's first and foremost, they have to have
a stable relationship; I think that keeps them grounded.” Table 5 illustrates interviewee
responses that support the theme of connectedness considerations in program structures and
individual engagement activities.

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Table 5
Interviewee Responses on Connectedness Considerations in Program Structures and Individual
Engagement Activities
Respondent Response on the integration of connectedness in program structure
P3 “The VA can't do everything for our vets and we don't mind picking up the load.”
“We think we can do as good a job or better than the VA, but we have to be able to
get contact with those people. “
“It should be a collaborative relationship between the government organizations
and the nonprofit organizations.”

P4 “I think what we do differently is we connect with everybody.”
“We have to connect in order to get a better understanding of each other.”
“Connectiveness is the number one role, because if you can't find the way that we
can connect people are gonna continue to sit stand on either side of the
room/problem.”

P7 “It’s constantly evolving. But the health plan is always creating support groups and
programs and community engagement, activities, and ways to reach people, but
also connect them with others.”

P8 “Relearn how to be with their families, first of all and to integrate back into civilian
world, which is, you know, the biggest thing I hear is that civilians don't
understand.”
“So we like to help them start with working with their families, getting the, the
networking with their families, with other vets, and then helping them move back
into civilian work.”
“It’s vital. It really is the foundation.”
“They have to have a stable relationship, I think that keeps them grounded.”

According to all eight respondents, decisions on how programs were structured to support
veterans were founded upon establishing a trust-based relationship with the individuals being
supported (including family and friends of the principles). Respondents acknowledged the
significance, both in scope and level of effort, required to address all aspects of repatriation. In

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different ways, all eight respondents identified a need to identify what the military services,
Veterans Administration, and other support entities were doing or not doing to enable local
organizations to focus their organizational efforts in the most effective way possible. The
respondents recognized the value and need for collaboration to optimize outcomes for the
communities they supported. Equally important to the support efforts, according to all eight
respondents, was the acceptance of the changing needs of their clients and the capacities and
capabilities of other supporting entities. This recognition drove a willingness to evolve the
support provided based on the client's individual needs and who or where is best equipped to
perform specific support roles. P7 emphasized the integration and growth considerations as
“constantly evolving,” where “the health plan is always creating support groups and programs
and community engagement, activities, and ways to reach people, but also connect them with
others.” Pursuing an enterprise perspective that grows services and program structures to
provide the best value to repatriating veterans positively contributes to successful repatriation.
Theme 3: Service Providers' Perspective on The Influence of Veteran’s Duration of Service
All the individuals interviewed had personal experience transitioning from military
service and experience engaging with veterans in the transition process. The research questions
and interviews were targeted at the interviewee’s perspective of how duration of service
impacted the transitioning veterans they were supporting, While the inquiries were posed to
target the transitioning veterans' experiences, and the preponderance of responses addressed
service duration impacts of the transitioning veterans being supported, it is prudent to
acknowledge the potential for personal bias in the responses driven by the interviewees' own
service and transition experience. Review of the responses identified only one instance (P7) of
obvious potential bias (first-person references, reclamas, or incongruent responses).

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The responses presented multiple perspectives on the impact of service duration on
veteran repatriation. P3 identified a longer duration of service as providing a more experienced,
employable, and mature individual who would “probably have an easier time simply because
they don't have the financial stress that goes along with the disability rating and waiting for all
that. They have been able to survive 20 years, they are more able to manage.” Following this
response, the individual added “they probably transition easier but it is still a difficult transition.”
Opposite this perspective, another respondent (P7) identified the longer duration as presenting a
more significant challenge because “assuming that the longer you're in the more that gets
instilled in you, so transitioning back to civilian life, is very overwhelming.”
In the responses, most of the services provided by participants’ organizations were
identified as being targeted to service members transitioning after shorter terms of service.
According to P8, “If I look at their time in service, very few actually had like career more of
them are six-year enlistments or even three years.” Those transitioning veterans with shorter
terms of service identified as having several common thoughts and experiences, according to the
participants: “It's a shock for our young guys and gals that are getting out” (P3); “I'm getting out
as quickly as I can then want nothing to do with any of those programs or VA” (P6);
“Everything's different, there's no structure.” (P7).
Regardless of the perspective of how much duration impacted transition, all respondents
identified a consistent underlying theme for transitioning serve members: service life is different
than civilian life. P3 described transitioning into the service this way: “we spend years, you
know, whether two years or 20, 20 plus years being a Patriot and get enculturated in a very
different system.” On leaving the service, P7 asserted “Everything's different, there's no
structure,” and another added, “they are not prepared for that.”

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The differing perspectives of participants on service duration's impact further highlight
that repatriation is an individual activity that uniquely impacts each individual veteran’s social
reintegration. The participant responses show there are underlying considerations focused on the
bioecological changes accompanying the transition from service to civilian life, and duration
either assists or exacerbates the individual’s ability to deal with those changes. Table 6 illustrates
interviewee responses on the theme of how service providers view the influence of a veteran’s
duration of service on their repatriation.

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Table 6
Interviewee Responses on Service Providers' Perspective on Influence of Veteran’s Duration of
Service
Respondent Response on the influence of duration of service
P3 “We spend years, you know, whether two years or 20, 20 plus years being a Patriot
and get enculturated in a very different system.”
“The guys and gals that have served longer and have retired with their time in
service, probably have an easier time simply because they don't have the
financial stress that goes along with the disability rating and waiting for all that.
they have been able to survive 20 years, they are more able to manage their
careers.”
“They are not prepared for that. It's a shock for our young guys and gals that are
getting out, especially after a 20 year war in the middle east.”

P6
“I'm getting out as quickly as I can then want nothing to do with any of those
programs or VA.”

P7 ”Even with the short period of time that I was in we develop a new way of life, a
new understanding, like even the relationships you have and how you interact
change.”
“Assuming that the longer you're in the more that gets instilled in you, so
transitioning back to civilian life, is it it's very overwhelming.”
“It takes a little while to adapt to it and I don't think I've fully adapted to it. I'm still
very structured, probably overly structured.”

P8 “Most of the vets that I work with, if I look at their time in service, very few actually
had like career more of them are six-year enlistments or even three years.”
“Very few are actually career, I have a few clients that are national guardsmen,
which puts them in a different arena because they are more civilian than they are
military.”

The data collected from participants, who were both service providers and veterans
themselves, suggests service duration plays a role in a veteran’s transition experience. The
specific nature of the service and the individual shapes the role duration plays in that experience.

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The respondents had differing perspectives on the role of service duration based on their support
experiences but concurred on the challenges presented by transitioning from service to civilian
life. This recognition again highlights the importance of the veteran's individual needs in
transition. Acknowledging that service duration can affect the nature of the challenges faced in
transitioning from service to civilian life and incorporating that consideration can positively
contribute to successful repatriation.
Theme 4: Discomfort With Acknowledging Weakness or Shortcomings, Particularly
Regarding Mental Health
All the individuals interviewed identified an impact of the military ethos as described in
Table 1 (stay strong, do not show weakness, do not be a burden) during the repatriation process.
Five respondents specifically identified the negative effects of this ethos on transitioning
veterans as interfering with their ability to pursue or sustain effective repatriation if mental health
care is a component of the process. Multiple interviewees described the ethos effect as a
“stigma,” “fear,” “weakness,” or “concern” that has the potential to drive veterans away from the
resources they need in order to avoid perceived negative impacts on their own, their families’, or
their Service’s perceptions. Veterans in transition often do not get the help they need because, as
P6 described, they have “been drilled to never show any weakness and, we're gonna get the
mission done at all costs.” Until, as P3 stated, we “get rid of the mental health stigma,” any
pursuit of help in the mental health arena is viewed as a weakness and counter to the ethos.
All respondents acknowledged the implications of military culture on transitioning to
civilian society, and several respondents addressed specific challenges they faced with veterans
who knew they needed help. As P7 relayed, “I think it's pretty similar across all branches, asking
for help or showing weakness is not really an option and it's kind of instilled in them.” P4

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emphasized that most support providers recognize the challenge and “want to give our customers
every opportunity they can to get the help that they need without fear of consequence when
they're in crisis.” Interviewees identified this challenge of overcoming the perception of seeking
mental health care as weakness as present both during service and post-separation. While
serving, “there's nothing about making it okay.” (P7); when leaving, the service veterans
reported they “don't remember any conversations like that.” (P7). Finally, all respondents
identified many transitioning veterans reported a less than positive relationship with the VA.
The persistent impact of the military ethos places a penalty on pursuing needed mental health
care per participant-reported data. This perspective, combined with both perceived and reported
failures in the Service and Veterans Administration programs for providing this type of care,
exacerbates an already complex repatriation effort, according to the participants. Table 7
illustrates interviewee responses on the theme of acknowledging weakness or shortcomings,
particularly as regards mental health.

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Table 7
Interviewee Responses on Stigma of Acknowledging Weakness or Shortcomings, Particularly in
Regard to Mental Health
Respondent Response on weakness or shortcomings, particularly as regards Mental Health
P3 “Got to get rid of the mental health stigma.”

P4 “We want to give our customers every opportunity they can to get the help that
they need without fear of consequence when they're in crisis.”

P6 ” It's so hard to talk about among veterans. “
“Been drilled to never show any weakness and, we're gonna get the mission done
at all costs.”

P7 “I think it's pretty similar across all branches, asking for help or showing
weakness is not really an option and it's kind of instilled in them.”
“When you're getting out, there's, there's nothing about making it okay.”
”I understand that in the military there's a certain image and structure that they hold
for operational standpoints, but I think there could be a much bigger effort when
people go back to civilian life and they are transitioning out connecting them
with, with other people that maybe encouraging them to get names and phone
numbers of people getting out, or and then probably like a prolonged, at least
counseling or therapeutic check-ins.”

P8 “The mental health stigma is still there.”
“The fear is still there.”
“The biggest fear is if they find out you have PTSD, then you're done.”
“ Whether they're active, they're guard, reserve, that creates some real concerns for
them because if their command finds out it could impact what they do.”
“If the command finds out that they're taking antidepressants, it would impact their
careers.”

Acknowledging weakness or shortcomings, particularly as regards mental health, is a
significant challenge in many veterans’ transition experiences. The specific nature of the service

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and the individual shapes that role. The respondents had differing perspectives on the role of
service duration based on their support experiences but concurred on the challenges presented by
transitioning from service to civilian life. This recognition again highlights the importance of the
veteran's individual needs in transition. Acknowledging service duration can affect the nature of
the challenges faced in the transition from service to civilian life, and incorporating that
consideration can positively contribute to successful repatriation.
Theme 5: Service Providers Critical of DOD TAP Programs Content and Implementation
All the individuals interviewed had both personal experience with transition assistance
programs (TAP) and experience engaging with veterans who had experience with transition
assistance programs. The research questions and interviews targeted identifying improvement
opportunities regarding connectedness's role in veteran repatriation to include TAP. The
responses integrated personal experience and support experience. A review of the responses
identified a coherent theme from all interviewees integrating their personal and support
experiences.
All respondents addressed TAP and presented several common observations addressing
inadequacies in the timing, duration, and content of the Service’s transition assistance programs
(TAP). All respondents asserted “there's no aftercare, there's no transition programs” (P3); that
Services were “rushing people through a mill.” (P3); that they and the veterans they were
assisting felt that the Services were “quick to kick somebody out, like, all right, you're done”
(P7). The interviewees identified challenges with the content of transition programs as well as
the timing and duration. Four respondents stressed transition programs were too short, with
comments such as the following: “Not more than about three days" (P6); “three days a checkout
and a transition class, nothing stuck with me” (P3); and “there could be a much bigger effort.”

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(P7). Finally, according to all participants, the execution was less than ideal: “best place is in that
period of 90 days before and after separation,” (P3); “expanding the programs could really
bolster their confidence and increase their self-efficacy,” and “I just wish there was more of a
follow up because for the veteran getting out it really just does become a check in the box” (P6).
Regardless of their perspective or their support to veteran transition perspective, the
interviewees found the transition assistance programs experienced by veterans to be lacking. P7
summarized the response in two significant ways: “at least counseling or therapeutic check-ins,
you know, if, if it wasn't just so quick to kick somebody out, like, all right, you're done” and
“they spend all this time on you, but then when you're out, it's like, okay, we don't have any more
time.” Table 8 illustrates interviewee responses on the theme of how service providers view the
DoD TAP program’s content and implementation.

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Table 8
Interviewee Responses on Service Providers' Considerations of DOD TAP Programs Content
and Implementation
Respondent
Response on service providers' considerations on DOD TAP Programs content and
implementation
P3 “When we get out, there's no aftercare, there's no transition programs.”
“If you don't know that, you're not prepared for that, it's a shock, it's a shock for our
young guys and gals that are getting out, especially after a 20-year war in the
middle east that are getting out.”
“Best place is in that period of 90 days before and after separation.”
“I mean, we are rushing people through a mill.”
“I received in my exit transition, you know, three days a checkout and a transition
class, nothing stuck with me.”

P4 “I think that it’s a huge thing, connecting people; it, you know plays a huge role.”

P6 “Not more than about three days.”
“How helpful they are. I don’t know.”
“Need more exposure to programs that are potentially available to folks.”
“I just wish there was more of a follow up because for the veteran getting out it
really just does become a check in the box.”
“It becomes perfunctory.”

P7 ”There could be a much bigger effort when people go back to civilian life.“
“Connecting them with other people that maybe encouraging them to get names
and phone numbers of people getting out.”
“At least counseling or therapeutic check-ins, you know, if, if it wasn't just so
quick to kick somebody out, like, all right, you're done.”
“I think there's more we can do when you get out to at least let people know that
when they're separating that you still matter to us.”

P8 “We could do a lot more in helping them learn how to be real intentional in the
connectedness.”
”By giving them some of the tools, logistics and the real comments, that it helps the
connectedness.”
“TAP reduces the stress and it reduces their doubt in themselves.”

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Respondent
Response on service providers' considerations on DOD TAP Programs content and
implementation
“I think expanding the programs could really bolster their confidence and increase
their self-efficacy of knowing who they are to be able to be to come out and know
themselves.”

The interviewees' responses across both individual experiences and their support
experiences illustrate a similar experience and consistent perspective. The respondents were
exposed to different transition assistance experiences based on their service, location, self, or
veteran supported input, but they all concurred on the shortcomings of those various programs.
This recognition highlights an evolving understanding of the service member’s transition back
into civilian life, specifically how and when transition assistance can be improved to facilitate
disconnecting from the military and reconnecting with civilian life in the pursuit of successful
repatriation.
Summary
The findings provided a broad perspective from the study participants addressing how
connectedness is perceived and utilized by the veteran support community. The perspectives
ranged from acknowledging the role of connectedness between veteran and provider to the need
for increasing efforts to facilitate and emphasize connectedness earlier in the veteran transition
sequence. The findings are expressed in the form of research question-related themes derived
from the responses to the lines of inquiry during the interview process.
Research Question 1 identified two themes. Those themes included: service providers
identifying connectedness as playing a critical role in repatriation and service providers
identifying connectedness as a component in suicidal ideation mitigation. The findings revealed

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that connectedness is a critical component in veteran repatriation. Additionally, service providers
recognize the value of connectedness as a tool in mitigating suicidal ideation.
Research Question 2 identified two themes. Those themes included: service provider
recognition and implementation of connectedness as a component in developing the service
provider program structures and the importance of considering connectedness in developing the
service provider's individual engagement activities. The findings revealed that providers reported
connectedness as a foundational component in developing and implementing service provider
programs supporting veteran repatriation.
Research Question 3 identified one theme. That theme acknowledged that experience
varied among service providers regarding the influence of duration of service on veteran
repatriation. The findings revealed that service provider experience did not support a singular
view of the impact of service member duration on veteran repatriation.
Research Question 4 identified two themes. Those themes included: service provider
recognition of veterans being uncomfortable with engaging support that acknowledged weakness
or shortcomings, particularly regarding mental health considerations. Veteran service providers
recognized the impact of the military ethos (not wanting to be a burden or to be perceived as
weak) on pursuing help following separation from service, particularly as regards mental health.
The findings also revealed the respondents had experiences both personally and with veterans
they provided support to that led them to identify the DoD Transition Assistance Program as
having significant room for improvement to better facilitate veteran repatriation.
The interviewee responses provided consistent, coherent data that addressed the role of
connectedness in addressing the challenges of repatriating veterans. These data provide a
foundation for identifying findings that need to be addressed to better facilitate successful

87
veteran repatriation. Chapter 5 will present evidence-based recommendations targeted at
addressing these findings.

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Chapter Five: Recommendations and Discussion
This study explored veteran service providers’ perceptions of the association between
connectedness and resilience in veterans repatriating into society. Additionally, it sought to
explore the role of resilience derived from connectedness in veteran suicide following separation
from military service as perceived by veteran service providers. The study questions guided the
research and provided a framework for characterizing the role of connectedness in veteran
repatriation. This chapter will connect results and findings with extant literature, present
recommendations, discuss limitations and delimitations affecting the study, and offer
recommendations for future research.
Discussion of Findings
The study explored how veteran service providers perceived and used connectedness in
their efforts to assist veterans in repatriating into a civilian social structure. The study collected
data through an open-ended interview process that leveraged research questions to initiate
dialogue about the service providers’ roles, missions, and experiences working with repatriating
veterans. One hundred percent of the participants had experience with service provider support to
suicide prevention within the general population as well as service provider support specific to
veteran suicide prevention.
The participants detailed their experience addressing several challenges repatriating
veterans face, including counseling transitioning veterans concerning transition coping skills, job
preparation or placement, finding shelter, and connecting to groups and individual environments
where they could engage others who had similar experiences. The participants supported non-
profit activities focused on bringing the veteran and mental health communities together in
informal constructs, free from reporting requirements or structured sharing events.

89
Bronfenbrenner's Bioecological Framework (Bronfenbrenner & Ceci, 1994), depicted in Figure
2, provided an appropriate theoretical lens to examine the environmental construct and
interactions of repatriating veterans. Bronfenbrenner emphasized the role of bidirectional
influences between individuals' development and their surrounding ecological contexts
(Bronfenbrenner & Morris, 2007). Connections between Bronfenbrenner’s micro, meso, exo, and
macro system levels translate directly into many of the influences, attributes, and behaviors of
civilians that were modified upon their entry into military service. When leaving the service and
returning to civilian life, the veteran must again modify many of their influences, attributes, and
behaviors to effectively restore their identity as a citizen in civilian life (Beier & Sienrukos,
2013). The responses given by Veteran Service Providers were found to be consistent with the
Bronfenbrenner model considerations in addressing veterans' changing ideas, attitudes, and
behaviors as they transitioned from military to civilian life and further acknowledged the
importance of these concerns during veteran repatriation. Participant data also support the CDC
(2005) and Department of Veterans Affairs (2018b) assertions that connectedness is fundamental
to the repatriation process as well as being a valid consideration in mitigating veteran suicidal
ideation.
The findings related to Research Question 1 highlighted service providers identifying
connectedness as playing a critical role in repatriation and service providers identifying
connectedness as being a component in suicidal ideation mitigation. This finding on
connectedness’s connection to repatriation is consistent with the extant literature emphasizing
the impact of connectedness in re-engaging or repatriating into relationships, families,
communities, and society (Demers, 2011; Kelley et al., 2011; Pease et al., 2015). The literature
also identified connectedness as a valid consideration in mitigating veteran suicidal ideation

90
(CDC, 2005; Chen et al., 2019; Department of Veterans Affairs, 2018b; Eber et al., 2013; Logan
et al., 2016; Pietrzak et al., 2017; Smith et al., 2016). The concepts of social integration, social
support, peer support, community involvement, and personal relationships have been frequently
identified as potential sources of resiliency during the repatriation process, and these elements
have also been identified as potential triggers for suicidal ideation when they are absent or
negative in character (Mavandadi et al., 2019; Olenick et al., 2015; Pietrzak et al., 2009a). Extant
research further supports the respondents’ position that resilience is supported by social
connectedness and presents as a protective factor when examining suicidal ideation (Pietrzak et
al., 2017; Smith et al., 2016). Figure 1 illustrates the transitions, influences, and outcomes
resident in the transition from civilian life to military service and the subsequent transition back
to civilian life. This conceptual framework is built upon the Bronfenbrenner theoretical
framework outlined in Figure 2.
The data derived from participant interviews supported the research findings that veterans
experiencing better connectedness, such as social integration, social support, peer support,
community involvement, and personal relationships, exhibit greater resiliency and have more
positive mental health outcomes, including lower rates of suicidal ideation (Adams et al., 2017;
CDC, 2018; Mavandadi et al., 2019; Olenick et al., 2015; Pietrzak et al., 2009a). These findings
indicate that veteran service providers acknowledge and incorporate the critical role of
connectedness in the repatriation process as well as a valuable tool in mitigating veteran suicidal
ideation.
The findings related to Research Question 2 highlighted service provider recognition and
implementation of connectedness as a component in developing the service provider program
structures and the importance of considering connectedness in developing the service provider's

91
individual engagement activities. One hundred percent of respondents identified connectedness
as a foundational component in developing and implementing service provider programs
supporting veteran repatriation. They also acknowledged leveraging connectedness as a tool in
the development of their program materials. This finding is consistent with the literature
regarding the effectiveness of practices that emphasize adjustment and adaptation in social
connectedness and engagement activities (House et al., 1988; Peterson & Seligman, 2004;
Pietrzak et al., 2009a) as well as practice and program development targeting transition stress
(Mobbs & Bonanno, 2018). The findings indicate that veteran service providers acknowledge
and incorporate connectedness in developing and implementing service provider programs
supporting veteran repatriation.
The findings related to Research Question 3 highlighted that experience varied among
service providers regarding the influence of duration of service on veteran repatriation. Veteran
service provider missions focus on veterans in need. In support of these missions, the
respondents' experience reflected serving a preponderance of younger veterans with relatively
shorter lengths of active duty service. The literature identified that suicidal ideation was greater
among transitioning veterans in the most densely populated 18-34-year-old age group
(Department of Veterans Affairs, 2018b). This population group that participants reported
serving is also congruent with post-9/11 era data that reflects the average length of service is 6.7
years for enlisted personnel and 11 years for commissioned personnel (Pew Research Center,
2012). In the same post-9/11 era, less than 17% of service members served to the historical 20-
year retirement metric, and less than 11% served long enough to receive modified retirement
option plans available as early as 15 years of service (Tilghman, 2022). These factors support
respondents having limited or no engagement with veterans who had served for longer periods

92
leaving, resulting in limited input to perspectives on the role of time in service regarding veteran
repatriation. The research provides context that supports the finding that service provider
experience did not support a singular view of the impact of service member duration on veteran
repatriation.
The findings related to Research Question 4 revealed that service providers recognize the
impact of the military ethos (not wanting to be a burden or perceived as weak, as identified in
Table 1) on pursuing help following separation from service, particularly with respect to mental
health. Research indicates as few as 23% of veterans with mental illness seek care (Eber et al.,
2013). All the individuals interviewed in this study identified an impact of the military ethos on
engaging and accepting assistance in transition among Veterans they served. Respondents
repeatedly reported veterans viewing themselves as a liability or burden to their families and
communities. Five respondents specifically identified the adverse effects of this ethos on
transitioning veterans as interfering with their ability to pursue or sustain effective repatriation,
particularly if mental health care is a component of the process. The extant research supports this
finding, highlighting that military service frequently inculcates a military ethos that instills a
belief that seeking help is a sign of weakness (Lacroix et al., 2018; Pease et al., 2015; Pietrzak et
al., 2019). The research also indicates a growing awareness of this challenge and efforts being
made to pursue potential avenues of redress (Kintzle et al., 2018 & Executive Order No. 13861,
2019).
The findings also highlighted service providers being critical of veteran transition
assistance programs' inadequacies in timing, duration, and content. One hundred percent of
respondents recognized the existence and intent of the DoD TAP program as an outcome-based
statutory program (10 USC, Ch. 58) that bolsters opportunities, services, and training for

93
transitioning Service members. Respondents consistently identified the need to address mental
health and warrior ethos considerations earlier in the transition effort. The participants made
repeated assertions that more relatable and in-depth content is needed. Additionally, participants
offered recommendations that these activities be initiated before departing the service and
offered with sufficient repetition or engagement opportunities to facilitate meaningful behavioral
or ideological growth for the transitioning veteran.
The National Defense Authorization Act (NDAA) for FY2019 (McGarry & Towell,
2019) mandated several changes to the TAP program to address the concerns expressed by the
participants. There is a potential disconnect between the implementation of a revised program of
record and the awareness and implementation of the program among those veterans the program
is intended to support and those working to support those transitioning veterans. Respondents
identified a need for better integration (depth and duration) of discussions on mental health
challenges and resources, as well as a better implementation strategy. This finding is consistent
with research before 2019; however, specific efforts were made and codified in government
guidance to assist with the challenges identified by the respondents. The NDAA for FY2019
mandated several changes to the TAP program. The program moved the mandatory enrollment
date from 90 days prior to separation to 365 days prior. The updated program lays out
requirements for a self-assessment and mandatory pre-separation counseling. Results from these
activities vector an individual to one of three tiers: Tier 1 is for servicemembers who already
have outlined a clear path to success and have extensive community and family support,
requiring minimal services; Tier 2 is for servicemembers who may have some idea of what they
want to do but need a bit more help to make an informed decision; and Tier 3 individuals often
need additional help. Tier 3 individuals are those who are identified as not having a plan in place

94
and may or may not have additional personal risk factors that would impact their transition, such
as PTSD (McGarry & Towell, 2019). Additional research may be warranted to specifically
explore Veteran and service provider perceptions of the implementation of the changes directed
through the NDAA to the TAP program. The program changes were substantive enough from a
policy perspective that it is notable that service providers did not identify these changes during
the course of the interviews.
Recommendations for Practice
The purpose of the study was to explore veteran service providers’ perceptions of the
association between connectedness and resilience in veterans repatriating into society. The
intent was to discover potential recommendations for individuals and groups assisting veteran
repatriation to leverage connectedness to increase veteran resiliency and ultimately mitigate
veteran suicidal ideation. This study substantiated that veteran service providers (outside the VA)
engaged with veterans in all stages of repatriation. Similar to other research findings (Hoffmire
et al., 2022; Ravindran et al., 2020; Sokol et al., 2021), the veteran service providers interviewed
in this study reported their most acute cases in terms of veterans expressing suicidal ideation
were consistently those individuals that were less than three years past separation.
The study also identified a common perception among respondents that veterans
regularly failed to engage available avenues of assistance, and when they did, they found the
duration/timeliness of the assistance to be sub-optimal. Identification of the impact of the
military ethos, as described in Table 1, combined with the respondents' acknowledgment and
acceptance of connectedness as a valuable tool in facilitating repatriation and mitigating suicidal
ideation, aligns with the U.S. White House focus on providing a comprehensive, cross-sector,
evidence-informed, public health strategy for moving forward on combatting veteran suicide.

95
The recommendations for future research facilitate building a bridge that takes the Veteran from
being a fully functioning service member to becoming a fully functioning member of the civilian
community.
Recommendation 1: DoD TAP Team to Formalize an Engagement Strategy that
Incorporates Civilian Veteran Service Providers at the Local Level
The findings identified many areas of interest; several were in line with the extant
literature, some were novel, and some presented opportunities for improvement, leading to the
recommendations presented here. In particular, the finding that highlighted a disconnection
between the national government-level TAP program and the implementation of the transition
effort at the local level led to the first recommendation. The NDAA for FY2019 updated the
implementation of the service’s transition programs to facilitate veteran success in transition and
potentially mitigate suicidal ideation. Coordinating the activities in the TAP program with
existing and evolving Veterans Administration programs and local veteran support entities could
provide a more coherent, cohesive, and robust network to drive effective repatriation and
mitigate veteran suicidal ideation. Amending TAP execution at the local level (the DoD site
where the veteran is transitioning) by formally integrating entities supporting transition activity
into the program would increase outreach and enhance awareness of additional resources.
This approach to program improvement is consistent with proven strategies in the
business arena. Business entities routinely leverage integrated local marketing technology and
services to advance their brands, enhance their market presence, and increase their bottom line
(Cucchiara, 2021). Sarah Cucchiara, Senior Vice President of Channel Marketing Strategy at
BrandMuscle, asserted that these goals are most commonly achieved by aligning the client’s
local marketing execution with its national strategy. In her 2021 article, she described how an

96
organization can leverage strength in numbers and consistent messaging to help protect partners
from the endless challenges they may face. While the end product in the TAP construct is not a
fungible asset that is bought or sold, the comparison is viable because it focuses on
understanding the interactions required at the local level to enable successful implementation of
the national strategy. In this case, the DoD TAP program is equivalent to the national strategy
and the execution at the local level is comparable to the local market. Leveraging understanding
of the local market, and its available resources, in the process of TAP execution can identify and
implement force multipliers and unique local considerations not visible at the national level.
Several of the areas Cucchiara identified as critical to her marketing strategy are applicable in the
veteran repatriation effort. Cucchiara identified four major thrusts in successful implementation
of a marketing strategy.
1) Power in numbers, economies of scale. Enabling the local level participants to see
themselves as partners as opposed to competitors. Sharing experiences and resources
aligned to the national strategy reduces development and evaluation timelines while
accelerating benchmarking and best practice identification.
2) Timely response to environments/influences. Increasing situational awareness as a
result of another local’s experience can accelerate recognition and instantiation of the
most effective tactics and facilitate better analytics. It can empower participants to track
the performance of every tactic, campaign, and unique program across groups, tiers, and
regions to make it easy for them to decipher if they’re headed in the right direction.
3) Course corrections. Shared experience can lead to recognizing a developing situation
before it drives your effort off course. Providing feedback to partners so they can
improve their own performance is critical to aligning local program execution within the

97
national strategy. Providing coherency with the national strategy while improving local
execution and incentivize ideal behavior.
4) Share the wealth. Integrating a larger input pool increases collective observations and
accelerates the movement of experience from lessons observed to lessons learned.
Similarly, templates for documentation, courseware, finances, and even points of contact
can increase local efficiency and effectiveness.
Adapting the type of marketing strategy described above to the repatriation effort could
be achieved through a government partnership with local veteran support providers to improve
TAP implementation focusing on thrusts such as:
• By six months prior to separation, conduct an individual review (accompaniment to the
tiered review) of service and experience-specific activities that might warrant unique
consideration (i.e., extended remote assignment, exposure to combat losses, exposure to
suicide, and mission/job-specific PTSD trends) and compile accessible lists of veteran
support providers who are skilled in dealing with those challenges
• Invite these veteran service providers to review and comment on the TAP program
• Invite veteran service providers to participate in TAP where/when appropriate
• Use the TAP program to introduce soon-to-be veterans to veteran service provider
capabilities and networks (in addition to, not in place of Veterans Administration)
The fundamental underpinning of the national TAP strategy target enabling authorities to canvas,
engage, and document opportunities for involvement at each stage of the program. This strategy
is illustrated by the updated TAP program timeline in Figure 11.

98
Figure 11
DOD Transition Assistance Program Timeline

Note. Figure adopted from the DoD TAP website.
https://www.dodtap.mil/dodtap/rest/docs?filename=Managing_Your_Transition_Timeline.pdf
98

99
Recommendation 2: Incorporation of Connectedness as a Foundational Element in Veteran
Repatriation Programs
As highlighted in the findings, one hundred percent of the veteran service providers
engaged in the research effort identified connectedness as a fundamental aspect of their veteran
interaction. The respondents acknowledged utilizing connectedness as a component in the
development and implementation of their programs for veterans at large as well as for individual
veteran support efforts. These actions are consistent with the CDC (2020) adopting the
Bronfenbrenner bioecological approach to addressing suicide, emphasizing connectedness across
the social fabric and layers as the cornerstone for violence prevention activities (Krug, Dahlberg,
& Mercy, 2001). In their Suicide Strategic Prevention Plan, the CDC identified promoting
opportunities and settings to enhance connectedness as one of their primary aims. The CDC plan
identifies connectedness as a common thread that weaves together many of the influences of
suicidal behavior and has direct relevance for suicide prevention.
Institutionalizing a common framework to be shared among all veteran service providers
and their government counterparts could establish benchmarks and accelerate promising
practices for leveraging connectedness in support of veteran repatriation and the mitigation of
veteran suicidal ideation. Working in conjunction with the government’s updated TAP program,
veteran service providers can create a mirror of the transition timeline illustrated in Figure 11
that applies a similar incremental approach covering a post-separation timeline. As the extant
literature indicates, the most significant risk for suicide is in the 24 months following separation
(CDC, 2016; Shen et al., 2016; Villatte et al., 2015); the repatriation timeline could target the
time from separation until 24 months past separation. An example of such a timeline is provided
in Figure 12.

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Figure 12
Post Transition Timeline

100

101
A public-private approach to defining and fulfilling a program, as illustrated in Figure 12,
could provide a continuity of care strategy that ensures veterans feel supported as they prepare to
separate and through the challenging post-separation transition. This approach can build upon
Recommendation 1 or be established independently among veteran service providers.
Additionally, this approach would provide a framework for exchanging strategies and best
practices regarding integrating connectedness at every level of veteran support activities. While
connectedness integration was consistent across the respondents in this study, it is important to
recognize two consequential delimitations of this study in generalizing the findings to the greater
veteran service support architecture: the geographic focus and focus on candidate participants
servicing veteran repatriation instead of repatriating veterans themselves. Acknowledging these
limitations highlights the potential for implementing such an approach across the veteran
repatriation enterprise without regard to geographic or scope of practice limitations. Identifying
roles and responsibilities for such an effort is necessary.
On the public-private consideration, leveraging the Department of Veterans Affairs to co-
chair an effort with either an existing or specifically established veteran support entity could
provide a focal point for interrogative integration and information promulgation. A similar
strategy was proven effective with the stand up of the Action Alliance (theactionalliance.org), a
public-private entity dedicated to advancing the National Strategy for Suicide Prevention through
a partnership focused on three priorities: transforming health systems, transforming
communities, and changing the conversation about suicide (U. S. Department of Health &
Human Services, 2012). This approach was assessed as successfully progressing toward its goals
in the National Strategy for Suicide Prevention Implementation Assessment Plan, 2017. A
similar public-private effort focused more closely on the veteran suicide challenge, could

102
accelerate progress toward the goal of mitigating veteran suicidal ideation. The following list of
focus areas could provide an initial foundation for such an effort:
• Establish and maintain a common lexicon
• Establish and maintain a veteran-specific bioecological reference (Providing a
veteran-specific interpretation of the application of the bioecological model)
• Establish and maintain a repository for references and toolkits (ownership not
required, can be as simple as a reference or link to a primary source)
• Facilitate recurring interface opportunities where experience and ideation can
intermingle and accelerate the sharing of knowledge, best practices, and
opportunities for improvement.
Instantiating such an approach among all parties engaged in assisting veterans in transition could
build upon the fundamentals in the bioecological approach for recognizing and advancing
connectedness to facilitate veteran repatriation, which can further resiliency and mitigate suicidal
ideation.
Limitations and Delimitations
The framework and methodologies chosen to research this problem exposed both
limitations and delimitations in the study. Limitations are influences that are typically seen as
outside the researcher’s span of control. They can be shortcomings, conditions, or influences
that the researcher cannot control and that can place restrictions on methodology and conclusions
(Theofanidis & Fountouki, 2018). In contrast to the limitations, delimitations are choices made
by the researcher and describe potential boundaries reflected in the study’s execution, analysis,
and conclusions (Theofanidis & Fountouki, 2018).

103
Three considerations were identified as potential limitations of the study. First, I could
not control the truthfulness of participants in the survey or interview responses. I made every
effort to create an environment without judgment to put the participants at ease and make them
more comfortable sharing their truths. Second, my bias and positionality can influence the
outcomes of the qualitative interviews. I attempted to mitigate perceived bias and positionality
by being as receptive and reflexive as possible, making a concerted effort to acknowledge the
potential for bias while actively presenting myself as motivated to hear and embrace the
participant’s message. Third, data collection methodologies (and subsequent analysis) may be
impossible to replicate due to geographic, participant makeup, and time considerations. The only
actions I could take to address these concerns were to openly acknowledge these considerations
and document any time they are present, which I have done in the study.
Three considerations were identified as delimitations for the study. First, the participant
pool was limited both in numbers and scope as it was bounded by geographic considerations and
focused on candidate participants who were servicing veteran repatriation as opposed to engaged
in veteran repatriation. Creating a methodology for identifying and prioritizing interviewees
based on veteran repatriation engagement activity and experience with, or as, a veteran helped
focus the effort on those who might have experience and perspective on connectedness in the
veteran repatriation process. The participation by the state of Nevada and the city of Las Vegas
in their respective Governor's and Mayor's Challenges to Prevent Suicide Among Service
Members, Veterans, and their Families required national, department-level coordination and
helped ensure a consistent strategic approach to the problem set. I chose this approach to
constrain the scope and limit the time required to conduct the study. Second, I also chose to
restrict the scope of document and artifact analysis to only those organizations with which the

104
interviewee participants were associated to ensure this data set was representative of the scope of
the participant pool. This choice limited the volume of potential documents and artifacts, but
ensured those that were utilized were familiar to the interviewees associated with the programs
from which they were drawn, adding coherence to the process. Third, I limited the recruitment
questionnaire response time to facilitate the timely completion of the ensuing research.
Recommendations for Future Research
The findings and recommendations to acknowledge and institutionalize connectedness as
a core element of veteran transition to civilian status do not speak to service-specific
activities/considerations when addressing this problem within the DoD prior to separation from
service. The research identified several common considerations in the repatriation process. The
size and variation in military service and the resulting experiences provide ample opportunity to
conduct service/experience-specific studies. These inherent differences in experience within each
service may contribute to how individuals separating from service are affected during the
transition to veteran status. Continued study to refine the findings from this study by including
service-specific experiences among the veteran population is required to improve understanding
of the role connectedness plays in veteran transition to civilian life.
The research recognized that significant emphasis has been placed on addressing the
challenge of veteran suicide, including the value and role of government-mandated transition
activities. The NDAA for FY2019 implemented substantive changes to the DoD-mandated
Transition Assistance Program. Many of these changes directly address several of the concerns
identified by veteran service providers in this study; however, there was a dearth of knowledge
regarding these changes on the part of the study respondents. Additional research may be

105
warranted to explore why Veterans and service providers lack awareness of these changes and
what can be done to better facilitate their implementation.
The research also highlighted two additional considerations directly related to
connectedness reported by the participants: failure to engage available avenues of assistance and
duration/timeliness of assistance. The conceptual framework used in this study highlights the
scope and level of effort allocated to transitioning civilians to service life. Months of basic
training or years of military academy training are required to facilitate that transition for the
individual into the military. Yet, transition in the opposite direction (military to civilian) is only
deemed worthy of a simple 3-day transition program followed by a voluntary handoff to the
Veterans Administration. Continued study to ascertain the value of the DoD engaging in a more
coherent (across all services) program of greater depth and duration is needed to determine if a
programmatic effort like the one used to indoctrinate service members could be employed to
facilitate more effective veteran transitions to civilian life.
Conclusion
This study’s findings illustrate that veteran repatriation is both a civilian society
challenge and a military service challenge. One hundred percent of the respondents
acknowledged incorporating the role of connectedness assists veterans in effectively rejoining
civilian society by providing a framework for encouraging engagement, sustaining engagement,
and leveraging that engagement to better access the resources available to veterans. One hundred
percent of the respondents also acknowledged the role of connectedness in establishing and
encouraging resilience, which Kintzle et al. (2018) specifically identified assists in mitigating
suicidal ideation, and as was stated more generally in the extant literature (Adams et al., 2017;

106
CDC, 2005; Department of Veterans Affairs, 2018c; Mavandadi et al., 2019; Olenick et al.,
2015; Pietrzak et al., 2009a).
The transition from being a service member to becoming a veteran is a challenge
recognized by veterans, veteran service providers, the Department of Defense, the Department of
Veterans Affairs, and the medical/mental health community. That challenge is most acute in the
first three years following separation (Hoffmire et al., 2022; Ravindran et al., 2020; Sokol et al.,
2021), but this period of transition can have a lingering impact. The government’s increasing
awareness and prioritization for addressing the problem is evident in the development of
programs such as the President’s Roadmap to Empower Veterans and End a National Tragedy of
Suicide (PREVENTS) Task Force (Executive Order No. 13861, 2019) and public
acknowledgment at venues such as the 2023 State of the Union Address (U.S. Government,
2023). In short, recognition and inclusion of connectedness in veteran transition programming is
critical to effectively addressing the veteran repatriation problem and furthering resiliency to
mitigate veteran suicidal ideation.

107
References
Adams, R. E., Urosevich, T. G., Hoffman, S. N., Kirchner, H., Hyacinthe, J. C., Figley, C. R.,
Boscarino, J. J., & Boscarino, J. A. (2017). Social support, help-seeking, and mental
health outcomes among veterans in non-VA facilities: Results from the veterans' health
study. Military Behavioral Health, 5(4), 393–405.
https://doi.org/10.1080/21635781.2017.1333067
Adler, Jager-Hyman, S., Brown, G. K., Singh, T., Chaudhury, S., Ghahramanlou-Holloway, M.,
& Stanley, B. (2020). A qualitative investigation of barriers to seeking treatment for
suicidal thoughts and behaviors among army soldiers with a deployment history. Archives
of Suicide Research, 24(2), 251–268. https://doi.org/10.1080/13811118.2019.1624666
Aherne, C., Coughlan, B., & Surgenor, P. (2017). Therapists’ perspectives on suicide: A
conceptual model of connectedness. Psychotherapy Research, 28(5), 803–819.
https://doi.org/10.1080/10503307.2017.1359428
Altheide, D. L. (1996). Qualitative media analysis (1st ed.). Sage Publications.
American Psychological Association. (2022). APA dictionary of psychology. American
Psychological Association.
https://dictionary.apa.org/resilience
Army Resilience Directorate. (2020, September 3). Suicide prevention month: The importance of
connectedness. JBSA News. https://www.jbsa.mil/News/News/Article/2335601/suicide-
prevention-month-the-importance-of-connectedness/
Bartow, C. (2012, April 5). Can you spot a veteran from across the room? - vantage point.
Vantage Point. https://blogs.va.gov/VAntage/6388/can-you-spot-a-veteran-from-across-
the-room/

108
Baumohl, J. (1996). Homelessness in America (1st ed.). Greenwood.
Beier, S. & Sienrukos, J. (2013). Helping military civilian personnel with repatriation.
Counseling Today. A Publication of the American Counseling Association.
http://ct.counseling.org/2013/04/page/3/
Besterman-Dahan, Chavez, M., & Njoh, E. (2018). Rooted in the community: Assessing the
reintegration effects of agriculture on rural Veterans. Archives of Physical Medicine and
Rehabilitation, 99(2), S72–S78.
https://doi.org/10.1016/j.apmr.2017.06.035
Britt, T. W., Adler, A. B., & Castro, C. A. (2006). Military life: the psychology of serving in
peace and combat. Praeger Security International.
Bronfenbrenner, U., & Ceci, S. J. (1994). Nature-Nurture Reconceptualized in Developmental
Perspective: A Bioecological Model. Psychological Review, 101(4), 568–586.
https://doi.org/10.1037/0033-295x.101.4.568
Bronfenbrenner, U., & Morris, P. A. (2007). The Bioecological Model of Human Development.
Handbook of Child Psychology.
https://doi.org/10.1002/9780470147658.chpsy0114
Brown, Stout, R. L., & Gannon-Rowley, J. (1998). 15Substance Use Disorder-PTSD
Comorbidity. Journal of Substance Abuse Treatment, 15(5), 445–448.
https://doi.org/10.1016/S0740-5472(97)00286-9
Bryan, C. J., & Cukrowicz, K. C. (2011). Associations Between Types of Combat Violence and
the Acquired Capability for Suicide. Suicide and Life-Threatening Behavior, 41(2), 126–
136. https://doi.org/10.1111/j.1943-278x.2011.00023.x

109
Bryan, C. J., Griffith, J. E., Pace, B. T., Hinkson, K., Bryan, A. O., Clemans, T. A., & Imel, Z. E.
(2015). Combat Exposure and Risk for Suicidal Thoughts and Behaviors Among Military
Personnel and Veterans: A systematic review and meta-analysis. Suicide and Life-
Threatening Behavior, 45(5), 633–649. https://doi.org/10.1111/sltb.12163
Buddin, R. (2005). Success of first-term soldiers: The effects of recruiting practices and recruit
characteristics. RAND Corporation. https://doi.org/10.7249/mg262
Carter, N., Bryant-Lukosius, D., DiCenso, A., Blythe, J., & Neville, A. J. (2014). The use of
triangulation in qualitative research. Oncology Nursing Forum, 41(5), 545–547.
https://doi.org/10.1188/14.onf.545-547
Centers for Disease Control and Prevention. (2017). Preventing suicide: a technical package of
policy, programs, and practices. Createspace Independent Publishing Platform.
Centers for Disease Control and Prevention. (2018). Strategic direction for the prevention of
suicidal behavior: Promoting individual, family, and community connectedness to
prevent suicidal behavior. Createspace Independent Publishing Platform.
Centers for Disease Control and Prevention. (2020). Suicide Prevention Strategic Plan. FY2020-
2022.
https://www-cdc-gov.libproxy1.usc.edu/suicide/pdf/SuicidePrevention_StrategicPlan-
508.pdf
Centers for Disease Control and Prevention. (2022, June 24). Reducing military and veteran
suicide. Centers for Disease Control and Prevention.
https://www.cdc.gov/washington/testimony/2022/t20220615.htm
CFR 38. (2022). Code of federal regulations title 38 volume i pensions, bonuses, and veterans'
relief.

110
http://www.ecfr.gov/current/title-38.
Charles, J. L., & V. Dattalo, P. (2018). Minimizing Social Desirability Bias in Measuring
Sensitive Topics: The Use of Forgiving Language in Item Development. Journal of
Social Service Research, 44(4), 587–599.
https://doi.org/10.1080/01488376.2018.1479335
Chen, J. I., Hooker, E. R., Niederhausen, M., E. Marsh, H., Saha, S., Dobscha, S. K., & Teo, A.
R. (2019). Social connectedness, depression symptoms, and health service utilization: A
longitudinal study of veterans health administration patients. Social Psychiatry and
Psychiatric Epidemiology, 55(5), 589–597. https://doi.org/10.1007/s00127-019-01785-9
Chu, C., Zuromski, K. L., Bernecker, S. L., Gutierrez, P. M., Joiner, T. E., Liu, H., Naifeh, J. A.,
Stein, M. B., Ursano, R. J., & Nock, M. K. (2020). A test of the interpersonal theory
of suicide in a large, representative, retrospective and Prospective Study: Results from the
Army Study to assess risk and resilience in Servicemembers (Army starrs). Behaviour
Research and Therapy, 132, 103688. https://doi.org/10.1016/j.brat.2020.103688
Clark, L., Birkhead, A., Fernandez, C., & Egger, M. J. (2017). A transcription and translation
protocol for sensitive cross-cultural team research. Qualitative Health Research, 27(12),
1751–1764. https://doi.org/10.1177/1049732317726761
Clark, R. E., & Estes, F. (2008). Turning research into results: A guide to selecting the right
performance solutions (na) (Revised ed.). Information Age Publishing.
Cleveland, E. C., Azrael, D., Simonetti, J. A., & Miller, M. (2017). Firearm ownership among
American veterans: Findings from the 2015 National Firearm Survey. Injury
Epidemiology, 4(1). https://doi.org/10.1186/s40621-017-0130-y

111
Cloninger. (1987). A Systematic Method for Clinical Description and Classification of
Personality Variants: A Proposal. Archives of General Psychiatry, 44(6), 573–588.
https://doi.org/10.1001/archpsyc.1987.01800180093014
Coghlan, & Brydon-Miller, M. (2014). The SAGE encyclopedia of action research (Coghlan &
M. Brydon-Miller, Eds.). SAGE.
Conway, Compton, W., Stinson, F. S., & Grant, B. F. (2006). Lifetime comorbidity of DSM-IV
mood and anxiety disorders and specific drug use disorders: Results from the National
Epidemiologic Survey on Alcohol and Related Conditions. The Journal of Clinical
Psychiatry, 67(2), 247–257.
https://doi.org/10.4088/jcp.v67n0211
Cope, D. G. (2013). Methods and meanings: Credibility and trustworthiness of qualitative
research. Oncology Nursing Forum, 41(1), 89–91. https://doi.org/10.1188/14.onf.89-91
Corbin, J., & Strauss, A. (2014). Basics of qualitative research: Techniques and procedures for
developing grounded theory (Fourth ed.). SAGE Publications, Inc.
Cucchiara, S. (2021, March 22). Get your ducks in a row: Align local marketing execution with
your national strategy. Localogy.
https://www.localogy.com/2021/03/get-your-ducks-in-a-row-align-local-marketing-
execution-with-your-national-strategy/
Dahlman, C. J. (2007). The cost of a military personyear: A method for computing savings from
force reductions. Rand Publishing.
Davidson, J. R., Stein, D. J., Shalev, A. Y., & Yehuda, R. (2004). Posttraumatic stress disorder:
Acquisition, recognition, course, and treatment. The Journal of Neuropsychiatry and
Clinical Neurosciences, 16(2), 135–147. https://doi.org/10.1176/jnp.16.2.135

112
Demers, A. (2011). When veterans return: The role of community in reintegration. Journal of
Loss and Trauma, 16(2), 160–179. https://doi.org/10.1080/15325024.2010.519281
Denneson, Teo, A. R., Ganzini,L., Helmer, D. A., Bair, M. J., & Dobscha, S. K. (2015). Military
Veterans’ Experiences with Suicidal Ideation: Implications for Intervention and
Prevention. Suicide & Life-Threatening Behavior, 45(4), 399–414.
https://doi.org/10.1111/sltb.12136
Department of Developmental Services. (2008). Fact book [PDF].
http://www.dds.ca.gov/FactsStats/docs/factbook_11th.pdf
Diagnostic and statistical manual of mental disorders: DSM-5-TR (5th edition, text revision.).
(2022). American Psychiatric Association Publishing.Dowling, M. (2006). Approaches to
reflexivity in qualitative research. Nurse Researcher, 13(3), 7–21.
https://doi.org/10.7748/nr2006.04.13.3.7.c5975
Dictionary of Military and Associated Terms. (2005). Repatriate. TheFreeDictionary.com.
https://www.thefreedictionary.com/repatriate
DoD Transition Assistance Program. (n.d.). DoD Transition Assistance Program.
https://dodtap.mil/dodtap/app/about/DoDTAP
Durkheim. (1951). Suicide, a study in sociology. Free Press.
Eaton, N.R., Krueger, R. F., Keyes, K. M., Skodol, A. E., Markon, K. E., Grant, B. F., & Hasin,
D. S. (2011). Borderline personality disorder co-morbidity: Relationship to the
internalizing–externalizing structure of common mental disorders. Psychological
Medicine, 41(5), 1041–1050.
https://doi.org/10.1017/S0033291710001662

113
Eber, S., Barth, S., Kang, H., Mahan, C., Dursa, E., & Schneiderman, A. (2013). The national
health study for a new generation of united states veterans: Methods for a large-scale
study on the health of recent veterans. Military Medicine, 178(9), 966–969.
https://doi.org/10.7205/milmed-d-13-00175
Einarsen, S., Aasland, M., & Skogstad, A. (2007). Destructive leadership behaviour: A definition
and conceptual model. The Leadership Quarterly, 18(3), 207–216.
https://doi.org/10.1016/j.leaqua.2007.03.002
Eisen, S. V., Normand, S.-L., Belanger, A. J., Avron Spiro, & David Esch. (2004). The Revised
Behavior and Symptom Identification Scale (BASIS-R): Reliability and Validity.
Medical Care, 42(12), 1230–1241.
https://doi.org/10.1097/00005650-200412000-00010
Executive Order No. 13861 (National roadmap to empower veterans and end suicide) [84 F.R.
8585]. (2019). Federal Register.
Farmer, C., Tanielian, T., Buttorff, C., Carter, P., Cherney, S., Duffy, E. L., Hosek, S. D.,
Jaycox, L. H., Mahmud, A., Pace, N. M., Skrabala, L., & Whaley, C. (2020). Integrating
Department of Defense and Department of Veterans Affairs Purchased Care: Preliminary
Feasibility Assessment. Rand Health Quarterly, 9(1), 7–7.
Finley, E. P. (2019). Fields of combat. Cornell University Press.
https://doi.org/10.7591/9780801460708
Garland, H. R. (2018). Systematic review of veteran suicide literature [Doctoral dissertation].
ProQuest Dissertations Publishing.
Gibbs, G. R. (2018). Analyzing qualitative data (qualitative research kit) (2nd ed.). SAGE
Publications Ltd.

114
Golden-Biddle, & Locke, K. (2007). Composing qualitative research (2nd ed.). SAGE.
Gutierrez, Brenner, L. A., Rings, J. A., Devore, M. D., Kelly, P. J., Staves, P. J., Kelly, C. M., &
Kaplan, M. S. (2013). A Qualitative Description of Female Veterans’ Deployment-
Related Experiences and Potential Suicide Risk Factors. Journal of Clinical Psychology,
69(9), 923–935.
https://doi.org/10.1002/jclp.21997
Hammersley, M. (2019). Values in social research. In The sage handbook of qualitative research
ethics (pp. 23–34). SAGE Publications Ltd. https://doi.org/10.4135/9781526435446.n2
Hoffmire, Borowski, S., Griffin, B. J., Maguen, S., & Vogt, D. (2022). Trajectories of suicidal
ideation following separation from military service: Overall trends and group differences.
Suicide & Life-Threatening Behavior, 52(3), 413–426. https://doi.org/10.1111/sltb.12831
Holyfield, L. (2011). Veterans' journeys home. Routledge.
https://doi.org/10.4324/9781315631318
House, Umberson, D., & Landis, K. (1988). Structures and Processes of Social Support. Annual
Review of Sociology, 14(1), 293–318.
https://doi.org/10.1146/annurev.so.14.080188.001453
Huberman, A. M., & Miles, M. B. (2002). The qualitative researcher's companion (1st ed.).
SAGE Publications, Inc.
Interian, A., Kline, A., Janal, M., Glynn, S., & Losonczy, M. (2014). Multiple deployments and
combat trauma: Do homefront stressors increase the risk for posttraumatic stress
symptoms? Journal of Traumatic Stress, 27(1), 90–97. https://doi.org/10.1002/jts.21885
Iphofen, R. (2011). Ethical decision making in qualitative research. Qualitative Research, 11(4),
443–446. https://doi.org/10.1177/1468794111404330

115
Iphofen, R., & Tolich, M. (2018). The sage handbook of qualitative research ethics. SAGE
Publications Ltd.
https://doi.org/10.4135/9781526435446
Jackson, J. J., Thoemmes, F., Jonkmann, K., Lüdtke, O., & Trautwein, U. (2012). Military
training and personality trait development. Psychological Science, 23(3), 270–277.
https://doi.org/10.1177/0956797611423545
Jakupcak, Tull, M. T., McDermott, M. J., Kaysen, D., Hunt, S., & Simpson, T. (2010). PTSD
symptom clusters in relationship to alcohol misuse among Iraq and Afghanistan war
veterans seeking post-deployment VA health care. Addictive Behaviors, 35(9), 840–843.
https://doi.org/10.1016/j.addbeh.2010.03.023
Jenkins, L. (2014). On assimilation: a Ranger's return from war. Blackside Publishing.
Johnson, B. (2005). PTSD: What you need to know. Military.com.
Joiner, T. (2005). Why people die by suicide (1st ed.). Harvard University Press.
Junger, S. (2010). War (1st ed.). Twelve.
Junger, S. (2016). Tribe: On homecoming and belonging (1st ed.). Twelve.
Kang, H. K., Bullman, T. A., Smolenski, D. J., Skopp, N. A., Gahm, G. A., & Reger, M. A.
(2015). Suicide risk among 1.3 million veterans who were on active duty during the Iraq
and Afghanistan wars. Annals of Epidemiology, 25(2), 96–100.
https://doi.org/10.1016/j.annepidem.2014.11.020
Kelly, D. C., Barksdale, S. H., & Gitelson, D. (Eds.). (2011). Treating young veterans:
Promoting resilience through practice and advocacy (1st ed.). Springer Publishing
Company.

116
Kelly, P. J., Nilsson, J., & Berkel, L. (2014). A gendered perspective on military deployment.
Women & Health, 54(1), 61–76.
https://doi.org/10.1080/03630242.2013.862897
Kemp, J. & Bossarte, R. M. (2012). Surveillance of Suicide and Suicide Attempts among
Veterans: Addressing a National Imperative. American Journal of Public Health (1971),
102(1), e4–e5.
https://doi.org/10.2105/AJPH.2012.300652
Kessler, Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. B. (1995). Posttraumatic Stress
Disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52(12),
1048–1060.
https://doi.org/10.1001/archpsyc.1995.03950240066012
Kintzle, S., Barr, N., Corletto, G., & Castro, C. (2018). Ptsd in u.s. veterans: The role of social
connectedness, combat experience and discharge. Healthcare, 6(3), 102.
https://doi.org/10.3390/healthcare6030102
Krug, E., Dahlberg, L., & Mercy, J. (2001). World report on violence and health: Summary.
World Health Organization.
Kulka. (1990). Trauma and the Vietnam war generation: Report of findings from the national
Vietnam veterans readjustment study. Routledge. https://doi.org/10.4324/9781315803753
Kumar, Hein, C. L., DiLillo, D., & Pietrzak, R. H. (2021). Resilience to suicidal ideation among
U.S. military veterans with posttraumatic stress: Results from the national health and
resilience in veterans study. Military Behavioral Health, 1–10.
https://doi.org/10.1080/21635781.2021.2015019

117
LaCroix, M. Baer, M., Harrington-LaMorie, J., & Ghahramanlou-Holloway, M. (2018). Missed
opportunities for military suicide prevention: Perspectives of suicide loss survivors.
Military Behavioral Health, 6(3), 252–257.
https://doi.org/10.1080/21635781.2017.1419893
Langhinrichsen-Rohling, J., Snarr, J. D., Slep, A., Heyman, R. E., & Foran, H. M. (2011). Risk
for suicidal ideation in the U. S. Air Force: An ecological perspective. Journal of
Consulting and Clinical Psychology, 79(5), 600–612. https://doi.org/10.1037/a0024631
Lieberman, H. R., Karl, J., Niro, P. J., Williams, K. W., Farina, E. K., Cable, S. J., & McClung,
J. P. (2014). Positive effects of basic training on cognitive performance and mood of
adult females. Human Factors: The Journal of the Human Factors and Ergonomics
Society, 56(6), 1113–1123. https://doi.org/10.1177/0018720813519472
Lincoln, Y. S., & Guba, E. (1985). Naturalistic inquiry (1st ed.). SAGE Publications.
Logan, J., Bohnert, A., Spies, E., & Jannausch, M. (2016). Suicidal ideation among young
afghanistan/iraq war veterans and civilians: Individual, social, and environmental risk
factors and perception of unmet mental healthcare needs, united states, 2013. Psychiatry
Research, 245, 398–405. https://doi.org/10.1016/j.psychres.2016.08.054
Macia, K. S., Moschetto, J. M., Wickham, R. E., Brown, L. M., & Waelde, L. C. (2020).
Cumulative trauma exposure and chronic homelessness among veterans: The roles of
responses to intrusions and emotion regulation. Journal of Traumatic Stress, 33(6), 1017–
1028. https://doi.org/10.1002/jts.22569
Magruder, K. M., & Yeager, D. E. (2009). The prevalence of ptsd across war eras and the effect
of deployment on PTSD: A systematic review and meta-analysis. Psychiatric Annals,
39(8). https://doi.org/10.3928/00485713-20090728-04

118
Maguen, S., Skopp, N. A., Zhang, Y., & Smolenski, D. J. (2015). Gender differences in suicide
and suicide attempts among us army soldiers. Psychiatry Research, 225(3), 545–549.
https://doi.org/10.1016/j.psychres.2014.11.050
Mares, A. S., & Rosenheck, R. A. (2004). Perceived relationship between military service and
homelessness among homeless veterans with mental illness. The Journal of Nervous and
Mental Disease, 192(10), 715–719. https://doi.org/10.1097/01.nmd.0000142022.08830.f4
Marvasti, J. A. (2012). War trauma in veterans and their families: diagnosis and management of
PTSD, TBI, and comorbidities of combat trauma: from pharmacotherapy to a 12-step
self-help program for combat veterans. Charles C. Thomas, Publisher.
Mavandadi, S., Ingram, E., Klaus, J., & Oslin, D. (2019). Social ties and suicidal ideation among
veterans referred to a primary care–mental health integration program. Psychiatric
Services, 70(9), 824–832. https://doi.org/10.1176/appi.ps.201800451
McFall, M.E., Mackay, P. W., & Donovan, D. M. (1992). Combat-related posttraumatic stress
disorder and severity of substance abuse in Vietnam veterans. Journal of Studies on
Alcohol, 53(4), 357–363.
https://doi.org/10.15288/jsa.1992.53.357
McGarry, & Towell, P. (2019). FY2019 National Defense Authorization Act (H.R. 5515). In
Policy File. Federation of American Scientists.
Merriam, S. B., & Tisdell, E. J. (2019). Qualitative research: a guide to design and
implementation (4th ed.). Wiley.
Miller, Monahan, C. J., Phillips, K. M., Agliata, D., & Gironda, R. J. (2020). Mental health
utilization among veterans at risk for suicide: Data from a post-deployment clinic.
Psychological Services, 17(2), 217–226.

119
https://doi.org/10.1037/ser0000311
Mitchell, M.M., Gallaway, M. S., Millikan, A. M., & Bell, M. (2012). Interaction of combat
exposure and unit cohesion in predicting suicide-related ideation among post-deployment
soldiers. Suicide & Life-Threatening Behavior, 42(5), 486–494.
https://doi.org/10.1111/j.1943-278X.2012.00106.x
Mobbs, M. C., & Bonanno, G. A. (2018). Beyond war and PTSD: The crucial role of transition
stress in the lives of military veterans. Clinical Psychology Review, 59, 137–144.
https://doi.org/10.1016/j.cpr.2017.11.007
Murphy, Xu, J., Kochanek, K. D., & Arias, E. (2018). Mortality in the United States, 2017.
NCHS Data Brief, 328, 1–8.
https://www.cdc.gov/nchs/data/databriefs/db328-h.pdf
Naderifar, M., Goli, H., & Ghaljaie, F. (2017). Snowball sampling: A purposeful method of
sampling in qualitative research. Strides in Development of Medical Education, 14(3).
https://doi.org/10.5812/sdme.67670
Najavits, Krinsley, K., Waring, M. E., Gallagher, M. W., & Skidmore, C. (2018). A Randomized
Controlled Trial for Veterans with PTSD and Substance Use Disorder: Creating Change
versus Seeking Safety. Substance Use & Misuse, 53(11), 1788–1800.
https://doi.org/10.1080/10826084.2018.1432653
National Center for Injury Prevention and Control. (2013, July 10). Promoting individual, family,
and community connectedness to prevent suicidal behavior: Strategic direction for the
Prevention of Suicidal Behavior. Centers for Disease Control and Prevention.
https://stacks.cdc.gov/view/cdc/5275
Nevada Department of Veteran Services. (n.d.). Take the Challenge – Be Part of the Solution.
https://veterans.nv.gov/suicide-prevention-awareness-mayors-challenge/

120
New Strategy Outlines Five Priorities for Reducing Military and Veteran Suicide. (2021). In
White House Press Releases, Fact Sheets and Briefings / FIND. Federal Information &
News Dispatch, LLC.
Olenick, M., Flowers, M., & Diaz, V. (2015). Us veterans and their unique issues: Enhancing
health care professional awareness. Advances in Medical Education and Practice, 635.
https://doi.org/10.2147/amep.s89479
Palinkas, L. A., Horwitz, S. M., Green, C. A., Wisdom, J. P., Duan, N., & Hoagwood, K. (2013).
Purposeful sampling for qualitative data collection and analysis in mixed method
implementation research. Administration and Policy in Mental Health and Mental Health
Services Research, 42(5), 533–544.
https://doi.org/10.1007/s10488-013-0528-y
Patton, M. Q. (2002). Qualitative research and evaluation methods (3 ed.). Sage Publications.
Pease, J. L., Billera, M., & Gerard, G. (2015). Military culture and the transition to civilian life:
Suicide risk and other considerations. Social Work, 61(1), 83–86.
https://doi.org/10.1093/sw/swv050
Peterson, K., & Bourne, D. (2018, September). Evidence Brief: Suicide Prevention in Veterans.
Department of Veterans Affairs. https://www.ncbi.nlm.nih.gov/books/NBK535971/
Peterson, & Seligman, M. E. P. (2004). Character Strengths and Virtues A Handbook and
Classification. Oxford University Press, Incorporated.
Pew Research Center. (2012, October). War and Sacrifice in the Post-9/11 Era: The Military-
Civilian Gap [PDF]. https://statistical-proquest-
com.libproxy2.usc.edu/statisticalinsight/result/pqpdocumentview?accountid=14749&gro
upid=95432&pgId=726aaaeb-42ab-4729-bc7c-39e8dc15c8a7#33

121
Pew Research Center. (2019, September). The American Veteran Experience and the Post-9/11
Generation [PDF].
https://statistical-proquest-
com.libproxy1.usc.edu/statisticalinsight/result/pqpresultpage.previewtitle?docType=PQS
I&titleUri=%2Fcontent%2F2019%2FR8596-131.19726.xml&accountid=14749
Pietrzak, R. H., Goldstein, M. B., Malley, J. C., Rivers, A. J., Johnson, D. C., & Southwick, S.
M. (2009a). Risk and protective factors associated with suicidal ideation in veterans of
Operations Enduring Freedom and Iraqi Freedom. Journal of Affective Disorders, 123(1),
102–107. https://doi.org/10.1016/j.jad.2009.08.001
Pietrzak, R. H., Johnson, D. C., Goldstein, M. B., Malley, J. C., & Southwick, S. M. (2009b).
Perceived stigma and barriers to mental health care utilization among OEF OIF veterans.
Psychiatric Services, 60(8), 1118–1122. https://doi.org/10.1176/ps.2009.60.8.1118
Pietrzak, R. H., Pitts, B. L., Harpaz-Rotem, I., Southwick, S. M., & Whealin, J. M. (2017).
Factors protecting against the development of suicidal ideation in military veterans.
World Psychiatry, 16(3), 326–327. https://doi.org/10.1002/wps.20467
Polit-O’Hara, & Beck, C. T. (2012). Nursing research: generating and assessing evidence for
nursing practice (9th ed.). Wolters Kluwer Health/Lippincott Williams & Wilkins.
Qualitative research practice: A guide for social science students and researchers (Second ed.).
(2014). SAGE Publications Ltd.
Rädiker, S., & Kuckartz, U. (2020). Focused analysis of qualitative interviews with maxqda:
Step by step. Maxqda Press.
Reger, M. A., Smolenski, D. J., Skopp, N. A., Metzger-Abamukang, M. J., Kang, H. K.,
Bullman, T. A., Perdue, S., & Gahm, G. A. (2015). Risk of suicide among us military

122
service members following operation enduring freedom or operation Iraqi freedom
deployment and separation from the us military. JAMA Psychiatry, 72(6), 561.
https://doi.org/10.1001/jamapsychiatry.2014.3195
Reger, M. A., Tucker, R. P., Carter, S. P., & Ammerman, B. A. (2018). Military deployments
and suicide: A critical examination. Perspectives on Psychological Science, 13(6), 688–
699. https://doi.org/10.1177/1745691618785366
Robinson, S. B., & Leonard, K. F. (2018). Designing quality survey questions (1st ed.). SAGE
Publications, Inc.
Rose, D. (2017). No joy: A recon marine's tales of (self) destruction. Rare Bird Books, A Vireo
Book.
Rowe, W. (2014). The sage encyclopedia of action research (D. Coghlan & M. Brydon-Miller,
Eds.; 1st ed.). SAGE Publications, Ltd.
Roy-Byrne, P. (2013). Suicide risk in the military Is unrelated to deployment. NEJM Journal
Watch. Psychiatry.
Sandelowski. (1986). The problem of rigor in qualitative research. Advances in Nursing Science,
8(3), 27–37.
https://doi.org/10.1097/00012272-198604000-00005
Sayer, N. A., Frazier, P., Orazem, R. J., Murdoch, M., Gravely, A., Carlson, K. F., Hintz, S., &
Noorbaloochi, S. (2011). Military to civilian questionnaire: A measure of postdeployment
community reintegration difficulty among veterans using department of veterans affairs
medical care. Journal of Traumatic Stress, 24(6), 660–670.
https://doi.org/10.1002/jts.20706

123
Sayer, N. A., Noorbaloochi, S., Frazier, P., Carlson, K., Gravely, A., & Murdoch, M. (2010).
Reintegration problems and treatment interests among Iraq and Afghanistan combat
veterans receiving VA medical care. Psychiatric Services, 61(6), 589–597.
https://doi.org/10.1176/ps.2010.61.6.589
Sayer, N. A., Orazem, R. J., Noorbaloochi, S., Gravely, A., Frazier, P., Carlson, K. F., Schnurr,
P. P., & Oleson, H. (2014). Iraq and afghanistan war veterans with reintegration
problems: Differences by veterans affairs healthcare user status. Administration and
Policy in Mental Health and Mental Health Services Research, 42(4), 493–503.
https://doi.org/10.1007/s10488-014-0564-2
Schiraldi, G. R. (2009). The post-traumatic stress disorder sourcebook: a guide to healing,
recovery, and growth. 2nd ed. New York, McGraw-Hill.
Shen, Y.-C., Cunha, J. M., & Williams, T. V. (2016). Time-varying associations of suicide with
deployments, mental health conditions, and stressful life events among current and
former us military personnel: A retrospective multivariate analysis. The Lancet
Psychiatry, 3(11), 1039–1048. https://doi.org/10.1016/s2215-0366(16)30304-2
Sher, L. (2019). Resilience as a focus of suicide research and prevention. Acta Psychiatrica
Scandinavica, 140(2), 169–180. https://doi.org/10.1111/acps.13059
Shrivastava, Kimbrell, M., & Lester, D. (2012). Suicide from a Global Perspective: Psychiatric
Approaches. Nova Science Publishers, Incorporated.
Smith, N. B., Mota, N., Tsai, J., Monteith, L., Harpaz-Rotem, I., Southwick, S. M., & Pietrzak,
R. H. (2016). Nature and determinants of suicidal ideation among u.s. veterans: Results
from the national health and resilience in veterans study. Journal of Affective Disorders,
197, 66–73. https://doi.org/10.1016/j.jad.2016.02.069

124
Sokol, Y., Gromatsky, M., Edwards, E. R., Greene, A. L., Geraci, J. C., Harris, R. E., &
Goodman, M. (2021). The deadly gap: Understanding suicide among veterans
transitioning out of the military. Psychiatry research, 300, 113875.
https://doi.org/10.1016/j.psychres.2021.113875
Southwick, & Charney, D. S. (2012). The Science of Resilience: Implications for the Prevention
and Treatment of Depression. Science (American Association for the Advancement of
Science), 338(6103), 79–82. https://doi.org/10.1126/science.1222942
Spencer, L., Ritchie, J., O'Connor, W., Morrell, G., & Ormston, R. (2014). Qualitative research
practice: A guide for social science students and researchers ( R., J. Lewis, & C.
McNaughton, Eds.; 2nd ed.). SAGE Publications Ltd.
Stone, D., Holland, K., Holland, B., Crosby, A., Davis, S., Wilkins, N., Atlanta GA. Centers for
Disease Control and Prevention, National Center for Injury Prevention and Control
(U.S.). Division of Violence Prevention. (January 01, 2017). Preventing suicide: a
technical package of policies, programs, and practice.
https://www.v.gov/violenceprevention/pdf/suicideTechnicalPackage.pdf).
Tanielian, T., & Jaycox, L. H. (2008). Invisible wounds of war: Psychological and cognitive
injuries, their consequences, and services to assist recovery (2008). RAND Corporation.
Teherani, A., Martimianakis, T., Stenfors-Hayes, T., Wadhwa, A., & Varpio, L. (2015).
Choosing a qualitative research approach. Journal of Graduate Medical Education, 7(4),
669–670. https://doi.org/10.4300/jgme-d-15-00414.1
Theofanidis, D., & Fountouki, A. (2018). Limitations and delimitations in the research
process. Perioperative Nursing.
https://www.spnj.gr/articlefiles/volume7_issue3/pn_sep_73_155_162b.pdf

125
Thomas, J.L., Wilk, J. E., Riviere, L. A., McGurk, D., Castro, C. A., & Hoge, C. W. (2010).
Prevalence of Mental Health Problems and Functional Impairment Among Active
Component and National Guard Soldiers 3 and 12 Months Following Combat in Iraq.
Archives of General Psychiatry, 67(6), 614–623.
https://doi.org/10.1001/archgenpsychiatry.2010.54
Thomsen, Stander, V. A., McWhorter, S. K., Rabenhorst, M. M., & Milner, J. S. (2011). Effects
of combat deployment on risky and self-destructive behavior among active duty military
personnel. Journal of Psychiatric Research, 45(10), 1321–1331.
https://doi.org/10.1016/j.jpsychires.2011.04.003
Thurairajah, K. (2019). Practicing reflexivity: balancing multiple positionalities during
fieldwork. Sage Publications Ltd. https://doi.org/10.4135/9781526483850
Tilghman, A. (2022, August 19). Is new retirement plan really better for career troops? Military
Times.
https://www.militarytimes.com/pay-benefits/military-retirement/2015/05/17/is-new-
retirement-plan-really-better-for-career-troops/
Torreon, B. S. (2012). U.S. periods of war and dates of recent conflicts (Library of Congress).
Congressional Research Service.
Tsai, J., Trevisan, L., Huang, M., & Pietrzak, R. H. (2018). Addressing veteran homelessness to
prevent veteran suicides. Psychiatric Services, 69(8), 935–937.
https://doi.org/10.1176/appi.ps.201700482
U. S. Department of Health & Human Services. (2012). 2012 National strategy for suicide
prevention: goals and objectives for action: a report of the U.S. Surgeon General and of
the National Action Alliance for Suicide Prevention.

126
https://www.hhs.gov/sites/default/files/national-strategy-for-suicide-prevention-
overview.pdf
U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services
Administration. (2017). National Strategy for Suicide Prevention implementation
assessment report.
U.S. Department of Health & Human Services. (2020). Governor's and Mayor's Challenges to
prevent suicide among service members, veterans, and their families.
https://www.samhsa.gov/smvf-ta-center/mayors-governors-challenges
U.S. Department of Housing and Urban Development Office of Community Planning and
Development. (2016, November). The 2016 annual homeless assessment report (ahar) to
congress, part 1: Point-in-time estimates of homelessness [PDF].
https://www.nhipdata.org/local/upload/file/2016-AHAR-Part- reduced(1).pdf
U.S. Department of Veterans Affairs, National Center for PTSD. (2018a). Fiscal Year 2018
annual report: National center for PTSD [PDF].
https://www.ptsd.va.gov/about/work/docs/annual_reports/2018/NCPTSD_2018_Annual_
Report_AllAppendices.pdf
U.S. Department of Veterans Affairs, Office of Mental Health and Suicide Prevention. (2018b).
VA national suicide data report 2005-2016.
https://www.mentalhealth.va.gov/docs/data-
sheets/OMHSP_National_Suicide_Data_Report_2005-2016_508.pdf
U.S. Department of Veterans Affairs, Office of Mental Health and Suicide Prevention. (2018c,
June). National strategy for preventing veteran suicide, 2018-2028 [PDF].

127
https://www.mentalhealth.va.gov/suicide_prevention/docs/Office-of-Mental-Health-and-
Suicide-Prevention-National-Strategy-for-Preventing-Veterans-Suicide.pdf
U. S. Department of Veterans Affairs, Veterans Health Administration, Office of Mental Health
and Suicide Prevention. 2020 National Veteran Suicide Prevention Annual Report. 2020.
https://www.mentalhealth.va.gov/docs/datasheets/2020/2020_National_Veteran_Suicide_
Prevention_Annual_Report_508.pdf.
U.S. Government. (2023). White House Fact Sheet: In state of the union, president Biden to
outline vision to advance progress on Unity Agenda in year ahead.
https://www.whitehouse.gov/briefing-room/statements-releases/2023/02/07/fact-sheet-in-
state-of-the-union-president-biden-to-outline-vision-to-advance-progress-on-unity-
agenda-in-year-ahead/
Villatte, J. L., O'Connor, S. S., Leitner, R., Kerbrat, A. H., Johnson, L. L., & Gutierrez, P. M.
(2015). Suicide attempt characteristics among veterans and active-duty service members
receiving mental health services: A pooled data analysis. Military Behavioral Health,
3(4), 316–327.
https://doi.org/10.1080/21635781.2015.1093981
von Unger. (2021). Ethical Reflexivity as Research Practice. Historical Social Research (Kö ln),
46(2), 186–204.
https://doi.org/10.12759/hsr.46.2021.2.186-204
Wade, J. O. (2016). Back home after war: When veterans live with their parents after combat
(10119471) [Doctoral dissertation, California School of Professional Psychology Alliant
International University San Francisco]. ProQuest Dissertations & Theses Global.
https://www.proquest.com/docview/1805341390?pq-origsite=primo&accountid=14749

128
Weiner, J., Richmond, T. S., Conigliaro, J., & Wiebe, D. J. (2011). Military veteran mortality
following a survived suicide attempt. BMC Public Health, 11(1), 374–374.
https://doi.org/10.1186/1471-2458-11-374
Westphal, & Convoy, S. (2015). Military Culture Implications for Mental Health and Nursing
Care. Online Journal of Issues in Nursing, 20(1), 47.
https://doi.org/10.3912/OJIN.Vol20No01Man04
Wolitzky-Taylor, Bobova, L., Zinbarg, R. E., Mineka, S., & Craske, M. G. (2012). Longitudinal
investigation of the impact of anxiety and mood disorders in adolescence on subsequent
substance use disorder onset and vice versa. Addictive Behaviors, 37(8), 982–985.
https://doi.org/10.1016/j.addbeh.2012.03.026
Worthen, M., Moos, R., & Ahern, J. (2012). Iraq and Afghanistan veterans’ experiences living
with their parents after separation from the military. Contemporary Family Therapy,
34(3), 362–375. https://doi.org/10.1007/s10591-012-9196-4
Wu, Feder, A., Cohen, H., Kim, J. J., Calderon, S., Charney, D. S., & Mathé, A. A. (2013).
Understanding resilience. Frontiers in Behavioral Neuroscience, 7(2013), 10–10.
https://doi.org/10.3389/fnbeh.2013.00010
Yehuda, Daskalakis, N. P., Desarnaud, F., Makotkine, I., Lehrner, A. L., Koch, E., Flory, J. D.,
Buxbaum, J. D., Meaney, M. J., & Bierer, L. M. (2013). Epigenetic biomarkers as
predictors and correlates of symptom improvement following psychotherapy in combat
veterans with PTSD. Frontiers in Psychiatry, 4, 118–118.
https://doi.org/10.3389/fpsyt.2013.00118

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Appendix A: Nonprofit and Community-Based Organizations Focused on Providing
Assistance to Veterans at Risk of Suicide
22 KILL
AUSTIN VETERAN ARTS FESTIVAL
SUICIDE PREVENTION RESOURCE CENTER
VETERANS SUICIDE PREVENTION ASSOCIATION
MISSION 22
NETWORK OF CARE
VSA TEXAS
SOLDIERS SONG & VOICE
(VA) US DEPARTMENT OF VETERANS AFFAIRS
ONCE A SOLDIER
WARRIOR SUICIDE PREVENTION FOUNDATION
STOP SOLDIER SUICIDE
AMERICAN FOUNDATION FOR SUICIDE PREVENTION
ACTIVE HEROES
22 WARRIORS FOUNDATION
NATIONAL SUICIDE PREVENTION LIFELINE
TAPS
NATIONAL VETERANS CONVENTION
OPERATION NEVER FORGOTTEN
REQUEST FOR PROPOSAL
VOLUNTEERS Of AMERICA
NATIONAL ALLIANCE TO END SUICIDE
VICTORY FOR VETERANS
ALL SECURE FOUNDATION
WOUNDED WARRIORS
SUICIDE PREVENTION ALLIANCE of NORTHERN VIRGINIA
ARMY ONESOURCE MILITARY SUICIDE PREVENTION
BOEING AWARD To PREVENT VETERAN SUICIDE
VETERANS SUICIDE PREVENTION CHANNEL

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Appendix B: Recruitment Questionnaire Protocol for Veteran Service Providers
RECRUITMENT SURVEY QUESTIONS:
NAME: _______________________________
EMAIL: ______________________________
PHONE: ______________________________
1. DID YOU SERVE IN THE MILITARY?
⮚ Yes
⮚ No
⮚ Decline to respond

2. IF YES, IN WHAT BRANCH OF SERVICE?
⮚ US Army
⮚ US Marines
⮚ US Air Force
⮚ US Navy
⮚ Other
⮚ Decline to respond

3. IF YES, HOW LONG DID YOU SERVE IN THE MILITARY?
⮚ Less than 4 years
⮚ 4 to <10 years
⮚ 10 to <20 years
⮚ More than 20 years
⮚ Decline to respond

4. HAVE YOU SUPPORTED VETERAN REPATRIATION PROGRAMS?
⮚ Yes
⮚ No
⮚ Decline to respond

5. IF YES, HOW LONG HAVE YOU SUPPORTED VETERAN REPATRIATION
PROGRAMS?
⮚ Less than 4 years
⮚ 4 to <10 years

131
⮚ 10 to <20 years
⮚ More than 20 years
⮚ Decline to respond

6. HAVE YOU SUPPORTED SUICIDE PREVENTION PROGRAMS?
⮚ Yes
⮚ No
⮚ Decline to respond

7. IF YES, HOW LONG HAVE YOU SUPPORTED SUICIDE PREVENTION
PROGRAMS?
⮚ Less than 4 years
⮚ 4 to <10 years
⮚ 10 to <20 years
⮚ More than 20 years
⮚ Decline to respond

8. HAVE YOU SUPPORTED VETERAN SUICIDE PREVENTION PROGRAMS?
⮚ Yes
⮚ No
⮚ Decline to respond

9. IF YES, HOW LONG HAVE YOU SUPPORTED VETERAN SUICIDE PREVENTION
PROGRAMS?
⮚ Less than 4 years
⮚ 4 to <10 years
⮚ 10 to <20 years
⮚ More than 20 years
⮚ Decline to respond

132
Appendix C: Interview Protocol

Introduction to the Interview:

Thank you for taking time out of your schedule to join me here today and for agreeing to participate in the study by answering a few
questions. The interview should take less than one hour, but we have allocated an hour and a half should we need to use more time.
My name is Rob Vanderberry, and I am the principal investigator and a doctoral candidate conducting research in support of
understanding the role of connectedness as a mitigating element in the fight to lessen veteran suicide. The information you provide
will contribute to understanding the critical elements of veteran repatriation, emphasizing the role of connectedness in facilitating
successful repatriation that, by definition, will assist in mitigating veteran suicide.

Your participation is completely voluntary. You may choose to pass over any questions you do not want to answer, and you may stop
the interview at any time. I respectfully request your permission to record our discussion to assist me with consistency and fidelity.
You can request that the recording be stopped at any time. Your personal information will be protected both in raw and edited format
through the use of an encrypted database and anonymizing your name and position while retaining the context and perspective of the
information you provide.

I very much appreciate your sharing your experience, knowledge, and perspective here today. Your contributions will provide the
context, depth, and detail needed to ensure traceability and credibility in the research. Thank you for your service to our community
and for your commitment and compassion in supporting our veteran population. If you have any questions, I would be happy to
answer them.

Then let us begin; do I have your permission to begin the interview and to record our exchange?

Interview Protocol Questions
.
131

133
Appendix C: Interview Protocol for Veteran Support Service Providers

Interview questions Potential probes RQ
Q type
{Patton}
1. Can you describe your work in veteran repatriation programs?
How long did you engage in veteran
support program (s)?
N/A 1,3,6
2. In your own words, can you describe what connectedness means to
you?
Give me an example of that.
Walk me through the experience. 1 2,3
3. How does your organization understand/perceive connectedness?
Do they perceive it as valuable?
What makes you feel that way? 1 2,4,5
4. In your opinion, what, if any, do you see as the relationship
between time served in the military and veteran connectedness
upon separation or retirement?
Give me an example of that?
What makes you feel that way? 3 1,2,5
5. What role, if any, does connectedness play in veteran repatriation
programming in your organization?
Give me an example of that? 2 2,3,5
6. What role, if any, do you think connectedness should play in
veteran repatriation programming in your organization?
Give me an example of that? 1 2,3,5
7. In what ways, if any, do you think connectedness in veteran
repatriation programs impacts veteran suicidal ideation?
What makes you feel that way? 1 2,3,5
8. What opportunities, if any, do you see for improvement regarding
the role of connectedness in veteran repatriation?
What are they? How would they help?
What will it take to implement them? 4 2,3,4,5
9. In what ways, if any, would the changes you propose to
connectedness in repatriation impact veteran suicidal ideation?
4 2
10. Can you think of anyone who could provide valuable input to this
discussion that I should speak with?
Would you be willing to share their
information with me? N/A 2
11. Can you think of any documents or artifacts that could provide
further insight or understanding of our conversation?
Would you be willing to share that
information, those items with me? N/A 2

132

134
Appendix D: Information Sheet for Exempt Research
STUDY TITLE: Mitigating Veteran Suicide: Exploring Connectedness in Veterans Repatriating
into Society as a Means of Increasing Resiliency

PRINCIPAL INVESTIGATOR: Robin Vanderberry

FACULTY ADVISOR: Jennifer Phillips, DLS

You are invited to participate in a research study. Your participation is voluntary. This document
explains information about this study. You should ask questions about anything unclear to you.

PURPOSE
The purpose of the study is to explore veteran service providers’ perceptions of the association
between connectedness and resilience in veterans repatriating into society. We hope to learn if
there are potential recommendations for individuals and groups assisting veteran repatriation to
leverage connectedness to increase veteran resiliency and ultimately mitigate veteran suicidal
ideation. You are invited as a possible participant because of your knowledge and experience
regarding veteran assistance activities.

PARTICIPANT INVOLVEMENT
If you decide to participate, you will be asked to respond to a short recruitment survey that
should take less than thirty minutes to complete. If selected based on your recruitment survey
responses, you will be asked to participate in a semi-structured, qualitative interview which
should take less than one hour to complete. The interview will be recorded (audio only if in
person, audio and video if in Zoom) to provide an opportunity for better comprehension and the
ability to revisit responses as the analysis evolves.

CONFIDENTIALITY
The members of the research team and the University of Southern California Institutional
Review Board (IRB) may access the data associated with the study. The IRB reviews and
monitors research studies to protect the rights and welfare of research subjects.

When the research results are published or discussed in conferences, no identifiable information
will be used.
Both audio and video recordings will be transcribed, coded, analyzed, and archived to support
the study. Transcription will be accomplished using third-party software, and a data log will be
used to record interview characterization data (location, time, participants, any additional
pertinent data). Anonymity of transcription is required to ensure confidentiality and is
particularly important in qualitative interviews because of the individuality of the data.
Participants have the right to review the audio/video recordings or transcripts if they desire.
Long-term disposal or protected preservation is not only an ethical consideration, but if done
correctly, it mitigates future concerns about confidentiality and anonymity. The data collected
will be kept for 90 days after dissertation acceptance and then deleted. To facilitate

135
confidentiality, ensure anonymity, and mitigate future concerns about data access, this project
will pursue the following strategies:
● Replace PPII (such as names and social security numbers) with identification
codes
● Remove PPII from all cover documents
● Destroy contact lists and recruitment records when no longer required
● When transferred or transported, all electronic data files will be password
protected and encrypted
● Physical data records will be secured in locked rooms or cabinets
● Electronic data are stored in password-protected files or computers
● Computers hosting electronic data files will be closed and locked when left
unattended
● Code lists and passwords will be securely stored separate from data
● Data, code lists, and passwords will be destroyed as soon as practical

INVESTIGATOR CONTACT INFORMATION
If you have any questions about this study, please contact the primary investigator: Robin
Vanderberry via email at robinvan@usc.edu or via telephone at 702-612-1513.

IRB CONTACT INFORMATION
If you have any questions about your rights as a research participant, please contact the
University of Southern California Institutional Review Board at (323) 442-0114 or email
irb@usc.edu.

Abstract (if available)

Abstract Following separation from the military, service members face challenges transitioning to a post-military civilian life. Evidence indicates these transitioning Veterans are at higher risk for suicide compared with both the broader Veteran population and the United States public. This research project focused on advancing the understanding of veteran service provider perceptions of the association between connectedness and resilience in veterans repatriating into society. The resulting data analysis offers an improved understanding of how individuals and groups assisting veteran repatriation leverage connectedness to increase veteran resiliency and ultimately mitigate veteran suicidal ideation. It explores the interaction between veterans and their environment using a bio-ecological approach to culture and context. Finally, it incorporates veteran service provider identified connectedness practices to recommend improvements in veteran transition assistance that can increase resiliency and mitigate veteran suicidal ideation.

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Asset Metadata

Creator Vanderberry, Robin P. (author)

Core Title Mitigating veteran suicide: exploring connectedness in veterans repatriating into society as a means of increasing resiliency

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Degree Conferral Date 2023-05

Publication Date 04/24/2023

Defense Date 04/13/2023

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag bio-ecological theory,interpersonal theory of suicide,OAI-PMH Harvest,transition assistance program,veteran suicide

Format theses (aat)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Phillips, Jennifer L. (committee chair), Foulk, Susanne (committee member), Seli, Helena (committee member)

Creator Email rob@vberry.com,robinvan@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC113078063

Unique identifier UC113078063

Identifier etd-Vanderberr-11705.pdf (filename)

Legacy Identifier etd-Vanderberr-11705

Document Type Dissertation

Format theses (aat)

Rights Vanderberry, Robin P.

Internet Media Type application/pdf

Type texts

Source 20230425-usctheses-batch-1030 (batch), University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

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Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA

Repository Email cisadmin@lib.usc.edu