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Post-traumatic stress disorder in the military and the associated stigmas: a gap analysis

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Post-traumatic stress disorder in the military and the associated stigmas: a gap analysis

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Content PTSD IN THE MILITARY AND ASSOCIATED STIGMAS

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Post-Traumatic Stress Disorder in the Military and the Associated Stigmas: A Gap Analysis

by

Jeremy M. Hendrickson

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

December 2019

Copyright 2019 Jeremy M. Hendrickson

PTSD IN THE MILITARY AND ASSOCIATED STIGMAS

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TABLE OF CONTENTS
ABSTRACT .................................................................................................................................. 10
CHAPTER ONE: INTRODUCTION ........................................................................................... 11
A. Introduction to the Problem of Practice ....................................................................... 11
B. Background of the Problem ........................................................................................ 12
C. Importance of Addressing the Problem ...................................................................... 13
D. Organizational Context and Mission .......................................................................... 14
E. Organizational Performance Status ............................................................................ 15
F. Organizational Performance Goal .............................................................................. 15
G. Description of Stakeholder Group .............................................................................. 16
H. Stakeholder Performance Goals ................................................................................. 17
I. Purpose of the Project and Questions ......................................................................... 17
J. Conceptual and Methodological Framework ............................................................. 18
K. Definitions .................................................................................................................. 19
L. Organization of the Project .......................................................................................... 19
CHAPTER TWO: REVIEW OF THE LITERATURE ................................................................. 21
A. Introduction ................................................................................................................ 21
B. General Review of The Literature ............................................................................... 21
1. Causes of PTSD ..................................................................................................... 22
2. Symptoms and Effects of PTSD ............................................................................ 23
3. PTSD and Stigma .................................................................................................. 24
C. The Clark and Estes' Gap Analytic Conceptual Framework ....................................... 26
D. Stakeholder Knowledge, Motivation, and Organizational Influences ........................ 27
1. Knowledge and Skills ............................................................................................ 28
a. Knowledge Influences 1-3 ............................................................................... 28
i. Sailors need an in-depth and accurate understanding of PTSD ............... 28
ii. Sailors need the ability to identify individual signs of PTSD that they
may be experiencing ............................................................................... 31
iii. Sailors need the ability to understand and recognize the associated
stigmas of PTSD ...................................................................................... 32
2. Motivation ............................................................................................................. 35
a. Self-Efficacy Theory ...................................................................................... 35
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i. Sailors deploying or supporting deployed units participating in peacetime
and Overseas Contingency Operations (OCO) need to see the value in
receiving medical care for PTSD. .................................................................. 35
b. Expectancy-Value Motivational Theory ......................................................... 36
i. Sailors deploying or supporting deployed units participating in peacetime
and Overseas Contingency Operations (OCO) need to see/feel the utility
value in receiving medical care for PTSD. .................................................... 36
3. Organization .......................................................................................................... 38
a. Organizational Influences 1 and 2 ................................................................... 38
i. The organization needs to provide Sailors pre/post-deployment training on
PTSD and stigmas ..................................................................................... 38
ii. The organization needs to create a culture that is free of stigmas relating to
mental health issues ................................................................................... 39
E. Conceptual Framework: The Interaction of Stakeholder's Knowledge and Motivation
and the Organizational Context ................................................................................... 42
F. Conclusion .................................................................................................................... 46
CHAPTER THREE: METHODOLOGY ...................................................................................... 48
A. Methodological Approach and Rationale ................................................................... 48
B. Participating Stakeholders ........................................................................................... 48
1. Survey Sampling Criteria and Rationale ............................................................... 49
a. Criterion 1 ........................................................................................................ 49
2. Survey Sampling (Recruitment) Strategy and Rationale ....................................... 49
3. Interview and/or Focus Group Sampling Criteria and Rationale .......................... 50
a. Criterion 1 ........................................................................................................ 50
4. Interview and/or Focus Group Sampling (Recruitment) Strategy and Rationale .. 50
C. Explanation for Choices .............................................................................................. 52
D. Data Collection and Instrumentation ........................................................................... 52
a. Surveys ............................................................................................................ 53
b. Interviews ........................................................................................................ 54
E. Data Analysis ............................................................................................................... 55
F. Validity and Reliability ............................................................................................... 56
G. Credibility and Trustworthiness .................................................................................. 57
H. Ethics ........................................................................................................................... 57
I. Limitations and Delimitations ..................................................................................... 58
J. Conclusion ................................................................................................................... 59
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CHAPTER FOUR: RESULTS AND FINDINGS……………………………………………….61
A. Survey .......................................................................................................................... 62
1. Survey Demographics ........................................................................................... 62
B. Knowledge Findings .................................................................................................... 63
a. Knowledge Influence #1: Sailors do have an in-depth and accurate
understanding of PTSD but lack a formalized and consistent knowledge source . 63
b. Knowledge Influence #2: Sailors are able to identify but are unable to
navigate through the associated stigmas ................................................................ 64
c. Knowledge Influence #3: Sailors are able to identify the individual signs of
PTSD that they may be experiencing but lack a formalized and consistent
knowledge source .................................................................................................. 66
C. Motivation Findings .................................................................................................... 66
a. Motivation Influence #1 and 2: Sailors are unable to see/feel (Utility Value)
the value in and are unconfident in receiving medical care for PTSD (Self-
Efficacy) ................................................................................................................ 66
D. Organization Findings ................................................................................................. 67
a. Organizational Influence #1: The organization does not provide Sailors
pre/post deployment training on PTSD and stigmas ............................................. 67
b. Organizational Influence #2: The organization culture consists of stigmas
relating to PSTD .................................................................................................... 67
E. Interview ...................................................................................................................... 68
1. Interview Demographics ....................................................................................... 68
F. Knowledge Findings .................................................................................................... 69
a. Knowledge Influence #1: Sailors do have an in-depth and accurate
understanding of PTSD but lack a formalized and consistent knowledge source . 69
b. Knowledge Influence #2: Sailors are able to identify but are unable to
navigate through the associated stigmas ................................................................ 69
c. Knowledge Influence #3: Sailors are able to identify the individual signs of
PTSD that they may be experiencing but lack a formalized and consistent
knowledge source .................................................................................................. 70
G. Motivation Findings .................................................................................................... 70
a. Motivation Influence #1 and 2: Sailors are unable to see/feel (Utility Value)
the value in and are unconfident in receiving medical care for PTSD (Self-
Efficacy) ................................................................................................................ 70
H. Organization Findings ................................................................................................. 72
a. Organizational Influence #1: The organization does not provide Sailors
pre/post deployment training on PTSD and stigmas ............................................. 72
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b. Organizational Influence #2: The organization culture consists of stigmas
relating to PSTD .................................................................................................... 72
I. Research Question Findings ........................................................................................ 73
a. Research Question #1 ..................................................................................... 73
b. Research Question #2 ...................................................................................... 74
c. Research Question #3 ...................................................................................... 74
J. Limitations and Delimitations .................................................................................... 75
K. Conclusion ................................................................................................................. 77

CHAPTER FIVE: RECOMMENDATIONS…………………………………………………….78
A. Introduction and Overview ....................................................................................... 78
B. Recommendations for Practice to Address KMO Influences ................................... 79
1. Knowledge Recommendations ............................................................................ 79
a. Introduction ...................................................................................................... 79
b. Increasing Sailors knowledge and understanding about PTSD and the
associated stigmas ................................................................................................. 81
2. Motivation Recommendations ............................................................................. 82
a. Introduction ...................................................................................................... 82
b. Increasing self-efficacy of Sailors to receive medical care for PTSD ............. 83
c. Increasing the utility value of receiving medical care for PTSD among Sailors
............................................................................................................................... 84
3. Organization Recommendations .......................................................................... 85
a. Introduction .................................................................................................... 85
b. Correlation of organizational resources and learning outcomes for Sailors .. 86
c. Organizational policies and practices that increase equity among Sailors ..... 87
C. Integrated Implementation and Evaluation Plan ....................................................... 88
1. Implementation and Evaluation Framework ........................................................ 88
2. Organizational Purpose, Need and Expectations ................................................. 89
3. Level 4: Results and Leading Indicators .............................................................. 90
4. Level 3: Behavior ................................................................................................. 92
a. Critical Behaviors ........................................................................................... 92
b. Required Drivers ............................................................................................ 93
c. Organizational Support .................................................................................. 94
5. Level 2: Learning ................................................................................................. 95
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a. Learning Goals ............................................................................................... 95
b. Program ........................................................................................................... 95
c. Evaluation of the components of learning ....................................................... 97
6. Level 1: Reaction ................................................................................................. 98
a. Evaluation Tools ............................................................................................ 99
i. Immediately following the program implementation .............................. 99
ii. Delayed for a period after the program implementation ........................ 100
b. Data Analysis and Reporting ........................................................................ 100
c. Further Research ........................................................................................... 101
d. Connection to Practice and Further Recommendations ................................ 101
e. Further Recommendations ............................................................................ 102
f. Summary ........................................................................................................ 104
APPENDIX A Survey Questions, KMO Relationship, Scale of Measurement, Potential
Analyses, and Visual Representation ................................................................. 106
APPENDIX B Interview Questions and KMO Relationship ..................................................... 115
APPENDIX C Disclosure and Consent Form ............................................................................ 116
APPENDIX D Interview Script .................................................................................................. 118
APPENDIX E Survey Instrument Question Template ............................................................... 121
APPENDIX F Sample Training Muster Sheet ........................................................................... 128
APPENDIX G Sample Pre-Training Survey on Post-Traumatic Stress Disorder (PTSD) and the
Associated Stigma .............................................................................................. 129
APPENDIX H Sample Post-Training Survey on Post-Traumatic Stress Disorder (PTSD) and the
Associated Stigma ............................................................................................... 130
APPENDIX I Sample Training Press Check Questions ............................................................. 131
APPENDIX J Sample 30-Day Post-Training Survey on PTST and the Associated Stigma ....... 132
APPENDIX K Sample Pre-Survey Results Bar Graph Chart ..................................................... 133
REFERENCES ............................................................................................................................ 134

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Epigraph
“Out of suffering have emerged the strongest souls; the most massive characters are seared with
scars” - Khalil Gibran

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Dedication
To the Sailors who have or think you may have PTSD, your courage to participate in my
study allowed me to be your voice on why you continue to suffer in silence. Without your
participation, this dissertation would not have been possible.

To the Sailors who participated in my study, the completion of this dissertation would not
have been possible without your candid input.

To my amazing children, I love you. Thank you for your understanding and sacrifice
throughout this journey. We will make up for the lost time and this would not have been possible
without you.

To my beautiful and amazing wife, thank you for your support, encouragement,
understanding, and sacrifice throughout this program. I am so thankful and blessed you are in my
life. I truly would not have been able to do it without you by my side and love you more than
words can express.

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Acknowledgments
I would like to express my deepest appreciation to my committee chair and members; Dr. Pat
Tobey, Dr. Jenifer Crawford and Dr. Kristin Forrester. Thank you for your encouragement,
support, and guidance to make this possible.

I would also like to extend my deepest gratitude to Dr. Don Murphy; thank you for your
encouragement and support to make my dissertation come to fruition. It would not have been
possible without the numerous hours you spent reviewing my dissertation and taking short notice
phone calls.

I am extremely grateful to all the professors I had throughout this program. Acknowledging that I
learned something from all of you is an understatement. My success and completion of this
program would not have been possible without the support and nurturing of all of you.

I cannot begin to express enough thanks to my peers in cohort 8, especially, Anthony, Ernie,
Edwin, Katie, Joe, Laura, Meredith, and Ruth. I learned so much from all of you and am a better
person, professional, and father because of you.

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Abstract
Post-Traumatic Stress Disorder (PTSD) has been part of the human condition since the evolution
of species. PTSD became a symbol of the wars in Iraq and Afghanistan because 20% of service
members were returning with symptoms of PTSD (How Common is PTSD, 2018). Research
indicates that 50% to 60% of service members do not seek treatment due to self-stigma reasons
(Barr, Sullivan, Kintzle, & Castro, 2016; Clement et al., 2015). The focus of this study was on all
active duty and reservist Sailors (enlisted and officers) who are serving in the United States
Navy. The organizational performance problem at the root of this study is the presence of stigma
among military personnel diagnosed with PTSD. The methodology design for this study
consisted of Clark and Estes’ (2008) Knowledge, Motivation, and Organization (KMO) Gap
Analysis and included an explanatory sequential mixed-method model, incorporating the
collection and analysis of both quantitative (surveys) and qualitative data (interviews). The
researcher found that Sailors have an in-depth and accurate understanding of PTSD, including
identifying individual signs of PTSD they may be experiencing but lack a formalized and
consistent knowledge source. Also, Sailors are able to identify, but are unable to navigate
through the associated stigmas. Sailors are unable to see/feel (Utility Value) the value in, and are
unconfident in, receiving medical care for PTSD (Self-Efficacy). Furthermore, the organization
does not provide Sailors pre/post-deployment training on PTSD and stigma, and the internal
culture consists of stigmas relating to PTSD.
Keywords: PTSD, stigma, combat, trauma, utility value, self-efficacy, signs and symptoms

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CHAPTER ONE: INTRODUCTION
Posttraumatic Stress Disorder (PTSD) has been part of the human condition since the
evolution of species. Some leading causes of PTSD to military personnel are combat, sexual
assaults, and witnessing or being involved in a traumatic event (National PTSD Center, 2018).
PTSD is more commonly known for the physiological and psychological effects service
members were experiencing long before the wars in Iraq and Afghanistan (History.com, 2017).
Moreover, before World War I and II, PTSD had other diagnostic terms associated with it, such
as war neurosis, battle exhaustion, and even post-Vietnam syndrome (Connell, 2015).
According to the National Institute of Mental Health (NIMH), about 8% of the
population experience a symptom of PTSD at some point in their lives (NIMH, 2016). These
estimates are for the general population and vary with specific categories and subgroups. There
is a significant prevalence of combat and non-combat related PTSD within the U.S. armed
forces. On average, 20% of military service members returning from a deployment to Iraq or
Afghanistan have PTSD (How Common is PTSD, 2018). Within the military, 23% were sexually
assaulted, and 55% of women and 38% of males experienced sexual harassment, further
increasing the number of service members who have PTSD (National PTSD Center, 2018).
The purpose of this study is to investigate the problem of the stigma associated with
PTSD. This problem negatively impacts the mission readiness of the military and the welfare of
its warfighters (service members) and their families. Research indicates that 50% to 60% of
service members do not seek treatment due to self-stigma reasons (Green-Shortridge, Britt, &
Castro, 2007). Research also stated that 60% of the service members who are seeking help for
PTSD feel that it will be perceived it is a weakness (Smith & Whooley, 2015).

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Background of the Problem

PTSD has become a symbol of the wars in Iraq and Afghanistan because 11% to 20% of
the U.S. service members participating in those conflicts were returning with symptoms
associated with the disorder (How Common is PTSD, 2018). While there is a significant amount
of history associating combat to PTSD, it is important to understand other traumatic situations
that may cause service members to have PTSD. Statistics indicate, that more than 50% of the
population is likely to experience other trauma, such as sexual assault, assault, child sexual
abuse, disaster, and a serious motor vehicle accident at least once in their lives (National Center
for PTSD, 2017). Schoenleber, Sippel, Jakupcak, and Tull (2015) conducted a study, which
consisted of male veterans, and found that 103 men reported being involved in a traumatic event,
84% reported a physical assault, 42% an assault with a deadly weapon, 4.9% a sexual assault,
and 30% an unwanted sexual assault. In their study, Hahn, Tirabassi, Simons, and Simons (2015)
found that out of 90 veterans, 1% to 13% of men and 14% to 42% of woman reported a military
sexual assault.
PTSD affects the lives of individuals as well as the people around them. PTSD is
commonly associated with uncontrolled anger, increased alcohol consumption, suicide,
depression, anxiety, decrease in sexual desire, night terrors, and lack of ability to concentrate
(Hahn et al., 2015). In a study of 1,353 pre-and-post 9/11 combat participants, 17.27% had heavy
alcohol use, 13.41% had suicidal ideations, 38% took pain medications, and 44% met criteria for
PTSD (Barr, Sullivan, Kintzle, & Castro, 2016). Heavy alcohol use has a negative physiological
impact and acts as a depressant, potentially increasing the chances of suicidal ideations and
becoming an actual suicide.
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A stigma is how society may view a physical or mental impairment adversely. This
stigma may also be self-induced, as the service member may have an “internalized” view on how
people in society, their loved ones, peers, or military leadership view their impairment (Greene-
Shortridge, Britt, & Castro, 2007). This societal or self-induced stigma creates an environment
that is not conducive for acknowledging they have PTSD, let alone getting treatment for it. In
their study of 272 Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF)
veterans, Pietrzak, Johnson, Goldstein, Malley, and Southwick (2009) concluded there were
noted stigmas toward receiving care from behavior health, the quality of care they would receive,
and whether or not their unit would truly support them. In Mittal’s et al. (2013) qualitative study,
16 treatment-seeking service members acknowledged, but resisted, the common stigmas
associated with PTSD; they were more concerned with being perceived as weak by their military
leadership. In another study, comprised of 731 respondents who met screening criteria for a
mental health illness, 38% did not trust mental health professionals, 41% felt it would be too
embarrassing, 50% felt it would harm their careers, 59% their peers and subordinates would have
less confidence in them, 65% felt they would be seen as weak, and 51% felt their unit leadership
would blame them for their problem (Hoge, et al., 2004). The stigma, whether it is societal or
self-induced, needs to be addressed in order for service members to feel more comfortable in
seeking help for PTSD.
Importance of Addressing the Problem

Stigma, whether societal or self-induced, needs to be addressed in order to encourage
individuals with possible PTSD to seek professional help. The United States continues to be a
nation who embodies freedom and democracy as represented by its involvement in combat
operations in Iraq, Afghanistan, Syria, and other countries. With the continuous involvement in
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combat and humanitarian operations, there will be an increasing number of individuals suffering
from PTSD because of various traumatic experiences (National PTSD Center, 2017). According
to Mittal et al. (2013), individuals diagnosed with PTSD resist professional help because of
stigma.
When individuals procrastinate or avoid professional help, this can have dramatic
consequences. These delays may cause individuals to continue using drugs and alcohol to care
for their conditions, adding to the duration of their untreated illness (Clement et al., 2015).
Stigma is one of the most common barriers an individual face when seeking professional help.
There is a need to reduce and eliminate stigma associated with PTSD in the family, community,
and at the societal level through a variety of intervention programs, educational campaigns, and
media efforts (Murry et al., 2011). Many researchers have already determined that stigma is one
of the leading factors preventing PTSD patients from seeking professional help. Thus, it is
important to understand stigma as it affects individuals diagnosed with PTSD. Through
understanding stigma among PTSD diagnosed individuals, support can be developed and
provided for the service members welfare and encourage them to seek professional help for their
mental illness.
Organizational Context and Mission
The focus of this study is on all active duty and reservist Sailors (enlisted and officers)
who are serving in the United States Navy. The Department of the Navy’s mission is to recruit,
train, equip, and organize to deliver combat ready naval forces to win conflicts and wars, while
maintaining security and deterrence through sustained forward presence.

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Organizational Performance Status
The organizational performance problem at the root of this study is the presence of
stigma among military personnel diagnosed with PTSD. Stigma about PTSD negatively impacts
the mission readiness of the military and the welfare of its warfighters (service members) and
their families. Research indicates that 50% to 60% of service members do not seek treatment due
to self-stigma reasons (Barr, Sullivan, Kintzle, & Castro, 2016; Clement et al., 2015).
Researchers have also found that 60% of the service members that are seeking help for PTSD
feel it will be perceived as a weakness (Smith & Whooley, 2015). Service members’ failure to
seek professional help may cause negative relationships with their families. It may also have a
serious impact on the physical and mental health of military personnel, which affects their
readiness to perform their duties.
Organizational Performance Goal
As of 2019, the United States Navy has 329,867 active duty Sailors who are deployed or
are supporting deployed units participating in peacetime and Overseas Contingency Operations
(OCO). The goal of this organization, specific to Sailors serving on active duty or are a reservist,
is to achieve by December 2019, a 50% decrease in medical discharges for PTSD or related
personal and professional problems. To attain this goal, specific knowledge and skills must be
ingrained in personnel. The achievement of this goal enables those Sailors to seek medical
assistance prior to it hindering their personal and professional lives. In addition, it allows the
Navy to retain those experienced Sailors, resulting in a more efficient organization during peace
and wartime.

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Description of Stakeholder Group
The stakeholder population of focus are the Sailors (officers and enlisted) in the United
States Navy, more specifically, active duty and reservists. Sailors, whether deploying or
supporting deployed units participating in peacetime and OCO, could be exposed to arduous
conditions, traumatic situations, and armed combat while performing their duties. Being exposed
to arduous conditions, traumatic situations, and armed combat could cause PTSD. The results of
the study will benefit senior naval leaders by enabling them to develop programs that can help
Sailors in mitigating stigmas on seeking professional help for PTSD. There are a number of
published research studies where service members returning from OCO deployments exhibit
signs and symptoms of PTSD (Kok et al., 2012; Britt et al., 2007; Hoge’s et al., 2004; Held &
Owens, 2012). Thus, it is important to understand stigmas that surround the diagnosis and
treatment of PTSD and how Sailors could be supported to overcome the stigmas.

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Stakeholder Performance Goals
Table 1.
Organizational Mission, Global Goal and Stakeholder Performance Goals
Organizational Mission
The Department of the Navy’s mission is to recruit, train, equip, and organize to deliver combat
ready naval forces to win conflicts and wars while maintaining security and deterrence through
sustained forward presence.
Organizational Performance Goal
As of 2019, the United States Navy has 329,867 Sailors who are deployed or are supporting
deployed units participating in peacetime and Overseas Contingency Operations (OCO). The goal
of this organization, specific to Sailors currently serving on active duty or a reservist, is to achieve
by December 2019, a 50% decrease in medical discharges for PTSD or related personal and
professional problems. To attain this goal, specific knowledge and skills must be ingrained in
personnel. The achievement of this goal enables those Sailors to seek medical assistance prior to
it hindering their personal and professional lives. In addition, it allows the Navy to retain those
experienced Sailors, resulting in a more efficient organization during peace and wartime.
Stakeholder 1 Goal Stakeholder 2 Goal Stakeholder 3 Goal Stakeholder 4 Goal
By December 2019,
The Navy will hire a
mental health staff
that is comprised of
civilian doctors and
nurses who specialize
in trauma and
behavioral health to
develop specific
training on PTSD and
Stigmas
By December 2019,
the Navy will
reconstruct the
current pre/post-
deployment survey
and implement it by
June 2020
By June 2020, the
Navy mental health
team will design
reintegration training
that focuses on the
signs and symptoms
of PTSD through real
testimony of Sailors
who have sought out
medical treatment

By June 2020, the Navy
will draft and implement
new policy that requires
any Sailor that is
exposed to direct combat
during their deployment
to receive at least 1-year
of mental health
evaluation

Purpose of the Project and Questions

The purpose of this study was to conduct a gap analysis to examine the root causes on the
problem of stigma among Sailors seeking treatment for, and those who have been diagnosed
with, PTSD. The focus of this gap analysis was on all Sailors (active and reserve) in the United
PTSD IN THE MILITARY AND ASSOCIATED STIGMAS

18
States Navy. The focus of the analysis was on causes for this problem due to gaps in
understanding the role of stigma among Sailors diagnosed with PTSD. The analysis began by
generating a list of possible or assumed influences that were used to systematically examine
actual or validated causes. As such, the questions that guided this study are:
1. What is the knowledge, motivation, and organizational influences that interfere with
achieving the goal of a 50% decrease in medical discharges for PTSD or related personal or
professional issues?
2. What are the Sailors’ recommended knowledge, motivation, and organization
solutions?
3. Does the organization create a culture free of stigmas relating to mental health issues
and those who seek treatment?
Conceptual and Methodological Framework
The conceptual framework for this study is Clark and Estes’ (2008) gap analysis, which
is a systematic, analytical method that helps to clarify organizational goals and identify the gap
between the actual performance level and the preferred performance level within an
organization. The methodological framework is a quantitative and qualitative case study with
descriptive statistics. Assumed influences of stigma that interfere with the decision to seek
professional help for PTSD were analyzed based on personal experiences, actual reports, and
related literature. These influences were assessed by using surveys, document analysis,
interviews, literature review, and content analysis. Research-based solutions were recommended
and evaluated in a comprehensive manner.

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Definitions
Post-Traumatic Stress Disorder (PTSD): is a psychiatric disorder that can occur in people
who have experienced or witnessed a traumatic event such as a natural disaster, a serious
accident, a terrorist act, war/combat, rape or other violent personal assault (American Psychiatric
Association, 2019).
Stigma: Stigma is how society may view a physical or mental impairment adversely
(Greene-Shortridge, Britt, & Castro, 2007).
Sailor: An individual, enlisted or officer, who serves on active duty or within the reserves
in the United States Navy.
Overseas Contingency Operations (OCO): A military operation that (a) is designated by
the Secretary of Defense as an operation in which members of the armed forces are or may
become involved in military actions, operations, or hostilities against an enemy of the United
States or against an opposing military force; or (b) results in the call or order to, or retention on,
active duty of members of the uniformed services under section 688, 12301(a), 12302, 12304,
12304a, 12305, or 12406 of this title, chapter 15 of this title, or any other provision of law during
a war or during a national emergency declared by the President or Congress (United States Code,
2018).
Arduous Conditions: Conditions that consist of hardship and require significant energy
and exertion to overcome.
Organization of the Project
This study consists of five chapters. This chapter consisted of a discussion of the key
concepts and terminology commonly found in a review of PTSD, stigma, and Sailors. The
organization’s mission, goals and stakeholders as well as the initial concepts of gap analysis
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20
were introduced. Chapter 2 contains a review of current literature surrounding the scope of the
study. Topics of PTSD supports, and interventions, policy, stigma, and mental health will be
addressed. Chapter 3 contains an explanation of the assumed interfering elements and
methodology regarding the selection of participants, data collection, and analysis. In Chapter 4,
the data and results are assessed and analyzed. Chapter 5 consists of solutions, based on data and
literature, for closing the perceived gaps, along with recommendations for an implementation
and evaluation plan for the solutions.

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CHAPTER TWO: REVIEW OF THE LITERATURE
Introduction
This literature review consists of an examination of the root causes and gaps relevant to
the problem of stigma among Sailors seeking treatment for, and those who have been diagnosed
with, post-traumatic stress disorder (PTSD). The first part is an overview of the general research
on PTSD. This section is followed by an overview of the literature on PTSD and its association
with combat. The review covers statistical data, ranging from Vietnam to engagements in Iraq
and Afghanistan. Following the literature on PTSD, the focus is on stigmas, more specifically,
statistical data on what military service members felt were associated stigmas and why. The last
portion contains a discussion of the Clark and Estes Gap Analytic Conceptual Framework and,
specifically, knowledge, motivation, and organization influences on post-traumatic stress
disorder and the associated stigmas in the military.
General Review of the Literature
The United States military has been actively engaged in combat and humanitarian
operations on multiple fronts for well over a century, directly exposing service members to
traumatic experiences. These traumatic experiences could cause them to have physiological and
psychological issues, known as PTSD (National PTSD Center, 2017). Before the American
Psychiatric Association (APA) added PTSD to its Diagnostic and Statistical Manual of Mental
Disorders (DSM-III) in 1980, it was commonly known as Nostalgia and Railway Spine during
the civil war, Shell Shock in World War I, Battle Fatigue and Combat Stress Reaction during
World War II, and Post Vietnam Syndrome in Vietnam (Friedman, Schnurr, & McDonagh,
2007).
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22
In OIF and OEF, 11% - 20% of veterans who participated in those conflicts have PTSD
in a given year (National Center for PTSD, 2018). The percentage of those diagnosed with PTSD
would be significantly higher, but three significant factors are hindering service members
(N=201) from seeking medical treatment for PTSD, the denial they have PTSD (90.24%), related
stigma (82.9%), and difficulty identifying and understanding their PTSD symptoms (74.14%)
(Dondanville et al., 2018).
Causes of PTSD
PTSD is the most common diagnosis among military veterans (Belsher et al., 2012).
While PTSD is caused by combat and other military experiences, sexual or physical assault,
learning about the death of a friend or loved one, child sexual or physical abuse, motor vehicular
accidents, natural disasters, and terrorist attacks; the focus of this literature review is on U.S.
military service members who have been exposed to combat and direct enemy fire (National
PTSD Center, 2018). During World War I, 4,734,991 Americans participated in combat
operations, a figure that grew to 16,112,566 in World War II, and then reached 5,720,000 in the
Korean War, 8,744,000 in the Vietnam War; and 2,322,000 during Desert Shield/Storm
(America’s War, 2017). From 2001 to 2012, more than 1,425,200 people participated in combat
operations during OIF and OEF (Belasco, 2009).
During OIF and OEF alone, PTSD in returning service members has been noted at 31%
in multiple research studies (Kok et al., 2012). In Hoge’s et al. (2004) study that consisted of
Army and Marine Corps service members who deployed to Iraq and Afghanistan, 89% of
Soldiers in Iraq reported being attacked or ambushed, 84% reported they received artillery,
rocket, or mortar fire in Afghanistan; 95% of Marines who participated in combat operations in
Afghanistan reported being attacked or ambushed and 94% saw dead bodies or human remains.
PTSD IN THE MILITARY AND ASSOCIATED STIGMAS

23
Symptoms and Effects of PTSD
The effects of PTSD not only have an impact on the service members, but it also affects
their loved ones, friends, and peers and subordinates at work. Per DSM 5, PTSD is classified into
20 symptoms that are listed in Table 2 (Cyniak-Cieciura, Staniaszek, Popiel, Pragłowska, &
Zawadzki, 2017). The symptoms listed in Table 2 are used to diagnose service members with
PTSD. Some common signs of PTSD consist of reliving the event, avoiding things that remind
one of the events, having more negative thoughts and feelings than before, and a feeling of being
on “edge” (National PTSD Center, 2018).
Service members with PTSD have other associated health issues, such as depression,
anxiety, isolation, alcoholism and drug dependency, and suicidal ideations. In a study of 1,353
pre-and-post 9/11 combat participants, 17.27% reported heavy alcohol use, 13.41% suicidal
ideations, 38% were on pain medications, 13.41% suicidal ideations, 9.14% planned suicide, and
19.69% unnecessary risk to life (Barr, Sullivan, Kintzle, & Castro, 2016).
Table 2.
Models of the Structure of PTSD Symptoms According to DSM-5
DSM-5 Symptoms
B1: Intrusive memories
B2: Recurrent distressing dreams
B3: Dissociative reactions (flashbacks)
B4: Emotional cue reactivity
B5: Physiological cue reactivity
C1: Avoidance of thoughts
C2: Avoidance of reminders
D1: Inability to recall
D2: Negative beliefs about self/world
D3: Blame of self or others
D4: Persistent negative trauma-related emotions
D5: Diminished interest or participation in significant activities
D6: Feelings of detachment
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24
D7: Constrict affect; inability to experience positive emotions
E1: Irritability/angry outbursts
E2: Reckless or self-destructive behavior
E3: Hypervigilance
E4: Exaggerated startle response
E5: Problems in concentration
E6: Sleep disturbance

PTSD and Stigma
While PTSD is the most common diagnosis among military veterans (Belsher et al.,
2012), up to 60% still do not seek medical treatment due to stigma (Britt et al., 2007).
A stigma is how society may view a physical or mental impairment adversely (Greene-
Shortridge, Britt, & Castro, 2007). Some common forms of stigmas that impact whether a service
member seeks medical care are public, personal, and self-stigma. Public or societal stigma is the
negative view that society or the public has regarding a physical or mental impairment, whereas,
a self-stigma is the negative self-perception the individual has about seeking medical care (Held
& Owens, 2012). While public or societal stigmas are different, they are closely intertwined. The
greater the public or societal stigma is, the greater the self-stigma is with the individual. A
personal stigma is the negative perceptions from friends, family, or those the individual interacts
with on a personal and professional basis (Held & Owns, 2012).
An overwhelming 50% to 60% of service members who might benefit from treatment do
not because of self-stigma (Green-Shortridge, Britt, & Castro, 2007). Sixty percent of service
members who are seeking help for PTSD believe it will be perceived (self-stigma) as a weakness
(Smith & Whooley, 2015). In a study that was comprised of 731 respondents who met screening
criteria for a mental health illness, 38% did not trust mental health professionals, 41% felt it
would be too embarrassing, 50% felt it would harm their careers, 59% felt their peers and
PTSD IN THE MILITARY AND ASSOCIATED STIGMAS

25
subordinates would have less confidence in them, 65% felt they would be seen as weak, and 51%
felt their unit leadership would blame them for their problem (Smith & Whooley, 2015).
In Hoge’s et al. (2004) study of Army service members who returned from Iraq (N=220)
and Afghanistan (N=151), 81% acknowledged a problem and only 38% were interested in
receiving medical care who returned from Afghanistan and 78% acknowledged a problem and
only 43% were interested in receiving medical care who returned from Iraq. The Marines
(N=127) who returned from Iraq, 86% acknowledged a problem and only 45% were interested in
receiving help. In the same study, a sample group of Army and Marines (N=731), 41% felt it
would be too embarrassing, 50% felt it would harm their career, 59% felt their unit would have
less confidence in them, 63% felt their leadership might treat them differently, 51% felt their
leadership would blame them for the problem, and 65% felt they would be seen as weak if they
sought out medical care.
Walter Reed conducted a study about PTSD treatment for soldiers (N=50) after
deployment and low utilization of mental health care and drop out; 38% dropped out of care due
to stigma, 24% because they felt judged or misunderstood by mental health professionals, and
38% felt their mental health treatment would not be confidential form their unit leadership (Hoge
et al., 2014). In a similar study where stigma was a factor, 156 acknowledged needing help and
only 75 (48%) were interested in receiving care upon return from Afghanistan; 104 acknowledge
needing help, and only 58 (56%) were interested in receiving care upon return from Iraq (Hoge
et al., 2014). In another sample group of 23 people with a positive screening for PTSD, 52%
were concerned with stigma and 48% were concerned with confidentiality and their leadership
knowing. Also, 17% did not trust mental health professionals, 6% did not know where to get
help, 17% felt it would be difficult to get an appointment, 18% felt it would be embarrassing,
PTSD IN THE MILITARY AND ASSOCIATED STIGMAS

26
24% felt it would harm their career, 31% felt members of their unit would have less confidence
in them, 33% felt their leadership would treat them differently, 20% felt their leadership would
blame them for their problem, 31% felt they would be seen as weak, and only 9% felt medical
care would not help (Hoge et al., 2014).
In a study that consisted of 1,356 pre and post 9/11 era military veterans regarding PTSD
and suicidal ideations, suicide plan, and non-suicidal risk to life behavior, 41 – 61% were at
greater risk of suicide than those in general population. Also, 38% took pain medication to
alleviate signs and symptoms, 17.27% abused alcohol, 13.41% had suicidal ideations, 9.14% had
a plan to commit suicide, and 20% had unnecessary risk to life (Barr, Sullivan, Kintzle, &
Castro, 2016). As a result, service members continue not to seek or are reluctant to seek mental
health assistance based on the stigmas associated with PTSD, reinforcing the need to address
stigma with Sailors’ pre/post-deployment.
The Clark and Estes’ Gap Analytic Conceptual Framework
The Clark and Estes (2008) gap analysis is a systematic, analytical method and
framework used to clarify organizational goals and identify the gap between the actual
performance level and the preferred performance level within an organization. Once the gap is
identified, this framework then can be used to analyze the stakeholder’s knowledge, motivation
and organizational (KMO) influences that may have an impact on the performance gaps.
Knowledge is broken down into four specific types: factual, conceptual, procedural, and
metacognitive to assess the stakeholder’s knowledge on how to achieve the performance goal.
Factual knowledge consists of the essential elements, whereas, conceptual deals with
more complex pieces, that when intertwined with factual details, allow function. Motivation is
another critical piece to the framework, as leaders and individuals within an organization need to
PTSD IN THE MILITARY AND ASSOCIATED STIGMAS

27
understand what motivation is, what motivates individuals, such as utility value and self-
efficacy, and how it aids in performance goal accomplishment. Finally, organizational
influences, such as workplace culture, training and incentive programs, and resources, can have
an impact on a stakeholder’s performance.
The KMO elements of Clark’s and Estes’s (2008) gap analysis will be addressed below
regarding Sailors knowledge, motivation, and organization needs to meet the performance goal
of a 50% decrease in discharges for PTSD or related personal or professional issues by
December 2019. The first section is a discussion of the influences of knowledge and skills on the
stakeholder’s performance goal. Then, motivational and organizational influences are discussed
in the following sections. Each of the KMO influences on the performance goal will be explored
through the methodology discussed in Chapter 3.
Stakeholder Knowledge, Motivation, and Organizational Influences
As of 2019, the United States Navy has 329,867 Sailors who are deployed or are
supporting deployed units participating in peacetime and Overseas Contingency Operations
(OCO). The goal of this organization, specific to Sailors currently serving on active duty or a
reservist, is to achieve by December 2019, a 50% decrease in medical discharges for PTSD or
related personal and professional problems. To attain this goal, specific knowledge and skills
must be ingrained within those stakeholders. Sailors, whether deploying or supporting deployed
units participating in peacetime and OCO, could be exposed to arduous conditions, traumatic
situations, and armed combat while performing their duties. Those Sailors need an in-depth and
accurate understanding of, and ability to, self-identify signs of PTSD and associated stigma
types. Also, Sailors require an understanding of the post-deployment medical evaluation and
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28
treatment process for PTSD. The literature reviewed in this study focuses on specific facets of
knowledge and skills that affect the ability of Navy in achieving their goal.
Knowledge and Skills
According to Krathwohl (2002), there are four types of knowledge; factual, conceptual,
procedural, and metacognitive. Factual knowledge consists of the essential elements, whereas,
conceptual deals with more complex pieces, that when intertwined with factual elements, allow
function. An example of factual knowledge would be understanding what PTSD is and a
conceptual form of knowledge would be to understand and recognize the associated stigmas of
PTSD. Metacognition is associated with cognition or the mind as a whole, but more specifically,
the individual; a form of metacognitive knowledge is Sailors having the ability to identify signs
of PTSD. Procedural knowledge consists of the steps and strategy of how something is
completed, such as, the mental health screening and treatment process after returning from a
deployment in support of OCO.
Knowledge Influence 1
Sailors must gain an in-depth and accurate understanding of PTSD and its effects
(conceptual knowledge). The United States military has been actively engaged in combat and
humanitarian operations on multiple fronts for well over a century. During World War I,
4,734,991 Americans participated in combat operations, a figure that grew to 16,112,566 in
World War II, and then reached 5,720,000 in the Korean War, 8,744,000 in the Vietnam War,
and 2,322,000 during Desert Shield/Storm (America’s War, 2017). From 2001 to 2012, more
than 1,425,200 people participated in combat operations during Operation’s Iraqi Freedom (OIF)
and Enduring Freedom (OEF) (Belasco, 2009). These engagements have directly exposed U.S.
service members to traumatic experiences that may lead to PTSD.
PTSD IN THE MILITARY AND ASSOCIATED STIGMAS

29
PTSD is not uncommon and is usually associated with combat and trauma (Friedman,
2007). Common causes of PTSD among military personnel include combat, sexual assaults, or
witnessing/being otherwise involved in various types of additional traumatic events or situations.
PTSD has been well-recognized by the public for the physiological and psychological effects
service members were experiencing long before the wars in Iraq and Afghanistan.
The symptoms and debilitations now associated with PTSD were historically recognized
under different nomenclature including war neurosis, battle exhaustion, and even Vietnam
syndrome (Connell, 2015). During both World War I and II, service members with PTSD were
also commonly diagnosed as suffering from ‘Shell Shock’ due to the symptoms they exhibited
after a combat experience. This particular diagnostic term remained in place until 1981, after the
Vietnam War, when PTSD became the new norm for linguistic description of this phenomenon
(Levinson, 2015).
Subsequently, PTSD became a symbol in some ways of the wars in Iraq and Afghanistan;
it was considered as such because 11% to 20% of the U.S. service members participating in those
conflicts returned with symptoms associated with the disorder (NIMH, 2016). In one study
consisting of a group of 127 service members from these conflicts, 18% reported having PTSD
(Held & Owens, 2012). Miller and Cromer (2013) reported that rates of service members with
PTSD returning from OIF and OEF were as high as 19.5%.
While there is a significant body of evidence associating combat with PTSD, it is
important to understand there are other traumatic situations that may also bring on the ailment
among service members. For example, more than 50% of the general population is likely to
experience trauma of other types, such as sexual assault, assault, child sexual abuse, disaster, or a
serious motor vehicle accident, at least once in their lives (How Common is PTSD, 2016).
PTSD IN THE MILITARY AND ASSOCIATED STIGMAS

30
Similarly, servicemen are not immune from these types of experiences either. Results of one
major study on this issue showed that among the sample group of men surveyed, 84% reported a
physical assault, 42% an assault with a deadly weapon, 4.9% a sexual assault, and 30% an
unwanted sexual assault (Schoenleber, Sippel, Jakupcak & Tull, 2015). In another study,
comprised of 90 OEF/OIF veterans, 1% to 13% of men, and 14% to 42% of women reported a
sexual assault that occurred while in the military (Hahn, Tirabassi, Simons, & Simons, 2015).
This history, background, and insight into the major causes of PTSD is the groundwork for the
next discussion of the impact PTSD has upon affected service members and their loved ones.
Dursa et al. (2014) recounted the plethora of empirical investigations that have
documented the frequent occurrence of PTSD among ex-military personnel. Evaluating National
Health Study for a New Generation of US Veteran data (a large cohort), the same researchers
found a high occurrence of positive PTSD screens among Operation Iraqi Freedom veterans
(15.8% of that population group). Noteworthy, African American veterans were found to be at an
increased risk of PTSD diagnosis. Dursa et al. (2014) concluded that PTSD is a primary U.S.
public health issue, specifically among Operation Iraqi Freedom veterans.
Jackson et al. (2016) provided a comprehensive review of PTSD, including its connection
to traumatic brain injury among military personnel, and also described relevant treatment
methods utilized by medical and psychiatric professionals. The researchers pointed out that cases
of PTSD are often un-diagnosed in returning soldiers, or are under-diagnosed in terms of
severity, despite potentially effecting up to 30% of this group. The latter statistic was particularly
associated with those recently returning from Iraq and Afghanistan.
Furthermore, due to the gap in diagnosis and treatment resulting from social stigma,
misunderstanding, and soldier reluctance to seek help, problems arising from untreated PTSD are
PTSD IN THE MILITARY AND ASSOCIATED STIGMAS

31
becoming more common among returning military personnel, including substance abuse, marital
infidelity, emotional withdrawal, secondary psychiatric disorders, and even physiological stress-
related outcomes (Jackson et al., 2016). For this reason, identifying negative stereotypes about
the disorder, heightening awareness among the population, and creating increased access to
resources and education regarding PTSD is imperative to improve emotional wellness for
veterans and their families.
Michalopoulou et al. (2016) reiterated these concerns and confirmed that multiple studies
have documented the under-use of mental health programs and assistive services by military
personnel, especially in comparison to the documented need, and the total number of cases of
PTSD among returning soldiers. They suggested this is likely due in large part to common
stigmas associated both with PTSD itself and with a need for treatment for the disorder. Seeking
mental health assistance is an action in direct psychological contradiction to the psycho-
emotional environment to which military personnel became accustomed while in the service:
suppression, repression, strength, and a reluctance to ask for help. To break down the psycho-
emotional environment, Sailors must have an in-depth and accurate understanding of the history
and effects of PTSD. This conceptual knowledge will aid in the reduction of medical discharges
for PTSD and related personal or professional issues.
Knowledge of Influence 2
To achieve the goal earlier stated in this study, it is critical that Sailors be able to identify
individual signs of PTSD they might be experiencing and the associated impacts on their
personal and professional lives (metacognitive knowledge). PTSD has been associated with
various behaviors, including uncontrolled anger, increased alcohol consumption, suicide,
depression, anxiety, a decrease in sexual desire, night terrors, and lack of ability to concentrate
PTSD IN THE MILITARY AND ASSOCIATED STIGMAS

32
(Hahn, Tirabassi, Simons, & Simons, 2015). In a study of 1,353 pre-and-post 9/11 combat
participants, 17.27% reported heavy alcohol use, 13.41% suicidal ideations, 38% were on pain
medications, and 44% met criteria for PTSD (Barr, Sullivan, Kintzle, & Castro, 2016). The first
of these characteristics, heavy alcohol use, is strongly associated with negative physiological
impacts and acts as a depressant, which could potentially increase the odds of suicidal ideations
becoming an actual suicide. McGillivray (2016) also reported that following the first Gulf War,
up to 69% of combat veterans experienced erectile dysfunction, premature ejaculation, and
impotence. Walters and Burger (2012) examined infidelity in relation to PTSD among military
personnel and found (through mixed-methods) that although infidelity itself was defined
differently depending upon varying situations, the likelihood of infidelity was apparently
exacerbated by military-related PTSD.
Having the metacognitive knowledge of being able to identify individual signs of PTSD
one might be experiencing allows for early intervention. Early intervention affords the
individuals an opportunity to obtain medical care on their own terms, instead of a negative
personal or professional incident forcing them to get help. Minimizing the personal and
professional incidents will aid in the decrease of medical discharges for PTSD or related personal
or professional issues.
Knowledge of Influence 3
It is imperative that Sailors are able to recognize the associated stigmas of PTSD
(conceptual knowledge). PTSD stigmas may stem from society at large, but are also often self-
induced, as the service member creates an internalized view regarding the way in which average
citizens, their loved ones, peers, or military leadership view their impairment (Greene-
Shortridge, Britt, & Castro, 2007). Whether societal or self-induced, this stigma creates an
PTSD IN THE MILITARY AND ASSOCIATED STIGMAS

33
environment unconducive for veterans acknowledging the existence of their PTSD, let alone
seeking treatment for it. This point was emphasized in the results of a study of 272 Operation
Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) veterans, who reported stigmas
regarding the receipt of care for behavioral health the quality of care they would receive, and
whether or not their unit would truly support them (Pietrzak, Johnson, Goldstein, Malley, &
Southwick, 2009). In Mittal’s et al. (2013) study, 16 treatment-seeking service members
acknowledged but resisted many of the common stigmas associated with PTSD; the stigma that
predominated their thoughts instead was being perceived as weak by military leadership.
Another study comprised of 731 military respondents who met screening criteria for
mental health illness, showed that 38% did not trust mental health professionals, 41% felt it
would be too embarrassing to seek help, 50% felt it would harm their careers, 59% thought their
peers and subordinates would have less confidence in them, 65% worried they would be seen as
weak, and 51% thought their unit leadership would blame them for their problem (Hoge et al.,
2004). Clearly, stigmas must be identified and mitigated so service members feel more
comfortable in seeking help for PTSD. A significant number of service members, upwards to
50% - 60% who might benefit from treatment, do not seek it due to self-stigmas (Green-
Shortridge, Britt, & Castro, 2007). Sixty percent of service members that are seeking help for
PTSD believe it will be perceived as a weakness (Smith & Whooley, 2015).
While the nation continues to be involved in multiple global combat operations, it must
recognize that roughly 20% of those who are at the forefront will observe or be part of a
traumatic incident (National PTSD Center, 2017). According to Iversen et al. (2011), less than
half of those returning from combat get mental health treatment. Not having the needed
conceptual knowledge to recognize stigmas associated with PTSD will have an impact on
PTSD IN THE MILITARY AND ASSOCIATED STIGMAS

34
whether or not personnel will determine they need mental health care. Not receiving mental
health care for PTSD will greatly hamper the Navy’s ability to achieve their goal and for
individuals to have stable personal and professional lives.
Table 3.

Knowledge Influence, Knowledge Types, and Knowledge Assessment

Organizational Mission
The Department of the Navy will recruit, train, equip, and organize to deliver combat ready naval
forces to win conflicts and wars while maintaining security and deterrence through sustained
forward presence.
Organizational Global Goal
As of 2019, the United States Navy has 329,867 Sailors who are deployed or are supporting
deployed units participating in peacetime and Overseas Contingency Operations (OCO). The goal
of this organization, specific to Sailors currently serving on active duty or a reservist, is to
achieve by December 2019, a 50% decrease in medical discharges for PTSD or related personal
and professional problems. To attain this goal, specific knowledge and skills must be ingrained in
personnel. The achievement of this goal enables those Sailors to seek medical assistance prior to
it hindering their personal and professional lives. In addition, it allows the Navy to retain those
experienced Sailors, resulting in a more efficient organization during peace and wartime.
Stakeholder Goal
By December 2019, the Navy will see a 50% decrease in medical discharges for PTSD or related
personal or professional issues.
Knowledge Influence Knowledge Type
(i.e., declarative
(factual or
conceptual),
procedural, or
metacognitive)
Knowledge Influence
Assessment
Sailors need an in-depth and accurate
understanding of PTSD
Conceptual Revised pre-deployment
assessment, survey, and or
training that includes PTSD and
stigmas
Sailors need the ability identify
individual signs of PTSD that they
may be experiencing
Metacognitive Pre/post-deployment and
pre/post training assessments
that include PTSD and stigmas

Sailors need the ability to understand
and recognize the associated stigmas
of PTSD
Conceptual Pre/post-deployment and
pre/post training assessments
that include PTSD and stigmas

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35
Motivation
Sailor motivation is critical to the Navy’s ability to achieve a 50% decrease in medical
discharges for PTSD or related personal and professional problems by December of 2019.
Sailors deploying or supporting deployed units participating in peacetime and Overseas
Contingency Operations (OCO) need to see the value in receiving medical care for PTSD. Also,
Sailors should feel that the signs and symptoms associated with PTSD are due to traumatic
experiences and not a result of someone’s inability to handle stress. Sailor motivation is
reinforced by expectancy motivational value and self-efficacy theories.
Self-Efficacy Theory
Pajares (2006) defines self-efficacy as “the self-perceptions that individuals hold about
their capabilities” (p. 1). Self-efficacy is better known as the bedrock for self-motivation, and
individual welfare and accomplishments. It is important that Sailors know they have the ability
to overcome PTSD, regardless of the verbal messages and social persuasions. According to
Blackburn and Owens (2014), higher levels of self-efficacy resulted in less PTSD symptoms.
If Sailors feel like they are unable to overcome PTSD or that their traumatic experience is
a result of their inability to handle stress, they will be less motivated to seek medical care or talk
to loved ones. Also, if they lack support through medical treatment, it could lead to isolation and
subsequently a lack of motivation to continue through treatment. In addition, the overall lack of
motivation through self-efficacy will impact motivational influences of utility value (Kelly &
Greene, 2014). However, virtual environments for combat-related PTSD are being used to build
self-efficacy through educational experiences and role play, greatly affecting personal utility
value (Holloway & Reger, 2013).

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36
Expectancy Motivation Value Theory
Expectancy-value theory consists of four associated constructs: “enjoyment in the task
(intrinsic interest); the extent the task is consistent with one’s self-image or identity (attainment
value), the value for facilitating one’s goals or helping one obtain rewards (utility value), and the
perceived cost of engaging in the activity” (Eccels, 2006, p. 2). In order for Sailors deploying or
supporting deployed units participating in peacetime and Overseas Contingency Operations
(OCO) to value receiving medical care for PTSD, they need to see/feel the utility value in it. The
assumed utility values for Sailors are, but not limited to, continued career progression and
longevity, not being medically discharged, stable personal relationships (family and friends), and
overall personal well-being (includes medical issues). Iversen et al. (2011) conducted a study of
10,272 service members through the use of a survey and telephone interview and were able to
find out the attainment value, utility value, and perceived cost regarding seeking medical care.
Sailor utility values can be obtained and assessed in the same manner by pre-post-deployment
surveys with questions similar to, “Is it important for you to seek medical care for PTSD
regardless of the stigma to maintain a healthy personal and professional life?”

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37
Table 4.

Motivational Influences and Motivational Influence Assessments

Organizational Mission
The Department of the Navy will recruit, train, equip, and organize to deliver combat ready
naval forces to win conflicts and wars while maintaining security and deterrence through
sustained forward presence.
Organizational Global Goal
As of 2019, the United States Navy has 329,867 Sailors who are deployed or are supporting
deployed units participating in peacetime and Overseas Contingency Operations (OCO). The
goal of this organization, specific to Sailors currently serving on active duty or a reservist, is to
achieve by December 2019, a 50% decrease in medical discharges for PTSD or related personal
and professional problems. To attain this goal, specific knowledge and skills must be ingrained
in personnel. The achievement of this goal enables those Sailors to seek medical assistance prior
to it hindering their personal and professional lives. In addition, it allows the Navy to retain
those experienced Sailors, resulting in a more efficient organization during peace and wartime.
Stakeholder Goal
By December 2019, the Navy will see a 50% decrease in medical discharges for PTSD or related
personal or professional issues.
Motivational Indicator(s)

Assumed Motivation Influences

Motivational Influence Assessment

Self-Efficacy – Sailors deploying or supporting
deployed units participating in peacetime and
Overseas Contingency Operations (OCO) need to
see the value in receiving medical care for PTSD
Survey item: “Overcoming PTSD is
dependent upon identifying the signs and
symptoms and the effort put toward
receiving medical care.”
Interview item: “What are some of the
causes for Sailors to seek or not seek
medical attention for PTSD?”
Utility Value – Sailors deploying or supporting
deployed units participating in peacetime and
Overseas Contingency Operations (OCO) need to
see/feel the utility value in receiving medical care
for PTSD
Survey item: “It is important for me to
seek medical care for PTSD regardless of
the stigma” to maintain a healthy personal
and professional life

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38
Organization

Organizational goal achievement is directly impacted by an organization’s internal
processes and available material resources. While individuals within an organization can have
the needed knowledge and skills (K) and motivation (M), inefficient and inadequate processes
and resources will prevent the closure of performance gaps, in turn, hindering organizational
goal achievement (Clark & Estes, 2008). Some common work processes are administrative,
operational, and training; these processes require functional knowledge, skills, and motivation to
produce the desired end state. Material resources, such as supplies, technological equipment, and
machinery are also directly tied to an organization’s ability to close performance gaps and
achieve goals. Without resources, there is no capacity for organizational growth and goal
achievement.
Organizational Influence 1
A Sailor’s mental and physical resiliency is partially dependent on being provided
pre/post-deployment training on PTSD and the associated stigmas by the Navy. While training
provides the Sailors knowledge and skills, the organization is responsible for the internal
processes (policies) on how, when, or even whether or not training is conducted. Material
resources such as technological equipment and specialized training environments are also needed
to achieve organizational process goals and provide Sailors the needed knowledge and skills
(Clark and Estes, 2008). If the Navy does not institute work processes and develop and dedicate
the needed resources to provide Sailors pre/post-deployment training on PTSD and the
associated stigmas, Sailors will not be able to get the needed knowledge and skills (K) needed in
Table 3.

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39
Organizational Influence 2
For this study, the Clark and Estes (2008) gap analysis proved to be an essential
conceptual framework because it is beneficial to use when identifying and closing an
organization’s performance gaps. According to Clark and Estes, “organizational culture is the
most important ‘work process’ in all organizations” (p. 107). An organizational culture that is
free of stigmas relating mental health issues and those who seek medical care dramatically
impacts whether or not Sailors will seek medical treatment for PTSD or other related problems
after being deployed or supporting deployed units participating in peacetime and OCO. The gap
in diagnosis and treatment due to stigmas, misunderstanding, and soldier reluctance to seek
medical assistance, and subsequent issues arising from PTSD are becoming more common
among returning from military personnel, such as substance abuse, marital infidelity, emotional
withdrawal, secondary psychiatric disorders, and even psychological stress-related outcomes
(Jackson et al., 2016).
In a qualitative study, Rüsch et al. (2017, p. 100), found most veterans perceive PTSD
disclosure and treatment negatively; they routinely associated the stigmas of “weakness,
incompetence, malingering and blame” with seeking help. These veteran-perceived stigmas were
found to be the primary barriers hindering veterans from receiving assistance, since veterans
feared being labeled as psychiatrically-ill and furthermore, feared such a stigma might jeopardize
their careers. Even more devastating is the fact that such veteran-perceived labeling was found to
decrease feelings of self-worth and self-confidence, thereby subconsciously exacerbating
feelings of stress and maladaptation (Rüsch et al., 2017). Finally, PTSD disclosure among
veterans is remarkably challenging and that stigmas, both as perpetuated by veterans themselves,
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40
the public, and an organization, serve as barriers to successful veteran re-integration, and
treatment of PTSD (Rüsch et al., 2017).
Table 5.
Organizational Influences and Organizational Influence Assessments
Organizational Mission
The Department of the Navy will recruit, train, equip, and organize to deliver combat ready
naval forces to win conflicts and wars while maintaining security and deterrence through
sustained forward presence.
Organizational Global Goal
As of 2019, the United States Navy has 329,867 Sailors who are deployed or are supporting
deployed units participating in peacetime and Overseas Contingency Operations (OCO). The
goal of this organization, specific to Sailors currently serving on active duty or a reservist, is to
achieve by December 2019, a 50% decrease in medical discharges for PTSD or related personal
and professional problems. To attain this goal, specific knowledge and skills must be ingrained
in personnel. The achievement of this goal enables those Sailors to seek medical assistance prior
to it hindering their personal and professional lives. In addition, it allows the Navy to retain
those experienced Sailors, resulting in a more efficient organization during peace and wartime.
Stakeholder Goal
By December 2019, the Navy will see a 50% decrease in medical discharges for PTSD or related
personal or professional issues.
Organizational Indicator(s)

Assumed Organization Influences

Organizational Influence Assessment

The organization needs to provide Sailors pre/post-
deployment training on PTSD and stigmas
Survey item: “Seeking medical assistance
for PTSD is fully or partially dependent
on whether or not the organization
provides training on PTSD and stigmas.”
Interview item: “Would organizational
training on PTSD and stigmas pre/post-
deployment have an impact on whether or
not you would seek out medical care for
PTSD?”
The organization needs to create a culture that is
free of stigmas relating to PTSD

Survey item: “It is important to have an
organizational culture that is free of
stigmas relating to mental health issues
for me to seek medical care for PTSD.”
Interview item: “Would an organizational
culture that included stigmas relating to
mental health issues prevent you from
seeking medical assistance for PTSD?”
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Table 6.

Summary Table of Assumed Influences on Performance
Assumed Influences on Performance
Source Knowledge Motivation Organization
Learning and
Motivation and
Organizational
Theory
• Sailors (active and
reservist) need an in-
depth and accurate
understanding of
PTSD (Conceptual).
• Sailors (active and
reservist) need the
ability to identify
individuals’ signs of
PTSD that they may
be experiencing
(Metacognitive).
• Sailors (active and
reservist) need the
ability to understand
and recognize the
associated stigmas of
PTSD (Conceptual).
• Self-Efficacy – Sailors
(active and reservist)
deploying or supporting
deployed units
participating in peacetime
and Overseas Contingency
Operations (OCO) need to
see the value in receiving
medical care for PTSD.
• Utility Value – Sailors
(active and reservist)
deploying or supporting
deployed units
participating in peacetime
and Overseas Contingency
Operations (OCO) need to
see/feel the utility value in
receiving medical care for
PTSD
• The
organization
needs to provide
Sailors (active
and reservist)
pre/post-
deployment
training on
PTSD and
stigmas.
• The
organization
needs to create
a culture for all
Sailors that is
free of stigmas
relating to
mental health
issues.
General
Related
Literature
• Sailors (active and reservist)
need an understanding of
PTSD.
• Sailors (active and reservist)
need an understanding of
what a stigma is, the stigma
process, and the different
types (Enacted, Felt,
Perceived, Societal, and
Individual).
• Sailors (active and reservist)
need an understanding of
how to cope with their
symptoms and the reactions
of other’s.
• Sailors (active and
reservist) need to see the
value of receiving medical
care (personally,
professionally, and for
families).
• Sailors (active and
reservist) need to
understand the
psychological and
physiological effects
PTSD has on their loved
ones and themselves.

• The
organization
needs to
recognize that
internal stigmas
impact whether
or not medical
care is sought
for PTSD.
• The
organization
needs clear
policy, training,
and procedures
to manage
stigma.
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Conceptual Framework: The Interaction of Stakeholder’s Knowledge and Motivation and
the Organizational Context
The conceptual framework is an intricate system of concepts, assumptions, beliefs,
expectations, and theories that support (justify) and inform the research in written or visual form.
The design itself is not universal and is specifically constructed with elements, such as, key
factors, concepts, or variables and their inter-relationship with each other (Maxwell, 2013). The
conceptual framework also includes influences of knowledge, motivation, and the organization
through gap analysis of the stakeholder goal attainment (Merriam & Tisdell, 2016). This
particular framework will be constructed based on experimental knowledge, existing theory and
research, pilot and exploratory research and thought experiments. The conceptual framework
provides an expressive and narrative explanation of the intertwined relationships.
The research problem of practice for this dissertation study was an exploration of the
knowledge, motivation, and organizational influences that interfere with Sailors who are
deployed or are supporting deployed units participating in peacetime and Overseas Contingency
Operations (OCO) from seeking medical care for PTSD. The research problem is indicative of
the conceptual framework, enabling the development of the problem, specific research questions,
data collection process and method, analysis approach, and methodology for interpretation.
Life experiences usually guide the researcher in choosing a research problem due to
experimental knowledge. Experimental knowledge through personal experiences, individual
technical knowledge, and background produces significant insight, hypotheses, and validity
checks (Maxwell, 2013). In this case, the researcher has deployed several times to the Middle
East in support of OCO, witnessed and experienced combat-related trauma, and has been under
direct enemy fire in combat. The researcher’s initial assumptions support the belief that if Sailors
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43
get pre/post-deployment training on PTSD and the associated stigmas, the organization also
needs to create an internal culture that is free of stigma related to seeking medical assistance in
order to achieve a 50% decrease in medical discharges for PTSD or related personal and
professional problems.
There is an abundance of research and theory regarding stigmas being a significant factor
that is taken into consideration when seeking medical treatment for PTSD. PTSD became the
symbol of the wars in Iraq and Afghanistan; it was considered as such because 11% to 20% of
the U.S. service members participating in those conflicts returned with symptoms associated with
the disorder (“How Common Is,” 2016). In one particular study group of 127 service members
from these conflicts, 18% reported having PTSD (Held & Owens, 2012). In another study, rates
of service members with PTSD returning from OIF and OEF were as high as 19.5% (Miller &
Cromer, 2013). Whether societal or self-induced, this stigma creates an environment
unconducive for veterans acknowledging the existence of their PTSD, let alone seeking
treatment for it. This point was emphasized in the results of a study of 272 Operation Iraqi
Freedom (OIF) and Operation Enduring Freedom (OEF) veterans who reported stigmas
regarding the receipt of care for behavioral health the quality of care they would receive, and
whether or not their unit would truly support them (Pietrzak, Johnson, Goldstein, Malley, &
Southwick, 2009). Mittal et al. (2013) reported that 16 treatment-seeking service members
acknowledged but resisted many of the common stigmas associated with PTSD; the stigma that
dominated their thoughts instead was being perceived as weak by military leadership.
Researchers who investigated of 731 military respondents, who met screening criteria for
mental health illness, found that 38% did not trust mental health professionals, 41% felt it would
be too embarrassing to seek help, 50% felt it would harm their careers, 59% thought their peers
PTSD IN THE MILITARY AND ASSOCIATED STIGMAS

44
and subordinates would have less confidence in them, 65% worried they would be seen as weak,
and 51% thought their unit leadership would blame them for their problem (Hoge et al., 2004).
Clearly, stigmas must be identified and mitigated so service members feel more comfortable in
seeking help for PTSD. A substantial figure of 50% to 60% of service members who might
benefit from treatment do not seek it due to self-stigmas (Green-Shortridge, Britt, & Castro,
2007). Sixty percent of service members who are seeking help for PTSD believe it will be
perceived as a weakness (Smith & Whooley, 2015). This conceptual framework addresses the
influences of knowledge (K), motivation (M), and the organization (O) on the study and research
into PTSD and the associated stigmas.

PTSD IN THE MILITARY AND ASSOCIATED STIGMAS

45

PTSD IN THE MILITARY AND ASSOCIATED STIGMAS

46
In Figure A, the United States Navy as an organization (external red circle) is influenced
by the internal cultural settings that foster or provide a misperception regarding stigmas relating
to PTSD and those who seek medical care. The organizational culture influences the (K) and (M)
of the Sailors who are deployed or are supporting deployed units participating in peacetime and
Overseas Contingency Operations (OCO (internal yellow circle). The lack of organizational
pre/post-deployment training regarding PTSD and stigmas directly affects the conceptual
knowledge of the Sailor. In addition, the ability to identify individual signs of PTSD is directly
related to the knowledge gained/not gained regarding PTSD and the associated stigmas.
Motivation (internal yellow circle) is directly tied to (K) and (O). Self-efficacy and
utility value are achieved if the organization (O) conducts the pre/post-deployment training and
fosters an organizational climate free of stigmas pertaining to PTSD and those who seek medical
care. The organization in the KMO diagram (Figure A) is the “trigger” to Sailors gaining the
conceptual and metacognitive knowledge and having the motivation to seek medical attention to
achieve (purple arrow) the goal (green box).
Conclusion
The purpose of this study was to conduct a gap analysis to examine the knowledge,
motivation and organizational influences that interfere with Sailors who are deployed or are
supporting deployed units participating in peacetime and Overseas Contingency Operations
(OCO) from seeking medical care for Post-Traumatic Stress Disorder (PTSD). The researcher
used the Clark and Estes (2008) KMO gap framework to generate a list of possible or assumed
interfering influences of knowledge, motivation, and organization that were examined
systematically to focus on actual or validated interfering influences. The conceptual and
metacognitive knowledge influences of having a proper understanding of PTSD and stigmas,
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47
being able to identify individual signs and symptoms of PTSD and have an understanding of
stigmas and the ability to identify them are directly tied to the motivational and organizational
influences.
Motivational influences of self-efficacy and utility value also play an important role in
organizational goal achievement and performance gaps. Sailors deploying or supporting
deployed units participating in peacetime and Overseas Contingency Operations (OCO) need to
see the value in receiving medical care for PTSD (Self-Efficacy). Also, those Sailors need to
see/feel the value personally and professionally in receiving medical care for PTSD (Utility
Value). Organizational influences of providing training on PTSD and stigmas, along with
creating a culture that is free of stigmas relating to mental health issues, contributes greatly to
knowledge and motivational achievement.
All the KMO influences were assessed by surveys and focus group interviews that
include specific questions specifically relating to the research questions of the study. These
KMO influences directly have an impact on whether or not the goal of a 50% decrease in
medical discharges for PTSD or associated personal and professional issues by December of
2019 will be achieved. The assumed interfering influences, as well as the methodology and
rational when it comes to the selection of participants, data collection, and analysis will be
covered in Chapter 3.

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CHAPTER THREE: METHODOLOGY
Methodological Approach and Rationale
As noted, the methodology design for this project consisted of Clark and Estes’ (2008)
KMO gap analysis and included an explanatory sequential mixed-method model, incorporating
the collection and analysis of both quantitative and qualitative data. This design was chosen
because of the “strength in drawing on both quantitative and qualitative research” and due to the
lack of published mixed-method research on stigma and PTSD in the military (Creswell, 2014).
The researcher addressed whether or not stigmas in society and the military prevents Sailors
from seeking help for PTSD. An explanatory sequential mixed-methods design involved
collecting quantitative data first and then explaining the quantitative results with in-depth
qualitative data.
In the first phase of the study (quantitative), survey data were collected from a large
group of Sailors (N=102) who are deployed or are supporting deployed units participating in
peacetime and Overseas Contingency Operations (OCO) to assess whether or not stigma relates
to Sailors not seeking medical care for PTSD. The results were then analyzed to allow the
researcher to identify themes across KMO and refine the protocol for face-to-face interviews that
occurred in the second phase. The second phase (qualitative) was conducted as a follow-up; the
tentative plan was to explore stigmas regarding medical care for PTSD with Sailors. Face-to-face
interviews were conducted in a small group (N=3) of Sailors who are deployed or are supporting
deployed units participating in peacetime and Overseas Contingency Operations (OCO).
Participating Stakeholders
The stakeholder population of focus for this study were the Sailors (officers and enlisted)
in the United States Navy, more specifically, active duty and reservists. Sailors whether
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49
deploying or supporting deployed units participating in peacetime and OCO could be exposed to
arduous conditions, traumatic situations, and armed combat while performing their duties. Being
exposed to arduous conditions, traumatic situations, and armed combat could cause PTSD. The
Sailors who participated in this study were evaluated to see if knowledge, motivation, and
organizational influences interfere with them seeking help for PTSD. This explanatory mixed-
methods study consisted of quantitative (surveys) and qualitative (interviews) data research in a
parallel sequential design.
Survey Sampling Criteria and Rationale
Criterion 1. All participants (Sailors) needed to be serving on active duty or as a
reservist in the United States Navy. This criterion was chosen because the problem of practice
focuses on PTSD and stigma among service members; it also directly relates to and aids in
answering the three research questions of the study. Sailors, whether deploying or supporting
deployed units participating in peacetime and OCO could be exposed to arduous conditions,
traumatic situations, and armed combat while performing their duties, which could result in
PTSD.
Survey Sampling (Recruitment) Strategy and Rationale
The sampling population consisted of the Sailors who are serving on active duty or as a
reservist in the United States Navy. The sampling strategy or method used was a convenience
sampling of the Sailors who are deploying or supporting deployed units participating in
peacetime and OCO. The sampling frame consisted of those active duty and reservist Sailors that
could be exposed to arduous conditions, traumatic situations, and armed combat while
performing their duties, which could result in PTSD. Those Sailors were solicited from the
following non-official Facebook forums: Navy Basic Mentoring (32,693), FMF Corpsman
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50
(8,073), US Navy Limited Duty Officer/Chief Warrant Officer (4,392), 6490/7490 Security
Officers (366), Navy Chief Warrant Officer (1,323), Iraq & Afghanistan Veterans PTSD, TBI,
and Physical Wounds Group (6,239) for a total of 53,086 personnel being solicited to participate
in the study. The small sampling frame size allowed the researcher to study the whole population
vice as a subset and minimized sampling error (Johnson & Christensen, 2014).
A researcher-developed survey (questionnaire) that consisted of 26 questions in a
standardized format relating to the study research questions and the KMO framework was
administered by a web-based version of Qualtrics to the Sailors within the sampling frame.
These questions were carefully worded so the researcher would not confuse the participants or
yield useless data (Merriam & Tisdell, 2016). The research questions on the survey were
predetermined in advance and the responses were fixed and short answer, with fixed responses
aiding in quick responses and data analysis (Johnson & Christensen, 2014). The answers were
reviewed and analyzed to validate approximately 18 questions for the qualitative portion of the
study to refine interview protocol.
Interview and/or Focus Group Sampling Criteria and Rationale
Criterion 1. All participants (Sailors) needed to be serving on active duty or as a
reservist in the United States Navy. This criterion was chosen because the problem of practice
focuses on PTSD and stigma among service members; it also directly relates to and aids in
answering the three research questions of the study. Sailors, whether deploying or supporting
deployed units participating in peacetime and OCO could be exposed to arduous conditions,
traumatic situations, and armed combat while performing their duties, which could result in
PTSD.
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51
Interview and/or Focus Group Sampling (Recruitment) Strategy and Rationale
The sampling frame consisted of those active duty or reservist Sailors who could be
exposed to arduous conditions, traumatic situations, and armed combat while performing their
duties, which could result in PTSD. The sampling strategy or method used was convenience
sampling (non-random/non-probability) solicited from the following non-official Facebook
forums: Navy Basic Mentoring (32,693), FMF Corpsman (8,073), US Navy Limited Duty
Officer/Chief Warrant Officer (4,392), 6490/7490 Security Officers (366), Navy Chief Warrant
Officer (1,323), Iraq & Afghanistan Veterans PTSD, TBI, and Physical Wounds Group (6,239)
for a total of 53,086 personnel being solicited to participate in the study. This form of sampling
was chosen because the military participants cannot be made to participate in an interview, but a
small purposeful sample is still needed. In addition, it saved the researcher time, money, and
allowed for thematic coding and interpretation of the narrative data (Maxwell, 2013). The study
originally had a convenience sample goal of 10 interviewees (N=10), but only three Sailors
volunteered to participate in an interview, making it a sample of three (N=3). This was due to
time constraints and most likely because of a negative comment a member within a Facebook
forum where the researcher solicited volunteers from made about the educational institution, the
surrounding stigma and sensitivity about the problem of practice, and concerns of confidentiality.
The interview was a highly structured/standardized open-ended discussion that consisted
of 18 predetermined questions. Each interview was approximately 30 minutes in duration and
conducted through Zoom. The open-ended questions were provided to all the participants in the
same order, manner, and format. These questions allowed the researcher to gain an in-depth
perspective about the Sailors’ beliefs, knowledge, reasoning, motivations, and feelings pertaining
to the purpose of the study (Johnson & Christensen, 2014). Once the interview was complete, the
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52
responses were then analyzed and combined with the quantitative data for overall analyzation
and triangulation.
Explanation for Choices
The study is an explanatory framework that consisted of quantitative and qualitative data
collection through the use of survey’s and interviews. The rationale for the specific data
collection methods used in the study are described in the interview and survey strategy and
rational sections. While this study consisted of interview and surveys for data collection, there
are other methods, such as observation and tests.
Observing the current stakeholder group for this study would not have resulted in any
usable data because the focus of the study and research questions did not involve the participants
being in their natural environment (deployed). If observation data collection were used, the
researcher would observe the participants in their natural and structured setting. The observations
would be recorded as field notes, by video, or as a drawing and analyzed. Another data collection
method are tests and they are normally used in quantitative studies to measure performance and
aptitude. This method was not used because the purpose of the study and research questions did
not deal with performance and aptitude. If tests were used, it would be standardized and
administered to the participants of the study to measure personality, attitudes, self-perceptions,
performance, and aptitude (Johnson & Christensen, 2014).
Data Collection and Instrumentation
Data collection consisted of explanatory sequential mixed-methods, incorporating the
collection and analysis of both quantitative and qualitative data. The researcher used surveys
(quantitative) and face-to-face interviews (qualitative) as instruments for data collection. This
design was chosen because of the added strength of research when using both quantitative and
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53
qualitative methods, and due to the lack of published mixed-method research on stigma and
PTSD in the military (Creswell, 2014). Specifically, surveys were chosen because of a large
number of responses needed and the ability to synthesize the data quickly. Face-to-face
interviews were chosen because they yield rich data and can easily be used for triangulation
purposes to increase validity and credibility.
Surveys
The quantitative portion of the mixed-methods framework of the study consisted of
surveys as an instrument to collect data. The survey consisted of 26 questions (Appendix A) to
seek out nominal/categorical, ordinal, and continuous (interval and ratio) data to assess whether
or not stigma relates to Sailors not seeking medical care, more specifically, PTSD. Data were
collected from a convenience sampling (non-random/non-probability). This form of sampling
was chosen because the military participants cannot be made to participate in an interview, but a
small, purposeful sample is still needed. Also, it saved the researcher time, money, and allowed
for thematic coding and interpretation of the narrative data (Maxwell, 2013). The convenience
sample consisted of Sailors (N=102) who are deployed or are supporting deployed units
participating in peacetime and Overseas Contingency Operations (OCO).
The researcher-developed survey consisting of standardized formatted questions were
electronically administered by Qualtrics software provided by the University of Southern
California. Each participant who volunteered received an “informed consent” disclosure
(Appendix C) at the beginning of the survey that described the purpose of the study,
methodology, informed consent, reciprocity, any promises, a risk assessment, confidentiality
agreement, data collection methodology, access, and ownership (Merriam & Tisdell, 2016).
Also, each participant was required to agree or disagree with the “informed consent” disclosure
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electronically before commencement of the survey. Survey results were analyzed to allow the
researcher to identify themes across KMO. The data were used to refine interview protocol for
face-to-face interviews that occurred in the second phase of the study. The analyzed quantitative
findings will be presented in Chapters 4 and 5.
Interviews
The qualitative portion of the study consisted of face-to-face interviews as an instrument
to collect data. Face-to-face interviews were conducted in a small group of active and reserve
Sailors (N=3) who are deployed or are supporting deployed units participating in peacetime and
Overseas Contingency Operations (OCO). Each participant was interviewed individually to
maintain confidentiality and obtain rich data. The interview was an approximately 30 minute
highly structured/standardized open-ended discussion that consisted of 18 predetermined
questions (Appendix B), which were revised based on the research questions and analyzed
quantitative data from the surveys. The interviews followed a predetermined script (Appendix D)
that aided in mitigating researcher bias. Also, the interviews were conducted through Zoom and
recorded by electronic means, if consent was given for memorialization and validity purposes.
Each participant who volunteered received an electronic (Zoom) of an “informed
consent” disclosure (Appendix C) that described the purpose of the study, methodology,
informed consent, reciprocity, any promises, a risk assessment, confidentiality agreement, and
data collection methodology, and access, and ownership (Merriam & Tisdell, 2016). Each
volunteer was required to verbally state they read and understood the “informed consent”
disclosure and agreed to participate in the interview. At the commencement of the interview, the
researcher asked the participants if they agreed to be recorded and understood they could decline
to participate or not answer specific questions at any point during the interview.
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The audio from the interviews (N=3) was transcribed upon reaching a predetermined
deadline. The transcribed data were then analyzed using ATLAS.ti to produce analyzed
qualitative data. The analyzed qualitative data and findings will be presented in Chapters 4 and 5.
Data Analysis
All data, electronic and written, was analyzed upon completion of the required surveys
and interviews. First, the raw quantitative data from all the completed surveys (N=102) were
exported from Qualtrics into Excel to clean and code into patterns and themes based on the
researcher’s interpretation and reflection (analytical coding) on the meaning (Merriam & Tisdell,
2016). Numerical values were used as codes for all multiple-choice questions to aide in the ease
of analyzation. Any questions not answered were coded “99999” to identify and mitigate bias
(item non-response etc.) that could be a potential threat (erroneous data) to validity and
credibility. All qualitative data (short answer questions) were then disaggregated and uploaded as
a Microsoft Word document to code in ATLAS.ti. A code book covering the quantitative data
was then developed to provide each variable/question name and answer options for each question
and their specific “code.” The researcher then reviewed the research questions to find portions of
analytically coded data that were relevant to this study to revise interview questions and
protocol.
Next, the qualitative data received during the interviews was transcribed using Zoom and
then uploaded into ATLAS.ti. The researcher then utilized ATLAS.ti. to code the data into
groups that corresponded to specific research questions, patterns, themes, and finite groups. The
coded data were analyzed and triangulated with the quantitative findings to develop data points
that supported whether or not knowledge, motivation, and organizational influences impacted
Sailors seeking treatment for PTSD.
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Validity and Reliability
The effect of the study on the problem of practice could have been impacted by validity
and reliability, making it a concern for researchers (Merriam & Tisdell, 2016). Validity is
concerned with “the way in which the data was collected, analyzed, interpreted, and the way the
findings are presented” (Merriam & Tisdell, 2016, p. 238). Some common themes to validity are
researcher bias and reactivity (Maxwell, 2013). Researcher bias occurs when the researcher
intentionally or unintentionally influences the results of the study. This form of bias was
mitigated by conducting respondent validation and survey question comparison with previous
similar studies. The researcher solicited feedback from Sailors after they completed the survey
and interviews to validate the data being provided. This feedback was documented and allowed
the researcher to identify any misunderstandings and his own biases (Maxwell, 2013). Also, the
researcher compared survey questions with similar studies about PTSD and stigmas prior to
starting the research study. Triangulation of quantitative and qualitative data sets was also used
to reduce the risk of researcher bias, greatly strengthening the results of the study (Merriam &
Tisdell, 2016).
Reactivity occurs when the researcher intentionally or unintentionally influences the
setting or the participants (Maxwell, 2013). Throughout the process of this study, the researcher
was assigned to the organization being studied and is also a naval officer who may, or may not,
depending on the participants rank, have influence over some of the Sailors being studied.
However, the bias was mitigated, as he conducted the survey through Qualtrics and there was no
personally identifiable information (PII) being obtained, making participation anonymous. Also,
as previously stated in validity, all survey and interview questions were compared to previous
similar studies of PTSD and stigma to mitigate bias prior to the start of the study.
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Reliability refers to the extent that the research findings can be replicated (Merriam &
Tisdell, 2016, p. 250). One concern with reliability is that the human behavior of the participants
could differ if the study is conducted again. However, use of standardized measures and tools
and transparency about the methods used in the study, sample size, and site used increased
reliability (Lincoln & Guba, 1985).
Credibility and Trustworthiness
Research, regardless of methodology, needs to produce data that are credible and
trustworthy. The degree to which data are believable and true determines credibility, whereas,
trustworthiness speaks to the infallibility of the data (Maxwell, 2016). Researcher bias and
reactivity are common threats to credibility and trustworthiness. The researcher solicited
feedback (respondent validation) from Sailors after they completed the surveys and interviews to
validate the data being provided. This feedback was documented and allowed the researcher to
identify any misunderstandings and his own biases (Maxwell, 2013).
Triangulation of quantitative and qualitative data sets was also used to reduce the risk of
researcher bias, greatly strengthening credibility and trustworthiness (Merriam & Tisdell, 2016).
Also, the researcher utilized a standardized interview process for conducting the interviews that
was defined earlier in Chapter 3 and is scripted in Appendix C. This process, along with the
researcher conducting 3 interviews (N=3) during the qualitative portion of the study, increased
credibility and trustworthiness.
Ethics
All aspects of research were conducted professionally and ethically to foster trust among
participants, peers, and society, produce valid and credible results and provide unbiased sound
knowledge. The researcher met the Institutional Review Board (IRB) ethical requirements and
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58
continually monitored how research was being carried out (Glesne, 2011). Also, to mitigate any
bias, the researcher ensured none of the interview participants worked or have worked for him
under the same command. The survey participants remained anonymous through Qualtrics.
Participating Sailors who volunteered received an “informed consent” disclosure at the
beginning of the survey and interview that described the purpose of the study, methodology,
informed consent, reciprocity, any promises, a risk assessment, confidentiality agreement, and
data collection methodology, and access, and ownership (Merriam & Tisdell, 2016). Each
volunteer was required to electronically (survey) and verbally (interview) consent (Appendix C)
prior to participation in the study. The researcher’s role was that of an advocate, as he
championed a cause (mitigate stigma) on behalf of the Sailors (Glesne, 2011). The “informed
consent” section informed the participants of the following: that their participation is voluntary,
about any aspects of the research that could adversely impact them mentally and physically, and
that they could decline to answer any specific questions or terminate their participation at any
time.
All electronic and paper data, including participant information, will remain confidential
and will not be shared unless authorized by the participant in writing. Maintaining their
confidentiality will allow them to stay anonymous and protect their confidences (Glesne, 2011).
In addition, the results of the study will be provided to the participants for review (if requested),
and all data will be safeguarded on an external hard-drive within a high-security safe when not in
use.
Limitations and Delimitations
As with all research studies, there are limitations and delimitations that should be
anticipated. Within this study, truthfulness of the study participants and role of the researcher
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have been identified as possible limitations and delimitations. The use of a standardized
interview protocol (Appendix D) that consisted of highly structured/standardized open-ended
questions were used to aid in participant truthfulness. The interview questions were validated,
and necessary adjustments were made to interview protocol or the questions themselves after
analyzing the quantitative data from the surveys. Also, the questions were compared to other
similar studies of PTSD and stigmas. Furthermore, the researcher solicited feedback (respondent
validation) from Sailors after they completed the survey and interviews to validate the data being
provided. This feedback was documented and allowed the researcher to identify any
misunderstandings and untruthfulness (Maxwell, 2013).
The researcher’s role was that of an advocate, as he championed a cause (mitigate
stigma) on behalf of the Sailors (Glesne, 2011). At one time, he was deployed in support of OCO
in 2009 and 2018. During his assignment to Afghanistan in 2009, he came under attack by
rocket-propelled grenades (RPG’s) and small arms fire that put his life at risk. Upon his return,
he did not seek out medical attention for possible signs and symptoms of PTSD due to the
associated stigmas. His personal experience remained unknown to the participants to prevent any
bias or coercion to participate.
Conclusion
To fully understand how stigma impacts a Sailors decision to seek mental health care for
PTSD, an explanatory sequential mixed-method model, incorporating the collection and analysis
of both quantitative and qualitative data was used. This design included both quantitative and
qualitative research due to the lack of published mixed-method research on stigma and PTSD in
the military (Creswell, 2014). The study consisted of surveys (quantitative) and interviews
(qualitative) as instruments to collect data.
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The methodology of this study was carefully evaluated and scrutinized to ensure the
benefits outweighed the costs, and that current validity, credibility, reliability, trustworthiness,
and ethical threats had been addressed. While these threats were addressed, the researcher
continued to monitor the study for any additional threats that may have arisen. This allowed the
researcher to provide valid and credible results that are trustworthy.

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CHAPTER FOUR: RESULTS AND FINDINGS
The purpose of Chapter 4 is to present the results of the data collected from Sailors that
are deployed or supporting deployed units participating in peacetime and OCO through surveys
and interviews that determine the knowledge, motivational and organizational influences
interfering with Sailors seeking medical care for PTSD. The research problem of practice for this
dissertation study was used to explore the knowledge, motivation, and organizational influences
that interfere with Sailors who are deployed or are supporting deployed units participating in
peacetime and OCO from seeking medical care for PTSD. The research problem is indicative of
the conceptual framework, enabling the development of the problem, specific research questions,
data collection process and method, analysis approach, and methodology for interpretation.
As previously mentioned in Chapter 3, the Research Questions (RQ) that guided this
study were:
1. What is the knowledge, motivation, and organizational influences that interfere with
achieving the goal of a 50% decrease in medical discharges for PTSD or related personal
or professional issues?
2. What are the Sailors’ recommended knowledge, motivation, and organization
solutions?
3. Does the organization create a culture free of stigmas relating to mental health issues
and those who seek treatment?
Data collection consisted of an explanatory sequential mixed-method, incorporating the
collection and analysis of both quantitative and qualitative data. This design was chosen because
of the strength that research has when both quantitative and qualitative methods are used, and
due to the lack of published mixed-method research on stigma and PTSD in the military
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(Creswell, 2014). The quantitative and qualitative data were then used to validate or invalidate
these assumed causes using the Clark and Estes (2008) gap analysis.
Overall, data collection occurred from May – July 2019, and all statistical data in the
form of percentages have been rounded. The results and findings are discussed in the following
sections. First, survey data that consists of an overview, demographics, and how that data relates
to the KMO influences will be covered, followed by an interview overview, demographics, and
how that data relate to the KMO influences. Then, there will be an explanation of how the survey
and interview data relate to the RQ’s for the study. Finally, limitations and delimitations and a
summary of the findings and overall impact will be discussed.
Survey
The researcher used the following unofficial social medical platforms (Facebook) to
solicit volunteers: Navy Basic Mentoring (32,693), FMF Corpsman (8,073), US Navy Limited
Duty Officer/Chief Warrant Officer (4,392), 6490/7490 Security Officers (366), Navy Chief
Warrant Officer (1,323), Iraq & Afghanistan Veterans PTSD, TBI, and Physical Wounds Group
(6,239). In addition, email, and personal contacts were also used to solicit volunteers. The total
number of participants solicited was approximately 53,086, and 102 consented to participate and
completed the survey. The survey consisted of 26 questions, 10 covering participant
demographics, and 16 on conceptual and metacognitive influences, focusing on RQ 1 and 3.
Survey Demographics
While the methodology of the study had a goal of 100 surveys, the total number received
(N=102) was analyzed. Of those who responded to the survey, 95% were active duty, 5% were
reservists, 72% were male, and 28% were female. Of those, 38% were in the paygrade of (E-1 –
E-3), 41% (E-7 – E-9), 9% (W-2 – W-5), 10% (0-1 – 0-3), and 3% (0-4 – 0-6). Due to the vast
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range of paygrades, 15% had less than 10 years of service, 33% had 10 – 15 years, 31% had 16 –
20 years, and 22% had 21 – 30 years of service within the Navy.
The stakeholder group routinely deploys or are supporting deployed units participating in
peacetime and OCO. Of those, 3% never deployed, 30% completed one to two deployments,
36% three to five, 19% six to nine, and 13% 10 or more. During those deployments, 7%
supported or deployed supporting in Operation New Dawn (OND), 35% Operation Enduring
Freedom (OEF), 26% Operation Iraqi Freedom (OIF), 15% Operation Inherent Resolve (OIR),
and 17% in Humanitarian Operations (all inclusive). While deployed, 32% participated in
Combat Operations, 20% Humanitarian, 33% were assigned to Arduous Duty, and 14% Isolated
Duty. Of those who deployed or fulfilled those duty assignments, 72% reported being exposed to
traumatic situations. Specifically, 52% were exposure to trauma due to enemy fire
(indirectly/directly), and 51% felt they have or may have PTSD as a result of their military
deployments, and 23% felt the possibility existed.
Knowledge Findings
Knowledge Influence #1: Sailors do have an in-depth and accurate understanding of
PTSD but lack a formalized and consistent knowledge source. Training that covers PTSD is
occurring at some level within the Navy, but not consistently enough because 26% of
respondents stated they never received training, 18% on one occasion, 15% on two occasions,
and 41% on three or more occasions (Q-12). Respondents also provided their own definition of
PTSD, and the terms used closely relate to that of the National Center for PTSD; their responses
in the form of terms to Q-13 are depicted in Figure B and move toward the center and become
larger in size based on the number of times used. Also, 41% of respondents were confident in
their abilities to self-identify the signs and symptoms of PTSD, followed by 32% being
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confident, 17% being neither confident or unconfident, 7% being unconfident, and 2% being
very unconfident (Q-16). Furthermore, 22% of respondents strongly agreed that the Navy
provided them with the needed support services in the event they needed to seek care for mental
health issues or PTSD, followed by 40% agreeing, 18% neither agreeing or disagreeing, 12%
disagreeing, and 8% strongly disagreeing (Q-26).

Figure B. Word cloud diagram created by Qualtrics from responses to Q-13
Knowledge Influence #2: Sailors are able to identify but are unable to navigate
through the associated stigmas. Training that covers stigmas is not occurring within the Navy
because 47% of respondents stated they never received training, 13% on one occasion, 5% on
two occasions, and 35% on three or more occasions (Q-18). Sailors also felt they were able to
identify stigmas within the Navy toward those who seek mental health care because 84% of the
respondents identified that stigmas exist and only 16% stated they did not (Q-20). Also, 51% of
respondents felt that stigmas further existed within their current organization (unit), 24% that it is
possible they exist, and 25% that none existed (Q-22). Furthermore, respondents also provided
their own definition of a stigma and the terms closely relate to that of the Mayo Clinic; the terms
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from their responses to Q-17 are depicted in Figure C and move toward the center and become
larger in size based on the number of times used. Moreover, respondents were able to identify
what stigmas exist toward those who seek out medical care for mental health issues or PTSD and
are depicted in Figure D and move toward the center and become larger in size based on the
number of times used (Q-23).

Figure C. Word cloud diagram created by Qualtrics from responses to Q-17

Figure D. Word cloud diagram created by Qualtrics from responses to Q-23
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Knowledge Influence #3: Sailors are able to identify the individual signs of PTSD
that they may be experiencing but lack a formalized and consistent knowledge source.
Training that covers PTSD is occurring at some level within the Navy but not consistently, as
26% of respondents stated they never received training, 18% on one occasion, 15% on two
occasions, and 41% 3 on three or more occasions (Q-12). Respondents also provided their own
definition of PTSD where the terms closely relate to that of the National Central for PTSD; the
terms from their responses to Q-13 are depicted in Figure B and move toward the center and
become larger in size based on the number of times used. Also, 41% of respondents were
confident in their ability to self-identify the signs and symptoms of PTSD, followed by 32%
being confident, 17% being neither confident or unconfident, 7% being unconfident, and 2%
being very unconfident (Q-16). Furthermore, 22% of respondents strongly agreed that the Navy
provided them with the needed support services in the event they felt the need to seek care for
mental health issues or PTSD (Q-26).
Motivation Findings
Motivation Influence #1 and 2: Sailors are unable to see/feel (Utility Value) the
value in and are unconfident in receiving medical care for PTSD (Self-Efficacy). Sailors felt
they were able to identify stigmas within the Navy toward those who seek mental health care
because 84% of the respondents identified that stigmas exist, and only 16% stated they did not
(Q-20). Also, 51% of respondents felt that stigmas further existed within their current
organization (unit), 24% that it is possible, and 25% that none existed (Q-22). Furthermore, 84%
of respondents felt stigmas existed within the Navy toward mental health care and those who
seek it (Q-22). The perceived consequences and stigmas, previously noted in Knowledge
Influences 1-3 and depicted in Figures C and D by the stakeholder group, outweigh the benefits
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of seeking medical care for PTSD. Moreover, the perceived stigmas do or would impact their
decision to seek medical care for mental health issues or PTSD; 30% of respondents stated that it
was very likely, 30% likely, 25% neither likely or unlikely, 6% unlikely, and 10% very unlikely
(Q-24).
Organization Findings
Organizational Influence #1: The organization does not provide Sailors pre/post-
deployment training on PTSD and stigmas. Training, whether general in nature or for pre/post
deployment, covering PTSD is occurring at some level within the organization, but not
consistently, as 26% of respondents stated they never received training, 18% on one occasion,
15% on two occasions, and 41% on three or more occasions (Q-12). Whereas, training covering
stigmas is not occurring within the organization because 47% of respondents stated they never
received training, 13% on one occasion, 5% on two occasions, and 35% on three or more
occasions (Q-18). While the survey questions did not focus on the title of the training,
respondents could have been referring to Operational Stress Control Training, which is typically
provided pre/post deployment but does not specifically cover PTSD and the associated stigmas.
More specific respondent feedback will be provided in the interview results under Organizational
Influence #2.
Organizational Influence #2: The organization culture consists of stigmas relating to
PTSD. The current organizational culture is not free of stigmas relating to PTSD. Sailors felt
they were able to identify stigmas within the Navy toward those who seek mental health care
because 84% of the respondents identified that stigmas exist and only 16% stated they did not
(Q-20). Also, 51% of respondents felt that stigmas further existed within their current
organization (unit), 24% that it is possible, and 25% that none existed (Q-22). The perceived
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consequences and stigmas, as previously noted in Knowledge Influences 1-3 and depicted in
Figures C and D by the stakeholder group, outweigh the benefits of seeking medical care for
PTSD. Moreover, the perceived stigmas within their unit do or would impact their decision to
seek medical care for mental health issues or PTSD because 30% of respondents stated that it
was very likely, 30% likely, 25% neither likely or unlikely, 6% unlikely, and 10% very unlikely
(Q-24). Within the Navy, 43% responded it was very likely that stigmas would impact their
decision to seek medical care, followed by 22% likely, 19% neither likely or unlikely, 7%
unlikely, and 10% very unlikely.
Interview
The researcher used the following unofficial social medical platforms (Facebook) to
solicit volunteers: Navy Basic Mentoring (32,693), FMF Corpsman (8,073), US Navy Limited
Duty Officer/Chief Warrant Officer (4,392), 6490/7490 Security Officers (366), Navy Chief
Warrant Officer (1,323), Iraq & Afghanistan Veterans PTSD, TBI, and Physical Wounds Group
(6,239). In addition, email, and personal contacts were also used to solicit volunteers. Total
number of participants solicited was approximately 53,086, and 3 consented to participate and
completed the interview. The interview consisted of 26 questions, 10 covering participant
demographics, and 16 on conceptual and metacognitive influences, focusing on RQ 1 – 3.
Interview Demographics
Three Sailors (N=3) consented to participate and completed the interview. Of those
Sailors who completed the interview, all were male and on active duty, one was in the paygrade
of (E-1 – E-6), one (E-7 – E-9), and one (0-1 – 0-3). All the interviewees have participated in or
supported OCO, more specifically within a combat zone.

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Knowledge Findings
Knowledge Influence #1: Sailors do have an in-depth and accurate understanding of
PTSD but lack a formalized and consistent knowledge source. All of the interviewees
exhibited an in-depth and accurate understanding of PTSD due to their own experiences and
operational deployments. Of note, one interviewee works within the Special Warfare
(SPECWAR) community and his leadership routinely talks about PTSD and “provide them with
the needed assets for help.” Also, a different interviewee commented that PTSD is so commonly
talked about now or “run of the mill” that most people know about it. However, two out of three
interviewees felt there needed to be formalized training within the Navy that included a
facilitator that “lived it” and had been through what they are experiencing. One interviewee in
particular said “people are more perceptive to be taught by those who have done it” and it would
be beneficial to have someone who could talk about navigating the associated stigmas.
Knowledge Influence #2: Sailors are able to identify but are unable to navigate
through the associated stigmas. All of the interviewees were able to understand and recognize
the stigmas associated with PTSD. Some of the stigmas identified by the interview respondents
were, being seen as weak, seen as broken, weak minded, unable to hold the load, loss of security
clearance, lessening of responsibilities and authorities, not being taken seriously, loss of orders
and special assignments, damage to career, and constantly having to fight the diagnosis
(cascading effect). As previously noted in Knowledge Influence 1, one interviewee in particular
said “people are more perceptive to be taught by those who have done it” and it would be
beneficial to have someone who could talk about navigating the associated stigmas. This is
reinforced by all interviewees unanimously stating that stigmas exist within the Navy and their
organizations or units in one-way shape or form. However, one interviewee that is assigned to
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SPECWAR community stated the stigmas that existed are diminishing. He further stated, “you
cannot eliminate stigma just because of a lack of knowledge,” there needs to be leadership
engagement.
Knowledge Influence #3: Sailors are able to identify the individual signs of PTSD
that they may be experiencing but lack a formalized and consistent knowledge source. All
of the interviewees were able to describe the signs of PTSD. Of note, one interviewee was aware
that he was experiencing signs and symptoms consistent with PTSD and sought out medical care
on his own. He has since been diagnosed with PTSD and stated, “signs and symptoms vary with
each person,” for him specifically, “certain smells trigger a reaction where I feel I am still in the
environment dealing with the traumatic situation.” Another stated, “PTSD is difficulty coping
with a traumatic experience from the past that creeps into the present,” and another with “it is a
mental state that a person is trying to cope with.” Also, one of the interviewees made a comment
that “Corpsman and Marines tend to have more awareness and exhibit signs well after most
because they are trained more on stress management providing an increase in resiliency.”
Furthermore, two of the three interviewees felt there needed to be formalized training within the
Navy that included a facilitator who “lived it” and had been through what they are experiencing.
Motivational Findings
Motivation Influence #1 and 2: Sailors are unable to see/feel (Utility Value) the
value in and are unconfident in receiving medical care for PTSD (Self-Efficacy). One
interviewee “wished more had the confidence to reach out when they are struggling; I believe
there are a lot of people suffering in silence.” He also believes “we (Navy) need to do a better job
supporting people that are struggling with PTSD.” An example he provided was:
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“A Sailor (Corpsman) left the support network of his peers and Marines who deployed
with and arrived at his command where leadership failed to properly coordinate a ride for
him. He was essentially forgotten about by the command leadership and the command
sponsorship program. Prior to arriving at the command, he recently completed a horrible
combat deployment where he lost his best friend whose arm was wounded. He attempted
to save his life, and at the same time, found out his spouse was cheating on him with his
close friend while he was overseas. While trying to cope, the Sailor took some
prescription medication that first weekend, took a urinalysis test for drugs, and
subsequently popped positive on the test. Due to him testing positive on the urinalysis, he
is now kicked out the Navy and no one looked past the results at what was going on with
him. It was like the epitome of how the onboarding and support process failed him.”
Also, he stated, “there was really no follow up from leadership, just kind of among yourselves
and peer-to-peer support.” The lack of resources options within the Navy and organization and
delay in getting appointments for support services within the Navy sometimes exceeds 90 days,
which greatly impacts whether they seek medical care. Furthermore, there is a lack of sincerity
when it comes to leadership stating they support their Sailors receiving care and when they
actually seek care. The interviewee stated:
“My leadership let me know I could just come and talk or go seek help if needed upon
knowing I had PTSD. One day a smell triggered probably the most extreme internal
reaction and was unable to get over it. I then went to the same person that told me I could
come talk and go get help if needed and they seemed shocked that I was even there
asking for help.”

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Organizational Findings
Organizational Influence #1: The organization does not provide Sailors pre/post-
deployment training on PTSD and stigmas. Two of the three interviewees felt the pre/post
deployment consisted of Operational Stress Control Training and not specifically on PTSD and
what they could experience within their deployed environment. The only exception was upon
return “when things went off script a little.” And, only one interviewee had training on PTSD
prior to their return from deployment because of their job within the Special Warfare
community. Another interviewee stated, “things were talked about within our unit by the
Chaplain mostly and kind of tapered off until something happened with someone, like a suicide”
making it feel like it was essentially a check in the box for leadership. Furthermore, two out of
the three interviewees felt there needed to be formalized training within the Navy that included a
facilitator who “lived it” and had been through what they are experiencing.
Organizational Influence #2: The organization culture consists of stigmas relating to
PTSD. All of the interviewees were able to understand and recognize the stigmas associated with
PTSD. Some of stigmas identified by the interview respondents were, being seen as weak, seen
as broken, weak minded, unable to hold the load, loss of security clearance, lessening of
responsibilities and authorities, not being taken seriously, loss of orders and special assignments,
damage to career, and constantly having to fight the diagnosis (cascading effect). The
interviewees unanimously stated that stigmas exist within the Navy and their organizations or
units in one-way shape or form. However, one interviewee who is assigned to SPECWAR
community stated the stigmas that existed are diminishing. He further stated that, “you cannot
eliminate stigma just because of a lack of knowledge,” there needs to be leadership engagement.

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Research Question Findings
Research Question #1. What is the knowledge, motivation, and organizational
influences that interfere with achieving the goal of a 50% decrease in medical discharges for
PTSD or related personal or professional issues? Sailors deploying or supporting deployed units
participating in peacetime and Overseas OCO do have an in-depth and accurate understanding of
PTSD and are able to identify individual signs and symptoms but lack a formalized and
consistent knowledge source. Training that covers PTSD is occurring at some level within the
Navy but not consistently, as 26% of survey respondents stated they never received training,
18% on one occasion, 15% on two occasions, and 41% on three or more occasions (Q-12). While
training on PTSD is occurring at some level, all of the interviewees stated pre/post deployment
training consisted of Operational Stress Control, not PTSD and stigma. This raises the question
of whether the survey participants were referencing or viewing Operational Stress Control
training as being on PTSD. However, there is a need for formalized training within the Navy that
includes a facilitator who “lived it” and had been through what the Sailors who have PTSD are
experiencing, according to two of the three interviewees.
Sailors deploying or supporting deployed units participating in peacetime and Overseas
OCO are able to identify, but are unable to navigate through, the associated stigmas; they are
also unable to see and feel the value in receiving medical care (Self-Efficacy/Utility Value).
Training that covers stigmas is not occurring within the Navy because 47% of respondents stated
they never received training, 13% on one occasion, 5% on two occasions, and 35% on three or
more occasions (Q-18). Sailors also felt they were able to identify stigmas within the Navy
toward those who seek mental health care because 84% of the respondents identified that stigmas
exist and only 16% stated they did not (Q-20). Also, 51% of respondents felt that stigmas further
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existed within their current organization (unit), 24% that it is possible, and 25% that none existed
(Q-22). The perceived consequences and stigmas, as previously noted in Knowledge Influences
1-3 and depicted in Figures C and D by the stakeholder group, outweigh the benefits of seeking
medical care for PTSD. Moreover, the perceived stigmas do or would impact their decision to
seek medical care for mental health issues or PTSD because 30% of respondents stated that it
was very likely, 30% likely, 25% neither likely or unlikely, 6% unlikely, and 10% very unlikely
(Q-24).
Research Question #2. What are the Sailors’ recommended knowledge, motivation, and
organization solutions? The interviewees recommended formalized training on PTSD and stigma
within the Navy that included a facilitator who “lived it” and had been through what they are
experiencing. One interviewee in particular said that, “people are more perceptive to be taught by
those who have done it” and recommended to have someone who could talk about navigating the
associated stigmas. Also, leadership within the Navy needs to address the support system, as
Sailors are resorting to peer-to-peer support due to the stigmas, perceived insincerity, and lack of
follow-up from leadership post-deployment until there is an incident such as someone
committing suicide. Furthermore, current naval support services in the Navy take upwards to 90
days for an appointment, discouraging those who seek medical care.
Research Question #3. Does the organization create a culture free of stigmas relating to
mental health issues and those who seek treatment? The culture within the Navy and at the unit
level consist of stigmas relating to mental health issues and PTSD. Sailors felt they were able to
identify stigmas within the Navy toward those who seek mental health care because 84% of the
survey respondents identified that stigmas exist and only 16% stated they did not (Q-20). Also,
all of the interviewees stated that stigmas exist within the Navy and their organizations in one-
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way, shape or form. However, one interviewee who is assigned to SPECWAR community stated
the stigmas that existed are diminishing. Conversely, 51% of survey respondents felt that stigmas
further existed within their current organization (unit), 24% that it is possible they exist, and 25%
that none existed (Q-22).
There is also a lack of empathy and sincerity when it comes to leadership stating they
support Sailors receiving care and when they actually seek it. In this case, actions speak louder
than words, and leadership are not following through with their verbal support, according to one
interviewee. This gives Sailors the perception leadership are more worried about the mission
than their well-being. Another interviewee whose specialty is within the SPECWAR community
commented that, “you cannot just limit stigmas, there needs to be leadership engagement.” He
further stated that leadership within his community are engaged and while the organization is not
free of stigmas, they are diminishing. The existence of stigmas and Sailors’ inability to navigate
through the stigmas within the Navy and at the unit level will continue to deter Sailors from
seeking medical care for PTSD.
Limitations and Delimitations
As with all research studies, there are limitations and delimitations that the researcher
encounters. First, the stigma or sensitivity of the problem of practice hindered the researcher’s
ability to get official approval from the Navy to conduct the study on base or within an official
organization. The researcher had sought out approval and was inundated with delayed responses,
legal questions, and deflection of whose authority could be used for the approval. He even was
told unofficially that no one wanted to touch it because it is such a sensitive topic and big issue
within the Navy and military as a whole. This diminished a substantial amount of research time,
in turn, leading the researcher to seek out volunteers from the stakeholder group through
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unofficial Navy and PTSD/Traumatic Brain Injury (TBI) social media support platforms
(Facebook), email, and personal contacts.
Next, the methodology for the study set a goal for 10 interview participants. However,
the researcher was only able to get three volunteers due to time constraints and a negative
comment toward the researcher’s solicitation post within one of the unofficial Navy Facebook
groups. Also, surrounding stigma and sensitivity about the problem of practice along with
confidentiality concerns most likely played a factor in the lack of interview volunteers.
The next step involved the researcher using a standardized interview protocol (Appendix
D) that consisted of highly structured/standardized open-ended questions that aiding in eliciting
participant truthfulness. The interview questions were validated and revised based on trends in
the qualitative data, and necessary adjustments were made to interview protocol. Also, the
questions were compared to other similar studies of PTSD and stigmas. Furthermore, the
researcher solicited and received respondent feedback (respondent validation) from Sailors after
they completed the survey and interviews to validate the data being provided. This feedback was
documented and allowed the researcher to identify any misunderstandings and untruthfulness
(Maxwell, 2013). Moreover, the data was triangulated for validity and credibility, resulting in no
issues being identified.
Finally, the researcher’s role was that of an advocate, as he championed a cause (mitigate
stigma) on behalf of the Sailors (Glesne, 2011). At one time, he was deployed in support of OCO
in 2009 and 2018. During his assignment to Afghanistan in 2009, he was exposed to a traumatic
event. Upon his return, he did not seek out medical attention for possible signs and symptoms of
PTSD due to the associated stigmas. His personal experience remained unknown to the
participants to prevent any bias or coercion to participate.
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Conclusions
The quantitative and qualitative results provided sufficient data to indicate there were a
number of gaps that existed within Knowledge Influences 1-3, Motivation Influences 1-2, and
Organizational Influences 1-2, impacting whether or not Sailors will seek medical care for
PTSD. Since the United States continues to be a nation that embodies freedom and democracy as
represented by its involvement in combat operations in Iraq, Afghanistan, Syria, and other
countries, there will be an increasing number of individuals suffering from PTSD because of
various traumatic experiences (National PTSD Center, 2017). The trend of Sailors not seeking
medical care due to stigma within the Navy and the organization and a lack of support and
effective training and policy being in place will continue if not addressed. The Navy needs to
address “the elephant in the room” and change the mindset of “ship, shipmate, self.” If there is
no self, there is no shipmate, in turn, no ship or mission accomplishment as one interviewee put
it.

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CHAPTER FIVE: RECOMMENDATIONS
Introduction and Overview
The findings from the study indicate that there is knowledge, motivational, and
organizational gaps affecting performance goal achievement. In order for the Navy to see a 50%
decrease in medical discharges for PTSD or related personal or professional issues by December
2019, an overarching and comprehensive training and evaluation program on PTSD and the
associated stigmas needs to be developed and instituted by the Navy to address the following
gaps:
1. Sailors have an in-depth and accurate understanding of PTSD but lack a formalized
and consistent knowledge source.
2. Sailors are able to identify but are unable to navigate through the associated stigmas.
3. Sailors are able to identify the individual signs of PTSD that they may be
experiencing but lack a formalized and consistent knowledge source.
4. Sailors are unable to see/feel (Utility Value) the value in and are unconfident in
receiving medical care for PTSD (Self-Efficacy).
5. The organization does not provide Sailors pre/post-deployment training on PTSD and
stigmas.
6. The organizational culture consists of stigmas relating to PTSD.
First, recommendations for practice to address the knowledge, motivational, and
organizational gaps influence identified above were developed. Then, the Kirkpatrick (2016)
New World Model framework was used to implement the KMO recommendations, including a
training and evaluation program:
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1. Results and leading indicators (Level 4); the degree to which targeted outcomes occur
as a result of the training and the support and accountability package.
2. Behavior (Level 3); the degree to which Sailors apply what they learned during
training when they were back on the job.
3. Learning (Level 2); the degree to which Sailors acquire the intended knowledge,
skills, attitude, confidence, and commitments based on their participation in the training
or learning event.
4. Reaction (Level 1); the degree to which Sailors find the training favorable, emerging
and relevant to their jobs.
While an overarching and comprehensive training and evaluation program is needed, it is
not enough, and further research is required to identify other knowledge, motivation, and
organizational gaps to provide additional recommendations. The researcher is personally and
professionally connected to the problem of practice as an active duty naval officer and provided
recommendations based on his experience within the organization that may or may not be
reinforced by the data received from study participants under connection to practice and further
recommendations within this chapter.
Recommendations for Practice to Address KMO Influences
Knowledge Recommendations
Introduction. The knowledge influences in Table 3 represent a complete list of assumed
influences and their validity based on qualitative and quantitative data produced from surveys
and interviews that impact stakeholder goal achievement and are supported by literature and
other similar conducted studies. According to Krathwohl (2002), there are four types of
knowledge: factual, conceptual, procedural, and metacognitive. Factual knowledge consists of
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the essential elements, whereas conceptual deals with more complex pieces that when
intertwined with factual elements, allow function. Metacognition deals with cognition or the
mind of the individual, whereas procedural knowledge deals with the steps and strategy of how
something is completed. The assumed conceptual and metacognitive knowledge influences listed
in Table 3 have context specific recommendations based on theoretical principles that will aid in
stakeholder goal achievement.
Table 3
Summary of Knowledge Influences and Recommendations
Assumed
Knowledge
Influence
Validated as
a Gap?
Yes, High
Probability
or No
(V, HP, N)
Priority
Yes, No
(Y, N)
Principle and Citation Context-Specific
Recommendation
Sailors need the
ability to
understand and
recognize the
associated stigmas
of PTSD (C)
V Y Managing intrinsic
load by segmenting
complex material into
simpler parts and pre-
training, among other
strategies, enables
learning to be enhanced
(Kirshner, Kirshner, &
Paas, 2006)

Increasing germane
cognitive load by
engaging the learner in
meaningful schema
construction facilitates
effective learning
(Kirshner et al., 2006)
Provide training on
PTSD and the associated
stigmas over multiple
sessions, introducing
increasingly more
complex information
along with advance
materials on basic
concepts surrounding
PTSD and the associated
stigmas

Sailors need the
ability identify
individual signs
of PTSD that
they may be
experiencing (C,
M)

V Y Managing intrinsic
load by segmenting
complex material into
simpler parts and pre-
training, among other
strategies, enables
learning to be enhanced
(Kirshner, Kirshner, &
Paas, 2006).

Provide training on
PTSD and the associated
stigmas over multiple
sessions, introducing
increasingly more
complex information
along with advance
materials on basic
concepts surrounding

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Increasing germane
cognitive load by
engaging the learner in
meaningful schema
construction facilitates
effective learning
(Kirshner et al., 2006)

PTSD and the associated
stigmas

*Knowledge of Influences: Conceptual (C) and Metacognitive (M)

Increasing Sailors knowledge and understanding about PTSD and the associated
stigmas. Both validated conceptual knowledge gaps were combined, as the same theory
principles and implementation strategies are appropriate for both influences. Sailors do have an
in-depth and accurate understanding of PTSD but lack a formalized and consistent knowledge
source. Sailors are able to recognize but are unable to navigate the associated stigmas, creating a
conceptual knowledge gap that impacts the organizational performance goal. A solution rooted
in cognitive load theory has been chosen to fill these gaps. Managing intrinsic load by
segmenting complex material into smaller parts and pre-training, among other strategies, enables
learning to be enhanced (Kirshner, Kirshner, & Paas, 2006). Also, increasing the germane
cognitive load by engaging the Sailors in meaningful schema construction facilitates effective
learning (Kirshner et al., 2006). Sailors not having the needed conceptual knowledge of PTSD
and the ability to recognize and understand the stigmas associated with PTSD will have an
impact on whether or not they decide to receive mental health care. Thus, the recommendation is
to provide training on PTSD and the associated stigmas over multiple sessions, introducing
increasingly more complex information, along with advanced materials on basic concepts.
Both conceptual knowledge gaps can be mitigated or closed by naval leadership
providing required annual face-to-face and computer-based training on PTSD and the associated
stigmas, introducing more complex information along with advanced materials on basic concepts
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increasingly. According to Samuelson et al. (2014), web-based PTSD training for primary care
providers resulted in significant increases in PTSD related knowledge, with sustained
improvement exceeding 30 days in duration. Training participants also stated, “the mixture of
learning modalities kept me interested and learning” and that “watching videos of interviewing,
and veterans describing their symptoms made it more real than just reading or being told the
symptoms,” further reinforcing cognitive load theory and the recommended solutions
(Samuelson, et al., 2014). This research supports cognitive load theory and the recommended
solution that naval leadership should provide required annual face-to-face and computer-based
training on PTSD and the associated stigmas, introducing more complex information along with
advanced materials on basic concepts increasingly.
Motivation Recommendations
Introduction. Sailor motivation is critical to the Navy’s ability to achieve a 50%
decrease in medical discharges for PTSD or related personal and professional problems by
December of 2019. Sailors deploying or supporting deployed units participating in peacetime
and Overseas Contingency Operations (OCO) need to see the value in receiving medical care for
PTSD. Also, Sailors should feel that the signs and symptoms associated with PTSD are due to
traumatic experiences and not a result of someone’s inability to handle stress. Sailor motivation
is reinforced by expectancy motivational value and self-efficacy theories listed in Table 4.

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Table 4
Summary of Motivation Influences and Recommendations
Assumed Motivation
Influence
Validated
as a Gap?
Yes, High
Probability
or No
(V, HP, N)
Priority
Yes, No
(Y, N)
Principle and
Citation
Context-Specific
Recommendation
Self-Efficacy – Sailors
deploying or supporting
deployed units
participating in
peacetime and Overseas
Contingency Operations
(OCO) need to see the
value in receiving
medical care for PTSD
V Y Feedback and
modeling increase
self-efficacy
(Pajares, 2006)

Use models (Sailors) that
build self-efficacy and
enhance motivation

Utility Value – Sailors
deploying or supporting
deployed units
participating in
peacetime and Overseas
Contingency Operations
(OCO) need to see/feel
the utility value in
receiving medical care
for PTSD
V Y Rationales that
include a discussion
of the importance
and utility value of
the work or learning
can help learners
develop positive
values (Eccles,
2006; Pintrich,
2003)

Learning and
motivation are
enhanced if the
learner values the
task (Eccles, 2006)

Be explicit about the
value and relevance of
the
learning task for the
Sailor; include rationales
about the importance and
utility value of receiving
medical care for PTSD

Increasing self-efficacy of Sailors to receive medical care for PTSD. Sailors deploying
or supporting deployed units participating in OCO assignments are concerned with the
consequences of stigma and do not see the value in receiving medical care for PTSD. Pajares
(2006) found that modeling and feedback increases self-efficacy. This suggests that the lack of
modeling and feedback for Sailors who have or have had PTSD will likely continue to drive low
levels of self-efficacy, and Sailors will not see the value in receiving medical care. The use of
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Sailors who overcame the stigma associated with PTSD and sought out medical care as models
during general military training and pre/post-deployment training will build self-efficacy
(individual and collective) and enhance motivation to receive medical care.
Social modeling is often used during group therapy sessions (Burlingame, Fuhriman, &
Johnson, 2001) and increases self-efficacy through the empathetic exposure of similar
experiences (Bandura, 1994). Lack of motivation through general self-efficacy impacts
motivational influences of utility value (Kelly & Greene, 2014), resulting in Sailors not seeing
the value of receiving medical care. But, higher levels of self-efficacy will result in less PTSD
symptoms (Blackburn & Owens, 2014), and Sailors will see past the associated stigmas to see
the value in receiving medical care.
Increasing the utility value of receiving medical care for PTSD among Sailors.
Sailors deploying or supporting deployed units participating in peacetime and Overseas
Contingency Operations (OCO) lack the needed utility value to receive medical care for PTSD.
Rationales that include a discussion of the importance and utility value of the work or learning
can help learners develop positive values (Eccles, 2006; Pintrich, 2003). Learning and
motivation are also enhanced if the learner values the task (Eccles, 2006). Sailors who lack the
needed utility value will not feel there is value in seeking medical care for PTSD, which could
result in an involuntary discharge for associated personal and professional issues. The Navy
could increase utility value among Sailors if they are explicit during general military and pre/post
deployment training about the value, relevance, rationale, and importance of Sailors receiving
medical care for PTSD.
Utility value is “the value for facilitating one’s goals or helping one obtain rewards
(utility value), and the perceived cost of engaging in the activity” (Eccles, 2006, p. 2). According
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85
to Eccles and Wigfield (2002), people are affected by perceptions of other peoples’ attitudes and
expectations for them, their memories, and their own interpretations of their previous
achievement outcomes. The assumed utility values for Sailors are, but not limited to, continued
career progression and longevity, not being medically discharged, stable personal relationships
(family and friends), and overall personal well-being (includes medical issues). In a utility value
intervention study with parents as participants, increased utility value among parents increased
after they were provided materials detailing the importance of STEM for their adolescents in
high school, therefore increasing STEM preparation among students (Rozek, Svoboda,
Harackiewicz, Hulleman, & Hyde, 2017). If Sailors do not see the utility value in receiving
medical care for PTSD, the perceived consequences will outweigh the benefits.
Organization Recommendations
Introduction. Organization goal achievement is directly impacted by an organization’s
internal processes and available material resources. While individuals within an organization can
have the needed knowledge and skills (K) and motivation (M), inefficient and inadequate
processes and resources will prevent the closure of performance gaps, in turn, hindering
organizational goal achievement (Clark and Estes, 2008). Some common work processes are
administrative, operational, and training; these processes require functional knowledge, skills,
and motivation, and the allocation of resources to produce the desired end state. Table 5 contains
the assumed organizational influences that impact goal achievement and individual
recommendations.

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Table 5
Summary of Organization Influences and Recommendations
Assumed
Organization
Influence
Validated as
a Gap?
Yes, High
Probability
or No
(V, HP, N)
Priority
Yes, No
(Y, N)
Principle and
Citation
Context-Specific
Recommendation
The organization
needs to provide
Sailors pre/post-
deployment training
on PTSD and
stigmas
V Y Insuring staff’s
resource needs are
being met is
correlated with
increased student
learning outcomes
(Waters, Marzano &
McNulty, 2003)
Align the allocation of
resources with the goals and
priorities of the organization
The organization
needs to create a
culture that is free
of stigmas relating
to mental health
issues
V Y Effective leaders
address institutional
policies and practices
that create barriers
for equity
(Bensimon, 2005)
The organization should
consider how current
practices either promote or
inhibit equity, diversity, and
inclusion

Ask questions of Sailors
within the organization in
order to gain feedback
regarding the effectiveness
of existing policies and
practices

The organization should
have training facilitators
who have “lived” through it
and have successfully
navigated through the
associated stigmas.

The organization needs
senior leadership (officer
and enlisted) engagement
during training to
alleviate stigma

Correlation of organizational resources and learning outcomes for Sailors. The
organization needs to provide pre/post deployment training on PTSD and stigmas. Ensuring
staff’s resource needs are being met is correlated with increased student learning outcomes
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87
(Waters, Marzano, & McNulty, 2003). Sailor mental and physical resiliency is partially
dependent on being provided pre/post-deployment training on PTSD and the associated stigmas
by the organization. If the organization does not institute work processes and develop and
dedicate the needed resources to provide Sailors pre/post-deployment training on PTSD and the
associated stigmas, Sailors will not be able to get the needed knowledge and skills (K) needed
that aid in mental and physical resiliency. To achieve this, leadership needs to align the
allocation of resources with the goals and priorities of the organization.
While training provides the Sailors knowledge and skills, the organization is responsible
for the internal processes (policies) on how, when, or even whether or not training is conducted.
According to Waters, Marzano, and McNulty (2003), allocated resources are needed to provide
adequate training, which directly increases knowledge through identified learning outcomes. If
Sailors continue to not receive pre/post deployment training specific to PTSD and the associated
stigma, the number of Sailors being medically discharged or administratively separated for
PTSD will remain steady or increase.
Organizational policies and practices that increase equity among Sailors. The
organization needs to create a culture that is free of stigmas relating to mental health issues.
Effective leaders address institutional policies and practices that create barriers for equity
(Bensimon, 2005). An organizational culture that is free of stigmas relating to mental health
issues and those who seek medical care dramatically impacts whether or not Sailors will seek
medical treatment for PTSD or other related problems after being deployed or supporting
deployed units participating in peacetime and OCO. The organization should consider how
current practices either promote or inhibit equity, diversity, and inclusion. Also, leadership
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88
should ask questions of Sailors within the organization to gain feedback regarding the
effectiveness of existing policies and practices.
The gap in diagnosis and treatment due to stigma, misunderstanding, reluctance to seek
medical assistance, and subsequent issues arising from PTSD are becoming more common
among returning from military personnel, such as substance abuse, marital infidelity, emotional
withdrawal, secondary psychiatric disorders, and even psychological stress-related outcomes
(Jackson et al., 2016). Organizational leadership needs to implement or revise policies and
practices to address issues of equity and diversity. Failure to address issues of equity and
diversity will continue to foster an organizational climate that consists of stigma, greatly
impacting whether or not Sailors seek medical care for PTSD.
Integrated Implementation and Evaluation Plan
Implementation and Evaluation Framework
The New World Kirkpatrick Model that was developed in the 1950’s, and most recently
modified to operationalize the fundamentals for “new world business, government, military, and
not-for-profit organizations,” served as a guide to develop organizational change
recommendations for this study (Kirkpatrick & Kirkpatrick, 2016, p. 10). This model uses four
levels in reverse order for planning. Level 1 (Reaction) deals with what degree Sailors (active
and reserve, officer and enlisted) find the training favorable, engaging, and relevant to their jobs.
Level 2 (Learning) deals with the degree to which Sailors (active and reserve, officer and
enlisted) acquire the intended knowledge, skills, attitude, confidence, and commitment based on
their participation in the training. Level 3 (Behavior) is the degree to which Sailors (active and
reserve, officer and enlisted) apply what they learned during training when they are back on the
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89
job. Level 4 (Results) is “the degree to which targeted outcomes occur as a result of the training,
support, and accountability package” (Kirkpatrick & Kirkpatrick, 2016, p. 10).
Organizational Purpose, Need and Expectations
The Department of the Navy recruits, trains, equips, and organizes to deliver combat
ready naval forces to win conflicts and wars, while maintaining security and deterrence through
sustained forward presence. As of 2019, the United States Navy has 329,867 Sailors who are
deployed or are supporting deployed units participating in peacetime and Overseas Contingency
Operations (OCO). The goal of this organization, specific to Sailors currently serving on active
duty or reservist, is to achieve by December 2019 a 50% decrease in medical discharges for
PTSD or related personal and professional problems.
Sailors, whether deploying or supporting deployed units participating in peacetime and
OCO, could be exposed to arduous conditions, traumatic situations, and armed combat while
performing their duties. Being exposed to arduous conditions, traumatic situations, and armed
combat could cause PTSD. In OIF and OEF, 11%-20% of veterans who participated in those
conflicts have PTSD in a given year (National Center for PTSD, 2018). The percentage of those
diagnosed with PTSD would be significantly higher, but three significant factors are hindering
service members (N=201) from seeking medical treatment for PTSD: the denial they have PTSD
(90.24%), related stigma (82.9%), and difficulty identifying and understanding their PTSD
symptoms (74.14%) (Dondanville et al., 2018). Stigma, whether societal or self-induced, needs
to be addressed in order to encourage individuals with possible PTSD to seek professional help.
The goal of this organization, specific to Sailors currently serving on active duty or
reservist, is to achieve by December 2019, a 50% decrease in medical discharges for PTSD or
related personal and professional problems. This goal was chosen because the United States
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90
continues to be a nation that embodies freedom and democracy as represented by its involvement
in combat operations in Iraq, Afghanistan, Syria, and other countries. With the continuous
involvement in combat and humanitarian operations, there will be an increasing number of
individuals suffering from PTSD because of various traumatic experiences (National PTSD
Center, 2017). According to Mittal et al. (2013), individuals diagnosed with PTSD resist
professional help because of stigma. The achievement of this goal enables those Sailors to seek
medical assistance prior to it hindering their personal and professional lives. In addition, it allows
the Navy to retain those experienced Sailors, resulting in a more efficient organization during
peace and wartime.
Level 4: Results and Leading Indicators
Both external and internal outcomes were used to determine whether stigma impacts a
Sailors decision to seek treatment for, and on those who have been diagnosed with PTSD.
Externally, improved quality of life for Sailors and their families will be measured by a decrease
in family advocacy issues and divorce rates due to PTSD and related personal and professional
problems. Naval leadership will use feedback and statistical data from Fleet and Family Support
Center leadership and the Navy OMBUDSMAN at Large from 2019-2020 as the method to
arrive at the outcome.
Internally, three outcomes were identified. The first outcome is improved self-efficacy
and utility value among Sailors about seeking medical care for PTSD or related personal and
professional problems. A metric would need to be developed within the Defense Organizational
Climate Survey (DEOCS), as no questions currently exist. Once developed and a baseline is
established, improved scores on self-efficacy and utility value among Sailors about seeking
medical care for PTSD or related personal and professional problem on the Defense
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91
Organizational Climate Survey (DEOCS) would be determined through a comparison of DEOCS
data from 2019-2020 by naval leadership. Also, naval leadership will need to develop, and
institute required training that covers PTSD and the associated stigmas, as none currently
exist. Once developed and a baseline is established, improved self-efficacy and utility value can
be determined by feedback from pre/post-deployment training through comparison of data from
2019-2020 by naval leadership. Next, a decrease number of Sailor discharges for PTSD or
related personal and professional problems would use improved retention rates as a metric
through comparison of administrative (discharge/punitive) statistical data from 2019-2020.
Finally, a decrease in the perception of stigma within the command about Sailors seeking
medical care of PTSD or related personal and professional problems would improve scores
regarding stigma within the command on the DEOCS as a metric through comparison of
previous DEOCS data from 2019-2020 by naval leadership. These outcomes are illustrated in
Table 6.
Table 6

Outcomes, Metrics, and Methods for External and Internal Outcomes
Outcome Metrics Methods
External Outcomes
Improved quality of life for
Sailors and their families
1a. Decreased family advocacy
issues related to PTSD or related
personal and professional
problems

1b. Decrease in divorces rates due
to PTSD or related personal and
professional problems
1a. Naval leadership will evaluate and
compare feedback from Fleet and Family
Support Center leadership and the Navy
OMBUDSMAN At Large from 2019-
2020

1b. Naval leadership will compare
statistical data from 2019-2020

Internal Outcomes
Improved self-efficacy and
utility value among Sailors
about seeking medical care for
PTSD or related personal and
professional problems
1a. Improved scores on self-
efficacy and utility value among
Sailors about seeking medical care
for PTSD or related personal and
professional problem on the
DEOCS
1a. Naval leadership compare previous
DEOCS data from 2019-2020

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92

1b. Feedback from training on
PTSD and associate stigmas
1b. Naval leadership compare previous
pre/post-deployment statistical data from
2019-2020
Decrease number of Sailor
discharges for PTSD or related
personal and professional
problems
Improved retention rates Naval leadership compare administrative
(discharge/punitive) statistical data from
2019-2020
Decrease in perception of
stigma within the command
about Sailors seeking medical
care of PTSD or related
personal and professional
problems

Improved scores regarding stigma
within the command on the
DEOCS
Naval leadership compare previous
DEOCS data from 2019-2020

Level 3: Behavior
Critical Behaviors. There are two critical behaviors that Sailors must demonstrate to
determine if the Level 4 outcomes have been achieved: (a) Sailor self-referral for medical care
due to PTSD and the associated personal and professional problems before an incident occurs or
they are command directed to receive care will be measured by the Department of Health
Services (DHS) patient care reporting on a monthly basis; and (b) Sailors feeling comfortable
providing unsolicited feedback on the organizational climate toward those who seek medical care
for PTSD and the associated personal and professional problems to naval leadership will be
measured by IG Complaint/CO’s Suggestion Box/DEOCS/All Hands Call data through
command reporting and surveys on a monthly basis. These behaviors, their metrics, methods,
and timing are illustrated in Table 7.
Table 7
Critical Behaviors, Metrics, Methods, and Timing for Evaluation
Critical Behavior Metrics
Methods
Timing
Sailor self-referral for medical care due to PTSD and
the associated personal and professional problems
before an incident occurs or they are command
directed to receive care
Number of Sailors
who self-report
increases month to
month
Patient Care
Reporting
Monthly
Sailors feel comfortable providing unsolicited
feedback on the organizational climate toward those
who seek medical care for PTSD and the associated
Increase in:

1a. IG Complaints

Command/Survey
Data

Monthly
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93
personal and professional problems to naval
leadership
1b. CO’s Suggestion
Box Submissions

1c. DEOCS
Participation

1d. All Hands Call
Feedback

Required Drivers. There are four command drivers that associate with reinforcing
encouraging, rewarding, and monitoring that support accomplishment of critical behaviors at
Level 3. First, peers who have PTSD and navigated through the associated stigmas are used as
models during training reinforces critical behavior. Next, naval leadership encouraging Sailors to
seek medical care for PTSD and contradicts the associated stigmas through training sessions and
all hands calls encourages critical behavior. Then, naval leadership recognizing Sailors who
complete the quality of life survey and DEOCS rewards critical behavior. Finally, the Navy
Sexual Harassment Prevention and Equal Opportunity Office and Navy Inspector General (IG)
conducting compliance reviews monitors critical behaviors. These drivers are illustrated in Table
8.
Table 8
Required Drivers to Support Critical Behaviors
Methods Timing
Critical Behaviors
Supported
1, 2, 3 Etc.
Reinforcing

Peers who have PTSD and navigated through the associated stigmas are
used as models during training
Monthly 1, 2
Encouraging

Naval leadership encourages Sailors to seek medical care for PTSD and
contradicts the associated stigmas through training sessions and all hands
calls
Monthly 1, 2
Rewarding

Naval leadership recognizes Sailors who complete the quality of life survey
and DEOCS
Annually 1, 2
Monitoring

The Navy Sexual Harassment Prevention and Equal Opportunity Office
and Navy Inspector General (IG) conduct compliance reviews
Quarterly
1, 2

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94
Organizational Support. There are a number of initiatives the organization needs to
support for level 4 outcome achievement. First, naval leadership needs to develop and implement
written policy, making leadership responsible and accountable for conducting annual face-to-
face, and monthly refresher training on PTSD and the associated stigmas. This training would
include open discussion and peer group workshops that consist of modeling with actual Sailors
who received medical care and overcame the associated stigmas toward seeking medical care for
PTSD. Also, key leadership would be required to talk about PTSD and contradict associated
stigmas within these sessions. Next, designated leadership would be required to develop and
revise a survey for Fleet and Family Support Center and the OMBUDSMAN At Large for
dissemination to gauge the quality of life of Sailors and their families. Then, naval leadership
within Navy Education and Training Command (NETC) would need to develop and implement a
training curriculum (face-to-face/electronic course of instruction) on PTSD and the associated
stigmas and personal and professional problems; this curriculum will be addressed next with the
learning program. Finally, naval leadership would need to develop questions covering stigma,
self-efficacy, and utility value regarding seeking medical care for PTSD for the DEOCS.
Level 2: Learning
Learning Goals. There are three conceptual (C) and metacognitive (M) learning goals or
objectives that Sailors need to be able to accomplish to perform the critical behaviors listed in
Table 7.
1. Sailors will demonstrate an in-depth and accurate understanding of PTSD, to include the
ability to identify individual signs of PTSD that they may be experiencing and understand
and recognize the associated stigmas (C, M).
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95
2. Sailors will demonstrate self-efficacy and utility value to receive medical care for PTSD
(C, M).
3. The organization will demonstrate the ability to create a culture that is free of stigmas
relating to PTSD (C, M).
Program. The Navy will need to direct the development and implementation of an
overarching and comprehensive training program on PTSD and the associated stigmas to support
goal achievement. More specifically, NETC should develop a training program that will consist
of a required annual Navy e-learning computer based training course, annual face-to-face
general military training (led by unit commanders etc.); quarterly reinforcement training that
occurs during safety stand-downs (to accompany existing trainings such as “don’t drink and
drive,” driving safely, suicide prevention, etc.) prior to major holidays (led by military
commanders etc.); focus group sessions (led by senior enlisted personnel); and pre/post-
deployment training for any unit deploying on PTSD and the associated stigmas with an
emphasis on what traumatic situations they could be exposed to.
The Navy e-learning course will be a timed computer-based course of instruction that
provides Sailors with the needed knowledge and motivation and consists of scenarios and a post
test that an 80% is required to get a certificate of completion. This course of instruction will need
to be completed annually and command leadership will be tasked with ensuring everyone under
their command completes it prior to the end of the fiscal year (FY). Sailors will also need to
complete annual general military training on PTSD and the associated stigmas. This training will
be facilitated by command leadership and consist of models (Sailors who have experienced
PTSD and navigated through associated stigmas), psychologists, and Navy Chaplains serving as
facilitators/guest speakers. Prior to the commencement of training, all participants will complete
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96
a pre-test, and the training will be concluded by command leadership conducting self-evaluation
exercises, a post-test, and solicitation for written feedback.
Reinforcement training will be conducted quarterly and in synch with holiday safety
stand-down where suicide prevention and other related tropics are routinely held. This training
will consist of command leadership talking about PTSD, the associated stigmas, and how they
support those who have or may have PTSD seeking medical assistance before there are personal
and professional issues. Command leadership will also ask participants to identify associated
stigmas, where leadership will then contradict those perceptions with how their command
supports those needing to seek medical care for PTSD and will not be penalized personally or
professionally. Senior enlisted leadership will also conduct focus group session’s 30-day post
training that will include scenarios with individual responses and role playing and conclude with
leadership seeking out written feedback from participants.
Finally, all units deploying will conduct pre/post deployment training that is facilitated by
command leadership and consists of models (Sailors who have experienced PTSD and navigated
through associated stigmas), Psychologists, and Navy Chaplains serving as instructors/guest
speakers. Prior to the commencement of training, all participants will complete a pre-test, and
topics will include scenarios that Sailors could experience on those deployments and conclude
with a post-test and solicitation for written feedback.
Evaluation of the components of learning. Sailors’ declarative knowledge will be
evaluated by knowledge checks using a pre/post training and pre/post-deployment training
surveys. Procedural knowledge will be assessed using self-reflection exercises and scenario-
based questioning/role playing during focus group sessions. Command leadership, instructors,
models, and guest speakers will observe student behavior during training and focus groups
PTSD IN THE MILITARY AND ASSOCIATED STIGMAS

97
sessions to assess their attitude toward the training. Pre/post training and pre/post deployment
training survey summaries and observations of student behavior while role playing during focus
group sessions measure Sailor confidence. Commitment is measured by pre/post training and
pre/post deployment training summaries. The methods or activities and timing are listed in Table
9.
Table 9
Evaluation of the Components of Learning for the Program
Methods or Activities Timing
Declarative Knowledge “I know it.”

Knowledge checks using a pre/post training survey Prior to and after each training
session
Knowledge checks using a pre/post deployment survey Prior to and after each deployment
supporting OCO
Procedural Skills “I can do it right now.”

Self-reflection exercises During each training session
Scenario based questioning/role playing during focus
group sessions
30 days post training
Attitude “I believe this is worthwhile.”

Observation of student behavior during training During each training session
Observation of student behavior during focus group
sessions
During each group session
Confidence “I think I can do it on the job.”

Observations of student behavior while role playing
during focus group sessions
30 days post training
Pre/post training survey summary After each training session
Pre/post deployment training survey summary After each pre/post deployment
training
Commitment “I will do it on the job.”

Pre/post training survey summary After each training session
Pre/post deployment training survey summary After each pre/post deployment
training

Level 1: Reaction
Engagement, relevance, and customer satisfaction will be used as methods or tools to
measure Sailors’ reaction to the training program. Quality of life survey data, DEOCS data, and
PTSD IN THE MILITARY AND ASSOCIATED STIGMAS

98
training feedback survey data are tools used to measure training program engagement. Also,
muster sheets from training on PTSD, follow-on refresher training, and focus group sessions are
additional tools to measure Sailor engagement. Next, pulse checks via discussion during training
and feedback from Sailors via survey during training on PTSD will show the relevance of the
training to Sailors. Finally, Sailors will provide feedback on training classroom materials (e.g.
audio visuals, etc.) and environment from training sessions and feedback on what about the
training they like and would change to measure customer satisfaction. The methods or tools and
timing are listed in Table 10.
Table 10
Components to Measure Reactions to the Program
Methods or Tools Timing
Engagement

Completion of quality of life survey and DEOCS Annually
Muster sheets for training on PTSD and the associated stigmas Annually
Muster sheets for refresher training on PTSD and the associated
stigmas
Quarterly
Post training feedback surveys Upon completion of
training session
Muster sheets for post training focus group training 30 days post training
session
Relevance

Pulse check via discussion during training During each training
session prior to breaks
Sailors provide feedback on the relevance of training that covers
PTSD and the associated stigmas to them via survey
Upon completion of
training session
Customer Satisfaction

Sailors provide feedback on training classroom materials (e.g.
audio visuals etc.) and environment
Upon completion of
training session
Sailors provide feedback on what about the training they like
and would change
Upon completion of
training session

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Evaluation Tools
Immediately following the program implementation. A training muster sheet
(Appendix F) will be used to assess Sailor engagement (participation) in the annual training on
PTSD and the associated stigmas (Level 1). A senior enlisted leader within the respective
organization or unit will be responsible for ensuring all personnel arriving at the training site,
print their rank, name, and provide a signature prior to the commencement of the course of
instruction. Also, at the completion of the training, the facilitator will request that anyone who
did not sign the muster sheet do so prior to departing from the training location.
During the introduction to the training topic, the facilitator will conduct a knowledge
check (Level 2) with only 10% of the participants (randomly picked) due to the large group size,
where he or she will hand out both the pre (Appendix G) and post (Appendix H) training survey
to the same individual. The pre training survey will consist of five Likert questions covering the
participants’ current knowledge and confidence with identifying the signs and symptoms of
PTSD, associated stigma, and whether or not their self-efficacy and perceived utility value
impact their decision to seek medical care for PTSD. At the completion of the training, the
facilitator will request those individuals who completed the surveys prior to training to complete
the post training survey and return it. The survey will consist of five Likert questions that inquire
if the participants knowledge and confidence with identifying the signs and symptoms of PTSD,
associated stigmas, and whether or not their self-efficacy and perceived utility value changed
upon completion of the training.
Finally, the facilitator will conduct a pulse check to assess Sailor relevance (Level 2) via
discussion prior to allowing participants to depart on a break. The pulse check will consist of two
predetermined questions (Appendix I) that utilize a Likert scale and the facilitator will randomly
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100
ask for a participant. Appendix 7 - 9 will be turned into the organization or unit Training Officer
(TO) for storage, data analysis, and reporting.
Delayed for a period after the program implementation. Within 30 days from
receiving training on PTSD and the associated stigmas, senior enlisted leadership will randomly
select 10% of the original training participants due to the large group size from the training
muster sheets (Appendix F) and provide them with a 30-day post-training survey (Appendix J).
This survey will consist of five Likert based questions that cover Level 1 - 4 areas of focus.
Appendix E will be turned into the organization or unit Training Officer (TO) for storage, data
analysis, and reporting.
Data Analysis and Reporting
Immediate and delayed instruments will be analyzed utilizing a color-coded bar graph
chart (Appendix K). The Training Officer within the organization or unit will input the data
received from all the surveys within 48 hours of completion into Microsoft Excel. The
aggregated data will then be used to create a color-coded bar graph chart within Microsoft
PowerPoint to depict and report specific responses to the survey questions. This will allow naval
leadership to quickly assess declarative knowledge and Sailor confidence and relevance.
Further Research
This research study only removed the surface layer of the problem of PTSD and
associated stigmas within the Navy. Further research needs to be conducted to identify other
contributing KMO influences to address the issue of stigma within the Navy as an organization.
The training and evaluation plan recommended earlier in this chapter will not be enough, there
needs to be a complete culture and mindset shift in order to minimize the stigma identified and
validated through this study. Those who serve within the military have been living with PTSD
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since World War I (Connell, 2015) and it is evident that Sailors will continue to be affected as
long as the United States continues to be a nation that embodies freedom and democracy. The
Navy owes its Sailors more than just “check in the box” training (operational stress control and a
Chaplain brief), and medical or administrative discharges (associated professional and personal
issues).
Connection to Practice and Further Recommendations
The researcher is personally and professionally connected to the problem of practice. He
is an active duty naval officer with 22 years of naval service who completed several OCO
deployments throughout the world. Throughout his 22 years of service he has personally
experienced “check in the box” pre/post deployment training, been part of several commands
where the culture consisted of stigma and observed a lack of sincerity on a number of occasions
by naval leadership toward Sailors who may be experiencing personal issues (e.g. stress, mental
health, family, and financial). Further recommendations are provided based on the researchers
personal and professional connection to the problem of practice and not data received during the
study.
Further Recommendations
The mindset and culture shift need to start at senior naval leadership with the
development and implementation of policy on PTSD and stigma along with leadership
engagement, in addition to the training and evaluation program previously recommended in this
chapter. There needs to be a career path (administratively and operationally) designated in
writing for anyone who is diagnosed with PTSD. This career path needs to include how selection
boards (officer and enlisted) will take into consideration the limiting factors associated with the
diagnosis and how those individuals will receive the same opportunity of equality as every other
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102
Sailor does. Also, the Navy should obtain and publish statistical data of how many Sailors are
retained after being diagnosed with PTSD and advancement statistical data of those retained
Sailors after seeking medical care. This statistical data should be published in accordance with
the Health Insurance Portability and Accountability Act (HIPAA) of 1996 and would aid in
organizational change. Without providing proof that the same measures of equality apply to
them, Sailors with PTSD will continue to feel they are required to fight harder for the same
benefits (orders, advancement, special pays, flight status, etc.), and this will deter them from
seeking medical care as described by their responses in Chapter 3.
In addition to the development of a training and evaluation program and designated
career path, the Navy should provide formal training to senior leaders on PTSD and the
associated stigmas. This training should combine leadership and empathy fundamentals toward
Sailors who seek out medical care for PTSD. There is a perceived lack of sincerity when it
comes to leadership stating they support their Sailors and then when they actually seek it; further
data in Chapter 4 show that stigma will not be eliminated just by training, there needs to be
leadership engagement. This perceived lack of engagement and sincerity adds to the
organizational stigma. This training could be implemented during command leadership training
pipelines (Commanding Officer, Executive Officer etc.), and the senior enlisted leadership
academy, while being reinforced by periodic training requirements.
Furthermore, ancillary support services (medical, Fleet and Family Support Center, etc.)
within the Navy for those have PTSD need to be evaluated for effectiveness, revised if needed,
or established. Sailors who have PTSD are experiencing appointment delays of up to 90 days,
resulting in them compartmentalizing their issues and not seeking further care as described by an
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interviewee who has been diagnosed with PTSD. The same interviewee further stated that it is
almost worth being discharged so they can receive quality medical care in a timely manner.
Finally, senior leaders within the Navy need to establish and implement benchmarking
criteria for compliance and accountability. This benchmarking criteria could be embedded within
the Navy DEOCS and provided in additional policy and directives. Without any benchmarking
criteria and accountability, it will most likely result in a lack of engagement and the Sailors will
continue to be medically or administratively discharged because of the associated personal and
professional issues of those who have PTSD. Leadership engagement should not initially occur
or reoccur when a Sailor commits suicide as described by an interviewee. There needs to be
more than just a training program, senior leadership engagement has to occur, as another
interviewee put it. Leadership engagement is knowing your personnel, making sure someone has
their “six,” that they know they can seek help if needed (for anything), and senior enlisted
leadership are identifying and addressing issues before an incident occurs. We have failed if a
Sailor commits suicide or is medically or administratively discharged and the Navy did not have
a culture that is free of stigma to seek medical care for PTSD and the needed support (all
inclusive) in place prior to this happening.
Summary
The researcher used Kirkpatrick's Four Levels of Training and Evaluation in reverse
order to develop recommendations to address gaps in knowledge (conceptual and
metacognitive), motivation (self-efficacy and utility), and organization (pre/post-deployment
training and culture) that impact performance goal achievement. First, in Level 4, external and
internal outcomes were used to determine whether stigma impacts a Sailor’s decision to seek
treatment for PTSD. Then, in Level 3, two critical behaviors were identified that Sailors must
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104
demonstrate to determine if the Level 4 outcomes have been achieved. Four command drivers
associated with reinforcing, encouraging, rewarding, and monitoring that support the
accomplishment of critical behaviors at Level 3 and what the organization needs to support Level
4 outcome achievement were also identified.
Next, in Level 2, three conceptual (C) and metacognitive (M) learning goals or objectives
were identified for Sailors to accomplish to perform the critical behaviors in Level 3. Also, the
overarching and comprehensive training and evaluation program on PTSD and the associated
stigmas to support goal achievement were developed along with the evaluation of the
components of learning for the program. Finally, in Level 1, engagement, relevance, and
customer satisfaction methods and tools were developed to measure the Sailors’ reaction to the
training program. Also, evaluation tools to use immediately and 30 days after training (delayed)
completion along with a data analysis and reporting program were developed for naval
leadership to close the identified gaps in Chapter 3 for performance goal achievement. Without
the use of Kirkpatrick’s four levels of training and evaluation to develop recommendations and a
training and evaluation program, gaps in knowledge, motivation, and within the organization will
continue to exist, resulting in the continuance of or increase in discharges for PTSD and
associated personal and professional issues because Sailors will not seek medical care for
PTSD.

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Appendix A

Survey Questions, KMO Relationship, Scale of Measurement, Potential Analyses, and Visual Representation
Research Question/
Data Type
KMO
Construct
Survey Item (question and
response)
Scale of
Measurement
Potential
Analyses
Visual
Representation
N/A
N/A 1. Consent to participate
in the study

N/A N/A N/A
Demographic A Sample
Description
2. Are you active duty or
a reservist?
Nominal Percentage,
Frequency
Pie Chart
Demographic B Sample
Description
N/A 3. What is your gender?
Short Answer:

Nominal Percentage,
Frequency
Pie Chart
Demographic C Sample
Description
N/A
4. What is your current
rank/grade?
Select One:
(a) E-1 – E-6
(b) E-7 – E-9
(c) W-2 – W-5
(d) 0-1 – 0-3
(e) 0-4 – 0-6
(f) 0-7 – 0-10
Nominal Percentage,
Frequency
Pie Chart
Demographic D Sample
Description
N/A 5. How many years of
service (active or
reserve) do you have?
Select One:
(a) Less than 5 years
(b) 10 – 15 years
(c) 16 – 20 years
(d) 21 – 30 years
Nominal

Percentage,
Frequency
Pie Chart
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106
Demographic E Sample
Description
N/A 6. How many
deployments have you
completed?
Select One:
(a) 0
(b) 1 – 2
(c) 3 – 5
(d) 6 – 9
(e) 10 or more
Nominal Percentage,
Frequency
Pie Chart

Demographic F Sample
Description
N/A 7. In which campaigns
have you deployed in
supporting?
Select All That Apply:
(a) Operation New Dawn
(OND)
(b) Operation Enduring
Freedom (OEF)
(c) Operation Iraqi
Freedom (OIF)
(d) Operation Inherent
Resolve (OIR)
(e) Humanitarian
Operations (all
inclusive)
Nominal Percentage,
Frequency
Pie Chart
Demographic G Sample
Description
N/A 8. To which
arduous/combat zone
location(s) have you
deployed?
Select All That Apply:
(a) Philippines
(b) Pakistan
(c) Afghanistan
(d) Yemen
Nominal Percentage,
Frequency
Pie Chart

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107
(e) Syria
(f) Jordan
(g) Other (Fill in the
blank)
Demographic H Sample
Description
N/A 9. To which types of duty
have you been
assigned to?
Select All That Apply:
(a) Combat
(b) Humanitarian
(c) Arduous
(d) Isolated
Nominal Percentage,
Frequency
Pie Chart
Demographic I Sample
Description
N/A 10. If you participated in
combat or
humanitarian
operations, or isolated
or arduous duty, were
you directly or
indirectly exposed to
any traumatic
situations?
Select One:
(a) Yes
(b) No
(c) N/A
Nominal Percentage,
Frequency
Pie Chart
Demographic J Sample
Description
N/A 11. If you were directly or
indirectly exposed to
any traumatic
situations while
deployed, were they
the result of enemy
fire (contact)?

Nominal Percentage,
Frequency
Pie Chart
PTSD IN THE MILITARY AND ASSOCIATED STIGMAS

108
Select One:
(a) Yes
(b) No
(c) N/A
What is the knowledge,
motivation, and organizational
influences that interfere with
achieving the goal of a 50%
decrease in medical
discharges for PTSD or
related personal or
professional issues?
Knowledge
(M&C)
Motivation
(Self-Efficacy
&Utility
Value)
12. How many times in
your naval career have
you received training
on Post-Traumatic
Stress Disorder
(PTSD)?
Select One:
(a) 0
(b) 1
(c) 2
(d) 3 or more
Nominal Percentage,
Frequency
Pie Chart
What is the knowledge,
motivation, and organizational
influences that interfere with
achieving the goal of a 50%
decrease in medical
discharges for PTSD or
related personal or
professional issues?
Knowledge
(M&C)
13. What is your definition
of PTSD?
Short Answer:

Nominal Percentage,
Frequency
Table
*********************** ************ 14. “Definition of PTSD” ********** ************* ************
PTSD IN THE MILITARY AND ASSOCIATED STIGMAS

109
What is the knowledge,
motivation, and organizational
influences that interfere with
achieving the goal of a 50%
decrease in medical
discharges for PTSD or
related personal or
professional issues?

Knowledge
(M&C)

15. If applicable; do you
feel you could have, or
may have had, PTSD
as a result from your
military related
deployment(s)?
Select One:
(a) Yes
(b) No
(c) Maybe
(d) N/A
Nominal

Percentage,
Frequency

Pie Chart

What is the knowledge,
motivation, and organizational
influences that interfere with
achieving the goal of a 50%
decrease in medical
discharges for PTSD or
related personal or
professional issues?
Knowledge
(M&C)
16. In general, how
confident are you in in
your abilities to self-
identify the signs and
symptoms of PTSD?
Select One:
1-Very Confident, 2-
Confident, 3-Neither
Confident or Unconfident, 4-
Unconfident, 5-Very
Unconfident

Ordinal Percentage,
Frequency
Pie Chart or Bar
Graph

PTSD IN THE MILITARY AND ASSOCIATED STIGMAS

110
What is the knowledge,
motivation, and organizational
influences that interfere with
achieving the goal of a 50%
decrease in medical
discharges for PTSD or
related personal or
professional issues?
Knowledge
(M&C)
Motivation
(Self-Efficacy
&Utility
Value)
17. What if your
definition of a stigma?
Short Answer:

Nominal Percentage,
Frequency
Table
What is the knowledge,
motivation, and organizational
influences that interfere with
achieving the goal of a 50%
decrease in medical
discharges for PTSD or
related personal or
professional issues?

Does the organization create a
culture free of stigmas relating
to mental health issues and
those who seek treatment?

Knowledge
(M&C)
Organization
Motivation
(Self-Efficacy
&Utility
Value)
18. How many times in
your naval career have
you been given
training on stigmas?
Select One:
(a) 0
(b) 1
(c) 2
(d) 3 or more

Nominal Percentage,
Frequency
Pie Chart or
Table

*********************** ************ 19. “Definition Stigma” ********** *********** ************
Does the organization create a
culture free of stigmas relating
to mental health issues and
those who seek treatment?
Organization 20. Do any stigmas
regarding mental
health care or those
who seek it exist
within the Navy?

Nominal Percentage,
Frequency
Pie Chart

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111
Select One:
(a) Yes
(b) No

What is the knowledge,
motivation, and organizational
influences that interfere with
achieving the goal of a 50%
decrease in medical
discharges for PTSD or
related personal or
professional issues?

Knowledge
(M&C)
Motivation
(Self-Efficacy
&Utility
Value)
Organization

21. If so, how likely is it
that these stigmas do,
or would impact your
decision to seek
medical care for
mental health issues?
Select One:
1-Very Likely, 2-Likely, 3-
Neither Likely or Unlikely, 4-
Unlikely, 5-Very Unlikely

Ordinal

Percentage,
Frequency

Bar Graph

Does the organization create a
culture free of stigmas relating
to mental health issues and
those who seek treatment?
Organization 22. Do any stigmas
toward mental health
care or those who seek
it exist within your
current organization
(unit)?
Select One:
(a) Yes
(b) No
(c) Maybe
(d) Don’t Know
Nominal Percentage,
Frequency

Pie Chart
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112
Does the organization create a
culture free of stigmas relating
to mental health issues and
those who seek treatment?
Organization 23. If so, what stigmas
exist regarding those
who seek out medical
care for mental health
issues or PTSD?
Short Answer:

Nominal Percentage,
Frequency
Table
What is the knowledge,
motivation, and organizational
influences that interfere with
achieving the goal of a 50%
decrease in medical
discharges for PTSD or
related personal or
professional issues?
Knowledge
(M&C)
Motivation
(Self-Efficacy
&Utility
Value)
24. If so, how likely is it
that these stigmas do,
or would impact your
decision to seek
medical care for
mental health issues or
PTSD?
Select One:
1-Very Likely, 2-Likely, 3-
Neutral, 4-Unlikely, 5-Very
Unlikely

Ordinal Percentage,
Frequency
Bar Graph

Does the organization create a
culture free of stigmas relating
to mental health issues and
those who seek treatment?
Organization

25. To what degree do
you agree or disagree
with the following
statement: The Navy
and/or my
organizational
leadership would
support me if I sought
out medical care for a
mental health issue or
PTSD.

Ordinal Percentage,
Frequency
Bar Graph
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113
Select One:
1-Strongly Agree, 2-Agree, 3-
Neither Agree or Disagree, 4-
Disagree, 5-Strongly Disagree

Does the organization create a
culture free of stigmas relating
to mental health issues and
those who seek treatment?

Organization 26. To what degree do you
agree or disagree with
the following
statement: The Navy
and/or my current
organization provides
me with the needed
support services in the
event I need to seek
care for mental health
issues or PTSD.
Select One:
1-Strongly Agree, 2-Agree, 3-
Neither Agree or Disagree, 4-
Disagree, 5-Strongly Disagree

Ordinal

Percentage,
Frequency
Bar Graph

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114
Appendix B

Interview Questions and KMO Relationship

Interview Questions

Interview Question

KMO Relationship

1. Describe the signs and symptoms of PTSD? Knowledge (K)
2. How do you feel the organization does with
regard to education on PTSD pre/post-deployment?
Organization (O)
3. What’s your opinion on those who have or may
have PTSD?
Motivation (M)
4. If you had or felt you had PTSD, what would be
your top 5 concerns with seeking medical care?
Motivation (M)
5. What stigmas pertaining to those who are seen
for mental health issues and PTSD exist in your
current organization?
Organization (O) and Motivation (M)
6. How do stigmas pertaining to mental health
illness or those who seek medical care impact you
or others within your organization?
Motivation (M) and Organization (O)
7. How would a stigma impact your desire to seek
medical care if you thought you had PTSD?
Motivation (M)
8. How well has your organization done with
treating those who have or may have PTSD?
Organization (O)
9. How would the organizational culture impact
whether or not you would seek medical care for
PTSD?
Organization (O)
10. What resources are available to those who have
or may have PTSD?
Knowledge (K)
11. What additional resources would you like to
see available for PTSD?
Knowledge (K), Motivation (M), and
Organization (O)
12. If those resources for PTSD were available,
would you utilize them if you had or thought you
had PTSD?
Knowledge (K), Motivation (M), and
Organization (O)
13. What would you implement to increase the
knowledge and understanding of PTSD among
Sailors?
Knowledge (K), Motivation (M), and
Organization (O)
14. What would you implement to increase the
knowledge and understanding of the stigmas
associated with PTSD?
Knowledge (K), Motivation (M), and
Organization (O)
15. What could the organization do better to create
an organizational culture free of stigma?
Knowledge (K), Motivation (M), and
Organization (O)

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Appendix C

Disclosure and Consent Form

University of Southern California
Rossier School of Education
3470 Trousdale Pkwy
Los Angeles, CA 90089

POST-TRAUMATIC STRESS DISORDER (PTSD) IN THE MILITARY AND THE
ASSOCIATED STIGMAS

You are invited to participate in a research study conducted by Jeremy Hendrickson, (Principal
Investigator) and Patricia Tobey (Faculty Advisor) from the Rossier School of Education at the
University of Southern California. You have been identified as a study participant because you
are an active duty (enlisted and officer) or reservist Sailor within the United States Navy and
volunteered to participate in the survey and/or interview portions of the research study. Your
participation is voluntary and may be terminated at any time. This document explains information
about this study. You should ask questions about anything that is unclear to you.

PURPOSE OF THE STUDY
The purpose of this study is to conduct a gap analysis to examine the root causes on the problem
of stigma among Sailors seeking treatment for and those who have been diagnosed with PTSD and
is being conducted as a part of a dissertation for completion of a doctorate degree in education.

PARTICIPANT INVOLVEMENT
If you volunteer to participate in this study, you will be asked to participate in a survey that is
administered electronically through USC Qualtrics and/or an interview with the principal
investigator. The survey will consist of 26 questions and should take no longer than 30 minutes
to complete. The interview will take no longer than 30 minutes and will be conducted in a private
location (face-t-face or through Zoom). The interview will be highly-structured, standardized
open-ended, i.e. the interviewer has some specific questions to ask you that will be in the same
order, manner, and format. You are not obligated to answer any questions and you may choose to
end the interview and/or survey at any time. If you are willing and provide written permission,
the interview will be tape-recorded and then transcribed. If you do not wish to be tape-recorded,
you can still participate in the study and the interviewer will take written notes.
POTENTIAL RISKS AND DISCOMFORTS
There are no anticipated risks to your participation in this study. Your participation in this study
is not required as part of your employment and there will be no consequences if you decline to
participate or chose to withdraw at any time.
POTENTIAL BENEFITS TO PARTICIPANTS AND/OR SOCIETY
Potential benefit for participation in this study include contributing to the general knowledge and
research regarding PTSD in the military and the associated stigmas.
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CONFIDENTIALITY
We will keep your records for this study confidential as far as permitted by law. However, if we
are required to do so by law, we will disclose confidential information about you. The members
of the research team and the University of Southern California’s Human Subjects Protection
Program (HSPP) may access the data. The HSPP reviews and monitors research studies to protect
the rights and welfare of research subjects.
The data will be stored on a password protected computer. You have the right to review and edit
any audio-recordings or transcripts as well as review the final report to ensure that your
anonymity is not inadvertently revealed. Pseudonyms will be used to protect your identity and
your role will be referred to as “stakeholder” rather than using your job title. The audio-
recordings and transcripts will be destroyed no later than three years after the research project
has ended. When the results of the research are published or discussed in conferences, no
identifiable information will be used.
INVESTIGATOR CONTACT INFORMATION

Jeremy Hendrickson (Principal Investigator) at jmhendri@usc.edu or 202-255-3623
OR
Dr. Patricia Tobey (Faculty Advisor) at Tobey@usc.edu or 231-740-7884

IRB CONTACT INFORMATION
If you have questions, concerns, or complaints about your rights as a research participant or the
research in general and are unable to contact the research team, or if you want to talk to someone
independent of the research team, please contact the University of Southern California,
Institutional Review Board, 1640 Marengo Street, Suite 700, Los Angeles, CA 90033-9269.
Phone (323) 442-0114 or email irb@usc.edu.

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Appendix D
Interview Script
Welcome and thank you for completing the online survey and volunteering to participate in a
follow-up interview. My name is Jeremy Hendrickson and I’m a graduate student at the
University of Southern California (USC) conducting my dissertation in partial fulfillment of the
requirements for a Doctor of Education in Organizational Change and Leadership. My research
is focused on studying how stigmas impact whether or not Sailors seek medical care for mental
health issues, more specifically, PTSD. The interview will take approximately 30 minutes in
duration and will consist of 18 questions pertaining to PTSD and the associated stigmas in the
Navy. I will need to get your verbal consent to participate in the interview portion of the study.
You will see a consent in front of you if you are doing the face-to-face interview or one will pop
up on the screen in Zoom for your review. Upon review, I would like to get and record your
verbal consent that you understand the information provided on the consent form and would like
to participate and in the interview portion of the study.
i. Now that you have provided consent to participate in the study, I would like your
permission to record this interview to more accurately document the information you
provide me. If at any time you wish to discontinue video recording or the interview itself,
please let me know.
ii. The purpose of this project is to conduct a gap analysis to examine the knowledge,
motivation, and organizational influences that interfere with Navy Sailors seeking help
for PTSD.
iii. All of your responses and personal information are confidential, will be stored under lock
and key, and will only be used to develop a better understanding of what knowledge,
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motivation, and organizational factors influence whether you or your peers would seek
medical care for PTSD.
i. Are you active duty or a reservist?
ii. What is your gender?
iii. What is your current paygrade, E-1 – E-6, E-7 – E-9, W-2 – W-5, 0-1 – 0-3, 0-4 – 0-6, or
0-7 – 0-10?
iv. How would you describe the signs and symptoms of PTSD?
v. How do you feel the organization foes with regard to education on PTSD pre/post-
deployment?
vi. What’s your opinion on those who have or may have PTSD?
vii. If you had or felt you had PTSD, what would be your top 5 concerns with seeking
medical care?
viii. What stigmas pertaining to those who are seen for mental health issues and PTSD exist in
your organization?
ix. How do stigmas pertaining to mental health illness or those who seek medical care
impact you or others within your organization?
x. How would a stigma impact your desire to seek medical care if you thought you had
PTSD?
xi. How well has your organization done with treating those who have or may have PTSD?
xii. How would the organizational culture impact whether or not you would seek medical
care for PTSD?
xiii. What resources are available to those who have or may have PTSD?
xiv. What additional resources would you like to see available for PTSD?
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xv. If those resources for PTSD were available, would you utilize them if you had or thought
you had PTSD?
xvi. What would you implement to increase the knowledge and understanding of PTSD
among Sailors?
xvii. What would you implement to increase the knowledge and understanding of the stigmas
associated with PTSD?
xviii. Finally, what could the organization do better to create an organizational culture free of
stigma?
xix. That concludes the questioning portion of the interview. I would like to thank you for
your participation and need to reiterate that your responses and information will remain
safeguarded and confidential.

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Appendix E
Survey Instrument Question Template
Thank you for volunteering to participate in my research study by completing a survey. My
name is Jeremy Hendrickson and I’m a graduate student at the University of Southern California
(USC) conducting my dissertation in partial fulfillment of the requirements for a Doctor of
Education in Organizational Change and Leadership. My research is focused on studying how
stigmas impact whether or not Sailors seek medical care for mental health issues, mores
specifically, PTSD. The survey will take approximately minutes in duration and will consist of
25 questions pertaining to PTSD and the associated stigmas in the military. Within the survey,
there are also some demographic questions that will aid my research study. The next screen will
present an information sheet about the study. Please read though information and click the “>>”
(next) navigation arrow to go to the consent form. Please read the consent form and upon
consent, click the “>>” (next) navigation arrow to launch the survey. You will continue to use
“>>” (next) navigation arrow to navigate through the remainder of the survey. You can skip or
omit any questions and withdraw from participation at any time during the survey.
The following questions are demographic based questions pertaining to your military rank,
years of service, deployments, and related experiences.
1. Consent to participate in the study.
2. Are you active duty or a reservist?
(a) Active Duty
(b) Reservist
3. What is your gender? (Short Answer)
4. What is your rank?
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121
(a) E-1 – E-6
(b) E-7 – E-9
(c) O-1 – O-3
(d) O-4 – O-6
(e) O-7 – O-9
5. How many years of service (Active or Reserves) do you have?
(a) Less than 5 years
(b) 10 – 15 years
(c) 16 – 20 years
(d) 21 – 30 years
6. How many deployments have you completed?
(a) 0
(b) 1 – 2
(c) 3 – 5
(d) 6 – 9
(e) 10 or more
6. In which campaigns have you deployed in supporting?
(a) Operation New Dawn (OND)
(b) Operation Enduring Freedom (OEF)
(c) Operation Iraqi Freedom (OIF)
(d) Operation Inherent Resolve (OIR)
(e) Humanitarian Operations (all inclusive)
8. To which arduous/combat zone location(s) have you deployed?
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(a) Philippines
(b) Pakistan
(c) Afghanistan
(d) Yemen
(e) Syria
(f) Jordan
(g) Other (fill in the blank)
9. To which types of duty have you been assigned to?
(a) Combat
(b) Humanitarian
(c) Arduous
(d) Isolated
10. If you participated in combat or humanitarian operations, or isolated or arduous duty, were
you directly or indirectly exposed to any traumatic situations?
(a) Yes
(b) No
(c) N/A
11. If you were directly or indirectly exposed to any traumatic situations while deployed, were
they the result of enemy fire (contact)?
(a) Yes
(b) No
(c) N/A
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The next set of multiple choice and short answer questions are pertaining to stigmas and
PTSD.
12. How many times in your naval career have you received training on Post-Traumatic Stress
Disorder (PTSD)?
(a) 0
(b) 1
(c) 2
(d) 3 or more
13. What is your definition of PTSD? (Short Answer)
14. American Psychiatric Association (APA) definition of PTSD.
15. If applicable; do you feel you could have, or may have had, PTSD as a result from your
military related deployment (s)?
(a) Yes
(b) No
(c) Maybe
(d) N/A
16. In general, how confident are you in your abilities to self-identify the signs and symptoms of
PTSD?
1. Very Confident
2. Confident
3. Neither Confident or Unconfident
4. Unconfident
5. Very Unconfident
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17. What is your definition of a stigma? (Short Answer)
18. How many times in your naval career have you been given training on stigmas?
(a) 0
(b) 1
(c) 2
(d) 3 or more
19. American Psychiatric Association (APA) definition of a stigma.
20. Do any stigmas regarding mental health care or those who seek it exist within the Navy?
(a) Yes
(b) No
21. If so, how likely is it that these stigmas do, or would impact your decision to seek medical
care for mental health issues?
1. Very Likely
2. Likely
3. Neither Likely or Unlikely
4. Unlikely
5. Very Unlikely
22. Do any stigmas toward mental health care or those who seek it exist within your current
organization (unit)?
(a) Yes
(b) No
(c) Maybe
(d) Don’t Know
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23. If so, what stigmas exist regarding those who seek out medical care for mental health issues
or PTSD? (Short Answer)
24. If so, how likely is it that these stigmas so, or would impact your decision to seek medical
care for mental health issues or PTSD?
1. Very Likely
2. Likely
3. Neutral
4. Unlikely
5. Very Unlikely
25. To what degree do you agree or disagree with the following statement: The Navy and/or my
organizational leadership would support me if I sought out medical care for a mental health issue
or PTSD?
1. Strongly Agree
2. Agree
3. Neither Agree or Disagree
4. Disagree
5. Strongly Disagree
26. To what degree do you agree or disagree with the following statement: The Navy and/or my
current organization provides me with the needed support services in the event I need to seek
medical care for mental health issues or PTSD?
1. Strongly Agree
2. Agree
3. Neither Agree or Disagree
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4. Disagree
5. Strongly Disagree

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Appendix F
Sample Training Muster Sheet

Date: Training Topic: Location:

Rank Name (e.g. Doe, John) Signature

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Appendix G

Sample Pre-Training Survey on Post-Traumatic Stress Disorder (PTSD) and the
Associated Stigma

Please rate your answers using a 5-point scale:

1. I am confident in my ability to identify the signs and symptoms of PTSD.

5 4 3 2 1
Strongly Agree Neither Agree Disagree Strongly
Agree or Disagree Disagree

2. I am confident in my ability to identify the stigma associated with PTSD.

5 4 3 2 1
Strongly Agree Neither Agree Disagree Strongly
Agree or Disagree Disagree

3. I see the value in receiving medical care for PTSD.

5 4 3 2 1
Strongly Agree Neither Agree Disagree Strongly
Agree or Disagree Disagree

4. I feel the value in receiving medical care for PTSD is greater than the associated
stigma.

5 4 3 2 1
Strongly Agree Neither Agree Disagree Strongly
Agree or Disagree Disagree

5. The associated stigma with PTSD impacts my decision in seeking medical care.

5 4 3 2 1
Strongly Agree Neither Agree Disagree Strongly
Agree or Disagree Disagree

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Appendix H

Sample Post-Training Survey on Post-Traumatic Stress Disorder (PTSD) and the
Associated Stigma

Please rate your answers using a 5-point scale:

1. Having completed this training, I am more confident in my ability to identify the
signs and symptoms of PTSD.

5 4 3 2 1
Strongly Agree Neither Agree Disagree Strongly
Agree or Disagree Disagree

2. Having completed this training, I am more confident in my ability to identify the
stigmas associated with PTSD.

5 4 3 2 1
Strongly Agree Neither Agree Disagree Strongly
Agree or Disagree Disagree

3. Having completed this training, I now see more value in receiving medical care for
PTSD.

5 4 3 2 1
Strongly Agree Neither Agree Disagree Strongly
Agree or Disagree Disagree

4. Having completed this training, I feel more value in receiving medical care for
PTSD.

5 4 3 2 1
Strongly Agree Neither Agree Disagree Strongly
Agree or Disagree Disagree

5. Having completed this training, the associated stigma with PTSD impacts my
decision less than before when deciding to seek medical care.

5 4 3 2 1
Strongly Agree Neither Agree Disagree Strongly
Agree or Disagree Disagree

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Appendix I

Sample Training Press Check Questions

1. Having completed this training, I am more confident in my ability to identify the
signs and symptoms of PTSD.

5 4 3 2 1
Strongly Agree Neither Agree Disagree Strongly
Agree or Disagree Disagree

2. Having completed this training, I am more confident in my ability to identify the
stigma associated with PTSD.

5 4 3 2 1
Strongly Agree Neither Agree Disagree Strongly
Agree or Disagree Disagree

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Appendix J

Sample 30-Day Post-Training Survey on Post-Traumatic Stress Disorder (PTSD) and the
Associated Stigma

Please rate your answers using a 5-point scale:

2. Having completed this training 30 days ago, I remain confident in my ability to
identify the signs and symptoms of PTSD.

5 4 3 2 1
Strongly Agree Neither Agree Disagree Strongly
Agree or Disagree Disagree

3. Having completed this training 30 days ago, I remain confident in my ability to
identify the stigma associated with PTSD.

5 4 3 2 1
Strongly Agree Neither Agree Disagree Strongly
Agree or Disagree Disagree

4. Having completed this training 30 days ago, I continue to see more value in
receiving medical care for PTSD.

5 4 3 2 1
Strongly Agree Neither Agree Disagree Strongly
Agree or Disagree Disagree

5. Having completed this training 30 days ago, I continue to see more value in
receiving medical care for PTSD than the associated stigma.

5 4 3 2 1
Strongly Agree Neither Agree Disagree Strongly
Agree or Disagree Disagree

6. Having completed this training 30 days ago, the associated stigma with PTSD
continues to impact my decision less than before when deciding to seek medical care.

5 4 3 2 1
Strongly Agree Neither Agree Disagree Strongly
Agree or Disagree Disagree

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Appendix K

Sample Pre-Survey Results Bar Graph Chart

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References
American Psychiatric Association. (2019). Retrieved from https://www.psychiatry.org/patients
families/ptsd/what-is-ptsd
Bandura, A. (1994). Self-efficacy. In V. S. Ramachaudran (Ed.), Encyclopedia of human
behavior (Vol. 4, pp. 71– 81). New York, NY: Academic Press.
Barr, N. U., Sullivan, K., Kintzle, S., & Castro, C. A. (2016). PTSD symptoms,
suicidality and non-suicidal risk to life behavior in a mixed sample of pre- and post-9/11
veterans. Social Work in Mental Health, 14(5), 465-473.
doi:10.1080/15332985.2015.1081666
Belasco, A. (2009). Troop levels in the Afghan and Iraq Wars, FY2001-FY2012: Cost
and other potential issues. CRS Report for Congress, R40682. Retrieved from
https://www.hsdl.org/?view&did=746013
Blackburn, L., & Owens, G. P. (2014). The effect of self-efficacy and meaning in life on
posttraumatic stress disorder and depression severity among veterans. Journal of Clinical
Psychology, 71(3), 219-228. doi:10.1002/jclp.22133
Britt, T. W., Ranes, B., Kelley, A. M., Grandizio, C., & Gaydos, S. J. (2014). Soldier beliefs
about the readiness of military personnel with mild traumatic brain injury. Army
Aeromedical Research Lab. doi:10.21236/ada616896
Brown, A. D., Antonius, D., Kramer, M., Root, J. C., & Hirst, W. (2010). Trauma centrality and
PTSD in veterans returning from Iraq and Afghanistan. Journal of Traumatic
Stress, 23(4), 496-499. doi:10.1002/jts.20547

PTSD IN THE MILITARY AND ASSOCIATED STIGMAS

134
Burlingame, G. M., Fuhriman, A., & Johnson, J. E. (2001). Cohesion in group psychotherapy.
Psychotherapy: Theory, Research, & Practice, 38, 373–379.
Carlson, E., & Ruzek, J. (n.d.). PTSD and the family. Veterans Affairs. Retrieved from
https://www.ptsd.va.gov/professional/treatment/family/ptsd-and-the-family.asp
Chase, R. P., Mcmahon, S. A., & Winch, P. J. (2016). “Tell me what you don’t remember”:
Care-seeking facilitators and barriers in the decade following repetitive blast exposure
among army combat veterans. Military Medicine, 181(2), 116-122. doi:10.7205/milmed-
d-14-00471
Christian, A. (2015). Trauma innovations: MDMA as a treatment intervention for PTSD. St.
Catherine University. Retrieved from
https://sophia.stkate.edu/cgi/viewcontent.cgi?article=1550&context=msw_papers
Clark, R. E., & Estes, F. (2008). Turning research into results: A guide to selecting the right
performance solutions. Charlotte, NC: Information Age Pub.
Clement, S., Schauman, O., Graham, T., Maggioni, F., Evans-Lacko, S., Bezborodovs, N.,
Thornicroft, G. (2015). What is the impact of mental health-related stigma on help-
seeking? A systematic review of quantitative and qualitative studies. Psychological
Medicine, 45(01), 11-27. doi:10.1017/s0033291714000129
Connell, C. L. (2015). PTSD in the 20th Century American Military: Its Diagnosis, Effects,
Treatment, and Management, With a Focus on the Vietnam War. Bound Away: The
Liberty Journal of History, 1(2).
Creswell, J. W. (2014). Research Design: Qualitative, Quantitative, and Mixed-methods
Approaches. Thousand Oaks, CA: SAGE Publications, Inc.
PTSD IN THE MILITARY AND ASSOCIATED STIGMAS

135
Cyniak-Cieciura, M., Staniaszek, K., Popiel, A., Pragłowska, E., & Zawadzki, B. (2017). The
structure of PTSD symptoms according to DSM-5 and IDC-11 proposal: A multi-sample
analysis. European Psychiatry, 44, 179-186. doi:10.1016/j.eurpsy.2017.02.491
Dictionary.com. (2019). Retrieved February 1, 2019, from https://www.dictionary.com/
Dondanville, K.A., Borah, E. V., Bottera, A. R., & Molino, A. T. (2018). Reducing stigma in
PTSD treatment seeking among service members: Pilot intervention for military leaders.
Best Practices in Mental Health, 14(1), 15-26.
Dursa, E. K., Reinhard, M. J., Barth, S. K., & Schneiderman, A. I. (2014). Prevalence of a
positive screen for PTSD among OEF/OIF and OEF/OIF-era veterans in a large
population-based cohort. Journal of Traumatic Stress, 27(5), 542-549.
doi:10.1002/jts.21956
Eccles, J. (2006). Expectancy-value motivational theory. Retrieved from
http://www.education.com/reference/article/expectancy-value-motivational-theory/
Eccles, J. S., & Wigfield, A. (2002). Motivational beliefs, values, and goals. Annual Review of
Psychology, 53, 109-32. Retrieved from http://libproxy.usc.edu/login?url=https://search-
proquest-com.libproxy1.usc.edu/docview/205754091?accountid=14749
Elliot, M., & Doane, M. J. (2015). Stigma management of mental illness: Effects of
concealment, discrimination, and identification on well-being. Self and Identity, 14(6),
654-674. doi:10.1080/15298868.2015.1053518
Emmons, M. (2013). Post-traumatic stress disorder stigma hurts veterans in job search. The
Mercury News. Retrieved from https://www.mercurynews.com/2013/06/21/post
traumatic-stress-disorder-stigma-hurts-veterans-in-job-search/
PTSD IN THE MILITARY AND ASSOCIATED STIGMAS

136
Expeditionary Combat Readiness Command (ECRC) Mission. (2018). Retrieved from
www.ecrc.navy.mil
Flood-Grady, E., & Kellas, J. K. (2018). Sense-making, socialization, and stigma: Exploring
narratives told in families about mental illness. Health Communication, 1-11.
doi:10.1080/10410236.2018.1431016
Fragedakis, T. M., & Toriello, P. (2014). The development and experience of combat-related
PTSD: A demand for neurofeedback as an effective form of treatment. Journal of
Counseling & Development, 92(4), 481-488. doi:10.1002/j.1556-6676.2014.00174.x
Friedman, M. J. (2007, January 31). PTSD. National Center for PTSD. Retrieved
https://www.ptsd.va.gov/professional/PTSD-overview/ptsd-overview.asp
Glesne, C. (2011). Becoming qualitative researchers: an introduction. Boston: Pearson.
Greene-Shortridge, T. M., Britt, T. W., & Castro, C. A. (2007). The stigma of mental
health problems in the military. Military Medicine, 172(2), 157-161.
doi:10.7205/milmed.172.2.157
Gynn, G., Wright, T. (2007). Return to the brain of Eden. Vermont: Inner Traditions.
Hahn, A. M., Tirabassi, C. K., Simons, R. M., & Simons, J. S. (2015). Military sexual
trauma, combat exposure, and negative urgency as independent predictors of
PTSD and subsequent alcohol problems among OEF/OIF veterans. Psychological
Services, 12(4), 378-383. doi:10.1037/ser0000060
PTSD IN THE MILITARY AND ASSOCIATED STIGMAS

137
Held, P., & Owens, G. P. (2013). Stigmas and attitudes toward seeking mental health treatment
in a sample of veterans and active duty service members. Traumatology, 19(2), 136-143.
doi:10.1177/1534765612455227
History.com. (2017). PTSD and Shell Shock. Retrieved from
https://www.history.com/topics/inventions/history-of-ptsd-and-shell-shock.
Hoge, C. W., Castro, C. A., Messer, S. C., Mcgurk, D., Cotting, D. I., & Koffman, R. L.
(2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to
care. New England Journal of Medicine, 351(1), 13-22.
Hoge, C. W., Grossman, S. H., Auchterlonie, J. L., Riviere, L. A., Milliken, C. S., &
Wilk, J. E. (2014). PTSD treatment for soldiers after combat deployment: Low utilization
of mental health care and reasons for dropout. Psychiatric Services, 65(8), 997-1004.
doi:10.1176/appi.ps.201300307
Holloway, K. M., & Reger, G. M. (2013). T2 Virtual PTSD Experience: A Virtual Worlds
Environment to educate service members and veterans about combat-related
posttraumatic stress disorder. International Journal of Human-Computer Interaction,
29(9), 594-603. doi:10.1080/10447318.2012.735186
Horwitz, A. G., Held, P., Klassen, B. J., Karnik, N. S., Pollack, M. H., & Zalta, A. K. (2018).
Posttraumatic cognitions and suicidal ideation among veterans receiving PTSD
treatment. Cognitive Therapy and Research, 42(5), 711-719. doi:10.1007/s10608-018-
9925-6
How common is PTSD? (2016). National Center for PTSD. Retrieved from
http://www.ptsd.va.gov/public/PTSD-overview/basics/how-common-is-ptsd.asp
PTSD IN THE MILITARY AND ASSOCIATED STIGMAS

138
Iversen, A. C., Staden, L. V., Hughes, J. H., Greenberg, N., Hotopf, M., Rona, R. J., . . . Fear, N.
T. (2011). The stigma of mental health problems and other barriers to care in the UK
Armed Forces. BMC Health Services Research, 11(1). doi:10.1186/1472-6963-11-31
Jackson, C. E., Green, J. D., Bovin, M. J., Vasterling, J. J., Holowka, D. W., Ranganathan, G.,
Marx, B. P. (2016). Mild traumatic brain injury, PTSD, and psychosocial functioning
among male and female U.S. OEF/OIF veterans. Journal of Traumatic Stress, 29(4), 309-
316. doi:10.1002/jts.22110
Johnson, B., & Christensen, L. B. (2015). Educational research: quantitative, qualitative, and
mixed approaches. Los Angeles: SAGE.
Kelly, J. F., & Greene, M. C. (2014). Where there’s a will there’s a way: A longitudinal
investigation of the interplay between recovery motivation and self-efficacy in predicting
treatment outcome. Psychology of Addictive Behaviors, 28(3), 928-934.
doi:10.1037/a0034727
Kirkpatrick, J. D., & Kirkpatrick, W. K. (2016). Kirkpatrick’s four levels of training evaluation.
Alexandria: ATD Press.
Kirschner, P., Kirschner, F., & Paas, F. (2006). Cognitive load theory. Retrieved from
http://www.education.com/reference/article/cognitive-load-theory/
Kirschner, P. A., Sweller, J., & Clark, R. E. (2006). Why minimal guidance during instruction
does not work: An analysis of the failure of constructivist, discovery, problem-based,
experiential, and inquiry-based teaching. Educational Psychologist, 41, 75–86.
Kleykamp, M. (2013). Unemployment, earnings and enrollment among post 9/11
veterans. Social Science Research, 42(3), 836-851. doi:10.1016/j.ssresearch.2012.12.017
PTSD IN THE MILITARY AND ASSOCIATED STIGMAS

139
Kok, B. C., Herrell, R. K., Thomas, J. L., & Hoge, C. W. (2012). Posttraumatic stress disorder
associated with combat service in Iraq or Afghanistan. The Journal of Nervous and
Mental Disease, 200(5).
Kolk, B. V. (2015). The body keeps the score. New York: Penguin.
Krathwohl, D. R. (2002). A revision of Blooms Taxonomy: An overview. Theory Into
Practice,41(4), 212-218. doi:10.1207/s15430421tip4104_2
Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic inquiry. Beverly Hills: SAGE
Litz, B., & Schlenger, W. (2009). PTSD in service members and new veterans of the
Iraq and Afghanistan. Retrieved from
https://www.ptsd.va.gov/professional/newsletters/research-quarterly/v20n1.pdf
Luszczynska, A., Benight, C. C., & Cieslak, R. (2009). Self-efficacy and health-related
outcomes of collective trauma. European Psychologist, 14(1), 51-62. doi:10.1027/1016-
9040.14.1.51
Maxwell, J. A. (2013). Qualitative research design: An interactive approach (3rd ed.). Thousand
Oaks, CA: SAGE.
Mccarron, K. K., Reinhard, M. J., Bloeser, K. J., Mahan, C. M., & Kang, H. K. (2014). PTSD
diagnoses among Iraq and Afghanistan veterans: Comparison of administrative data to
chart review. Journal of Traumatic Stress, 27(5), 626-629. doi:10.1002/jts.21961
Mcgillivray, K. (2016). Application of the intersystem approach for combat veterans
experiencing sexual problems related to trauma and injuries of war. Journal of Family
Psychotherapy, 27(4), 243-259. doi:10.1080/08975353.2016.1235431
PTSD IN THE MILITARY AND ASSOCIATED STIGMAS

140
Mcgraw, L., Pickering, M. A., Ohlson, C., & Hammermeister, J. (2012). The Influence of Mental
Skills on Motivation and Psychosocial Characteristics. Military Medicine, 177(1), 77–84.
doi: 10.7205/milmed-d-11-00060
Merriam, S. B., & Tisdell, E. J. (2016). Qualitative research: A guide to design and
implementation. (4th ed.). San Francisco: Jossey-Bass.
Michalopoulou, L. E., Welsh, J. A., Perkins, D. F., & Ormsby, L. (2016). Stigma and mental
health service utilization in military personnel: A review of the literature. Military
Behavioral Health, 5(1), 12-25. doi:10.1080/21635781.2016.1200504
Mittal, D., Drummond, K. L., Blevins, D., Curran, G., Corrigan, P., & Sullivan, G. (2013).
Stigma associated with PTSD: Perceptions of treatment-seeking combat
veterans. Psychiatric Rehabilitation Journal, 36(2), 86-92. doi:10.1037/h0094976
Pajares, F. (2006). Self-efficacy theory. Education.com. Retrieved
from http://www.education.com/reference/article/self-efficacy-theory/
Pietrzak, R., Johnson, D., Goldstein, M., Malley, J., & Southwick, S. (2009). Perceived
stigma and barriers to mental health care utilization among OEF-OIF
veterans. Psychiatric Services, 60(8). doi:10.1176/appi.ps.60.8.1118
Pintrich, P. R. (2003). A motivational science perspective on the role of student motivation in
learning and teaching contexts. Journal of Educational Psychology, 95(4), 667–686.
PTSD: National Center for PTSD. (2018). Retrieved from
https://www.ptsd.va.gov/understand/common/common_veterans.asp

PTSD IN THE MILITARY AND ASSOCIATED STIGMAS

141
PTSD: National Center for PTSD. (2017). Retrieved from
https://www.ptsd.va.gov/understand/common/common_veterans.asp
PTSD: National Institute of Mental Health (NIMH). (2016).
Retrieved 2016, from https://www.nimh.nih.gov/health/index.shtml.
Rosa, G. M., Delaney, E. M., Webb-Murphy, J. A., & Johnston, S. L. (2015). Interactive effects
of stress and individual differences on alcohol use and posttraumatic stress disorder
among personnel deployed to Guantanamo Bay. Addictive Behaviors, 50, 128-134.
doi:10.1016/j.addbeh.2015.06.016
Rozek, C. S., Svoboda, R. C., Harackiewicz, J. M., Hulleman, C. S., & Hyde, J. S. (2017).
Utility-value intervention with parents increases students’ STEM preparation and career
pursuit. Proceedings of the National Academy of Sciences, 114(5), 909-914.
doi:10.1073/pnas.1607386114
Rüsch, N., Rose, C., Holzhausen, F., Mulfinger, N., Krumm, S., Corrigan, P. W., Zimmermann,
P. (2017). Attitudes towards disclosing a mental illness among German soldiers and their
comrades. Psychiatry Research, 258, 200-206. doi:10.1016/j.psychres.2017.08.028
Salkind, N. J. (2017). Statistics for people who (think they) hate statistics. Thousand Oaks, CA:
SAGE Publications.
Samuelson, K. W., Koenig, C. J., Mccamish, N., Choucroun, G., Tarasovsky, G., Bertenthal, D.,
& Seal, K. H. (2014). Web-based PTSD training for primary care providers: A pilot
study. Psychological Services, 11(2), 153-161. doi:10.1037/a0034855

PTSD IN THE MILITARY AND ASSOCIATED STIGMAS

142
Schoenleber, M., Sippel, L. M., Jakupcak, M., & Tull, M. T. (2015). Role of trait shame
in the association between posttraumatic stress and aggression among men with a history
of interpersonal trauma. Psychological Trauma: Theory, Research, Practice, and Policy,
7(1), 43-49. doi:10.1037/a0037434
Shin, D. D., Lee, M., Ha, J. E., Park, J. H., Ahn, H. S., Son, E., . . . Bong, M. (2019). Science for
all: Boosting the science motivation of elementary school students with utility value
intervention. Learning and Instruction, 60, 104-116.
doi:10.1016/j.learninstruc.2018.12.003
Smith, R. T., & Whooley, O. (2015). Dropping the disorder in PTSD. Contexts, 14(4),
38-43. doi:10.1177/1536504215609300
Stone, C., & Stone, D. L. (2015). Factors affecting hiring decisions about veterans. Human
Resource Management Review, 25(1), 68-79. doi:10.1016/j.hrmr.2014.06.003
Sundin, J., Fear, N. T., Iversen, A., Rona, R. J., & Wessely, S. (2009). PTSD after
deployment to Iraq: conflicting rates, conflicting claims. Psychological Medicine, 40(03),
367. doi:10.1017/s0033291709990791
Taff, B., Dattilo, J., Davis, K., & Moeller, J. (2016). Leisure perceptions of combat veterans of
operations enduring freedom and Iraqi freedom. Journal of Leisure Research, 8(4), 265-
284.
Telch, M. J., Beevers, C. G., Rosenfield, D., Lee, H., Reijntjes, A., Ferrell, R. E., & Hariri, A. R.
(2015). 5-HTTLPR genotype potentiates the effects of war zone stressors on the
emergence of PTSD, depressive and anxiety symptoms in soldiers deployed to
Iraq. World Psychiatry, 14(2), 198-206. doi:10.1002/wps.20215
PTSD IN THE MILITARY AND ASSOCIATED STIGMAS

143
The stigma that stops veterans from getting help for PTSD. (2017). PBS. Retrieved from
https://www.pbs.org/newshour/show/stigma-stops-veterans-getting-help-ptsd
Thomson, S. B., & Grandy, G. (2018). Stigmas, work and organizations. New York:
Palgrave Macmillan US
Walters, A. S., & Burger, B. D. (2012). “I love you, and I cheated”:
Investigating disclosures of infidelity to primary romantic partners. Sexuality & Culture,
17(1), 20-49. doi:10.1007/s12119-012-9138-1

Abstract (if available)

Abstract Post-Traumatic Stress Disorder (PTSD) has been part of the human condition since the evolution of species. PTSD became a symbol of the wars in Iraq and Afghanistan because 20% of service members were returning with symptoms of PTSD (How Common is PTSD, 2018). Research indicates that 50% to 60% of service members do not seek treatment due to self-stigma reasons (Barr, Sullivan, Kintzle, & Castro, 2016

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Asset Metadata

Creator Hendrickson, Jeremy Matthew (author)

Core Title Post-traumatic stress disorder in the military and the associated stigmas: a gap analysis

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Publication Date 11/14/2019

Defense Date 11/13/2019

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

Tag combat,OAI-PMH Harvest,PTSD,self-efficacy,signs and symptoms,stigma,trauma,utility value

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Tobey, Patricia (committee chair), Crawford, Jenifer (committee member), Forrester, Kristin (committee member)

Creator Email hendo2379@me.com,jmhendri@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-233346

Unique identifier UC11673436

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Legacy Identifier etd-Hendrickso-7923.pdf

Dmrecord 233346

Document Type Dissertation

Rights Hendrickson, Jeremy Matthew

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