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An action plan for prevention and wellness for gen Z soldiers
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Content
AN ACTION PLAN FOR PREVENTION AND WELLNESS FOR GEN Z
SOLDIERS
Amy L St Luce
University of Southern California
Suzanne Dworak-Peck School of Social Work
DSW Program
Professor Renee Smith-Maddox
27 March 2023
May 2023
2
Acknowledgments
Partial funding for this doctoral program was provided by the United States Army
through the Academic and Career Training program for Department of Army civilians. The
views expressed are those of the author and do not reflect the official policy of the Department of
the Army, the Department of Defense, or the U.S. Government.
I would not have been able to complete this doctoral journey without the support of the
many individuals in my life, both personal and professional, who supported me on this project.
LTC James Macdonald, LCSW, Ph.D., for mentoring me through this project from beginning to
end. CPL Aleksandra Brajovic for being my course and app design partner. The AIT LPN
soldiers and their instructors for allowing me to pilot my design with them. Dr. Colette Candy,
Ph.D., for being my constant sounding board, providing feedback and being a trusted confidant,
supervisor, and friend. Dr. Tamela Bresler, Ph.D., for providing invaluable feedback, friendship,
and motivation. Ms. Kaleena Garcia, MS, for giving feedback, encouragement, and friendship.
Dr. Jaime Gonzalez, Ph.D., for providing discussion and feedback. Ms. Cynthia Garber, M.Ed.,
for review, discussion, and invaluable friendship throughout this process. All the Gen Z
teenagers who trusted me with their thoughts, opinions, feedback, and insights into their
worldviews. Without them, there is no basis for this project. My colleagues in the accelerated
DSW Cohort 14, you motivated me to power on and kept me sane every step of this program.
The Social Work Internship Program students at JBLM for being my practice audience and
providing me with feedback. My family - my parents, Gary Wilhelm and Pamela and Fred
Kemp; my brother and sister-in-law, Aaron and Suzie Wilhelm, and their children, Jackson and
Marcus Wilhelm. Their love, support, opinion, feedback, and encouragement throughout this
doctoral degree have kept me moving forward. And finally, my husband Lawrence and my two
Gen Z teenagers, Lorenzo and Gabi. They provided me with time and space to do this work.
3
They cooked dinner, cleaned the house, kept the dogs quiet and entertained, provided opinions
and feedback, and kept me sane. Without them, I would not be who or where I am today.
4
TABLE OF CONTENTS
Page Number
I. Introduction 9
II. Problems of Practice and Literature Review 10
III. Conceptual Framework 18
IV. Project Description 21
I. Methodology 28
VI. Implementation Strategy 30
VII. Conclusion 34
References
Appendices
5
Abstract
The rate of suicide in the Army Gen Z population has almost doubled that of the general
population of 18 to 25-year-olds (Defense Suicide Prevention Office, 2022; National Institute of
Mental Health, 2022). Suicide directly results from stressors that have not been successfully
managed and, as a result, become mental health problems that the individual believes are too
hard to live with (Ruiz, 2014). Surveys conducted by this author with Gen Z (b.1997-2012,
Dimock, 2019) in 2022, both in the general population and the Army, are consistent with current
research, citing themes of broad mental health problems, desires to be heard, fear of world
problems, anger at older generations, and expectations that leaders will provide a similar
environment in which they were parented. Gen Z experienced childhoods with parents who were
intensive, protective, and solved all their problems, coupled with warmth, responsiveness, and
collaboration. This parenting style has led to underdeveloped coping skills, increased anxiety,
depression, a lack of self-efficacy, and a lack of autonomy in the generation (Belz, 2021;
Weiland & Kucirka, 2020). These characteristics formed a generation of soldiers unable to cope
with the everyday demands of life in the military. The solution outlined in the project aims to
prevent mental and behavioral health problems in Gen Z soldiers through the Action Planning for
Prevention and Wellness course. The project is an instructor-led course that guides the soldier
through writing identified skills, attributes, and solutions into a PDF workbook associated with
the course. An app to accompany the workbook is in development and will make the content
more readily accessible to the soldiers. To be successful, this solution will be implemented at
Advanced Individual Training (AIT) courses for new recruits, arenas that have not traditionally
focused on mental health.
6
Introduction
This capstone paper will discuss how the Action Planning for Prevention and Wellness
project will be used to improve the mental and behavioral health
1
of Gen Z soldiers. It embraces
the theory that the Gen Z population, born between 1997 and 2012 (Dimock, 2019), has
underdeveloped coping skills that prevent them from positively managing their emotions when
faced with adversity. Unmanaged emotional distress often leads to mental health problems,
increasing the risk of experiencing suicidal ideation, attempts, and death by suicide. It is
anticipated that as a result of this project, Gen Z soldiers will identify and use coping skills
before their emotional distress becomes an intractable crisis.
The project begins with an understanding of the problem of practice through a
comprehensive literature review of the Gen Z population, suicide, mental health, behavioral
health, and change theories. Included are interviews with subject matter experts and surveys with
Gen Z youth, both the civilian and Army populations, Army leaders, and parents of Gen Z. The
information gained from these elements supports the Grand Challenge of Social Work: Ensuring
Health Development for All Youth. This grand challenge focuses on the prevention of mental
health problems in youth.
The conceptual lens and theory of change are explained using evidenced-based theories
of habituation and self-determination. Learning and applying new skills are required to meet this
project’s goals, and these theories explain this process.
The project was developed by understanding current solutions and why they are
inadequate to “fix” it. The prototyping process included feedback from Gen Z soldiers, which
1
Mental health and behavioral health are both used to describe the problem in this paper. Mental health refers to a
psychological state, and behavioral health is a blanket term encompassing mental and physical health.
7
informed this project’s design. The project has three forms: the six-session Action Planning for
Prevention and Wellness instructor-led course; a PDF workbook to be used during the instructor-
led course; and a plan for creating an app of the workbook. The wireframe of the app is available
at the end of the paper.
The human-centered design process and implementation strategy are explained using the
design thinking concepts of what is, what if, what wows, and what works. As this project was
piloted during the design process, the Gen Z soldiers, and the co-instructor of the course were
integral design partners in the final iteration.
The final section includes the process of funding the project through the Army, the
involvement of stakeholders, and the communication strategies necessary to implement and scale
the project. Challenges, ethical considerations, and next steps complete this capstone paper.
Problems of Practice and Literature Review
Grand Challenge: Ensuring Healthy Development for All Youth
When the American Academy of Social Work and Social Welfare (AASWSW) sought to
identify the grand challenges of social work in 2012, there were 80 proposed ideas (Fong et al.,
2018, p.8). Of the 80, twelve made the final cut. One of these is the grand challenge of Ensuring
the Healthy Development of All Youth. It is defined by Fong et al. (2018) as the following:
More than 6 million young people receive treatment for severe mental, emotional, or
behavioral problems each year. Strong evidence shows us how to prevent many
behavioral health problems before they emerge. By unleashing the power of prevention
through the widespread use of proven approaches, we can help all youth grow up to
become healthy and productive adults (p. 10).
8
The AASWSW identified the initiative Unleashing the Power of Prevention to combat
youth’s growing behavioral health and social problems. The goals of this initiative are to 1)
reduce the incidence and prevalence of behavioral health problems in the population of young
people from birth through age 24 years by 20% from current levels over the next decade; and 2)
reduce racial and economic disparities in the behavioral health problems by 20% over the next
decade (Fong et al., 2018, p. 19).
Ensuring the Health Development of All Youth is focused on scaling and implementing
prevention programs to reach all youth, regardless of race, ethnicity, gender identity, or
socioeconomic status. In youth, behavioral health problems have significant lifelong impacts
ranging from delinquency to violence to suicide (Fong et al., 2018, p. 20). This generation has
never known a world without the internet and social media (Parker & Igielnik, 2020), which did
not exist for previous generations. Preventing behavioral health problems and suicide in these
youth require transformational thinking, innovation, and implementation on a grand scale.
Wicked Problem: The Mental Health Crisis in the Army Gen Z population
Concerns about the mental and behavioral health of the Gen Z population have existed
since 2010. In addition to the Social Work Grand Challenges (Fong et al., 2018), the Healthy
People 2020 and Healthy People 2030 initiatives, led by the Office of Disease Prevention and
Health Promotion [ODPHP] (n.d.-a & -b), have attempted to address them. The Healthy People
2030 (ODPHP, n.d.-b) initiative has dedicated 25 objectives to improving the nation's mental
health. Twenty-four of these goals note at least minimal change or better, but one is worsening:
MHMD-02 - reduce suicide attempts by adolescents (ODPHP, n.d.-b). The military uses the
Healthy People initiatives as a framework for their goals to reduce suicide, but the opposite has
happened. While the suicide rate in older service members has decreased since 2019, the rate of
9
suicidal thoughts, attempts, and deaths by suicide has continued to rise in Gen Z (DSPO, 2022.;
National Center for Injury Prevention and Control [NCIPC], 2022; ODPHP, n.d.-b).
Suicide is the third leading cause of death in Gen Z adults (National Institute for Mental
Health [NIMH], 2022; Substance Abuse and Mental Health Services Administration
[SAMHSA], 2022, pp 43-48). Like their non-military peers, Gen Z Army soldiers are victims of
suicide at an increasing rate. In 2021, the rate of suicide among Army Gen Z soldiers was 53.8
per 100,000 (DSPO, 2022). This is almost twice the U.S. Gen Z civilian rate of 28.2 and one and
a half times the rate of the total Army at 35 (DSPO, 2022; NIHM, 2022). The Gen Z soldier
population accounts for 50.5% of deaths by suicide in the Army (DSPO, 2022).
Improving the mental health of Gen Z soldiers may positively impact the suicide rate of
the population. SAMHSA (2022) estimates that 33.7% of 18-25-year-olds in the United States
experienced a mental illness in 2021. The military collects data on the Army’s mental health
through its suicide and suicide attempt reporting system (DSPO, 2022). The data shows that 45%
of deaths by suicide and suicide attempts had a known mental illness; approximately 60% of
these deaths and attempts were Gen Z. The stressors that Gen Z soldiers experience are like those
going to college or into the workforce for the first time. It is their first time navigating adult
responsibilities such as sleep, eating habits, finances, and social activities away from their
parents (Acharya et al., 2018). Both the civilian and soldier Gen Z populations cite the top
sources of stress as not getting along with others, personal debt, housing instability, not getting
enough to eat, drugs and alcohol use, and dealing with gender identity and sexual orientation
issues (American Psychological Association [APA], 2018; St Luce, 2022). Difficulties in these
areas are risk factors contributing to a decline in mental health functioning, which, if left
10
unmanaged, can result in suicide (Department of Veteran Affairs, Department of Defense
[VA/DOD], 2019, p 21).
Surveys of Army Gen Z (St Luce, 2022) are consistent with surveys conducted by the
APA (2018) and The Harvard Institute of Politics (2022); coping with stress and mental health
issues is at a deficit in Gen Z. They report not having the appropriate coping skills to manage
their mental health (APA, 2018; St Luce, 2022), even though they are comfortable reaching out
for professional help. Ruiz (2014) found that even for those with a mental health problem, the
suicide event most often occurs during an individual, family, economic or social crisis.
The failing mental health of a soldier has dangerous effects on the soldier’s unit (Bryan et
al., 2017). Between 2016 and 2020, 94.7% of service members seeking behavioral health
treatment were diagnosed with adjustment disorder (Armed Forces Health Surveillance Branch,
2021). Adjustment disorder is characterized by the inability to use appropriate coping skills to
respond to stressors (American Psychiatric Association, 2022). Kaplansky et al. (2021) found
that 29% of service members with behavioral health concerns had the intent to leave the Army.
As service members discharge early from the military due to difficulties coping with stress,
leadership incongruence, and behavioral health problems, the reduction in force which occurs
can compromise the mission of protecting the country. The Defense Manpower Data Center
(n.d.) shows a reduction in force of 21,882 Army soldiers between October 2021 and October
2022. This, combined with the severe challenges in recruiting new service members (Novelly et
al., 2022), will lead to severe shortages of national security missions, humanitarian needs, and
partnerships worldwide.
11
Stakeholder Analysis
The stakeholders impacted by this problem are the Army leaders, Army units, Army
Behavioral Health, Gen Z soldiers, and their families and friends. Their level of understanding of
this problem depends on their role with Gen Z. (Appendix A)
Battle Buddies
2
and Army leaders are the caregivers of Gen Z soldiers with mental and
behavioral health problems. Studies conducted to assess the effects of suicide exposure on
military members have consistently found that service members exposed to suicide or significant
mental health problems in their peers experience increased depression, anxiety, PTSD, suicide
ideations, and suicide attempts (Bryan et al., 2017; Ursano et al., 2017). Pak et al. (2021) found
that 52.4% of service members have experienced one or more suicide deaths in their unit. When
a unit loses functionality due to the mental health of one of its members, it is unprepared to fulfill
its mission, impacting the safety of service members and national security (Pak et al., 2021).
Loss of functionality leads to a lack of what the Army calls readiness: the number of soldiers in
optimal physical and mental health determines whether the unit is ready for a mission.
Surveys with Army leaders indicate they do not understand Gen Z (St Luce, 2022). They
see them as more immature than older generations and recognize that the generation does not
understand how to manage hardship. This leads to frustration among leaders and “confusion on
enforcing standards and discipline without being the bad person (St Luce, 2022).”
The Army Healthcare system is a directly involved and impacted stakeholder in this
problem. Mental health treatment ranges from short-term inpatient stays to residential treatment
programs, with outpatient behavioral health care as the most widely accessed intervention. The
demand for treatment, however, has dramatically exceeded the supply (Smith, 2021). Although
2
A battle buddy is someone who “always has your back.” They are typically assigned and expected to assist their
partner in and out of combat situations. https://en.wikipedia.org/wiki/Battle_buddy
12
the pandemic saw a widespread increase in the use of telehealth for mental health care, there
continues to be a shortage of mental health providers. A January 2022 report to Congress by the
Department of Defense (H.R. 6395 HASC Report 116-442, 2022, p 150) indicated a gap of
approximately 1,050 behavioral health providers in 2020 required to meet the demands of
delivering behavioral health care to the military. The shortage increases the demand on current
providers, risking burnout, and continued loss of providers (Smith, 2021).
Literature Review
A literature review of academic publications, gray literature, and popular media was
conducted on the following topics related to Gen Z: characteristics of 18- 25-year-olds, mental
health, behavioral health, suicide, parenting, leadership, theories of change, technology, and Gen
Z in the military.
The literature consistently shows that Gen Z endorses higher rates of mental health
problems than other generations ( APA, 2018; DSPO, 2022; Schaughency et al., 2021), and the
rates of suicidal thoughts, suicide attempts, and deaths by suicide have continued to increase
in this age group while decreasing in all others. Gen Z, however, is more open to and likely to
seek help than older generations (APA, 2018; Della Volpe, 2022). Many reasons soldiers seek
professional treatment do not meet the threshold for a DSM-5-TR diagnosis (American
Psychiatric Association, 2022). The Gen Z soldier seeks help due to experiencing difficulties
adjusting to the military leadership style, thwarted belongingness, lack of job satisfaction, lack of
purpose, and loneliness (Mcknight, 2019). When people experience these negative emotions
without direct support, they experience increasing behavioral health problems. Gen Z soldiers'
difficulties coping with general life stressors combined with leaders who do not know how to
13
help them have created a generation that quickly turns to professional behavioral health
treatment to solve their problems (APA, 2018).
Literature about leadership styles shows that the Army has traditionally led with an
authoritarian style. This style embraces absolute leadership control and decision-making. It is
rule-oriented, highly structured, and rigid and discourages input from subordinates (Cherry,
2022). Older military leaders are accustomed to hierarchies of power and individualism, but Gen
Z does not respond to this type of leadership (Della Volpe, 2022; Katz et al., 2021). Gen Z
responds best to leaders who are “respectful, caring, and willing to take on the responsibility for
the good of the group” (Katz et al., 2021, pp. 128-130). The differences in parenting and military
leadership ideologies present a significant problem for Gen Z soldiers and the leaders who lead
them. They view leadership as a group function rather than the function of one person. They
believe influence and guidance should be the primary traits of a leader (Katz et al., 2021, pp.
128-130).
Generation X (b. 1965 to 1980, Dimock, 2019) raised Gen Z. They are an independent,
resourceful, problem-solving, and individualistic generation with an overdeveloped need for
control due to growing up with a lack of safety and security (Belz, 2021). Thus, they became
“helicopter parents.” This term initially developed out of fear for a child’s physical safety. It
evolved into intensive parenting, hovering, and displaying “over-involvement, intrusiveness, and
control in the lives of children, teens, and college students (Wieland & Kucirka, 2020)”. The
helicopter parent solves their child’s problems but is coupled with high parental warmth and
responsiveness (Miller & Bromwich, 2019; Wieland & Kucirka, 2020). This parenting style
results in increased anxiety, depression, learned helplessness, suicidal ideation, attempts, and a
14
lack of autonomy, self-efficacy, and identity in the Gen Z population (Wieland & Kucirka,
2020), ultimately resulting in underdeveloped coping skills when confronted with failure.
It is necessary to appreciate technology’s influence on this generation to understand this
problem and its solution. Recent literature derived from interviews with Gen Z and taking the
historical influences of technology on society into consideration, cite the difference between
being born into a digital world, as Gen Z has, versus growing up in one, as have all other
generations (Della Volpe, 2022; Katz, 2021). Gen Z is an expert when it comes to technology
and communication. Whereas older generations struggle to understand and effectively use social
media and the internet, it has shaped the culture of Gen Z. Being born into the digital world, Gen
Z has developed new social codes, behaviors, and attitudes related to the use of time and
relationships and have redefined what it means to collab and whom they view as fam (Katz et al.,
2021). These themes are inherent to Gen Z but foreign to other generations. The urge to view
Gen Z through the lens of older, wiser generations is strong, but the literature shows that this
generation does not fit into previous generational molds (Della Volpe, 2022; Katz et al., 2021).
Technology for behavioral health support continues to develop. Hoermann et al. (2017)
found increasing efficacy and demand for mental health support and therapy using technology. A
study by Boustani et al. (2021) found that participants enjoyed interacting with and felt they
could be more honest with a virtual agent than a real person during treatment for their alcohol
use behaviors. Toscos et al. (2019), Schimelpfening (2022), and Verran et al. (2018) found that
the use of chat and text-based mental health support is an increasingly accepted and effective
way of seeking mental health support.
15
Conceptual Framework
Positionality Statement
I began working in behavioral health for the Army in 2010 when the United States was
still engaged in the Global War on Terrorism. At that time, the Army was increasing the number
of behavioral health providers to treat soldiers returning from war. The number of soldiers
deploying to combat zones decreased when the United States’ (U.S.) role in the conflict changed
after 2012. The rate of suicide in the Army, however, increased as did the demand for behavioral
health services. Experiencing the suicide of a patient is an unfortunate reality of treating
behavioral health problems; between 2011 and 2021, I lost five patients under the age of 25 to
suicide.
As the U.S.’s involvement in the war changed, healthcare and behavioral healthcare
funds were diverted to other priorities. Hiring behavioral health providers slowed (National
Defense Authorization Act, 2017), but military recruiting continued. The current recruits are
very different from any generation the Army has previously seen. They quickly seek behavioral
health help, increasing the demand for behavioral health services. By the time COVID-19 came
around, the demand for behavioral health services could not meet the supply, and COVID-19
only served to magnify the problem (Smith, 2021).
I am a Gen X, and I see how I fit the mold of the Gen X parent (b.1965-1980; Dimmock,
2019) described by Belz (2021). I was a “latch-key kid” – a child who went home to an empty
house and stayed there until my parents came home from work (Belz, 2021). This early
independence led to resourcefulness, problem-solving, and a heightened sense of individualism
in the generation. We have an overdeveloped need for control due to growing up as “latch-key
kids” and the fears created by being home alone at a young age.
16
I am a parent of two Gen Z’s, and I have witnessed their knowledge and use of
technology. It was not until I began this project that I realized they are the first “digital natives,”
as Della Volpe (2022) and Katz et al. (2021) call them. They have information at their fingertips
24 hours a day through social media and the internet. My friends and I are warm and loving
parents, but we try to prevent our kids from experiencing disappointment. While Gen X parents
have good intentions, our “helicopter” parenting style has led to an entire generation of people
with significantly underdeveloped coping skills (Miller & Bromwich, 2019; Wieland & Kucirka,
2021).
I have seen the lack of coping skills repeat itself in every Gen Z who walks into my
clinic. A lack of coping does not bode well in the Army. The military’s favorite saying,
“Embrace the Suck,” has not been embraced by Gen Z. The Army expects recruits to have basic
life skills upon entry and that Basic Training will fill in the needed gaps. This, however, has not
worked for Gen Z. Their response to stress is to seek behavioral health help to gain life skills,
coping mechanisms, and stress management. This is what they did growing up, asking Mom and
Dad for help; they do not know a different way, and for most Gen X parents, we are glad they
ask. Most of us grew up in households where we were expected to be independent and figure out
life on our own at a very young age. Without their parents, Gen Z often does not have the skills
to solve their problems. If they cannot get the help they want or it does not work, they turn to
suicide faster than any previous generation, and tragically, the suicide rate continues to climb
(DSPO, 2022).
The generation’s difficulty coping with adversity has significantly overwhelmed the
behavioral healthcare treatment system. As a leader in a large Army behavioral health clinic, I
must balance the needs of soldiers seeking care and the providers and administrative staff I
17
supervise. The caseloads of my providers hover around 70, which is too many to provide
effective treatment. I recently pulled data from my clinic on the top diagnoses being treated. The
top five were occupational stress, relationship stress, attention deficit hyperactivity disorder
(ADHD), adjustment disorder, and substance use disorder. Only three of the top five are clinical
diagnoses from the DSM-5-TR – adjustment disorder, ADHD, and substance use disorder. Two
are often related to stress and a lack of good coping. The coping deficits of Gen Z must be
improved. If Gen Z learns to manage their general stress, they will be less likely to seek
specialized behavioral healthcare, provider burnout will be lessened, and access to care will
improve.
Army leadership does not understand the Gen Z mindset (St Luce, 2022). The Army is
great at reacting to a problem but falls short when the solution requires a proactive and
preventative approach. I see two solutions to this problem: a change in the Army’s approach to
leadership and training. A change in the Army’s leadership style requires systemic change from
the top down, something that I have very little ability to impact. I am a mental and behavioral
health expert, so I have focused on the second solution. This solution describes a prevention
program to be implemented during early recruit training that aims to improve the mental and
behavioral health of Gen Z. It will expose them to and train them to use coping skills before their
stress turns into an insurmountable problem.
Conceptual Lens and Theory of Change
This project aims to help Gen Z soldiers manage their behavioral health through the
principles of self-determination and habituation. Self-determination theory proposes that to
thrive, humans must meet the needs of autonomy, competence, and relatedness (Sheldon et al.,
2003). It focuses on the person’s need for “greater self-ownership of motivated behavior”
18
(Sheldon et al., 2003, p. 17). Habituation occurs when repeated exposure to a stimulus reduces an
elicited response (Groves & Thompson, 1970). When a feared stimulus is present, repeated
exposure to a more adaptive behavioral response is elicited and habituated (Gallagher & Resick,
2012; Groves & Thompson, 1970).
The change process in this capstone project is accomplished when the user reviews their
action plan daily. The concepts become embedded in their cognitive processes creating new
responses to stress and other emotional stimuli. As soldiers repeatedly review their action plans
and have quick and easy access, they use the tools to manage their behavioral health. They
maintain daily wellness, translating into a more positive emotional response to stress. They gain
ownership over the reactive behaviors surrounding their mental health. They achieve self-
determination and self-awareness and improve their self-esteem. This process is shown in the
Logic Model and the Theory of Change (Appendices B and C, respectively).
Project Description
Proposed Solution
This project has been in a pilot phase since September 2022. It is designed to provide
training in coping skills and mental health wellness to Gen Z soldiers, allowing them to take
personal responsibility for managing their behavioral health. The solution aims to improve the
mental and behavioral health of Gen Z soldiers through the Action Planning for Prevention and
Wellness course and app (which is in the conceptual stage). The course content will be included
in Advanced Individual Training (AIT) that every enlisted Army soldier attends. AIT courses
specifically focus on training soldiers in the skills they need to do their job in the Army, but the
courses lack education and training on mental health and coping. Because soldiers are in training
19
and excited about their future in the Army, the AIT course is an opportune time to include
training in coping skills and mental health wellness in the overall AIT curriculum.
This proposed solution draws on research from Boyle (2019), Della Volpe (2022), Katz
et al. (2021), Miller & Bromwich (2019), and Wieland & Kucirka (2020). It embraces the theory
that Gen Z has underdeveloped coping skills due to being rescued by their parents at the onset of
frustration and distress. Gen Z is less likely to take risks than previous generations while growing
up (Della Volpe, 2022; Katz et al., 2021). Apart from being less likely to get a driver’s license,
this may be considered positive, as they are less likely to try alcohol or drugs and date or have
sexual relations. However, Gen Z also does not benefit from parents’ guidance during these
important developmental firsts when they occur after age 18. When Gen Zers enter the Army,
temptations to experience these activities are rampant, and they are left to their own decision-
making. For many, decision-making of this magnitude is not something they are accustomed to
(Wieland & Kucirka, 2020). Making the wrong decision can have catastrophic impacts,
especially in a military environment. Evidenced-based coping skills and prevention programs
supported the concept for this proposed solution.
This project was piloted from September 2022 to December 2022 and again in January
2023 in the United States Army Licensed Practical Nurse course at Joint Base Lewis-McChord
(JBLM), Tacoma, Washington.
Solution Landscape
Existing solutions to this problem are insufficient and aimed only at decreasing suicide
and not reducing the symptoms or issues that lead to suicide. A global review of existing
solutions included how colleges and the military have approached this problem and existing
technology resources. Colleges have responded by increasing their counseling centers,
20
establishing psychoeducational prevention programs, and developing peer support programs
(Acharya et al., 2018; Oehme et al., 2020; Sandra, 2019). Military programs focus on developing
resiliency, suicide prevention, peer support programs (DSPO, n.d.), and professional behavioral
health services. Mental and behavioral health support has been increasing with technology-based
solutions. Colleges and the military have created apps aimed at improving coping skills - Virtual
Hope Box, Mindfulness Coach, PTSD Coach, CBT-I Coach, Ask Ari, and the Mindful USC
mobile app, to name just a few. In a search for coping skills on the iPhone App Store, more than
ninety apps were found to help someone gain or improve coping skills. These technology-based
solutions provide skills to use in moments of distress but do not aim to teach coping skills that
can be accessed of one’s own volition.
The Army Suicide Prevention Program educates and trains personnel on “suicide
prevention and postvention actions to minimize the risk of suicide, including indicators of
potential suicide behavior, intervention strategies, and services and resources (Army Resiliency
Directorate, n.d., “About SP2 [Suicide Prevention]” section).” The program provides resources
and support for soldiers and commanders but does not provide concrete prevention strategies.
The program provides a handbook to unit commanders with concepts related to the engagement
of soldiers and tools to assess risk and protective factors. It provides a framework to commanders
interested in creating a prevention program within their unit, but it is based on theoretical
principles with no concrete tools for action. Embedded in the SP2 program is the ACE: Ask,
Care, Escort program (DSPO, n.d.), which teaches soldiers to identify warning signs of suicide
in their battle buddies and apply the three steps of Ask, Care, Escort to prevent suicide. With the
increased numbers of soldiers seeking behavioral health care and the increased rate of suicide in
the Army, the effectiveness of this program is limited at best.
21
The Master Resilience Training (MRT) program was developed to train soldiers in six
resiliency competencies – self-awareness, self-regulation, optimism, mental agility, strengths of
character, and connection (Army Resilience Directorate, n.d.-b). This program began in 2009 to
help soldiers and families to build resilience during the Global War on Terrorism (Army
Resilience Directorate, n.d.-b). The MRT program teaches the philosophy of resilience but does
not allow for the practice of skills or the long-term assessment of effectiveness. The program
depends on whether a unit
3
has a soldier trained in MRT to train and mentor soldiers. The
program does not reach every soldier, and the concepts are not trained at the beginning of a
soldier’s career.
Army mental health treatment ranges from short-term inpatient stays to residential
treatment programs, but outpatient behavioral health care is the most widely used intervention.
However, the demand for treatment has dramatically exceeded the supply. A report to Congress
in 2022 (H.R. 6395 HASC Report 116-442, 2022, p 150) found that shortages already existed in
2020 and that COVID-19 only exacerbated the problem. The demand for treatment in the Army
was 25% higher in the fiscal year 2022 than in the previous year (Rainier Embedded Behavioral
Health Clinic, 2022), but staffing was 40% lower. This is likely to continue as the effects of
COVID-19 continue to impact the mental health of behavioral health providers (Bernstein,
2022). The increased demand for behavioral health treatment combined with a shortage of
providers increases the chance that soldiers will not get the care they need resulting in the tragic
loss of life.
3
A unit is an organized group of soldiers that are part of the larger Army organization such as a Brigade, Battalion,
or Company. https://www.britannica.com/topic/military-unit
22
Prototype Description
The project is adapted from Mary Ellen Copeland’s guide, Action Planning for
Prevention and Recovery (2003). The guide was created for SAMHSA and is in the public
domain for use and adaptation. The original course designed by Copeland was intended to be
used by people who had struggled with mental health and substance use. The program took the
user through the action planning course, starting with wellness, and ending at crisis, developing a
plan each step of the way to prevent relapse and encourage recovery. The prototype for this
project’s first iteration is in a PDF workbook (Appendix D) for soldiers to use during the Action
Planning for Wellness and Prevention course. The change in title and curriculum follows the
concepts of the original program but stops at the crisis planning stage, making the focus on
wellness and prevention. The course was taught over six one-hour sessions. During each session,
the instructor gave examples of coping mechanisms such as listening to music, going to the gym,
and taking a walk, then explained the concept of habituation and how planning for distressing
emotions is essential to prevent emotions from escalating into crisis. The course guides soldiers
through writing self-identified skills, attributes, and solutions in the workbook. Daily review of
the workbook develops habituation of skills that become automatic responses when increased
emotional distress occurs.
During the first pilot, soldiers reported they could only access the workbook if they were
on a desktop computer. They reported needing something accessible on their phone to use the
plans developed during the course. This discussion led to the suggestion from soldiers that an
app would better accomplish the goal of having their action plans accessible when needed
(Appendix E). Using a digital platform to meet this need is congruent with Gen Z’s use of
technology (Katz, 2021). Current research also supports using technology for behavioral health
23
intervention and support (Boustani, 2021; Hoermann, 2017). The Action Planning for Prevention
and Wellness app has been tested in simulation mode with Gen Z soldiers and has received a
positive response. It has not been tested during the pilot as it is not developed and published.
A second iteration of the course revised Section Five, Crisis Plan, to focus on prevention
rather than reaction (Appendix F). This iteration is in the app’s wireframe. The second iteration
of the course has six sections:
1. Wellness Toolbox
2. Daily Maintenance Plan
3. Triggers
4. Early Warning Signs
5. Breaking Down
6. Supporters.
It is possible that a soldier will become upset and need crisis intervention during both the
instructor-led portion and the individual review of the course materials. There is a structured way
for a soldier to get help in the Army that instructors will initiate if needed during the instructor-
led course. This process is discussed with soldiers, who are reminded that they may request to
speak with an instructor after class. If a soldier becomes triggered during the private review of
their action plans, there is more than one place in the app where soldiers can tap and call 988 the
suicide hotline, or 911 for emergency services. Soldiers are also expected to reach out to their
battle buddies during times of distress for support and assistance. The workbook and the
wireframe for the app contain a list of available resources for additional assistance and support to
soldiers.
24
The design team chose to add mindfulness activities at random during the course. These
received positive feedback. These activities have been added to the in-person course based on
this feedback. Many mental health apps, such as Virtual Hope Box, CBT-I Coach, and
Mindfulness, are available, but none allow users to put their thoughts into a plan. Instead, they
provide coping exercises such as meditation, yoga, mindfulness, deep breathing, and guided
imagery and these activities could be a positive addition to the app. Future iterations of the
workbook and app will include links to these and other coping activities.
Likelihood of Success
After two pilot iterations, soldiers’ feedback reported that they felt the course provided
helpful information and planned to review the workbook and practice the action plans they
wrote. They have not been able to pilot the course using the app, which they have stated is their
preference, but the soldier’s feedback implies that it will be well-received once developed and
implemented. There has not been enough time following the end of the course to measure the
project’s effectiveness on improved coping as the measurements will not occur until six months
following the end of the course which ended in December 2022.
The next step is developing the app. This will start with a meeting with the Defense
Health Agency (DHA) Center of Excellence for Healthcare Technology to pitch the app for
approval for development. If approved, it will be tested in the usability lab and then piloted with
the course. This project will succeed if the Army embraces its value as a behavioral health
prevention tool and implements it in AIT programs throughout the service.
25
Methodology
Human-Centered Design
The design thinking concepts from Liedtka and Ogilvie (2011) were used to guide the
design process of this project. Data from and on the Gen Z Army population was collected to
clarify and understand the problem during the what is phase. During the what if phase,
brainstorming was used to identify ideas for approaching the solution. In the what wows phase,
the prototyping process began and iterated as user feedback occurred. Finally, during the what
works phase, the solution was piloted and iterated based on design partners, stakeholders, and
user feedback.
Much time was spent during the what is phase to understand the problem. The research
was conducted using surveys created in February 2022 using Qualtrics
(https://usc.ca1.qualtrics.com; [Appendix G]) and distributed to the public on social media
platforms Instagram and Facebook. Data was collected from the Gen Z population, the parents of
Gen Z, the Army leaders of Gen Z, and the Army Gen Z population. The results of these surveys
found consistencies in topics across categories: Gen Z’s concerns about their financial future,
healthcare, mental health, and older generations. Gen Z expressed an understanding of both the
positive and negative impacts of social media and the internet but acknowledged its importance
in their lives. They also expressed fears about the country's political and racial divisions and
beliefs about older generations perseverating these problems.
Army leaders of Gen Zers admitted to having limited insight into Gen Z soldiers. Their
surveys revealed that they want to understand and know how to lead them better. Their surveys
also expressed frustration with the lack of coping skills observed among Gen Z soldiers. Surveys
of parents revealed a combination of results between Gen Z leaders and Gen Z soldiers.
26
An interview with Mr. John Della Volpe, director of polling at the Harvard Kennedy
School Institute of Politics and Author of Fight: How Gen Z is Channeling Their Fear and
Passion to Save America (2022), was conducted in February 2022. Mr. Della Volpe coordinates
and directs widespread polling initiatives on understanding youth and is considered an expert on
youth’s opinion, influence, and understanding of digital and social media. The interview
contained themes consistent with survey responses and literature reviews.
During the what if phase, brainstorming of potential solutions occurred using the solution
landscape uncovered during the what is phase. A global view of solutions began this phase,
focusing on solutions used in suicide prevention and treatment utilizing technology.
Consideration of how other entities, such as colleges and the military, have responded to the Gen
Z mental health crisis was also considered during this phase. The design team was an integral
contributor to this phase of the project.
The what if phase identified the need to focus on the underdeveloped coping skills of Gen
Z (APA, 2018; St Luce, 2022). Two areas of potential solutions were developed: one focusing on
Gen Z coping skills and another focusing on changing the leadership climate in the Army. Due to
the project’s time constraints, the what wows phase focused on prototype development to
improve coping skills in Gen Z. What wows and what works are thoroughly described in the
Project Description and Implementation sections, respectively.
This project will continue to iterate as the what works phase moves forward with the
design team, stakeholders, and Army leader feedback.
Design Criteria
The design criteria that guided this project can be found in Appendix H.
27
Implementation Strategy
Implementation Plans
Methods for Assessment
As stated earlier, the project's primary objective is to improve the mental and behavioral
health of Gen Z soldiers. The development and use of coping skills will be evidenced by
decreasing levels of severity on given screeners. At the beginning of the instructor-led course,
baseline screening will be conducted to gather each soldier's emotional functioning level using
the Behavior and Symptom Identification Scale 24, BASIS-24 (Eisen et al., 2004; Appendix I)
and the Response to Stressful Experiences Scale, RSES, (Johnson et al., 2008; Appendix j). The
instructors will screen for suicide severity using The Columbia Suicide Severity Rating Scale, C-
SSRS (Posner, n.d.; Appendix K). Each screening tool is available through the Department of
Defense and the VA National Center for PTSD. Soldiers scoring high (2 or higher) on the C-
SSRS will be referred to the behavioral health clinic for risk assessment to ensure no imminent
suicide risk is present. A soldier referred for risk assessment will not be excluded from the
course and will be encouraged to seek behavioral health treatment. These scales will be
conducted again six months after course completion to assess for skills habituation. Improvement
will be noted when the scores reach the sub-clinical level of the scale. Any soldier scoring in the
sub-clinical range at the six months post-course survey will be considered to have habituated
their coping skills. The sub-clinical scores on the screeners are as follows: a) BASIS-24 is 1.09 or
less out of 4.00 (Eisen et al., 2004), b) RSES is a score of 15 to 16 (Johnson et al., 2008), where
lower scores indicate less resiliency, and c) the C-SSRS is 0 (Posner, n.d).
Two long-term goals that are difficult to measure but essential to address are the use of
the app and the decline in the rate of suicide in the Gen Z soldier population. To measure the use
28
of the app, the app development team will embed analytics that will track how many times and
how often an individual uses the app. Successful utilization of the app would be daily, as the
prototype prescribes.
The suicide rate is tracked by the Department of Defense quarterly (DSPO, 2022). While
it would be impossible to make a correlation between the use of the app and a decline in deaths
by suicide, the program, workbook, and app are additional prevention initiatives that, if
implemented in all AIT programs Army-wide, may contribute to lowering the suicide rate and
saving lives.
Financial Plan
This course and app are specifically being developed for the military. The cost to
develop, test and publish an app in the military is embedded in the military’s research and
development budget. The process involves (a) presenting the app concept to the DHA
Psychological Technology Center of Excellence, (b) receiving approval of the app concept for
development, (c) development of the app to DHA standards, (d) usability testing, (e) revisions as
needed, (f) advertisement and publishing, and (g) sustainment. This process can take years to
complete. Keeping this in mind, the project will continue with the PDF workbook with pre-and
post-assessments to measure mental and behavioral health improvement in Gen Z soldiers. The
costs associated with the workbook are the instructors’ time and copy paper. Depending on who
instructs the course, this cost could range from $24 to $65 per hour. These costs are embedded in
the Army healthcare budget, as is the cost of copy paper. See Appendix L for a theoretical
breakdown of the costs of this program.
The cost of this app’s development for this author is a monthly fee of $29 on the
JustInMind website (https://www.Justinmind.com). In the civilian sector, most apps are
29
developed through online companies that help clients make and customize apps. They charge
anywhere from $54 (https://www.Justinmind.com) to $199+ monthly (https://crowdbotics.com).
The price depends on the app's complexity and how long the services are used. These costs are
inclusive of maintaining and upgrading the app. The human cost of app development is time and
knowledge. The time associated with developing and iterating the current app was approximately
40 hours, mainly due to the steep learning curve for the author. The costs to publish an app range
from $25 per app on the Google Play Store to $99 yearly on the Apple Store. It is essential to
publish an app in a public space to achieve widespread use.
Plans for Stakeholder Involvement
The LPN AIT instructors at JBLM have expressed a desire for this course to continue in
every subsequent group of AIT trainees. With the assistance of ancillary staff, the course will
remain available to any AIT program that desires it. Instructors of AIT soldiers will continue to
provide feedback and encourage other AIT programs to adopt this project into their schedules.
Other important stakeholders include behavioral health leadership, the installation risk
prevention team, and the installation leadership. Ongoing meetings and presentations will be
scheduled to educate and disseminate the value of Action Planning for Prevention and Wellness
to gain their support to implement this project into all AIT programs on the installation.
Iterations of the course will continue as feedback is gained from Gen Z soldiers and leaders.
Communication Strategies
Communication on the need to improve the mental and behavioral health of Gen Z
soldiers has been ongoing since the return to work after the COVID-19 lockdown. Continuing
communication with leaders regarding the differences between Gen Z soldiers and older
generations will be essential to move this project forward. Leadership professional development
30
opportunities are avenues to discuss Gen Z soldiers and the leadership’s impact on their
behavioral health. These professional development discussions occur within various units
quarterly, and it will be necessary to be available when the opportunity is presented.
Continued communication with local Army leaders will keep the project moving forward.
Through word of mouth about the program’s merits, other AIT programs will become aware of it
as a possible addition to their curriculum. The need for higher-level leadership support presents
challenges to this project that are described below.
Challenges
The challenge of attitude and understanding Gen Z is ever-present. As recent as last fall,
it was evident that there continues to be a lack of understanding of this generation. In an
interview with The Spokesman Review in September 2022 (Slayton, 2022; Welsch, 2022),
Lieutenant General Xavier Brunson, the Commanding General of JBLM, stated, “Some of the
challenges we have are obesity, we have pre-existing medical conditions, we have behavioral
health problems, we have criminality, people with felonies, and we have drug use. This is not an
Army problem; this is an American problem.” It was noted by Slayton (2022) that this quote
directly contrasted Army Secretary Christine Wormuth and Chief of Staff General James
McConville’s statements in a memo in July 2022, where they touted that the Army must “find
more ways to make the Army more attractive to young Americans.” While both sets of
statements may be partially true, neither considers what Gen Z says about the world and how it
impacts their behavioral health. The Army’s strict rules, regulations, and structure are in direct
contrast to how Gen Z was raised. The project cannot scale until widespread support among
high-ranking leaders has occurred.
31
The most pressing challenge, however, is getting the app developed and published. This
process, as noted earlier, can be very lengthy in the military system. In the civilian sector,
financing the app may be a barrier to success; in the military, the process is the barrier. Working
through the process will require leadership support. Support from healthcare leadership is
already present, as is proven by the involvement of current stakeholders. Support from leaders
higher up the chain of command will take longer and may be harder to gain.
Ethical Considerations
Ethical considerations in this project involve the potential risk of harm to the user. During
the daily review of their action plans, users may become triggered. This could lead to the need
for emergency intervention. The use of the app is an autonomous choice made by the individual.
The app provides direct links to emergency services so the user can request immediate help.
Suicide and mental health problems impact all races, ethnicities, and genders (NIHM,
n.d.). This project can benefit any group, but currently, only Army soldiers will have access to it.
Conclusion
Advancing the Next Steps
An essential step in scaling this project is gaining the support of a broader range of
stakeholders. Meeting with and pitching the program to the JBLM command team will be
necessary. The mentor involved in this project will be a critical element in the success of the
pitch to leadership. The scaling of the project will only occur if the pitch succeeds, and approval
is granted by senior leadership.
Once installation leadership approves, the next step will be to pitch this program to the
prevention team, whose mission is to provide risk prevention activities to soldiers and leaders on
JBLM. Prevention is not typically a healthcare function in the military. As this project has been
32
developed as a prevention program, it would best be delivered by the JBLM risk prevention
team. Should the prevention team choose not to use this project, the behavioral health team can
embed it into the treatment process, adding prevention to its repertoire of resources.
A vital next step is to proceed with the second proposed solution to this problem. It is to
add course content to the leadership courses that all Army leaders attend. A review of these
courses found that no course content educates junior leaders on the mental and behavioral health
problems their subordinates may experience while under their leadership (Non-Commissioned
Officer Leadership Center of Excellence, n.d.). Army leadership courses also lack training in
transformational leadership. This leadership style is considered the most effective at developing
a team mindset, which is required for the Army to complete its missions. Developing content to
be added to Army leadership courses in these areas will help all leaders be more effective and
will keep the military in a state of readiness with the ability to meet its mission. This proposed
solution is consistent with a set of recommendations made by the Suicide Prevention and
Response Independent Committee (2023) in their publication Preventing Suicide in the U.S.
Military: Recommendations from the Suicide Prevention and Response Independent Review
committee. Recommendations 5.5 and 5.6 suggest adding skills training on transformational
leadership and navigating difficult conversations to leadership courses across the military.
Implications for Practice and Future Use
A review of Blueprints for Healthy Youth Development (n.d.), a project at the
University of Colorado that provides a registry of evidence-based interventions designed to
“reduce antisocial behavior and promote a healthy course of youth development and adult
maturity, “ yielded sixty-seven programs listed in their prevention registry. Only thirteen have
demonstrated efficacy for change over time and are recommended for large-scale
33
implementation. The other fifty-four programs are in the “promising” range, which means they
show promise for efficacy but not for large-scale implementation. After testing this with
proposed outcome data, this project could be added to this and other program registries to
provide mental health and prevention service providers with more options.
This project will not solve the problem of suicide or mental health problems in the Army
Gen Z population, but it will add a missing step to the solution. Currently, no prevention
programs exist that effectively teach general coping skills on a large scale. Most coping skill
programs are implemented after identifying a mental health problem. This project acknowledges
the characteristics of a generation of youth who need to learn coping skills to succeed in the
Army. If this project is implemented throughout AIT programs, a generation of youth may be
better equipped to combat life’s frustrations, and lives may be saved.
34
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42
Appendix A
Stakeholder Map
43
Appendix B
Logic Model and Theory of Change
44
Appendix C
Theory of Change
50
Appendix D
Action Planning for Prevention and Wellness Workbook
Action Planning
for Prevention and Wellness
Rainier Embedded Behavioral Health
Behavioral Health Service Line
Madigan Army Medical Center
51
Introduction
An action plan for prevention and wellness works because it is easy to
develop and easy to use. YOUR plan—developed by you with assistance and
support from others—directly addresses the feelings, symptoms,
circumstances, and events that are most troubling to you and lists actions to
respond to them.
You may want to review and revise your plan as you learn new things about
yourself and ways you can help yourself feel better. You may want to carry
this plan, or parts of it, with you so you can refer to it if triggers or symptoms
come up when you are away from home.
People who have an action plan usually find that they have fewer difficult times and that
when
they do have a hard time, it’s not as bad as it used to be and does not last as
long. A plan of action will renew your sense of hope that things can and will
get better. You have control over your life and the way you feel. Start
planning!
* This workbook was designed to be used independently or with “Action
Planning for Prevention and Recovery, A Self-Help Guide,” produced by the
U.S. Department of Health and Human Services (DHHS), Substance Abuse
and Mental Health Services Administration (SAMHSA), Center for Mental
Health Services (CMHS), and prepared by Mary Ellen Copeland, MS, MA,
under contract number 99M005957. Acknowledgement is given to the many
mental health consumers who worked on this project offering advice and
suggestions.
52
Wellness Toolbox
Develop a Wellness Toolbox. List the things you use to help yourself feel better when
you are having a hard time. Ideas for your Wellness Toolbox include eating healthy,
drinking plenty of water, getting to bed at a good regular time, doing something you
enjoy, exercising, doing a relaxation exercise, writing in your journal, talking to a
friend, and taking medications, as well as vitamins, and other food supplements. Ask
your friends and family members for suggestions and self-help resource books. The
toolbox works best if you have a lot of choices. Continue over time to add ideas to
your Wellness Toolbox and cross off ideas that no longer work for you.
Remember to review your plan regularly. Cross out items that stop working for you
and add new items as you think of them. Tear out pages and/or use extra sheets if
you need them. You will be surprised how much better you feel after taking these
positive steps on your own behalf.
53
SECTION 1: DAILY MAINTENANCE PLAN
Feeling Well. Describe yourself when you are feeling all right. If you can’t
remember, or don’t know how you feel, describe how you would like to feel.
Make it easy. Some descriptive words might include bright, talkative,
outgoing, energetic, humorous, reasonable, argumentative. When you aren’t
feeling well, you can refer back to how you want to feel.
WHEN I’M FEELING WELL
54
Dreams and Goals. Make a list of goals you could work toward. Write down
far-fetched and easily achievable ones. It is really helpful to remember your
goals and dreams, so you always have something to look forward to. Then
write the steps to take to achieve them. Make these steps part of your daily
maintenance plan.
DREAMS/GOALS STEPS TO TAKE
55
Daily List. Describe the things you need to do every day to maintain your
wellness. Use your Wellness Toolbox for ideas. Writing things down and
reminding yourself daily to do them is an important step toward wellness.
When you start to feel “out of sorts,” you can often trace it back to “not
doing” something on the list. Make sure you don’t put so many things on
this list that you couldn’t possibly do them all. This is a list of things you
must do, not things you would choose to do. Examples of things to write include: eat
three healthy meals and three healthy snacks; drink at least 8 ounces of water; get exposure to outdoor
light for at least 30 minutes; take medications and vitamin supplements; have 20 minutes of
relaxation or meditation time; write in my journal; spend at least half an hour enjoying an activity;
and check in with my partner and with myself.
THINGS I MUST DO TO MAINTAIN WELLNESS
56
Reminder List. Make a reminder list for yourself of things you might need
to do. Check the list each day to be sure that you do those things that you
need to do sometimes to keep yourself well. Remembering important but
occasional tasks will help you avoid the stress that comes from forgetting.
Include things on this list such as: set up an appointment with one of my
health care professionals; spend time with a friend or be in touch with my
family; do peer counseling; do some housework; buy groceries; do the
laundry; have some personal time; plan something fun; write some letters;
and go to a support group.
DO I NEED TO?
57
SECTION 2: TRIGGERS
Identifying Triggers. Write down those things that, if they happen, might
increase your symptoms. They might be things that triggered your symptoms
in the past. Continue to add triggers to your list as you become aware of them.
Some examples of common triggers are: anniversary dates of losses or trauma;
frightening news events; feeling overwhelmed; family friction; the end of a
relationship; spending too much time alone; being judged, criticized, teased,
or put down; financial problems; physical illness; sexual harassment; being
yelled at; exposure to anything that makes you uncomfortable; being around
someone who has treated you badly; and certain smells, tastes, or noises.
TRIGGERS
58
Triggers Action Plan. List what you can do if a trigger comes up to comfort
yourself and keep your reactions from becoming more serious symptoms.
Include tools that have worked for you in the past and new ideas. Refer back
to your Wellness Toolbox. Your plan might include: make sure I do
everything on my daily maintenance list; call a support person and talk
through the situation; do a relaxation exercise; spend at least a half hour
writing in my journal; exercise; pray; work on a fun activity for an hour.
Keep looking for and trying new ideas until you find what is the most helpful.
Learn new tools in workshops and lectures, by reading self-help books, and
by talking to providers and others who experience similar symptoms.
TRIGGERS ACTION PLAN
59
SECTION 3: EARLY WARNING SIGNS
Identify Early Warning Signs. List early warning signs you noticed in yourself
in the past. How do you feel when you know you are not feeling quite right?
How did you feel right before you had a hard time in the past or when you
noticed that your habits or routines changed? Your early warning signs might
include: anxiety; nervousness; forgetfulness; inability to experience pleasure;
lack of motivation; feeling slowed down or speeded up; being uncaring;
avoiding others; being obsessed with something that doesn’t really matter;
irrational thought patterns; feeling unconnected to your body; increased
irritability or negativity; and changes in appetite.
EARLY WARNING SIGNS
60
Early Warning Signs Action Plan. Develop a plan for responding to your
early warning signs. Refer to your Wellness Toolbox for ideas. Some of the
things you list may be the same as those you wrote on your Triggers Action
Plan. If you notice these symptoms, take action while you still can. The
following is a sample plan for dealing with early warning signs: do my daily
maintenance tasks whether I feel like it or not; tell a supporter how I am
feeling; do at least three relaxation exercises daily; write in my journal at
least 15 minutes every day; do an activity I enjoy at least an hour every day;
and ask others to take over my household responsibilities for the day. Revise
or re-write your list until you have a plan that helps you feel better.
EARLY WARNING SIGNS ACTION PLAN
61
SECTION 4: WHEN THINGS ARE BREAKING
DOWN
When Things Are Breaking Down or Getting Worse. Make a list of symptoms
that tell you that things are getting worse. Remember that symptoms and
signs vary from person to person. What may mean “things are getting much
worse” to one person may mean “crisis” to another. Your signs or symptoms
might include: feeling oversensitive and fragile; responding irrationally to
events and the actions of others; feeling very needy; being unable to sleep;
sleeping all the time; avoiding eating; wanting to be totally alone; substance
abusing; taking anger out on others; chain smoking; and eating too much.
WHEN THINGS ARE BREAKING DOWN
62
Action Plan for When Things are Breaking Down or Getting Worse. Write an
action plan that you think will help reduce your symptoms when they have
progressed to this point. The plan now needs to be very direct, with fewer
choices and very clear instructions. Some ideas for an action plan are: call
my health care professional; talk to my supporters; arrange for someone to
stay with me until my symptoms subside; get help right away if my symptoms
worsen; do everything on my daily checklist; take time off from any
responsibilities; have at least two peer counseling sessions; do three relaxation
exercises; and ask to have medications checked. Always look for new tools
that might help you through difficult situations. Revise your plan as needed.
ACTION PLAN TO REDUCE SYMPTOMS
63
SECTION 5: CRISIS PLAN
In spite of your best planning and assertive action on your own behalf, you
could find yourself in a situation where others will need to take responsibility
for your care. A written clear crisis plan instructs others how to care for you
when you are not well and helps you maintain responsibility for your own
care.
Part 1. Feeling Well. Write what you are like when you are well. You can
copy from your Daily Maintenance Plan. This can educate the people trying
to help you. Writing down what you are like when you are well might help
someone who knows you well understand you a little better, and for someone
who doesn’t know you well—or at all—it is very important.
PART 1. FEELING WELL
64
Part 2. Symptoms. Describe symptoms that would indicate to others that they need to be
responsible for you and make decisions on your behalf. A careful, well-developed description of
symptoms that indicate that you can’t make smart decisions anymore will allow you to stay in
control. Be very clear and specific. Your list might include: being unable to recognize or
identify family and friends; uncontrollable pacing; inability to sit still; neglecting personal
hygiene (for how many days?); not cooking or doing housework (for how many days?); not
understanding what people are saying; thinking I am someone I am not, or that I have the ability
to do something I don’t; displaying abusive, destructive, or violent behavior; and substance
abusing.
PART 2. SYMPTOMS
65
Part 3. Supporters. List the people you want to take over for you when the symptoms you listed in
the previous section arise. Before you list someone, talk with him or her about your plan and what
you’d like from them. Make sure they understand and agree to be in the plan. Include the family
members, friends, or heath care providers who are committed to following your written plan. List
at least five people to make sure you have enough help available when you need it. You may
want to list the people you don’t want to be involved in your care and include a section that
describes how to settle possible disputes between supporters.
PART 3. SUPPORTERS
66
Part 4. Health Care Providers and Medications. List the information related to
your providers and your medications as described below. Use more paper if
needed.
PART 4. HEALTH CARE PROVIDERS AND MEDICATIONS
Physician: Phone:
Pharmacist: Phone:
NCO: Phone:
Commander/1SG: Phone:
Behavioral Health Clinic: Phone:
List the medications you are currently using, the dosage, and why you are using them:
List medications you would prefer to take if medications or additional medications became necessary—like those
that have worked well for you in the past—and why you would choose them:
67
PART 4. HEALTH CARE PROVIDERS AND MEDICATIONS (continued)
List the medications that would be acceptable to you if medications became necessary and why you would
choose them:
List the medications that must be avoided—like those you are allergic to, that conflict with
another medication, or cause undesirable side effects—and give the reasons why:
List any vitamins, herbs, alternative medications, and supplements you are taking. Note which should be
increased/decreased if you are in crisis, and which are not good for you.
68
YOU DID IT!
You’ve now completed your action plan for prevention and recovery. Review it
regularly. Update it when you learn new information or change your mind about
things. Date your plan each time you change it and give revised copies to your
supporters. Signing your plan in the presence of two witnesses may ensure that
your plan will be followed.
Having a strong team of supporters is so important. Distributing your crisis
plan to your supporters and discussing it with them is absolutely essential to
your safety and well-being.
Resources:
988 - Suicide Hotline (text or call); 911 - emergency services
JBLM Resource Finder: https://www.madigan.tricare.mil/counseling
69
Appendix E
Action Planning for Prevention and Wellness App Wireframe (justinmind.com)
Link will be sent to the Committee for the Oral Defense presentation.
Action planning
prototype wirefram.vp
St Luce App prototype
Screen 1
Interactions
1 on Click: goes to 'Introduction' →
70
01. Screens / St Luce App prototype
Introduction
Interactions
2 on Click: goes to 'Wellness Toolbox' →
71
01. Screens / St Luce App prototype
Wellness Toolbox
Interactions
3 on Click: goes to 'Daily Maintenance Plan' →
7 on Click: goes to 'Screen 1' →
72
01. Screens / St Luce App prototype
Daily Maintenance Plan
Interactions
8 on Click: goes to 'Dreams and Goals' →
9 on Click: goes to 'Feeling Well' →
10 on Click: goes to 'Daily List' →
11 on Click: goes to 'Reminders List' →
13 on Click: goes to 'Triggers' →
73
01. Screens / St Luce App prototype
Feeling Well
Interactions
15 on Click: goes to 'Dreams and Goals' →
16 on Click: goes to 'Screen 1' →
74
01. Screens / St Luce App prototype
Dreams and Goals
Interactions
17 on Click: goes to 'Daily Maintenance Plan' →
18 on Click: goes to 'Daily List' →
19 on Click: goes to 'Screen 1' →
75
01. Screens / St Luce App prototype
Daily List
Interactions
20 on Click: goes to 'Wellness Toolbox' →
21 on Click: goes to 'Daily Maintenance Plan' →
22 on Click: goes to 'Reminders List' →
23 on Click: goes to 'Screen 1' →
76
01. Screens / St Luce App prototype
Reminders List
Interactions
24 on Click: goes to 'Triggers' →
25 on Click: goes to 'Daily Maintenance Plan' →
26 on Click: goes to 'Screen 1' →
77
01. Screens / St Luce App prototype
Triggers
Interactions
27 on Click: goes to 'Identifying Triggers' →
28 on Click: goes to 'Triggers Action Plan' →
30 on Click: goes to 'Early Warning Signs' →
31 on Click: goes to 'Screen 1' →
78
01. Screens / St Luce App prototype
Identifying Triggers
Interactions
32 on Click: goes to 'Triggers' →
33 on Click: goes to 'Triggers Action Plan' →
34 on Click: goes to 'Screen 1' →
79
01. Screens / St Luce App prototype
Triggers Action Plan
Interactions
35 on Click: goes to 'Wellness Toolbox' →
36 on Click: goes to 'Early Warning Signs' →
38 on Click: goes to 'Screen 1' →
80
01. Screens / St Luce App prototype
Early Warning Signs
Interactions
39 on Click: goes to 'Identify Early Warning Signs' →
40 on Click: goes to 'Warning signs action plan' →
41 on Click: goes to 'Wellness Toolbox' →
43 on Click: goes to 'Identify Early Warning Signs' →
44 on Click: goes to 'Screen 1' →
81
01. Screens / St Luce App prototype
Identify Early Warning Signs
Interactions
45 on Click: goes to 'Early Warning Signs' →
46 on Click: goes to 'Warning signs action plan' →
47 on Click: goes to 'Screen 1' →
82
01. Screens / St Luce App prototype
Warning signs action plan
Interactions
48 on Click: goes to 'Wellness Toolbox' →
49 on Click: goes to 'Triggers Action Plan' →
50 on Click: goes to 'Breaking Down' →
83
01. Screens / St Luce App prototype
Breaking Down
Interactions
52 on Click: goes to 'Symptoms' →
53 on Click: goes to 'Reduce symptoms' →
55 on Click: goes to 'Symptoms' →
56 on Click: goes to 'Reduce symptoms' →
57 on Click: goes to 'Screen 1' →
84
01. Screens / St Luce App prototype
Symptoms
Interactions
58 on Click: goes to 'Breaking Down' →
59 on Click: goes to 'Reduce symptoms' →
60 on Click: goes to 'Screen 1' →
85
01. Screens / St Luce App prototype
Reduce symptoms
Interactions
61 on Click: goes to 'Plan' →
63 on Click: goes to 'Screen 1' →
86
01. Screens / St Luce App prototype
Plan
Interactions
64 on Click: goes to 'Triggers Action Plan' →
65 on Click: goes to 'Warning signs action plan' →
67 on Click: goes to 'Supporters page' →
68 on Click: goes to 'Screen 1' →
87
01. Screens / St Luce App prototype
Supporters page
Interactions
70 on Click: goes to 'Important Numbers' →
71 on Click: goes to 'Screen 1' →
88
01. Screens / St Luce App prototype
Important Numbers
Interactions
73 on Click: goes to 'Resources' →
89
01. Screens / St Luce App prototype
Resources
Interactions
80 on Click: goes to 'End' →
90
01. Screens / St Luce App prototype
End
Interactions
83 on Click: goes to 'Introduction' →
91
Appendix F
Action Planning for Prevention and Wellness App Contents
1. Wellness Toolbox: Students identify and list what they do to help themselves feel better
when struggling. This list is individualized to the person and can and should often change
as their needs change.
2. Daily Maintenance Plan: This section should be reviewed daily to embed it into memory.
a. Feeling Well: Students use descriptive words to identify how they know when
they are feeling all right.
b. Dreams and Goals: Student will write their dreams and what they will need to do
to accomplish them, the goals that will help them reach their dreams which helps
them to have something with which to look forward.
c. Daily List: Students will list what they must do daily to stay well, such as taking
medicine, eating healthy, and exercising.
d. Reminders List: Students will write a list of things they might need to do. This list
could change daily depending on what they need to do. Keeping a list helps
reduce stress and feelings of being overwhelmed.
3. Triggers: This section explains triggers and how they impact daily functioning when they
are not recognized and reacted to appropriately. This section helps the student become
more aware of their triggers and develop a plan to avoid or deal with them, ultimately
increasing the ability to cope and keep from symptoms becoming more severe.
a. Identifying Triggers: Students will make a list of things that may occur that cause
their symptoms to get worse.
b. Trigger Action Plan: Students will develop a plan to calm themselves and keep
their symptoms from becoming more severe when triggered.
4. Early Warning Signs: Students will learn how to recognize internal warning signs that
may signal to them that they may need to take more action to prevent their symptoms
from worsening.
a. Identifying Early Warning Signs: Students will list warning signs they have
noticed that occur when they are not feeling all right or just before they have a
difficult time.
b. Early Warning Sign Action Plan: Students will develop a plan to prevent their
symptoms from worsening. Many of the items on this plan will be the same as
their Trigger Action Plan and are in their Wellness Toolbox.
92
5. When Things are Breaking Down: This section describes the signs that symptoms are
getting close to a “crisis” or may already be in a “crisis,” and something must be done
immediately.
a. Symptoms: Students list signs and symptoms that signal they need immediate
action and help.
b. Plan to Reduce Symptoms: Students write a plan to reduce their symptoms, often
involving others to help them.
c. Identifying Supporters: Students will list the people in their lives whom they can
trust to help them through a difficult time or get them to emergency help if
needed.
d. Identifying Important Information; Students will list important people and phone
numbers, medications they take, and any allergies.
e. Further Resources: A list of resources the student can access beyond the app or
PDF.
6. Supporters
93
Appendix G
Gen Z Survey
Q1 What is your age?
________________________________________________________________
Q2 What is your Gender Identity?
________________________________________________________________
Q3 What is your Race?
________________________________________________________________
Q4 What is your Ethnicity?
________________________________________________________________
Q5 1. How do you describe depression? (check all that apply)
▢ Feeling Sad (1)
▢ Thoughts of wanting to be dead (2)
▢ Wishing your situation was different (3)
▢ Having no hope for the future (4)
▢ Feeling helpless in your situation (5)
▢ Other (6) ________________________________________________
Q6 Have you ever been depressed?
o No (1)
o Yes (2)
Q7 Do you have friends who say they are depressed?
o No (1)
o Yes (2)
Q8 Do you have friends you think are depressed but they don't say anything about it?
o No (1)
o Yes (2)
Q9 Have you ever been the victim of sexual assault or rape?
o Yes (1)
o No (2)
Q10 Do you know someone who has been the victim of sexual assault or rape?
o Yes (1)
94
o No (2)
Q11 Do you know someone who has ever had suicidal thoughts?
o No (1)
o Yes (2)
Q12 Have you ever had suicidal thoughts?
o No (1)
o Yes (2)
Q13 Do you know someone who has attempted suicide?
o No (1)
o Yes (2)
Q14 Have you ever attempted suicide?
o No (1)
o Yes (2)
Q15 What do you do when you feel depressed or anxious?
________________________________________________________________
Q16 Do you share your feelings of depression or anxiety with a parent or trusted adult?
o No (1)
o Yes (2)
Q17 Are you open with your parent or trusted adult about your problems or things that trouble you?
o No (1)
o Yes (2)
Skip To: Q18 If Are you open with your parent or trusted adult about your problems or things that trouble you? =
No
Q18 Why?
________________________________________________________________
Q19 Do you prefer online social interaction or face-to-face social interaction?
o Online social interaction (1)
o Face-to-face social interaction (2)
Skip To: Q20 If Do you prefer online social interaction or face-to-face social interaction? = Online social interaction
Skip To: Q21 If Do you prefer online social interaction or face-to-face social interaction? = Face-to-face social
interaction
Q20 Why?
________________________________________________________________
95
Q21 Why?
________________________________________________________________
Q22 Do you think social media has a positive or negative impact on your life?
o Positive (1)
o Negative (2)
Skip To: Q23 If Do you think social media has a positive or negative impact on your life? = Positive
Skip To: Q24 If Do you think social media has a positive or negative impact on your life? = Negative
Q23 Why?
________________________________________________________________
Q24 Why?
________________________________________________________________
Q25 Which of the following substances have you used?
o None (1)
o Alcohol (2)
o Tobacco (3)
o Marijuana (4)
o Cocaine (5)
o Heroine (6)
o MDMA (7)
o LSD (8)
o Spice (9)
o other (10) ________________________________________________
Q26 Do you want to get married in your future?
o Definitely not (1)
o Probably not (2)
o Might or might not (3)
o Probably yes (4)
o Definitely yes (5)
Q27 Do you want to have children?
o Definitely not (1)
o Probably not (2)
o Might or might not (3)
96
o Probably yes (4)
o Definitely yes (5)
Q28 Do you feel proud to be an American? or if you are not American born, do you feel proud to live in America?
o Definitely not (1)
o Probably not (2)
o Might or might not (3)
o Probably yes (4)
o Definitely yes (5)
Q29 What do you think are the biggest challenges facing America?
________________________________________________________________
Q30 Do you worry about how these problems will impact your future?
o No (1)
o Yes (2)
Q31 What is the biggest challenge you face in your future?
________________________________________________________________
Q31 What do you think older generations need to know about your generation, Gen Z?
Q33 Do you identify as LGBTQAI++?
o No (1)
o Yes (2)
Skip To: Q34 If Do you identify as LGBTQAI++? = Yes
Q34 What is the biggest challenge you face?
Military Leaders of Gen Z
What is your Age? Click to write the question text
o Under 18 (1)
o 18 - 24 (2)
o 25 - 34 (3)
o 35 - 44 (4)
o 45 - 54 (5)
o 55 - 64 (6)
o 65 - 74 (7)
o 75 - 84 (8)
o 85 or older (9)
97
Q2 What is your gender identity?
o Male (1)
o Female (2)
o Non-binary / third gender (3)
o Prefer not to say (4)
Q3 What is your ethnicity?
o White (1)
o Black or African American (2)
o American Indian or Alaska Native (3)
o Asian (4)
o Native Hawaiian or Pacific Islander (5)
o Other (6) ________________________________________________
Q4 What is your time in service?
________________________________________________________________
Q5 What is the biggest issue you face leading service members in the Gen Z generation (those between 18 and 26
years old)?
Q6 Do traditional military disciplinary actions achieve the desired result in Gen Z service members?
o Never (1)
o Sometimes (2)
o About half the time (3)
o Most of the time (4)
o Always (5)
Q7 Is this the same or different than previous generations?
o Same (1)
o Different (2)
o Not sure (3)
Q8 In your experience, what motivates Gen Z service members to succeed?
________________________________________________________________
Q9 Do you think technology has had a positive or negative impact on the mental health of Gen Z service members?
o Extremely negative (1)
o Somewhat negative (2)
o Neither positive nor negative (3)
98
o Somewhat positive (4)
o Extremely positive (5)
Q10 Why did you choose this answer?
________________________________________________________________
Q11 So you think social media has had a positive or negative impact on Gen Z service members?
o Extremely negative (1)
o Somewhat negative (2)
o Neither positive nor negative (3)
o Somewhat positive (4)
o Extremely positive (5)
Q24 Why did you choose this answer?
________________________________________________________________
Q12 Have you had to manage mental health issues in Gen Z service members?
o No (1)
o Yes (2)
Q13 Have you had to manage suicidal ideation in Gen Z service members?
o No (1)
o Yes (2)
Q14 Has one of your Gen Z service members completed suicide?
o No (1)
o Yes (2)
Q15 Have you experienced Gen Z service members being supportive of each other during times of distress?
o No (1)
o Maybe (2)
o Yes (3)
Q16 What do you think helps Gen Z service members cope during times of distress?
________________________________________________________________
Q17 Gen Z service members are more mature than previous generations.
o Strongly disagree (1)
o Somewhat disagree (2)
o Neither agree nor disagree (3)
99
o Somewhat agree (4)
o Strongly agree (5)
Q18 Gen Z service members are more inclusive of racial diversity than previous generations.
o Strongly disagree (1)
o Somewhat disagree (2)
o Neither agree nor disagree (3)
o Somewhat agree (4)
o Strongly agree (5)
Q19 Gen Z service members are more inclusive of gender identity diversity than previous generations.
o Strongly disagree (1)
o Somewhat disagree (2)
o Neither agree nor disagree (3)
o Somewhat agree (4)
o Strongly agree (5)
Q20 Gen Z service members are more inclusive of sexual orientation diversity than previous generations.
o Strongly disagree (1)
o Somewhat disagree (2)
o Neither agree nor disagree (3)
o Somewhat agree (4)
o Strongly agree (5)
Q21 What advantages do you think Gen Z service members have compared to previous generations?
________________________________________________________________
Q22 What disadvantages do you think Gen Z service members have compared to previous generations?
________________________________________________________________
Q23 Gen Z service members are more difficult to lead than previous generations.
o Strongly disagree (1)
o Somewhat disagree (2)
o Neither agree nor disagree (3)
o Somewhat agree (4)
o Strongly agree (5)
Q25 Why did you choose this answer?
________________________________________________________________
100
Q26 Do you think you understand Gen Z service members?
o Definitely not (1)
o Probably not (2)
o Might or might not (3)
o Probably yes (4)
o Definitely yes (5)
Q27 What do you want to understand better about Gen Z service members?
Q28 What do you think the military needs to understand about Gen Z service members in order to fulfill the
military's mission?
________________________________________________________________
Gen Z parents Survey
Q1 What is your age?
o 35 - 44 (1)
o 45 - 54 (2)
o 55 - 64 (3)
o 65 - 74 (4)
o 75 - 84 (5)
o 85 or older (6)
Q2 What is your gender identity?
o Male (1)
o Female (2)
o Non-binary (3)
Q3 What is your race?
________________________________________________________________
Q4 What is your ethnicity?
________________________________________________________________
Q5 How old is your Gen Z? (born between 1995 and 2012)
________________________________________________________________
Q6 What is the biggest issue you face when parenting your Gen Z?
________________________________________________________________
Q7 What motivates your Gen Z to succeed?
________________________________________________________________
101
Q8 Technology has had a positive impact on the mental health of your Gen Z?
o Strongly disagree (1)
o Somewhat disagree (2)
o Neither agree nor disagree (3)
o Somewhat agree (4)
o Strongly agree (5)
Q9 Why did you choose this answer?
________________________________________________________________
Q10 How often are you concerned about the mental health of your Gen Z?
o Never (1)
o Sometimes (2)
o About half the time (3)
o Most of the time (4)
o Always (5)
Q11 Has your Gen Z had suicidal ideation?
o No (1)
o Yes (2)
Skip To: Q12 If Has your Gen Z had suicidal ideation? = Yes
Q12 If you know, what led to the ideation?
________________________________________________________________
Q13 Do you think Gen Z is more inclusive of racial diversity than your generation?
o No (1)
o Yes (2)
Q14 Do you think Gen Z is more inclusive of gender identity diversity than your generation?
o No (1)
o Yes (2)
Q15 Do you think Gen Z is more inclusive of sexual orientation diversity than your generation?
o No (1)
o Yes (2)
Q16 Have you experience Gen Zers being supportive of each other during times of stress?
o Never (1)
o Sometimes (2)
102
o About half the time (3)
o Most of the time (4)
o Always (5)
Q17 What does your Gen Z do when they feel stress?
________________________________________________________________
Q18 Does social media have a positive or negative impact on the mental health of Gen Z?
o Extremely negative (1)
o Somewhat negative (2)
o Neither positive or negative (3)
o Somewhat positive (4)
o Extremely positive (5)
Q19 Does your Gen Z talk to you about their problems?
o Never (1)
o Sometimes (2)
o About half the time (3)
o Most of the time (4)
o Always (5)
Q20 What world issues does your Gen Z worry about?
________________________________________________________________
Q21 What is the biggest issue facing your Gen Z?
________________________________________________________________
Q22 Do you think your Gen Z has more stable financial future than your generation did?
o No (1)
o Yes (2)
Q23 Why?
________________________________________________________________
Q24 Do you think Gen Z views the work world the same way your generation does?
o No (1)
o Yes (2)
Q25 Why?
103
Appendix H
Design Criteria
Design Criteria
Design Goal
• The design must provide training on how to effectively manage emotional wellness with coping
skills.
• The design must teach coping skills.
• The design must include an instructor-led course.
• The design must include a workbook.
• The design must include technology.
• The design must come from a prevention perspective.
• The design must address these needs in an easy-to-follow format that includes technology.
• The design should be easy to teach and use
• Pre and post assessment is necessary to measure success of habituation.
User
Perceptions
• Gen Z wants to improve their behavioral and mental health.
• Gen Z wants help to improve their behavioral and mental health.
• Gen Z wants to learn coping skills.
• Gen Z is most comfortable using technology to learn, interact, and experience life, but they also
enjoy face-to-face interaction.
• The design must combine face-to-face interaction and technology.
Physical
Attributes
• The design must be able to store Gen Z ’s information about their mental health and emotional
wellness.
• The design needs to be accessible at any time.
• The design should be in paper and app form and include face to face instruction.
• The design must be used in a training course (classroom) for new Army Gen Z recruits.
Functional
Attributes
• The design must allow for individual input of information.
• The design should be easy to use.
• The design must be usable on all technology operating systems – iPhone, Android, Windows
• The design should receive input in various ways, such as tap, click, and keyboard.
• The design must allow for changing information at the user ’s demand.
• The design must allow for emergency services to be contacted when necessary.
Constraints • Personal devices may not be allowed in all Army training environments.
• Time is limited in Army training environments.
• Measurement for success must be easy to do and take little time.
• Post assessment may not be available in every training environment.
104
Appendix I
105
106
107
108
Appendix J
109
Appendix K
Columbia Suicide Severity Rating Scale (C-SSRS)
SUICIDAL IDEATION
Ask questions 1 and 2. If both are negative, proceed to “Suicidal Behavior” section. If the answer to
question 2 is “yes”, ask questions 3, 4 and 5. If the answer to question 1 and/or 2 is “yes”, complete
“Intensity of Ideation” section below.
Lifetime: Time
He/She/They
Felt Most
Suicidal
Past 1
month
1. Wish to be Dead
Person endorses thoughts about a wish to be dead or not alive anymore or wish to fall asleep and not wake up.
Have you wished you were dead or wished you could go to sleep and not wake up?
If yes, describe:
Yes No
□ □
Yes No
□ □
2. Non-Specific Active Suicidal Thoughts
General non-specific thoughts of wanting to end one’s life/die by suicide (e.g., “I’ve thought about killing myself”) without thoughts of
ways to kill oneself/associated methods, intent, or plan during the assessment period.
Have you actually had any thoughts of killing yourself?
If yes, describe:
Yes No
□ □
Yes No
□ □
3. Active Suicidal Ideation with Any Methods (Not Plan) without Intent to Act
Person endorses thoughts of suicide and has thought of at least one method during the assessment period. This is different than a
specific plan with time, place or method details worked out (e.g., thought of method to kill self but not a specific plan). Includes person
who would say, “I thought about taking an overdose but I never made a specific plan as to when, where or how I would actually do
it…and I would never go through with it.”
Have you been thinking about how you might do this?
If yes, describe:
Yes No
□ □
Yes No
□ □
4. Active Suicidal Ideation with Some Intent to Act, without Specific Plan
Active suicidal thoughts of killing oneself and person reports having some intent to act on such thoughts, as opposed to “I have the
thoughts but I definitely will not do anything about them.”
Have you had these thoughts and had some intention of acting on them?
If yes, describe:
Yes No
□ □
Yes No
□ □
5. Active Suicidal Ideation with Specific Plan and Intent
Thoughts of killing oneself with details of plan fully or partially worked out and person has some intent to carry it out.
Have you started to work out or worked out the details of how to kill yourself? Did you intend to carry out this plan?
Yes No
□ □
Yes No
□ □
110
If yes, describe:
INTENSITY OF IDEATION
The following features should be rated with respect to the most severe type of ideation (i.e., 1-5 from above, with 1 being
the least severe and 5 being the most severe). Ask about time he/she/they were feeling the most suicidal.
Lifetime - Most Severe Ideation: _______ ________________________________________
Type # (1-5) Description of Ideation
Recent - Most Severe Ideation: _______ ________________________________________
Type # (1-5) Description of Ideation
Most
Severe
Most
Severe
Frequency
How many times have you had these thoughts?
(1) Less than once a week (2) Once a week (3) 2-5 times in week (4) Daily or almost daily (5) Many times each day
____
____
Duration
When you have the thoughts how long do they last?
(1) Fleeting - few seconds or minutes (4) 4-8 hours/most of day
(2) Less than 1 hour/some of the time (5) More than 8 hours/persistent or continuous
(3) 1-4 hours/a lot of time
____ ____
Controllability
Could/can you stop thinking about killing yourself or wanting to die if you want to?
(1) Easily able to control thoughts (4) Can control thoughts with a lot of difficulty
(2) Can control thoughts with little difficulty (5) Unable to control thoughts
(3) Can control thoughts with some difficulty (0) Does not attempt to control thoughts
____ ____
Deterrents
Are there things - anyone or anything (e.g., family, religion, pain of death) - that stopped you from wanting to
die or acting on thoughts of suicide?
(1) Deterrents definitely stopped you from attempting suicide (4) Deterrents most likely did not stop you
(2) Deterrents probably stopped you (5) Deterrents definitely did not stop you
(3) Uncertain that deterrents stopped you (0) Does not apply
____ ____
Reasons for Ideation
What sort of reasons did you have for thinking about wanting to die or killing yourself? Was it to end the pain
or stop the way you were feeling (in other words you couldn’t go on living with this pain or how you were
feeling) or was it to get attention, revenge or a reaction from others? Or both?
(1) Completely to get attention, revenge or a reaction from others (4) Mostly to end or stop the pain (you couldn’t go on
(2) Mostly to get attention, revenge or a reaction from others living with the pain or how you were feeling)
(3) Equally to get attention, revenge or a reaction from others (5) Completely to end or stop the pain (you couldn’t go on
____
____
111
SUICIDAL BEHAVIOR
(Check all that apply, so long as these are separate events; must ask about all types)
Lifetime
Past 3
months
Actual Attempt:
A potentially self-injurious act undertaken with at least some wish to die, as a result of act. Behavior was in part thought of as method to kill
oneself. Intent does not have to be 100%. If there is any intent/desire to die associated with the act, then it can be considered an actual suicide
attempt. There does not have to be any injury or harm, just the potential for injury or harm. If person pulls trigger while gun is in
mouth but gun is broken so no injury results, this is considered an attempt.
Inferring Intent: Even if an individual denies intent/wish to die, it may be inferred clinically from the behavior or circumstances. For example, a
highly lethal act that is clearly not an accident so no other intent but suicide can be inferred (e.g., gunshot to head, jumping from window of a
high floor/story). Also, if someone denies intent to die, but they thought that what they did could be lethal, intent may be inferred.
Have you made a suicide attempt?
Have you done anything to harm yourself?
Have you done anything dangerous where you could have died?
What did you do?
Did you______ as a way to end your life?
Did you want to die (even a little) when you_____?
Were you trying to end your life when you _____?
Or Did you think it was possible you could have died from_____?
Or did you do it purely for other reasons / without ANY intention of killing yourself (like to relieve stress, feel better,
get sympathy, or get something else to happen)? (Self-Injurious Behavior without suicidal intent)
If yes, describe:
Has person engaged in Non-Suicidal Self-Injurious Behavior?
Yes No
□ □
Total # of
Attempts
______
Yes No
□ □
Yes No
□ □
Total # of
Attempts
______
Yes No
□ □
and to end/stop the pain living with the pain or how you were feeling)
(0) Does not apply
112
Interrupted Attempt:
When person is interrupted (by an outside circumstance) from starting the potentially self-injurious act (if not for that, actual attempt would have
occurred).
Overdose: Person has pills in hand but is stopped from ingesting. Once they ingest any pills, this becomes an attempt rather than an interrupted
attempt. Shooting: Person has gun pointed toward self, gun is taken away by someone else, or is somehow prevented from pulling trigger. Once
they pull the trigger, even if the gun fails to fire, it is an attempt. Jumping: Person is poised to jump, is grabbed and taken down from ledge.
Hanging: Person has noose around neck but has not yet started to hang - is stopped from doing so.
Has there been a time when you started to do something to end your life but someone or something stopped you before
you actually did anything?
If yes, describe:
Yes No
□ □
Total # of
interrupted
______
Yes No
□ □
Total # of
interrupted
______
Aborted or Self-Interrupted Attempt:
When person begins to take steps toward making a suicide attempt but stops themselves before they actually have engaged in any self-
destructive behavior. Examples are similar to interrupted attempts, except that the individual stops him/herself, instead of being stopped by
something else.
Has there been a time when you started to do something to try to end your life but you stopped yourself before you
actually did anything?
If yes, describe:
Yes No
□ □
Total # of
aborted or
self-
interrupted
______
Yes No
□ □
Total # of
aborted or
self-
interrupted
______
Preparatory Acts or Behavior:
Acts or preparation towards imminently making a suicide attempt. This can include anything beyond a verbalization or thought, such as
assembling a specific method (e.g., buying pills, purchasing a gun) or preparing for one’s death by suicide (e.g., giving things away, writing a
suicide note).
Have you taken any steps towards making a suicide attempt or preparing to kill yourself (such as collecting pills,
getting a gun, giving valuables away or writing a suicide note)?
If yes, describe:
Yes No
□ □
Total # of
preparatory
acts
______
Yes No
□ □
Total # of
preparatory
acts
______
Most Recent
Attempt
Date:
Most Lethal
Attempt
Date:
Initial/First
Attempt
Date:
Actual Lethality/Medical Damage:
0. No physical damage or very minor physical damage (e.g., surface scratches).
1. Minor physical damage (e.g., lethargic speech; first-degree burns; mild bleeding; sprains).
2. Moderate physical damage; medical attention needed (e.g., conscious but sleepy, somewhat responsive; second-degree
burns; bleeding of major vessel).
3. Moderately severe physical damage; medical hospitalization and likely intensive care required (e.g., comatose with reflexes
intact; third-degree burns less than 20% of body; extensive blood loss but can recover; major fractures).
Enter Code
______
Enter Code
______
Enter Code
______
113
4. Severe physical damage; medical hospitalization with intensive care required (e.g., comatose without reflexes; third-degree
burns over 20% of body; extensive blood loss with unstable vital signs; major damage to a vital area).
5. Death
Potential Lethality: Only Answer if Actual Lethality=0
Likely lethality of actual attempt if no medical damage (the following examples, while having no actual medical damage, had
potential for very serious lethality: put gun in mouth and pulled the trigger but gun fails to fire so no medical damage; laying
on train tracks with oncoming train but pulled away before run over).
0 = Behavior not likely to result in injury
1 = Behavior likely to result in injury but not likely to cause death
2 = Behavior likely to result in death despite available medical care
Enter Code
______
Enter Code
______
Enter Code
______
Retrieved from The Columbia Lighthouse Project. 2016. https://cssrs.columbia.edu/the-
columbia-scale-c-ssrs/cssrs-for-communities-and-healthcare/#filter=.general-use.english.
114
Appendix L
Financial Plan and Cost Analysis
The development of a realistic financial plan is not possible because the project will occur only
within the military environment. The budget for programs is embedded in the National Defense
Authorization Act and specifics of this budget are not available to this author. The following is a
breakdown of costs incurred by the author and the steps to which an app is developed within the
DHA Center of Excellence for Technology
First Year Costs for Action Planning for Prevention and Wellness Course and App Development by Author
Activities for Development Volume of Activities Potential First Year Costs
App Design 40 hours $2,400
App development Monthly $348
Publish app on Apple Store Yearly $99
PDF Adaptation 4 hours $240
Paper 12 Reams $72.00
Pilot Course 6 hours $460
Second Course Pilot 3 hours $130
Sustainment of App Monthly $648
Totals $4,397
DHA Center of Excellence App
Development
a) Present app concept to DHA Center of
Excellence for Technology Costs are embedded into DHA Budget
b) Receive approval of app concept Costs are embedded into DHA Budget
c) Center of Excellence develops app Costs are embedded into DHA Budget
d) Usability testing Costs are embedded into DHA Budget
e) Publish app Costs are embedded into DHA Budget
f) Advertise app Costs are embedded into DHA Budget
g) Sustainment Costs are embedded into DHA Budget
Abstract (if available)
Abstract
The rate of suicide in the Army Gen Z population has almost doubled that of the general population of 18 to 25-year-olds (Defense Suicide Prevention Office, 2022; National Institute of Mental Health, 2022). Suicide directly results from stressors that have not been successfully managed and, as a result, become mental health problems that the individual believes are too hard to live with (Ruiz, 2014). Surveys conducted by this author with Gen Z (b.1997-2012, Dimock, 2019) in 2022, both in the general population and the Army, are consistent with current research, citing themes of broad mental health problems, desires to be heard, fear of world problems, anger at older generations, and expectations that leaders will provide a similar environment in which they were parented. Gen Z experienced childhoods with parents who were intensive, protective, and solved all their problems, coupled with warmth, responsiveness, and collaboration. This parenting style has led to underdeveloped coping skills, increased anxiety, depression, a lack of self-efficacy, and a lack of autonomy in the generation (Belz, 2021; Weiland & Kucirka, 2020). These characteristics formed a generation of soldiers unable to cope with the everyday demands of life in the military. The solution outlined in the project aims to prevent mental and behavioral health problems in Gen Z soldiers through the Action Planning for Prevention and Wellness course. The project is an instructor-led course that guides the soldier through writing identified skills, attributes, and solutions into a PDF workbook associated with the course. An app to accompany the workbook is in development and will make the content more readily accessible to the soldiers. To be successful, this solution will be implemented at Advanced Individual Training (AIT) courses for new recruits, arenas that have not traditionally focused on mental health.
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Asset Metadata
Creator
St Luce, Amy Lynn
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Core Title
An action plan for prevention and wellness for gen Z soldiers
School
Suzanne Dworak-Peck School of Social Work
Degree
Doctor of Social Work
Degree Program
Social Work
Degree Conferral Date
2023-05
Publication Date
04/13/2023
Defense Date
03/27/2023
Publisher
University of Southern California
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