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Mitigating the risk of veteran suicide: an evaluation study of suicide prevention resiliency implementation

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Content Mitigating the Risk of Veteran Suicide 1

MITIGATING THE RISK OF VETERAN SUICIDE: An Evaluation Study of Suicide
Prevention Resiliency Implementation

by

Zachary Unger

A Dissertation Presented to the
FACULTY OF THE USC ROSSIER SCHOOL OF EDUCATION
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF EDUCATION

May 2019

Copyright 2019 Unger

Mitigating the Risk of Veteran Suicide 2
Epigraph
“So let me say it as clearly as I can to any of our troops or veterans who are watching and
struggling: Look at this man. Look at this soldier. Look at this warrior. He’s as tough as they
come. And if he can find the courage and the strength, to not only seek help, but also to speak
about it, to take care of himself and stay strong, then so can you.”
- Barack Obama, President of the United States (2008-2016)

Mitigating the Risk of Veteran Suicide 3
Dedication
To my parents, thank you for your continued belief in me and always encouraging my
studies through the years. Your effort and sacrifices allowed me to pursue my dreams.

To my loving wife, thank you for your encouragement in starting, enduring, and
finishing this process. You never wavered in your support and selflessness and for that I love
you. I only hope that someday I can be half as brilliant as you.

Mitigating the Risk of Veteran Suicide 4
Acknowledgements
To the brave men and women of USSOCOM. Your contributions to this country on
battlefields far from home, your sacrifices, and your willingness to sprint head-first in danger
are more than can be imagined. Yet somehow, you have assembled a holistic pre-habilitative
program during a time of crisis that may demonstrate an example of socio-cognitive and
holistic approaches to preserving USSOCOM’s greatest asset: it’s people.
To my seniors for that encouragement in an offer of support in any way, you
demonstrated to all of us that there are no ends you would not go to so that someday not one
more of our people would be lost to suicide.
To my peers who aided in this work, your willingness to contribute demonstrated to
me an acknowledgment of caring about a problem, and a mind-set shift to being overtly
willing to help in any way to solve it.
To my dissertation advisor Doctor Hirabayashi, I admired your willingness to not
only allow but encourage a “no-breaks” pace with my writing, it made for a truly enjoyable
and memorable experience and allowed for a familiar initial entry into the academic realm.
Even more, you matched it the same in your thoughts and considerations towards my work.
To my committee chairs, Doc Astor and Doc Andres, thank you for your interest and
enriching vantage points as a result of diverse professional backgrounds. At any given time,
we were all taking different sightlines on the problem and as a result, I believe we identified
a diversity of perspective that only served to create a more holistic and diverse contribution
to the subject than we would have had we all shared one point of view or one professional
background.

Mitigating the Risk of Veteran Suicide 5
Abstract
The CDC (2016) notes that over 20 veterans a day commit suicide. New programs
and interventions, exemplified by the pre-habilitative and holistic Preservation of the Force
and Family (POTFF) program evaluated in this study, aim to build resiliency and lower the
number of suicides. This qualitative study evaluated the current status of implementation of
suicide prevention resiliency measures by the resiliency staff in an overseas deployed
military unit, focusing on members with an average of ten years-experience and previous
overseas deployed experience. Evaluation method used was a modified Clarke and Estes
(2008) organizational change evaluation model with respect to the goal of 100%
implementation of suicide prevention resiliency measures. Multiple methods (observations,
interviews, and document analysis) were used. Objectives were defined as identifying
knowledge, motivational, and organizational influencers as they affected progress towards
the goal to determine success or areas of possible improvement, potentially identifying a
promising practice or noting areas for improvement in the fight against veteran suicide.
Analysis of data occurred during and at the conclusion of the
observation/interview/document analysis period. Results demonstrated initial success and
emerging promising practices. Noted areas for further development pertained to
communication and further social cognitive theory approaches empowering peer
participation and shared experiences as a means to lessen stigma and negative career
implications. Results were documented and published for future contributions to an emerging
field of research with a current need for more data and education/research

Mitigating the Risk of Veteran Suicide 6
Table of Contents
Epigraph .................................................................................................................................... 2
Dedication .................................................................................................................................. 3
Acknowledgements ................................................................................................................... 4
Abstract ...................................................................................................................................... 5
Table of Figures ......................................................................................................................... 8
CHAPTER ONE: INTRODUCTION ....................................................................................... 9
Introduction of the Problem of Practice ................................................................................ 9
Organizational Context and Mission ..................................................................................... 9
Organizational Goal ............................................................................................................. 10
Related Literature ................................................................................................................ 13
Importance of the Evaluation .............................................................................................. 14
Description of Stakeholder Groups ..................................................................................... 15
Stakeholder Performance Goals .......................................................................................... 16
Stakeholder Group for the Study ......................................................................................... 18
Role of Stakeholder Group of Focus ................................................................................... 19
Purpose of the Project and Questions .................................................................................. 19
Methodological Framework ................................................................................................ 20
List of Acronyms ................................................................................................................. 20
Organization of the Project .................................................................................................. 21
CHAPTER TWO: REVIEW OF THE LITERATURE ........................................................... 23
Unique and Accelerated Contributing Factors for Special Operations Forces (SOF) ......... 23
Challenges to Preventing Veteran Suicide and Measuring Effectiveness ........................... 24
Deriving Best Practices from Past Success ......................................................................... 27
Explanation of the Clark an Estes Framework .................................................................... 29
Stakeholder Knowledge, Motivation and Organizational Influences .................................. 30
Conceptual Framework: The Interaction of Stakeholders’ Knowledge and Motivation and
The Organizational Context ................................................................................................ 52
Summary .............................................................................................................................. 56
CHAPTER THREE: METHODS ............................................................................................ 58
Methodological Approach and Rationale ............................................................................ 59
Participating Stakeholders ................................................................................................... 62
Mitigating the Risk of Veteran Suicide 7
Ethics ................................................................................................................................... 75
Limitations and Delimitations ............................................................................................. 77
CHAPTER FOUR: FINDINGS .............................................................................................. 79
Overview and Participating Stakeholders ........................................................................... 79
Findings ............................................................................................................................... 83
Themes .............................................................................................................................. 117
Summary ............................................................................................................................ 118
CHAPTER FIVE: RECOMMENDATIONS ........................................................................ 121
Recommendations for Practice to Address KMO Influencers .......................................... 122
Evaluating Recommendations ........................................................................................... 132
Implementation and Evaluation Plan ................................................................................. 133
Limitations ......................................................................................................................... 146
Strengths and Weaknesses of This Approach ................................................................... 149
Recommendations for Future Research ............................................................................. 151
Conclusion ......................................................................................................................... 153
References ............................................................................................................................. 155
Appendix A - KMO Influences and Research Questions Matrix .......................................... 164
Appendix B - KMO Influence and Instrument Protocol ....................................................... 167
Appendix C - Interview Protocol .......................................................................................... 168
Appendix D - Research Questions and Applicable Instruments ........................................... 172
Appendix E - Interview Questions and Corresponding Research Questions ........................ 173
Appendix F - Observation Instrument ................................................................................... 176
Appendix G - Document Analysis Instrument ...................................................................... 177
Appendix H - List of Relevant Terms Specific to Findings .................................................. 178
Appendix I - NVivo Word Cloud Created Derived from Interview ...................................... 179

Mitigating the Risk of Veteran Suicide 8
Table of Figures
Figure 1. Four pillars of the POTFF. ...................................................................................... 12
Figure 2. Expectancy value. .................................................................................................... 41
Figure 3. Conceptual framework. ........................................................................................... 54
Figure 4. Multi-method sources. ............................................................................................. 62
Figure 5. Data collection, analysis, and timeline. ................................................................... 69
Figure 6. Credibility and trustworthiness triangulation. ......................................................... 74

Mitigating the Risk of Veteran Suicide 9
CHAPTER ONE: INTRODUCTION

Introduction of the Problem of Practice
In the current era of two continuing wars, the Center for Disease Control and
Prevention (2016) has noted that over 20 veterans a day commit suicide. Historically, the
suicide rate of veterans who served in Vietnam was less than the general population;
however, the current Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF)
veteran population has reversed this trend (Kang and Bullman, 2010). This reversal could be
due in part to the current all-volunteer force, which makes up less than 1% of the general
population (Gilreath, Wrabel, Sullivan, Capp, Roziner, Benbenishty, & Astor, 2016). The
small population of service members means more deployments by fewer individuals as
compared to Vietnam when 9% of the population was employed in military service at some
point during that conflict (Gilreath et al., 2016). Although this factor is listed as one of many
reasons why historical rates are trending upwards, it affirms a rising suicide trend is present
across the military.
Organizational Context and Mission

United States Special Operations Command (USSOCOM) is one of nine Combatant
Commands (COCOM) within the United States Military. The mission of USSOCOM is “the
planning of Special Operations and provides Special Operations Forces to support persistent,
networked and distributed Global Combatant Command operations in order to protect and
advance our Nation’s interests” (USSOCOM, 2017). Headquartered at MacDill Air Force
Base, Florida, USSOCOM maintains a worldwide presence. USSOCOM is composed of
nearly 70,000 personnel with an average age of 34 for officers and 29 for enlisted personnel
(Feickert, 2017). The Commander’s priorities include a focus on ensuring the wellbeing of
his personnel and their families (USSOCOM, 2017). Thus, during Operation Enduring
Mitigating the Risk of Veteran Suicide 10
Freedom (OEF), USSOCOM unveiled the Preservation of the Force and Family (POTFF)
program.
POTFF has a stated mission to “identify and implement innovative, valuable solutions
across the USSOCOM Enterprise aimed at improving the short and long-term well-being of
our Special Operations Forces (SOF) warriors and their families” (USSOCOM, 2017).
POTFF representatives are comprised of both civilians and military members, including
medical personnel and counselors. A persistent state of conflict, beginning with OEF in 2001
and continuing to present day, has resulted in a fraying force (McCraven, 2012). SOCOM
established POTFF seeking to improve SOF resiliency of warriors and their families and
combat the negative implications associated with combat. Furthermore, the POTFF initiative
seeks to remove stigmas attached to physical, spiritual, social, and behavioral help and
encourage USSOCOM members to seek help for issues such as alcoholism, addiction,
depression, anxiety, and PTSD (Chaby, 2013).
Organizational Goal
The Preservation of the Force and Family Initiative maintains a goal to preserve the
short term and long-term well-being of its Special Operations Forces (USSOCOM, 2017).
The initiative was derived from the original 2012 study, directed by then USSOCOM
Commander Admiral Olsen, which found the force was being frayed and noted an increase in
suicides (Lefebvre, 2017). As a result, key SOF leaders and government officials noted the
cause for concern (JSOU, 2016). In 2014, then USSOCOM Commander Admiral William
McRaven observed, “There is a lot of angst. There's a lot of pressure out there. My soldiers
have been fighting now for 12, 13 years in hard combat. Hard combat” (McRaven, 2014).
Thus, the initiative sought to counter this pressure by increasing resilience among the
command’s members. The program targets four pillars of well-being: spiritual, physical,
social, and psychological (USSOCOM, 2013). The four pillars and their contributions to
Mitigating the Risk of Veteran Suicide 11
resiliency are demonstrated in Figure 1. One of the most pertinent targets to address is the
number of suicides, which falls under the pillar of physiological well-being.

Mitigating the Risk of Veteran Suicide 12

Figure 1. Four pillars of the POTFF.
The POTFF initiative supports a line of effort to lower the incidents of suicides
among its members. Lowering the number of suicide incidents towards pre-OEF/OIF surge
rates, given the influx of assistance provided by measures such as the Preservation of the
Force and Family, is a goal that could be pursued and measured. Evaluation of the POTFF
could aid in determining the effects of intervention measures into the fraying effects upon the
SOF community and suicides within the community. Evaluation based on implementation of
resiliency measures compared to incidents of suicide or the suicide rate per year provide
metrics to assess intervention measures implemented by USSOCOM. Through evaluation,
Mitigating the Risk of Veteran Suicide 13
determinations can be made as to if programs such as POTFF are succeeding, lacking, or in
need of further resources.
Therefore, evaluation of suicide prevention resiliency measures implementation and
potential needs analysis could aid future decision makers and serve as a reference point for
the military enterprise and civilian professionals to utilize in achieving success in lowering
suicide rates among all veterans. Without evaluation of intervention measures, successes,
failures, and needs assessments, effectiveness of current programs promoting well-being and
combating suicide prevention could remain potentially ambiguous, with a continued outcome
of over 20 veteran suicides per day.
Related Literature
Veterans pose unique contributing factors that can contribute to suicide. Multiple
deployments are one factor present in instances of veteran suicide (Cerel et al, 2015).
Veterans are often exposed to unique stressors or combat experiences that can leave them
more susceptible to suicidal behaviors or ideations (Bryan et al, 2015). Negative emotions as
a result of combat experiences also contribute to the potential pool of unique stressors
experienced by veterans and contributing to negative emotions and potential suicides
(Ramirez & Andreu, 2006). Not only are these topics perhaps most prevalent among
USSOCOM personnel, which will be discussed in Chapter 2, they are evident and elevated in
the current era of two wars. Veterans of OIF and OEF are nearly twice as likely to commit
suicide compared to non-veterans within the country (Kang, 2010). This elevated suicide
rate among the veteran population is a problem that needs to be addressed and further
studied.
As noted by Ganz and Sher (2013), evidence highlights that some psychosocial
characteristics as well as key contributor characteristics, such as combat related Post-
Mitigating the Risk of Veteran Suicide 14
Traumatic Stress Disorder (PTSD) and injuries, tend to be unique to veterans and put them at
a higher risk for suicide. Lambert (1997) reported that a suicide risk factor ratio of 1.9 to 1
could be found among VA patients as compared to the general US population. Nine separate
studies in recent years have demonstrated that when comparing veterans to non-veterans,
both men and women experience a higher risk for suicide (Chapman, 2014). Even more
concerning, specific explanations for the increased instances of veteran suicide have yet to be
identified or understood (Sher and Yehuda, 2011). This problem is important because, as
Sher and Yehuda (2011) note, a persistent state of war and continued increase in the number
of discharged veterans with higher suicide risks will only continue to grow.
Importance of the Evaluation
There are a variety of avenues available to address the increased rate of veteran
suicide. Future research is needed to continue to focus on improving suicide prevention and
at-risk diagnosis. Flagging possible at-risk personnel through key indicators, such as access
to firearms, alcohol abuse, and psychosocial disorders, continues to progress (Mills, Huber,
Watts, & Bagian, 2011). Methods in reducing common errors, such as failing to identify
suicidal potential and treating non-suicide cases as suicides, need improvement (Diggory,
1969). The wars in the Middle East and Asia continue with no future end in sight. Thus, the
number of veterans needing care and vigilance to prevent suicide losses will continue to grow
as identified by Sher and Yehuda (2011). Innovative initiatives, better diagnosis methods,
best practices, levels of care, tracking systems within the VA system, and vigilance with
respect to identifying at risk individuals is needed to slow the growing rate of veteran suicide
from its current rate. Without changes, the consequences will not only be further loss of life
but also a loss of military effectiveness due to attrition.
Mitigating the Risk of Veteran Suicide 15
It is important to evaluate the organization’s performance in relationship to the goal
of 100% implementation of suicide prevention resiliency measures for three primary reasons.
First, as literature in chapter two will discuss, there is a need for new and innovative
programs and research to assist in lowering veteran suicide across the population (Bongar et
al, 2017). The POTFF provides an example of one such program, with evaluation serving as
feedback and benchmarks for peer programs to observe. Additionally, evaluation of the
POTFF and implementation of resiliency measures will provide key data as USSOCOM
continues to leverage the POTFF in preserving the long-term health and well-being of its
force. Lastly, evaluation of organizational performance provides key formative data as the
POTFF continues to grow and change to meet the long-term needs and health and wellbeing
of the force.
Description of Stakeholder Groups
POTFF has a mission to preserve the short term and long-term well-being of Special
Operations Forces (USSOCOM, 2017). USSOCOM directly benefits from the wellbeing of
its members as it is beholden to the department of defense to man, train, and equip combat
ready Special Operations Forces. Furthermore, USSOCOM maintains a responsibility for the
health, morale, and welfare of its members. Occurrences of suicide present challenges to the
morale, health, and welfare of the organization and limit the total number of members at
hand to provide to combatant commanders in times of conflict. Thus, suicide erodes
USSOCOM’s mission.
As the parent organization to POTFF, Headquarters USSOCOM POTFF oversees
implementation and monitoring of the POTFF initiative for USSOCOM. Charged with
maintaining the short and long-term health and wellness of USSOCOM members, the
Director oversees POTFF organizational members, administrative requirements, research,
Mitigating the Risk of Veteran Suicide 16
tracking, and administration. Suicide among the USSOCOM population signals deficiencies
or improvements to be made among POTFF teams by the Director and his staff. This
responsibility is delegated down to the POTFF Directors and their teams at the individual
Theater Special Operations Commands (TSOCs). The POTFF TSOC teams are accountable
for POTFF program performance up to the Commander at each of their units.
The TSOC Commander (or director) is entrusted with a responsibility to maintain the
morale, health, and welfare as well as a positive unit climate for members under their
respective command and to provide combat ready forces. Suicide amongst unit members
directly challenges the morale, health, and welfare of the unit. Furthermore, suicide
decreases the total number of combat ready forces available during conflict. As a direct
challenge to the unit’s responsibilities, commanders are stakeholders in the effort to combat
veteran suicide.
Theater Special Operations Command (TSOC) personnel represent both a stakeholder
and the population of focus with respect to the POTFF. The TSOC is a subset of USSOCOM
with a geographic area of responsibility based of differing regions of the world. Personnel are
entrusted to both perform the mission while simultaneously ensuring the long-term health
and well-being of themselves and their peers. Often personnel are charged with performing
the role of “battle-buddy” or “wingman,” terms meant to articulate the responsibility to look
out for the well-being of peers on and off duty and to monitor for signs of distress or
problematic situations. As both the target population and, often times, the first line of defense
in preventing suicide and promoting resiliency, TSOC personnel are a key stakeholder in
suicide prevention and resiliency implementation measures.
Stakeholder Performance Goals
Each stakeholder in this study has a performance goal and implied task related to
suicide prevention resiliency. Table 1 demonstrates the respective stakeholder goals from the
Mitigating the Risk of Veteran Suicide 17
USSOCOM POTFF down to the TSOC POTFF, TSOC Directors, and TSOC personnel.
Each of the TSOC stakeholder’s goals enable the overall organizational mission of
identifying and implementing valuable solutions across the enterprise to improve the short-
and long-term well-being of USSOCOM personnel and families. The specific goal with
respect to this study and suicide prevention resiliency measures is noted as the organizational
performance goal. The performance goal can best be evaluated with a focused evaluation on
the pertinent stakeholders discussed in the following section.

Mitigating the Risk of Veteran Suicide 18
Table 1

Organizational Mission, Global Goal and Stakeholder Performance Goals
Organizational Mission
Identify and implement innovative, valuable solutions across the USSOCOM Enterprise aimed at
improving the short and long-term well-being of our SOF warriors and their families
Organizational Performance Goal
By 4th quarter 2018, 100% of the TSOC POTFF team will implement suicide prevention resiliency
measures.
TSOC POTFF TSOC Directors TSOC Personnel
By 4th quarter 2018, 100% of the
TSOC POTFF team will
implement suicide prevention
resiliency measures.

Within 30 days of arrival, TSOC
supervisors will brief 100% of
incoming members on suicide
prevention and resources and
experience zero suicide incidents
by 4
th
Quarter 2018
Within 30 days of
individual’s arrival, TSOC
personnel section will make
contact and brief 100% of
incoming members on
program and services
available and experience
zero suicide incidents by 4
th

Quarter 2018

Stakeholder Group for the Study
While many of the stakeholders mentioned above contribute toward lowering the
incidents of suicide and ensuring long term health and well-being of TSOC personnel, it
would be impractical to cover all stakeholders in this study. The TSOC POTFF team had, at
the time of this study, achieved its first fully manned functional staff. Therefore, this study
focused specifically on the TSOC POTFF team as well as personnel. Specifically, this study
provided an initial evaluation of POTFF efforts towards achieving 100% of its team members
implementing suicide prevention resiliency measures. Furthermore, the Department of
Defense Suicide Prevention Office (DDSPO) tracks suicides quarterly and annually,
providing benchmarks and milestones with which to measure performance against. Thus, the
goal established for the TSOCC POTFF team can be measured against empirical data
quarterly and annually. The success of achieving this goal aids the global goal within
USSOCOM of reducing suicide and ensuring the short and long-term health and well-being
Mitigating the Risk of Veteran Suicide 19
of its members. Failure to meet these goals could result in perpetuation of the veteran suicide
rate of over 20 deaths per day.
Role of Stakeholder Group of Focus
The POTFF emerged as a result of the degradation of United States Special
Operations Forces during a time of two wars. Sustained increases in both deployments and
casualties led to a strain on the force (Bongar et al., 2017). The POTFF was implemented to
create a holistic program that would lead to increased resiliency and reverse the trend of
degradation among USSOCOM members. In a testimony to congress, former USSOCOM
Commander Admiral William McRaven identified the POTFF as the number one priority as
personnel are the most important USSOCOM resource (McRaven, 2010). Recently, the
current USSOCOM Commander highlighted to congress support and funding for POTFF
continues as does the priority to invest in personnel resiliency and well-being (Thomas,
2017). Currently, the POTFF continues its ongoing mission of bolstering resiliency through
physical, mental, spiritual, and social performance. With staff members consisting of
Medical Doctors, Physical Therapists, Psychiatrists, Peer Networks Coordinators, and
Chaplains, POTFF staffs pursue a holistic perspective in bolstering physical, mental,
spiritual, and social performance among their populations of special operations forces
(Lefebvre, 2017). Further discussion of the POTFF responsibilities and performance will be
discussed with respect to the KMO framework.
Purpose of the Project and Questions
The purpose of this project is to evaluate the degree to which POTFF is meeting its
goal. The analysis will focus on knowledge, motivation, and organizational influences
related to achieving the organizational goals. As such, the following questions will guide this
study:

Mitigating the Risk of Veteran Suicide 20
1. What is the stakeholder knowledge and motivation related to implementing suicide
prevention resiliency measures?
2. What is the interaction between organizational culture and context and stakeholder
knowledge and motivation?
3. What are the recommendations for organizational practice in the areas of knowledge,
motivation, and organizational resources?
Methodological Framework
This study will use a qualitative, exploratory case study methodological framework.
Interviews will be conducted with the population of the POTFF team and operations
directorate of an overseas deployed TSOC unit. The study and interview methodology
worked in conjunction with the conceptual framework and the Clark and Estes (2008)
framework. An initial recruitment effort narrowed the population, and subsequent interviews
addressed the commonalities of gaps noted in the literature review. Lastly, the methodology
explored the K, M, and O performance gaps and influencers described in the literature review
as well as the common gaps identified in SOF suicide and POTFF specific literature.
List of Acronyms
This following list contains key acronyms contained within the organization and of
specific note for understanding the narrative of this study.
COCOM: Combatant Command
DDSPO: Department of Defense Suicide Prevention Office
FRG: Family Readiness Group
KMO: Knowledge, Motivation, and Organization
HPP: Human Performance Program
IPR: In-Progress Review
LOE: Line of Effort
Mitigating the Risk of Veteran Suicide 21
OEF: Operation Enduring Freedom
OIF: Operation Iraqi Freedom
OCO: Overseas Contingency Operations
OPT: Operational Planning Team
POAM: Plan of Action and Milestones
POTFF: Preservation of the Force and Family
PPP: Psychological Performance Program
PTSD: Post Traumatic Stress Disorder
SITREP: Situational Report
SOF: Special Operations Forces
TMT: Task Management Tool
TSOC: Theater Special Operations Command
USAF: United States Air Force
USA: United States Army
USMC: United States Marine Corps
USN: United States Navy
USSOCOM: United States Special Operations Command
Organization of the Project
This five-chapter dissertation addresses the problem of increased suicide rate in
veterans versus the general population in the United States. Specifically, it focuses on a
stakeholder within the problem, USSOCOM, with narrowed focus on the POTFF efforts to
combat suicide among USSOCOM personnel, already discussed in Chapter One. Chapter
Two discusses literature on suicide, suicide prevention trends, the POTFF, and the KMO
model. Chapter Three provides a description of the knowledge, motivation, and
organizational aspects surrounding the study and the methodology with respect to
Mitigating the Risk of Veteran Suicide 22
instruments, participants, and study design. Chapter Four discusses resultant data and
analysis. Lastly, Chapter Five provides recommendations and solutions based upon both data
and noted literature. Solutions address closing discovered performance gaps and
recommendations for improvement or sustainment highlighted for future evaluations and
solutions.

Mitigating the Risk of Veteran Suicide 23
CHAPTER TWO: REVIEW OF THE LITERATURE
Examined in this chapter are organizational influences in preventing veteran suicide.
The review first focuses on literature identifying common challenges to interventions and
measures of effectiveness in suicide prevention programs. The review then shifts to examine
previously successful programs and best practices. Third, the review will examine the
POTFF as a key stakeholder as well as agreements and differences contained in the literature
regarding POTFF practices and accountability measures. Finally, the review will focus on
the Clark and Estes 2008 gap analysis model specifically identifying what knowledge,
motivation, and organizational influencers are present in the problem of practice. For
contrast, peer suicide prevention programs from the Army, Air Force, Navy, and Marine
Corps will also be compared in this section.
Unique and Accelerated Contributing Factors for Special Operations Forces (SOF)
The unique nature of SOF and their mission has created problems since the beginning
of 2001 that lead to significant contributing factors for suicide. Lefebvre (2017) discussed the
higher operations tempo that is a cultural norm among the SOF community combined with
short, no-notice deployments around the world as contributing factors unique to the SOF
community. The time and space displacement presents its own challenges to both SOF and
SOF support forces. As Lefebvre (2017) described, challenges such as austere operating
locations in remote parts of the world prevent SOF personnel from easily seeking psycho-
social support.
Other aspects of the SOF community exacerbate the problems associated with
multiple deployments and time and space displacement and pose challenges to suicide
intervention. Bongar et al., (2014) discuss that SOF face a unique set of mental health
challenges. SOF often find themselves in high stress environments for prolonged periods of
time. As a result, these individuals spend less time at home with their family and friend
Mitigating the Risk of Veteran Suicide 24
support network (Bongar et al., 2014). Rogers et al., (2017) also noted prolonged exposure
to combat makes veteran deployers more susceptible to suicidal thoughts. Furthermore,
extended time away from home raises the instances of psychosocial disorders such as PTSD
(MacGregor et al., 2012). The sustained operations tempo of SOF forces appears to be a new
norm. In an address to Congress, the current USSOCOM Commander noted that while SOF
was once a contingency only force, the utilization of SOF on today’s battlefield has become a
standard expectation (Thomas, 2017). As a result of this increased need for forward presence
of SOF, the force has grown upwards of 75%. However, USSOCOM still strives to recruit
members displaying above average resiliency capabilities (Thomas, 2017). Thus, Thomas
(2017) highlights the POTFF as a continued command priority. Ultimately, factors unique to
SOF pose their own problems with respect to contributing to prevention of suicide,
suggesting the necessity of the POTFF for this population. However, the POTFF program
also faces existing challenges that will be further discussed in the next sections.
Challenges to Preventing Veteran Suicide and Measuring Effectiveness
It is difficult to assess the effectiveness of suicide prevention measures and programs.
A fundamental problem with determining best practices in suicide prevention, as highlighted
by Ramchand et al. (2011), lies in the difficulty in assessing program effectiveness at
achieving its intended goal. Effective assessment of POTFF is challenged by a lack of SOF-
specific research, the youthfulness of the POTFF program, and lack of SOF participation in
studies. Measuring effectiveness requires both further data and time to determine whether a
program is succeeding or failing (Bongar et al., 2014).
The POTFF program has been in existence for less than ten years. In the realm of
veteran suicide, a lack of data and paucity present their own challenges to programs
attempting to determine effectiveness (Ramchand et al., 2014). Bongar et al. (2014) noted
that future data collection methods pertaining to veteran suicide must be done in a series of
Mitigating the Risk of Veteran Suicide 25
more varied ways. Specifically, POTFF programs face the challenge of its sub-programs not
being fully utilized or realized, creating a gap in effectiveness determination (Bongar, 2014).
Ramchand (2014) noted that due to a lack of resources available to study veteran suicide
there is less veteran-specific research conducted and thus less data available. Finally,
Ramchand (2011) highlighted that a need exists for a strategy that creates more research
opportunities, identifies areas in need, and makes recommendations for future efforts and
research due to a lack of current data. Thus, there is common agreement in literature that
assessing effectiveness requires more time, research, and data in order to measure
effectiveness of intervention programs.
A common theme found across the limited amount of literature available for the
POTFF program is a lack of SOF-specific research. Levfebvre (2017) discussed this need for
more complete research within the special operations community. He identified the research
needs to include not just SOF but SOF families as well to create a complete picture of the
challenges faced within the community. The need to incorporate SOF families in this
research is notable as the average SOF member is married with two children (USSOCOM,
2017). Furthermore, as of 2017, only two of three of the POTFF Wave Data assessments
have been analyzed and published (Lefebvre, 2017). Lefebvre (2017) asserted that more
formative research is needed as well as a thorough assessment of the POTFF program’s
development as it moves forward. Research in SOF resiliency also demonstrates a need for
expansion (Bongar et al., 2017). Although much of the literature suggests there is a need for
suicide data and analysis for all veterans (Lambert at al., 1997), data for SOF and the POTFF
is extremely limited as a subset of the military and veteran community (Bongar et al, 2017).
In the instance of the POTFF, available research sits in the single digits with respect to
community generated research and studies.
Mitigating the Risk of Veteran Suicide 26
Disagreements within available literature on which contributing factors to address,
confounding variables, and determining which variables to measure when researching
veteran suicide present challenges. Disagreements in the hierarchy or selection of suicide
risk factors and warning signs leads to a lack of clarity of what should be addressed and
targeted (Ramchand et al., 2011). Furthermore, some risk factors cannot always be readily
observed. Ramchand et al. (2011) identified a few examples of these factors as ideations or
attempts versus instances of completed suicide. They further highlighted that disagreements
exist among literature in whether to treat ideations, attempts, and completions as one
category or multiple distinct categories (Ramchand et al., 2011). Lastly, they noted that the
variations in categories and what constitutes measurable data poses a further challenge to the
limits of available research.
The different branches of the military have focused on divergent contributing factors
to suicide as a result of the different available metrics with which to measure suicide risk.
The focus on different factors in turn complicates attempts to measure the effectiveness of
interventions. As noted in the War Within (Ramchand et al., 2014), the Navy and Marine
Corps rely primarily on gatekeepers to identify the most at-risk personnel while the Army
and Air Force rely on either expansive or investigative procedures, respectively. They also
noted that among the branches variations exist with respect to the overall degree in which
personal information or disclosure of medical information is protected, from no policy to
limited privileges (Ramchand et al., 2014). Additionally, Ramchand et al. (2014) noted the
branches vary on emphasis items, including emotional well-being (Army), stress reduction
(Navy), reducing penalties for seeking mental health care (Air Force), and training
gatekeepers to predict and prevent suicide (Marine Corps). Ultimately, literature suggests the
need to look at actual suicides, suicide attempts, suicide ideations, or some combination of
Mitigating the Risk of Veteran Suicide 27
the three as distinct. As a result, the different branches focus on different factors creating a
lack of agreement on both metrics to track and interventions to put in place.
Deriving Best Practices from Past Success
Historically, there have been suicide prevention programs within the military that
were successful. Prior to the beginning of OEF and the persistent state of war that has
existed for the military since 2001, literature demonstrates the branches of the military
achieved success in suicide intervention programs, lowering increasing suicide rates, and
creating organizational change. These achievements suggest that over time the POTFF has
the same opportunity to succeed.
Though literature demonstrates a commonality among a group of best practices and
although the military branches differ in specific order, depth, and specificity of intervention
measures, commonalities can be found also in the POTFF. Increased alcohol or drug usage is
a common warning sign (Diggory, 2014; Lambert, 1997; Sher & Yehuda, 2011).
Psychosocial disorders, such as PTSD and depression, are commonly agreed upon as risk
factors for veterans (Cerel et al, 2015; Chaby, 2013; Sher & Yehuda, 2011). Vietnam era
literature as well as current literature highlight that multiple deployments are a key
contributor to suicide (Cerel et al, 2014; Mills, 2011; Rogers et al., 2017; Diggory, 1969).
Literature presents physical commonalities presenting risk factors exemplified by poor
physical health, sexual assault, or combat injury (Ganz & Sher, 2013; Kimmerling et al.,
2016; Blosnich & Bossarte, 2013). Other commonly agreed upon potentialities for suicide
risks are negative feelings of self-blame, shame, survivor guilt, perceived incorrect combat
decisions, grief, and poor reintegration following combat (Rogers et al, 2017; Ganz and Sher,
2013; Cerel et al., 2017). Everyday occurrences such as financial difficulty, relationships,
and divorce are common contributors as noted by multiple authors (Kaplan et al, 2010;
Rogers et al.; 2017). Thus, whereas literature does note conflicts in best practices, literature
Mitigating the Risk of Veteran Suicide 28
also identifies multiple commonalities in suicide risk factors that can be used as screening
criteria for the at-risk population.
Sentell et al. (1997) highlighted that the USAF, USN, USA, and USMC suicide
prevention programs had seen suicide rates below that of the civilian population at points in
the past. Sentell et al. (1997) further focused on the Army as its prevention efforts saw
success in suicide reduction through education, training, targeting of supervisory officers,
and identification of at-risk groups. Knox et al. (2003) used the Air Force as an example of
successful suicide intervention measures when it achieved a 33% reduction rate in suicide in
1997. Knox (2007) noted that by using a multi layered program, the USAF was able to
increase help seeking behavior, reduce fear of stigma, and lower suicide rates. Of specific
note to this dissertation and the KMO model, Knox (2007) emphasized that the Air Force
program educated its population on mental health and changed social norms with respect to
help seeking.
Literature consistently notes commonly agreed upon risk factors, red flags, and means
of identification for potential suicides among veterans. Additionally, literature identifies best
practices that can be implemented by each of the four branches of the military as well as
SOCOM. As Ramchand et al. (2014) noted, best practices include screening, protective, and
prevention measures. They further discussed the need for a strategic implementation plan to
lower the cost of suicide intervention measures in order to preserve more funds to help the at-
need population. Lastly, Ramchand et al. (2014) also posed micro level recommendations,
such as restricting at-risk members’ access to firearms. In addition to limiting access to
firearms, Kirsch (2014) suggested taking the step of identifying other means of suicide
available and also limiting access to those means. Kirsch (2014) noted that reducing means
are important but should be combined with recommendations for outreach programs. Lastly,
Mitigating the Risk of Veteran Suicide 29
Kirsch (2014) emphasized the importance of strategic implementation of preventative
strategies.
In a study prior to the 2014 study, Ramchand et al. (2011) emphasized the need to
promote self-care. Concurrently, they emphasized the need to then provide access to quality
care. Both examples noted by Ramchand et al. (2011) were incumbent on the need to identify
the most at-risk populations or individuals. They further re-iterate the importance that all
aspects of suicide, including ideations, attempts, and completions, must be responded to by
intervention programs. This importance is specified by Ganz and Sherl (2013), who stated
that no matter what the level of suicidal possibility, anyone who expresses suicidal possibility
should either be encouraged or required to undergo preventative treatment or hospitalization.
In summary, while there are differing opinions on what constitutes higher risk factors
or higher risk populations as well as treatment, literature also notes areas of agreement.
Reducing means of suicide, identifying at risk populations and individuals, as well as the
need for strategies, guidance, and more data and research can be agreed on. Still needed are
central research nodes, closure in the amount of missing and incomplete veteran suicide
related data, effectiveness determinations, and further agreement upon variables, definitions,
and identification of at-risk populations or individuals. In regard to these considerations,
Clark and Estes’s gap analysis (2014) provides a framework with which to further evaluate
literature and veteran suicide.
Explanation of the Clark an Estes Framework
The Clark and Estes (2008) gap analysis framework is a useful reference in analyzing
organizational performance gaps. The model identifies gaps experienced by stakeholders
within an organization and posits that gaps can be grouped into knowledge, motivational, or
organizational (KMO) factors. This study will use a modified framework, focusing on
influencers related to the problem of practice as opposed to gaps. Clark and Estes (2008)
Mitigating the Risk of Veteran Suicide 30
note that identifying stakeholders is a critical first step in their framework. Influences on
stakeholders can then be broken into KMO factors. While knowledge can be broken into
declarative, conceptual, procedural, and metacognitive (Krathwohl, 2002) categories, it will
be clustered around declarative and procedural. Motivational factors can be described as an
individual’s motivation or lack thereof to complete a task. Finally, organizational factors can
be described as lack of processes or resources to perform a task. Each one of these factors
will be applied to specific stakeholders identified within the TSOC as described below.
The K, M, and O factors identified in Clark and Estes (2008) gap analysis will be
described in the following pages as they affect the stakeholders within the TSOC in reaching
the goal of 100% implementation of suicide resiliency measures. The first section will
discuss assumed stakeholder influences with respect to knowledge, particularly declarative
and procedural knowledge. The second section will then examine assumed influences on the
stakeholder’s performance based upon the context of motivation, and the third and final set
of assumed influences discussed will examine organizational factors. All three of the
previously mentioned sections will discuss KMO indicators, influences, and assessments.
The chapter will conclude and be followed with the influences examined through
methodology in Chapter 3.
Stakeholder Knowledge, Motivation and Organizational Influences
Three large areas for focus with respect to understanding human behavior,
performance, and problem solving can be found in the exploration of knowledge, motivation,
and organization (KMO; Clark& Estes, 2008). Knowledge explains the how or the what,
whereas motivation provides the focuses on getting started, keeping movement, and
expending the appropriate amount of effort needed to accomplish goals or tasks (Clark &
Estes, 2008). Lastly, organization focuses on characteristics such as resources available,
policies, organizational culture, and organizational context. Knowledge, motivation, and
Mitigating the Risk of Veteran Suicide 31
organization factors will be discussed in this section along with specific influences and
implications for each impacting stakeholder goals.
Knowledge and Skills
Knowledge can be categorized into four types when evaluating performance gaps:
factual, conceptual, procedural, and metacognitive (Krathwohl, 2002). Factual knowledge in
the case of this study is represented by knowledge of terms, definitions, elements, or facts
associated with the problem (Krathwohl, 2002). Conceptual knowledge can be defined as the
skills needed by members related to theories, models, complex relationships, associations, or
interactions among different pieces of factual data (Krathwohl, 2002). Procedural knowledge
is the “how to” knowledge to perform tasks or responsibilities, relying on skill sets, methods,
procedures, tactics, or techniques (Krathwohl, 2002). Additionally, procedural knowledge
also requires the ability to apply appropriate procedures or methods based upon criteria
presented (Krathwohl, 2002). The last of the four knowledge types is metacognitive; the
ability to reflect upon one’s own cognition or awareness of individual’s own cognitive
abilities, which in the case of this study could specifically pertain to application of
contextually appropriate and contextual knowledge (Krathwohl, 2011).
Knowledge and skills can directly affect engagement, personal performance, team
performance, and success in achieving goals (Grossman & Salas, 2011). The following
sections will provide an overview of literature addressing knowledge related influences,
specifically related to the global and stakeholder goal of lowering veteran suicide.
Knowledge influences play a critical role in achievement of reducing veteran suicide as
literature identifies there are still solutions yet to be fully identified and future challenges are
still anticipated (Ramchand et al., 2011). In the presence of unknown solutions and
unanticipated future challenges requiring novel solutions, knowledge and skills are
paramount (Clark and Estes, 2008).
Mitigating the Risk of Veteran Suicide 32
It is important to identify the knowledge and skills needed as they provide a
framework for identifying the knowledge gaps that prevent stakeholders from achieving their
goals. Moreover, study of an organization can identify knowledge influences present or
missing towards achieving specific goals (Clark & Estes, 2006). Specifically, two
knowledge types are identified here for discussion: declarative and procedural. Declarative
knowledge provides specific points of factual knowledge, such as definitions or specific
facts, whereas conceptual knowledge combines multiple pieces of knowledge or theory
(Krathwohl, 2002). On the other hand, procedural knowledge provides process or procedure
and methodology, or the “how” to accomplish a task (Krathwohl, 2002).
Declarative knowledge is important in lowering veteran suicide. As Lefebvre (2017)
noted, not only is a lack of data available, a lack of agreement on common terms surrounding
suicide is also a challenge. Veteran suicide also poses a need for procedural knowledge as
the current level of clarity on risk factors, contributors, and predictors challenge prevention
procedures (Ramchand et al., 2011). Knowledge influences identified through literature
during this study will be further categorized by type later in this section, which is important
because different types of knowledge gaps require different methods of solutions (Clark &
Estes 2008).
Declarative knowledge and effectiveness of POTFF. Knowledge of best practices
in combating veteran suicide is reliant upon knowledge of which methods are effective and
which are ineffective. Identifying best practices in combating veteran suicide is difficult for a
variety of reasons. These reasons range from measuring differing programs’ effectiveness to
an adequate amount of available data and research as well as finding consensus on the largest
suicide risk factors. Specifically, data from SOF related suicide continues to be a desired
item for increased suicide prevention effectiveness (Lefebvre, 2017). Determining which
risk factors or warning signs for prediction need higher levels of focus is an ever-present item
Mitigating the Risk of Veteran Suicide 33
for further pursuit of knowledge (Ramchand et al., 2016). Additionally, most literature
reviewed for SOF specific suicide, which directly concerns POTFF teams, continues to voice
a need for measures that can assess a specific program’s level of effectiveness (Bongar et al.,
2017). Levels of effectiveness, available data, and identification and/or categorization of risk
factors or barriers to care, when combined, present conceptual knowledge. The acquisition,
combination, and understanding of this knowledge is necessary for determining best practices
for POTFF teams in pursuit of the global goal of reducing veteran suicide (Bongar et al.,
2017; Lefebvre, 2017).
Literature identifies that community-wide there is a need for access to more SOF
specific suicide data (Lefebvre, 2017). This data can directly impact assessment for how
POTFF teams measure effectiveness and best practices. Towards this effort, Lefebvre (2017)
noted that effectiveness and more complete personnel profile data is needed. He further
noted that access to data can be even more challenging due to lack of published SOF specific
suicide data, particularly before 2007 when tracking began. Ramchand et al., (2014) also
noted that measuring effectiveness can be difficult as a result of challenges in acquiring data
or data paucity. Ramchand (2014) noted the need for centralized data management and
research for reference and study within the DoD, which would aid POTFF teams. However,
as previously identified, SOF specific data is not published regularly and access to POTFF
data waves is currently limited (Lefebvre, 2017; Ramchand 2011). Challenges to data also
include inconsistencies and difficulty in tracking completed suicide or attempts versus
suicide ideation (Ramchand, 2011). Ultimately, each of the items noted from literature
identify data and research points needed for knowledge influences. This knowledge can be
used conceptually towards work on best practices, effectiveness, and contributions towards
POTFF team’s learning and success, as well as specifically towards the goal of lowering
veteran suicide.
Mitigating the Risk of Veteran Suicide 34
As previously noted, declarative knowledge of best practices in combating veteran
suicide is reliant upon identifying which methods are effective and which are not.
Particularly of interest to POTFF teams would be the knowledge of the effectiveness of the
relatively new program and its wealth of resource in preventing suicide among its own
population (Ramchand, 2011). Continued effectiveness or ineffectiveness could be gleaned
from USSOCOM wave data (Lefebvre, 2017). As previously noted by Bongar et al. (2017),
data on effectiveness is lacking. Additionally, time poses a challenge to measuring
effectiveness in suicide prevention measures (Ramchand, 2011), which is of concern for
POTFF teams as they have only been in existence within the last 10 years. Furthermore,
allowing members time on task with respect to problem solving is a component for achieving
goals (Yough & Andermann, 2006). This notion challenges the specific goal of reducing
suicide in some cases, which will be discussed more in depth in the section on goal
orientation theory.
Whereas there are examples of evidenced based effectiveness of specific treatments
for suicide contributors, such as PTSD (Eftekari, 2017), specific evidenced based literature
on POTFF effectiveness has yet to be formally published. As a result, the addition of specific
knowledge of POTFF programs’ effectiveness represents a knowledge influence of note.
With every intervention there is a need for determining effectiveness (Lefebvre, 2017). At
the current rate of 16% feedback to POTFF needs assessment surveys among the USSOCOM
population; POTFF effectiveness is undetermined (Bongar et al., 2017). However,
complicating effectiveness determination further is knowledge agreement upon what are the
largest and specific challenges to address (Lefebvre, 2017; Ramchand, 2014, Bongar et al.,
2017).
In summary, progress towards levels of effectiveness and best practices can be
difficult to determine as agreement or standardization on risk factors and barriers to care
Mitigating the Risk of Veteran Suicide 35
remain a challenge (Ramchand, 2014). A prime example of specific knowledge terms, such
as what criteria constitutes stigma (Ramchand, 2011), represent a challenge in even the most
basic of knowledge; factual knowledge. Further examples of challenges to basic knowledge
can be found in literature. Two such examples are simple agreement upon the largest risk
factors as well as term definitions that continue to lack expert agreement and standardization
(Lefebvre, 2017; Ramchand, 2014). Procedural knowledge, which will be discussed in the
following section, compliments knowledge influences with respect to performance and
stakeholder goals in reducing instances of suicide.
Procedural Knowledge. Procedural knowledge is a key influencer in suicide
prevention resiliency. POTFF needs to assess personnel knowledge of help seeking and
reporting processes, persistent barriers to care, and what risk factors exist within
organization. Procedural knowledge is needed due to a lack of clarity on risk factors, and
contributors present challenges to prevention procedures (Ramchand et al., 2011).
Identifying potentially suicidal personnel is difficult and often fails (Diggory, 1969). Thus,
knowledge of contributing factors to suicide and procedures for identifying factors is
incumbent for POTFF teams. Common indicators that can be linked to potential suicide, such
as financial difficulties, mental health disorders, and substance abuse, require procedures be
in place to properly identify at-risk individuals (Kaplan et al., 2012). Ramchand (2011)
noted two procedures or methodologies used to predict possible suicide are promoting
awareness and screening. However, current screening procedures used in the military pose
challenges due to perceived negative impacts to career by members as well as a fear of
stigma (Lefebvre, 2017; USAF 2003).
Currently, POTFF teams work to reduce stigma associated with seeking help (Chaby,
2013). However, procedural challenges still exist as current procedures in treating mental
health disorders and suicide potentials can result in loss of career potential, suspension of
Mitigating the Risk of Veteran Suicide 36
security clearances, or disqualification of duty status (Ramchand, 2011). Thus, it becomes
incumbent upon POTFF teams to practice or develop procedures that can identify and avoid
barriers to care, avoid stigma, identify and diagnose potential risk factors leading to suicide,
and encourage use of the POTFF resources (Bongar et al., 2017). Furthermore, the same
literature notes a procedure to determine effectiveness is a need for implementation. This
development and adherence to procedural standard, combined with the needed knowledge
factors listed above, will help address the goals noted in Figure 2.
Figure 2 identifies the SOCOM POTFF mission, the global goal, and stakeholder
goals. Additionally, Figure 2 provides examples of factual, conceptual, and procedural goals.
Specifically, Figure 2 identifies the two knowledge influences mentioned previously in this
section. Similarly, motivational influences will be discussed in the same manner in the next
section.

Mitigating the Risk of Veteran Suicide 37
Table 2
Knowledge Influences
Organizational Mission
Identify and implement innovative, valuable solutions across the USSOCOM
Enterprise aimed at improving the short and long-term well-being of our SOF warriors
and their families.
Organizational Global Goal
By 2020, the USSOCOM will reduce suicide rates for personnel to zero from the
present rate overall rate of more than one per day.
Stakeholder Goal
By 4th quarter 2018, 100% of the TSOC POTFF team will implement suicide
prevention resiliency measures.

Knowledge Influence Knowledge Type Assessment Procedures Used
POTFF needs to know
the effectiveness of
suicide prevention
measures and best
practices for suicide
prevention
Declarative Interview, Document
Analysis, Observations
POTFF needs to assess
personnel knowledge of
help seeking and
reporting process,
persistent barriers to
care and what risk
factors exist within
organization

Declarative and
Procedural
Interview, Document
Analysis, Observations

Motivation
As with knowledge, motivation plays an integral piece in gap analysis and
performance problems with respect to problems of practice. According to Clark and Estes
(2008) motivation can be quantified as the active choice to begin a task, maintain persistence
in the task or goal, and apply the appropriate amount of dedication or effort as needed.
POTFF teams can be evaluated with respect to motivation in assessing the active decision to
address veteran suicide, persistence in efforts to prevent suicide, and a desire to solve the
problem (Eccles et al., 1983; Kaplan, 2007; Pajares, 2006; Rachmand, 2014; USAF; 2001).
Mitigating the Risk of Veteran Suicide 38
Whereas there is a wealth of literature on motivational factors, this section will specifically
focus on self-efficacy, expectancy value, and attribution. This section also discusses goal
orientation theory as the study makes numerous references to organizational goals. As
applied to the global goal of reducing veteran suicide and localized POTFF team’s efforts to
increase resiliency, efficacy and goals can be assessed both at the POTFF team level as well
as the individual unit personnel level.
Self-Efficacy. When analyzing POTFF team’s effectiveness or potential gaps in
performance with respect to lowering the rate of suicide, self-efficacy is a useful motivational
influence for evaluation. Self-efficacy is described as the personal belief that one can
succeed in accomplishing a task or goal (Pajares, 2006). Furthermore, it is critical
individuals are made to understand that they can succeed in a task or goal (Pajares, 2006).
According to Clark and Estes (2008) motivation is critical because it plays a crucial role in
closing performance gaps in problems of practice. Higher levels of self-efficacy can result in
success whereas lower levels of self-efficacy can result in lack of active choice, or failure to
even begin a task (Pintrich, 2003).
Those who have self-efficacy will tend to master a task (Yough et al., 2006). Self-
efficacy theory is the belief that one can experience success or is capable of performing a
task or achieving a specific outcome (Pintrich, 2003). Self-efficacy is important in
preventing suicide as it can provide and encourage both individual and collective social
responsibility (Pintrich, 2003). Literature on self-efficacy in suicide demonstrates that the
military has in fact believed that it can succeed in successfully completing the task of
lowering veteran suicide (USAF, 2001). In the late nineties the United States Air Force
(USAF, 2001) noted a rise in suicides, demonstrated active choice in addressing the issue,
and achieved 33% reduction in suicides among its members (Goldney, 2008).
Mitigating the Risk of Veteran Suicide 39
However, given the persistent state of war that began shortly thereafter in 2001 with
OEF, challenges to self-efficacy arose with the DOD’s inability to prevent the beginning rise
in veteran suicides. With the rise of contributing factors as a result of war, such as
psychosocial conditions, substance use disorders, and numerous deployments, literature
began to identify both increased rates of suicide and a military population with a risk of
suicide higher than the general population (Kang & Bullman, 2010). As Bongar (2017)
noted, little effort has been put forward to address key suicide contributors like mental health
as opposed to great investments made in physical health. Failure in preventing increased
suicides over the past 16 years poses a challenging long-term effort and persistent problem,
negatively impacting self-efficacy among the military population.
POTFF teams need to possess the influences of self-efficacy, such as support and
feedback, to reduce the level of suicides (Pajares, 2006). Additionally, continual feedback
contributes towards demonstrating progress in learning and improvement (Pajares, 2006;
Brogogni et al., 2011). In the case of the POTFF, learning and improvement can equip teams
to increase long term effort and performance towards their goal. Ultimately, as Anderman
and Anderman (2006) note, efficacy has an impact on all individuals and can increase
performance and, with respect to POTFF teams, aid in lowering suicides. However, a lack of
self-efficacy has been a key contributor to rising suicides among veterans as well. Members
in the POTFF team should want to decrease suicide and provide an environment that
empowers others to lower it as well with the addition expectancy value (Eccles, 2006),
attribution (Schunk, 2012), and goal orientation theory (Yough, 2006).
Expectancy-Value. Expectancy value theory evaluates individuals’ desire to
accomplish a task and confidence that they can accomplish the task in relation to the amount
of effort expended (Eccles, 2006). Value can be defined as how much the stakeholder
prioritizes or apportions importance to a task (Green, 2002). Expectancy can be defined as a
Mitigating the Risk of Veteran Suicide 40
stakeholder’s belief in their ability to succeed in a task (Wigfield & Eccles, 2000). Thus,
expectancy value must be thought of with both the expected outcome of success (expectancy)
and the associated worth of the outcome (value) as an interconnected relationship (Eccles,
2006). Figure 2 depicts the relationship between efficacy and desire and demonstrates
expectancy value, which is further discussed in the following paragraphs.

Mitigating the Risk of Veteran Suicide 41

Figure 2. Expectancy value.
The question of both desire and ability to accomplish a task are a critical motivation
influencer in the ability for the POTFF and unit personnel to accomplish goals. A key
influencer, the POTFF need to feel it is important to implement suicide prevention resiliency
measures. According to Wigfield et al. (2006), a belief that an individual can succeed in
accomplishing a task, as well as the value they place on the task and its successful
completion, can lead to both task accomplishment and ability to take on more challenges.
Furthermore, belief is a strong predictor of success (Eccles, 2006). Thus, the belief that
POTFF members and personnel can accomplish the organizational goal can be a predictor of
accomplishing future suicide prevention resiliency goals.
The desire to actually engage on a task is equally important to expectancy value and
motivation. Choosing to engage on a particular task can be affected by variables such as
interest, consistency with the organization’s identity, and how the goal and short-term reward
can lead to long-term success (Eccles, 2006). Engagement is also dependent upon an
Mitigating the Risk of Veteran Suicide 42
individual’s perceptions of how goal achievement can aid in their long-term plans (Eccles,
2006). Furthermore, personal interest in how engagement can affect personal interest is of
note as well (Eccles, 2006). Another aspect of engagement is empowerment. Eccles (2006)
noted that empowering individuals and acknowledging the value their specific effort brings
towards success and accomplishment also leads to engagement. This level of engagement,
combined with the belief the task can be accomplished, directly addresses a person’s need to
feel it's important to implement suicide prevention resiliency measures.
Equally important to desire for task completion is the utility that completion will
provide. Stakeholders must believe that solving a problem is important, and perceived utility
aids in the importance of a task. According to Eccles and Wigfield (2002), utility provides a
degree of usefulness or value to a task. Furthermore, if completion of a task or goal provides
a path to future success or future goals it can lead to increased motivation (Eccles and
Wigfield, 2002). The combination of an expected successful performance and value of the
resultant outcome play a key role in motivation (Greene, 2002). Ultimately, a POTFF team
could increase motivation if it were able to both create the expectancy of success in
implementing suicide measures and create a value for the outcomes associated with lower
instances of suicide.
Attribution. Attribution theory highlights individual’s assignment of causes to
conclusions and outcomes (Schunk, 2012). Poor attribution can lead to multiple failures
(Schunk, 2012). Furthermore, repeated failures with perceived attributable causes can lead
individuals of the organization to a belief they will fail or be unable to achieve a goal
(Anderman & Anderman, 2006). Additionally, false attributions can be spread across the
organizations’ members leading to inaccurate perceptions of failure or inability to succeed
(Anderman & Anderman, 2006). The negative attributions that can be associated with suicide
can also prevent progress in combating suicide. As Anderman and Anderman (2009) discuss,
Mitigating the Risk of Veteran Suicide 43
attributions focused on failure can be a result of effort, not necessarily ability. The presence
of the above attributions, among others, as well as a failure in preventing increased suicides
over the past 16 years poses a challenging long-term effort and persistent problem, negatively
impacting self-efficacy among the military population. Thus, it is notable that members must
not feel they are unable to accomplish a task or failure will thus become a distinct possibility.
POTFF members and unit personnel must be able to know their attempts to improve
suicide prevention resiliency can succeed, thus they need positive attributions. Attribution
theory can be important to the POTFF and unit personnel with respect to assigning cause to
the possible outcome of achieving organizational goals. Positive attributions are those aspects
that members can to assign to a task they succeed in (Schunk, 2012). Members of an
organization can attribute efforts to goals and positively foster efficacy, and attainment value,
ultimately contributing to success. Furthermore, individuals can teach or be taught the
process of assigning positive attributions that can lead to sustained positive effects on
individual’s engagement and performance towards success (Anderman & Anderman, 2006).
Thus, individuals need to feel that their own efforts can influence suicide prevention
resiliency.
Goal Orientation. Goal Orientation theory is a critical aspect in the POTFF’s
implementation of suicide resiliency measures. Although not specifically in the conceptual
framework, goal orientation understanding is necessary for discussion and understanding
pertaining to organizational goals and the goal of 100% implementation of suicide prevention
resiliency measures. Specific goals have been found to encourage performance (Dembo &
Eaton, 2000). Goal orientation theory is described as a theory which examines achievement
motivation, both ‘performance’ goal orientation and ‘mastery’ goal orientation (Pintrich,
2003). Performance goal orientation can be described as demonstrating a perception of
Mitigating the Risk of Veteran Suicide 44
progress or success while mastery can be described as furthering learning and understanding
(Pintrich, 2003).
With respect to performance goal orientation, Bongar et al. (2017) note the POTFF is
clearly presenting performance achievement characteristics with its numerous studies,
publications, and lines of funding. However, the same article notes that suicides continue to
persist in the SOF community, posing challenges to the notion that the POTFF has yet to
fully pursue or achieve mastery in the goal of reducing suicides among its population.
Goldney (2008) notes in the past, goals and defined objectives have led to suicide reductions
in national programs. As exemplified in the previous section, the USAF demonstrated this
notion with its 33% reduction in suicides in the late 90s (Goldney, 2008). As a historical
example, the USAF (2001) identified that all representatives in the community needed to be
involved in not only the effort but the result as well. However, the continued elevated rate of
suicide among the USSOCOM population and limited number of individuals familiar with
the POTFF, as well as numerous suggestions in literature that the POTFF has yet to identify
how to determine its effectiveness, demonstrate a lack of mastery and clearly defined goals
with the appropriate level of effort in their pursuit (Bongar et al., 2017; Lefebvre, 2017;
Ramchand 2011; Ramchand, 2014).
Table 3 demonstrates the USSOCOM POTFF organizational mission, derived global
goals, and motivational influences. Specifically, it identifies two examples of motivational
influences as they relate to stakeholder goals. The first motivational influence is self-efficacy
with respect to belief in the ability to lower instances of suicide and to achieve 100%
implementation of suicide prevention resiliency measures. The second influence is
expectancy-value, with respect to the need for personnel to feel it is important to implement
suicide prevention resiliency measures. Lastly, the motivational theory of attributions is
identified as personnel must feel their own efforts can influence suicide prevention.
Mitigating the Risk of Veteran Suicide 45
Table 3
Motivational Influences
Organizational Mission
Identify and implement innovative, valuable solutions across the USSOCOM Enterprise
aimed at improving the short and long-term well-being of our SOF warriors and their
families
Organizational Global Goal
By 4th quarter 2018, 100% of the TSOC POTFF team will implement suicide prevention
resiliency measures.

Stakeholder Goal
By 4th quarter 2018, 100% of the TSOC POTFF team will implement suicide prevention
resiliency measures.

Motivational Indicator(s)
This study will not have motivational indicators as it is an evaluation study

Assumed Motivation Influences

Motivational Influence Assessment

Self-Efficacy- POTFF members need to feel
confident in their ability to implement suicide
resiliency measures.

Interview
Expectancy Value- Personnel need to feel it's
important to implement suicide prevention
resiliency measures.

Interview
Attribution- POTFF members need to feel that
their own efforts can influence suicide prevention
resiliency.

Interview

Organization
The third and final component in the Clarke and Estes (2008) KMO gap analysis
model is the “O” that designates organization. The organization itself presents numerous
factors that can both contribute to organizational performance problems as well as close gaps
in performance towards achieving an organization or global goal. Clarke and Estes (2008)
note that these organizational factors can be exemplified by a lack of resources and deficient
Mitigating the Risk of Veteran Suicide 46
(or absent) processes. As a result of these deficiencies, organizational barriers can be created
that lead to performance gaps. The following section will review organizational change
literature.
Organizational Change Theory. Organizational change and learning can drive
improvement, but change requires strength-based leadership, as both changing an
organization and leading it require a continual process (Rath 2009; Moran, 2000).
Organizational change can indicate leaders have seen the necessity for change or
stakeholders to improve, learn, or change patterns of behavior (Kezar, 2001). Organizational
change and learning are not mutually exclusive events. Leaders can embrace and facilitate
change as well as learning within organizations (Senge, 1990). Furthermore, leaders can
achieve expected results when they address the climate within their organization (Schneider,
Brief & Guzzo, 1996). Equally important to leadership in facilitating change is culture
(Berger, 2014). As changes to organizations do not happen instantaneously, cultural and
climate changes must be sustainable (Schneider, Brief & Guzzo, 1996). Each of the above
considerations can be found in the POTFF.
The POTFF exemplifies an effort by USSOCOM as an organization to both learn and
change as it has encountered the problem of increased suicide since 2001. Noted first by
Admiral Olsen (Bongar et al., 2017) in his identification of the increased rise in suicides and
direction to conduct a study to learn about the depth of the problem, the POTFF’s beginnings
demonstrate willingness by USSOCOM to lean towards change. Olsen’s predecessor further
combined organizational learning into change as evidenced by his implementation of the
POTFF program and a change in culture of help seeking behavior (McCraven, 2014). Thus,
in a time of two wars the leadership of USSOCOM demonstrated learning and change are not
Mitigating the Risk of Veteran Suicide 47
mutually exclusive events. Furthermore, they demonstrated Senge’s (1990) notion that
leaders can embrace and facilitate sustained change over time within an organization.
Cultural Settings and Models. Cultural models and settings are a critical aspect of the “O”
factor in organizational change and represent the two O influencers in this studies research
design. Cultural models can be thought of as a shared (common) understanding, visions,
rules, ideals, or mental conception on how the world works (Gallimore & Goldberg, 2001).
Additionally, cultural settings are the visible manifestations of such models that could be
exemplified by two or more individuals coming together to solve a problem, challenge, or
task (Gallimore & Goldberg, 2001). Cultural models and settings together provide insight
into organizational culture. Schein (2004) captures both the concept of cultural models and
setting in organizations as he describes underlying assumptions (invisible) and artifacts
(visible). Cultural models and settings provide distinct yet interconnected factors that can
lead to general achievement (Gallimore & Goldberg, 2001).
Both models and settings are key factors for organizational change because, with
respect to this study, they identify organizational influences such as resources, time, trust,
accountability, communication, and leadership need to be present. Cultural settings and
models that promote these influences need to be present (see Figure 3). Cultural setting
influences need to be indicative of the organization providing ongoing resources and support
for suicide prevention resiliency measures. Additionally, the organization needs to provide a
culture of trust around suicide prevention. Cultural settings need to exist with leaders
allowing time for POTFF members both the climate and resources to enable 100% of POTFF
teams to implement suicide prevention resiliency measures. Lastly, with respect to cultural
settings, the POTFF team needs leaders in the chain of command to provide opportunities to
Mitigating the Risk of Veteran Suicide 48
both measure effectiveness and determine accountability. These influences are listed in figure
1 along with posited “O” factors for potential application.
Leadership Trust, and Culture. There are many factors that can present a challenge to
organizational change. Organizational change is hindered by factors such as engagement,
silence, resistance, agreement, or lack of trust (Korsgaard et al, 2002). Specifically, trust is
critical to organizational change. As Korsgaard (2006) notes, success or failure of groups can
be attributed to trust. Leaders in particular affect organizational change through trust. Leaders
can build trust in good times as well as in challenging or difficult times by turning difficulty
into opportunity (Korsgaard, 2006). Communication, both internal and external, is both a
necessity and a challenge for leaders. Common language for common goals is also critical to
communication (Krathwohl, 2002).
Poor communication can lead to lack of trust and engagement. However, effective
communication can lead to buy in, action, and progress towards change (Berger, 2014).
Additionally, leaders must manage conflict and opposing ideas in challenging times. The
leader’s successful management of polarity as well as conflict can increase positive
engagement and performance (Alper et al., 2000; Martin, 2009). Thus, challenges to
organizational change with respect to conflict, difficult times, communication, silence,
resistance, and lack of engagement can be addressed and turned into opportunity and growth
through strong leadership and trust.
The same challenges related to the organizational process as described by the general
literature can be found specifically within the POTFF. Issues of trust in leadership are found
as a result of fear of stigma in seeking help for mental health or substance abuse issues
(Lefebvre, 2017). Silence poses a challenge to POTFF success as well with the POTFF Wave
Three Survey data only demonstrating a 17% return (POTFF, 2015). A potential help or
Mitigating the Risk of Veteran Suicide 49
hindrance to trust and action, internal and external communication can lead to both trust and
success or failure of organizational change. Polarities and lack of agreement exist in best
methods to prevent suicide, ranging from the definitions of what constitutes stigma to best
practices in prevention (Blosnich and Bossarte, 2013; Kang & Bullman, 2010; Lefebvre,
2017). However, work by Mills (2006) identifies that when working together, researchers
have identified 16 root causes to suicide that were agreed upon by a 98% rate of agreement.
Thus, there needs to be a culture of trust within the unit to utilize POTFF services as well as
efforts by leaders to manage conflict and opposing ideas to best practices in order to prevent
suicide.
Resources and Accountability. Resources and accountability presents challenges to culture
change and organizational change performance. As Dubnick (2014) notes, accountability is a
cultural keyword in important governmental change. Important factors in accountability
include evidence shown toward achieving a mission or priorities set forth by governance as
well as ensuring quality of advertised programs and services (Burke, 2004). Furthermore, as
Darling Hammond et al. (2015) note, accountability should be anchored in vision, change,
goals, and culture. Resources, a key to the “O” factor in the Clark and Estes (2008) model,
also play a key role in accountability. As Elmore (2002) identifies, organizations need to
ensure presence of resources for organizational and individual performance, development,
improvement, and change. Thus, measures of performance, or outcomes-based performance
standards can be used for both accountability and effectiveness determinations (Heinrich,
2002). Furthermore, resources, time, data, culture, and policy are organizational needs to
facilitate change (Berbarry & Malinchak, 2011; Callahan et al., 2015).
Certain aspects of accountability and resources pose challenges to the organization by
virtue of either absence or incomplete measures. Lack of accountability measures specifically
Mitigating the Risk of Veteran Suicide 50
poses a problem to POTFF. A key indicator of this lack of accountability within POTFF is
the low return returns in response to initial wave surveys conducted for the program
(Lefebvre, 2017). Ramchand et al. (2011) note that time is needed to address effectiveness of
the POTFF as effectiveness measures still prove difficult to define. Time is also needed both
for accountability and resources. Furthermore, a lack of data and paucity exist, which can
challenge determination of effectiveness and thus challenge accountability (Ramchand et al.,
2014). Lastly, a clearly delineated criterion for POTFF success also presents challenges as
accountability measures needed for determinations of success are lacking as is sufficient SOF
specific suicide research (Bongar et al, 2017). Thus, the organization could benefit from
increased resources, time, data, participation, accountability, and measures of effectiveness
with respect to POTFF initiatives.

Mitigating the Risk of Veteran Suicide 51
Table 4

Organizational Influences

Organizational Mission
Identify and implement innovative, valuable solutions across the USSOCOM Enterprise
aimed at improving the short and long-term well-being of our SOF warriors and their
families
Organizational Global Goal
By 2020, the USSOCOM will reduce suicide rates for personnel to zero
Stakeholder Goal (If Applicable)
By 4th quarter 2018, 100% of the TSOC POTFF team will implement suicide prevention
resiliency measures.

Assumed Organizational Influences

Organization Influence Assessment
The organization needs to provide ongoing
resources and support for suicide prevention
training (cultural setting influence).
Interview, Document Analysis
The organization needs to provide a culture
of trust around suicide prevention (Cultural
Model Influence)
Interview

Closing performance gaps requires attention to K, M, and O factors. This section has
discussed the factors that encompass K, M, and O influences. Literature noted the
importance of stakeholder declarative and procedural knowledge as influencers in suicide
prevention resiliency. The need for motivational influencers based upon expectancy-value,
self-efficacy, and attribution theory were also found to be key stakeholder influences. Goal
orientation theory, although a motivational factor, is critical in each aspect of the K, M, and
O factors as this paper makes mention to stakeholder goals and performances. Resources,
accountability, leadership, culture, and trust are common themes found to influence
stakeholders, and these themes were found in both general literature and POTFF focused
suicide literature. General literature highlights the important role leaders and culture play in
organizational change. Current POTFF initiatives within USSOCOM need changes to both
culture and trust in leadership to progress further. Thus, recognition and sustained attention
Mitigating the Risk of Veteran Suicide 52
and action with respect to O factors, combined with previously mentioned K and M factors,
are key factors in closing performance gaps with respect to both localized reduction of
suicide and the larger global goal of veteran suicide prevention.
Conceptual Framework: The Interaction of Stakeholders’ Knowledge and Motivation
and The Organizational Context
The overarching topic of veteran suicide has spanned centuries in the United States
and for the purpose of this study needs a more narrowed and specified focus provided by a
conceptual framework. A conceptual framework provides focus to a study by describing
general ideas and beliefs about the topic of the study (Maxwell, 2013). The theoretical
framework affects each of the aspects contained within a study, including key terms,
concepts, literature, knowns, and unknowns as they apply to the focused area of study
(Merriam & Tisdell, 2016). In the case of this study, the conceptual framework (Figure 2)
centers on the phenomena of veteran suicide prevention. The following section describes
independent K, M, and O factors and assumptions; how they interact to form the basis of the
conceptual framework; and illustrates the framework through a graphical depiction (Figure
2).
Stakeholders within an organization have K and M factors that directly contribute to
the success or failure of veteran suicide prevention. These K and M factors found in each
individual stakeholder, however independent they may be, are influenced and interdependent
when nested within and influenced upon by the organization. As an example, POTFF
stakeholders must possess knowledge of program effectiveness (Ramchand et al., 2011),
status of member training, available services, and best practices. Furthermore, POTFF
members must close motivation gaps by creating an atmosphere of positive self-efficacy
(Bongar, et al. 2017), expectancy value, positive attribution, and goal orientation directed
towards suicide prevention. This conceptual framework assumes that given these K and M
Mitigating the Risk of Veteran Suicide 53
considerations, the organization must provide resources, processes, cultural models, and
settings to ensure success. The organization must prioritize POTFF principles and services to
create a cultural context that demonstrates trust, time to provide POTFF services, training,
and accountability measures to track effectiveness. Ramchand et al., (2014) noted resources,
new lines of research, and a culture of understanding help-seeking and at-risk populations
must be present in in order to prevent suicide. Supervisors must understand what constitutes
stigma and remove stigma related to help seeking behaviors (Lefebvre 2017; Chaby, 2013;
Kaplan et al., 2012).
Tracking effectiveness is important to accountability as the POTFF is a USSOCOM
command-funded initiative. As Dubnick (2014) noted, bureaucratic accountability is a focus
and priority of those in the upper levels of the chain of command. Lastly, individuals
themselves must possess self-efficacy and embrace active-choice in help seeking (Pintrich,
2003). Thus, the K, M, and O factors within the organization are most effective when
interaction between all three occurs, as represented in Figure 3.

Mitigating the Risk of Veteran Suicide 54

Figure 3. Conceptual framework.
Figure 3 demonstrates the relationship between the TSOC, POTFF, and the
organizational goals. The figure further represents where the K, M, and O factors and
influences fall within the three:
1. The outer ring is representative of the organization, consisting of the TSOC and the
organizational factors. Cultural settings and models indicative of the organization are
present within the outer circle.
2. Nested within the organizational circle are two stakeholders - the POTFF and unit
personnel. K and M factors influence both the POTFF and unit personnel within this
inner circle.
3. The organizational goal is represented by the bottom box. The arrow from the
organization and POTFF circles represents that the interaction of both entities, and
Mitigating the Risk of Veteran Suicide 55
their respective K, M, and O factors and influences, leads towards closing
performance gaps and achieving the organizational goal.
The individual stakeholders represented by the POTFF and unit members must
contain specific K and M factors. Procedural knowledge of POTFF processes and training
are important to suicide prevention and reporting. Declarative and conceptual knowledge,
such as at-risk population identification and best practices, must be present as they are factors
in prevention (Ramchand et al., 2014; Lambert & Fowler, 1997). Motivational factors also
play an integral role in suicide prevention efforts. Self-efficacy by stakeholders is important
as it allows members to believe that the knowledge and organizational factors available can
allow them to succeed in prevention measures. Additionally, active choice contributes to
stakeholder efforts as prevention requires that specific tasks or decisions be made (Pintrich,
2003). Both the K and M factors described above are important as independent factors.
However, in this conceptual framework the K and M factors are also interdependent upon the
TSOC as an organization to which the POTFF and unit personnel belong.
The TSOC is the organization that oversees the POTFF and the unit personnel.
Within the organization are critical O factors such as resources, processes, and cultural
settings and models. Cultural settings and models are represented in the outer circle of the
framework. A cultural setting that ensures leaders prioritize POTFF principles and services
is an assumed influence. A second cultural model is the fostering of trust within the
organization to utilize POTFF services. Additionally, leadership needs to provide
opportunities to determine if accountability measures are being met. In order to determine if
accountability is being met, effectiveness measures need to be developed. The conceptual
framework assumes these cultural settings and models are necessary for achieving the
organizational goal, but they depend upon the stakeholders with their respective K and M
factors to succeed.
Mitigating the Risk of Veteran Suicide 56
All three K, M, and O factors and influencers are interdependent for success towards
the organizational goal. Without the stakeholders and their K and M influences and factors,
the organization lacks a suicide prevention mechanism. Without the organization, the
POTFF ceases to exist and the personnel are left without resources, processes, and training.
Thus, the framework asserts that all K, M, and O factors, as well as the relationship between
leadership, POTFF, and personnel, are necessary for success in lowering suicides within the
organization and 100% implementation of suicide prevention resiliency measures.
Summary
This chapter examined literature addressing organizational performance gaps
identifying challenges to suicide prevention and measures of effectiveness. Whereas general
literature noted common themes and challenges contributing to veteran suicide, SOF specific
literature further noted unique suicide factors present in USSOCOM. When compared to
organizational change literature, parallels emerged between performance gaps faced by
organizations undergoing change and those faced by USSOCOM in its effort to lower suicide
among its population.
Literature notes common factors between military suicide and SOF specific suicide.
Multiple deployments, lack of available data to determine effectiveness of prevention
measures, and the need for further research were frequently noted. Specific to SOF, the need
to identify effectiveness in the POTFF program and further time, more literature, additional
data, expanded resources, and accountability were noted as due outs. Multi-layered
programs and cultural changes, such as stigma reduction, were also noted as gaps. Various
studies suggested the need for continued organizational change to address SOF specific
suicide. Finally, literature noted that common organizational performance influencers were
evident.
Mitigating the Risk of Veteran Suicide 57
Knowledge influencers such as best practices, program effectiveness, and lack of
literature are common themes in the limited available literature. Also common were
motivation factors such as self-efficacy, expectancy value, and attributions. Lastly,
organizational factors such as accountability, building trust while reducing stigma, increased
research, and time and settings to promote POTFF practices were all commonly found
challenges. The aforementioned commonalities in research directly contribute to this study’s
design methodology.

Mitigating the Risk of Veteran Suicide 58
CHAPTER THREE: METHODS
The purpose of this case study was to conduct a qualitative evaluation of the Theater
Special Operations Command (TSOC) Preservation of the Force and Family (POTFF)
program, specifically analyzing local suicide prevention. The project goal was to examine
how the TSOC POTFF was currently addressing the problem of veteran suicide at the theater
level during a period of observation at the local headquarters by focusing on operations
personnel. At this phase of the study, suicide was defined and used with respect to
completed suicides versus attempts or ideations. The study used the Clarke and Estes (2008)
gap analysis model, examining what knowledge, motivational, and organizational (KMO)
influences were present that were either helping or hindering the organization in lowering
veteran suicide by implementing suicide prevention resiliency measures.
This study used a qualitative, exploratory case method. Interviews were conducted
with the population of the operations directorate of an overseas deployed TSOC unit. The
study and interview methodology worked in conjunction with the conceptual framework and
Clark and Estes (2008) framework. An initial questionnaire narrowed the population, and
subsequent interviews addressed the commonalities of gaps noted in the above literature
review. Lastly, the methodology explored the K, M, and O performance gaps and influencers
described in the literature review as well as the common gaps identified in SOF suicide and
POTFF specific literature.
Ultimately, the analysis generated influences and needs determined through KMO
analysis and research questions to examine the current progress towards 100%
implementation of suicide prevention resiliency measures. The following questions guided
the study:
1. To what extent is the TSOC POTFF Team meeting its goal of 100% team
implementation of suicide prevention resiliency measures?
Mitigating the Risk of Veteran Suicide 59
2. What is the stakeholder knowledge and motivation related to implementing suicide
prevention resiliency measures?
3. What is the interaction between organizational culture and context and stakeholder
knowledge and motivation?
4. What are the recommendations for organizational practice in the areas of knowledge,
motivation, and organizational resources?
Methodological Approach and Rationale
The design of this study took into account both the Clarke and Estes (2008) gap
analysis model and a qualitative model as described by Creswell (2017). The approach used
in this study was a qualitative exploratory case study. Creswell (2017) described qualitative
methods as unique and diverse in design, drawing on natural setting, multiple data sources,
and the use of the researcher as the instrument. The natural setting was provided by the
overseas deployed environment. Multiple sources (see Figure 3) were used by implementing
a multi-method design consisting of interviews, observation, and document analysis (see
Appendix A through G). Data was collected in two phases; document analysis followed by
observation and interviews. The data collected in the first phase included, but was not
limited to, congressional testimony, publicly available USSOCOM suicide statistics, data on
in-place programs, emerging programs, benefits, opportunities, budgets, and accountability
and training requirements. The data gathered served as one aspect of triangulation followed
by interviews, and observation.
The qualitative exploratory design is appropriate for this study for a few reasons.
Assuming each method—interviews, observations, and document analysis—has strengths
and weaknesses, the combination of the three allowed data from one to inform the other
methods (Creswell, 2014). Furthermore, as related to the research questions, the combination
of the three methods, data, and exploratory nature of the design can aid in informing why
Mitigating the Risk of Veteran Suicide 60
KMO gaps might exist when the data shows opposing trends in success or failure.
Additionally, the explanatory nature of qualitative data that follows up the document and
artifacts analysis provide interpretation (Creswell, 2017) that can aid in the current limitation
of research, as noted by Lefebvre (2017). Lastly, as an evaluation study focusing on gap
analysis, the question of “what is going on” can be best informed by the exploratory nature
and multiple methods employed in the study (McEwan & McEwan, 2003).
Need for diverse research, as noted in the literature review, contributes to the
rationale for the methods in this study. Weiss (2004) described qualitative as useful for
uncovering deep, rich data. Data in the realm of veteran suicide is highlighted by literature in
Chapter Two as lacking. Also noted as lacking, multiple methods of data and research. The
multi-method design for gathering data provides three separate methods to address this
study’s research questions. This is particularly important as the combination of the methods
sought to increase trustworthiness and reliability as well as mitigate researcher bias. Specific
detail on observations, interviews, and document analysis is provided in the following
sections as well as in depth description of reliability and trustworthiness.
The first phase of the design used observation, document review, and publicly
available historical wave data as quantitative data. The data was used to identify trends
across the POTFF populations and used to compare to the larger populations, both
USSOCOM and the broader US military. An advantage to this design was it helped inform
current cultural trends occurring during the time of the study (Creswell, 2017). Furthermore,
it provided a basis for current locations of potential gaps in the K, M, or O (or a combination
of the three) as it relates to gap analysis. The findings then informed and shaped the
sequence of interviews and questions in the second phase.
In phase two, interviews, informed by results from phase one, guided the evaluation
study in exploration and triangulation. Specific interview questions, reflexively shaped from
Mitigating the Risk of Veteran Suicide 61
previously derived observations and document analysis, guided the second phase of the
study. As it is advantageous to encouraging openness for the participants, a semi-structured,
open-ended interview was used (Merriam & Tisdell, 2016). Data highlighted current culture,
KMO gaps, accountability measures success or failures, and perceived determinations of
effectiveness. The conclusion derived from the sequential combinations will inform
discussion and recommendations as well as evaluative findings.

Mitigating the Risk of Veteran Suicide 62

Figure 4. Multi-method sources.
Participating Stakeholders
While many of the stakeholders previously mentioned contribute toward lowering the
incidents of suicide and ensuring long term health and well-being of personnel, it would have
been impractical to cover all stakeholders in this study. The TSOC POTFF team had, at the
time of this study, achieved its first fully manned functional staff. Therefore, this study
focused specifically on the TSOC POTFF team of five members, and a purposefully selected
small group of 15 of the operations personnel for initial evaluation of POTFF efforts towards
achieving 100% team implementation of suicide prevention resiliency measures. The five-
person POTFF team members were each used as participants as they represent the respective
four pillars and director role, and they are a representative population of the dozens of
Mitigating the Risk of Veteran Suicide 63
POTFF teams throughout USSOCOM. The five individuals were selected from the Physical,
Spiritual, Human, and Mental performance roles as well as the Director role.
In addition, a small, purposeful sample of the personnel population serviced by the
POTFF were included. These individuals resided in the Operations Directorate and are
representative of the thousands of operators within the larger global population of
USSOCOM operations personnel. The purposeful selection of Operations Directorate
personnel yielded information rich data from the population, which will be further discussed.
The sampling methods and specific criteria for the selected stakeholders is listed in detail in
the following sections.
Interview Sampling Criteria and Rationale
Criterion 1. POTFF/Operations Directorate Personnel. POTFF/Operations
personnel best represent the population within the problem of practice, general literature, and
conceptual framework.
Criterion 2. Ten years of experience including multiple overseas deployment. Ten
years in service identifies personnel typical of the average SOF operator as described by
USSOCOM (USSOCOM, 2017).
Criterion 3. Multiple deployments inclusive of experience in OEF and/or OIF. This
criterion identifies members who fit into the population described in the problem of practice
and at-risk personnel as described in the literature review.
Criterion 4. Permanently assigned military personnel. Controlling for temporary
duty (TDY) personnel or augmented staff not permanently assigned to the TSOC will control
for personnel outside the population of note in the problem of practice as they are not
available for prolonged availability or in-processing training by POTFF personnel.
Mitigating the Risk of Veteran Suicide 64
The interviews for this study used three criteria with the following specific rationale
to glean results rich in substance. First, personnel were purposefully selected from the
POTFF/operations directorate and informed on from the survey for specific criterion. The
benefits of a purposeful sample allow for specific criteria as noted above, and, as Creswell
(2014) notes, will identify individuals who best aid in understanding the problem of practice
as well as the research questions. Both general literature and SOF specific literature
identified unique factors inherent in the SOF community. Thus, the criterion targeted
personnel with SOF operations background, experience in OEF and OIF, and currently
overseas deployed to conflict status.
Explanation for Choices
The choices in this section describe the selection of interviews, observations, and
document analysis for sampling purposes. Recruitment identified and selected members with
a SOF operations directorate background and overseas deployed history inclusive of OIF or
OEF experience with a minimum of ten years of service. The use of individuals selected as a
result of the recruitment criterion, informed the interview process. Specific criterion
provided a purposely selected population to be sampled from for interviews. Interviews can
be useful for extracting knowledge, meaning, motivation, and feelings on a topic (Johnson,
2015). The interview used provided data points related to these four facets with respect to
the problem of practice and POTFF program. Of importance, as noted by Maxwell (2013),
both interviewer and interviewee will have the appropriate background to inform research
questions and the stated problem of practice.
Interviews
Fifteen interviews informed this study. The individuals were purposefully selected
as this method allows the researcher the best possibility of addressing the research questions
Mitigating the Risk of Veteran Suicide 65
and problem (Creswell, 2014). Although Creswell (2014) noted there is no specific ideal
number of interviews, 15 can approach the limit of saturation given the relatively small size
of both the unit and TSOC POTFF staff numbering seventy overall. The specific interviews
used can be found in Appendix A. Members were interviewed once, but as noted in the
credibility and trustworthiness section of this study, a follow up was used to secure for
member checking.
Interviews were semi-structured and took place outside of the workplace as much as
possible to prevent distraction or influence of interview answers. All interviews to the
maximum extent possible were conducted in individual’s homes or other location preferred
by the interviewee, such as via video teleconference or phone. Interviews were not audio
recorded and transcribed to the maximum extent possible (Creswell, 2014). The semi-
structured format of the interviews allowed the interviewer to determine the best sequence of
questions and use of probes based of the direction and atmosphere of the interview (Creswell,
2014). The semi-structured format was combined with open ended questions in the interview
protocol found in Appendix A. Use of open-ended questions allows for depth and richness in
qualitative interviews (Weiss, 1994). Each of the interview questions asked corresponded to
one or more of the four research questions and the noted KMO influencers in this study as
annotated in Appendix C.
Observations
A minimum of two observation periods, including at least five specific observation
activities informed this study: unit in-processing and follow-on POTFF sponsored activities
within the unit. The observations occurred preferably before the interview process. This
sequential approach enabled clarification of observations during interviews when necessary,
which Merriam and Tisdell (2016) noted as an advantage for triangulation. The two
observation periods enabled the study to observe both stated values of the organization
Mitigating the Risk of Veteran Suicide 66
during the first period, and what is demonstrated during the second. This two-phase
construct used aspects of Schien’s (2004) model with respect to artifacts versus values.
According to Schien (2004), artifacts can represent external representations of intentions
versus values which can represent deeper cultural beliefs or nature. Thus, during
observation, the researcher can both study what is advertised to the population versus what is
provided or used.
During theater in-processing, unit members receive their initial introduction to the
POTFF. The POTFF provide unit personnel an overview of the unit culture and context, as
well as opportunities, benefits, resources, and services available to members during the
duration of their tour. Expected duration of each monthly iteration was approximately one
day. Actual length of both monthly iterations observed matched anticipated one day length.
The researcher was in the observer as participant role (Creswell, 2014). Creswell (2014)
described the advantageous nature of this role as conducive to the researcher recording
observations as they occur. Notes were taken by hand and synthesized for later triangulation.
General information, knowledge, culture and context, and resources available informed the
four research questions.
The second observation activity and follow-on activities were subsequent POTFF
sponsored unit activities. Focus was given on attempting to attend more activities led by
separate POTFF pillars (one physical event, one peer network coordinator event, one spiritual
event, etc.). These activities were, but were not limited to, morale building functions,
physical therapist sessions, Chaplain lunches, group physical fitness events, family readiness
group meetings, and/or POTFF sponsored team-building activities. Observed instruction,
distribution of information, and other general knowledge passed on during events exemplify
instances that informed knowledge influencers. Instances of time allotted, resources
provided, and participant numbers were noted. Each one of these activities, with the
Mitigating the Risk of Veteran Suicide 67
exception of morale building events, were approximately one hour in duration. In this case,
the researcher acted in the role of what Creswell (2014) described as a complete participant,
which provides the researcher the benefit of firsthand experience. Where possible, notes
were taken during the activity, but when the activity precluded note taking during the event,
post observation notes were annotated. All observations of pillar specific activities were
documented, themed, and maintained for triangulation. The study anticipated that
observations would inform KMO influences through observables noted by Merriam and
Tisdell (2016) to include: context, setting, behavior, resources and space provided, observed
artifacts, activities, interactions, communication, and interaction, to name a few. All
observations were noted and documented in the observation worksheet (Appendix D) and
assigned to respective KMO categories to inform the study. As with the previously noted in-
processing observations, results from these observed activities aligned with the conceptual
framework by providing insight into culture, context, knowledge, and motivation.
Documents and Artifacts
This study utilized publicly available documents such as, operational instructions
(OIs), operations directives, web-based organizational sites, local newsletters, journal
articles, publications, advertisements, research, job postings, and congressional documents.
Of note, no documents or artifacts that are characterized as ‘For Official Use Only” were
used or studied for consideration. Reviewed documents that contributed the majority of
significance to analysis and findings were identified as the weekly and monthly unit specific
articles published by POTFF members and specific Operating Instructions.
Documents and artifacts play an important part in study, providing insights not found
in interviews or observations. Merriam and Tisdell (2016) described documents and artifacts
as a kind of physical manifestation of culture. Creswell (2014) noted that documents provide
the words or the language of the organization or participants. Documents and artifacts both
Mitigating the Risk of Veteran Suicide 68
played a key role in triangulation and sequencing of interview questions. Furthermore,
documents and artifacts demonstrate what Kotter (2012) described as a visible component of
organizational culture. The studied documents and artifacts provided insight into aspects of
motivation, declarative, procedural, and metacognitive knowledge, as well as insights into
culture and context. Lastly, documents were combined with interviews and observations for
triangulation.

Mitigating the Risk of Veteran Suicide 69

Figure 5. Data collection, analysis, and timeline.
Phases of Analysis and Corresponding Actions
A phase-based analysis process was used in this study. There were three phases,
numbering one through three. During phase one, in-progress coding, initial codes were
concluded after each interview, observation, or document analysis activity. Initial a priori
codes were input into NVivo via a codebook matrix and were sorted into either a K, M, or O
node. Completion of interviews, observations, and document analysis signaled the start of
phase two. Phase two included further refinement of codes into respective sub themes. An
example would be moving a code from the motivation node to the expectancy-value sub-
node. The conclusion of phase two was signaled by the end of associating codes to the
findings outline, creating the structure for Chapter Four and restarting the coding process for
a second iteration. The third and final phase was a second iteration of coding. The second
round of coding examined data for emerging themes or missed themes not included in the
first iteration of coding and framework for findings. Themes deemed important but not
Document Analysis
4 months
• Occurred throughout
• Able to inform or clarify
observations and interviews
• Articles, Operating
Instructions, Publications, and
Congressional Testimony
• Longest in length
Observations
3 Months
• 5 Periods of observation
• Cultural Setting/Models
• Provide insight/staging for
interview process
• Intermediate in length
Interviews
2 Months
• 15 personnel
• Clarify observations
• Compare espoused values to
underlying assumptions
• Focused in Length
Feedback/Inform
Feedback/Inform
Concept
Framework
And
Literature
Review
Analysis
and
Findings
Mitigating the Risk of Veteran Suicide 70
aligned or as significant to this study’s conceptual framework design were noted for
inclusion as potential suggestions for further research.
Use of Codebook
The codebook referenced in the previous section included a priori codes and sub
codes, or themes. Initially codes were stored in a word matrix labeled by study activity
(observation, interview, and document analysis) and then further broken into themes before
uploading into NVivo. The majority of effort was spent on coding within the word document
and moving to NVivo as the final step since NVivo was both a means of storage and
organization for findings analysis and Chapter Four drafting. A word document provided a
back-up, including observer notes, had the NVivo files become corrupted. A codebook
exemplar is included in Appendix J.
Accounting for Typicality
Typicality was mitigated through multiple methods. First, each analysis and writing
session was conducted with the use of Clarke and Estes (2008) gap analysis framework.
Definitions of what constitutes knowledge, motivation, or organization were matched against
themes before themes were further sub-coded. Other aspects of typicality, such as the author
sorting based off what they think is typical, were mitigated through member checking as well
as close coordination with the dissertation advisor, peer review, and inquiry instructors.
Lastly, the use of triangulation quickly highlighted if one of the three methods did not appear
congruent to the other two descriptions, posing a need for further analysis and refinement.
This process was iterative during the second coding process as well. Thus, through two full
reviews, triangulation, member checking, reference documents, and stringent coding
processes, analysis to inform Chapter Four Findings maintained categorized and
methodological approaches for themes and evidence.
Alignment with the Conceptual Framework
Mitigating the Risk of Veteran Suicide 71
The words matrix and use of NVivo nodes matched in title and in chronological order
the conceptual framework’s KMO format. The first three nodes were titled “K” with sub-
codes titled either PN or CN. The second node was titled “M” with sub codes titled either
EV, SE, or GO. The final code was titled “O” with sub-codes of CS and CM. The outline
aligned both in chronological order with the Chapter Two literature review as well as the
tables indicating the order of the influences found in Chapter One. Through adherence to
these methods, alignment was constantly monitored. Anything falling outside the noted
codes was documented and included in future research suggestions.
Codes to Findings
Multiple methods for crafting findings from codes are possible using NVivo software.
Use of a word cloud (example in Appendix I) was used in coordination with the query
function to provide a holistic visual of what was being said most often and provide the
researcher a visual representation during different periods of analysis. The themes code and
the sub themes code were evaluated for proper order and common characteristics. The sub
themes creating the most common description were turned into draft themes for findings.
The draft themes were written as the opening sentence of the section with each of the node’s
excerpts being used as a sentence or evidence. The conclusion of the individual findings was
finalized only after the paragraphs were evaluated against the research questions to determine
alignment. Once the findings paragraphs were completed, the most common themes and
their data analysis was summarized for potential attention in Chapter Five recommendations.
Summary of Data Analysis
The preceding sections described the strategy for coding, analysis, and alignment
during the data analysis phase of this study. Evaluation of the above strategies originally
determined an estimated time of completion of approximately 120 days (four months).
Given the analysis was conducted in parallel with the data collection, the early conclusion of
Mitigating the Risk of Veteran Suicide 72
data collection allowed for more time to be spent on data analysis, creating a slightly longer
data analysis period. The additional time allowed for focus restricted to only one influencer
at a time to ensure alignment with the conceptual framework. The end description of each
influencer was matched against not only the conceptual framework but also the research
questions as well. The end state desired was a format that was easily navigable, highly
uniform, and inclusive of all three influencers broken down further by sub theme and
concluding analysis. Lastly, analyzed information outside the bounds of this particular study
was not lost, as it will be suggested for future research in the concluding pages of this study
with potential data as well for future use.
Credibility, Trustworthiness, and Reflexivity
Credibility, trustworthiness, and considering reflexivity are key components of
qualitative research. Maintaining credibility closes the gap between what is observed or real
and what is written (Merriam & Tisdell, 2016). Reflexivity centers around the researchers’
relationships with members involved in the study and the shifting dynamics of the
relationships (Maxwell, 2013). All three of the ethical aspects are crucial aspects to
qualitative studies (Creswell, 2008). The following paragraphs will discuss credibility,
trustworthiness, and reflexivity as they pertain to this study.
Credibility and trustworthiness were increased by implementing several specific
strategies in this study. Implemented strategies will increase the credibility in the study. One
such strategy that was used was triangulation (see Figure 6). As described by Merriam and
Tisdell (2016), triangulation uses multiple methods to reinforce data. This study used
interviews, documents, and observations to provide three sets of qualitative data. A second
method for increasing credibility is member checking. As described by Merriam and Tisdell
(2016), member checking allows a researcher to minimize misinterpretation or
Mitigating the Risk of Veteran Suicide 73
misunderstanding by soliciting feedback from previously interviewed individuals on what the
researcher thought they understood to be true during the data gathering. Member checking
also helps combat personal bias in the researcher by allowing the researcher to confirm a
second time the intended meaning of what was seen or heard during the first iteration of data
collection. For this study, after transcription, the researcher readdressed incomplete or
questionable results to confirm respondent’s original intent. A third and final strategy is peer
review. Merriam and Tisdell (2016) noted that, like a journal article, having a peer or
individual similar in background or knowledge helps derive meaning from the gathered
research and to confirm accuracy. This study used a peer review by way of collaboration
with separate POTFF representatives from outside the POTFF organization that is the subject
of this study. Also, of importance are reflexivity and bias.

Mitigating the Risk of Veteran Suicide 74
Figure 6. Credibility and trustworthiness triangulation.
Reflexivity is a key component of consideration in the study. Reflexivity concerns
power relationship and the relationship between the researcher and the subjects (Merriam and
Tisdell, 2016). Challenges that can hinder researchers, such as being viewed as an outsider
or the perception the researcher’s power can influence the behavior of the subjects, must be
considered. For sake of this study, the researcher is a member of the organization and equal
or lesser in rank than all members interviewed. Thus, being viewed as an insider and
wielding no power to negatively affect members being interviewed minimized the
influencing of answers and behaviors. Researcher bias is also important to note. In
qualitative study, the researcher is the primary instrument (Merriam and Tisdell, 2016). The
Mitigating the Risk of Veteran Suicide 75
researcher in this case has personal bias that cannot be completely removed but can be
mitigated with acknowledgement. This study will use Maxwell’s (2013) validity checklist
items of long-term involvement, rich data, and member checking to combat bias, which will
be explored further below.
Ethics
Responsibility and ethical practice are paramount in research and critical to this
study. As Glesne (2011) noted, ethical considerations should inform questions, plans,
thought processes, and framework in research. The following section will describe ethical
considerations with respect to this study. Considerations included: informed consent,
voluntary participation, access and placement, permission, protection of data, and
confidentiality. This section will also look inward at the author’s own bias as well as his
relationship to the stakeholders.
During the study and research process, all potential risks to participants should be
mitigated (Glesne, 2011). This study aimed to mitigate or eliminate unnecessary risk to
participating members. Each member interviewed received a standardized memorandum
with informed consent considerations notated. Informed consent is critical to defining the
relationship between the researcher and the members being interviewed (Glesne, 2011). The
memorandum noted that participation is voluntary and that subjects may discontinue their
participation in the study at any time. Additionally, the memorandum re-assured the subject
of their anonymity throughout the course of the study and following its conclusion.
Furthermore, absolutely no personally identifiable data, personal medical history,
names, or personal use of POTFF services were asked for or noted as they are not pertinent to
this study. Questions were directed towards members’ knowledge, perceptions, and
qualitative considerations of the program itself. All interview notes and records were kept
secured in a lock box and members will be informed of the security status and appropriate
Mitigating the Risk of Veteran Suicide 76
destruction of notes at the conclusion of the study. Only after all of these considerations are
provided to the member will consent be reaffirmed verbally and interviews commence. The
above ethical considerations with respect to the research-researched relationship provided a
requisite duty to the research. As described by Rubin and Rubin (2012), doing no harm is an
obligation to the relationship between the interviewer and subjects of the study. Equally
important to address are considerations of transparency with respect to the researcher.
Providing transparency and identifying bias is essential to a successful study. It is
important to note that the author of this study is a member of the TSOC and resides within
and around the Operations Directorate. This status aids the author because, as Kreuger and
Casey (2009) noted, individuals need to be found that demonstrate the characteristics desired
in the study. Furthermore, it should be noted the author is a military officer, which carries a
baseline assumption of being in a position of authority. However, the rank of officer and
position within the Operations Directorate is alleviated of perceived coercion as a result of
the factors described below, particularly given the researcher is equal or junior in rank to
participants in the study.
Informed consent establishes a relationship between the parties during the interview
process (Glesne, 2011). The author fulfills the position of a Liaison Officer (LNO) outside
the command structure and neither supervises members nor influences performance reports
or future job opportunities for the participants. Furthermore, the author provided no
incentive and did not seek any higher authority within the chain of command to direct
participation in the study. These considerations will help avoid the perception of coercion.
Avoiding coercion is important because, as Glesne (2011) noted, individuals should be able
to volunteer as well as discontinue participation in the study at their will. The POTFF exists
outside the chain of the command of the Operations Directorate, and members have no direct
interest or stake in the results of the study with respect to their position or career. However,
Mitigating the Risk of Veteran Suicide 77
to reinforce there is no requirement to provide beneficial answers, verbal confirmation was
given that the author is in the researcher role, not that of superior or subordinate, and
members were reminded participation is voluntary.
Personal bias in this study is also important to note as it cannot be completely
eliminated by the author in conducting this qualitative study. This is important to note given
the author’s involvement in this study, as it is a qualitative study. As Merriam and Tisdell
(2016) noted, the researcher is the primary instrument for data collection. The author is a
member of the organization and a stakeholder within the realm of veteran suicide prevention.
As a member of USSOCOM, the author has served with military members who have
committed suicide. Although it is an assumption most members of the military serving
during OEF and OIF have served with members who have either attempted or completed
suicide, it should still be noted that the author and stakeholders interviewed have personal
bias towards veteran suicide. Although stakeholders would benefit from reduced suicide,
verbal reminders were administered that skewing of answers would provide no benefit
towards the goal of lowering instances of suicide. Lastly, although the author exhibits a high
level of contributing factors in veteran suicide (male, veteran, gun owner, and nine overseas
deployments), these characteristics should be noted but not negatively bias the data that
evaluates effectiveness, perceptions, accountability, or data gathering from other members.
Limitations and Delimitations
Limitations are the things that cannot be controlled by the researcher in a given study.
One limitation to this study could be the influence on interview answers due to the
relationship between the researcher and member being interviewed. Given the approximately
four-month window of study, context and culture could be negatively affected by deployed
geopolitical considerations outside the control of the Organization and thus unable to be
accounted for in the construct of the study. Additionally, interviews cannot account for
Mitigating the Risk of Veteran Suicide 78
variations in individual members’ articulation or perceptions (Creswell 2014). It must also
be noted that there are limitations to the researcher’s individual observation and attending
abilities (Creswell, 2014). The presence of the researcher in one on one interviews also
could present limitations as a result of contributing to bias or issues with truthfulness.
Given the previously mentioned limitations, the qualitative multi-method approach
presents opportunities for delimitations. Three different qualitative methods allowed for
triangulation, which yielded more credible data and account for issues with truthfulness
(Creswell, 2014). The 15 interview members were of equal or greater rank to the
interviewer, but the interviewer sought to limit power relationships or biased answer from
interview participants. Follow up member checking attempted to alleviate limitation issues
of individual abilities with respect to attending and articulation (Creswell, 2014). Lastly,
consideration of Maxwell’s (1992) validity checklist as well as Creswell’s (2014) advantages
and limitations in data collection were considered and then used throughout the course of the
study.

Mitigating the Risk of Veteran Suicide 79
CHAPTER FOUR: FINDINGS
Overview and Participating Stakeholders
The purpose of this project was to evaluate the degree to which POTFF is meeting its
goal of implementing suicide prevention resiliency measures. The analysis focused on
knowledge, motivation, and organizational influences related to achieving the organizational
goal. Within each of the K, M, and O categories, influencers were identified with respect to
the needs of the POTFF in implementing suicide prevention resiliency measures. As such,
the following questions guided this study:
1. What is the stakeholder knowledge and motivation related to implementing
suicide prevention resiliency measures?
2. What is the interaction between organizational culture and context and
stakeholder knowledge and motivation?
3. What are the recommendations for organizational practice in the areas of
knowledge, motivation, and organizational resources?
The further identification of influencers within each respective K, M, and O provided a
narrow focus, identifying the needed influencers that members of the POTFF, operations
personnel, and the organization must possess as they implement suicide prevention resiliency
measures. The influencers noted in Table 5 shaped the conceptual framework and
synthesized common needs necessary for resiliency as noted by the literature in Chapter
Two.
The data collection period of this study occurred during an overseas deployment
within a TSOC. Personnel involved in the study were POTFF and operations personnel. The
research method used was a multi-method exploratory qualitative study. Data collection
consisted of a literature review followed by observations, interviews, and document analysis.
The use of observations, interviews, and document analysis allowed collected data to be
Mitigating the Risk of Veteran Suicide 80
input in NVivo software for triangulation. Triangulation, as noted by Merriam and Tisdell
(2016), uses multiple methods to reinforce data and provide confirming synthesis. The use of
triangulation in the case of this study allowed for analysis of the alignment of key influencers
in suicide prevention resiliency measures as they relate to not only knowledge and
motivation but also culture and context of the organization. The following is a brief
description of how the three methods were conducted and will be further discussed during
each description of individual influencer findings.
Observations
Two types of observation were used with each being conducted in an open viewable
environment lasting approximately one hour each. The first style consisted of viewing the
initial in-processing period of 14 personnel (occurring within the first 30 days of arriving in
theater). The second style was in the environment, or presence, of each of the four different
pillars of the POTFF program (psychological, human performance, spiritual, and social). The
observations occurred in accordance with the conceptual framework with little deviation.
Due to the frequent amount of activities and observed behavior of the POTFF team moving
about the command and openly interacting with unit members in a repetitive manner, the
initial period of observations was achieved more quickly than originally anticipated.
Interviews
The interview period was characterized by interviews of both POTFF and operations
personnel. Each interview was structured to occur for approximately one hour. Interviews
were conducted outside of members’ duty locations. Given the joint (presence of multiple
armed services branches) nature of the command, the composition of the interview members
included Army, Air Force, Marine Corps, and Navy personnel as well as differing
demographics of ethnicity, gender, age, and rank. These individuals are described in the
following section as “interview participant” (IP) followed by numbering 1-15 (i.e. IP3 is the
Mitigating the Risk of Veteran Suicide 81
third participant interviewed). The intent for characterizing these individuals by
chronological order and not branch, race, or ethnicity was chosen to prevent disclosure of
identifiable characteristics of participants while at the same time maintaining the highly
experienced, joint, and diverse nature of a USSOCOM population.

Mitigating the Risk of Veteran Suicide 82
Table 5.
Overview of Interview Participants

Designator

Experience
(Years)
Previous
Deployment
Experience

Gender
IP1 20 Yes M
IP2 10 Yes M
IP3

20 Yes M
IP4 15 Yes F
IP5 15 Yes M
IP6 10 Yes M
IP7 10 Yes M
IP8 15 Yes M
IP9 10 Yes M
IP10 5 Yes M
IP11 5 Yes F
IP12 15 Yes M
IP13 10 Yes M
1P14 15 Yes F
1P15 15 Yes M

*Years of experience categorized as 5 (5-9), 10 (10-14), 15 (15-19), and 20 (20-24)
Mitigating the Risk of Veteran Suicide 83
The overt willingness to participate, level of support, and availability provided by unit
members in interviews allowed for the number of planned interviews to be conducted
without delay following the IRB approval period of this study. During the period of data
collection, the lack of anticipated delays allowed time for member checking, a follow up
period, and peer checking to be feasible as called for in the conceptual framework.
Document Analysis
The document analysis portion of the study consisted of evaluation of publicly
available or publicly searchable documents. Items used were publicly available documents
such as operational instructions (OIs), operations directives, Headquarters and local
command’s online presence and organizational sites, local newsletters, journal articles,
publications, advertisements, research, job postings, and congressional documents. In
accordance with the conceptual framework, document analysis was conducted throughout the
period of data collection but was noted to be readily available almost immediately given the
large amount and open nature of POTFF material found online and USSOCOM’s ongoing
socialization of the program.
Findings
Discussed in the following sections are findings. Three sections discuss Knowledge,
Motivation, and Organizational findings as they relate to this study and the assumed
influencers. Each of the KMO findings are further divided into sections indicating method of
inquiry: interview, observations, of document analysis. Synthesis of the individual methods
inform assertations pertaining to each influencer for further discussion in Chapter Five. A
summary table (Table 6) lists each influencer with a summary preview of assertations
derived. The section closes with common themes and interactions between the three
knowledge, motivation, and organizational based findings and summary.

Mitigating the Risk of Veteran Suicide 84
Table 6
Influencers and Summary Preview of Findings

Influencer

Summary Assertion

POTFF needs to know the effectiveness of suicide
prevention measures and best practices for suicide
prevention. (KI1)

The TSOC POTFF and personnel demonstrate a
high awareness of risk factors, predominantly
stress, and best practices for suicide prevention.

Knowledge of the effectiveness of locally
implemented measures is unclear.

POTFF needs to assess personnel knowledge of help
seeking and reporting process, persistent barriers to
care, and what risk factors exist within organization.
(KI2)
POTFF and operations personnel demonstrate a
strong knowledge of the help seeking process and
its considerations.

Knowledge of how to successfully move past
barriers to care is still undetermined.

POTFF members need to feel confident in their ability
to implement suicide resiliency measures. (MI1)

Personnel within the command possess confidence
in their ability to implement suicide prevention
resiliency measures but increased proactive
engagement could be improved.

Personnel need to feel it is important to implement
suicide prevention resiliency measures. (MI2)

Personnel in the command feel suicide prevention
resiliency is important and they can make a
positive difference in implementing suicide
prevention resiliency measures.

Some members still question the follow through of
the program.

POTFF members need to feel their own efforts can
influence suicide prevention resiliency. (MI3)
Members feel their efforts directly contribute to
suicide prevention resiliency.
The organization needs to provide ongoing resources
and support for suicide prevention training. (OI1)
The organization provides and prioritizes
resources and ongoing support, to include budget
and manpower increases, for suicide prevention
resiliency.
The organization needs to provide a culture of trust
around suicide prevention. (OI2)
A culture of trust in the command and local
commanders and supervisors is present and
provided.

Uncertainty about consequences of help seeking
behavior outside the protection of the command
persist.

Mitigating the Risk of Veteran Suicide 85
Knowledge Findings
Discussed in this section are knowledge results and findings. Presented in this section
are common themes found during analysis and assert where the themes inform the conceptual
framework and competing themes, if any, as identified in Table 7. Knowledge, according to
Clark and Estes (2008), is important because the attainment of professional expertise is
critical in attaining performance goals. As such, three knowledge influencers were
developed and aligned with the interview, document analysis, and observation protocol. The
three influencers identified conceptual and procedural knowledge needs to implementing
suicide prevention resiliency measures.
Interview questions, observations, and document analysis looked for evidence
personnel were familiar with, and instructed on, effective suicide prevention measures as
well as how to address them. Common ideas were coded as K-Interviews, K-Observations,
and K-Document analysis. Once coded to the KMO the sorted codes were then further
divided between the three knowledge influencers listed below as Knowledge Influencers 1, 2,
and 3.
Knowledge influence #1: Awareness of risk factors. Analysis of the data indicated
that the TSOC POTFF and personnel demonstrate a high awareness of risk factors,
predominantly stress, and best practices for suicide prevention; however, their knowledge of
the effectiveness of locally implemented measures is unclear. The conceptual framework
identified that POTFF needs to know the effectiveness of suicide prevention measures and
best practices for suicide prevention, noted as knowledge influencer one. Interviews,
observations, and document analysis each made contributions to determining both the
understanding of best practices among the command as well as noting the effectiveness
levels yet to be determined. Each method and information derived therein follows in the
following three paragraphs.
Mitigating the Risk of Veteran Suicide 86
Interviews. Interviews demonstrated that personnel identified risk factors to suicide
with specific focus on stress reduction as a best practice to prevent suicide. All 15 of the
interviewees could identify the pillars, personnel, and characteristics of the program. As
described by IP8, “a lot of Docs in one spot, [a] surgeon, psychologist, chaplain, and peer
coordinator, physical therapist, sometimes trainers, and some assistants.” The idea of stress
as a contributing factor was highlighted by the interviewee in 13 of the 15 interviews.
Common themes revolving around stress were highlighted as deployments, operations tempo,
and minimal personal time outside the workplace. IP11 identified that the time outside the
workplace is further complicated as “people don’t venture out” and that “they become
withdrawn and isolated.” Other items noted contributing to stress were relationships,
separations, divorces, and depression. These common themes are noted in Table 7.

Mitigating the Risk of Veteran Suicide 87
Table 7
Commonalities Among Interview Responses Pertaining to Knowledge

Knowledge of

Interviews

Observations

Document Analysis

Pillars, Personnel,
and Characteristics

Staff Specialties, name
recognition by all 15
interviewees, utilization
procedures

Staff specialties,
services available

Opportunities available, staff
specialties, upcoming events

Most commonly
Noted Risk Factors

Stress, lack of time
away from work,
OPSTEMPO

Isolation, Stress, little
time outside work

Stress, stigma, isolation,
previous deployment history,
depression
Other Common
Factors

Isolation, previous
deployments, substance
abuse, divorce,
separation
Depression, poor
physical health,
substance abuse,
deployment history
Substance abuse, regret,
anger, poor physical health,
fear of unknown and
professional impacts

Each of the commonalities noted in Table 7 were also noted in the literature review as
contributors to suicides. One individual (IP4) noted that “stress piles on until you just don’t
notice or don’t care about it anymore.” A second individual (IP3) identified that a common
best practice is to identify contributing factors to stress and solve them at a local level
highlighting “Ask what in the command is stressing people out and find ways to solve what
stresses people out, maybe even help relieve some stress at home.” IP 15 also noted a best
practice related to achieving buy in stating that “Once you get people to initially buy-in you
can tell they bought in and people who seem like they wouldn’t naturally care do now and
actually show up and participate when we have resiliency days.” When asked about dealing
with the increased levels of stress, IP1 highlighted the POTFF had recognized increasing
stress levels during a period of high operations tempo (OPSTEMPTO). IP1 described how
Mitigating the Risk of Veteran Suicide 88
they successfully endorsed and secured a 48-hour period off duty for personnel to rest and
refit, directly reducing the frequency of noticeably elevated stress levels within the
command. However, none of the other personnel interviewed were familiar with the
successful intervention, indicating that personnel might not be aware the POTFF had acted
on their behalf. In one instance, IP5 noted they assumed they only got the time off because
there was nothing to do. IP15 was aware that it was a good change but was unsure why.
Lastly, when queried about whether or not the entirety of prevention measures implemented
had been successful in stopping suicide, IP13 noted that “time will tell, but trending
positive.” This sentiment was similarly echoed by three other participants (IP 6, 8, and 14).
Observations. During the observation periods, members were required to participate
in an in-processing with each of the four POTFF members before finalizing in-processing
and prior to beginning duties. Each member of the POTFF team was observed educating
their specific pillar’s contributions to resiliency and services or opportunities available.
During OP 2, one POTFF member lectured on how family and friends can break the chain of
events that lead to suicide. Additionally, personnel were presented suicide prevention
resiliency training during a resiliency day within the command. The ranking Commander led
with the opening that “our most important resource is all of you.” POTFF personnel then
highlighted contributing factors that can be present in the surrounding operational
environment the command is located within, stress in particular. The POTFF briefed
different methods of reducing stress and preventing suicide (ASIST training as an example),
and the use of a 10-step checklist to determine potential for suicide risk. Said one member
(IP13), “the checklist was useful, I ran through the steps in my head and was like, damn, I
have seen all of those at some point.” The POTFF concluded by emphasizing that monthly
resiliency training was being implemented with each month being led by a different POTFF
Mitigating the Risk of Veteran Suicide 89
member to focus on practices within their pillars to increase resiliency and prevent suicide
risk.
Four of the five observation periods (1,2,4, and 5) specifically highlighted common
risk factors and mitigation or prevention techniques as related to suicide. Stress and isolation
were noted during OPs 1,3, and 5. OP 1 and 5 introduced members to unique stressors that
could be encountered in their new theater of operations (stressors unique to the region and
job). Considerations for unique stressors are of particular note as Bongar et al., (2014)
highlight that SOF often face unique stressors. Stress negatively impacting the fight or flight
response was of critical nature in theater as noted by a POTFF briefer in OP4. The POTFF
team member further described the process by which continuous unmitigated stress leads to
degradation over time but can be mitigated through four different practices (they) could
provide from within the PPP office. Isolation was also discussed by a second POTFF team
member briefing the importance of staying connected with the command while friends and
family were, in many cases, far away. During OP5 the following formative assessment was
demonstrated: “Can I see a show of hands how many of you are familiar with the POTFF, ok,
all of you, well, let me tell you then what is unique maybe to this theater and what challenges
might come up why you are here?” Specifically, self-care and balance were two mitigation
and prevention techniques highlighted (named as the title of the presentation and reinforced
with named audio-visual training aids) in both OP 1 and 5. One briefer described how self-
care is holistic, that taking care of mind, body, and spirit is important and the POTFF
program can bolster resiliency in these areas. Balance was noted as critical as well,
encouraging members divide their 24 hours a day into nine hours of work (with an additional
two hours of physical fitness), seven hours of sleep, and six hours of personal time, as an
example. The balance discussed in the brief is of further interest when considering that
Mitigating the Risk of Veteran Suicide 90
Thomas (2017) stated a high operations tempo is the new norm for SOF. This specific
example of balance will also be referenced in separate document analysis descriptions.
Document analysis. Document analysis revealed POTFF use of weekly and monthly
article publications to educate members on the four different domains of the POTFF pillar
considerations as well as general morale, health, and welfare related topics. Each member of
the POTFF creates weekly articles within their respective field identifying how fitness,
mental well-being, social well-being, and spiritual well-being contributes to resiliency.
Publicly posted as well as directly emailed, this information was typically posted at each
week’s end. Examples ranged from winter fitness performance plans and nutrition for
performance guidance to spiritual self-assessments and information on cognitive behavioral
therapy (CBT). Notable examples of opportunities were physical training or physical therapy
sessions, family-centered suicide prevention training, physical challenges, marriage retreats,
and a resiliency hiking club. All articles included contact information for more details and
direct links to sign up for scheduled appointment slots or resiliency building activity
opportunities. The availability of these opportunities was found to be in accordance with
strategies found in USSOCOM Directive 10-12 (2017) outlining operations and functions of
the POTFF. Lastly, although many of the operational instructions (OIs) were found to be
publicly available, as were informative handouts, congressional budgets, and program
pamphlets, what was not found were published rates of success, testimonials, or exemplars of
effectiveness. Whereas this was noted by IP3 as a need during the interview period, a
deliberate search for published and relevant measures of effectiveness was inconclusive.
Summary. In summary, instances of knowledge instruction as well as knowledge
recalled by members with respect to best practices and awareness of risk factors was evident.
Evidence on whether the local POTFF team or personnel could adjudicate that measures
were found to be effective has yet to be observed or determined. All four POTFF pillars
Mitigating the Risk of Veteran Suicide 91
were noted as implemented and performing as assessed through interview, observations, and
document analysis. With regards to the overall effectiveness of the implementation and
members performance, as noted by several individuals, time will tell.
Knowledge influence #2: help seeking process. POTFF and operations personnel
demonstrate a strong understanding of the help seeking process and its considerations,
however, knowledge of how to successfully move past barriers to care is still undetermined.
Knowledge influencer #2 assumed that the POTFF needed to assess personnel knowledge of
help seeking and reporting process, and persistent barriers to care exist within the
organization. Interviews yielded multiple responses reinforcing procedural knowledge while
observations and document analysis noted both real world application and information
mechanisms to reach the required resources. A brief explanation of each follows in the next
three paragraphs.
Interviews. Interviews demonstrated members possessed a strong recall of the
procedures and processes for seeking or utilizing POTFF services. All of the 15 members
interviewed were able to accurately describe each of the roles of the POTFF, who works in
the respective role, and where they are located within the command. IP14 provided a more
enhanced assessment of the newest of the two team members’ performance and the
expansion. According to IP4, SM 4 was “positively killing it” with respect to the Spiritual
Performance Program and had teamed up with SM3 to create a handful of more dual-
purposed POTFF instructional activities since both members possessed certification in
multiple roles. The multiple activities instructed on reinforced the requisite knowledge
pertaining to seeking or utilizing services. As exemplified by IP13, names and positions
were also combined with procedures of what can be expected from who:
Mitigating the Risk of Veteran Suicide 92
Let’s see, you have (SF1) in Psychological, (SF2) in the Human Performance
Program, (SF3) does Peer Network, (SF4) is the Spiritual so depending on what
someone needs they know where to go. Different things are good for different people.
This knowledge was quantified in IP5’s interview where it was noted that since
implementation:
The POTFF has become more openly understood, I was here when it started
with just one Doc and a bunch of ideas, [it] has come a long way in a short
amount of time. Now they’re pushing out lots of digestible left-of-bang info. I
watched one of [SF1’s] breathing techniques class, [it] taught other tools for
dealing with everyday stress.
IP4 noted that he was taught immediately upon assuming his supervisory role “who to call in
the rolodex from where and how to get what I need for them.” IP3 also noted that:
Once implemented, they taught me how to utilize the Family Readiness Group, who
the pertinent players are, and where each POTFF person fits in so we all were not
doing discovery learning on the fly in a crisis.
Interviews also highlighted specific barriers to care that were known, and perhaps some
unknown, that await resolution. Among the barriers noted by interviewees were: stigma,
isolation, no early warning system, fear of professional impacts, the approachability of
doctors, and lack of access.
Stigma and approachability. IP4 had noted that fear of stigma and fear of unknown
consequences can keep individuals from seeking help for fear of negative impacts to their
career. IP4 noted that doctors can be less approachable, and individuals might “feel more
comfortable hashing it out with their buddies.” Approachability is also noted later in the
analysis of motivation influences as a contributor or detractor to self-efficacy.
Mitigating the Risk of Veteran Suicide 93
Knowledge of isolation and early warning. IP4 and IP14 both addressed isolation of
members overseas as a barrier to care and risk factor for suicide. Perhaps one contributor to
the mentioned access limitation was a barrier identified by IP12 in which IP12 noted that
access to information was more difficult for members without Facebook or members without
spouses. Both of these instances prevented members from receiving information as they
were coordinated in an environment that single members or non-users of social media cannot
access. IP12 noted that without one of these access points (social media, Facebook groups,
family members in spouses’ clubs) members often do not know what is going on within their
community and can be left out and further isolated.
Knowledge of trust or fear as a barrier to help seeking. With respect to stigma and
professional impacts, 15 of 15 interviewees cited trust in the unit or its leadership was not an
issue but acknowledged the importance of trust as a potential barrier to care to be aware of
among their peers and subordinates. Although the 15 personnel felt they could trust the
command, stigma and fear of professional impacts remained the most common barrier to care
noted. Observed techniques in addressing this barrier to care were found in the observations
section, discussed next.
Observations. Observations noted numerous instances of members trying to both
reinforce how and when to use the POTFF as well as how to feel comfortable without
creating barriers using the process. Ramchand et al. (2011) noted the need to encourage self-
care. OP 5 saw the entirety of the present command instructed on sequential steps to both
talk about self-care and reduce the risk of suicide. During OP 3, one briefer noted a
metaphor comparing physical help seeking and self-care to mental self-care stating, “if the
General injured himself in PT, fell and broke his leg, you wouldn’t call him weak for going
to the Doc[tor] would you? The rest of this stuff isn’t any different.”
Mitigating the Risk of Veteran Suicide 94
During OP5, training tips surrounding members becoming isolated or depressed were
discussed. Cerel et al (2015) identified psychosocial disorders, including depression, as
contributors to suicide. The briefer in OP5 highlighted that isolation, as noted in KI#1,
becomes a risk factor and must be addressed. As described previously by IP11, “people
don’t venture out they become isolated, withdrawn, disconnected, [they] just try and get
through their time overseas.” The Spiritual Performance Program briefer discussed a good
procedural method as “building rapport, building trust, get them to talk.” The briefer further
discussed this trust building is not instantaneous, the programs and activities supported by the
command and the podium create space to form these relationships. Regimented physical
fitness programs were also noted in observations as a means to target risk factors. As noted
by the HPP briefer, “fitness enables resiliency, resiliency fights off negativity.” Lastly, with
respect to Spiritual Performance Program, one briefer was observed identifying where social
performance targets risk factors stating, “relationships are a key catalyst in preventing suicide
and mortality.” Of notable absence during the observation period were evidence-based
instances of how the staff specifically demonstrated that stigma or negative career impacts
were mitigated and would have no impact on career. Specific examples of a means to
display this detailed evidence is discussed in the next paragraph on observations, as it
pertained to the higher headquarters level.
Document analysis. Document analysis revealed suicide prevention processes,
available services and opportunities, utilization methods, and barriers to seeking care. Noted
as a priority in the POTFF’s informational brochure was the need to reduce the stigma
associated with seeking care. Some specific procedural processes noted in multiple POTFF
sponsored weekly articles was behavioral self-monitoring as a procedure to improving one’s
ability to deal with negative emotions and interact with those around them in order to reduce
isolation. An October 2018 article discussed how family members and friends can intervene
Mitigating the Risk of Veteran Suicide 95
in the process of suicide and ways to seek help in their actions. The article also solicited
family members for procedural training in suicide prevention. Furthermore, USSOCOM
Directive 10-12 noted the need to include family members in the resiliency building process.
Also discovered were physical training programs and regiments to prolong and improve
physical health and avoid injury (the loss of a sense of mission resulting from injury was
noted as a contributing factor in Chapter 2 as well as interviews). Specific documentation of
the ability to maintain a successful career without impacts to qualification or security
clearance were not discovered locally. In 2016, USSOCOM POTF created a specific article
discussing metrics related to how many personnel had lost security clearances a as result of
seeking help (see Appendix H). The article noted that out of the thousands using POTFF
services, only .04% lost their clearance and often this was a bi-product of personal decision
making and not using the service itself. However, this data was not discovered at the
command level for this TSOC POTFF during document analysis.
Summary. In summary, the three methods evaluating knowledge influencer #2
revealed numerous instances of discussed and instructed procedural methods to combat
suicide across the four domains as well as recall of proper utilization. Barriers to care were
recognized, namely stigma and negative professional impacts, and noted by interviewees to
be alleviated. However, stigma and fear of professional consequences was still vocalized in
two interviews (related to future commands) even though trust was not identified to be an
issue within the command. Higher headquarters POTFF has released documentation noting
the rarity of care seeking utilization negatively affecting careers. However, these perception
barriers, in the initial period of this new POTFF, still appear present at the local level.
Motivation Findings
Discussed in this section are motivational results and findings. The section identifies
common themes found during analysis and assert where the themes inform the conceptual
Mitigating the Risk of Veteran Suicide 96
framework and competing ideas as discussed in Table 8. According to Clark and Estes
(2008), motivation provides the energy to start, momentum, and amount of force or effort
needed to keep moving forward. Three motivational influences were developed to include:
self-efficacy, expectancy value, and attribution theory.
Interview questions, observations, and document analysis allowed the researcher to
look for evidence that personnel possessed or demonstrated motivational characteristics
noted as influencers of suicide prevention resiliency measures. Common ideas were coded as
SE (self-efficacy), EV (expectancy-value), AT (attributions) for analysis and further sub-
coding. Once coded to the KMO, the sorted codes were then further divided between the
three motivational influencers listed below as Motivational Influencers 1, 2, and 3.

Mitigating the Risk of Veteran Suicide 97
Table 8
Common Responses or Themes Among Motivation Interviews

Motivational
Theory

Interviews

Observations

Document Analysis

Self-efficacy

Confidence and ability to
act

Confidence, ability to
succeed, change will
occur

Confidence, commitment to
succeed

Attribution

Personally have
prevented suicide,
lowered stress

Actions taken helped,
tools provided to promote
resiliency

Have had great results,
expect great results to
continue
Expectancy Value

Worth the time and
money and will succeed,
a command priority
Actions can make a
positive difference
People as the greatest asset
and the ability to preserve
them through resiliency and
well-being

Motivation influence #1 finding. Personnel within the command possess confidence
in their ability to implement suicide prevention resiliency measures but increased proactive
engagement could be improved. Motivation Influencer #1 (MI1), focused on self-efficacy,
stated that members need to feel confident in their ability to implement suicide resiliency
measures. Interviews, observations, and document analysis sought to determine if stated
motivation or self-efficacy was present. The following paragraphs identify and summarize
interviews, observations, and document analysis pertaining to MI1.
Interviews. Interviews demonstrate that members were confident in ability to
implement suicide prevention resiliency. Each of the fifteen members noted a positive
degree of confidence varying from the IP4 description of “confident, very confident” to a
Director’s description of “confident, yes, and confident that [members] can act if the
Mitigating the Risk of Veteran Suicide 98
situation arises.” Zero of the fifteen interviewees noted any answer demonstrating a lack of
confidence in their abilities to implement measures. IP10 noted that “overall, the program
provides the skills and space to put in safeguards.” The point by IP10 was noted as the
providing of skills and space contributed to self-efficacy. Of note though, IP11 identified
that in the future members will need to continue to demonstrate or present continued
confidence outwardly for others to keep a group mentality of success through confidence. As
described by IP11 “it is an iterative process, the more you demonstrate confidence the more
people see it and it becomes a pattern.” This point by IP11 is of note because Pajares (2006)
identified the need to reinforce to individuals that they are capable of performing tasks as a
means to positively influence motivation. Also noted by IP14 was the need for the POTFF
staff members to leave their workspaces, move about the organization, and engage members
in their duty locations periodically. The approachability and accessibility of the staff
member in this case is identified for note because, as discussed by Pajares (2006),
opportunities to observe or model credible individuals is critical to self-efficacy. The staff of
the POTFF serves as credible models in the command. Pajares (2006) also noted the need
for models (individuals) that are engaging to provide opportunities for increasing self-
efficacy. IP14 stated that if members are not willing to approach POTFF workspaces or
“doctors stay in their offices” not engaging members, some members might not have the
confidence to utilize POTFF services, further stating that “it is hard enough to talk to doctors
as it is.” IP14 highlighted that staff members confining themselves to their workspaces
makes some POTFF members less engaging.
Observations. Direct observation of confidence would be difficult to ascertain but
two instances during OP 4 and OP5 were noteworthy as behaviors consistence with
confidence. Both of the highlighted observations parallel the description of self-efficacy by
Pajares (2006) asserting that with a strong belief, and modeling as examples, goals can be
Mitigating the Risk of Veteran Suicide 99
accomplished. While briefing the differences between the four pillars and different skills
each pillar brings during OP4, one participant noted that they were “confident each of the
four areas can be implemented by different types of individuals effectively.” This same
participant (IP5) when interviewed noted they were confident of their ability to implement
their specific program and confident it could keep individuals from becoming isolated.
Document analysis. Although it is difficult to discern from document analysis or
observations actual individual self-efficacy of personnel and are therefore only included for
context alignment with the study. Some document analysis showed positive confidence
levels displayed from the highest levels of command to local Directorate levels and in-
between. One weekly article written at the local level noted the testimony given to congress
by the USSOCOM Commander stating that they were confident they would get resources
needed to succeed. Another weekly article found emphasis on their “confidence and ability
to implement physical, spiritual, psychological, and social resilience.” Furthermore, locally
used regulation USSOCOM 10-12 (2017) identified that with proper implementation,
resiliency of the force and families could be successful. Lastly, one article noted the
confidence the command has gained from the belief that “with this strategy will come
success.”
Summary. In summary, confidence in the ability to implement suicide prevention
resiliency measures was found to be consistently present. What was not found at this point in
the study were any negative indicators with respect to confidence or self-efficacy. Interviews
all demonstrated a spoken and demonstrated belief, commitment, and confidence in ability.
It should be noted though the one instance highlighting the need for continued demonstration
of confidence among participants belief in the ability to succeed to prevent a future slip in
confidence levels, as previously noted by IP11.
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Motivational influence #2 finding. Participants feel suicide prevention resiliency is
important and they can make a positive difference in implementing suicide prevention
resiliency measures; however, some members still question the follow through of the
program. Motivational influencer #2 (MI2) focused on expectancy value stating that
personnel need to feel it is important to implement suicide prevention resiliency measures.
Interviews yielded instances of participants identifying that not only did they see the value in
implementing measures, they felt the results would turn out positive (expectancy).
Observations noted instances of reaffirmed importance of positive results in combating
suicide and implementing resiliency. Document analysis identified writings highlighting the
expected positive results of resiliency. A description of interviews, observations, and
document analysis followed by synthesis is below.
Interviews. Interviews demonstrated numerous instances of participants noting both
the importance and expectation of success, which makes up the foundations of expectancy
value. IP1 noted in numerous instances the notion of worth. In one response, IP1 stated
“…worth it, it’s worth trying, we have good money for the effort” and that they expect it will
succeed. IP1 further noted it is important the POTFF program succeeds, stating again that
they “believe it will be successful” and that their personal efforts as an initial stakeholder
would be successful. IP1’s constant use of terms like succeed, successful, and important
were echoed by other participants as well. For instance, IP7 noted that they believed the
POTFF program could work and that they “thought it was important enough to go get the
money and hire for it and push it aggressively.” IP4 simply noted “Helps, worth it, worth the
time, worth the money…and the effort.” IP15 further mentioned they expected they could
affect change as they described that they expected that “I can make a difference, where
maybe I didn’t in the past.” When asked about the value and expectation of success IP15
Mitigating the Risk of Veteran Suicide 101
noted that it was: “One of our top three priorities, we got the buy in, so yeah, I am confident
we can at least figure out if people need help or have something going on.”
As noted previously in the first knowledge influence, IP15 had referenced the success gained
in achieving necessary buy-in by members and that buy achieving buy-in, they could directly
contribute their efforts to resiliency. In IP15’s own words: “once you get people to initially
buy-in you can tell they bought in and people who seem like they wouldn’t naturally care do
now and actually show up and participate when we have resiliency days.” With respect to
the mentioned resiliency days, IP15 suggested that in previous units “[we] just took these
days off.” With respect to whether or not participants had expectations of success and
whether they were worth the effort, IP9 noted “People are starting to use the services. Small
nagging stuff dudes put off for years they now talk about because I think people realize they
can get help and it can work.”
How high of a priority and how much value, effort, and expectation for success from
the participants is one area that was noted as both important but open for interpretation.
Other interviewees highlighted stakeholder responsibility for results, with IP11 noting
“It’s about personal responsibility. People need to be active participants, you have to be
willing to try to see the results.” Lastly, IP8 identified that “I think it will succeed based of
the effort and people caring. The money is nice, but our success is not dependent on it.”
In one instance, individual value of the program was questioned. IP14 stated “the program
checks a box…it checks a box but we’ll see.” IP14 also noted that the program was less
valuable than camaraderie and that a better alternative was discussing troubles with a peer.
IP15 stated that the program might help but for now it is “one more metric to track and
another time commitment.” Although these instances were isolated, they are noteworthy as
they echo other statements suggesting more time is needed. They also suggest more time is
needed to cultivate trust, as it relates to importance, among members with respect to the
Mitigating the Risk of Veteran Suicide 102
programs intentions and results. These two noteworthy items will be further discussed in
Chapter 5 recommendations.
Observations. Observations were limited to instances of personnel noting the value
of the POTFF, as individual expectancy would be difficult to accurately observe. During the
OP3 welcome, attended by 32 families, one briefer asserted that personal investment can
provide positive results, noting that “each time I do one of these I learn something new and
am glad I did.” During OP1, one participant identified that resiliency is important to them
and that they “will do whatever they can to keep people healthy and in the fight, that’s what
matters to me.” During the opening of OP4, another participant noted the importance of
resiliency and “that it makes us all, us and our families, better off.” The noting of personal
belief in the value of the program, importance, and being worth the effort and time is similar
to Eccles’s (2006) description of desire and importance as necessary for expectancy value.
Lastly, OP5 saw the final briefer reiterate the importance of support structures noting “effort
and a vigilance, family, friends, co-workers, and leaders can break the suicide chain.”
Document analysis. Determining individual motivation through expectations and
values would be difficult to ascertain through document analysis. Short of an individual
testimonial, which was not discovered during document analysis, articles and documentation
provide little insight into individual expectancy-value motivation. Although document
analysis demonstrated an importance placed on protecting SOF lives and expectations of
positive results, it could be more directly related to organizational perspective. The idea of
documentation of individual motivation as it relates to expectancy and value was noted for
future consideration in follow on studies.
Summary. In summary, evidence of both an expected level of success and value
placed on the results of success were found to be evident in interviews. Numerous interviews
noted ideas such as importance, success, value, and confidence. Observations and document
Mitigating the Risk of Veteran Suicide 103
analysis, due to their limitations in identifying motivation, could only at a minimum suggest
the POTFF emphasize both the importance of resiliency and positive outcomes that can be
expected for members, family, friends, and the mission. It was noted in some interviews that
personal stakeholder-ship or effort is required, nevertheless, the message emphasized by the
command highlighted both the importance and value of expected successful results with
respect to suicide prevention resiliency measures.
Motivational influence #3 finding. Members feel their efforts directly contribute to
suicide prevention resiliency. The third and final motivational influencer was focused on
attribution theory. In this case, attribution meant that POTFF members needed to feel their
own efforts could influence suicide prevention resiliency. Multiple interview questions
targeted whether members could attribute their direct efforts to success while observations
and document analysis monitored for instances of proclaimed attribution. Each of the three
methods yielded affirmative instances of attribution discussed in further detail below.
Interviews. Interviews of all 15 members showed members felt their actions could
directly lead to suicide prevention resiliency. In some cases, members noted where in the
past they did not feel they had and now do feel they have the ability to directly influence,
demonstrating an internal attribution locus. Particularly notable was IP15. When asked if
their actions had directly influenced resiliency, IP15 noted frankly they had an employee in a
previous command commit suicide during the holidays. IP15 went on to describe that while
he noticed changes in the members behavior happening beforehand, as two other
interviewees noted “often the first time you figure out something is wrong it is when
someone turns up dead.” One member (IP15) described that they now felt their actions
directly contribute to prevention and resiliency. IP15 went on to describe:
Now I keep an eye on it, last Christmas I noticed one of my guys acting funny. I
asked him if anything was going on and there was. I grabbed him and told him
Mitigating the Risk of Veteran Suicide 104
were going to see the POTFF. I think nothing less of him either. I told him I
think nothing less. No harm done.
Other members noted specific skills they use that they directly attribute to mitigating risk
factors. IP7 stated that they can “act as a pressure release valve for stress, when I can release
some of the pressure it helps guys get at the root causes of what’s going on.” IP12 identified
that “I play a large role in resiliency and prevention, I discuss and meet with them during
onboarding, I introduce them to the Family Readiness Group and get them direct access to
services.” IP12 also noted that they personally get individuals connected and ensure they do
not become isolated. As previously noted, IP1 directly attributed their attainment of a 48-
hour period of rest and refit as a direct contribution to lower instances of members citing
service needs due to stress.
Observations. Individual attributions would be difficult to assess from observations.
Observations showed some instances of members stating their actions positively affect
suicide prevention resiliency as well as instilling into others that their own actions can affect
suicide prevention resiliency. However, true individual assessment of internal attribution
could not be observed. Whereas a first-person account directly discussing individual
attributions regarding suicide prevention resiliency by a participant could provide insight,
similar to the noted limitation in the following document analysis section, potentialities for
first-person attributions in the future was noted for discussion in future recommendations.
Document analysis. Document analysis provided no overt demonstrations of
motivational theory related to attributions. Individual attributions would be difficult to
discern through documents unless first-person accounts were described. Although no
instances of first-person attributions were noted in document analysis.
Summary. In summary, interviews demonstrated that POTFF members believe
resiliency is bolstered through their efforts. Members interviewed described specifically how
Mitigating the Risk of Veteran Suicide 105
their efforts contribute to resiliency and the overall program. As noted in other influencers,
the theme of time was again brought up suggesting that with more time (at a later date), the
degree of how much participants can attribute to individual efforts will gain further clarity.
The notion of time will be further discussed in the recommendations section of this study.
Organizational Findings
Discussed in this section are organizational results and findings. The section will
identify common themes found during analysis and assert where the themes inform the
conceptual framework or contradict previously mentioned themes. Organizations can drive
change and improvement while closing performance gaps, according to Clark and Estes
(2008). Two organizational influencers examining cultural models and cultural settings were
developed and evaluated through interviews, document analysis, and observations.
Interview questions, observations, and document analysis looked for evidence the
organization was consistent in providing a means and promoting an atmosphere consistent
with HQ USSOCOM POTFF principles. According to Gallimore and Goldberg (2001),
cultural settings include two or more individuals coming together to address a common
problem, challenge, or task. Similarly, Gallimore and Goldberg (2001) also described
cultural settings as creation of spaces that encourage meaningful collaboration. Cultural
models can be defined as a common understanding or mental schema of how things should
work (Gallimore and Goldberg, 2001). The two motivational influencers listed below are
identified as Organizational Influencers 1 and 2.
Organizational influence #1 finding. The organization provides and prioritizes
resources and ongoing support, to include time, budget, and manpower increases, for suicide
prevention resiliency. Organizational Influence one noted the organization needed to provide
ongoing resources and support for suicide prevention resiliency training (a cultural setting
influence). Specifically, interviews queried if funding was readily available and appropriate
Mitigating the Risk of Veteran Suicide 106
or expanding. Interviews also inquired into whether time, money, and staff were made
available for members to use the POTFF. Observations and document analysis looked for
the same characteristics noted above as well as agreement with what interviews revealed.
The triangulation revealed the organizational support through a prioritization of time,
manpower, and financial allocation towards resiliency measures.
Interviews. Interviews showed a strong commonality in positive responses on the
organization’s cultural setting with respect to suicide prevention resiliency. The common
themes are broken down in the following two sub-sections by manpower and time as well as
budget.
Manpower and time. The resources of manpower and time were identified in
interviews. IP2 noted they had been in the command since before the POTFF stood up and
watched as “the Commanding General saw there was no program, researched it, and went out
and got the resources and directed the staff to stand one up.” IP2 further noted that in the
beginning, while waiting for more staff, the Commanding General required all Directors to
take part in a pre-development of the program to keep it moving forward, further
demonstrating the organization’s dedication of manpower to resiliency implementation. IP2
further described the creation of time and space available by establishing the POTFF as a
prioritized effort and mandating the time in the weekly schedule by removing a previously
standing battle-rhythm event. Before the staff was complete, the Commanding General
brought in experts from other units to speak to the available resources and capabilities the
program possessed. This is significant as IP1 noted, when speaking of another branch of the
military, he was never aware and could not remember if they had had any programs or
resources provided.
Budget. IP4 noted that in his first year working with the program he watched the
budget double from the previous year. He further noted at the end of year if budgeted funds
Mitigating the Risk of Veteran Suicide 107
were in a surplus and requests for spending came in, the Commanding General made the
POTFF the first priority to receive them. IP4 mentioned specifically that this money further
enabled opportunities for both single and married members to attend resiliency retreats. IP9
identified an instance where money was used to make available extra advanced fitness
courses. Another member, IP5 noted of the leadership: “This year we had plenty for
resources, but CG has asked for more and directed to continue to expand services and
provides them with the increases…I think this program is near and dear to him.”
IP5 went on to describe the Commanding General’s deliberate approach, further stating that
he wanted a fully resourced POTFF. Referring to a briefing the Commanding General gave
on personally using the available psychological performance resiliency tools the POTFF
provides, IP10 noted that “it was refreshing to see someone leading by example.” Multiple
interviewees highlighted the money being useful and appropriately used, as exemplified by
IP14s saying “the different facets of pre-habilitative training help a lot of people, a lot, I think
most would agree it is money well spent.” Observations of resources and implementation by
the leadership noted during interviews were found to be reinforced during observation
periods.
Observations. Observations showed evidence of the resource and support levels
identified by multiple individuals during the interview period. During the five observed
activity periods, resources, support, and availability of personnel was evident immediately.
One such example could be found in the setup of the “First Friday” mandatory resiliency
training. Members of the command were excused from additional duty responsibilities,
creating opportunities to attend a POTFF-led physical fitness challenge and resiliency
training followed by lunch with their spouses and families. The availability of the staff
members and the time away from primary duties provided for members to take part shares a
significance previously discussed in the interviews, and literature review, as a way to combat
Mitigating the Risk of Veteran Suicide 108
stress. The construct of the observed resiliency day (OP5) provided suicide prevention
training by the chaplain, winter fitness strategies by the HPP, emergency medical care tactics,
a briefing on all upcoming POTFF sponsored events, and a few hours to bring the command
and family together in a relaxed environment with a meal provided. The event provided time
away from duties to relax, resembling a technique suggested by IP1 “to gift people time.”
During OP1, the Commander noted that he had the POTFF briefing shortly after he finished
because he wanted personnel and families to know who the POTFF was and how to use
them.
The time given, setting provided, and stated importance of OP1 professed by the
Commander describe what Galimore and Golberg (2001) described as interconnected cultural
factors that can lead to achievement. The statement by the Commander is important to note
as he was encouraging both time and budget be made available to members. The
Commanding General further re-iterated the amount of varying resources available through
the POTFF and encouraged members to use them. Communication and leadership were both
identified as necessary for POTFF success in Chapter Two. Of the over ten briefs provided
at OP1 and OP4, the POTFF directly followed the Commanding General and were resourced
the largest amount of time for introductions, approximately two hours and thirty minutes.
The noted resources, as well as time, parallel Chapter Two’s statement of the necessity of
leadership to provide both climate and resources for the POTFF to succeed.
During OP2, one POTFF staff member noted to the audience “we are fortunate to
have the resources for pre-habilitation and services that other programs do not.”
Additionally, during OP4 this notion of being fortunately resourced was echoed by one
briefer in highlighting the availability of advanced technology to improve cognitive function,
made available by the POTFF. Lastly, the resource of time was evident in allowing members
to take part in personal physical therapy sessions, group led workout sessions, peer network
Mitigating the Risk of Veteran Suicide 109
activities, and psychological performance improvement during the duty day hours. The
resources made available through budgeting for the program further ensured the previously
mentioned services were always available within the command with no risk of a prolonged
waiting period for appointments, as IP13 had previously noted was an issue in other branches
of the military.
Document analysis. Document analysis showed a level of resources, time, and
support made readily available by the command and reflected findings noted during
observations and interviews. Locally archived congressional testimony noted USSOCOM
requests and approvals each year to expand the budget of the POTFF program. No events
offered required financial burden on the members as the monthly and weekly articles noted
the events were sponsored by the POTFF budget. The following sub-sections further define
the above-mentioned resources of manpower and time, as well as budget.
Budget. Financial resources appeared to be spread among the four pillars equitably,
exemplified by advertisements and postings of resourced social outings through the PNC,
meditation classes by the PPP, physical therapy sessions by the HPP, and resiliency retreats
by the SPP. Each program had one of the contracted POTFF personnel present if not more,
as in the case of advertised resiliency retreats and PNC sponsored events. Other local
archived excerpts noted previous assertions by the Commander highlighting enabled ability
as a result of the POTFF structure to positively impact resiliency through financial support of
the program. Furthermore, the Commander noted that work on resiliency so far has had a
direct impact on lowering suicides. A separate article written in the weekly distribution
stated that with the great care we use to protect and invest resources in our people we can
“expect great results, for a long time.” The distribution and availability of resources as noted
in the document analysis was noted to be in accordance with USSOCOM 10 12 (2017).
Mitigating the Risk of Veteran Suicide 110
Manpower and time. The weekly and monthly articles identified upcoming POTFF
sponsored activities, individual POTFF personnel availability, and opportunities with
imbedded links to enroll in the events, which provided ease of access for stakeholders to the
programs. One article further noted the amount of time and training put into “protecting our
people.” Descriptions of available events noted that personnel were authorized to take part
and granted participation to be absent from competing duty day responsibilities. One specific
member of the POTFF published in the weekly article the proclamation of the cutting-edge
technology available in their office that has been shown to positively affect cognitive
behavioral training skills necessary to promote resiliency. Furthermore, the Commander
states in his displayed policy that their commitment to POTFF implementation has directly
contributed to readiness.
Lastly, one article noted the continued progress the POTFF has experienced in
bolstering resiliency. The articles further stated that POTFF efforts have paid off and been
worthwhile, while reminding members that continued progress is possible with each and
every one of their efforts, and time will ultimately tell how “we” have done. Most commonly
observed in the documents was that in all cases (four articles per month over four months)
each article contained encouragement to stop by the respective office, contact information,
and a forum to solicit questions. One command level article noted that “resiliency is taken
seriously in SOF” and “we must work to protect our greatest asset, our people.” Articles
noted congressional testimony in which the USSOCOM Commander discussed the
willingness to leverage all means and resources available to protect and take care of
USSOCOM people allowing them to conduct the missions asked of them. A separate article
noted a belief in a vision that if the POTFF can ensure members are healthy in all four
domains (pillars) members would be able to go out and accomplish the missions that needed
to be done.
Mitigating the Risk of Veteran Suicide 111
Summary. In summary, interviews, observations, and document analysis all
demonstrated an agreement in the notion that resources, support, and time is positively
allocated by the command for use by its personnel. Each observation period demonstrated
instances of resourced support (contracted staff members) and time (made available during
the duty day) by the command for members to participate. Members interviewed
consistently noted that plenty of resources were available and well spent. Document analysis
contained instances in every article of time and money made available for personnel to take
part in one of the four pillar programs for resiliency. Ultimately, the triangulation between
interviews, observations, and analysis demonstrated commonality with respect to the
presence of the needed resources, time, and personnel.
Organizational influence #2 finding. A culture of trust in the command and local
commanders and supervisors is present and provided; however, uncertainty about
consequences of help seeking behavior outside the protection of the command persist.
Organizational Influence #2 (OI2) posited that the organization needs to provide a culture of
trust around suicide prevention (a cultural model influence). Interview questions focused on
not only trust but perceived willingness of members to use services and take part in resiliency
building. The willingness was also queried with respect to whether or not the potential
consequences of negative professional effects or stigma were present. Observations during
the five periods looked for evidence of a culture of trust (such as individual proclamations of
anecdotal stories of trust) while document analysis looked for discoveries that would either
confirm the culture exists or is yet to be established. Findings of each of the three methods
are noted below.
Interviews. Of the 15 members interviewed, none of the 15 felt there were issues of a
lack of trust at the local command level with respect to suicide prevention resiliency
measures. As noted by IP5 “people openly talk, casually talk, about going to see the POTFF.
Mitigating the Risk of Veteran Suicide 112
I’ve also seen people tell other people to go to the POTFF.” This example was also found in
IP8’s description of the command in which they noted that “the command’s focus on
resiliency says we care, and we can be trusted to let you take care of yourself, even though
we are busy, we care.” Trust is of note as, previously described by Korsgaard (2006), trust
and leadership can either help or hinder positive change. IP8 further noted the sense of
comfort and absence of fear by the staff of the POTFF being composed of individuals outside
of their chain of command. Furthermore, when directly asked if a culture of trust exists
surrounding the command’s POTFF team each of the 15 answered in the affirmative,
exemplified by IP 13 affirming that “a culture of trust exists in the command so yeah, you
gotta be willing to try it.”
When interviewees were asked if they felt negative consequences would occur as a
result of seeking help or taking part in resiliency focused activities, one of the members
(IP14) felt it would be held against them in a future command outside their current
assignment. This residual fear is important to note as stigma has been identified as a barrier
to care during both the literature review and throughout this chapter’s analysis. However,
this question stipulated negative consequences and trust with respect to the local command,
not higher headquarters or members specific branches. IP3 noted that even if someone was
seen going towards the POTFF spaces or facilities, it would be unknown why. IP3 stated that
given the proximity of the HPP fitness facilities, many day-to-day events were conducted
there. IP3 further stated that the POTFF members also moved about the command often and
freely in a fashion that it would be “impossible to know who is up to what.” IP3 added that
“buy-in” comes all the way down from the top of the chain of command, pointing out that
previous USSOCOM Commanders have discussed their use of POTFF programs and that
senior officers down to the local level have “bought in.” IP2 directly noted that “there is a
Mitigating the Risk of Veteran Suicide 113
culture of trust, that (they) trust the use of the POTFF,” and further stated that “the leaders
make it ok.”
Both the trust and leadership buy-in are significant because, as Korsgaard (2006)
noted, success can directly be attributed to trust. The notion of leadership support and
cultivation of trust was noted by other members as well. As previously mentioned, one
interviewee asserted that his own stance was to direct individuals to go to see the POTFF and
“thinking no less of them.” The same individual (IP15) further noted that he looks down
more on individuals who risk the mission if they are having unresolved resiliency issues.
This idea was also mentioned by IP14 when they noted that, “Do I think there are trust
barriers, not really, guys are pretty good about bringing it up if they think it will affect
performance?” IP7 stated that “we have made using the POTFF the norm,” as well as, “guys
coming in now just think this is standard practice.” IP14 echoed the idea of a standard by
pointing out that “between mandatory in processing, briefings during onboarding by the
POTFF, and monthly resiliency days, it would be odd not to have some sort of relationship or
interaction with them.” Although each of the members interviewed declared no trust issues
exist locally, multiple answers still yielded unresolved fears and lack of trust of anyone
outside the local command.
Fear of the unknown, professional consequences, and stigma still presented themes
during the interview portions focus on trust. The following sub-section describe fear,
professional consequences, and stigma. The second sub-section describes trust and notable
suggestions made regarding trust.
Fear of the unknown, professional consequences, and stigma. Members noted that a
holdover may exist from previous years where the fear of “not wanting to look anything else
than invincible” as articulated by IP13 existed. IP13 also noted that previous usage may not
have happened for the sake of “needing to look tough.” Two members (IP9 and IP11) also
Mitigating the Risk of Veteran Suicide 114
prefaced questions of trust issues present with statements such as “not in this command, but
definitely in my last one” as well as “people used to avoid it for trust or stigma.” These
sentiments suggest a fear of stigma persists from experiences in other branches or commands.
IP8 noted that although he thinks the program works, without an individual (model)
providing direct testimonial it had worked for them, uncertainty left the possibility open that
it might not work for others. Fear of the unknown was brought up in a separate instance by
IP8, as they wondered what professional consequences or medical disqualifications might
occur. Similarly, in Chapter Two it was noted by Lefebvre (2017) that stigma and negative
challenges to one’s career are barriers to help seeking. This chapter previously mentioned an
article put out by USSOCOM to combat this thinking related to negative consequences, but
as this study has emphasized this program is new, it is perhaps plausible this information is
continuing to make its way through the chain of command.
Trust. Multiple members made suggestions to continue to cultivate trust in the future
with respect to professional consequences and stigma. This assurance seeking is in line with
both Lefebvre (2017) highlighting of fear of stigma and damage to career as well as Chaby’s
(2013) stated need of POTFF teams work to reduce stigma through trust. The inclusion of
testimonials of successful individuals who thrived free of stigma and the removal of
governing documents penalizing or temporarily disqualifying members for physiological or
psychological conditions were two suggestions by unit members. The use of mandatory
episodic POTFF appointments in conjunction with annual physicals as well as semi-annual
currency standards requiring POTFF interaction were also suggested. Lastly, also suggested
was staff resourcing such as ensuring that a minimum, one of the doctors maintains an overly
approachable demeanor as a trusted confidant. It should be noted that some of these items
are addressed in the observation section below.
Mitigating the Risk of Veteran Suicide 115
Observations. Observations demonstrated a cultural model that emphasizes trust
exists within the command with respect to suicide prevention resiliency measures. During
OP1, the Commanding General deliberately stated that “no stigma exists for seeking help or
admitting something is wrong.” The statement by the General was reinforced during a
follow-on interview in which IP7 emphasized that since their arrival and the inception of the
POTFF “trust is better now than when I first got here,” acknowledging the shift in culture.
The tie in of communication, no stigma, and leadership echo both Chaby (2013) and
Korsgaard (2006) with respect to communication, trust, and leadership. The General brought
up previous USSOCOM commanders who have openly stated the pre-habilitative measures
they have sought out. This is of note as both Rath (2009) and Moran (2002) emphasized the
need for strength-based leadership. During OP5, one briefer highlighted the amount of
people who have sought help for behaviors listed as suicide factors and that after successful
changes “they are still in the fight.” The briefer during OP4 specifically noted the largest
fear of help seeking individuals is fear of stigma and described stigma as an “archaic myth”
that is being stamped out while noting “admitting you need a little tune-up takes strength.”
The briefer also noted that, at a minimum, the mandatory training events the POTFF leads
ensures that all members will get periodic access whether they actively choose to seek it or
not, ensuring at least some instances of resiliency training is available aside from a fear of
stigma. During OP3, one briefer highlighted that trust exists within the command. However,
IP3 noted that members must be willing to use the services (active choice). The OP3 briefer
also noted the internal challenge individuals face in seeking help, stating that “asking for an
assist is a real indicator of emotional strength and intelligence.” The noting of
communication in OP3 was similar to Korsgaard et al. (2002) stating the need to mitigate
resistance and lack of trust with communication. Lastly, a common occurrence noted in OPs
1,3,4, and 5 was the observed behavior of individuals talking during breaks or at the event’s
Mitigating the Risk of Veteran Suicide 116
conclusion of instances where they had either used one of the services or reasons why the
still needed to. Perhaps more notable, in three of these instances, the individuals were senior
members of the command.
Document analysis. Document analysis showed numerous instances of
proclamations that trust is present in the command with respect to suicide prevention
resiliency. Weekly and monthly articles reinforced the notion of trust in suggesting no
negative results would come from help seeking behavior and the benefits of help seeking.
This directly correlates to two separate operating instructions evaluated during document
analysis. Both mentioned the criticality of stigma reduction and the need to create an
environment free of stigma and free of fear of professional consequences.
One of the first items received by new members is the Commander’s “View on
Holistic Wellbeing Policy” letter. The letter directly states, “there will be no stigma for
anyone making themselves better by improving their psychological performance.”
Furthermore, the Commanding General’s policy reiterates the command fully supports
“taking advantage” of the available services to improve overall physical and mental
performance and operations readiness. Furthermore, the policy letter echoes higher
headquarters USSOCOM 10-12 (2017) notion that stigma related to the help seeking process
as well as trust must be promoted. Much like the pre-habilitative nature the POTFF is
described as having in the operating instructions, weekly articles, and the literature review,
the command’s documents reinforce the service as pre-habilitative, performance enabling,
and an investment in future performance. The nature of describing the service as pre-
habilitative in numerous articles and instructions appears to present the idea of the resources
as an opportunity for “honing skills” and “betterment,” suggesting independence of stigma
while increasing physical, spiritual, social, and psychological performance.
Mitigating the Risk of Veteran Suicide 117
Summary. Interviews, observations, and document analysis demonstrated that, at the
local level, a culture of trust exists with respect to suicide prevention resiliency measures.
All members interviewed noted a culture of trust exists and they do not fear stigma from the
local level. Observations revealed senior leaders, directors, and POTFF personnel
proclaiming no fear of stigma and no betrayal of trust was occurring. Documents noted
support and encouragement with no consequences with respect to utilizing POTFF services.
Although this concept of trust and stigma reduction is made clear at the headquarters level of
USSOCOM and in literature, consequences beyond the time spent at this command remain
unclear. Specifically, service unique (specific branch, i.e. USA, USN, USMC, and USAF)
administrative actions still present a challenge to members outside of USSOCOM policies or
culture. Multiple individuals noted that while fear of what happens after they leave the
command could contribute to residual apprehension to use services, all agreed that the
current command presents no threat to career or possibility of violations of trust.
Themes
The multi-method design sought to examine KMO influences evaluated through
interviews, observation and document analyses. The triangulation used in this study noted a
strong consistency in findings among the three methods used. In most instances the
knowledge influencers were found evident in interviews, document analysis, and
observations. Two common caveats (trust and fear of future consequences) for further
improvement were noted as consistent and will be discussed in Chapter Five. Motivational
influences maintained consistency between interviews. Most individuals felt they could
make a difference, that they could expect positive results by implementing measures, and
they valued the result.
Opportunities were identified for continued enhancement. A commonly mentioned
theme was the notion of time and how time will ultimately tell whether the program will or
Mitigating the Risk of Veteran Suicide 118
will not help. Another caveat noted was the approachability of POTFF staff and POTFF
work spaces. Also noted for improvement was the questioning of the follow through of the
program and whether the additional time spent following metrics of the program was not
another contributor to increased stress.
Lastly, organizational factors, as they pertained to the local level, were consistently
positive while remaining only cautiously optimistic beyond the local command level. These
noted factors concerned the area of trust. Trust was noted in documents, proclaimed during
observations, and expressed during interviews. However, trust of organizations outside of
the local command and trust surrounding either previous or potentially future commands was
noted as still contributing to fears of stigma, professional consequences, and fear of the
unknown. These themes and recommendations will be discussed in Chapter Five’s
discussions of research question three and recommendations.
Summary
By examining the seven KMO influencers noted previously, the results, through
triangulation, were able to inform research questions number one and two and provide
background for research question three (to be discussed in Chapter Five). Some themes had
unanimous response, as noted in Table 9.

Mitigating the Risk of Veteran Suicide 119
Table 9
Themes with Unanimous Agreement Among Participants

Theme Question

Example Response

POTFF Services
Available

2

“a lot of Docs in one spot, [a] surgeon,
psychologist, chaplain, and peer coordinator,
physical therapist, sometimes athletic
trainers, and some assistants.” (IP8)

Trust

8

Do they trust they can use it? Yes, people
trust they can use it and not worry about not
being supported.” (IP13)

No large-scale disagreements between each method’s results were noted, indicating
that what is written, what is observed, and what is spoken within the organization with
respect to knowledge demonstrates uniformity. Knowledge influencers such as best
practices, barriers to care, and risk factors necessary to implement suicide prevention
resiliency measures were present in interviewed members. The motivational factors needed,
self-efficacy, attribution and goal orientation, were also commonly noted. Interviewees
commonly mentioned the notion of “confident” with respect to stakeholder perceptions on
the viability and success of the POTFF. Culture and context of the organization appears to
foster trust within the command and provide resources and support to members while
demonstrating consistency. Furthermore, among the command’s espoused values and
observed culture and context, consistency was noted. Specifically, consistency was found as
it related to the time available to utilize POTFF services as well as the budgeting and
resource increases enabling POTFF expansion. However, continued areas for improvement
and pursuit of rehabilitative resiliency training exist as well.
Several members noted key areas for improvement or potentialities for future
research. Knowledge suggestions included how best to provide members a source of
Mitigating the Risk of Veteran Suicide 120
decompression, testimonials, and how to encourage members to make time for professional
readings related to resiliency enhancement. Motivational suggestions included ensuring staff
member credibility and ensuring peer network activities develop multiple methods to ensure
inclusion of single members. Organizational suggestions were ensuring approachability,
creating a currency program making POTFF interaction mandatory for all members on an
annual basis, and including the staff psychologist during annual preventative health
assessments. The suggested changes proposed by members along with the findings as a
result of research questions one and two will inform research question three in Chapter Five;
recommendations.

Mitigating the Risk of Veteran Suicide 121
CHAPTER FIVE: RECOMMENDATIONS
Discussed in this chapter are recommendations, implementation, evaluation,
limitations, strengths and weaknesses, and recommendations for future research. The
previous four chapters of this study provided a background to the problem of practice,
literature review, methodology, and findings. Specifically, Chapter Four addressed interview
questions one and two. Research question one asked what KMO factors were present in the
organization influencing suicide prevention resiliency measure implementation. Research
question two asked how organizational culture and context affected stakeholder knowledge
and motivation. This chapter addresses research question three: what are the
recommendations for organizational improvement in the areas of knowledge, motivation, and
organization. The recommendations will be organized by influence, applying
recommendations to noted areas needing improvement. Also included will be
recommendations for sustainment concerning successful practices. Lastly, this chapter will
describe and use the Kirkpatrick and Kirkpatrick (2016) new world model to suggest an
implementation and evaluation plan for the noted recommendations. The following summary
review of the study and problem of practice will provide context to the recommendations.
This study addressed the problem of the increased number of veteran suicides within
the U.S. military. The study identified an organization, USSOCOM, and its new approach to
ensuring physical, spiritual, social, and psychological resiliency. Specifically, the study
focused on an overseas deployed Special Operations Unit as it implemented the Preservation
of the Force and Family initiative. Using a modified Clark and Estes (2006) model, assumed
influencers related to knowledge, motivation, and organization were developed and crafted
into seven subthemes (influences).
The findings for each of the influences were evaluated in a multiple method research
framework using triangulation including interviews, observations, and document analysis.
Mitigating the Risk of Veteran Suicide 122
Also informing the findings were considerations from the literature noted in chapter two.
Significant agreements in the literature and the triangulated data were noted.
Recommendations for Practice to Address KMO Influencers
Discussed in the following sections are recommendations. The section includes a
summary table that contains: respective KMO influencer, priority of influencer, principle
literature cited, and context-specific recommendations. Each recommendation will contain
the assumed influencers, a brief description of what supports the recommendation from data
collection, and a synopsis of principle literature supporting the recommendation. Lastly,
before concluding, recommended practices for successful practices will be noted for
sustainment.
No significant deficiencies were found concerning knowledge. However, data
collection yielded potential areas for improvement that, if implemented, could prevent
common barriers to suicide prevention and resiliency as noted in Chapter Two. Significant
deficiencies were not found with respect to motivation. However, Chapter Four results
demonstrated areas where self-efficacy, expectancy-value, and attributions could be
bolstered. Chapter Four results combined with Chapter Two literature identified multiple
opportunities for continued progress with respect to organizational influences. The majority
of the recommendations address organizational factors while also incorporating critical
knowledge and motivational factors (Table 10).

Mitigating the Risk of Veteran Suicide 123
Table 10
Summary of Recommendations
Assumed
Motivational
Influence

Principle and
Citation

Context-Specific
Recommendations

POTFF needs to
know the
effectiveness of
suicide
prevention
measures and
best practices for
suicide
prevention

Information must be
presented clearly
towards attaining
goals (Clark and
Estes, 2008)

Anchor changes in
corporate culture
(Kotter, 2012)

Provide a mechanism (i.e.
quarterly release, staff
briefing, report to
command) to present and
promote the effectiveness
of locally implemented
resiliency measures

POTFF needs to
assess personnel
knowledge of
help-seeking and
reporting
process,
persistent barriers
to care, and what
risk factors exist
within the
organization

Inadequate
information
negatively harms
performance,
especially towards
attaining goals (Clark
and Estes, 2008)

Anchor changes in
corporate culture
(Kotter 2012)

Multiple mediums and
procedures for
communicating social
performance programs need
to be developed, and drilled
100% of members receive
information on events and
activities

POTFF members
need to feel
confident in their
ability to
implement
suicide resiliency
measures

Positive, peer-based
suicide prevention
measures can yield
success (Petrova,
2015)

Include testimonials or
peer-led discussion from
unit members on successful
interventions during
training of First Friday
events.

Personnel need to
feel it's important
to implement
suicide
prevention
resiliency
measures

Clark and Estes
(2008) note that
expectations can be
raised if members are
given more power
and control

Require Psychological
Performance Program
(PPP) use as either a semi-
annually currency or with
Preventative Health
Assessments (Annual
Physical)
Mitigating the Risk of Veteran Suicide 124

POTFF members
need to feel that
their own efforts
can influence
suicide
prevention
resiliency

Eccles and Wigfield
(2000) highlight that
motivation and effort
can be achieved by
creating connections
between individual’s
values and beliefs to
the organizational
goals

Allow each POTFF pillar
the opportunity to instruct
on one additional subject
tangential to their primary
position and reward
accordingly

The organization
needs to provide
ongoing
resources and
support for
suicide
prevention
training

Trust can be garnered
through peer
involvement, which
can take prevention
one step further and
provide resiliency
(Jenssen, 2013)

The Organization should
create a duty position for an
approachable, mid-level,
peer uniformed service
member to act as a Liaison
within the POTFF

The organization
needs to provide
a culture of trust
around suicide
prevention

Anchor changes in
corporate culture
(Kotter 2012)

The Organization should
rescind policies imposing
negative career
consequences or those
policies that contribute to
stigma for help-seeking
individuals

The organization should rescind policies imposing negative career consequences or
those policies that contribute to stigma for help-seeking individuals
Clark and Estes (2008) note procedures and communications must align with values
for success. Although the command highlights that there will be no stigma for help-seeking,
POTFF staff and operations personnel acknowledge the stigma and fear of professional
consequences is a factor in preventing help-seeking and resiliency. Furthermore, Lefebvre
(2017) noted that the simple perception of a negative impact on a career can lead to stigma.
Historically noted as unfounded in most cases, many members still fear stigma's
consequences on their career (Porter et al., 1994). This suggests that policies imposing
negative career impacts should be removed if the organization wants to encourage help-
seeking and resilience.
Mitigating the Risk of Veteran Suicide 125
Trust in the organizational culture is imperative in teamwork (Clarke and Estes,
2008). POTFF teams and operations personnel could be confident in encouraging resiliency
and help-seeking behaviors if they trust no adverse consequences were present to act as
barriers. Possemato (2013) highlighted that trust forms the basis in preventing barriers to
care in veteran suicide prevention. Furthermore, Possemato (2013) emphasized that fear of
disclosure and negative consequences both present a barrier to care. Vansickle et al. (2016)
identified reducing barriers to care as a required tactic for encouraging help-seeking and
reducing suicide in the military.
Furthermore, Vansickle (2016) noted that in a study of over 1,700 service members,
the top three barriers to care were stigma related. Ultimately, the literature suggests the
removal of professional consequences as a contributor to stigma and barrier to care would be
beneficial. By removing or rescinding negative professional help-seeking implications, the
organization could eliminate a significant barrier to help-seeking.
Official removal of barriers to care must be published and communicated
Fear of the unknown and uncertainty concerning professional consequences were
noted as barriers to help seeking during the data collection phase. Clark and Estes (2008)
noted that information is a necessity, especially when organization members need to attain
goals or behavior. If the POTFF and Commanders believe there is no stigma and have taken
measures to remove professional impacts to the careers of help-seeking individuals, then
ensuring all individuals are aware is necessary to provide and promote resiliency. As
discussed in Chapter Four, the command has noted that stigma and negative professional
consequences will not occur in welcome letters, articles, and briefs, which is a strong start to
removing barriers to care. Kotter (2012) noted the importance of institutionalizing change as
a final step in the change process. A mechanism to anchor would be a published directive.
The formally published instructions would need to state negative professional implications
Mitigating the Risk of Veteran Suicide 126
for help-seeking individuals would be prohibited similar to other banned discriminatory.
Current policy that imposes negative career consequences upon help-seeking members, such
as operating instructions directing loss of qualification (aviation, diving, jumping) as a result
of help-seeking, need to be rescinded. Without rescinding these directives, negative career
implications do exist. Whereas the rescinding may be an organizational factor, the
communication of the change is a knowledge factor. The changes the organization makes
with respect to procedures are only half of the implementation, the communication of the
knowledge to the unit members will ensure no barriers to care exist as a result of lack of
knowledge of new procedures.
Provide a mechanism to present and promote the effectiveness of locally implemented
resiliency measures
Data analysis of influencers demonstrated that understanding of effective locally
implemented measures remains unclear. Clark and Estes (2008) noted that inadequate
information can make performance worse. Furthermore, information must be presented
clearly towards attaining goals. Although in some instances during data analysis it was noted
that specific resiliency measures implemented showed success in lowering stress, both the
attribution and realization as to the local POTFF's efforts and results were left unrealized by
unit members. The recognition and dissemination of locally successful measures are critical
for POTFF team members and operations members alike, as noted in Chapter Two.
Furthermore, a means of distributing success stories and positive implications will enable and
reinforce knowledge of best practices. It will also complement motivational factors, which
will be described further with respect to recommendations. Lastly, the ability to generate and
disseminate “quick wins” is critical to organizational change (Kotter, 2012).
Concept of operations for communication of POTFF activities must be standardized
and drilled to ensure 100% of unit members have accountability
Mitigating the Risk of Veteran Suicide 127
Clark and Estes (2008) noted that inadequate information negatively harms
performance, especially towards attaining goals. During the data collection phase, three
individuals indicated that they were unaware of and, in some cases, felt excluded from events
or activities as a result of not having an online social media presence. To prevent a lack of
awareness in the social performance category, the command must promote inclusion and
robust communication as a means to avoid isolation.
Promotion of communication and prevention of isolation must be prioritized.
Batterham (2018) noted the attribution of isolation to suicide. In some cases, during the
interview and observation period the researcher noted social media and spouses were a
primary or sole mode of communication. Membership groups such as these have a potential
to be can be exclusionary and contribute to isolation if they stifle or channelize
communication. Clark and Estes (2008) highlighted the need for communication to be both
constant and clear as a way to handle changing or unexpected events. Furthermore,
communication is an important step to organizational change (Kotter, 2008). To promote
inclusion and robust, agile communication, a standardized CONOP would need to be
established and drilled to 100%. As previously noted by Clark and Estes (2008) information
is a necessity for attaining performance goals. The standardized communication procedures
would ensure messages reach the entire command, prevent isolation with inclusion, and
would ensure equal opportunity to attain social details as well as other POTFF activities.
Include testimonials or peer-led discussion from unit members on successful
interventions during training of First Friday events
First Friday events present an opportunity the local command is using to provide
resiliency training. Currently, the members of the POTFF team lead the events and alternate
between the pillars. The inclusion of operations personnel who have personally intervened in
suicide with success would demonstrate personal testimonials, as suggested by members
Mitigating the Risk of Veteran Suicide 128
during the interview portions of data collection. As noted by Bandura (1997), individuals
who believe they can be successful in a task tend to be more successful in task
accomplishment than those who do not believe they can be successful. Hence, personal
testimonials by operations personnel would demonstrate to an audience of peers the power of
self-efficacy in suicide intervention. The use of a peer-led discussion on intervention would
thus build upon the respective POTFF speaker during a given session as well as previous
knowledge and skills as a result of instruction.
According to Clark and Estes (2008), confidence and belief can be very beneficial in
the pursuit of goals. In the case of self-efficacy in suicide prevention and resiliency, this
means instilling confidence from the POTFF into the operations personnel. Positive, peer-
based suicide prevention measures can yield success (Petrova, 2015). Clarke and Estes
(2008) also noted that increasing individual’s belief in the ability to use newly developed
skills can enhance their ability to succeed. The combination of both practicing skills in
recognizing and assessing suicide risk combined with higher levels of self-efficacy result in
better ability to predict suicidal tendencies (Lee et al., 2016). Thus, the combination of both
instructing resiliency and intervention techniques and concluding with specific peer examples
of success could further POTFF suicide prevention resiliency efforts.
Require psychological performance program use as either a semi-annually currency or
with annual preventative health assessments (annual physical)
Data collection and analysis during Chapter Four found that some members in the
unit still question the follow through of the program among the many other goals present in
the command. Clark and Estes (2008) noted that motivation is challenged, and persistence
stalled in pursuit of less critical goals. As the POTFF is still in its infancy, as indicated by
multiple members during data collection, it is understandable why members have a cautious
view of the programs staying power. Questions of the program’s ability to persist as well as
Mitigating the Risk of Veteran Suicide 129
previously noted uncertainty concerning the effectiveness of the program could leave
members wondering how important it is to the organization’s members and how much the
program values itself or expects its own success. Eccles (2006) and Pintrich (2002), both
noted that expectancy value can be improved with thoughtful discussion on the utility and
importance of valued organizational goals. Clark and Estes (2008) also noted, once a goal is
chosen by, or in some cases selected for, an individual they can pursue a goal actively.
Requiring POTFF staff interaction as a portion of the annual preventative health assessment
or requiring a visit to the PPP as a semi-annual currency (requirement) would establish the
team’s belief and value in the utilization of the POTFF.
Cited in one case as simply "checking a box," and by others as time-dependent
before progress or value can be determined, the value and expectancy of the program could
be described as optimistic yet currently in progress. However, education and interaction can
combine to increase self-efficacy and positive values and expectations within suicide
prevention (King, 1999). Thus, the continued training and guaranteed contact could improve
expectations and value in both POTFF team members and operations personnel alike.
Furthermore, Clark and Estes (2008) noted that expectations can be raised if members are
given more power and control. Requiring members to utilize POTFF services would give
POTFF members the ability to retain more control over the amount of interaction they have
with the command. The requirement would also demonstrate the importance of the program
and the commands belief in positive expectations of success should they determine it
important enough to mandate a currency requirement. Lastly, step eight in Kotter's (2012)
model notes that for meaningful and enduring change, the changes made must be
institutionalized into the organizational culture. In this case, the meaningful change is
institutionalized by its inclusion in published theater standard operating procedures.
Mitigating the Risk of Veteran Suicide 130
Allow each POTFF pillar the opportunity to instruct on one additional subject
tangential to their primary position and reward accordingly
POTFF members need to feel their own efforts can lead to suicide prevention. As
discussed in Chapter Two, the military has previously utilized service-wide suicide
interventions deemed successful in lowering suicide rates (Knox et al., 2003). Furthermore,
Clark and Estes (2008) noted that an individual's value of a task, as well as effort exerted by
individuals as a result of the two, often determine the chances of success. During data
collection, multiple members noted they felt suicide prevention resiliency was important.
The same members also indicated they felt that their efforts directly contributed to resiliency.
Further promotion of positive attributions as they relate to suicide prevention could
provide more members the opportunity to feel their efforts contribute to resiliency, raising
motivation, and positive attribution within the entirety of the local command. Advertisement
of current POTFF successes at First Fridays and how the command as a whole took part in
creating success could reinforce command members’ belief in their efforts and overall
contributions to resiliency. Recognition of command climate success and tie in of local
contributions to resiliency efforts during First Fridays would quantify successes. Thus,
positive attributions could be increased if individuals were given the opportunity to pursue
additional duties or projects they value that also contribute to resiliency, reinforced by both
utility and quota schemes.
The opportunity for POTFF personnel to pursue an additional tangential duty that
they value and deemed beneficial to resiliency would ensure personnel feel their
contributions make a difference in suicide prevention resiliency. Eccles and Wigfield (2000)
highlighted that motivation and effort can be achieved by creating connections between
individual’s values and beliefs to the organizational goals. Clark and Estes (2008) noted that
one technique to increase positive attributions is to attribute success to the individual's ability
Mitigating the Risk of Veteran Suicide 131
or effort exerted. Thus, if the organization allowed pursuit of one particular interest or
personal project by each POTFF member aside from their primary duty, individuals could
excel in a task they value and can be expected to exert effort pursuing successful
accomplishment. One example is that of the PNC being provided the opportunity to include
nutrition advice education which contributes to resiliency as a result of the PNC’s individual
valuation of the secondary duty. Clark and Estes (2008) noted that individuals will do best at
what interests them the most. Ultimately, the latitude to allow more pursuits towards efforts
valued by individuals and reinforced by rewards systems, recognition, or compensation,
could lead to positive attributions and further success.
The organization should create a duty position for an approachable, mid-level, peer
uniformed service member to act as a liaison within the POTFF
Some individuals noted the need for approachable staff within the POTFF.
Additionally, other responses emphasized the need to have a peer with whom to discuss
shortcomings or troubles as medical and behavioral doctors can be difficult to approach.
Organizational influencer one noted the need for ongoing resources and support to enable
suicide prevention resiliency training. Clark and Estes (2008) indicated that the selection of
individuals within an organization at the same level and with similar goals do well for group
interaction.
Furthermore, Yosik et al. (2011) noted that peers present an effective yet
underutilized resource. Additionally, Smith-Osborne et al. (2017) noted that peer injection in
suicide prevention processes shows promise in efficacy and resiliency. Finally, multiple
members noted during the interview period that trust was not an issue among other
operations personnel. This suggests that the addition of an approachable, mid-grade
uniformed military member could provide further support via having a familiar outlet for
service command members.
Mitigating the Risk of Veteran Suicide 132
Clark and Estes (2008) noted the need for a culture of trust within the organization.
In the case of suicide prevention and resiliency, trust is imperative as it could mean the
difference between help-seeking or isolation. Trust can be garnered through peer
involvement, which can take prevention one step further and provide resiliency (Jenssen,
2013). Furthermore, Krenke (2017) identified peer support and interaction as a means to
proactively reduce or mitigate stigma. Yosick et al. (2011) identified peer-to-peer methods
as improving social cohesion. Alternatively, without the trust or support noted by the three
authors above, alienation can happen, which as Lin (2016) noted, will lead to isolation.
Ultimately, the literature suggests trust can be built with peer availability or peer
intervention. Thus, the addition of the liaison role is in line with literature and provides a
resource and ongoing support.
Evaluating Recommendations
The previous recommendations are based on prioritized Chapter Four findings from
assumed KMO influencers. Whereas no significant issues were present with respect to the
organization's culture and climate concerning suicide prevention resiliency, improvements
can be made. Other considerations related to attribution, expectancy-value, and self-efficacy
provide further opportunities for improvement on initial efforts. The proposals would ensure
that all members would know steps the organization has taken to prevent barriers to care,
including isolation, lack of information, stigma, and fear of consequences. The
recommendations also aim to prevent confusion or lack of information that, as Clark and
Estes (2008) noted, present a barrier to knowledge and organizational improvement. Each
solution has a tangible and quantifiable intervention that can be explicitly applied to the
command’s context and will be further discussed in this chapter’s implementation and
evaluation section.
Mitigating the Risk of Veteran Suicide 133
However, merely stating recommendations for improvement are of no value without a
sustainable plan for addressing interventions and evaluating progress towards achieving the
goals of the recommendations. The following section will provide an implementation and
evaluation plan for the local implementation. Through the use of the New World Kirkpatrick
Model, four steps will be used to suggest realistic and actionable interventions that can be
taken and implemented, monitored, and corrected or redirected if needed.
Implementation and Evaluation Plan
Change implementation or interventions to increase behavior benefit from an
evaluation to monitor the intervention’s progress. This study recommends using the
approach of the New World Kirkpatrick Model (2016), which focuses on four levels of
training evaluations. Using the order of results desired (Level 4), behavior (Level 3),
learning (Level 2), and reaction (Level 1), the model presents a quantifiable mechanism to
provide monitoring and evaluation of the recommendations made in this chapter. The
following sections will give a brief description of the four levels, how each level applies in
the context of this study, and an application of the levels in an easy to follow path to further
positive impacts in suicide prevention resiliency implementation.
Level One will provide a means to gauge how the training or intervention is received
by the local command. Level Two will determine how much of the intervention or training
was retained. Level Three will identify if members are exhibiting the behavior desired as a
result of the training or instruction provided. Ultimately these three levels will lead to Level
Four, evaluation of results, and determine the overall success of the recommendations chosen
for implementation.
The use of the Kirkpatrick and Kirkpatrick's (2016) Four Levels of Evaluation, both
implementation and ongoing evaluation, can provide a successful process for application of
the study’s noted recommendations. The recommendations noted are measurable, attainable,
Mitigating the Risk of Veteran Suicide 134
and realistic goals that are contextually specific to this command but could be of use to any
resiliency program looking to adjust further improve their current plan. Kirkpatrick and
Kirkpatrick’s (2016) noted the tendency for implementation and evaluation programs to get
expensive quickly putting a demand on resources. The suggested process to address
recommendations of this study followed Kirkpatrick and Kirkpatrick’s (2016) techniques to
prevent wasting resources, particularly by avoiding extraneous costs in Level One and Level
Two.
Furthermore, the pursuit to keep recommendation implementation within fiscally
responsible constraints, this study hopes to avoid draining resources that could in-turn create
another negative O influencer in the Clark and Estes (2008) KMO gap analysis model.
Additionally, upon initial completion and closure of this study’s recommendations, the same
POAM, TMT, and Readiness Tracking procedures would remain in place to provide ongoing
evolution and early warning of negative implications in the original influencers noted in this
study. Ultimately, this process will address current deficiencies while enforcing and
sustaining or complimenting in-place resiliency measures currently. This section describes
the implementation and evaluation of the recommendations for this study beginning with
Level 4 and working backwards as recommended by Kirkpatrick and Kirkpatrick (2016).
Level 4: Results
The desired results are the reason the intervention or training made by these
recommendations is performed (Kirkpatrick, 2016). Each of the eight recommendations
made in the previous section contributes toward the overall organizational goal of improving
or sustaining suicide prevention resiliency. Measuring results utilize tools such as internal or
external leading indicators, which can be described as progress targets or benchmarks
towards achieving results (Kirkpatrick & Kirkpatrick, 2016). Specifically, Kirkpatrick and
Kirkpatrick’s (2016) recommended military organizations use mission-driven metrics to
Mitigating the Risk of Veteran Suicide 135
create leading indicators. Timing, data, and surveys during the process of determining results
also play critical roles in measuring success. Most importantly, Kirkpatrick (2016) noted that
determining Level Four results is not a singular event but rather a process of monitoring
leading indicators towards the end desired goal or mission.
The desired outcomes provide the basis of Level Four and the three levels following.
Table 11 demonstrates the desired outcomes based on the recommendations of this study.
Additionally, Table 11 describes metrics to use as leading indicators and methods by which
to produce the outcomes.

Mitigating the Risk of Veteran Suicide 136
Table 11
Outcomes, Metrics, and Methods

Outcomes Metrics Method

Mechanism present that promotes
the effectiveness of locally
implemented resiliency measures

POAM briefed and approved by
Commander

Operational Planning Team (OPT)
creates a plan of action and
milestones
(POAM)

CONOP and in-place procedure
capable of 100% notification of
command members regarding
POTFF events or messages.

100 percent directorate
notification response and
approved closure of required task
management tool

Special Staff Directorate creates
the task in task management tool
and suspense for directorate
acknowledgment upon release of
supplemental guidance

First Friday activities contain
Testimonials or peer-led
discussion from unit members on
successful interventions or
resiliency techniques

Command Strategic yearly
calendar reflects 12 peer-led
activities assigned evenly along
the Directorates

Commanders Decision Board OPT
to assign Required Directorate by
Month responsible for First Friday
concept of operation
Mandatory requirement for PPP
through either appointment
during annual physical health
assessment or semi-annual
currency
Universal compliance with
readiness program, 100% noted
in weekly tracker
Operations staff includes PPP
currency in required Readiness
Tracking Program
No policies remain present that
impose negative career
consequences as a result of help-
seeking behavior. Should other
service maintain restrictive
policies, POTFF will provide its
members privilege.

Recommended and approved
rescinding of publications or
segments in conflict with the
policy
Legal review OPT to consist of
Judge Advocate and Personnel
Assigned and filled Liaison role
in the POTFF staff filled by a
mid-grade officer
Required and 100% sourced billet
of appropriate rank adjudicated by
Personnel Directorate
Special Staff and Personnel section
creation of Unit Manning
Document update in Task
Management Tool

Level 3: Behavior
Level Three consists of evaluating behavior as training or interventions alone will not
guarantee results, but participants retention and application is also needed (Kirkpatrick,
2016). In their description of Level Three, Kirkpatrick and Kirkpatrick (2016) also noted
that this phase is the most disruptive or critical transition as often the process of training or
intervention does not transfer to application towards desired results. Of the eight
Mitigating the Risk of Veteran Suicide 137
recommendations made in this study, a successful outcome will only be possible with the
correct positive application of the recommendations to actions implemented. For a
successful implementation, Kirkpatrick and Kirkpatrick (2016) recommended identifying a
few critical behaviors that will need to be present for successful transfer. Furthermore, they
noted the need for the utilization of required drivers (monitoring, reinforcing, encouraging,
and rewarding) that can be used to provide both support and accountability. Level Three
behavior is the critical juncture where transfer takes place, and this level relies upon the
required drivers, critical behaviors, reinforcing monitoring, and organizational support.
Critical Behaviors. Critical behaviors create a link from learning to desired
outcomes. To ensure the desired end state is met, critical behaviors must be those that most
likely influence results (Kirkpatrick & Kirkpatrick, 2016). The critical behaviors need to
address current personnel as well as future personnel arriving into the theater after changes
have taken place. The first critical behavior is the completion of a weekly OPT during which
metrics aligned with leading indicators are reviewed, progress is determined, and deficiencies
are addressed and corrected or noted as alibis. The second critical behavior is a situational
report delivered to the commander weekly by the OPT lead. The SITREP will note training,
progress towards goals, alibis, deficiencies, and a plan to resolve deficiencies. The last
critical behavior is the reporting of complete, overdue, or non-current status of personnel.
Directors would share responsibility with POTFF staff to identify and explain status, as well
as instruct the needed steps for completion of due outs.

Mitigating the Risk of Veteran Suicide 138
Table 12
Critical Behaviors

Critical Behavior Metrics Method Timing

Completion of Weekly
OPT

Current milestones
meet POAM
designated dates

The team uses Task
Management Tool

Weekly until
full
accountability
completed.

Every month
thereafter.

Provide weekly
Situational Report
(SITREP on progress
for Commander)

Percentage complete
towards identified
goals

The team uses Task
Management Tool

Weekly

Identify and report
deficient, overdue, or
non-current personnel
during

Total number of
discrepancies, fewer
alibis

Director required push
note or waiver to Chief
of Staff

Weekly

Required Drivers. Required drivers are those things that enable and energize critical
behaviors. Kirkpatrick and Kirkpatrick (2016) noted these as either supporting (reinforce,
encourage, reward) or accountability (monitoring). The required drivers indicated in Table
13 enable the required behaviors in Table 12. The weekly reminder with attached work
review checklist sent digitally to directors provides reinforcement and enables the weekly
OPT. Monthly encouragement from the Commander at First Friday events provides both
motivation and encouragement to members to complete required tasks enabling goal
completion for the Commanders SITREP. Lastly, by monitoring the command status as an
accountability measure combined with the reward of a goal day, identification and addressing
of deficiencies are enabled.

Mitigating the Risk of Veteran Suicide 139
Table 13
Required Drivers

Method Timing Critical Behaviors Supported

Reinforce. Reminder sent with
attached work review checklist

Weekly

1, 3

Encourage. Commander addresses
progress and program during First
Friday

Monthly

1, 2, 3

Reward. Set milestones within
POAM that if adhered to, result in
Goal Day

Quarterly

1, 3

Monitor. The team tracks metrics
towards completion in TMT,
successful pace with POAM
results in Goal Days

Weekly

2

Level 2: Learning
Kirkpatrick and Kirkpatrick (2016) noted learning is the amount to which individuals
retain the desired skills, aptitude, or confidence as a result of the desired intervention or
training. While the previous step focused on learning transfer to job performance, Level Two
is focused on acquisition and retention. Useful tools for formative evaluation of the desired
learning objectives could be evaluated by assessment, discussion, group sessions, role-
playing in case studies, or simulations (Kirkpatrick & Kirkpatrick, 2016). Other useful tools
for summative evaluation as described by Kirkpatrick and Kirkpatrick (2016) would be focus
groups, surveys, testing, interviews, or activities. Of the eight recommendations made, there
exist opportunities to apply both formative and summative evaluation focused on desired
learning objectives, which will be discussed in the implementation plan section. Ultimately,
Mitigating the Risk of Veteran Suicide 140
the evaluation will coincide with what Kirkpatrick and Kirkpatrick (2016) noted as the need
to plan for evaluation of desired or required skills, knowledge, attitude, and dedication.
At the conclusion of the initial OPT detailing recommendations and Level One
Reaction, multiple, yet efficient, methods will be used to determine to what degree the
POTFF team and operations personnel have retained the needed attitudes, methods,
requirements, and knowledge. A list of the prioritized learning takeaways will be noted for
retention should in progress reviews identify needs, confusion, or clarification. These
methods as suggested by Kirkpatrick and Kirkpatrick (2016) could be: discussion (brief),
teach back, focus group, and action planning. The noted methods are familiar to the military
culture and should reduce if not eliminate extraneous cognitive load that might otherwise
distract from the task at hand. Cognitive load in this context would be any extraneous
requirements focused on instruction style, facility resources, and unfamiliar planning
processes that would otherwise be better used for cognitive function on the task at hand.
(Sweller, 1994). The structure of the OPT is known and available in publication format for
military members. It provides sequential steps ultimately addressing mission, goals, courses
of action, contingencies, and other procedural planning considerations designed to be
understood universally and simple to implement. The following goals are those identified for
completion with regard to the recommendations. The team will be able to…
1. Codify local best practices and demonstrate effectiveness through an appropriate
mechanism.
2. Communicate social performance programs through multiple means to ensure all
members and family members are aware of social performance program
opportunities.
Mitigating the Risk of Veteran Suicide 141
3. Implement a rotating process by which peer members participate in First Friday
events and present testimonials on experience and successful techniques used to
promote resiliency and prevent suicide.
4. Create, administratively staff, and track a new required readiness item detailing
either a semi-annual individual PPP session requirement in conjunction with
annual physicals.
5. Identify and administratively staff rescinding of policies that result in negative
professional consequences for help-seeking behavior.
6. Create and distribute mission essential task list (METL), and utilize a mid-grade
liaison officer within the POTFF cell capable of providing approachability.
Kirkpatrick (2016) notes that it is often easy to spend too many resources on Level
Two Learning. The resource of note that this study identifies as the only significant resource
present in this instance is time. The creation of the liaison billet would have a human
resources cost, especially if it were sourced outside of authorized manning document
requirements. However, this study assumes the unit would retain the option to source
individuals from within the command eliminating the additional billet, as a contingency. The
timing required in learning as well as the other levels are noted in the section tables.
Kirkpatrick and Kirkpatrick (2006) noted that almost any activity can be used to evaluate
accomplishment of Level Two. This study poses the observation or evaluation of Level Two
Learning can be accomplished during the initial OPT or subsequent OPTs. The following
methods for evaluating learning as suggested by Kirkpatrick and Kirkpatrick (2016) and
noted for use in this study are found in Table 14.

Mitigating the Risk of Veteran Suicide 142
Table 14
Learning: type, activity, and timing

Component Type Activity/Method Timing

Knowledge

Knowledge check on Plan of Action
Status and upcoming milestones

Knowledge Check on Ends, Ways, and
Means

Formative In-Brief with Summative
Out-brief and Mid-Course progress
checks throughout

Weekly

Weekly

Throughout

Skills

Rehearsal of Concept

Monthly

Attitude

Instructors Observations

OPT Participation/Attendance

Weekly

Commitment

Post OPT Summary Feedback

Weekly

Level 1: Reaction
Level One can be described as the overall impression of the training or experience of
being favorable as well as applicable and engaging to participating individuals. Similar to
Level Two, formative and summative evaluation of Level One can be conducted. In-
progress reviews can be performed by an observer or a solicitation for questions to gauge
interaction. Possible tools for summative evaluation can be surveys post training or
intervention with the possibility of further follow-up surveys. Summative assessment of
reaction to training or intervention is standard practice in military organizations and will
make an evaluation of Level One non-interference as further described in the evaluation plan
section.

According to Kirkpatrick and Kirkpatrick (2016), Level One Reaction should be the
most familiar of the four levels. Reaction, as noted by Kirkpatrick and Kirkpatrick (2016),
contains the following three pieces: engagement, favorability, and relevance. This study
Mitigating the Risk of Veteran Suicide 143
posits that initial reaction would be gauged at the Commanders Initial Guidance if the
Commander chose to implement this plan’s recommendations. Kirkpatrick and Kirkpatrick
(2016) recommend prioritizing formative reaction. This study, therefore, recommends three
formatives with two summative feedback tools and techniques. In order to reduce extraneous
cognitive load, the familiar formatted of receiving of commander’s guidance followed by
questions, answers, or clarifications with an initial brief back shortly thereafter is a familiar
process, thus limiting extraneous cognitive load is recommended.

Mitigating the Risk of Veteran Suicide 144
Table 15
Reaction: Methods, Tools, & Timing

Method Tool Timing

Formative

Instructor/Commander Observation

Beginning and Middle of
Commanders Guidance

Formative

Pulse Check

Midway through
Commanders
Guidance at a minimum,
or throughout as needed

Formative

Dedicated Observer

During Commanders
Initial Guidance and
Brief-Back to the
Commander

Summative

Around the Room Inputs, Feedback,
and alibis.

Post Initial Guidance
Brief with concluding
solicitation

Summative

Brief-back to Commander
on Initial Guidance and Commander’s
Intent

One week from receipt of
Commanders Initial
Guidance

Evaluation Tools and Reporting
Throughout the implementation and evaluation plan set forth by this study, three main
evaluating tools will be used. The instruments consist of a Task Management Tool, POAM,
and readiness tracker. Furthermore, reporting will consist of aggregated data from each of
the three for inclusion in Commander's SITREPs and in-progress reviews. Following is a
brief description of the evaluating and reporting tools.
The Task Management Tool will provide access to all assigned members of the
POTFF, OPT, and Special Staff in order to monitor, update, directly task, and update
progress on assigned and emerging requirements. All relevant material for background,
briefs, metrics, and archives will be stored in the program. Furthermore, notifications for
upcoming events and required submissions or briefs would ensure continuity and
communication among the assigned stakeholders.
Mitigating the Risk of Veteran Suicide 145
The POAM, created after Commanders Initial Guidance, provides a training plan of
action, relevant dates, requirements, and benchmarks to be achieved upon a conceptual
timeline. The POAM is a living document and will continue to be shaped by the OPT to
reflect in-progress checks, feedback, and completed goals. As a living document, the POAM
also presents in-progress feedback at any time. Furthermore, the POAM will include a stop
light charts that presents completed tasks (green), in-progress tasks (yellow), and past-due
tasks (red).
The readiness tracker is the adjudicator of whether or not individuals have met the
newly established requirements. Trackable items would include semi-annual PPP session
and required resiliency briefs as an example. Updated and reported weekly, and viewable at
any time, the readiness tracker will provide in-progress feedback on the distance to go in
achieving the required 100% readiness rate. The combination of the readiness tracker with
the POAM and TMT integrate to provide positive redundancies into either monitor and
report progress or deficiencies while pursuing performance goals.
Reporting progress or deficiencies will be conducted weekly. The status of tasks in
the Task Management tool and individual or directorate deficiencies would be noted. The
current readiness percentages would be computed and noted. The two metrics would be
matched against the POAM to determine if the recommendation implementation process was
on or off track and what planned or unplanned milestones may be affecting results. The
synthesis of the data between the three would be included in the Commander's weekly
SITREP with an explanation on the current status, success, deficiencies, reasons, and weekly
reports of upcoming efforts and corrective actions to be implemented. Changes in behavior
could be demonstrated during the SITREPs through trending data, exemplified by readiness
numbers climbing or falling as well as participation in POTFF events rising or falling.
Mitigating the Risk of Veteran Suicide 146
Ultimately, this ongoing process of implementation and evaluation provides what Kirkpatrick
and Kirkpatrick (2016) noted is a need: an ongoing process of evaluation.
Limitations
This study was not without limitations. Constraints can challenge both internal and
external validity. Limitations identified are those that were either beyond the control of the
researcher, deficient, or a result of restrictions placed upon the study. The limits to this study
that were observed early and often were contextually specific to the command’s region and
the period of the study. The following is a brief description of observed limitations: unique
geopolitical environment, inability to control for members with negative experiences form
previous units, the program’s limited period of existence, small amount of studies and data,
and the inability to directly observe motivation.
The period of this study occurred during a time of increased geopolitical tensions. As
a result, the individuals observed and interviewed were most likely under a significant
amount of stress unrelated to the focus of the study. At a minimum, data provided by the
members was shaped by a significantly increased workload and potential for armed conflict
that might not be present in the same unit if they were redeployed back to the United States.
Furthermore, this unit is a sample size designed to represent dozens of units containing
thousands of personnel. Thus, the issues surrounding suicide prevention resiliency could be
different between, as an example, the Middle East, Far East Asia, or Tampa, Florida. The
resiliency programs or cultures in other locations could also have had a direct effect on the
unit members before they arrived at the TSOC as noted in the next paragraph.
A limitation that was evident was the lack of ability to control for previous negative
experiences with the stigma surrounding suicide or suicide resiliency implementation. This
study evaluated a unit with a Commander visibly determined to encourage POTFF use and
lessen the stigmas associated with help-seeking behavior. However, the researcher assumed
Mitigating the Risk of Veteran Suicide 147
that over a member’s ten-plus year careers their perceptions of help-seeking, feelings of trust
or mistrust, and willingness to help seek may not have had the same cultural acceptance or
resources available depending upon the cultural setting. Furthermore, the study cannot also
account for what happens if these members leave and join another command that is less
accepting of help-seeking or self-betterment.
Due to the relative newness of the program, the researcher assumes one limitation
was that members might not have had prolonged experience with the POTFF to form
complete opinions. This was evident in some answers during data collection citing the need
for more time before determining effectiveness. Each member within the command has
military service that pre-dates the beginnings of the POTFF program, and as previously
mentioned, their opinions on trust and culture could have been shaped long before the
POTFF program began. Ultimately though, based on interviews and observations, this did
not appear to have an overly visible effect upon this command’s implementation of suicide
prevention resiliency measures. Given there were no instances of suicide that occurred
during the course of this study, it would be pure speculation to determine if attitudes or
actions would have changed given a different contextual environment. However, the holistic
nature of the POTFF allows teams to specifically tailor services appropriate to the assigned
units climate, culture, and needs.
The last significant limitation noted was that of observing motivation. Reeve (2008)
indicated that motivation cannot be observed, but behaviors consistent with motivated people
can be observed. It would be impossible for the researcher to assign specific meaning to
individuals’ motivation during the course of this study. It would further be impossible to
know what specifically and internally was motivating individuals to pursue implementing the
measures they did and creating the trusting environment they did. The researcher assumes
that individuals implement these measures because of the alarming rate of veteran suicide
Mitigating the Risk of Veteran Suicide 148
and a sense of caring and duty to uniformed service members. However, it must be noted
that as military members, following orders is paramount and in some cases can be the reason
members complied with program implantation. Based on the researcher’s observations
though, the observed reasons for implementation centered around benevolence and
preservation of resources.
Delimitations are those that are used to bound the focus of a study. This study did not
solicit nor create space to explore any HPAA information. No solicitation of personal or
professional loss to suicide was ever asked or needed during the course of the study, although
several members wanted to share, and in some cases discussed past stories of fellow service-
members of their own volition. During numerous of these unsolicited exemplars, the
researcher noted that it was outside the needs of the study, but the following study would do
well to explore this population (exposure to POTFF and how it could have helped individuals
in the past). Furthermore, the study avoided individual service branch comparisons that
contribute personnel and resources to USSOCOM (USA, USN, USMC, and USAF),
members were noted as unit members or POTFF team members. This study focused on
individuals currently deployed overseas. Stateside units, TDY members, or members
redeployed from overseas were not included for the population. Lastly, due to bounds set
forth by the duration of the study, the time spent on document analysis, the numbers of
individuals interviewed, and the number of observations activities were not given unlimited
time. More researchers, funding, and an extended period of collection could return, perhaps,
more robust and refined results. Lastly, this case assumed numerous identifications of
performance gaps would emerge immediately and thus, was not wholly prepared for the
numerous initial positive data points, strengths, and opinions that emerged. Although almost
any study could find areas for improvement, it would be prudent to note that the researchers
exploring this topic must also be prepared for population samples or programs that
Mitigating the Risk of Veteran Suicide 149
demonstrate overly positive initial results, such as this one, even if the study model is
characterized by evaluation. Put simply; the delimitations should have allowed for initial
large-scale success.
Strengths and Weaknesses of This Approach
This use of the Clarke and Estes (2008) modified gap analysis model when studying a
military organization presented both strengths and weaknesses. Advantages of an approach
not familiar to personnel provided a new lens with which to evaluate an ongoing problem.
On the contrary, the new method required an explanative preamble when conducting
interviews or explaining the study to military personnel. The following section will briefly
discuss the strengths and weakness of the Clark and Estes (2008) model as it pertained to the
study and note areas where future research could benefit from the use of a different model.
The use of Clark and Estes (2008) provided an analysis tool far different than
typically used in the military, exemplified by doctrine, tactics, or planning procedures.
Overfamiliarity with the military planning process or operational planning team process
could create issues with the investigator becoming channelized. Clark and Estes (2008)
noted that when pursuing goals, it is important not to assign a task so familiar that it requires
little effort or motivation will decline. This is the same case for the use of this model. The
relative lack of familiarity of the KMO model between both the researcher and the
interviewees led to opportunities for discussion on where challenges exist within the
organization. Although using an unfamiliar and foreign model given the population, the
extra time lost to explanatory preambles was made up for by the relative simplicity of
restricting problems to K, M, or O. Furthermore, the use of Clark and Estes (2008) for
qualitative study was useful by providing the themes for a priori coding and grouping of
trends in findings almost immediately.
Mitigating the Risk of Veteran Suicide 150
A considerable weakness of the selection of the KMO model was individual’s
unfamiliarity with using a model that was not military or another common doctrine.
Although this seems simple enough, specific words between the Clark and Estes (2008)
model posed the possibility to present confusion. Resources were an exemplar of confusion.
Doctrinally, resources in the military fall under a directorate whose duty is to manage
budgets and programs. Thus, when the researcher would inquire into if the organization was
providing the POTFF the appropriate resources meaning could be made multiple ways. In
numerous instances, individual’s initial answers noted they were unaware of what resources
(budget) the POTFF had. With a further explanation of the contextual meaning of
"organization" and "resources" confusion was always remedied. The researcher would have
done well to adapt the language from Clark and Estes (2008) to a more suitable doctrinal
term.
Other strengths and weaknesses noted were again specific given the military
population. Documents and publications were readily available and posted by respective
department branches online or in congressional archives and a publicly available budget.
Suicide specific statistics involving military personnel were readily available as a result of
the CDC published suicide statistics. Support and resources provided by senior leadership
and mid-level management towards the pursuit of the study method were enthusiastically
offered, and support was never questioned. Additionally, access to POTFF and operations
personnel, and an overall universal agreement in USSOCOM that veteran suicide is a
problem of practice resulted in a large pool of interviewees to query and observation
activities to join. The access provided and participants willingness made for a smooth data
collection period with plenty of time to member check, which added to validity.
A considerable weakness of the study was assumed to be the potential for honest
answers or overly courteous interviewees criticizing the command. Although the researcher
Mitigating the Risk of Veteran Suicide 151
was either a peer or junior to the population interviewed, it was initially assumed individuals
might be hesitant to note areas where improvement could occur based off military courtesy.
However, given some candid feedback and precise answers rendered by interviewees, these
concerns were somewhat lessened but cannot be wholly dismissed. Additionally, due to
different classification levels of various facilities, as well as individuals personal comfort
levels, recording devices and identifying personal information were never planned for use.
The real cost of the inability to use technology and identifying information was realized
mostly by time consumed coding notes by the researcher and the added time needed for
member checking to ensure notes taken captured the spirit and intent of the interviewee.
However, given the population, this is an assumption that would most likely not change with
any approach.
Recommendations for Future Research
There are numerous potentialities for future research regarding suicide prevention
resiliency. This study highlighted the discussed recommendations below. Suggestions from
the interviews in this study identified research articles written by individual POTFF members
that could be of utility. Additionally, based upon analysis of Chapter KMO influencers in
Chapter Four, this section recommends research regarding KMO topics noted below.
The first recommendation for future research this study asserts is a longitudinal study
of USSOCOM members as they progress through their career. Chapter Two had noted the
need for more data while interviews emphasized the need for more time. A longitudinal
study of USSOCOM individual members, tracked by the POTFF, could both contribute more
data and evaluate the effects of suicide prevention resiliency measures over time.
Furthermore, the study could also address a line of outstanding research called for by the
current USSOCOM Commander General Thomas (2018) to measure behavioral health in the
context of trauma over time.
Mitigating the Risk of Veteran Suicide 152
A second recommendation for future research would be a specific study focused on
motivation, specifically active choice in utilizing veteran suicide prevention resiliency
measures. Chapter Four identified a strong presence of knowledge and resources noted
among POTFF members and operations personnel. Limitations concerning the ability to
observe motivations were also recorded. Individuals appear to understand and have access to
benefits provided through resiliency programs. A study focused on active choice could
highlight other areas beyond the perception of stigma and harm to career that prevents
members from actively choosing to seek assistance to bolster individual resiliency.
A third recommendation based on the limitations section of this study would focus on
the history of professional impacts of help-seeking behavior and stigma. The potential of
exploring instances of negative or benign impacts on members careers could inform a
literature review. Data would be collected on current interventions designed to remove the
negative associations of resiliency or help-seeking behaviors. This data could provide both
POTFF and academia more research on the effectiveness of interventions contributing to
suicide prevention, resiliency, and help-seeking programs effectiveness. The data would also
provide in-progress feedback potentially adding to further interventions.
Peer-reviewed POTFF sponsored case studies published quarterly were noted as a
recommendation during the interview portion of this study. Both a professional expectation
and a useful tool to USSOCOM members, the addition of research published by POTFF team
members would both contribute to the body of research and improve factual, procedural,
metacognitive, and conceptual knowledge of POTFF members. Furthermore, the overall
contribution of peer-reviewed journal articles and research could be of use to the
conventional arms of the military as well as academia and veteran support organizations.
Lastly, Chapter Two, as well as interviews and document analysis, found instances of
USSOCOM’s desire to partner with academia regarding resiliency. A formal partnership
Mitigating the Risk of Veteran Suicide 153
with specific university system could provide USSOCOM and the respective partner
University access and placement within each other to further research. This opportunity to
effectively collaboration and liaison to promote further research and create academic synergy
while simultaneously increasing the number of available researchers to study and publish on
suicide prevention resiliency. Currently, USSOCOM issues an annual call for research topics
that in the past (2017) listed force preservation as a topic for research. Expanding these
solicitations to partner Universities could render a more substantial potential for academic
engagement.
Conclusion
After 18 years of continuous conflict, the veteran population of the United States has
seen an increase in suicide rates above that of the general population. A period of two wars
and numerous commitments to smaller crises have challenged the resiliency of the all-
volunteer force of the United States Military. The population of USSOCOM has not been
immune to the increased rates of suicide. Noticing the increased degradation of the force,
USSOCOM created the resiliency program that was the focus of this study: The Preservation
of the Force and Family.
USSOCOM has attempted to create a pre-habilitative approach to bolster resiliency
before it becomes too late for SOF members and their families. At the onset of this study, it
was immediately evident through literature that much remains to study on veteran suicide,
both in data and publication. Even more is yet to be explored on SOF-specific suicide and
the Preservation of the Force and Family program. Future researchers would do well to find
opportunities to measure the effectiveness of the program across SOCOM entities and
quantify the strengths, weaknesses, and lessons learned from this holistic, pre-habilitative
program that might only be discovered through more rigorous research. Contributions to the
USSOCOM and Academia partnership would advance research as noted by so many in
Mitigating the Risk of Veteran Suicide 154
literature, by the Centers for Disease Control, and by congressional testimony. Perhaps in
time, research of newer holistic practices can prevent the loss of our nation’s military
members to the invisible wounds of war and conflict that ultimately end in suicide.

Mitigating the Risk of Veteran Suicide 155
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Mitigating the Risk of Veteran Suicide 164
Appendix A
KMO Influences and Research Questions Matrix

KMO Influence Interview Questions Observations Documents
POTFF needs to know the
effectiveness of suicide
prevention measures and
best practices for suicide
prevention

● Can you tell me about a
time in your career
involving your most
challenging case or example
before coming here?
● What would be your
approach if you saw the
same case today?
● What do you think the most
effective strategies are for
suicide prevention or
implementing resiliency
measures?
Observe the different
measures

and

practices POTFF and
the organization
implement
Operating
Instructions

Training
Publications

General
Knowledge
publications
on hand

Availability or
resource
listings
POTFF needs to assess
personnel knowledge of
help seeking and
reporting process,
persistent barriers to care
and what risk factors exist
within organization

• Describe the initial stages in
your in-processing
requirements with respect to
POTFF, if any?
• What are things you see and
hear about as barriers to
individuals accessing
services?
• How do you address them
or address incidents of
perceived barriers?

Observe instruction
of help seeking,
reporting

or

Available services
and how to utilize
them
Initial
Inproccesing
checklists

POTFF Wave
Surveys
POTFF needs to know
how to implement suicide
prevention strategies.

• Do you think your approach
to suicide prevention and/or
resiliency measure
implementation has changed
during your career? If so,
how?
• What do you do in your
specialty that contributes
towards resiliency?
• Follow up- How does it do
that?
• Hypothetically, what do you
do now when faced with a
potential red flag situation
or when instructing others
on how to avoid red flag
situations?
• If you were training other
unit personnel what
strategies would you
recommend they use?

Observe safety
briefings

In-processing

Safety Briefs

POTFF sponsored
activities
Operating
Instructions

POTFF Wave
Surveys

In processing
instructions
POTFF members need to
feel confident in their
ability to implement
• How confident are you in
your ability implement and
Observe what
members choose to
say and do
POTFF Wave
Data results

Mitigating the Risk of Veteran Suicide 165
suicide resiliency
measures.

sustain suicide prevention
measures?
• How do you feel about the
work you do?
• How do you feel about how
you implement resiliency
measures currently as
compared to your past duty
assignment?
• Follow up: What do you
think contributes to your
feeling like this? (What
affects your confidence?)
• Is it a specific instance or
example or trends?
surrounding the work
environment and
during POTFF
centered events
Publicly
available
bulletins
Personnel need to feel it's
important to implement
suicide prevention
resiliency measures.

• In general, how important is
it that suicide prevention
resiliency measures get
implemented within the
unit?
• What are your general
individual thoughts about
the importance of resiliency
efforts as compared to other
ancillary duties?
• Where do you think the
importance of resiliency
falls in the organizations
priorities and why?

Observe what
members choose to
say and do
surrounding the work
environment and
during events
Training
documents

Safety briefs

Resiliency
training

wingman
briefs/
policies
POTFF members need to
feel that their own efforts
can influence suicide
prevention resiliency.

• What kinds of factors do
you think affect the
implementation of suicide
prevention resiliency
measures?
• How do individual efforts
impact resiliency efforts for
the unit?
• In what ways do you believe
individual efforts can
contribute towards
resiliency implementation
and suicide prevention?
Welcome briefs

Safety Briefs

Inproccessing

POTFF hosted events
Wave Data
Trends

Operating
Instructions

Publicly
available
bulletins
The organization needs to
provide ongoing resources
and support for suicide
prevention training

• What are the challenges in
implementing resiliency
measures during times of
heightened tension or
conflict?
• Follow up: What resources
and support currently enable
resiliency?
• Do you feel you receive
enough resources like time,
money, or space, or
materials?
• In what ways?
Unit All-Calls

Welcome briefs

Safety Briefs

Inproccessing

POTFF hosted events
Training
documents

Budget

UFR
allocations

Calendar

Mitigating the Risk of Veteran Suicide 166
The organization needs to
provide a culture of trust
around suicide prevention

• Do you believe individuals
feel a culture of trust exists
in the organization?
• Do you feel like you
contribute to an atmosphere
where if someone needed
help they could ask?
• Do you feel like members
would speak up on their
own or someone else’s
behalf with respect to
suicide prevention?
• Do you think use of
resiliency services,
measures, or help seeking
behavior would negatively
impact perceptions of
individuals?
• Follow up: What are your
perceptions of the
organization’s approach to
suicide prevention?
• How do you think the
organization conveys their
beliefs of providing a
culture of trust?
Welcome briefs

Safety Briefs

Inproccessing

POTFF hosted events
Welcome
package

Inproccesing
checklist

Welcome brief
handouts

Display boards

Publicly
available
bulletins

Mitigating the Risk of Veteran Suicide 167
Appendix B
KMO Influence and Instrument Protocol

KMO Influence and Instrument
KMO Influence Observation Interview
Document
Analysis
POTFF needs to know the effectiveness
of suicide prevention measures and best
practices for suicide prevention
In-Processing,
Pillar
Sponsored
Activities
1,2,3, 5,6,9,10,11,12 X
POTFF needs to assess personnel
knowledge of help seeking and reporting
process, persistent barriers to care and
what risk factors exist within
organization
In-Processing,
Pillar
Sponsored
Activities
1,2,3,5,6,9,10,11,12 X
Self-Efficacy- POTFF members need to
feel confident in their ability to
implement suicide resiliency measures
N/A 4,5,7,8,9,11,12 X
Expectancy Value- Personnel need to
feel it's important to implement suicide
prevention resiliency measures
N/A 4,5,7,8,9,11,12 X
Attribution- POTFF members need to
feel that their own efforts can influence
suicide prevention resiliency
N/A 4,5,7,8,9,11,12 X
The organization needs to provide
ongoing resources and support for
suicide prevention training
In-Processing,
Staff Meetings,
Pillar
Sponsored
Activities
1,2,3, 4,5,6,8,9,10,11,12 X
The organization needs to provide a
culture of trust around suicide
prevention
In-Processing,
Staff Meetings,
Pillar
Sponsored
Activities
1,2,3,4,5,6,8,9,10,11,12 X

Mitigating the Risk of Veteran Suicide 168
Appendix C
Interview Protocol

Thank you for taking the time to for this interview. This brief, semi-structured
interview will last no more than one hour and will help inform me on my study of the
POTFF’s efforts in suicide prevention resiliency measures. As a reminder this is completely
voluntary, and as I am outside your chain of command, there is no requirement for you to
participate. I am going to ask you twelve questions surrounding knowledge, motivation, and
organization related on how the POTFF is functioning. Where most of these questions will
be open ended or hypothetical, none will ask personally identifiable information or questions
about specific individuals. These questions should seem fairly simple in nature to you and
should not raise concern, but I want to remind you if at any time you do not wish to continue
or feel uncomfortable about any questions or the interview, you are free to stop at any time
and not have your responses or participation included. Your name, as well as the
organizations, and your participation will not be noted anywhere in this study and transcripts
and/or notes will be deleted and/or shredded when I have completed this study. If you do not
mind I will record our conversation for transcription purposes, this will allow me to focus
solely on what you have to say and keep me from being distracted and slowing you down by
note-taking. Nevertheless, if you do not want me to record I am happy to take notes and will
double check with you that I captured your intended responses. The informed consent sheet I
have provided you should help with any of the information I have described. Do you have
any questions for me before we begin? Great, while we are talking about beginning, lets
discuss your beginning with respect to the POTFF.

1. Describe the initial stages in your in-processing requirements with respect to
POTFF, if any. (K, O) (Experience)
Mitigating the Risk of Veteran Suicide 169
Follow Up/Clarification/Probe: Describe any requirements similar to that of the services the
POTFF has?
Transition: Let’s talk about once you were already in-processed.
2. Tell me about your last experience in which the POTFF interacted with or
instructed the unit or directorate as a whole, if any. (K, O) (Experience, Sensory)
Follow Up/Clarification/Probe: Were there any instances you were aware of other than
formal instances you could describe such as useful emails, service advertisements, exercise
recommendations, or peer network activities you could describe?
Transition: Let’s talk about POTFF services with respect to how familiar they are made and
prioritized.
3. Describe the different services and opportunities of the POTFF you have seen
advertised to your fellow directorate members, if any. (K, O) (Experience, Sensory)
Follow Up/Clarification/Probe: What focus area of the POTFF have you heard advertised the
most?
Transition: I am curious as to your thoughts on how you feel these efforts contribute.
4. What ways do you feel the POTFF contributes to resiliency, if any? (M, O)
(Interpretive, Belief/Value)
Follow Up/Clarification/Probe: Can you describe which of the POTFF benefits or
opportunities you see as the most popularly used or overt?
Transition: There is always room for improvement, let’s explore that.
5. Imagine a perfectly operated POTFF program for the Operations Directorate, what
would that look like? (K, M, O) (Ideal, Sensory)
Follow Up/Clarification/Probe: How might that look different than what you see now?
Transition: So why we are discussing hypotheticals, let’s look at another.
Mitigating the Risk of Veteran Suicide 170
6. Describe a hypothetical scenario if you could in which you would recommend the
POTFF services to another unit member. (K, O) (Hypothetical, Belief/Value)
Follow Up/Clarification/Probe: Which would you recommend most in this circumstance and
describe how?
Transition: Lets continue to discuss hypothetical environments assuming suicidal tendencies
existed.
7. What aspects of the POTFF do you believe could combat suicidal tendencies
amongst directorate members, if any? (M, O) (Opinion/Value)
Follow Up/Clarification/Probe: Can you describe a few warning signs of suicide the POTFF
model might be able to stave off?
Transition: While we are thinking of these aspects, lets imagine they were being used by
members frequently and discuss.
8. Can you imagine a possible situation in which stigma might be present surrounding
use of the units POTFF services? (M, O) (Interpretive, Opinion/Value)
Follow Up/Clarification/Probe: Have you seen outside environments where stigma could
have been overt?
Transition: Moving away from negative side effects, let’s talk about positive side effects.
9. How do you believe successful implementation of resiliency programs can build
resiliency and prevent suicide, if at all? (K, M, O) (Belief/Value)
Follow Up or Clarification: If not, how about physical, social, or spiritual?
Transition: Let’s look at a future possible scenario.
10. Describe a hypothetical scenario in which a member came to you asking to utilize
POTFF medical or psychological services, what would your responding considerations be.
(K, O) (Hypothetical, Sensory)
Follow Up or Clarification: Where might you point them know or get them information?
Mitigating the Risk of Veteran Suicide 171
Transition: So, let’s say in our fictional scenario a member did not come to you, but you
thought you tell them about what is available at the POTFF.
11. Walk me through a situation in which you might recommend a member go see the
POTFF. (K, O) (Background/Demographic)
Follow Up or Clarification: Describe a situation where you might recommend to the POTFF
they provide information to the unit.
Transition: Well you have given me a lot to think about with respect to knowledge,
motivation, and organizational factors present let me ask one last question
12. Are there any topics with respect to the POFTT or suicide prevention we have not
discussed today that you think might be worth talking about?

Thank you for your time today. If you have any questions you would like to follow
up on you have my card. I want to remind you that your participation was voluntary, and
should you want to be excluded simply let me know. As long as you do not mind once I
have compiled and transcribed my notes there is a possibility I might seek clarification from
you to make sure I accurately represent what you told me. Thank you again for your time
and have a good day.

Mitigating the Risk of Veteran Suicide 172
Appendix D
Research Questions and Applicable Instruments

Mitigating the Risk of Veteran Suicide 173
Appendix E
Interview Questions and Corresponding Research Questions

Interview Questions Corresponding Research Questions
1 - Describe the initial stages in your in-
processing requirements with respect to
POTFF, if any.

Follow Up: Were there any requirements
similar to that of the services the POTFF has?

1, 2, 3
2 - Tell me about your last experience in
which the POTFF interacted with or
instructed the unit or directorate as a whole, if
any.

Follow Up: Were there any instances you
were aware of other than formal instances you
could describe such as useful emails, service
advertisements, exercise recommendations, or
peer network activities you could describe?

1, 3
3 - Describe the different services and
opportunities of the POTFF you have seen
advertised to your fellow directorate
members, if any.

Follow Up: What focus area of the POTFF
have you heard advertised the most?

1,2,3
5 - What ways do you feel the POTFF
contributes to resiliency, if any?

Follow Up: Can you describe which of the
POTFF benefits or opportunities you see as
the most popularly used or overt?

2, 3, 4
6 - Imagine a perfectly operated POTFF
program for the Operations Directorate, what
would that look like?

Follow Up: How might that look different
than what you see now?

2, 4
Mitigating the Risk of Veteran Suicide 174
7 - Describe a hypothetical scenario if you
could in which you would recommend the
POTFF services to another unit member.

Follow Up: Which would you recommend
most and describe how.

2, 3, 4
9 - What aspects of the POTFF do you assess
can Combat suicidal tendencies amongst
directorate members, if any?
Probes: Can you describe warning signs of
suicide the POTFF model might be able to
stave off?

Follow Up: Describe peers response.

1, 3,
10 - Can you describe a situation in which
stigma might be present surrounding use of
the units POTFF services?

Follow Up: Have you seen previous
environments where stigma could have been
overt?

2, 3
11 - How do you believe successful
implementation of POTFF resiliency
programs can build resiliency and prevent
suicide, if at all?

Follow Up: If not, how about physical, social,
or spiritual?

1, 2, 4
12 – How might a fictional directorate
member might be treated within the unit if
they were perceived to be using POTFF
services for mental well-being?
Probes: If not, how about physical, social, or
spiritual?

Follow Up: Would you know where to get
them information?

2,3
13 - Describe a hypothetical scenario in
which a member came to you asking to utilize
POTFF services, what would your responding
considerations be.

2
Mitigating the Risk of Veteran Suicide 175
Follow Up: Would you know where to get
them information?

14 - Walk me through the characteristics of a
situation in which you might recommend a
member go see the POTFF.
Follow Up: Describe a situation where you
might recommend to the POTFF they provide
information to the unit.

1, 2
15 - Are there any topics with respect to the
POTFF or suicide prevention we have not
discussed today that you think might be worth
talking about?

1,2,3,4

Mitigating the Risk of Veteran Suicide 176
Appendix F
Observation Instrument

Time/Personnel Observation Consideration

Mitigating the Risk of Veteran Suicide 177
Appendix G
Document Analysis Instrument

Mitigating the Risk of Veteran Suicide 178
Appendix H
List of Relevant Terms Specific to Findings

The following list contains key acronyms or pseudonyms contained within Chapter 4
as they reference participants and observed activities:
ASIST: Applied Suicide Intervention Skills Training
FRG: Family Readiness Group
HPP: Human Performance Program
IP1-IP15: Interview Personnel identified as 1-15
KI- Knowledge Influencer
MI- Motivational Influencer
OI- Organization Influencer
OIs- Operating Instruction
OP: Observation Periods, further identified as 1-5
OPSTEMPO: Operations tempo (workload and pace of work)
PNC: Peer Network Coordinator
PPP: Psychological Performance Program
SPP: Spiritual Performance Program
SM: Staff Member (pseudonym) numbered 1-4

Mitigating the Risk of Veteran Suicide 179
Appendix I
NVivo Word Cloud Created Derived from Interview

Appendix I. This visual is derived from the initial interview data input into the NVivo. Instances of words move
more to the center and grow in size based on the number of times used. This initial world cloud was generated
for future use at it demonstrated early on themes of: stress, people, stigma, and resources.

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Asset Metadata

Creator Unger, Zachary Daniel (author)

Core Title Mitigating the risk of veteran suicide: an evaluation study of suicide prevention resiliency implementation

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Publication Date 04/15/2019

Defense Date 03/08/2019

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

Tag DOD,gap analysis,Knowledge,Military,Motivation,OAI-PMH Harvest,organization,Prevention,resiliency,SOF,SOF suicide,Suicide,suicide prevention,suicide prevention strategies,USSOCOM,veteran

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Hirabayashi, Kim (committee chair), Andres, Mary (committee member), Astor, Ron (committee member)

Creator Email zdunger36@gmail.com,zunger@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-138168

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