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High rates of suicides among active-duty military population: how exposure to a suicide event affects behaviors

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High rates of suicides among active-duty military population: how exposure to a suicide event affects behaviors

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High Rates of Suicides Among Active-Duty Military Population: How Exposure to a
Suicide Event Affects Behaviors
by
Anderson A. Nyeche

Rossier School of Education
University of Southern California
A dissertation submitted to the faculty
in partial fulfillment of the requirements for the degree of
Doctor of Education

August 2022

© Copyright by Anderson A. Nyeche 2022
All Rights Reserved

The Committee for Anderson A. Nyeche certifies the approval of this Dissertation

Eric Canny
Jennifer Phillips
Patricia Elaine Tobey, Committee Chair

Rossier School of Education
University of Southern California
2022

iv
Abstract
This research examined qualitative data on the effect of suicide on the behavior of active-duty
military personnel. Interviews were conducted with 11 retired military members who volunteered
to share their experiences on active duty in the Marine Corps, Army, Navy, and Air Force. The
data showed that exposure to a suicide event affected the behavior of active-duty military
personnel. Behavioral changes included psychological pain and mental health problems, changed
the cognition and perspectives of survivors, and provoked negative emotions. A perceived
culture of stigma towards mental health problems in the military exacerbated fear of losing
security clearances or military careers and fear of demotion and discouraged help-seeking
behavior for mental health problems, behavioral disorders, and alcohol and substance abuse
issues. This culture worsened suffering and medical conditions. Recommended coping
mechanisms to adapt and adjust when exposed to a suicide event included connection with
family and community of like-minded people, therapy and mental health treatment, exercise and
staying busy, and learning and sharing experience with others. The study integrated social
cognitive theory as a framework and perspective to understand how losing someone to suicide
affects people’s behavior. These findings suggest the need to examine the culture of stigma and
mental health in the military, leadership practices, and the support for active-duty personnel
experiencing loss.
Keywords: suicide event, exposure, active-duty personnel.

v
Dedication
To my family, Joy, Chidinma, Beauty, Abbie, and my mother Peace Nyeche who love and prays
each day for my success. Girlfriend Adriane who provided encouragement, support, and the
motivation to keep discipline and commitment to study.

To my loving father, Samuel Adiele Nyeche. Thank you for the inspiration to pursue higher
education and may you rest in eternal peace in heaven.

vi
Acknowledgements
It takes a village and a community to raise a child. One person alone cannot complete a
doctoral degree without the help and support of an entire village and the community. During this
journey, I received consistent support, encouragement, inspiration, and motivation from friends,
neighbors, sailors across the fleet, and co-workers. Thank you for believing in me as I completed
my dissertation.
Special thanks to Dr. Patricia Tobey. Your commitment as chair and dedication to duty as
a professor is inspirational to all students, especially me. You have consistently demonstrated
loyalty and service to see others succeed, and your ability to inspire and motivate students is
unmatched. Thank you for giving me the chance to grow both personally and professionally as a
researcher and a leader as I engaged in one of the most challenging and rewarding projects of my
life.
Thank you, Dr. Eric Canny. I became a better writer after taking your classes. You force
me to think critically about subjects and increase awareness and lens regarding DEI. Your
feedback as a member of my committee was instrumental in the successful completion of the
final capstone.
Thank you, Dr. Lynch Doug, for teaching me how to be provocative and diverse in my
reasoning. Through your teaching style, I have learned how to reframe problems and think
inclusively on effective ways to solve problems.
Thank you to my cohort who provided guidance and support along the way. You have
embraced me as a friend, and I am humbled and blessed to have you as my network and
members of my community and family. Your life and individual stories matter, and the lessons
and wisdom we have accumulated through the program will change the world.
vii
Table of Contents
Abstract .......................................................................................................................................... iv
Dedication ........................................................................................................................................v
Acknowledgements ........................................................................................................................ vi
List of Tables ...................................................................................................................................x
List of Figures ................................................................................................................................ xi
List of Abbreviations .................................................................................................................... xii
Chapter One: Introduction to the Study ...........................................................................................1
Background to the Problem of Practice ...............................................................................2
Purpose of the Study and Research Questions .....................................................................3
Importance of the Study .......................................................................................................4
Overview of Theoretical Framework and Methodology .....................................................6
Definitions of Terms ............................................................................................................7
Organization of the Dissertation ..........................................................................................9
Chapter Two: Literature Review ...................................................................................................11
Historical Context ..............................................................................................................11
Challenges to Solving the Problem ....................................................................................26
The Effect of Suicide on Active-Duty Military Population ...............................................33
Existing Strategies for Solving the Problem ......................................................................37
Command-Level Intervention ............................................................................................42
Theoretical Framework ......................................................................................................43
Conceptual Framework ......................................................................................................44
Past Research Using Social Cognitive Theoretical Framework ........................................46
Reasons Underlying Problem of Practice ..........................................................................47
Summary ............................................................................................................................48
viii
Chapter Three: Methodology .........................................................................................................50
Research Questions ............................................................................................................50
Overview of Design ...........................................................................................................51
Research Setting.................................................................................................................53
The Researcher’s Positionality ..........................................................................................53
Conflict of Interest .............................................................................................................55
Data Sources ......................................................................................................................55
Data Analysis .....................................................................................................................61
Credibility and Trustworthiness of Research .....................................................................63
Ethics..................................................................................................................................64
Limitations and Delimitations ............................................................................................64
Chapter Four: Findings ..................................................................................................................66
Participants .........................................................................................................................67
Results and Findings for Research Question 1 ..................................................................72
Results and Findings for Research Question 2 ..................................................................87
Results and Findings for Research Question 3 ..................................................................96
Summary ..........................................................................................................................104
Chapter Five: Discussion and Recommendations........................................................................105
Overview of the Study .....................................................................................................105
Summary of Findings .......................................................................................................106
Implications of the Study .................................................................................................117
Recommendations for Practice ........................................................................................117
Recommendations for Future Research ...........................................................................130
Conclusion .......................................................................................................................130
References ....................................................................................................................................132
ix
Appendix A: Interview Protocol ..................................................................................................146
Appendix B: Suicidality Prevention Assessment ........................................................................147
Question Response/Score.................................................................................................147
Interpreting the Total Score .............................................................................................148
Resources .........................................................................................................................148
Appendix C: Introduction and Conclusion of the Interview ........................................................150
Appendix F: Recruitment Email Message for Research ..............................................................154
Appendix H: Informed Consent for Research .............................................................................156
Introduction ......................................................................................................................156
Detailed Information ........................................................................................................156
Procedures ........................................................................................................................157
Risks and Discomforts .....................................................................................................157
Benefits ............................................................................................................................158
Privacy/Confidentiality ....................................................................................................158
Payments/Compensation ..................................................................................................159
Voluntary Participation ....................................................................................................159
Participant Termination ...................................................................................................159
Contact Information .........................................................................................................159

x
List of Tables
Table 1: Annual Suicide Counts and Rates Per 100,000 Service Members by Military
Population, and Service CY 2017–CY 2019 14
Table 2: Service Members Suicide Counts and Percentages for CY 2019 16
Table 3 Methods of Suicide Death by Military Population for CY 2019 23
Table 4: Three Research Questions That Guided Data Collection 52
Table 5: Participants’ Names, Ages, Self-Identified Ethnicities, and Branch of Military
Service 68
Table 6: Participants and Their Years of Service, Job, and Self-Identified Gender 69
Table 7: Participants’ Response to How Stigma Affected Their Ability to Seek Help 95
Table 8: Recommendation 1: Implementation Plan and Evaluation Criteria 120
Table 9: Recommendation 2: Implementation Plan and Evaluation Criteria 122
Table 10: Recommendation 3: Implementation Plan and Evaluation Criteria 125
Table 11: Equity Evaluation Framework and Three Practice Recommendations 129
Appendix D: Interview Questions 151
Appendix E: Theoretical Framework Alignment Matrix 153
Appendix G: Code Book 155
xi
List of Figures
Figure 1: The Mean Medical and Work-Loss Cost Per Injury Death by Intent in the United
States 37
Figure 2: Enterprise-wide Program Evaluation Framework 40
Figure 3: Conceptual Framework of How Exposure to a Suicide Event Affect Behavior and
Suicide Rates 45
Figure 4: NVivo Word Frequency 57
Figure 5: The Process used to Code and Analyzed Data 63

xii
List of Abbreviations
ASR Annual Suicide Report
AC Active Component
CO Commanding Officer
CY Calendar Year
CDC Center for Disease Control and Prevention
CMC Command Master Chief
DH Department Heads
DRC Deployed Resiliency Counselor
DoDSER Department of Defense Suicide Event Report
DoD Department of Defense
FY Fiscal Year
PHCE Psychological Health Center of Excellence
WHO World Health Organization

1
Chapter One: Introduction to the Study
Death by suicide among the active-duty military population has remained consistently
high every year, exposing active-duty sailors to suicide events, which increases suicidal
behaviors and suicide in the military. The Centers for Disease Control and Prevention (CDC,
2019) defined suicide as a premeditated death or self-harm caused by individuals on themselves
with the intention to die. More than 48,000 people died by suicide in 2018, and 47,500
Americans committed suicide in 2019, with one death occurring every 11 minutes (CDC, 2021).
Particularly, over 800,000 people die by suicide globally every year, which links to significant
increases in suicide attempts affecting families, friends, colleagues, communities, and societies at
large (World Health Organization, 2021). Rowan et al. (2014) asserted that the high rate of
suicides among the active-duty military population is attributable to increased suicide attempts
across the military population. Research shows that 2,872 active-duty military personnel
committed suicide between 2009 and 2018 showing this is a problem (Department of Defense,
2021; Psychological Health Center of Excellence, 2021).
Despite access to healthcare and prevention efforts by the military, the rates of suicide
among the active-duty population have consistently remained high and unchanged (Ramchand et
al., 2011). Notably, suicide is the second leading cause of death in the Air Force and is
responsible for one-fourth of deaths among active-duty Airmen (Welton & Blackman, 2006). In
fact, 20 veterans and active-duty personnel commit suicide every day in America, showing
suicide is a public health problem that affects people nationwide (Lutwak & Dill, 2017).
Exposure to a suicide event (death by suicide of a person) affects families, personnel
performance, mission, and operational readiness of the military (Reimann & Mazuchowski,
2018).
2

Furthermore, research concerning military suicides has focused on examining the rates of
suicides, risk factors that increase suicides, prevention strategies, and recommended solutions to
solve the problem. However, literature on how exposure to a suicide event increases suicidal
behaviors and the rate of military suicide is scarce and limited in the subject matter. Therefore,
deaths by suicide among the active-duty military population have remained consistently high,
affecting retention, unit morale, and operational readiness (Mazuchowski, 2018). By extension,
exposure to a suicide death is associated with depression, anxiety, and suicidal ideation
(Psychological Health Center of Excellence, 2021). Since 2001, the rate of suicide among the
active-duty population in the U.S. armed forces has remained high despite access to care,
improved behavioral health, and support services for combat troops in Iraq and Afghanistan
(Mastroianni & Wilbur, 2011). Thus, understanding the link between exposure to a suicide event,
suicidal behaviors, and increases in rates of suicide is critical to reframing the problem to create
an effective mitigation strategy to save lives.
Background to the Problem of Practice
The military suicide rate is often compared with the general population’s rate to ensure
accuracy of results, and suicide rates are presented using estimated numbers of suicides that
occurred for every 100,000 people within a population (DoDSER, 2021). Such comparisons
separate demographics for organizational leaders to better understand the trends and patterns
within each population. Despite access to healthcare and preventive programs, the rate of suicide
among the active-duty population has remained consistently high every year (Wolfe-Clark &
Bryan, 2017). Suicide among active-duty military members has a long history dating back to
when 274 soldiers committed suicide between 1795 and 1801, and 239 service members died by
suicide from 1781 to 1786 in France (Welton & Blackman, 2006). During this period, the rate of
3

military suicides among the active-duty population was significantly high compared to the
general population in Europe (Welton & Blackman, 2006). Losing sailors, soldiers, airmen,
marines, and service members (enlisted and officers) affect the mission and operational readiness
of the military (Reimann & Mazuchowski, 2018). Thus, finding solutions to mitigate the problem
of high rates of suicides among the active-duty military population has become a significant
concern for the DoD, military commanders, and members of Congress (Hyman et al., 2012;
Linberry & O’Connor, 2012; Ramchand et al., 2011).
Suicide is the 10th leading cause of death in the U.S. general population and is
responsible for more than 45,000 deaths annually (Hoyt et al., 2020). Compared to the general
population, the frequency of death by suicides among the active-duty military population is
consistently higher. Military suicide affects command climate, personnel morale, and readiness
poses a challenge for military commanders to manage (Elspeth, 2003). From 2004 to 2008,
military suicides increased by 80% among active-duty soldiers forcing the DoD to establish the
DoDSER as a prevention effort to collect and examine data on suicides across the military to
better comprehend the problem (DoDSER, 2021; Linberry & O’Connor, 2012; Ramchand et al.,
2011). According to the Psychological Health Center of Excellence (2012), more than 48,000
Americans committed suicide in 2018, with each death affecting 135 people with varying
degrees of trauma caused by exposure to the loss. Death by suicide is a public health issue that
directly affects military members, families, and the general population (Scoville et al., 2007).
Purpose of the Study and Research Questions
The purpose of the study was to investigate how exposure to a suicide event affects the
behavior of active-duty military personnel to increase knowledge about how suicide affects the
behaviors of people who experience loss. Understanding the effect of suicide on behavior may
4

increase awareness of the problem to provide healthcare and support to people who experience
the loss of someone to suicide. The research questions are as follows:
1. How does the experience of losing someone to suicide influence behaviors of active-
duty military personnel?
2. What role does stigma play in seeking help from mental health among active-duty
military personnel?
3. What are the recommended methods used by retired military personnel to cope with
the loss of someone to suicide while on active duty?
Importance of the Study
The increase in death by suicide among active-duty personnel is a public health concern
that needs an effective framework and solutions to mitigate the problem (Short et al., 2019).
Baily (2020) asserted that the high rates of suicides among the military population are
concerning nationally and have been a significant social problem in the last decade. Selby et al.
(2010) agreed with the assertion and suggested that military suicide increased since Operation
Iraqi Freedom and Operation Enduring Freedom and emphasized the need to advance risk
assessment techniques and create effective prevention programs to treat mental health problems.
While there are extensive studies on military suicide, such as on risk factors that influence
behaviors, frequency of death by suicides across services, best practices for assessing risks, and
prevention programs, there is limited research about how exposure to a suicide event affects the
behaviors of military members emotionally, cognitively, and socially. This study focused on the
behavioral changes that occur in the lives of active-duty military personnel who were exposed to
a suicide event and attempted to find the correlation between behavioral changes and suicide in
the military. Understanding how exposure to a suicide event affect human behaviors and
5

influence choices that result in committing suicide will help create an effective framework to
prevent suicide in the military and provide adequate support services to assist people affected by
the loss.
Also, national defense is vital to protect America’s political and economic interests and
superiority as a leader across the globe (Richardson, 2016). Ensuring a strong national defense,
active-duty military personnel are highly trained and equipped to support operational readiness to
defend the country from national and international threats. Hence, the mission of the Navy is to
protect America from attack and to preserve strategic influence in key regions of the world
(Richardson, 2016). Deaths by suicide affect families, friends, colleagues, communities, military
retention, and operational readiness of DoD and impede mission success (Reimann &
Mazuchowski, 2018; World Health Organization, 2021). Understanding how suicide affects
suicidal behaviors, suicide attempts, and rates of suicides among the active-duty military
population is critical to America’s national defense and national security. In other words, given
the prevalence of suicides in the military, it is critical to know how the frequency of deaths by
suicide changes how people think, believe, interpret the meaning of experiences (cognition),
performance behaviors (ability to self-regulate), affects suicidal behaviors, and suicide in the
military (Everinghan, 2011).
Lack of understanding of the correlation between military suicides and behavioral
changes due to exposure is detrimental to efforts to decrease the rates of military suicides and
national security. Landers (2017) warned that the death by suicide of a soldier assigned to a
combat unit creates a significant staffing gap, making that unit vulnerable and less combat-ready,
which directly impacts the mission readiness of that command. Similarly, Noble (2020) asserted
that suicide affects command readiness and the ability of members to continue the mission in that
6

soldier who witness suicide experience anxiety, depression, and demotivation to continue the
mission. Understanding how exposure to a suicide event affects suicidal behaviors and rates of
suicide will help reframe how military organizations and leadership culture view the problem of
suicide and create better strategies and effective programs to support personal behavioral issues
and mental health and provide adequate care to support members. Lack of understanding will
continue to increase military suicide rates and the frequent loss of lives among the active-duty
military population.
Overview of Theoretical Framework and Methodology
Social cognitive theory (SCT) is used as background to examine literature from previous
work, and a constructivist interpretive paradigm was integrated as a lens and worldview to
analyze data from semi-structured interviews of retired military members exposed to a suicide
event while on active duty. Integrating the lived experiences of retired military members
contributed quality data from 11 subject matter experts across four military branches with
diverse experiences. Bandura (2005) developed SCT in the late 1970s to understand how human
beings learn through observation and interactions with the environment. It is a learning theory
that uses observational, retention, and self-regulatory processes to emphasize the role of behavior
and individual beliefs within an environment. The theory views human beings as change agents
who actively take part in changing their conditions and environment, which creates constraints
that influence behaviors. Typically, the theory supplies the framework to understand how an
individual’s beliefs and values influence the capacity to make choices and construct meaning to
life experiences (Bandura, 2005).
Furthermore, all research has a qualitative grounding (Aliyu et al., 2015). The qualitative
research method shaped the study’s design and was used inductively to construct the meaning of
7

the participants’ lived experiences. Integrating the semi-structured interview and constructivist
worldview, the study described the experiences of 11 retired military members across the four
branches who were exposed to a suicide event and attempted to correlate the results to increases
in suicides among the active-duty military population. The research design aligns with the
purpose of this study in that suicide is a complex social problem with diverse manifestations
based on personalities, behaviors, and influences within the environment. Credibility (accurate
and believable), transferability (evidence applies to other situations), dependability (consistency
and trackability of research), and confirmability (data is accurate and leads back to sources) were
addressed in several ways. Audio and video recording interviews were completed through the
USC Zoom site. Interview notes were downloaded and transcribed coded using NVivo software
to store data for safety and easy reference. Data analysis was conducted using codes, themes, and
patterns extracted from participants’ answers. Likewise, data interpretation integrated the
constructivist interpretive paradigm that aligned with the conceptual framework and social
cognitive theoretical perspective to ensure accountability and accurately interpret findings. Also,
the use of research journals, a spreadsheet, and handwritten field notes ensured easy access to
reference materials during data analysis.
Definitions of Terms
The following definitions provide clarity for their use throughout this study. The words
and terms follow established usage throughout the DoD and serve are foundational to the
concepts grounding the examination of military suicides.
• Active duty: Per the Office of the Chief Management Officer, the active component is
the portion of the armed forces as identified in annual authorization acts as “active
8

forces” and in section 115 of Title 10 USC as active-duty personnel paid from funds
appropriated for active-duty personnel (DoDSER, 2018).
• Deployment: Troop movement due to military orders issued by the commanders for
30 continuous days or greater to a foreign location of military operations (DoDSER,
2018).
• DoDSER report: Annual descriptive report containing the number of suicides and
suicide attempts within the U.S. armed forces beginning January 1 and ending
December 31 each year (DoDSER, 2018).
• DoDSER system: A secure web-based data collection program where suicide and
suicide attempt events forms are submitted via https://dodser.t2.health.mil.
• Military branch: There are four military branches within the DoD: the Army, Marine
Corps, Air Force, and Navy (DoDSER, 2018).
• Prevention: A strategy or approach that reduces the risk or delays the onset of adverse
health problems or reduces the likelihood that an individual will engage in harmful
behaviors. Also known as primary prevention (DoDSER, 2018).
• Protective factors: Factors that stem from physical, psychological, spiritual, family,
social, financial, vocational, and emotional well-being, i.e., factors that make it less
likely that individuals will develop a disorder. Protective factors may encompass
biological, psychological, or social factors in the individual, family, and environment
(DoDSER, 2018).
• Risk factors: Characteristics, variables, or hazards that make it more likely that
individuals will develop self-injurious behaviors. Risk factors may encompass
9

biological, psychological, or social factors in the individual, family, and environment
(DoDSER, 2018).
• Self-harm: Injuries inflicted upon self to cause harm without the intent to commit
suicide (DoDSER, 2018; CDC, 2020).
• Service member: A person appointed, enlisted, or inducted into a branch of the
Military Services, including Reserve Components (e.g., National Guard), cadets, or
midshipmen of the Military Service Academies (DoDSER, 2018).
• Stigma: Negative perception by individuals that seeking mental health care or other
supportive services will negatively affect or end their careers (DoDSER, 2018).
• Suicidal behaviors: Behaviors related to suicide, including preparatory acts, as well
as suicide attempts and deaths (DoDSER, 2018).
• Suicide exposure: A person who knows or identifies with someone (workplace
acquaintances, supervisor, members from the same command) who committed
suicide (Cerel et at., 2019).
• Suicide ideation: Thinking about, considering, or planning suicide (DoDSER, 2018).
• Suicide attempts: A self-inflicted, potentially injurious behavior with a nonfatal
outcome for which there is evidence (either explicit or implicit) of intent to die
(DoDSER, 2018).
• Suicide rates: The estimated number of suicides that occur for every 100,000 people
within a population (DoDSER, 2021).
Organization of the Dissertation
The dissertation follows a traditional five-chapter model. Chapter One provides an
introduction and overview of the study. Chapter Two highlights the relevant literature and the
10

conceptual framework. Chapter Three details the research methodology. Chapter Four provides
the findings from the qualitative interviews. Chapter Five details the proposed recommendations.

11

Chapter Two: Literature Review
This review integrates literature from diverse organizations and perspectives to facilitate
understanding of the significant impact of how exposure to a suicide event increases suicidal
behaviors and contributes to the high rates of suicide among the active-duty military population.
The literature will examine two distinct areas of focus: how exposure to a suicide event affects
suicidal behaviors of active-duty members and environmental factors that contribute to increased
military suicide rates. Scholars across disciplines have used the framework (social cognitive
theory) to solve problems in various organizations and advanced discussions concerning the
subject matter. However, this literature review focuses on understanding how death by suicide of
active-duty military personnel increases the suicidal behaviors of military personnel and the rates
of suicide to increase understanding of the problem and create effective solutions to care for and
support personnel affected. Knowing the historical background of military suicide rates is crucial
to understand the depth of the problem of suicide among the active-duty military population.
Historical Context
The military suicide rate is often compared with the general population’s rate to ensure
accuracy of results, and suicide rates are presented using estimated numbers of suicides that
occurred for every 100,000 people within a population (DoDSER, 2021). Comparing suicide
rates between the military and the general population separates demographics for organizational
leaders to better understand the trends and patterns for each population. Despite access to
healthcare and preventive programs across the military, the rate of suicides among the active-
duty population has remained consistently high every year (Wolfe-Clark & Bryan, 2017).
Suicide among active-duty military members has a long history dating back to when 274 soldiers
committed suicide between 1795 and 1801, and 239 service members died by suicide from 1781
12

to 1786 in France (Welton & Blackman, 2006). During this period, the rate of military suicides
among the active-duty population was significantly high in comparison to the general population
in Europe (Welton & Blackman, 2006). In 2018, 325 active-duty members committed suicide,
and 24.8 deaths per 100,000 persons were reported within the active-duty population
(Psychological Health Center or Excellence, 2021).
By extension, the rate of suicide for each military branch was reported as 18.5 deaths per
100,000 airmen), 29.5 deaths per 100,000 soldiers, 31.4 deaths per 100,000 marines, and 20.7
suicides per 100,000 sailors (DoDSER, 2021). In contrast, the suicide rate for the general U.S.
population was 18.3 per 100,000 in the same year. After accounting for differences in age and
sex between the military and general U.S. populations, the CY18 suicide mortality rates for both
the active and reserve components were statistically not different from the CY17 U.S. adult
population rate (DoDSER, 2021). Losing sailors, soldiers, airmen, marines, both enlisted and
officers, who volunteered to serve the nation directly affects their unit’s mission readiness
(Reimann & Mazuchowski, 2018). Thus, finding solutions to mitigate the problem of high rates
of suicides in the active-duty population has become a concern for the DoD, military
commanders, and members of Congress (Hyman et al., 2012; Linberry & O’Connor, 2012;
Ramchand et al., 2011).
Currently, suicide is the 10th leading cause of death in the U.S. general population and is
responsible for more than 45,000 deaths annually (Hoyt et al., 2020). Compared to the general
population, the frequency of death by suicide among the active-duty military population is
consistently higher. For example, Scoville et al. (2007) conducted a study to describe the
epidemiology of suicides among active-duty military recruits across service branches and
indicated 9.0 to 15.0 deaths per 100,000 active-duty suicides compared to 10.4–12.4 deaths per
13

100,000 people in the general population from 1980 through 2004. Similarly, suicide was the
second leading cause of death among active-duty members of the Air Force between 1985 and
1990, with 12.2 deaths per 100,000 and significantly increased to 16.4 deaths per 100,000 airmen
between 1991 and 1996 (Welton & Blackman, 2006). From 1980 to 1990, deaths by suicide
within the active-duty military population remained steadily high, with 14.1 deaths per 100,000
soldiers, 12.2 per 100,000 airmen, 11 deaths per 100,000 sailors, and 13.7 per 100,000 marines
documented. Active-duty suicides trended upward from 1991 to 1996, with 16.4 deaths per
100,000 Airmen, 12 per 100,000 sailors, and 13.6 per 100,000 marines. Table 1 shows the annual
suicide committed and rates per 100,000 service members for active duty, reservist, and national
guard from 2017 to 2019 (ASR, 2021).

14

Table 1
Annual Suicide Counts and Rates Per 100,000 Service Members by Military Population, and
Service CY 2017–CY 2019
Military population/ Service CY 2017 CY 2018 CY 2019
Count Rate Count Rate Count Rate
Active component 287 22.1 326 24.9 344 25.9
Army 116 24.7 141 29.9 142 29.8
Marine Corps 43 23.4 57 30.8 47 25.3
Navy 65 20.1 68 20.7 72 21.5
Air Force 63 19.6 60 18.5 83 25.1
Reserve 93 25.7 81 22.9 65 18.2
Army Reserve 63 32.1 48 25.3 36 18.9
Marine Corps Reserve 10 -- 19 -- 9 --
Navy Reserve 9 -- 11 -- 7 --
Air Force Reserve 11 -- 3 -- 13 --
National Guard 133 29.8 136 30.8 89 20.3
Army National Guard 121 35.5 119 35.6 74 22.3
Air National Guard 12 -- 17 -- 15 --

Note. Suicide rates for the SELRES include all service members irrespective of duty status. From
Annual Suicide Report: Calendar Year 2019 by the Undersecretary of Defense for Personnel and
Readiness, 2020. U.S. Department of Defense. Copyright 2020 by the U.S. Department of
Defense.

In 2000, Army suicide rates increased to 19.1 deaths per 100,000 soldiers, above the
national average of 10.1 deaths per 100,000 persons (Welton & Blackman, 2006). Conversely,
Hoyt and Holtz (2020) highlighted errors often cited by researchers and news media about the
trends of military suicides to question the validity of the high rate of suicides in the military.
Data provided by the researchers suggest that Army suicide rates of 24.8 per 100,000 persons in
2011 and 29.8 in 2019 have remained within the same statistical margin of error, contrary to the
15

notion of a steady increase each year (Hoyt & Holtz, 2020). Results reported in the literature
about military suicide rates prior to establishing DoDSER in 2008 are inconsistent with the
DoDSER report due to systematic errors, calling the results into question (Hoyt & Holtz, 2020).
The DoD Annual Suicide Report (ASR) was created in 2019 as an official source used by DoD
to publish annual suicide counts (Table 2) and unadjusted rates of suicides (ASR, 2021).

16

Table 2
Service Members Suicide Counts and Percentages for CY 2019
Count Percent Count Percent Count Percent
Total 344 100% 65 100% 89 100%
Sex
Male 315 91.6% 62 95.4% 83 93.3%
Female 29 8.4% 3 4.6% 6 6.7%
Age group
17–19 27 7.8% 4 6.2% 5 5.6%
20–24 134 39.0% 16 24.6% 29 32.6%
25–29 92 26.7% 13 20.0% 21 23.6%
30–34 40 11.6% 15 23.1% 15 16.9%
35–39 32 9.3% 6 9.2% 5 5.6%
40–44 16 4.7% 5 7.7% 5 5.6%
45–49 3 0.9% 6 9.2% 5 5.6%
50–54 0 0% 0 0% 3 3.4%
55–59 0 0% 0 0% 1 1.1%
Race
White 260 75.6% 50 76.9% 74 83.1%
Black or African American 36 10.5% 8 12.3% 11 12.4%
American Indian/Alaska
Native
7 2.0% 0 0% 1 1.1%
Asian/Pacific Islander 22 6.4% 4 6.2% 2 2.2%
Other/Unknown 19 5.5% 3 4.6% 1 1.1%
Rank
E (Enlisted) 319 92.7% 54 83.1% 80 89.9%
E1–E4 170 49.4% 32 49.2% 44 49.4%
E5–E9 149 43.3% 21 32.3% 36 40.5%
Unknown 0 0% 1 1.5% 0 0%
O (Commissioned officer) 20 5.8% 9 13.8% 7 7.9%
W (Warrant officer) 4 1.2% 2 3.1% 2 2.2%
Cadet 1 0.3% 0 0% 0 0%
Marital status
Never married 151 43.9% 32 49.2% 49 55.1%
Married 170 49.4% 31 47.7% 33 37.1%
Divorced 23 6.7% 1 1.5% 7 7.9%
Unknown 0 0% 1 1.5% 0 0%

17

Note. From Annual Suicide Report: Calendar Year 2019 by the Undersecretary of Defense for
Personnel and Readiness, 2020. U.S. Department of Defense. Copyright 2020 by the U.S.
Department of Defense.

Suicide in the military affects command climate, personnel morale, and readiness and
poses a challenge for commanders and leadership to manage (Elspeth, 2003). Indeed, from 2004
to 2008, military suicides increased by 80% among active-duty soldiers, forcing the DoD to
establish the Department of Defense Suicide Event Report (DoDSER) as a prevention effort to
collect and examine data on suicides across the military to better comprehend the problem and
develop an effective mitigation strategy (DoDSER, 2021; Linberry & O’Connor, 2012;
Ramchand et al., 2011). According to the Psychological Health Center of Excellence (2012),
more than 48,000 Americans committed suicide in 2018, with each death mourned by families
and co-workers and affecting 135 people with varying degrees of trauma caused by exposure to
the loss. The CDC (2019) reported that 47,500 people died from suicide in 2019, averaging one
death every 11 minutes, 12 million adults seriously thought about suicide, 3.5 million adults
made plans to commit suicide, and 1.4 million attempted suicides in the general population that
same year.
Globally, 800,000 people die by suicide every year, with one suicide occurring every 40
seconds (WHO, 2021). In 2006, the Navy reported a 9.1 suicide rate with 32 sailors on active
duty committing suicide, and a 21.8 suicide rate in 2019 with the death of 73 sailors on active
duty; the Navy’s suicide rate decreased in 2020 to 19.1 death per 100,000 and 63 deaths by
suicide (21st Century Sailor, 2021). Death by suicide is a public health issue that directly affects
military members, families, and the general population (Scoville et al., 2007). Understanding the
18

history of military suicides and how active-duty suicide rates have remained consistently high
each year will help to increase knowledge on how exposure to suicide events affects suicidal
behaviors and the rates of suicide among the active-duty military population.
How Exposure to Suicide Events Affects Suicidal Behavior
Learning is a process that changes a person’s behavior through experience, which
increases the potential to improve performance and future learning (Ambrose et al., 2010). The
learning theory suggests that learning occurs through observation and interactions with the
environment, using both intrinsic motivation and self-regulation to figure out individual suicidal
behaviors (Bandura, 2005). Hedstrom et al. (2008) suggested that actions stem from personal
desires and beliefs are influenced by the environment in which the action is deemed reasonable.
Using attribution path-way sequence, Elliot et al. (2018) explained how causal thinking
processes directly produce motivation to show positive or negative behavior in a person
depending on personality inferences.
The first step to problem-solving is diagnosing the human causes and finding effective
solutions to the problem (Clark & Estes, 2008). In brief, an outcome of events forces a person to
interpret results and evaluate their competence, which informs a person’s cognition and directly
affects reasoning to self-regulate their behavior (Elliot et al., 2017). Thus, suicidal behaviors of
military personnel increase due to circumstances or difficulties in the individual’s life, which
affect their decision-making skills (Heyman et al., 2012). For example, Martin et al. (2015)
observed that substance abuse that leads to overdose increased the mortality rate worldwide,
which increased environmental risk factors directly influencing suicidal behaviors (Hancock,
2007; Dhamoon, 2011). Reger et al. (2018) suggested that combat exposure of soldiers to dead
bodies during deployment affected their cognition and impaired mental health increasing the risk
19

of committing suicide. Bryan et al. (2015) agreed that exposure to killing or atrocities in combat
increases service members’ risk factors to commit suicide by 43%. Within the DoD, high rates of
suicide among the active-duty population significantly increased personnel’s exposure to suicide
events, lowering their cognition and unit morale and increasing the likelihood for an individual
to commit suicide (VanSickle et al., 2016). Bryan et al. (2019) examined a sample of 97 soldiers
identified as suicide attempters to determine their motivation for future suicide and attributed the
desire to reduce emotional stress as motivation to commit suicide in the future. Research results
revealed that soldiers with prior history of suicide attempts experienced relief from guilt,
depression, and hopelessness (Bryan et al., 2019), which informed their cognition and inspired
motivation to attempt suicide the second time (Elliot et al., 2017).
Furthermore, Cerel et al. (2019) surveyed 1,736 adults to determine the number of people
exposed to suicide events. Results indicated that each suicide event affects 137 people, and 20%
reported experiencing grief, traumas, and a need for mental health support. Additionally, 7% of
adults in the general population know someone who committed suicide, 1.1% acknowledge the
loss of a relative by suicide, and 5.4% reported exposure through the death of a coworker (Cerel
et al., 2019). Hedstrom et al. (2008) suggested that increased sympathy generated towards the
suicide committed by one person may trigger the desire and decision of another person to
commit suicide. The frequent exposure to a suicide event influences the focal person’s beliefs
about their ability to commit suicide, which increases suicidal behaviors, mental health
problems, and the decision to commit suicide (Hedstrom et al., 2008). Military members exposed
to a suicide event are at increased risk of mental and behavioral health issues and impaired
functioning (cognition), which increases suicidal behaviors (Andriessen et al., 2017). Another
study conducted by Pitman et al. (2017) to understand how exposure to a suicide event affected
20

429 adult students who lost friends by suicide indicated that exposure to a suicide event changes
personal belief to commit suicide. The belief that people who look like us succeeded in
performing an action strengthens a person’s restraints to perform similar behavior (Bandura,
1997). In fact, risk factors associated with increasing the likelihood of a person committing
suicide are experiences of loss and previous suicide attempts (WHO, 2021). According to
Bandura (2005), human beings’ personal choices and behaviors are shaped by the power of
social modeling.
Conversely, a study conducted by Miklin et al. (2019) examining the vulnerabilities of
people who are dealing with the loss of a close relative by suicide suggested that exposure to
suicide does not increase the risk of a person committing suicide. Instead, results from the
research showed that vulnerabilities are linked to how the person interpreted the situation and
experienced the loss (Miklin et al., 2019). After the exposure, respondents defined suicide as
optional, while others reframed their experience as harming others through trauma and grief,
which discouraged them from committing suicide. Overall, the conclusion is that exposure to
suicide is distressing but not inherently risky, and increased vulnerabilities and experiences
depend on the individual’s meaning-making (Miklin et al., 2019). This study is limited given that
all respondents were only, limiting the perspectives and experiences to women and excluding the
life experiences of men exposed to a relative’s death by suicide. Therefore, the research
conclusions cannot be generalized to the general population without integrating the overall
perspective and experience of both men and women.
Suicide is the leading cause of death among people 15 to 29 years old, with 79% of
suicides occurring in low- and middle-income countries (World Health Organization, 2021).
Adinkrah (2011) agreed that the frequency of death by suicide and increased suicidal behaviors
21

occur among the young and poor community. Also, suicide is the leading cause of death in the
general population and the second leading cause of death in the U.S. armed forces, as more than
47,000 people die by suicide every year, 1,000,000 people attempt suicide, and 500,000
Americans visited the emergency room in 2017 due to suicide (Guitierrez, 2021). Knowing how
exposure to a suicide event affects active-duty military members’ suicidal behaviors will help
increase understanding of the risk factors in the environment that increase suicides.
Environmental Risk Factors That Contribute to Increased Military Suicides Rates
Suicide is the tenth leading cause of death in the United States, and despite research and
preventive efforts, the ability to proactively reduce the rates of suicide has remained the same
over time with negative outcomes (CDC, 2021; Deming et al., 2021). A consistent finding in the
literature is a steady increase in active-duty suicides and an elevation in risk factors, including
suicide ideation and suicide attempts by military members (Buchman-Schmitt, 2020). Risk
factors that contribute to suicidal behaviors and suicides are complex and consist of events that
affect the individual, influencing their decision to commit suicide (1smallact, 2021). For
example, risk factors that exacerbate military suicide rates are mental health problems, substance
abuse, history of suicide attempts, financial problems, social isolation, preoccupation with
deaths, access to lethal means, thwarted belongingness, legal problems, failure in relationships,
and perceived burdensomeness (OPNAVINST, 2018). Personal exposure and interactions with
environmental factors affect the individual’s behaviors, cognition, and choices (Bandura, 2005).
Environmental risk factors associated with suicides affect motivation, self-regulatory
processes and personal beliefs, narrowing choices and decisions within an environment
(Bandura, 2005). Results from a qualitative study performed by Skopp et al. (2019) to
understand the influences of risk factors on military suicides examined 135 active-duty soldiers
22

using data from DoDSER, CDC, and National Violent Death Reporting System (NVDRS).
Results showed that intermate problems (63%), mental health and substance abuse (51.9%), job-
related issues (46%), financial problems (17.8%), and legal issues (16.3%) are risk factors that
affected active members who commit suicide. Risk factors inside the environment influence
behaviors, values, and a person’s choice to commit suicide (CDC, 2021).
The environmental risk factors that influence suicidal behavior and decisions to commit
suicide are previous suicide attempts, mental illness, social isolation, impulsive or aggressive
tendencies, substance abuse, job loss, criminal problems, relationships, and financial problems
(CDC, 2021). Because of the frequency of death by suicides among the active-duty population, it
is critical to understand the risk factors that lead to suicidal behaviors of active-duty military
personnel (McLean et al., 2017). Buchman-Schmitt (2020) agreed that identifying risk factors
that increase suicidal behaviors, suicide attempts, and suicides is essential to preventing death.
This research focused on two major risk factors that consistently impede suicide prevention
efforts among the active-duty military population: access to firearms and mental health and
substance abuse disorders (DoDSER, 2021).
Firearms
Firearms are the most often used method to commit suicide and a risk factor that serves
as a barrier and is counterproductive to preventing high rates of suicides among the active-duty
population. Firearms are the most common means of suicide in U.S. civilian and military
population due to access and high lethality (DoDSER, 2019). Also, the use of firearms is the
most common method to commit suicide in the United States and in the military and accounted
for half of the deaths in the United States and the military in 2016 (DoDSER, 2021). In the
general U.S. population, firearms accounted for 54.6% of all deaths by suicides between 1999
23

and 2004 (Martin et al., 2009). Houtsma et al. (2018) warned that half of the suicides committed
in the United States are attributed to access to firearms.
In 2017, personal firearms caused 65.5% of all active-duty suicides and were the most
used method to commit suicide due to access and lethality. Research also shows that the absence
of firearms during stress and high-risk period decreases the likelihood of military personnel in
crisis attempting suicide (21st Century Sailor, 2021). A Department of Defense suicide event
report from 2018 suggested that personal firearms accounted for 66.5% of all military suicides
that year and were the most used method to commit suicide in 2018. Personal firearms were used
as the primary method of choice (Table 3) to commit suicide by 59% (205 of 344 deaths) among
the active-duty military population.

Table 3
Methods of Suicide Death by Military Population for CY 2019
Active component Reserve National Guard
Method of death Count Percent Count Percent Count Percent
Total 344 100% 65 100% 89 100%
Firearm 205
108
59.6%
31.4%
43
14
66.2%
21.5%
70
12
78.7%
13.5% Hanging/asphyxiation
Drugs/alcohol 6
7
1.7%
2.0%
1
0
1.5%
0%
0
1
0%
1.1%
Sharp/blunt object
Poisoning 9 2.6% 0 0% 0 0%
Falling/jumping 3 0.9% 0 0% 0 0%
Other 3 0.9% 0 0% 2 2.2%
Pending/unknown 3 0.9% 7 10.8% 4 4.5%

Note. From Annual Suicide Report: Calendar Year 2019 by the Undersecretary of Defense for
Personnel and Readiness, 2020. U.S. Department of Defense. Copyright 2020 by the U.S.
Department of Defense.
24

Access to firearms is a risk factor associated with suicidal behaviors and increases in the
rates of suicide among the active-duty population (ASR, 2021). A case study conducted by
Scoville et al. (2007) examined 46 military recruits’ suicides to investigate methods used to
commit suicides during basic military training and suggested that gunshot (39%) was the most
frequently used method. The same study shows that Marine Corps and Army recruits committed
one-half of suicides using gunshot methods, and no Navy or Air Force recruits committed
suicide that way (Scoville et al., 2007). Another study conducted by Mahon et al. (2005)
examined epidemiology and workplace risk factors that increased suicide. The results indicated
that 53% of active-duty members who committed suicide used firearms and suggested that a
person’s occupation of influences the methods they used to commit suicide. Marine Corps and
Army recruits with infantry jobs are more likely to commit suicide using firearms than recruits
with no infantry experience (Scoville et al., 2007). Understanding how access to firearms
contributes to increasing suicide rates among the active-duty military population helps to
examine the link between mental health and substance abuse disorder in terms of suicidal
behaviors and suicide rates.
Mental Health and Substance Abuse Disorder
Mental health and substance abuse disorder are barriers to implementing successful
suicide awareness and prevention programs in the military because substance abuse resulting in
overdose has increased mortality worldwide (Martin et al., 2015). According to the Substance
Abuse and Mental Health Services Administration (SAMHSA, 2021), 61.2 million adult
Americans were diagnosed with a mental disorder, and 31.4% of that number presented with a
substance abuse disorder in 2019. Similarly, 59.7% of suicide attempters among active-duty
military used drug overdose and excessive consumption of alcohol as a method of injury, and
25

45.3% of service members who committed suicide were diagnosed with behavioral health
problems (DoDSER, 2018). Understanding the relationship between the environment, behaviors,
and the capacity of the individual to self-regulate their choices is essential to creating effective
solutions (Elliot et al., 2017). For example, the inability to manage stress due to relationship
problems produces hopelessness, which is a cognitive component of depression, often cited in
the literature as a risk factor associated with suicides (Martine et al., 2009).
Integrating social cognitive theory using observational and self-regulatory processes is
helpful to investigate how human interactions with the environment shape behavior and people's
choices (Bandura, 2005). Pintrich (2003) stressed using a multidisciplinary approach such as
developmental science, personality science, and learning sciences to analyze human behaviors
and create effective solutions to mitigate barriers to preventing suicide. Mental health and
substance abuse disorders are linked with socioeconomic issues such as unemployment, legal
problems, homelessness, and suicide, which diminish quality of life (SAMHSA, 2019). More
than 95,000 people die from excessive use of alcohol every year, which cost the American
taxpayers a quarter trillion dollars in 2010 (CDC, 2021). Dependency on substance abuse and
alcohol are culpable risk factors that increase the rate of suicide among the active-duty military
population, directly affecting mission readiness and retention (Jeffery & Mattiko, 2016).
Therefore, substance abuse is a risk factor, and the literature suggests that overdose is a common
method often used by active-duty military members to commit suicide (Bohnert, 2010).
Furthermore, Allen et al. (2005) observed that two-thirds of veterans who commit suicide
visited a physician a month prior to their death and warned that over 90% of veterans who
commit suicide have a diagnosable psychiatric condition. Additional evidence suggests that the
prevalence of mental health problems within the veteran’s community and the lack of access to
26

healthcare in rural areas to treat mental illness contribute to increased suicides rates among this
population (Allen et al., 2005). Lutwak and Dill (2017) observed that suicide rates increased by
8.8% among veterans who use VA health services compared to a 38.6% rate of suicides within
the population of veterans who do not use VA health services for mental health issues. The
literature indicated that the rate of suicide among male veterans who use VA services increased
by 11% and by 35% within the population of male veterans who do not use VA services to treat
mental health issues. Research shows a 4.6% increased suicide rate among female veterans who
use VA services compared to a 98% increase in the rate among veteran females who do not use
VA services to treat behavioral health problems (Lutwak & Dill, 2017).
Typically, veterans with mental health illnesses who reside in rural areas have 70% lower
odds of receiving treatment compared to veterans with the same mental health condition who
reside in urban areas, with 52% lower odds of receiving outpatient treatment and a 64% lower
chance of receiving prescription medications compared to veterans that maintain urban residency
(Allura & Arthur, 2019). Despite these challenges, most veterans and active-duty military
personnel with mental health or substance abuse disorder do not commit suicide, but most people
who committed suicide were diagnosed with mental health and substance abuse disorder (Martin
et al., 2009). Knowing how access to firearms, mental health problems, and substance abuse
disorder increase suicide rates among active-duty military will lead to examining how stigma
affects seeking help for mental health issues.
Challenges to Solving the Problem
The challenges surrounding effective mitigating suicides in the military, especially
among the active-duty population, to save lives is a major concern for leadership across DoD.
Prior to 2008, data collection and information management presented a challenge across the
27

military, as each service branch used different reporting systems to manage information
(DoDSER, 2021). The DoDSER was created in 2008 as a single system to collect data on suicide
events across the DoD as part of the prevention effort (DoDSER, 2021). However, despite the
withdrawal of troops from combat zones, which significantly decreased the number of
deployments and deaths during combat in Iraq and Afghanistan, suicide has remained the second
leading cause of death among active-duty military personnel every year, with accidental death is
the first (Hoyt & Holtz, 2020). Mastroianni and Wilbur (2011) agreed that in 2009 suicide
accounted for the death of more soldiers than combat fatalities, despite noteworthy progress
achieved in providing access to mental health, aggressive postvention programs, and support
services. Hoyt and Holtz (2020) asserted that despite access to care and resources to support
mitigation and prevention efforts, the rate of suicide among the active-duty military population
has remained unchanged. Suicide events happen in diverse settings with barriers and challenges
unique to each environment, personality, behavior, and culture, making it difficult to solve the
problem. This review highlights four distinct barriers and impediments to effectively mitigating
high rates of suicide among the active-duty military population, such as the lowering of military
recruitment standards, existing risk factors associated with suicide, the role of stigma in help-
seeking behavior for mental health issues, and ineffective prevention programs implemented at
command levels to prevent suicide.
Lowering Recruitment Standards
Lowering standards to entice more people to join the military is a barrier to effective
management and prevention of suicide among the active-duty military population. The Army
suicide prevention report released in 2010 found lowering the standards of recruiting to increase
the number of enlistments during major campaigns (wars) and poor leadership as barriers to
28

effective mitigation of suicide (Mastroianni & Wilbur, 2011). The war in Iraq and Afghanistan is
significant in that frequent deployments of troops and exposure to combat increased mental
health problems, post-traumatic stress disorder (PTSD), and depression (Ryman, 2006). To
reinforce the military, Congress authorized increasing the size of the Army with 30,000 more
soldiers through aggressive recruitment. To meet this goal, the Army lowered its requirements
for recruits in 2004 and successfully recruited more than 77,000 personnel (Schmitt, 2004). In
2005, the relaxation of military standards to allow more recruits, however unqualified, with
behavioral and mental health issues and restrictions on separating soldiers with legal and
performance problems helped maintain the military’s 2.7 million force (Mastroianni & Wilbur,
2011; Ryman, 2006).
However, research conducted by Ramp (2014) using a quantitative correlational study of
26,925 recruits found a significant relationship between recruitment waivers (lowering
qualification requirements) for the first term of service soldiers with attrition, suicidal behaviors,
and suicides. For example, research shows that suicide is the most common type of traumatic
death during military training across the U.S. armed forces (Gutierrez et al., 2021). Another
study conducted by Griffith and Bryan (2018) using administrative data to investigate the
characteristics of Army recruits to determine risks of suicide indicated significant life
experiences prior to joining the military, such as childhood physical abuse, family history of
mental health issues, and growing up in foster homes (Griffith & Bryan, 2018).
Consequently, the lowering of qualification standards to accommodate more people to
join the military during war increased admittance of recruits with high-risk behavior such as drug
and alcohol abuse, mental health issues, legal and financial problems, risk factors that exacerbate
the rate of suicides among the active-duty population (Mastroianni & Wilbur, 2011). Likewise,
29

studies show that life experiences such as relationship failure, past behavioral health conditions,
history of substance abuse, and prior suicide attempts are associated with suicides among
military recruits (Griffith & Bryan, 2018). Basic military training transforms recruits from
civilian life to military culture and way of life to master the skills and discipline required to
perform in operational and stressful environments upon completion. During basic training,
military recruits endure emotional and physical stress and psychological challenges necessary to
develop the discipline to perform military duties (Drehner et al., 1999). Basic training across all
service branches is challenging in that 12% of recruits fail every year to complete Marine Corps
basic training (Horton et al., 2014). Understanding how lowering recruiting standards affects the
rates of suicide among the active-duty military population helps to increase awareness of risk
factors that exacerbate suicides across the military.
Role of Stigma in Help-Seeking Behavior for Mental Health Issues
Mental health issues have significantly worsened in the military due to the stigma
attached to personnel who seek help for mental health and behavioral disorder, a barrier to
suicide prevention. Indeed, since 1995, clinicians have identified mental health disorders, such as
adjustment disorders, depression, alcohol-related disorders, and personality disorders, as the
second leading cause of hospitalization of active-duty military personnel (Westphal, 2007).
According to the 2015 Army Health of the Force Report, 17% of the force are medically unfit for
full duty due to physical and behavioral problems (Landers, 2017). Exposure to combat
assignments and the frequent deployments to Iraq and Afghanistan and across the globe to
engage in military operations have produced diverse mental health problems for active-duty
military personnel (Waitzkin et al., 2018).
30

Despite access to care and increases in mental health conditions among the active-duty
military population, the number of personnel who seek help for treatment is low (Krunnfusz,
2018). The stigma attached to seeking help for mental health issues and the fear of how it affects
service members’ careers present a challenge to access treatment for mental health services,
contributing to increased suicidal behaviors in the military. For example, stigma and fear of
career failures cause underutilization of healthcare facilities to manage behavioral issues, which
contributes to personal suffering, increases healthcare costs and expenditure, and affects military
units’ mission readiness (Westphal et al., 2018). Tal (2021) agreed that untreated mental illness,
behavior disorders, and substance abuse disorders increase health problems, leading to poor
decision-making. Results from a study of 128 male first responders (firefighters, paramedics,
EMTs, and police officers) to investigate the relationship between behavior, health stigma,
coping strategies, and burnout suggests the attitude of avoiding mental health experience is a
predictor of emotional exhaustion and depersonalization (Tal, 2021). Creating effective programs
to mitigate stress and decrease the high rates of suicides among the active-duty military
population is a concern for DoD (Gochicoa, 2019).
Price (2011) examined the relationships between mental health and help-seeking behavior
and suggested that stigma and perception of fear affected participants' attitudes toward seeking
help for mental health problems. Notably, results show a strong relationship between the military
culture of toughness and decreased openness to seek mental health and treat behavioral issues
(Price, 2011). The study found stigma as a significant barrier to help-seeking behavior in the
military. The belief and perceived stigma directly affect members' decisions to seek help to treat
mental health issues, worsening mental health problems, increasing risk factors that result in
suicides (Westphal et al., 2018). However, the research failed to consider the role of effective
31

leadership and command climate, lack of protective factors such as family support, personal
resiliency, self-regulation, sense of community and belonging, spirituality, the critical thinking
skills as factors, besides stigma, which serve as barriers to suicide prevention.
It is important to understand why active-duty members do not seek help for mental health
issues (Gochicoa, 2019). The structure within a military organization is unique in that the
supervisor has complete authority over subordinates' personal and professional development,
career progression, and promotion. Military culture consists of shared values, beliefs, and
behaviors that inform positionality, sense of belonging, and meaning across the organization
(Convoy & Westphal, 2013). Thus, the belief of stigma from supervisors and senior leadership of
junior personnel who seek mental health, members identified as at risk, suicide attempters, and
behavioral health problems is detrimental to career enhancement. For instance, research suggests
that marines diagnosed with mental health conditions received demotion and separation from
active duty, and pre-existing behavioral and mental health disorders are the number one reason
for post-deployment demotion (Varga et al., 2018).
The cultural influence of the military affects the help-seeking behavior of active-duty
members towards therapy and adherence to treatment regimens (Convoy & Westphal, 2013).
Westphal et al. (2018) asserted that stigma and the fear of the negative impact on military careers
are why military members mostly underutilize mental health services. The willingness of
military members to show and seek treatment for mental health problems depends on personal
beliefs about career outcomes and military status (Convoy & Westphal, 2013). Landers (2108)
reported a significant increase in soldiers’ behavioral health problems from 9.4% diagnosed in
2007 to 15% diagnosed in 2014. Gochicoa (2019) advises military leaders to create a climate to
32

model positive attitudes towards behavioral disorders to increase help-seeking behaviors for
mental treatment among the active-duty population as preventive measures to mitigate stigma.
Nonetheless, Cerrully et al. (2018) argued that empirical data to support evidence of
stigma as a barrier to help-seeking for mental health care in the military lacks results, correlation,
and consistency. The literature analyzed 10 databases and 2,409 sources linking stigma and
mental health treatment between 2004 and 2014 show no evidence of a direct effect of stigma on
treatment-related outcomes among military members with mental health issues (Cerully et al.,
2018). Dondanville et al. (2018) posited that only 23 to 40% of active-duty members seek help
for PTSD and mental health-related traumas and attributed the low percentage due to stigma and
the belief that admitting to having mental health problems would be harmful to their careers.
However, a study conducted by Krunnfusz (2018) using a self-report survey examined
322 active-duty military members across services to figure out the relationships between mental
health conditions, stigma, and willingness to seek mental health care. Evidence in the literature
suggests personal, and public stigma contributed to diminished willingness to seek care for
mental health problems among active-duty military personnel (Krunnfusz, 2018). Also, the
stigma of mental health treatment, fear of consequences, and the belief of losing security
clearances affect help-seeking behavior (McKnight, 2019). According to Westphal (2007), the
stigma of military senior leadership attitudes towards behavioral illness and the fear of the
negative impact on subordinates’ careers affect help-seeking behaviors for mental health
problems. Knowing that stigma affects help-seeking behavior and increases risk factors and
suicide rates among the active-duty military population helps to examine the effectiveness of
suicide awareness and prevention programs across military commands.
33

Ineffective Prevention Programs
The United States and other countries recognize suicide as a public health problem that
affects lives, families, and the operational readiness of the military. Griffith and Bryan (2018)
agreed that increases in the rates of military suicides are a health concern for military leaders,
policymakers, and researchers. As a result, organizations and the military developed prevention
programs to facilitate awareness of risk factors that increase suicide: education to first responders
and bystanders, warning signs to enable early detection of crisis to provide access to care and
helping families who experience suicide (Quick series suicide prevention, 2021). For instance,
the Navy suicide prevention program integrates operation stress control and suicide prevention to
decrease the risk of suicide by improving mental health and sailor resiliency to achieve the
mission through teamwork and effective implementation of prevention practices (1smallACT,
2021). However, findings in the literature suggest a lack of evidence of effective and successful
suicide prevention programs across military organizations (Harmon et al., 2016). Despite efforts
to create prevention programs, the rates of suicide among the active-duty military population
have remained high due to the lack of a framework implemented to evaluate gaps in prevention
programs to create effective solutions (Griffith & Bryan, 2018). Understanding the barriers to
mitigating the rate of military suicide will help examine how exposure to a suicide event affects
the active-duty military population.
The Effect of Suicide on Active-Duty Military Population
Research shows active-duty military personnel’s death by suicide correlates with
increased suicidal behaviors, ideation, and suicide attempts in the military population (Bryan et
al., 2016; O’Connor & Portzky, 2017). The high rate of suicide among the active-duty population
elevates suicide attempts in the same demographics (Rowan et al., 2014). Likewise, death by
34

suicide affects the behavior and ability of a person exposed to the event to perform their job
effectively (Psychological Health Center of Excellence, 2021). In other words, when a person
commits suicide in a command, coworkers, family members, and friends experience grief and
bereavement, mourning their loss. Often, military personnel who worked with the deceased such
as colleagues, roommates, and supervisors, are sad, angry, and feel guilty for not doing enough
to prevent the suicide (PHCE, 2021). Andriessen et al. (2017) agreed that people who experience
exposure to a suicide event also experience more feelings of guilt, shame, social stigma, and
difficulty finding meaning to understand and cope with the situation. Thus, the high rates of
suicide among the active-duty military population began to increase in 2005, which correlates
with a significant increase in the numbers of suicide survivors, friends, relatives, co-workers,
mental health professionals, and unit members coping with loss (Postvention, 2018).
Healthcare workers and providers such as physicians, social workers, command
chaplains, and command suicide prevention program managers in relationship with the decedent
are affected with doubts and question their ability to provide quality care. For example,
qualitative research conducted to study the emotional responses of 26 psychotherapists after their
patients committed suicide revealed that 50% responded with shock, and 12% reported unbelief
with a range of emotions such as grief (65%), guilt (50%), anger (46%), fear of blame (42%),
self-doubt (42%), and fear of lawsuit (38%) (Welton & Blackman, 2006). Gerada (2018) noted
that the rates of depression and anxiety are higher among physicians compared to the general
population and other professions. The Psychological Health Center of Excellence (2021) asserts
that an individual’s belief of closeness with people who committed suicide is psychologically
more damaging to the people exposed to suicide than physical proximity and relationships. A
study conducted by Welton and Blackman (2006) had limitations in that the researchers did not
35

account for past traumas suffered by respondents due to no suicide deaths that contributed to
their grief. Information about each providers’ family history of mental health, childhood traumas,
life events, or mental health of the respondents was not examined prior to the study to eliminate
bias and false attribution of the trauma to the exposure of their patients who committed suicide.
Consistent findings in the literature show that suicide is a public health problem that
interrupts families’ quality of life, harms the close friends of the deceased, and affects the social
environment (Yamane & Butler, 2009). Also, people who experience emotional distress,
prolonged grief, and bereavement caused by suicide are less likely to receive support and access
to healthcare compared to others who experience grief by other causes (Pitman et al., 2017).
Sanford et al. (2016) concurred with the significant gap in providing access to care and support
services for people bereaved by suicide. Deaths by suicide affect 135 people within the same
social environment as the deceased, and 800,000 people die by suicide every year, making it a
public health problem (Lestienne et al., 2021; WHO, 2021).
The complexity surrounding the manifestation of suicide is one of the central issues to
address through public and mental health with consideration for associated risk factors like social
isolation, alcohol and drug abuse, and family events (Javier et al., 2020). The consequences of
suicide bereavement are the negative effect on the mental health of families and friends of the
deceased and their ability to function socially. Findings in the literature show the prevalence of
experiencing bereavement caused by suicide is 4.3% of people in 2020 and 21.8% in a lifetime;
and people who experienced exposure to a suicide event have a higher risk of developing mental,
emotional, and physical illness, social problems, and suicidal behaviors compared to the general
population (Lestienne et al., 2021).
36

Death by suicide causes significant suffering and emotional trauma to the decedents’
families and presents a heavy financial burden to society. Suicides and suicide attempts cost the
American taxpayers an estimated $58.4 billion and a loss of man-hours in national productivity
(Skopp et al., 2019). Suicide and suicide attempts incur direct costs related to the injury, such as
inpatient hospitalization, investigation, ambulance transport, and follow up care and economic
cost such as losses in productivity due to sudden death, net present value of future salaries,
wages, and value of household reduced by suicide (Shepard et al., 2015). The average cost of
suicide in the United States is $1,329.553, with a 97% lost productivity due to medical treatment
and the total cost of suicide and suicide attempts amounts to $93.5 billion (Suicide Prevention
Resource Center, 2021). Understanding the economic impact (Figure 1) of suicide is critical to
creating policy and effective programs (SPRC, 2021).

37

Figure 1
The Mean Medical and Work-Loss Cost Per Injury Death by Intent in the United States, 2013

Note. From Estimated Lifetime Medical and Work-Loss Costs of Fatal Injuries — United States,
2013 by the Centers for Disease Control and Prevention. Copyright 2015 by the Centers for
Disease Control and Prevention.

Existing Strategies for Solving the Problem
To prevent a person from committing suicide is like finding a needle in a haystack, citing
the complexity involved in using a multifaceted approach and integrating diverse frameworks as
a solution (Gerada, 2018). Suicide is a complex social problem with diverse risk factors inside
the environment influencing individual behaviors; and requires a comprehensive public health
approach towards prevention efforts (Defense Suicide Prevention Office, 2021). Recently, DoD
increased awareness of prevention efforts by creating an effective strategy to reduce military
38

suicides (Bryan & Rozek, 2018), such as creating the Defense Suicide Prevention Office Annual
Report, the Department of Veterans Affairs Clinical Practice Guidelines for Assessment of
Patients at Risk for Suicide, and the National Research Action Plan (Griffith & Craig, 2018). The
current framework implemented by DoD integrates the public health approach used by the CDC
that accounted for the influences of environmental risk factors, personal behaviors, and
personality of the member to create suicide prevention programs (ASR, 2019). In 2017, DoD
strategically adopted the CDC evidence-based prevention strategies with a public health
approach to decrease environmental risk factors and increase resiliency protective factors of
individuals (ASR, 2019). Implementing this multifaceted and diverse approach helped increase
awareness and mitigation efforts to decrease the rates of suicide among the active-duty military
population.
The CDC strategies (Figure 2) adopted by the DoD to mitigate suicide among the active-
duty military population are to strengthen economic support, strengthen access and delivery of
suicide care, create protective environments, promote connectedness, teach coping and critical
thinking skills, identify and support people at risk, lessen harms, and prevent future risk (ASR,
2019). The left side of the chart has the framework and seven strategies prescribed by CDC as
initiatives to prevent military suicides, increase protective factors, and reduce risk factors.
Implementing the strategy will change the proximal outcomes. The proximal outcome will
directly affect the protective factors and risk factors influencing the environment, which mitigate
suicidal behaviors, and suicides. Positive changes in proximal outcomes decrease distal
outcomes, which is the reduction of suicide deaths and attempts. Although reductions in these
behaviors constitute the ultimate indicators of success, reducing these behaviors requires a
coordinated implementation of multiple suicide prevention initiatives and activities over a
39

prolonged period (ASR, 2019). Figure 2 shows enterprise-wide program and evaluation
framework.

Figure 2
DoD Enterprise-wide Program Evaluation Framework for Suicide Prevention Efforts

Note. From Annual Suicide Report: Calendar Year 2019 by the Undersecretary of Defense for Personnel and Readiness, 2020. U.S.
Department of Defense. Copyright 2020 by the U.S. Department of Defense.

40
41

Furthermore, command resiliency programs such as Comprehensive Soldier and Family
Fitness, Comprehensive Airman Fitness, Sailor Assistance and Intercept for Life (SAIL), and
Combat Operational Stress Control are designed to assist military personnel to develop valuable
skills to manage stressors, thereby reducing environmental risk factors for suicide (Griffith &
Craig, 2018). For instance, SAIL is designed as an intervention program to deliver help during a
crisis, risk assessment, coordinate healthcare, and reintegrate Navy personnel identified with
suicidal behaviors back into the command climate (1smallACT, 2019). Connecting with family
and social groups is a protective factor effectively used to help reintegrate military personnel
treated with mental health issues back into their command, which is essential to achieve well-
being and develop the ability to manage emotional and psychological stress (Barry et al., 2019).
Likewise, a strong connection with family and a supportive community serves as protective
factors for service members during a crisis and provide support that promotes a sense of
belonging and mental health (Barry et al., 2019; Laerke Mai Bonde, 2021). Rahman (2022)
agreed that maintaining effective communication and a healthy relationship with families
significantly increased resiliency and improved the mental health of nurses during the pandemic.
Another study shows that eating healthy and integrating daily exercise, such yoga, breathing
exercises, dancing, cooking, and reading, are positive coping mechanisms to help manage stress
and improve mental health (Rahman, 2022).
The primary intervention programs implemented by DoD increased communication, ,
educated military personnel on warning signs, risk factors, and protective factors, and
encouraged help-seeking behaviors (Griffith & Craig, 2018). An effective intervention protocol
is critical for providing timely response and treatment for mental health and support services
(Stallman & Allan, 2021; WHO, 2014). Similarly, sharing experiences through storytelling and
42

speaking publicly about a personal struggle with suicide serves as a strong coping mechanism
(Hua et al., 2020). Participating in meetings and baseline interviews concerning suicide helped
study participants avoid social isolation and adjust to their loss (Saarinen et al., 2000).
Additionally, joining groups online to share experiences facilitates the exchange of ideas that
helps to empower bereaved individuals, reframe, and destigmatize individual experiences of
suicide narratives (Hagstrom, 2017). Research also shows that providing psychological
assessment and counseling for suicide survivors helps them adapt and cope (Hua et al., 2020).
Military personnel complete mandatory suicide awareness and prevention training annually to
understand environmental risk factors, warning signs, available resources, intervention strategies,
and activities that strengthen individual protective factors (OPNAVINST, 2018). Particularly,
strong connections with family and friends, seeking help for mental health issues, team unity and
camaraderie, beliefs that support self-preservation, positive attitudes towards life, and effective
critical thinking skills are taught as human protective factors used as coping mechanisms and
decrease the risk for suicidality (OPNAVINST, 2018).
Command-Level Intervention
A well-planned and properly executed training program evaluation is vital to finding the
outcomes and benefits of a personnel development program for the individual and the
organization (Hauser & Weisweiler, 2020). Currently, command-level training programs
promote the truth about stigma and encourage help-seeking behaviors for mental health and
substance abuse issues (OPNAVINST, 2018). Once a year, active-duty personnel attend suicide
awareness and prevention training as a requirement across military units. The training program
helps to educate and increase member’s knowledge on suicide prevention topics, such as
• Anyone can be at risk regardless of age, sex, race, military title, and years of service.
43

• How to recognize risk factors, early intervention plan, and use protective factors.
• Protocols and local resources available to respond to crisis.
• Promotes firearms safety measures and voluntary use of gun lock and storage of
personal weapons.
• Facilitate understanding the Ask, Care, and Treat action plan to encourage peer
intervention during crisis.
• Developing important life skills to increase coping skills, resiliency, health, and
fitness.
• Teaches effective reintegration strategy to support members returning from suicidal
treatment, mental health issues, and substance abuse problems.
• Effective reporting process to facilitate immediate response to prevent suicide.
• Postvention plans to help heal the command team at once after a suicide death.
Theoretical Framework
Social cognitive theory (SCT) is used as background to investigate how exposure to a
suicide event increases suicidal behaviors and the rates of suicide among the active-duty military
populations. Moreover, the literature review was conducted using SCT as a lens to examine
empirical from previous work completed by researchers to increase knowledge. Originally
developed in the late 1970s, SCT uses observation and modeling of others’ behavior, attitudes,
and emotional reactions as the basis of social learning (Bandura, 2005). The theory suggests that
most human behaviors are learned from watching other people's behaviors in the environment
(Bandura, 1994). Thus, SCT states that learning occurs by seeing other people's behaviors and
then modeling the behaviors that help the person and avoiding behaviors that produce negative
outcomes (Bandura, 2005). It is a learning theory that uses observational, retention, production,
44

motivational and self-regulatory processes to emphasize the role of behavior and individual
beliefs within an environment (Bandura, 2005). The SCT proposes that all human activities and
performance are embedded into a broad network of social systems that allows people to drive
their function and regulate their activities based on values, self-efficacy, interests, and goals
(Bandura, 2005).
Additionally, SCT views human beings as change agents who actively participate in
changing their conditions and are changed by their environment, which creates constraints on
human performance to produce responses and behaviors (Bandura, 2005). In addition, SCT
provides a framework to understand how individuals’ beliefs in self-efficacy influence their
abilities to organize, create, and manage circumstances inside the environment. The theory also
argues that people can motivate and self-regulate their own behavior to set and achieve personal
goals based on self-interest, benefits and material costs, and personal standards (Bandura, 2005).
I will describe and interpret the lived experiences of retired military personnel affected by
exposure to a suicide event while on active duty to understand its effect. Using SCT as
background to frame the study is effective because suicide is a complex social issue with diverse
manifestations on personalities, experiences, and behavior.
Conceptual Framework
The high rates of suicide among the active-duty military population significantly increase
the chances of exposing active-duty military personnel to a suicide event. Consequently,
exposure to a suicide event affects the members psychologically, emotionally, cognitively, and
behaviorally changing values, personal beliefs, and choices. Continuous exposure due to the high
rates of military suicides increases mental health issues and substance abuse problems leading to
increased suicidal behaviors, mental health problems, substance abuse, and military suicides. The
45

core concept (Figure 3) is that increases in the rates of active-duty suicide affect the beliefs,
values, cognition, and mental health of military members who are frequently exposed to suicide
events in the military environment. As a result, active-duty military personnel experience
increased mental health problems and suicidal behaviors that lead to suicides.

Figure 3
Conceptual Framework of How Exposure to a Suicide Event Affects Behavior and Suicide Rates

High Rates of
Suicide Among
Active Duty
Population
Environment
-Norm
-Culture
-Stigma
Person
-Self-regulation
-Beliefs
-Cognition
Behavior
- Mental Health
- Emotions
-Help-seeking
Suicides
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Past Research Using Social Cognitive Theoretical Framework
In the past, researchers used the SCT framework across academic disciplines to
investigate various subjects affecting human behaviors and interaction with the environment. The
increase in suicide rates is a public health issue that affects society both socially and
economically and requires using SCT to reframe the problem, enhance knowledge, and create
effective solutions. For example, Innamorato (2020) used the SCT lens to investigate the impact
of long-term stress and coping among the military reserve and veteran populations, increasing
knowledge and improving resiliency programs across the military population. The researcher
used cognitive theories of PTSD and stress coping to show gaps in addressing the need to create
military stress readiness and training in the Air Force Reserve. The study examined data
collected from Air Force reservists and veterans across the armed forces through semi-structured
interviews and used interpretative phenomenological analysis to compare the experiences and
perceptions of participants with stress within the military environment. Results from the study
indicate a lack of standardized training on healthy coping strategies within the military
organization, with recommendations such as strong leadership, command support, and creating
formal training to help manage stress for military personnel (Innamorato, 2020).
Also, Douglas-Parham (2020) integrated SCT to examine the lived experiences of women
who experienced intimate partner violence while parenting. The researcher used a semi-
structured interview method with an open-ended questioning technique to interview six abused
women to collect and examine behavior patterns due to exposure to violence. Findings from the
literature show that intimate partner violence negatively affects women and their children
psychologically, emotionally, and physically (Douglas-Parham, 2020). Results from the study
suggested that abused women develop low self-esteem, which affects their personal beliefs in
47

their ability to perform as parents and develop healthy relationships with their children, the
inability to leave the environment or abuser, increased awareness of impending violence
behaviors and developing passive behaviors as protection for survival (Douglas-Parham, 2020).
The research used an SCT framework as a lens to highlight the cognitive, environmental, and
behavioral experiences that affect intimate partner violence on women and children and
developed interventions (Douglas-Parham, 2020).
Fagan (2019) used SCT to explore the experiences of women enrolled in an
undergraduate engineering program at a research university. The phenomenological study used
SCT as a lens to increase understanding of the factors that influence the choices and motivation
of women to enroll in and graduate from engineering programs. Using the SCT as a framework,
the researcher examined how participants educational choices influenced personal
characteristics, lived experiences, and environmental factors. Findings in the literature reveal
behavioral patterns that align with the SCT framework in that exposure to STEM and
engineering programs, self-efficacy in math and science classes, engineering agency beliefs,
outcome expectations, and pre-college environmental support influenced women’s decision to
enroll in college engineering programs. Additionally, patterns that inspired women’s persistence
in engineering are engineering barriers for women, engineering coping strategies, and
engineering environment support (Fagan, 2020).
Reasons Underlying Problem of Practice
The high rates of military suicides have remained unchanged every year despite access to
healthcare, showing the lack of an effective framework for suicide prevention (Griffith & Craig,
2018). While there are extensive studies on military suicides, risk factors that influence
behaviors, prevention programs, and protective factors to increase resiliency, there is limited
48

research on how exposure to a suicide event affects suicidal behaviors and its correlation with
high rates of suicide among the active-duty military population. Using the SCT framework will
facilitate an understanding of associations between exposure to suicide events, suicidal
behaviors, and high rates of suicides among the active-duty military population. Understanding
correlation between exposure to suicide event and changes in behavior will help increase
awareness and galvanize support assisting people who experienced death by suicide of a
colleague and family members.
Death by suicide is a global phenomenon that is trending upwards nationally every year,
with evidence seen among the military population (Defense Suicide Prevention Office, 2021).
Baily (2020) agreed that the military population’s high rates of suicides are concerning and a
significant social problem. Death by suicide has been steadily increasing in the general U.S.
population, killing more males (49.2%) and young adults, directly affecting military
organizations consisting mostly of males (81.7%) and young adults (Defense Suicide Prevention
Office, 2021; DoDSER, 2019). Selby et al. (2010) concluded that military suicide increased
since Operation Iraqi Freedom and Operation Enduring Freedom and emphasized the need to
advance risk assessment techniques and create effective prevention programs to treat mental
health problems. The increase in deaths by suicide of active-duty personnel is a public health
concern that requires effective solutions to mitigate it and save lives (Short et al., 2019).
Summary
High rates of suicides among the active-duty military population cause continuous
exposure of military members to a suicide event, which affects their cognition, values, and
beliefs; and increases mental health issues, suicidal behaviors, and suicide rates. Despite access
to healthcare and prevention efforts, the rates of military suicides have remained unchanged
49

every year (Ramchand et al., 2011). Even more, research shows that 2,872 active-duty military
members committed suicide between 2009 and 2018 (DoDSER, 2021; PHCE, 2021). Suicide is
the second leading cause of death in the Air Force and is responsible for one-fourth of deaths
among active-duty Air Force (Welton & Blackman, 2006). Particularly, 20 veterans and active-
duty members commit suicide every day (Lutwak & Dill, 2017). More than 48,000 Americans
died by suicide in 2018, and 47,500 committed suicide in 2019, with one death occurring every
ele11ven minutes (CDC, 2021). Globally, 800,000 people die by suicide every year, with one
suicide happening every 40 seconds (WHO, 2021). Exposure to a suicide event affects personnel
behavior, performance, and operational readiness (Reimann & Mazuchowski, 2018; Rowan et
al.,2014).
Barriers, such as lowering military recruitment standards, substance abuse, mental health
problems, and access to firearms, increase risk factors that lead to more suicides in the military.
The cultural stigma attached to mental health treatment directly affects the help-seeking behavior
of personnel with mental health problems to seek treatment, which increases suffering that leads
to suicides (Westphal et al., 2018). Using SCT as a lens to examine the association between
exposure to suicide events, suicidal behaviors, and suicide will help reframe the problem to
create effective solutions. The purpose of the study was to investigate how exposure to a suicide
event affects the behavior of active-duty military personnel to increase knowledge about how
suicide affects the behaviors of people who experience loss. Understanding the effect of suicide
on behavior may increase awareness of the problem to provide healthcare and support to people
who experience the loss of someone to suicide. Failure to understand how interaction with the
environment affects personal behavior and influences choices will lead to more death by suicide
among the active-duty military population.
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Chapter Three: Methodology
The purpose of the study was to investigate how exposure to a suicide event affects the
behavior of active-duty military personnel to increase knowledge about how suicide affects the
behaviors of people who experience loss. Understanding the effect of suicide on behavior may
increase awareness of the problem to provide healthcare and support to people who experience
the loss of someone to suicide. Applying SCT as a framework, the study focused on
understanding the link between experiencing loss by suicide, suicidal behaviors, and suicides to
fully understand the causes of military suicides to create effective solutions to the problem. In
other words, it is important to know the what, why, and how of the methods used to conduct
effective and successful research (Morgan, 2014). Chapter Three discusses the research design,
study sample, research methods used to obtain data, ethical standards implemented to protect the
study population, and how the participants’ confidentiality was maintained throughout the study.
Also, this chapter describes the measurement instruments used, data collection methods, and
analytical process applied to obtain findings, validity, and reliability in the study.
Research Questions
1 How does the experience of losing someone to suicide influence the behaviors of
active-duty military personnel?
2 What role does stigma play in seeking help from mental health among active-duty
military personnel?
3 What are the recommended methods used by retired military personnel to cope with
the loss of someone to suicide while on active-duty military?
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Overview of Design
The study integrated qualitative analysis with a constructivist-interpretive worldview as a
paradigm to collect, analyze, and accurately interpret and present findings. In effect, the study
integrated past research and findings in the literature to understand the depths and complexities
surrounding suicide. Then, it combined data from the lived experiences of 11 retired military
personnel to add depth and knowledge to the existing literature about how suicide affects the
behaviors of people with loss. Indeed, 11 retired military personnel across the four service
branches were recruited to participate in the study through word of mouth and an invitation
posted on my page on the LinkedIn website. The interview instrument and questions created
through a pilot study were used to collect data from participants who were exposed to a suicide
event while on active-duty military service to help broaden knowledge and understanding of the
interrelationship between the environment, personal behavior, and military suicide rates. The
dependent variable is active-duty military suicide, while the independent variable is the changes
in the behaviors of active-duty military personnel upon exposure to a suicide event. Thus, SCT
was used as background to frame the study, and a constructivist-interpretive worldview was used
as a paradigm to describe and interpret the lived experiences of active-duty sailors through the
lens of retired military personnel. During the research, each person’s experience was treated as
occurring within a specific context that consisted of their whole life as well as the larger cultural
and social forces that shaped their meaning (Morgan, 2014).
Suicide is a complex social problem with diverse factors affecting the environment and
influencing the individual that requires a comprehensive public health approach to prevention
efforts (Defense Suicide Prevention Office, 2021). Baily (2020) agreed that the high rates of
suicides among the military population are concerning nationally and present a significant social
52

problem in the last decade. Conducting qualitative research helps to facilitate learning about the
problem directly from the participants and strategically guides the research to obtain needed
information to increase knowledge (Creswell & Creswell, 2016). A qualitative research design is
appropriate for this research on the retired military personnel’s experiences to increase
knowledge on how exposure to a suicide event affects individual’s behavior and choices. A
comprehensive understanding of the effect of suicide and its influences on human behaviors will
help to create an effective framework to mitigate the high rates of suicide in the military and
provide better support and healthcare to people affected by loss. Lack of knowledge and holistic
understanding of the link between exposure and behavior will perpetuate increased rates of
suicide among the military population and globally. Three research questions (Table 4) guided
data collection and analysis for this research.

Table 4
Three Research Questions That Guided Data Collection
Research questions Method: Qualitative
How does the experience of losing someone to
suicide influence the behaviors of active-duty
personnel?
Interviews
What role does stigma play in seeking help for
mental health among active-duty personnel?
Interviews
What are the recommended methods used by
retired military personnel to cope with the loss
of someone to suicide while on active-duty
military?
Interviews

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Research Setting
This study sampled 11 retired military members who experienced exposure to a suicide
event (experienced loss of a friend, close relative, colleague, or family member to suicide) while
on active-duty military service. The study integrated the lived experiences and perspectives of
male and female retired military members to understand the effect of suicide on the behavior of
survivors. This population is important and proper for the study to understand the association
between exposure to a suicide event, suicidal behaviors, and high rates of suicides among the
active-duty military population. Each participant’s experience was treated holistically as
occurring within a specific context as well as the larger cultural and social forces that shaped
their lives while serving on active-duty military (Morgan, 2014). The method and approaches to
the study align with SCT to know how interactions with the environment influence human
behavior and the choices of the individuals in that environment (Bandura, 2005). In addition, I
used purposeful sampling with a convenient approach to recruiting 11 interviewees. Using
purposeful sampling and selecting the 11 volunteers was beneficial to the study because they are
experts and experienced exposure to a suicide event (Maxwell, 2013).
The Researcher’s Positionality
A researcher’s choice of theory and conceptual framework shows their personal beliefs,
perspectives about knowledge, worldview, and positionality (Osanloo & Grant, 2016). I
currently serve on active duty in the Navy onboard a Navy aircraft carrier in Norfolk, Virginia. I
have completed two combat tours in Iraq during Operation Iraqi Freedom and Afghanistan
during Operation Enduring Freedom in support of national taskings. The positionality and
approach concerning suicide was shaped by 20 years of life experience serving on active duty
and continuous exposure to suicide events. As a Navy corpsman (combat medic), I experienced
54

the loss of co-workers, friends, sailors, and marines on several occasions while serving on
combat tours and after deployment. I also served as command drug and alcohol program adviser
(DAPA) for 2 years while stationed overseas. As command DAPA, I provided intervention
services, counseling support, and access to specialty care to active-duty sailors with substance
abuse problems, alcohol dependency, and mental health problems. Serving as DAPA
significantly increased my awareness of the problem of suicide ideation, alcohol abuse,
psychological trauma, and environmental risk factors associated with influencing the behaviors
and choices among active-duty military personnel.
Furthermore, as a senior enlisted leader in the Navy, I also took part in countless medical
evacuations from overseas duty stations of active-duty sailors who tried to commit suicide. On
three occasions, I responded to a medical emergency to find the body of a sailor who committed
suicide in the barracks at an earlier duty station. Indeed, my experience of losing friends to
suicide, aiding sailors through interventions, and providing counseling on substance abuse
problems may affect the accurate interpretation of data, which will decrease the reliability and
validity of the results. To avoid this, I kept a focus on interpreting and understanding the
meaning presented by the participants, not the meaning that the researcher brings to the research
(Creswell & Creswell, 2016). Also, using reflexivity and an integrated approach to inductively
construct meaning based on the participants' lived experiences ensured the correct interpretation
of data (Creswell & Creswell, 2018). I am responsible for accurately describing participants' life
experiences, constructing their meanings in that environment, and actively interpreting and
communicating findings (Merriam & Tisdell, 2016). Separating my experiences in dealing with
suicides and positionality allowed the research method and instruments to guide the study. Thus,
successful qualitative research integrates multiple sources of qualitative data to make
55

interpretations of a research problem and find effective solutions (Creswell & Creswell, 2016).
Also, the theoretical framework for the study connected links between concepts and the basis for
examining and understanding the effect of military suicides (Osanloo & Grant, 2016).
Conflict of Interest
The most critical factor in using a qualitative research method is selecting the sample,
population, time, and settings that offer the researcher valuable information to answer the
research questions (Maxwell, 2013). Conflict of interest was prevented during the research by
recruiting a retired military population to take part in the study. Even more, participants were
recruited from a network (LinkedIn site), served across military branches, and had diverse
experiences, environments, and perspectives on the effect of suicide. Qualitative researchers
collect data in the field and natural setting where participants experience the problem of practice
they are examining (Creswell & Creswell, 2016). Also, a purposeful sampling method was used
to recruit retired military participants who were exposed to several suicide events. No active
military personnel participated in this study to prevent conflict of interests and increase research
credibility (Merriam & Tisdell, 2016).
Data Sources
Qualitative Interviews
The study was designed to collect data through qualitative interview from 10 retired
military personnel (five males and five females) who retired between 2018 and 2022. However,
25 people volunteered to participate in the study and 11 people signed and returned their consent
form to meet deadline. A qualitative interview instrument was designed through a pilot and
implemented to collect data on the lived experiences of 11 participants (nine males and two
females) who were exposed to a suicide event. As a result, the interviews were conducted using a
56

semi-structured interviewing approach to gain rapport with respondents to encourage
participation and increase confidence and trust between researcher and respondents. Quality
fieldwork is the goal in showing the relationship between researchers and subjects (Bogden &
Biklen, 2007). The semi-structured interview approach entails proper use of the targeted
population because it allows participants to be comfortable sharing individual experiences of
dealing with the loss of a friend, family member, or active-duty military member to suicide.
Patton (2002) agreed that the purpose of interviewing is to allow the researcher to enter the other
person’s perspective to gain valuable insights to broaden knowledge. Using a semi-structured
interview approach ensured information sharing and balance between researcher and respondents
to explore the problem of military suicide among the active-duty military population. I used
interview transcripts integrating a constructivist-interpretive paradigm during data analysis and
interpretation. Figure 4 shows the most popular words used during interviews.

57

Figure 4
NVivo Word Frequency

Participants
Purposeful sampling was used with a network approach to recruiting 11 interviewees.
Email description of the purpose of the study, researcher’s USC email, and phone number was
drafted and submitted to IRB for approval and used as recruiting tool. Upon approval from IRB,
the email was posted on my Linkedin page asking for retired military personnel to volunteer. A
network approach was integrated asking classmates to copy and repost study on their Linkedin
pages, which increased awareness of the study to participants. Volunteers consisted of 25 active
duty and retired military personnel. However, only retired military personnel from 2018 to 2022
were selected to participate in the study to align with IRB standard protocol. Purposefully
sampling retired military population for this study facilitated data collection from people who are
58

uniquely informative and experienced in the subject matter (Maxwell, 2013). The retired military
personnel are appropriate for the study because of their experience of exposure to suicide events
from several duty stations and are able to contribute freely to the study without fear or restraint
from their unit commander. Each person’s experiences were treated holistically as occurring
within a specific context as well as the larger cultural and social forces that shaped their meaning
and choices (Morgan, 2014). This aligns with the SCT framework on how interaction with the
environment influences human behavior and individuals’ choices. Using qualitative methods, I
purposefully selected participants who would best help the researcher to understand the problem
and answer the research questions (Creswell & Creswell, 2016).
Risk to Participants and Mitigation Plan
Overall, 25 people volunteered to participate in this research, but only 11 signed and
returned the consent form. As a requirement, participants signed a consent form to participate in
the study. The risk of participation in the research was assessed as a trigger due to a family
history of mental health problems, previous suicide attempts, suicidal behaviors, and painful
memory of loss. Also, participants with recent exposure to a suicide event could be experiencing
painful bereavement during the interviews, which presented minimal risks. To mitigate the risks
associated with participation, all participants were assessed for suicidality (Appendix B shows
suicidality assessment) before the interview to ensure they were emotionally stable and
psychologically capable of fully participating in the research. I provided resources, such as
contact numbers to Military One source, VA healthcare, and the national suicide prevention
lifeline that provides assistance free of charge, mental healthcare facilities, professional
counseling, and support service after the interview. Likewise, participation was voluntary and
without coercion. Researchers are responsible for increasing participants’ level of comfort and
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encouraging them to talk about what they normally talk about to contribute effectively to the
research (Bogden & Biklen, 2007). All participants completed the interview peacefully and
answered questions comfortably without interruptions or emotional problems.
Protection of Confidentiality
All interviews are conducted and recorded using USC’s Zoom website. Data were stored
on my personal computer to easily reference transcription notes and deleted from the Zoom
website. Participants used pseudonyms when they entered the room (Zoom website) and wearing
military uniforms was prohibited during interviews. The study’s purpose was explained to all
participants prior to the interviews, and each signed a consent form as required for the study. All
documents, transcription notes, audio, and video recordings were deleted upon completion of the
research to protect the anonymity of participants. All data, audio, and video recordings,
transcription notes, and information that traces back to participants were deleted at the
completion of the research. Confidentiality was maintained by protecting data, audio, and video
recordings collected from participants on the Zoom website and used only for this research. Also,
I assigned pseudonyms to all participants during data analysis to increase confidentiality.
Additionally, I kept information from interviews private in a personal computer inside a folder
protected by password and removed them after completion of the study. It is the responsibility
of researchers to conduct research as ethically as possible (Merriam & Tisdell, 2016). I did not
share information collected from participants with any organization or person outside of the USC
research team to ensure confidentiality.
Instrumentation
There were 12 open-ended interview questions (Appendix D) designed through a pilot
study and used to facilitate discussions about participants lived experiences of losing someone by
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suicide. I asked more probing questions to further the discussions, broaden explanations to help
guide inquiry, and clarify how exposure to a suicide event affected their behavior, mental health,
and environment. The 12 questions are causally related to the conceptual framework in that
exposure to a suicide event affects personal behavior and the environment, which influences
individual choices. Research questions formulate what researchers want to understand, while the
interview questions are what they ask people to gain that understanding (Maxwell, 2013). The
interview questions about the changes in mental health and behaviors address the research
questions.
An outcome of events forces a person to interpret results and evaluate their competence,
which informs their cognition and directly affects reasoning to self-regulate their behavior (Elliot
et al., 2017). Likewise, questions about the influence of stigma address the role of stigma in
impeding seeking help for mental and behavioral health problems. Stigma directly affects active-
duty members’ decisions to seek help to treat mental health issues, which worsens mental health
problems, increasing risk factors that result in suicides (Westphal et al., 2018). Indeed, increases
in suicidal behaviors among military personnel is due to unresolved difficulties in their lives,
which affect their decision to commit suicide (Heyman et al., 2012). The selection criteria for
interviewees required that participants be retired military personnel exposed to a suicide event
during active-duty military service (Appendix A), sign a consent form (Appendix H), voluntarily
participate in the interview, and complete the screening for suicidality (Appendix B).
Data Collection Procedures
A recruiting message was posted using the LinkedIn website in the third week of January
2022 to invite retired military personnel to participate in the research. Within two days, 25
participants responded to the message and volunteered to participate and contribute their
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experience to the study. However, only 11 volunteers returned their consent forms before the
deadline and participated in the study. Each interview lasted between 45 and 60 minutes and was
conducted through Zoom as the primary site for audio and video recording. The application of
the Zoom site ensured privacy for participants to share their personal stories and life experiences,
facilitating easy access to data and its preservation for referencing and analysis of transcribed
notes. The most crucial factor in conducting qualitative research is choosing the population, time,
and settings that can provide information to answer the research questions (Maxwell, 2013).
Interview data were used for this research purpose and deleted after the research was
completed. Before the interview, all participants were informed about the purpose of the study
and the significance of their contribution. They were also screened for suicidality, which
significantly minimized risks. Likewise, each participant was informed with the understanding
that they were free to stop the interview or decline to answer any questions. After the interview,
transcript data were downloaded and reviewed for accuracy, correction of misspelled words, and
analyzed by the researcher. Qualitative researchers try to develop a complex picture of the
problem or issue under study. This involves reporting multiple perspectives, identifying the
many factors involved in a situation, and sketching the larger picture (Creswell & Creswell,
2016).
Data Analysis
After the interviews, I performed data analysis using NVivo software to generate codes
from transcripts, reviewed codes, established patterns, and categorized data based on themes.
Data analysis was a challenging process that helped me identify consistent pattern, which
enhanced understanding of direction of the study increasing knowledge on particulars that make
up the details of this study (Merriam & Tisdell, 2019).
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Method 1
I achieved successful analysis of qualitative data through open coding. After the
interview, I downloaded transcripts from Zoom, labeled accordingly, and uploaded them to the
NVIVO website. Using transcript notes from the first interview to establish a road map for
scanning the documents, I identified relevant statements that correlated to this study's research
questions, concepts, and theoretical framework (Merriam & Tisdell, 2019).
Method 2
I integrated thematic analysis of the data and coding approach to isolate themes and
identify patterns and categories of data emerging in the research. I categorized themes,
formulated them into patterns, and interpreted them to answer the research questions. Assigning
notes to interview data helps to create categories (Merriam & Tisdell, 2019). Also, I used
analytical coding to group themes, patterns, and concepts to construct meaning of what
participants described. Data verification ensured accuracy, and open coding was repeated to re-
examine transcripts with multiple reads to prevent errors and accurately translate meaning.
Figure 5 shows the process used to code and analyze data.

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Figure 5
The Process used to Code and Analyzed Data

Credibility and Trustworthiness of Research
Trustworthiness of a qualitative study is linked to the credibility, trustworthiness, and
competence of the researcher who collected and interpreted the data (Merriam & Tisdell, 2016).
Using established measurement instruments with an acceptable level of reliability and validity is
critical to ensure results accuracy and confidence in the quality of the research. For example, the
research questions and interview questions should inform the conceptual framework and directly
align with the theoretical framework to achieve the overall objective of the research. Questions
created should measure how exposure to a suicide event affected the behavior of military
personnel who experienced loss. In other words, the instrument selected should be able to
Codes
Coding
Iterative
comparison
Themes
Qualitative
data
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measure the changes in the behaviors of active-duty personnel within the military environment
when a suicide occurs (Salkind, 2014).
Ethics
Maintaining ethical standards is critical to successful research in the validity and
reliability of a study depend on the researcher's ethics (Merriam & Tisdell, 2016). During the
interviews, privacy allowed participants to share their individual experiences, and they were
given enough time to participate fully and share their thoughts. After the interviews, I provided
contact information to access professional counseling free of charge to participants that may
experience trauma caused by interview questions. The researcher is responsible for upholding
ethical standards to preserve human lives and protect privacy and anonymity. Ethical codes guide
the researcher's behavior, but the degree to which the research is ethical depends on continual
communication and interaction with research participants throughout the study (Glesne, 2011).
No participant was interviewed without a consent form and approval of the study from the
institutional review board (IRB).
Limitations and Delimitations
Limitations of the study is that the research premise was that understanding the effect of
suicide on behavior may increase awareness of the problem to provide healthcare and support to
people who experienced the loss of someone to suicide. However, findings from the study are
based on the lived experiences of retired military personnel and may not correlate with the
experiences of military personnel currently serving on active duty. Also, only 11 participants
affected by exposure to a suicide event were interviewed for this research. Therefore, findings
from this study may not be attributable to everyone in the military exposed to a suicide event.
Similarly, the study does not account for past trauma, emotional pain, and mental health
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problems of participants by non-suicidal deaths. For instance, respondents may have answered
questions based on experiences from trauma caused by losing someone to accidental deaths in
place of death caused by suicide, resulting in wrongful attribution of data. An outcome of events
forces a person to interpret results and evaluate their competence, which informs a person’s
cognition and directly affects reasoning and behavior (Elliot et al., 2017).
Delimitation of the research is that it highlighted suicide as a social problem using the
social cognitive theoretical framework with a public health perspective to address the effect of
suicide on emotional, psychological, and mental health. It showed the interrelationship between
human beings and the environment and how they both influence each other to produce results
and increase knowledge, adding value to the literature and the use of SCT framework (Creswell
& Creswell, 2018). Integrating the lived experiences of retired military personnel across the
service branches added credibility and validity to the study. Findings from this research can be
attributable to the general military population and the public to provide proper care and support
of people affected by loss. The aim of social science research is enabling the community to
prosper (Glesne, 2011).

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Chapter Four: Findings
The study examined how exposure to a suicide event affected the behavior of active-duty
military personnel to increase knowledge about how suicide affects the behaviors of people who
experience loss. Understanding the effect of suicide on behavior may increase awareness of the
problem to provide healthcare and support to people who experienced the loss of someone to
suicide. The secondary aim was to use findings from this study to develop interventions and a
framework to provide healthcare to support this unique population in the hope of decreasing the
rates of suicide in the military. The conceptual framework focused on the behavioral changes
that occur due to human interactions with the environment as factors in understanding high rates
of military suicide. Additionally, the framework also captured the influence of stigma on help-
seeking behaviors for mental health problems and the choices people used to cope with problems
developed from exposure to a suicide event.
Findings from this study resulted in three themes: behavioral changes, effect of stigma on
help-seeking behavior, and recommended solutions to reduce the rates of military suicide.
Behavioral changes were negative emotions such as anger, guilt, blame, anxiety, depression, and
stigma stemming from the perceived culture in the military and fear. Coping mechanisms used
were strong connection with family and community, seeking therapy and mental health
treatment, daily exercise, and learning and sharing experience with others. The SCT was used as
a framework to develop concepts that created the following research questions:
1. How does the experience of losing someone to suicide influence the behaviors of
active-duty military personnel?
2. What role does sigma play in seeking help for mental health problems among active-
duty military personnel?
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3. What are the recommended methods used by retired military personnel to cope with
the loss of losing someone to suicide while on active duty?
Appendix E shows the theoretical framework alignment matrix.
Participants
I interviewed retired military personnel and used pseudonyms instead of their real names
to protect their identities and minimize risk. I did not interview active-duty personnel due to the
high risk of losing their jobs, to protect participants, and to ensure alignment with IRB policy.
Overall, 25 retired and active-duty military personnel volunteered to participate in the research.
However, only 11 retired military participants returned their consent forms and were interviewed
in January 2022 through the USC Zoom site, where 10 participants used video and audio
recording, and 1 used only audio recording. No active-duty military personnel were interviewed
for this study to align with IRB standard protocol. The participants were recruited through a post
about the study on my LinkedIn page and selected to collect quality data based on their lived
experiences of being affected by exposure to a suicide event while serving on active duty. Also,
participation in the study was strictly voluntary and aligned with IRB guidelines.
Before the interviews, all participants voluntarily signed an informed consent form
(Appendix H), and I screened them for suicidality (Appendix B) using the Columbia-Suicide
Severity Rating Scale (C-SSRS) risk assessment to minimize the risk of trauma and maximize
the protection of human life. No participant presented with suicidal thoughts or suicidal ideation
during the interview. After the interview, I gave participants contact information for support
services such as VA, Military OneSource, and the national suicide prevention lifeline to facilitate
access to healthcare and professional counselors to mitigate a crisis triggered by interview
questions. The participants were nine men and two women from across the four military service
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branches. Table 5 shows participants’ demographic information. Table 6 shows the participants’
years of service in the military, job, and self-identified gender.

Table 5
Participants’ Names, Ages, Self-Identified Ethnicities, and Branch of Military Service
Name Age Ethnicity Branch of service
Alan 42 Caucasian Navy
Bill 45 Caucasian Navy
Chua 32 Asian Marine Corps
David 38 Caucasian Army
Holly 34 Caucasian Navy
Lisa 48 Caucasian Air Force
Rahim 47 African American Navy
Ricky 40 Caucasian Air Force
Ryan 43 Caucasian Army
Joseph 35 Caucasian Air Force
Steve 44 Caucasian Marine Corps

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Table 6
Participants and Their Years of Service, Job, and Self-Identified Gender
Participants Years of service Job Self-identified gender
Allan 26 Navy pilot Male
Bill 28 Explosive ordinance disposal Male
Chua 18 Admin clerk Male
David 30 Combat medic Male
Holly 26 Admin officer Female
Lisa 24 Chaplain Female
Rahim 26 Navy corpsman Male
Ricky 23 Instructor Male
Ryan 20 Logistics Male
Joseph 8 Air transportation Male
Steve 28 Avionics mechanics Male

Allan Served as a Navy pilot for 24 years. He was a trained on flying the Lockheed S-3
Viking twin-engine jet aircraft that is used primarily as anti-submarine warfare missions. He
served as a flight instructor on C40 aircrafts (Boeing 737) and transported logistics. He was
responsible for the command mishap incident program and casualty response standardization
across the naval aviation community. He designed the command suicide prevention protocol,
apps, and smart phones application, and frequently experienced exposure to suicide. He lost one
of his instructors to suicide while serving as a flight instructor, which affected him emotionally
and in relationships.
Bill was serving onboard a Navy submarine in the early years of his career when he
experienced a crew member commit suicide. He completed his naval career and transferred to
serve in the Air force as a civil engineer and commissioned officer for two years. Subsequently,
he changed jobs, worked in explosive ordinance disposal (EOD) and served three tours in Iraq
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and two tours in Afghanistan. He experienced exposure to multiple suicide bombers detonating
explosives at close range.
Chua served in the Marine Corps as an administrative clerk for 18 years on active duty.
He completed multiple combat tours and was stationed oversea in Okinawa, Japan, when a
member of his unit committed suicide. The experience affected him emotionally and affected his
unit socially.
David served as Army combat medic and sergeant major (E9) with conventional force
and light infantry for 30 years in the military. He conducted special operations, civil affairs, and
assigned to a combat hospital. He completed his military career as task force medical sergeant
major in Iraq. He lost his mother to suicide during the first 3 months of his career in the military
and prevented his father from committing suicide by taking the gun away from him. As first
sergeant, he experienced a soldier commit suicide, and another soldier killed himself during
sergeant major academy.
Holly served as lieutenant commander in the Navy for 26 years. She started her career as
an enlisted sailor and a commissioned officer. She served as security officer doing detainee
operations at Guantanamo Bay, Cuba, nuclear weapons security with the Marine Corps in Kings
Bay, Georgia. She completed one tour as executive officer of the Blue Angels and admin officer
onboard two aircraft carriers. She lost her brother, her nephew, her mentor, and her best friend to
suicide. She was affected emotionally by being exposed to several suicides.
Lisa served as a chaplain in the Air Force for 29 years. She was responsible to provide
spiritual counseling and support services to help treat people with trauma, pain, behavioral and
relationship problems. Lisa worked at the unit level for 12 years in education and training, at the
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pentagon for several years, and in major commands at the end of her military career. She lost a
client to suicide and assisted to prevent the death of another client who tried to hang themselves.
Rahim served as a Navy corpsman (medic) and senior chief petty officer for 26 years in
Navy medicine. He is a certified anesthesia technician, surgical technician, and senior enlisted
leader. He completed his tours with the Marines overseas and at Naval Hospital Okinawa Japan
where he lost a sailor to suicide. His exposure to a suicide event devasted his team and affected
him personally and emotionally.
Ricky served on active-duty air force for 26 years as a university instructor. He
specialized in teaching professional development at various universities and facilitated calm
activities, and computer networks. He retired in 2017 in Montgomery, Alabama. In 2014, his
wife committed suicide, and he became a single father of three girls. Ricky currently teaches
public speaking, resiliency training, suicide awareness and prevention, and assists in providing
counseling services to people affected by loss.
Ryan served as Army officer for 10 years and specialized in logistics, maintenance,
supply chain management and distribution. He completed three deployments within 10 years and
served in places such as Fort Benning, Georgia, Poorly Virginia, COM Fort Carson Colorado,
and Fort Campbell, Kentucky, where he was exposed to two suicide events that changed his
cognition and perspectives.
Joseph served in the Air Force for 13 years in air transportation and was responsible for
clearing pastors and cargo for airlift throughout DoD. He was medically retired from active duty
due to injuries sustained while deployed to a combat zone. His first experience with losing
someone to suicide was after deployment to Iraq when one of his airmen committed suicide. As a
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technical sergeant, another member of his crew also committed suicide that affected him
personally as a supervisor.
Steve joined the Marine Corps in 1996 as enlisted Marine and specialized in avionics for
12 years working on cobra helicopters, attack helicopters, and crewmember. He completed
several combat tours and overseas tours. He was selected to serve as chief warrant officer and
was responsible for supervising Division of 220 Marines. Steve lost 18 members of his team and
friends to suicide and suffering from PTSD injuries sustained in combat. He retired from active
duty in 2019 from the Marine Corps.
Results and Findings for Research Question 1
The first research question asked, “How does the experience of losing someone to
suicide influence the behaviors of active-duty personnel?” Thematic data analysis produced three
themes that addressed Research Question 1: causes psychological pain and mental health
problems, changes cognition and perspectives, and provokes negative emotions.
Causes Psychological Pain and Mental Health Problems
Eleven retired military participants narrated their lived experiences of being affected by
the loss of family members, friends, soldiers, and co-workers to suicide while serving on active
duty in the military and discussed how each experience changed their behavior. As a result of
being exposed to two suicide events and one suicide attempt, David stated, “Oh, it did change me
totally as a person, and I have a lot of problems afterwards, but I think I have been able to keep
them hidden and every now and then they come out.” They shared similar experiences from
diverse military backgrounds, duty stations, and occupations across service branches, narrating
the effect of suicide on themselves and their unit. Ryan suggested that the death by suicide of a
military leader has a larger traumatic effect on the unit than that of junior ranking personnel:
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You now, I think that when a leader commits suicide, it can be extremely hard on our
soldiers in a way that we can’t predict. I think most suicides in the military are lower
ranks, and so as a soldier, you probably know that person a little bit more intimately, and
maybe you stayed in the barracks with them. But in terms of having a leader whom you
are supposed to perceive as being bulletproof commit suicide; I kind of had to take pulse
of the company.
Also, Ryan discussed how, after losing a soldier to suicide, he became focused and concerned
about his unit’s wellbeing: “After I stopped worrying about me for that day or 2, I immediately
went to worry about the company.” Likewise, Steve described how the death of the unit’s first
sergeant by suicide affected his marines and him psychologically. He provided details of mental
health issues caused by losing a leader within his command, struggles with seeking healthcare
for mental health treatment, and inability to process information properly due to PTSD:
That is a dynamic question because not only did it affected me, but it affected the marines
under my charge, and that was where I focused my effort. So, my effort was focused on
taking care of the marines that were struggling with it, and what led to my biggest
problem and what actually sent me to therapy was I always ignored what was happening
with me. I always put it aside, so I could take care of the marines. Over the years, I
started experiencing the processing of the suicides. It wasn’t until much later where I
started actually taking care of myself and processing what happened.
Eight participants suggested that death by suicide affects active-duty military personnel both
psychologically and mentally, causing trauma and changing a person's behavior. Likewise,
Rahim discussed his experience of focusing on the responsibility of caring for others when his
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team experienced one member committing suicide. He noticed that his team was affected
emotionally and devasted by the loss:
Kind of like a lot of guilt there because it is not like you don’t know that they are going
through this; they are always complaining. Then, to see how everybody else is feeling,
you got to go to the musters, and everybody got to talk, but you have to be strong for
everybody else no matter how you feel it personally, and that is draining for me. I thought
that was very draining. I felt like it made everything I was feeling worse because it’s like
I didn’t have to vent. So, it was extremely hard, kind of like the more you think about it,
you just get depressed. So, I look at it from those perspectives, which really hit me hard.
David, who served on active duty as an Army combat medic and a retired sergeant major,
discussed his struggles and experiences of losing his mother to suicide as a teenager and
explained how the death of one of his soldiers by suicide changed his behavior:
The experience changed me very much as a person, and I probably saw behavioral health
before I retired, and turns out what I experienced that I went through, I have a tendency
to do everything to the extreme. After being exposed to suicide, I used to go out and run
12 miles. I used to buy stuff to the extreme. I would drink throughout the day and not in
one seating but say over a 12- to 16-hour period, I might have 12 shots of bourbon. So, I
would do everything excessively, and they basically told me that was my coping
mechanism. I would do stuff in excess that would be dangerous to my overall health.
While narrating his experiences, David became emotional, started crying while speaking about
losing his soldiers to suicide, and stated, “I am affected by his suicide more than my mother’s.”
Another participant referenced his experiences dealing with psychological pain caused by
his exposure to multiple suicide events while serving on active duty in the Marine Corps. Steve
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suggested his participation in funeral details for 18 members of his unit who committed suicide
on active duty resulted in significant psychological trauma, which led to his suicidal behaviors.
He discussed how experiencing 18 members of his unit dying by suicide changed his behavior,
stating, “I have never been an alcoholic, but I would immediately turn to a few bourbons to cope
with the pain.” As a chief warrant officer, Steve suggested that drinking excessively and
recklessly helped to norm the pain of losing his marines to suicide and as a strategy to cope with
the psychological pain of coordinating funerals and 21-gun salute events for the deceased and
their families:
I would go to lunch with some close friends of mine that are retired military, and we
have a cold beer and talk about it. Then, the interesting part about going to have a drink
or two drinks is when you start feeling some significant regrets about having that drink.
You start regretting it by looking at it, saying wait a minute. … Maybe this was the
reason why they did it? And why am I here drinking, and I don’t need to drink this stuff
to cope. I mean, alcoholism doesn’t run in my family anywhere, and I have never had an
issue with it, but it became a go-to to instantly calm the nerves. Unfortunately, it was a
coping mechanism, and as a result, I had to seek significant therapy because my self-hate
and my ability to tear myself down emotionally was really bad. It was bad, and I at one
point, was absolutely suicidal.
Three participants discussed The sale of alcohol inside military bases and easy access to
guns as environmental risk factors that contributes to increased military suicide rates. For
instance, Allan stated, “I think that alcohol is a big contributor too. So, if you look at the Navy
and the glorification of alcohol, I mean there’s alcohol everywhere. I think that’s probably a
contributor.” Excessive use of alcohol, substance use/abuse, and mental health problems were
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suggested by two participants as risk factors associated with suicide attempts and suicide among
the active-duty military population. Also, Ryan, an Army officer, explained how priority placed
on mission success, maintaining operational tempo (OPTEMPO), and operational readiness in
the military cause stress among the troops and suggested that it leads to substance abuse and
increases in military suicide rates:
Our training cycle and our OPTEMPO creates a lot of issues, but that’s something that’s
never going to change. So, we can’t really change that because we’re always going to be
at a high OPTEMPO. It means substance abuse is obviously a problem in the military as
well. Does that lead to increased number of suicides? I mean, it maybe it could. But you
know the military has a very, very tough job, and it’s not going to get any easier.
Eight participants discussed poor leadership structure, lack of knowledge and
understanding of triggers, and unmitigated risk factors within the environment as major concerns
that result in mental health issues that perpetuate increases in military suicide rates. The lack of
psychoeducation training for military leaders across branches of services created a significant
gap in knowledge and understanding the manifestation of mental illness and ways to provide
resources to assist their troops during crisis. As a result, military leaders unintentionally created a
toxic climate that impede prevention efforts and exacerbate suicides. For example, after
receiving the news that one of his soldiers committed suicide, Ryan questioned if the poor
leadership that produced a toxic environment caused the member to commit suicide:
Because the individual that I felt who was running that unit, I perceived there is a very
toxic person, and I couldn’t help but wonder if this person, if she’d still be alive, if maybe
the climate was a little less toxic. I just wondered how much of what we did as a culture
influenced that suicide, as opposed to we’re kind of told a lot of times suicide is an
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outside. A lot of outside influences on the personnel level as opposed to maybe a
professional level. So, that was my first experience with suicide and kind of seeing it as
more of something we cannot see.
Additionally, one participant also shared their experiences of dealing with the trauma of losing
someone they deployed with to suicide. Bill, a retired EOD Navy commander, explained that “it
is traumatic especially when you see someone who came back from deployment as a comrade of
yours you’ve served with and they off and commit suicide. That hits you in the guts and adds to
the overall trauma.” Understanding how losing someone to suicide causes psychological pain
and increased mental health problems is essential to managing the changes in cognition and
perspectives of people who experienced loss.
Changes in Cognition and Perspectives
Nine participants described how exposure to a suicide event changed their cognition
(reasoning) and choices and motivated them to set personal goals such as learning to better
understand risk factors of suicide, mental health stigma, increasing their self-awareness to
identify people at risk early, and provided resources to support people who experienced loss that
significantly affected change in their behaviors. They attributed their positive behavior and
healthy perspectives to losing someone to suicide which changed their cognition. For example,
David explained his experience of losing his mother to suicide as a teenager: “I think it made me
a better person as I got older.” He suggested that losing his mother to suicide enhanced his
resiliency as an adult in the military to manage disappointments and critical thinking skills.
Rahim explained how his reasoning shifted from working long hours in the Navy to spending
time with his three children after losing a Sailor to suicide, stating, “I thought about my children
and how much I have left in this world to spend with them.” Similarly, Lisa, a retired Air Force
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chaplain, referenced how losing an airman to suicide changed her cognitively in understanding
the value of time, which is important to achieving life-work balance, and caring for her family.
Behaviorally, she changed her work schedule to invest more time in raising her children:
Because I had gone in and out of suicidal moments, particularly, it helped me realize that
if you have children, that you really need to put their needs first and part of their need is
for you the be a healthy and whole parent. So, it changed that concept in me so that if I
ever had thought again of taking some sort of suicidal action, I needed to go get help and
support from mental health to stay healthy. It helped me know that I need to think about
what the effect would have on my kids and think of a better way to live and progressing
in my life. So, it really kind of changed that perspective to it’s not about you.
Also, Ricky, an Air Force logistics officer who experienced the death of his wife to suicide,
mentioned the cognitive change because of losing his wife “it helped me prioritize my time for
me, and the impact on me was understanding the importance of time because we cannot get time
back.” Before his exposure to suicide, Ricky prioritized work and career advancement over
spending time with his family and three daughters, and his behavior and value of time changed
after the loss of his wife to suicide:
At that point, I kind of stepped back and said there were times where I was so focused on
trying to help people outside of my family and volunteering to assist the homeless, and I
became aware that something was wrong within my family, resulting in some aspect that
led to my wife committing suicide. That experience right there is the reason why I do
what I do today. So, now I teach resilience, suicide prevention, and sexual assault
prevention because I don’t want to see other folks go down that road either.
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Allan, a Navy pilot also shared a similar experience of cognitive change and increased
knowledge and understanding of the challenges people face during crisis and suicide. Allan
referenced his lack of knowledge and understanding of the rationale of people who commit
suicide or attempt suicide, stating, “I didn’t understand how people could get to a point where
you are so hurt that that hurt can overcome the biological tendency to try to live.” He discussed
his personal struggle with failures in relationships, career in the Navy, and child custody battle
with his ex-wife as factors that led him to contemplate committing suicide. His cognition and
perspective changed drastically and “actually in a positive way” after his co-worker committed
suicide:
I think one of the reasons that it was such a profound impact on me is because it was that
moment of recognition that I was so consumed by my own life trauma that I didn’t even
notice that this guy was struggling. So, it was profound and contributed to my efforts to
focus on suicide prevention and response. Being exposed to suicide increased my
empathy and drove me to care more about people, and I have also volunteered to
participate in suicide prevention stuff through naval aviation.
Holly is a retired Navy administration officer affected by the experience of losing her
brother, nephew, best friend, and mentor to suicide while serving on active duty. She suggested
that her exposure to several suicide events helped increase her awareness and cognition, stating,
“You just become more aware, and you take more seriously when people make comments or do
things that are off the wall, and you make it a point to try to help them instead of just
overlooking it.” Experiencing the loss of her relative and best friend to suicide changed her
reasoning to care more and support people suffering from loss. Even more, the changes in her
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cognition inspired the motivation and boldness to speak up against military leadership when her
mentor committed suicide:
You probably gathered from my voice that I am very soft-spoken and probably a quiet
person. But when my friend committed suicide, she was a lesbian, and she left very
detailed notes about why she committed suicide that she was being harassed about it, and
talked about, and not being supported by her command. And when I heard that, I marched
right over to the ship and demanded to speak to the command master chief. I was so filled
with rage, like just accept people for who they are. Look what you have caused this
person to do to themselves because you didn’t accept them. So, I found myself more like
I got some guts finally and spoke up. It also made me feel like this is so important to
accept people for who they are. People, they are human beings, right.
Rahim also experienced a positive change in cognition when one of his sailors died by suicide
while stationed overseas. His empathy to care for others changed when his sailor committed
suicide, and he encouraged others across the department and their command to “just do more to
take care of people and really take that seriously.”
Additionally, four participants affected cognitively by exposure to a suicide event started
self-reflection and evaluated their individual behaviors, resulting in making choices to seek help
for mental health problems. Joseph experienced a cognitive change where he examined his
behavior and perspective on life and realized that “after a while, just the whole thing really
changed my perspectives on who I was and how I had a lot that I needed to let go and get help
with.” The death by suicide of one of his soldiers positively changed his reasoning and his
behavior towards others. He increased his situational awareness to understand people, decided to
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know people around him as persons first and soldiers second to serve them. As a supervisor, he
changed his leadership style and approach to accommodate others:
My perspective in life leading up to the first suicide incident was that it was easy for me
to get through it because I have survived so many things in life that I wasn’t supposed to
survive. So, I felt invincible to the outside world, and internally I felt invincible, too.
Then after a while, I needed a lot of help. That was the catalyst, and I hate that that was
the catalyst, but the catalyst for me to change was a member of my team took his own life
that I didn’t see coming, and it allowed me to see that I was struggling and I was to that
point where I had contemplated suicide as well, and I didn’t give much weight to it, but I
had personally had feelings and suicidal ideations, and it was very eye-opening that I had
to look internally to realized that I was hurting and I was no longer invincible.
Two participants also described inconsistent lack of leadership support in military
command and five participants suggested ineffective measures to prevent military suicide as
factors that contribute to increased suicide rates among the active-duty military population. The
change of command by military commanders creates a different culture, climate, mission
priority, and inconsistency from leadership to provide adequate support to people experiencing
loss. Four participants described their experiences of being supported by their senior leaders
providing time to grief, which was discontinued after the change of command.
Allan suggested that military priority on mission success and operational readiness results
in deprioritizing personnel and fails to provide psychological safety, stating, “I think what
happens with that is we do prioritize people by deprioritizing people. We create a scenario where
psychological safety is exceedingly difficult to build and maintain.” Holly discussed her lack of
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awareness and knowledge of how to assist personnel affected psychologically as a reason she
failed to help sailors while on active duty:
Looking back over my career, I wish that I would have taken that more seriously and, as
a leader, promoted it more for those that needed it. You do it. You say like, “Oh you
know that the services are available,” but like in the back of your mind, you’re like, “I
need you to do this job, and I don’t need you to be going and sitting in medical; I need
you to go do this job.” Now that I have experienced what I’ve experienced, I wish it was
something I would have taken more seriously when I was active duty.
Provokes Negative Emotions
Seven participants discussed experiencing the death of colleagues, relatives, friends, and
family members using words such as guilt, depression, anger, frustration, anxiety, and blame to
describe their emotions during that period. They narrated their experiences and how suicide
affected them emotionally, resulting in seeking help for mental health as well as using different
support programs and mechanisms to cope with their emotions to adjust their lives. For example,
participants experienced mood swings, anger, and confusion while struggling to rationalize their
experience to understand what they could have done to prevent the suicide. Steve stated, “The
number one thing around the household that my wife pointed out was mood swings shifts
because of it, driven by anger and confusion as to why. That is how it affected me emotionally
and physically.” Bill discussed his exposure to suicide bombers while deployed to Iraq and
Afghanistan as an explosive ordinance disposal (EOD) expert responsible for deactivating
bombs. He experienced several suicide bombers commit suicide at close range and lost three of
his comrades who committed suicide after the deployment:
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As I was an EOD officer, you are experiencing a lot of different things during a
deployment. You are experiencing death of soldiers, death of airmen, death of military
members. Let’s just say it like that you’re also experiencing the death of civilians. It
frustrates you because they see that that is the end. Then, we have to go into like combat
situations, and we experienced that quite a bit. I am still focused on this internally and
externally, which is why I participate in things like the American Legion in my local
community.
He expanded his experience to share his struggle dealing with anxiety and how it affected his
life, referencing his relationship with his wife and daughter for support:
Well, I have to have conversations with my wife about why I’m anxious at different
times, why this slamming the cabinet doors or the front door, shaped me in a different
way than it would anybody else. Well, you know there’s explosions that have occurred
that were close aboard. That door sounds like that. So, these are different conversations
that most people don’t have to even have to think about, but these are conversations that
my wife and daughter are aware of because I don’t want the slamming the door because it
drives my emotional reactions to that.
Holly described the impact suicide had on her emotions when she lost her 18-year-old
nephew, her best friend, a Navy chief, and her mentor who was a master chief, all to suicide. She
discussed feeling anger, stating,
I couldn’t even grieve because I was just so mad, so mad at him for doing this to my
family, knowing what we had went through with my brother. And now he did this, and so
I was just really mad.
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She suggested that losing someone to suicide provokes negative emotions on people who are left
behind by the deceased:
I feel like I’ve been surrounded by it, and it’s like, at first, you’re really angry because
it’s how selfish, and then it’s a lot of guilt, like what could I have done differently? Or I
should have reached out, and then you just constantly are thinking about the signs like
how could I, what did I miss? What could I seen to have helped? So, it’s hard for the ones
that you leave behind. It’s constant. There’s a lot of emotions.
Lisa had a similar experience of losing someone to suicide and feeling angry and
frustrated: “It took us a long time to get over that one.” Her team dealt with a client who
attempted suicide twice and succeeded in committing suicide the third time. As a chaplain in the
Air force, Lisa and her team were responsible for providing spiritual health and support to assist
the Airman in coping during crisis to improve quality of life. Unfortunately, he took his own life,
which “the effect that it had on the unit was so profound,” both emotionally and personally:
Yeah, I was assigned to a hospital as the chaplain to the staff and patients at the hospital
and was working closely with the mental health ward where they had an individual who
had attempted suicide. He was on a second attempt to suicide, and I was working with
him for spiritual care personally and then with the staff, just on a touch-and-go basis. And
he not successfully completed a suicide in his home. He tried to hang himself from the
banister, and his kids came home and found him, so there was a lot of that was a lot of
anger and frustration that he would do that to his children, and it was devastating to the
staff. It was devastating to me. I mean, it was a rough time, and we were all exceedingly
angry. I was frustrated and angry because I felt like he had betrayed me, and he had
betrayed the staff.
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After exposure to a suicide event, 11 participants discussed rationalizing their
experiences to understand what happened and what role they could have played to prevent
someone from committing suicide. This rationalization resulted in provoking negative emotions
that manifest as self-blame, anxiety, feeling anger, and “looking at it from that aspect of guilt. …
What else could we have done, you know? Why didn’t we notice more, you know? Who was
talking to him, you know?” Ricky explained how losing his wife to suicide and the thought of his
three daughters losing their mother affected him emotionally and negatively:
I went through the grieving process and all that kind of stuff, but I think for me
personally, it hit me hard losing my wife and my girls losing their mom, and that was 8
years ago, and I don’t think this grieving process to some aspect is still happening and
still ongoing.
He described using his faith and understanding his purpose in life to manage his crisis, seeking
mental health treatment, and using his friends and church for support. Also, he changed his work
schedule to socialize more with his children as a coping mechanism because “emotionally
broken I think would probably be the best way to put it; so, it surely broke me, and it took me
some time.”
Sense-making through rationalization was a consistent theme for 11 participants upon
experiencing exposure to a suicide event. They described going through painful emotions and
struggling with sense-making, blaming themselves for their oversight, and not being aware to
prevent death by suicide. Ryan explained how losing the first sergeant of his unit affected him
emotionally with self-blame:
I was completely awash with emotion. I really did what I could to temper them because I
was around family and I didn’t want to upset anyone, but I let them know what happened.
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I knew that he was dead, and I knew that it was self-inflicted. And I knew that I had a lot
of people back at Fort Campbell that was now without a strong leadership structure. I
started to blame myself. I wondered if there was anything that I could have done. I’ve
seen it coming, and I immediately knew that I had to cope with this as best I could,
whether that’s through some sort of internal wrestling rationalization or just kind of an
emotional outpouring. I think I kind of blamed myself a little bit, and I was in disbelief.
But again, I knew that there was nothing I could do at that moment but did what I could
to get back as soon as I could to hopefully at least add some leadership and some clarity
to that situation.
In discussing how suicide affected members of his unit, Steve described how his marines blamed
themselves and reacted emotionally with regrets and self-hate when a marine and a member of
their unit committed suicide:
And I watched their behavior, and it was complicated. A lot of them were very emotional.
A lot of them were thinking instantaneously that they did something wrong, which
resulted in the suicide. So, there was a lot of instance self-hate and self-regret on the
Marines, and I had to run block on that. I had to try to tell them that it wasn’t their fault
you can’t predict this kind of stuff.
Steve stated that “watching the Marines instantly turn to self-hate and self-regret because they
don’t think they did enough to help that person was rough.” In discussing their loss of comrades,
family members, and friends, participants expressed their emotions by being judgmental, critical,
and blaming their command suicide program for their lack of knowledge on the effective
mitigation strategy to prevent suicide. Steve suggested changing the suicide prevention and
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training program to help educate military personnel and increase awareness and prevention
effort:
We get suicide training, every year. At least we did when I was active duty and all that
training, they gave us: look for the signs. Look for the signs means if they’re giving their
furniture away, if they’re self-isolating. But that’s really never the case with the guys. In
my experience with the people who actually completed suicide, that’s not how they
behaved. I watch how it devasted my marines emotionally, and that’s where my heart
went as I watched and tried to help them. I got them counseling they needed, and I told
them to stay home and not stress; and to talk to whoever you need to, I would call people
from the command to help.
In summary, losing someone to suicide correlated with changes in the behavior of active-
duty military personnel causing psychological and mental health problems, changes the cognition
and perspectives of personnel, and provokes negative emotions. Poor leadership and lack of
training and understanding mental illness impedes providing adequate support and access to care
for people at risks of committing suicide. Untreated mental health problems developed from
exposure to suicide event exacerbates suffering and results in suicides in the military.
Results and Findings for Research Question 2
The second research question asked, “What role does stigma play in seeking help for
mental health among active-duty personnel?” Two themes emerged that addressed Research
Question 2: Stigma exacerbated perceived fear, and Perceived culture of stigmatization
discouraged help-seeking behavior.
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Stigma Exacerbated Perceived Fear of Losing Military Careers
Nine participants discussed extensively the military culture of stigmatization of personnel
suffering from mental health problems, suggesting that it affected their decision to not seek
treatment while on active duty. The nine participants implicated stigma as a major challenge
across the military with severe consequences and detrimental to careers advancement,
promotion, and the loss of security clearance, which results in losing position, rank, and chances
for promotion. Stigmatization of personnel with mental health problems, substance use/abuse,
and behavioral disorder played a significant role in increasing fear of losing their military career,
and they choose not to seek help.
Allan, a navy pilot, explained he suffered silently and emotionally to avoid being
stigmatized for his mental health issues, and “the reason is because the consequences are too
severe.” He discussed the consequences of seeking help from mental health as it relates to stigma
attached to careers within the aviation community, stating, “I didn’t tell. The first time that I told
anyone related to the military about my suicidal ideation at all was during my VA interview
process after retirement.” He suggested that seeking help from a navy flight surgeon resulted in
severe consequences as a pilot:
And so, with that and combined with the military culture. Like certain fields as a pilot. If
I went in and I told the doc, “Hey doc, I am really struggling with and from mental health
perspective.” That has real and perceived consequences. And that is really the bigger
issue. So, if I were to argue what is really the issue, it is that the consequences for being
honest about being hurt are so severe that people delay getting help when, when they
should before they should. That is just my perspective.
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Likewise, David discussed how stigma impeded his willingness to seek help from the
command mental and behavioral team when he was affected psychologically to cope with the
loss of a soldier to suicide. As the unit sergeant major, he “almost felt like a hypocrite because I,
I pushed my soldiers to go, but I was unwilling to go myself.” In particular, he implicated the
military culture for stigmatizing soldiers who present with mental health issues as “being weak”
and “incapable to lead and fight and get the mission done.” Like Allan’s experience, David
stated,
One of the providers came to me one day and said Sergeant major you need to see
somebody, and I said, it is not the time right now because when I was growing up, there
was always a stigma in the military with seeing behavioral health. And then, as I was
getting ready to retire, I finally made the decision that I needed to get seen there for the
longest time, I think going to see behavioral health was seen as a weakness, and it could
potentially stop you from moving up.
He avoided seeking help for mental health treatment due to fear of being seen as weak and
incompetent, and as a result stated, “I think I pushed a lot of things aside, just so that I wouldn’t
be viewed as weak and regret doing that because my mental health is more important than
anything else.” Also, five participants suggested that the consequences of stigma significantly
enhanced their perceived fear of being seen as weak, losing rank, military status, and leadership
position, which influenced their decision to not seek help for mental health problems caused by
exposure to a suicide event.
Holly, a female administrative officer, chose to ignore her mental health issues “because I
worked for an old crusty bosn’s mate master chief, and I was not going to show any weakness
around him.” She discussed the military culture of stigma and experiencing discrimination from
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her leadership as a woman which motivated her to never show weakness or seek help for
psychological pain and trauma. Bill rationalized the significance of his military job as an EOD
commander and discussed how losing his security clearance due to mental health problem is
detrimental to his military career:
One of the challenges in the military, especially if you have a security clearance, is the
belief that if I have to go to counseling, I have to report that my Ts clearance is in
jeopardy, and I’m not going to do that. I talked to a retired army EOD Colonel about a
year ago he’s working for a company that’s a Beltway band and around the Pentagon
trying get all kinds of contracts for EOD work and other stuff, and he’s like, “I am never
going to tell the government that I got PTSD” even though I do. I don’t want to ruin my
clearance.
Also, two participants suggested that losing a security clearance separates the person
from their job and their unit creating staffing gaps for critical jobs, resulting in more work and
burden for their team. Knowing the consequences and implications surrounding stigma,
perception, and culture of the military, they chose to avoid seeking help to treat mental health
problems. Similarly, participants discussed how the military warrior mindset and culture of
toughness negatively affected their willingness to ask for help during a crisis. Holly intentionally
avoided seeking access to mental health services and supportive leadership while stationed
onboard a Navy aircraft carrier: “I didn’t want to be seen as weak, so I didn’t. I was like, “No,
I’m fine, but thank you.” And so that’s that was my experience.” The stigma associated with
mental health and the fear of being seen as weak, combined with the stereotype of women in the
military leadership ranks, affected her willingness to seek help:
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I don’t think I need to tell you that it’s already hard being a female in the military. And
coupled with that, you also want to be tough because you don’t want to think that you’re
getting special treatment because you’re a female. And so, you suck it up, and you just
deal with it. There are so many things that you don’t seek that help for so that you can,
for instance, be qualified to go to sea duty. When I was doing nuclear weapons security,
we were in the PRP program. And so, you have to be very like you can’t even go to
dental without having to go out of the program.
Eight participants discussed perceived stigma as the main reason they chose not to seek
help for their mental health problems, ask for support from their supervisors, or use military
treatment facilities. Lisa discussed her experiences on active duty and seeing others avoid mental
health services due to fear and suggested people are more comfortable using the chaplain
services than speaking to mental health:
But I’ve seen it in other units where no one. They only talk to chaplains. They don’t talk
to mental health providers because they’re afraid of career problems, and if they are on
security certain security clearances, they get those revoked. And then they can’t do their
job, and they feel bad for their entire unit. So, I was at that point in my career, which was
a mid-level career. I’m resigned to the fact that I wouldn’t progress because I was told if
you go to mental health, you will not progress.
Similarly, Joseph described how stigma affects people with security clearance in the military. He
suggested that the loss of security clearance directly affects their job and trust in leadership, with
a significant impact on the operational readiness of the command. Additionally, he suggested
that people who seek help from mental health are treated with suspicion by their leaders:
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The stigma as a real people believe I mean it can affect their security clearance and they
can’t do their job. “Oh, you’re seeking help, so now we don’t trust you to do your job.
We don’t trust you to be you know ready to take the fight to you know our nation’s
enemies.” The statements are “Oh, well, he or she is getting out of work for hours on end
to go get help and doesn’t really appear there’s anything wrong with them, so now
they’re just skating. They don’t want to do their job.”
Even more, the eight participants served in different military branches but shared
comparable stories of experiencing stigma, which enhanced their fear for their military careers,
rank, position, and leadership for seeking help for mental health. Holly discussed how her group
of retired military friends who served across service branches shared similar experiences of fear
and refused to seek help and counseling to treat mental health conditions:
I’m in a group now of female veterans. People that are going to retire or people who have
retired, and it’s like we all have the same story where we didn’t want to be seen as weak,
so we never seek out treatment or help. And now that we’re retired, it’s like, oh, we wish
we would have.
Perceived Culture of Stigmatization Discouraged Help-Seeking Behavior
“One of the commanders told his commanding officer that he had been feeling suicidal,
that he needed to get help, and he was relieved of his command.” Lisa explained people are
encouraged to seek help in the military but getting help often results in losing trust in leadership,
military command, and being passed over for promotion. As a result, people who are suffering
from crisis, mental health issues, and substance abuse problems are reluctant to seek help and
treatment. Their mental health condition worsened as they suffered in silence resulting in suicide
ideation and increased military suicide. Five participants blamed poor leadership within their
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military commands, and “I also think that the military create situations that make people very
helpless.” Rahim discussed how he was discouraged from seeking help for anxiety caused by
stress from losing one sailor to suicide. He explained seeing people who came back from Iraq
and Afghanistan with mental health problems were stigmatized and talked negatively about by
the command master chief:
I saw people who are marginalized and labeled as people who couldn’t cut it, couldn’t
cope, couldn’t hack it when they came back from Iraq, Afghanistan, and they need help
suffering from PTSD. I’ve been in the room. I heard those conversations. So, yeah, I
didn’t feel like I could talk to anybody and go talk to command master chief or some of
them. I didn’t feel like I could do that because I saw it happen. I just thought it will
happen to me, so I never said anything. You said to deal with it, which sucks. It’s not me.
It’s not good That’s a lot of mental stress: the turmoil and pressure. It can lead you down
the road to depression.
Additionally, the fear of being perceived by the command master chief as incapable of leadership
and doing his job due to mental health problems discouraged him from seeking help, which
worsened his health resulting in depression. As a single parent with three children, Rahim
discussed the fear of losing his career and the thought of not being able to provide and care for
his family as the reason he did not seek help from mental health:
I’m a single parent for two of my children, and if I didn’t make it happen, it’s not gonna
happen for them. So, for me, I just have to keep going. I cannot. I can’t. I can’t put
myself in a situation where I would jeopardize any.
Joseph concurred by discussing his experience dealing with stigma as a young airman. He
stated, “Oftentimes, you get told that there’s nothing wrong with mental health, but that feels like
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judgement, and that’s not right.” He suggested that people who seek treatment for mental
problems are often stigmatized by peers and seen as no longer qualified by the military and
incapable to do their jobs:
It’s the stigmas are that if you go to mental health, your peers are going to look down on
you or the military as a whole is going to look down on you, and now you’re not
qualified. I’m not talking about just qualified to do your job statements or you’re not
qualified as a person anymore, and that’s a military mindset that’s just garbage. It truly is
garbage, but it’s there. And I experienced that as a young airman to a seasoned NCO. I
know dozens upon dozens of people who have gone to mental health and felt the exact
same way. Stigmas are real. They’re unfortunate, and there’s something that needs to be
done about it.
Steve agreed that the stigmatization culture in the military is detrimental to help-seeking
behavior. He explained his personal struggle and challenge in asking for help due to fear of
stigma, which discouraged him from seeing mental health:
I learned so much about the importance of getting help, but it took me about 5 years to
really learn how to ask for help because the number one concern for every service
member is how is this going to affect my career adversely If I asked for help? Okay,
everybody talks. Everybody gossips in the military. They call it the lance corporal
underground. There’s a lot of people, and this bleeds over into the sexual assault category
too, that are scared to get help because they’re afraid their career is going to suffer.
Stigma played a significant role in impeding the help-seeking behavior of participants
who experienced mental health problems caused by exposure to a suicide event. Seeing how
people were stigmatized by their peers and leadership for seeking treatment for mental health
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increased perceived fear, which changed participants’ help-seeking behavior to avoid treatment
for mental health problems. Table 7 shows sample statements for the participants’ experience of
stigma.

Table 7
Participants’ Response to How Stigma Affected Their Ability to Seek Help
Participant Sample statement of how stigma impeded their help-seeking
Allan I didn’t tell anyone about my mental health problems because the consequences
are too severe.
Bill One of the challenges is that my security clearance will be jeopardized.
David Going to see behavioral health was seen as weakness.
Holly I pushed a lot of things aside just so that I wouldn’t be seen as weak.
Lisa I have seen it in other units where security clearances got revoked.
Rahim I saw the way others were labeled and marginalized, so I couldn’t have the
conversations.
Ricky The stigma is still there, and people are worried about their security clearance.
Ryan The stigma increases as your rank increases.
Joseph Stigma affects security clearances.
Steve The number one concern for every service member is this going to affect my
career.

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Results and Findings for Research Question 3
The third research question asked, “What are the methods used by retired military
personnel to cope with losing someone to suicide?” The 11 participants discussed different
coping mechanism they used to cope with exposure to a suicide event. Qualitative analysis of
data suggested four reoccurring themes that addressed this question: connection with family and
community, therapy and mental health treatment, exercise and staying busy, learning, and
sharing experience with others. These themes where used as coping mechanisms by the 11
participants.
Connection with Family and Community
The 11 Participants used different coping mechanisms to alleviate suffering from the
effect of their exposure to a suicide event. However, eight participants suggested being
connected to their family and community and relying on them for support during a crisis.
Particularly, Allan who was fearful of being stigmatized by his peers and military supervisor
relied on his family and community stating, “and people who cared about me.” Allan
intentionally avoided using the military system and chain of command for support due to a lack
of trust that stemmed from the mismanagement of a family advocacy program (FAP) case. He
relied on his wife and friends for support and a coping method:
What actually helped me were people that cared about me. People that cared about me
kind of got me through the FAP situation and getting through the FAP situation didn’t
fully solve everything, but it was enough of a boost that other things started to work
together. My wife was super supportive throughout the whole FAP process. She knew
that I was suffering. She didn’t know I was like suicidal, but she knew I was suffering.
And so, as I would leave for trip, she would do things like stick pictures of our kid in my
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bag when I left. So, it was not the professionals. What got me through was regular
people. It was my and particularly an admiral that I’m connected to and his wife. Those
were kind of the three people that got me through, even though none of them knew they
got me through for years afterwards.
After his deployment and tour in Afghanistan and Iraq, Bill relocated and found
connecting with a community of likeminded military people, his wife, and daughter, and “finding
and doing things that make you happy” as coping methods to navigate the effect of being
exposed to suicide bombers:
It’s really important that you find that community that understands you, and your
personal relationships are not going to know the kind of experiences that you went
through. Internally, but that’s when you say how did it affect me? That’s one of the things
that it did. I reached out to the community in the area that I’m living in. This could
potentially relate to what I have experienced personally so that I could share those if I
need to. I will tell you that I’m part of a group on Facebook called after the long walk. in
EOD, the long walk is leaving the safe area, going down on a bomb, and working to get it
safe. That’s the long walk. after the long walk, it’s considered like when you retired, and
you’re not doing that anymore. The group is really focused on suicide and me, and I think
it might be something you might be interested in.
While deployed, he implemented a coping method where “we would sit around a barrel fire in
Iraq, after mission, and smoke some cigars and talk about that mission and decompress. those
were the best, and we needed to do that and share that.” He also relied on his wife and daughter
for support at home and to cope with the mental and psychological problems of losing someone
to suicide:
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My wife is supportive, and my family are very supportive. Not just my wife, but my 16-
year-old daughter, who understands that slamming the front door on the way out for
school in the morning is not good for me. When I have someone who’s a colleague of
mine who chooses to commit suicide, I tell my wife about it because I’m going to be
bummed about it. And I want her to know that I’m bummed, and it’s not because of you
and daughter. it’s not because of you. it’s because I knew this person, and they decided
that they didn’t want to deal with what they were dealing with anymore or whatever their
reasons were.
David used connection with his family to cope mentally from exposure to a suicide event,
stating, “I have been married with the same woman for 30 years; good woman, she dealt with a
lot with because I haven’t been the easiest person to deal with.” Likewise, Lisa reached out to a
community of people with military experience and background as a way of coping. She
suggested that methods used for coping depend on individual preferences and choice, stating, “I
really do think that it means for each individual there’s a different type of support that works; for
me, it was group.” Joseph agreed with Lisa’s view, stating, “Coping mechanisms are weird.
Some people have counseling. Some people have faith. Some people have talking to others about
it, and I my coping mechanism are similar. I lean back on my faith.” Ricky discussed using his
team at work for support and receiving help from members of his church to cope emotionally
with the loss of his wife to suicide:
Two teams really helped me as far as emotionally and through the process. That was my
work team who said, “Hey, we are here to do whatever you need. As much time as you
need off you have it.” So, that support structure there. And this also blends into the social
aspect as well, but those at church did the same exact thing, so I had folks at church that
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would stay at the hospital with me for days and days and days. So, the social aspect of it,
for me because I’d already had a social. I was fairly healthy on the social side. Those
people showed up. Friends from church, friends from work, and really helped through
that particular process and then after that socially.
Therapy and Mental Health
Three participants suggested seeking help from therapists and mental health services after
retirement to cope and treat traumas, emotional issues, changes in behavior and disorder, and
psychological problems caused by exposure to a suicide event. Two participants unaffected by
perceived fear and culture of stigma in the military used professional counseling support services
to seek help to cope and treat mental health problems. Steve used therapy to cope with his
inability to process information, self-hate, and mood swings:
My ability to process things in life is more difficult than other people because of my brain
injuries. Right here in the front and the frontal lobe is what does all the processing. And I
don’t have that ability, so I continue to seek help I’ve been in therapy for years and I have
systematically worked my way out of being somebody who is a victim of suicidal
thoughts and self-hate. But if I could go back and do it all over again, I would have taken
care of myself much better in the moment, instead of always focusing elsewhere and
letting this boil over later on in life. I would journal, I have a journal that I use that’s kept
in a secret place that has some pretty disturbing things written in it. But it’s because I’m
able to draw I’ve learned through therapy, that if I journal things and get them out of my
head, I process things much better, so I mean. I wouldn’t want anybody to read that thing
because there’s some spooky stuff in there, but it was from my heart, and I was able to
journal it out.
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One participant also recommended “talking to a therapist or a chaplain” as a mechanism
to cope. Lisa described her experience of creating a program in the Air Force that embedded a
team of medical personnel, mental health experts, social workers, and chaplains that provided
support to the military unit. She suggested integrating animals, such as service dogs, and
providing workable hours for short staff units to help people cope and improve mental health:
When I was leaving the Air Force, I’d been working on a project where we were
embedding mental health support and chaplains, so we were embedding teams in units of
high-stress units, particularly maintainer where our high-stress units, and that seemed to
be working really, really well. So, each unit had a chaplain a mental at least one mental
health provider, probably a couple social workers in the unit. And sometimes a not a
service dog but a mental health, kind of dogs. The animal. They found animals help a
great deal. And then, some of them also had doctors that were embedded in the unit. And
that was giving people a sense of, they could talk to a mental health provider without
going to the office without getting stigmatized, and then get some support within the unit
where they were at, and it seemed to be working really, really well.
Additionally, Holly “reached out to mental health, and I cannot tell you how it helped just to be
able to speak to that lieutenant and him telling me that I’m not crazy, that I’m normal, everything
that I’m feeling is normal.” She described using mental health services to cope with losing her
brother, nephew, mentor, and best friend to suicide. Bill agreed that “counseling is part of it,”
while discussing how he coped with the trauma of exposure to a suicide event. Overall, seeking
help from mental health professionals was recommended as a coping mechanism by 11
participants to help manage health problems caused by exposure to a suicide event.
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Exercise and Stay Busy
Four participants recommended exercising and staying busy as a coping strategy to
effectively mitigate and manage emotional and behavioral changes caused by suicide. Allan used
long-distance running to cope with his suicidality: “I have been an avid runner for my whole life,
so running probably made a difference.” Similarly, Lisa exercised daily to cope with the stress of
dealing with clients who ended up committing suicide. She stated, “I’m a big one for exercise as
a coping mechanism that really helps me a lot.” While Ricky recommended staying busy at the
beginning as a coping method, suggesting that it helped to facilitate grieving:
Staying busy, especially during that initial time because I so when the event happened,
I’m now a single dad full time working two kids going to school, so there was a point
there were all of that stuff definitely helped me cope, as I was going through that. And it
allowed the grieving process to expand out a little bit and where I didn’t have to go
through everything all at once because I have had other responsibilities that were more
top of mind. I was able to take the grieving in a little in smaller chunks to deal with the
situations more spaced out, and that was another way that was beneficial for me to stay
healthy through that time.
Also, Bill recommended staying busy and “finding and doing the things that make you happy” as
cope mechanism to deal with the loss of someone to suicide. He suggested that doing the things
you enjoy helps people to cope better and move forward with the grieving process. All
participants discuss their experiences and different methods they used to cope with loss.
However, only four participants recommended exercising regularly and staying busy as effective
coping methods.
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Learning and Sharing Experience With Others
Three participants discussed how sharing their experiences of losing someone to suicide
helped them to cope with their loss. They joined groups in their local community and platforms
to teach others about their experiences to increase knowledge and awareness about suicide
prevention. As a result, helped them cope emotionally and psychologically. Holly used her
experience to educate people around her and encouraged them to seek help:
So, I love to talk about it. So, especially with my sailors if they were experiencing
something. I always like to bring up what my brother did, what my mentor did, what my
best friend did, so I use those examples to talk to people. And I want to talk about it
helped me as well. I didn’t ever seek counseling or anything, but the biggest thing was
just talking about it and being able to tell stories about them and share their experiences
with others, how I coped with it.
Lisa agreed that “going and talking to people” helped her cope better. As an Air Force chaplain,
she also suggested that reading and learning about suicide to broaden her knowledge and
understand the causes of why people commit suicide helped her to cope with her loss:
Reading learning more because it took us so much by surprise. And just learning more
about, I did that right, not right after but a few years after experiencing this, but that
helped me understand better some of the perceptions of how people get into that
headspace and having been in that headspace myself how to help people break out of the
pattern how to do some preventative stuff but in terms of military members.
Ricky volunteers to teach resilience and suicide prevention classes and share his stories to
increase awareness, contribute to prevention efforts, and help save lives. He suggested that
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teaching classes and receiving feedback from people whose life was saved by his story helped
me cope with the loss of his wife to suicide:
A big thing for me was teaching the resilience and the suicide prevention, so it’s still
beneficial for me today. I’ve had people tell me this all the time that because of the talk
that we had in the auditorium that day, I was planning on going to kill myself after that,
but because of your story and the way that you have been able to walk through your event
that helped me not do that, on the other side. I think God never wastes to hurt, so taking a
hurt that happened to me and then using that to be able to help somebody else not go
through that same thing that was extremely beneficial was and still is very beneficial for
me to be able to cope through that.
Joseph shared his knowledge gained from experiencing the effect of exposure to a suicide
event with others to save lives and as coping mechanism to manage the effect of his loss.
Understanding the importance of leading others, he became aware of the people around him and
interested in serving them as a leader:
I lean on my understanding that I gained from having that experience and then every time
someone tells me that you know me being you know being approachable or me helping
them out, it just means that You know those coping mechanisms are now working and
that just makes me feel like, okay, finally, I’m not guilty for the action that that young
man took. But for a while, I did feel guilty and my coping mechanisms were negative, but
now they’re at the positive where I want to see change and coping mechanisms or just
helping others as much as I can to possibly either get through a similar situation that
they’re dealing with or maybe they’re dealing with someone who has committed suicide,
and there are not dealing with that individual obviously but dealing with that situation.
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Maybe they’re dealing with suicidal ideations and just being open to helping and sharing
my story, and it’s strange to say, but a couple of mechanism. It’s just not being so angry
all the time, you know.
Summary
Losing someone to suicide affected participants differently, causing significant
psychological pain and mental health problems and changing their cognition and perspectives
towards people suffering from mental health problems and people experiencing trauma from
losing someone to suicide. Their experience provoked negative emotions causing significant pain
to participants, resulting in feelings of anger, frustration, guilt, and blame. Rationalization and
sense-making were used often to interpret and ascribe meaning to multiple exposures to suicide
events. Each participant’s experience and exposure were unique to their job, environment, and
military branch of service. However, their experiences of stigma, perceived fear, and responses
to seeking help to treat mental health problems were similar. They chose to avoid seeking help
from mental health to protect their careers, not to show weakness, and fear of losing their
security clearance, which worsened their suffering and mental health problems. Stigma played a
significant role in increasing participants’ fear and discouraging help-seeking behavior. After
retirement, participants shared a similar experience of regretting not seeking help and using
available support to treat mental health problems. They used different coping mechanisms such
as connecting with family and community, therapy and mental health clinics, exercise (running)
and staying busy, learning about suicide prevention, and sharing their experiences with others.
Participants also used their knowledge and experience extensively to help people who are
struggling with the loss of someone to suicide by sharing their stories to save lives.

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Chapter Five: Discussion and Recommendations
Suicide is a social problem that affects people socially and psychologically and increases
mental health problems, which results in suicidal behaviors and suicides if left untreated.
Consequently, losing someone to suicide affects a person’s behavior and increases suicidal
behaviors, suicide ideation, and suicide attempts (Bryan et al., 2016; O’Connor & Portzky,
2017). Similarly, exposure to a suicide event decreases performance behavior and the ability of a
person to do their job effectively (PHC, 2021; Rowan et al., 2014). Active-duty military
personnel exposed to suicide are affected emotionally and socially and experience trauma
perpetuated by cultural stigma within their command, which discourages help-seeking behavior.
Leaders, healthcare personnel, and support staff such as chaplains and counselors who
collaborated with the deceased are devasted and affected emotionally and overwhelmed with
feeling guilty, anger, and blame (PHCE, 2021). Andriessen et al. (2017) agreed that people who
experience exposure to a suicide event also experience more guilt, shame, social stigma, and
difficulty finding meaning to understand and cope with the situation.
Overview of the Study
This study focused on the high rates of suicide in the military and how exposure to
suicide events affected members' behavior on active duty and recommended effective solutions
to provide adequate care and support to service members affected by loss. Using the SCT
framework on the interrelationship between humans, behavior, and the environment, this
research connected the link between exposure to suicide events, behavior, and suicide in the
military to create effective solutions to the problem to decrease the rates of military suicide. The
study integrated the lived experiences of retired military members, who provided rich data and
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broadened knowledge in understanding the effect of suicide on the behavior of active-duty
personnel.
Summary of Findings
Research findings emerged from qualitative data analysis using the constructivist
interpretive worldview paradigm, SCT, and conceptual framework as a lens to accurately
interpret participants' experiences. The SCT premise is that human activities and performance are
embedded into a broad network of social systems that allows people to regulate their activities
based on values, self-efficacy, interests, and goals (Bandura, 2005). This theoretical perspective
highlighted connection with family and community, therapy and mental health treatment,
exercise and staying busy, and learning and sharing experiences with others as different
mechanisms participants use to cope and self-regulate their behavior. The theory views human
beings as change agents that actively take part in changing their conditions and are changed by
their environment, which creates constraints on human performance to produce responses and
behaviors (Bandura, 2005). This theoretical perspective aligns with the effect of suicide on
participants causing psychological pain and mental health problems, changes in cognition and
perspectives, and experiencing negative emotions. Perceived culture of stigma in the military
contributed to impeding help-seeking behavior for mental health and exacerbated perceived fear
which produced negative responses (constraints) to seek treatment for psychological and
behavioral problems caused by exposure to a suicide event. SCT aligned with consistent findings
in this study regarding the experiences of participants’ interrelationship with the environment
and how they responded to the situation based on constraints and their ability to self-regulate
their behavior.
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Research Question 1 focused on how losing someone to suicide influences the behavior
of active-duty military personnel. Three themes emerged from the analysis of qualitative data.
The first is exposure to a suicide event causes psychological pain and mental health problems for
active-duty personnel. Moreover, 8 of 11 participants suggested that experiencing the loss of
someone to suicide caused severe psychological pain leading to mental problems. They
explained that exposure to a suicide event while serving on active-duty military changed them
mentally and behaviorally. This finding is consistent with the literature on psychological pain
and mental health problems. The Psychological Health Center of Excellence (2012) reported that
48,000 Americans committed suicide in 2018, with each death affecting 135 people with varying
degrees of trauma caused by the loss. Cerel et al. (2019) surveyed 1,736 adults to determine the
number of people exposed to suicide events and indicated that each suicide affected 137 people,
and 20% of people exposed experienced grief, traumas, and were in need of mental health
support. Likewise, the literature showed military members exposed to a suicide event are at
increased risk of mental and behavioral health issues and impaired functioning (cognition),
which increases suicidal behaviors (Andriessen et al., 2017). Participants admitted experiencing
psychological trauma and pain after losing someone to suicide and observed the same effect on
their command and team members. However, they neglected to seek help from mental health
clinics to treat their psychological trauma and pain. Social cognitive theory suggests that human
interaction within an environment creates changes and constraints on human performance and
response (Bandura, 2005).
The second theme focused on changes in cognition and perspectives of the individual
exposed to a suicide event. Cognitive changes are the changes that occur in a person’s reasoning
to influence their choices and decision-making skills. An outcome of events forces a person to
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interpret results and evaluate their competence, which informs their cognition and directly affects
reasoning to self-regulate their behavior (Elliot et al., 2017). Eight participants discussed
experiencing a cognitive shift and increased awareness to know more about members of their
team, learn about suicide prevention, and share their experiences with others to prevent suicide.
After experiencing the loss of someone, they experience empathy for others' suffering and
increased willingness to provide support and access to care for others. Similarly, three
participants discussed their increased awareness of people affected by loss and suffering from
mental health problems and their motivation to research and learn about the effect of suicide.
Eight participants also discussed that their reasoning (cognition) and behavior towards
people who attempted to commit suicide, people with mental health problems, and behavioral
disorders changed after their exposure. Personal exposure and interactions with environmental
factors affect the individual's behaviors, cognition, and choices (Bandura, 2005). The change in
their cognition is supported by literature on the individual's meaning-making. Miklin et al.
(2019) examined the vulnerabilities of people dealing with the loss of someone to suicide and
suggested that vulnerabilities are linked to how the person interpreted the situation and
experienced the loss. Results from the research concluded that exposure to a suicide event is
painful but not risky, increases a person’s vulnerability and that the experience depends on the
individual’s meaning-making. The participants' perspectives changed from blame, grief, and
feeling guilty to sharing their experience of loss to assist others to cope during command suicide
awareness and prevention training. Integrating SCT provides a framework to understand how
individuals' belief in self-efficacy influences their abilities to organize, create, and manage
circumstances in their environment (Bandura, 2005).
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Finally, the third theme centered on experiencing negative emotions such as blame, guilt,
anger, anxiety, depression, and frustration. Participants discussed feeling overwhelmed
emotionally by their loss and mentally processing the situation while trying to rationalize their
role and questioning what they could have done to prevent the death of the deceased. The
meaning-making process led to self-blame, feeling guilty for not being present or doing enough
resulting in anger, anxiety, and frustration. Participants experienced mood swings and
relationship problems caused by grief, self-hate, emotions, and depression. This finding is
consistent and supported by the literature on emotional trauma.
Death by suicide causes emotional trauma to decedents’ families (Skopp et al., 2019).
When a person commits suicide in a command, coworkers, family members, and friends
experience grief and bereavement and mourn their loss. Often, military personnel who worked
with the deceased experience sadness, anger, and guilt for not doing enough to prevent the
suicide (PHCE, 2021). A study on the emotional responses of 26 psychotherapists after their
patients committed suicide revealed that 50% responded with shock, and 12% reported unbelief
with a range of emotions such as grief (65%), guilt (50%), anger (46%), fear of blame (42%),
self-doubt (42%), and fear of lawsuit (38%). Also, the literature suggests that exposure to a
suicide event is linked to PTSD, depression, and anxiety (Welton & Blackman, 2006).
Participants who provided chaplain support and mental health support felt guilt, anger, and
frustrated with the deceased for not allowing her to provide more support and save his life. The
Psychological Health Center of Excellence (2021) asserted that an individual’s belief of
closeness with people who committed suicide is psychologically more damaging to the people
exposed to suicide than physical proximity and relationships. Overall, the themes that appeared
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from data analysis answered Research Question 1: How does the experience of losing someone
to suicide affect the behavior of active-duty military personnel?
Research Question 2 captured the role that stigma played in negatively affecting help-
seeking behavior among the active-duty military population. Two themes emerged from
qualitative data analysis. First, stigma exacerbated perceived fear. All participants extensively
discussed being fearful of losing their career, security clearance, and leadership position if their
military supervisor found out they had a mental health problem. Stigma attached to mental health
treatment, fear of consequences, and the belief of losing security clearances affected the help-
seeking behavior of military personnel (McKnight, 2019). Despite access to care and increases in
mental health problems, the number of active-duty personnel who seek help for treatment is low
(Krunnfusz, 2018).
One participant suggested that stigma is a major challenge across the military with severe
consequences and detrimental to career advancement, promotion, and the loss of security
clearance, which decrease the chances for promotion. Seeing how people with mental health
problems are mistreated (stigmatized) by their supervisors and peers increased the fears of three
participants and their lack of trust in command leadership. Price (2011) examined the
relationships between mental health and help-seeking behavior and suggested that stigma and
perceived fear affected participants' attitudes to seeking help for mental health problems.
Stigmatization of personnel with mental health problems, substance use/abuse, and behavioral
disorders played a significant role in discouraging them from seeking help. As a result, their
mental health problems worsened, causing more suffering leading to suicide.
Results from the DoD Annual Suicide Report (2019) suggest active-duty military
personnel were most likely to avoid seeking treatment for mental health problems due to the
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following reasons: loss of privacy and confidentiality (68%), fear of being perceived as broken
and incompetent by their chain of command or peers (67%), negative impact to their career
(65%), and not knowing who to turn to (50%). These results aligned with the literature on mental
health stigma in the military and civilian organization. Stigma and fear of career failures cause
underutilization of healthcare facilities by active-duty personnel to manage behavioral issues,
contributing to personal suffering, increased healthcare costs and expenditure, and affecting
military units’ mission readiness (Westphal et al., 2018). Similarly, results from a study of 128
male first responders (firefighters, paramedics, EMTs, and police officers) investigated the
relationship between behavioral health stigma, coping strategies, and burnout suggested the
attitude of avoiding mental health experiences is a predictor of emotional exhaustion and
depersonalization (Tal, 2021). Nine participants suggested that stigma significantly increased
their fears and decisions to avoid seeking help and treatment for behavioral and mental health
problems, which worsened their suffering. They sought help and treatment after retirement. Only
two participants were unaffected by perceived stigma for this study.
The second theme that emerged is that a perceived culture of stigmatization of people
with mental health problems in the military discouraged help-seeking behavior. Participants
discussed their perception of a cultural stigma in the military and individual experiences of lack
of support from their supervisors and command leadership. They provided personal examples of
their leadership not providing enough time to grieve their loss, lack of sympathy for emotional
distress, or access to support services such as chaplains and behavioral health. It is important to
understand why active-duty members do not seek help for mental health issues (Gochicoa,
2019). One participant, a Navy pilot, suggested that the perceived culture of stigmatizing active-
duty Navy pilots with mental health and behavioral disorder results in removal from schedule to
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fly missions. Consequently, removing a pilot from the schedule to fly missions decreases their
chances of competing for promotion with other pilots with more flight time. The perceived
culture of stigma combined with fear of career stagnation impedes help-seeking behavior for
mental health problems in the aviation community.
Data from this study is supported by recent research suggesting that Marines diagnosed
with mental health conditions received demotion and separation from active duty. Pre-existing
behavioral and mental health disorders are the primary reason for post-deployment demotion
(Varga et al., 2018). Likewise, military members’ willingness to show and seek treatment for
mental health problems depends on personal beliefs about career outcomes and military status
(Convoy & Westphal, 2013). Also, Dondanville et al. (2018) posited that only 23% to 40% of
active-duty members sought help for PTSD and mental-health-related traumas and attributed the
low percentage due to stigma and the belief that admitting to having mental health problems
would be harmful to their careers. This aligned with the SCT framework that suggests human
behavior is learned through observation; seeing how other people avoid seeking help for mental
health motivated participants to model the same behavior (Bandura, 2005; Bandura, 1994).
Overall, themes that appeared from data analysis addressed Research Question 2: What role does
stigma play in seeking help for mental health?
Research Question 3 concentrated in understanding the different mechanisms used by
active-duty personnel to cope with the loss of someone to suicide. Four themes emerged from
qualitative analysis of data. The first is connection with family and the community. Participants
suggested that having a strong connection with their family and a community of people who care
about their well-being provided resources that helped them to cope emotionally and
psychologically with their loss. They discussed how connecting with a community of like-
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minded people in the local church (faith and spiritual) and online group (social and emotional)
for support enhanced their ability to cope during a crisis. Maintaining effective communication
with families and friends is associated with improving the mental health of nurses during the
COVID-19 global pandemic (Rahman, 2022). They also used their family and friends as a source
of support to cope with their loss, especially participants who were fearful of stigma, demotion,
and losing their security clearance for experiencing mental health problems caused by exposure
to a suicide event.
Findings for this study aligned with the literature in that the seven broad and evidence-
based strategy adapted by DoD from CDC included human protective factors such as strong
connections with family and friends, seeking help for mental health issues, team unity and
camaraderie, beliefs that support self-preservation, positive attitudes towards life, and effective
critical thinking skills as mitigation for suicide (ASR, 2019; OPNAVINST, 2018). Results from
2018 Defense Climate Survey to determine connectedness baseline metric suggested 70% of
Service members reported high connectedness with others. Junior enlisted Service members
reported 63.8% connectedness and 83.7% for senior officers (ASR, 2019). According to five
participants, using their families and friends and moving into a community of people who
understand them helped them cope mentally, psychologically, and socially. Also, connecting
with family and social groups are protective factors used to help reintegrate military personnel
treated with mental health issues back into their command, which is essential to achieve well-
being and develop the ability to manage emotional and psychological stress (Barry et al., 2019).
Likewise, a strong connection with family and a supportive community serves as protective
factors for service members during a crisis and provides support to promote a sense of belonging
and mental health (Barry et al., 2019; Laerke Mai Bonde, 2021). Moreover, the five participants
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discussed that they felt a sense of relief using connection with family and friends for support,
knowing that their career is safe from social stigma and isolation from their peers at the
command.
The second coping mechanism recommended by participants is seeking help from
therapy and mental health treatment. They suggested seeking help from mental health clinic as
an effective way to treat and cope with behavioral disorders, trauma, and emotional problems
caused by exposure to a suicide event. To avoid stigma from their peers and military supervisors,
nine participants sought help through therapy after they retired from active duty; and only one
participant used therapy for emotional support while on active duty. Participants also discussed
how their position as senior military officers and leaders within their command served as a
barrier and hindrance to them asking for help while on active duty. However, they sought help
from mental health and support services such as chaplains and professional counseling services
after retirement from active duty.
Literature showed that psychological assessment and counseling to suicide survivors is a
helpful way to adapt and cope with the psychological trauma and emotional pain caused by their
loss (Hua et al., 2020). The primary intervention programs implemented by DoD increased
communication, public awareness campaigns, and educated military personnel on warning signs,
risk factors, and protective factors; it also encouraged help-seeking behaviors to prevent suicide
(Griffith & Craig, 2018). Hence, implementing an effective intervention protocol is critical for
mental health and support services to provide timely response and treatment to prevent suicide
(Stallman & Allan, 2021; WHO, 2014).
Participants recommended seeking help and treatment for mental health problems using
available resources while on active duty to lessen suffering and damage to health. They
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encouraged supervisors and military leaders to create resources that provide access to healthcare,
support services, counseling services, and a positive command climate to support active-duty
personnel to seek therapy and treatment. Some participants suggested that the lack of time to
visit therapy and treatment facilities is lacking due to the mission schedule and lack of support
from supervisors. Consistent findings in the literature are that people who experienced emotional
distress, prolonged grief, and bereavement caused by suicide are less likely to receive support
and access to healthcare compared to others who experience grief by other causes (Pitman et al.,
2017). A significant gap exists within the military structure and healthcare system in providing
access to care and support services for people bereaved due to exposure to a suicide event
(Sanford et al., 2016). Participants recommended using therapy and mental health treatment as
effective coping mechanisms to manage emotional pain and psychological trauma caused by
losing someone to suicide.
Thirdly, exercise and staying busy emerged as a theme used by participants. They
recommended these as a coping mechanism for active-duty personnel to manage emotional
trauma and pain caused by exposure to a suicide event. They attributed their success to daily
exercising and staying busy doing the things they enjoyed, such as spending time with family,
socializing with friends, and writing their experiences in journals. One participant, who suffered
from PTSD and emotional pain from the loss of 18 friends to suicide, found journaling helpful in
sense-making and as a positive way to interpret his experience of losing his friends. He
suggested that staying busy writing his thoughts helped him remember that what happened was
not his fault and decreased his self-hate, feeling guilty, and self-blame.
Eight participants used daily exercise as a coping mechanism to alleviate emotion and
manage stress; two participants took part in marathon and long-distance running. Considerable
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evidence in the literature showed that exercise and taking part in relaxation activities are helpful
coping mechanisms for stress management and improved mental health. For instance, study
showed that two-thirds of nurses used relaxation activities such as exercise, yoga, meditation,
dancing, cooking, and cleaning as a coping mechanism to manage stress and anxiety during the
pandemic (Rahman, 2022). The same study suggested that deep breathing exercises strengthened
the parasympathetic nervous system, which is responsible for regulating body function and
supporting rest. Also, skipping rope daily and eating nutritious food increased resistance and
decreased stress (Rahman, 2022). Participants integrated exercise regimens and activities that
kept them busy as coping mechanisms to manage stress, emotional pain, and psychological
trauma they experienced from exposure to a suicide event.
Finally, learning and sharing experiences with others appeared as a consistent theme in
the data. Participants often volunteered to take part in discussions pertaining to suicide to share
their experiences and encourage people. For example, participants admitted that they volunteered
to participate in this study to share their stories about losing someone to suicide and how it
affected them personally and psychologically to help those who are going through a similar
experience cope and save lives. Some discussed how experiencing the loss of their friend,
relatives, and colleagues to suicide increased their awareness of the prevention efforts, which
motivated them to learn about suicide and engage in public speaking.
Findings in the literature showed that participating in meetings and baseline interviews
concerning suicide helped study participants avoid social isolation, adjust to their loss, and use a
coping method (Saarinen et al., 2000). They volunteered to join groups online using the platform
to serve as counselors for people during a crisis. They participated as guest speakers to share
their experiences with others during suicide awareness and prevention training, which helped
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them cope mentally. Sharing of experiences through storytelling and engagement in speaking
publicly about a personal struggle with suicide serves as a strong coping mechanism (Hua et al.,
2020). Additionally, joining groups online to share experiences facilitated the exchange of ideas
that empowered bereaved individuals, reframed, and destigmatized individual experiences of
suicide narratives (Hagstrom, 2017). They discussed how researching suicide and prevention
helped increase their knowledge, and they experienced a shift in their mental model leading to
the motivation to support their co-workers and others suffering. Overall, themes that appeared
addressed research question three: what are the recommended methods used by retired military
personnel to cope with losing someone to suicide while on active duty?
Implications of the Study
The purpose of the study was to investigate how exposure to a suicide event affects the
behavior of active-duty military personnel. Findings may increase awareness in the DoD and
across military organizations of the challenges in preventing suicide. The study highlighted
increases in risk factors associated with suicidal behaviors, suicide ideation, and suicide.
Therefore, it is the responsibility of DoD and military commanders to create an effective
framework to mitigate high rates of suicide among the active-duty military population and
provide access to healthcare and professional support services to help people suffering from loss.
Suicide is a public health problem that affects military members and civilians and interrupts the
structure of families globally (Yamane & Butler, 2009).
Recommendations for Practice
There are three recommendations suggested to help mitigate findings from the research:
(a) implement training models that use qualified medical personnel to facilitate suicide
prevention training; (b) destigmatize mental health problems, behavioral disorders, and substance
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abuse disorders through mandatory leadership education to increase knowledge about
psychoeducation and create awareness to encourage help-seeking behavior; and (c) strengthen
access to mental health services and professional support and create a policy to allow personnel
affected by losing someone to suicide longer period to grieve properly. The logic model is
integrated to plan, evaluate, and adjust program resources as needed to achieve program
objectives and sustain change. This model is beneficial to implementing suicide prevention
efforts in the military in that it accounted for resources (input and outputs) and the chain of
causes and effects that leads to an outcome. Also, incorporating the logic model aligns with
military program evaluation plan, culture of accountability, management of resources, and
increases understanding of program cost benefits and buy-in from commanders.
Recommendation 1
Findings in this study showed peer-group discussion training facilitated by qualified
medical personnel is effective and engenders trust and openness that encourages participants to
seek help. Four participants explained that trust is important to discuss sensitive issues and
exchange experiences that increase understanding and the use of resources to treat mental health
problems. This study found that “using non-medical people to teach suicide prevention training
using power point format is ineffective.” Literature also emphasized a lack of effective
framework and ineffective suicide prevention programs across the military (Griffith and Craig,
2018; Harmon et al., 2016).
Steve suggested that Integrating qualified medical personnel to facilitate suicide
prevention training in a peer group using “a discussion format to share experiences and make
suicide training real instead of fabricated stories, power points, and reading from a book.” Also,
talking to trained medical people about mental health, emotional trauma, and psychological
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manifestations on behavior is easier during training focused on resources like protective factors
that support the needs of people dealing with the loss. Similarly, a recent study showed that
medical provider peer-focused training increased knowledge and understanding of suicide
prevention and referrals to seek help for mental health problems (MacPhee et al., 2021). This
aligned with the SCT framework and concept of how belief in self-efficacy influences the ability
to organize, create, and manage circumstances in the environment. People can motivate and self-
regulate their behavior to set and achieve personal goals based on self-interest and benefits
(Bandura, 2005). Effective program evaluation is vital to finding the outcomes and benefits of
personal development programs for individuals across organizations (Hauser & Weisweiler,
2020).

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Table 8
Recommendation 1: Implementation Plan and Evaluation Criteria
Resources Activities Outputs Short/long-term
outcomes
Impact
Time allocation;
training
materials and
supplies.
Create
command/unit
level
orientation
training and
suicide
prevention
training.
Integrate
medical
personnel to
teach
command
Indoctrination
and suicide
prevention
training.
Increased
awareness,
trust, and use
of resources
by people
affected by
loss.
Increased help-
seeking
behavior
among active-
duty personnel
affected by
loss.
Time allocation;
training
materials and
supplies.
Update
command
indoctrination
and suicide
prevention
training.
Command
training
division will
manage
training
schedule for
all personnel
and training
materials.
Decrease mental
health
problems,
psychological
suffering, and
pain among
active-duty
personnel
affected by
loss.
Decreased
military
suicide rates.

Note. Adapted from Using Logic Models to Bring Together Planning, Evaluation, and Action:
Logic Model Development Guide, 2004, by the W.K. Kellogg Foundation. © 1998 by the W.K.
Kellogg Foundation.

Recommendation 2
The second recommendation is to provide leaders with psychoeducation training to
increase awareness and knowledge about mental illness and stigma. This study found that stigma
played a significant role in impeding seeking help for mental health problems, anxiety,
depression, and suicidal ideation, which prolonged suffering. Both perceived culture of stigma
and the experiences of stigmatization significantly increased fear of losing their career, security
121

clearance, military promotion, and social isolation. The perception and experience of being
looked at by peers and supervisors as weak and incompetent are why participants refused to seek
help from mental health, which increased their suffering and worsened their health. Research that
examined the link between help-seeking behavior and mental health showed that stigma and
perception of fear affected the participants’ attitudes regarding seeking help for mental health
problems (Price, 2011). Likewise, cultural factors play a significant role in influencing the
stigma of mental health problems (Ran et al., 2021). This aligned with the SCT conceptual
framework in that most human behaviors and learning occur through seeing others’ behaviors
and then modeling the behaviors that help and avoid those that produce negative outcomes
(Bandura, 2005). Seeing how people with mental health problems are stigmatized and mistreated
by others discourages people from seeking help or using resources during a crisis. Learning
theory uses observational, retention, production, motivational and self-regulatory processes to
emphasize the role of behavior and beliefs within an environment (Bandura, 2005).
A comprehensive training program designed to educate military leaders in
psychoeducation increases understanding of mental illness, emotional trauma, and the link
between personal behaviors and mission readiness. Studies have found that destigmatizing
mental health and promoting leadership awareness education and training led to a 33% reduction
in suicide rates (McPhee et al., 2021). This approach to intervention is critical to help
destigmatize mental health problems and military culture, increase help-seeking behavior, and
decrease military suicide rates. The strategy is to design a curriculum on mental health education
for senior enlisted leaders and officers and integrate it into training schools to educate leaders
across the fleet on the detrimental effect of stigma toward help-seeking behavior and the overall
health of military personnel. This also aligned with the premise that all human activities and
122

performance are embedded into a broad network of social systems that allows people to drive
their function and regulate their activities based on values, self-efficacy, interests, and goals
(Bandura, 2005). Implementing awareness training increases knowledge and awareness to
change the behavior and attitudes of leaders towards people with mental health problems and
foster a positive climate that encourages help-seeking behavior.

Table 9
Recommendation 2: Implementation Plan and Evaluation Criteria
Resources Activities Outputs Short/long-
term
outcomes
Impact
Time allocation,
training
materials, and
supplies.
Redesign
command
suicide
awareness and
prevention
program.

Facilitate mental
health
awareness
training for
leaders.
Suicide awareness
and prevention
program with
integrated
psychoeducation.
Increased
leadership
knowledge
and
available
resources.

Increased
support
from
leaders to
personnel
affected by
loss.
Increased help-
seeking
behavior from
personnel
affected by
loss.

Decreased
military
suicide rates.

Note. Adapted from Using Logic Models to Bring Together Planning, Evaluation, and Action:
Logic Model Development Guide, 2004, by W.K. Kellogg Foundation. © 1998 by the W.K.
Kellogg Foundation.

123

Recommendation 3
The third recommendation is to strengthen access and delivery of care to support
personnel affected by loss. This research found that military members lacked access to mental
health treatment and adequate time to grieve properly, worsening their mental health problems.
Evidence from this study showed that mission OPTEMPO is prioritized over the well-being of
military personnel, with no professional support provided to those who experienced complicated
grief caused by losing someone to suicide. Likewise, due to mission requirements and
operational readiness, active-duty personnel experiencing complicated and prolonged grief lack
access to mental health and time off work to grieve properly.
Sajan et al. (2021) concurred that families who lose someone to suicide often experience
a higher risk of complicated grief compared to people who experience loss by other means;
therefore, they need more time to grieve. The lack of support from command leadership to
provide access to care or allocate enough time for people who experienced grief worsened their
health and medical readiness. Martins et al. (2015) agreed that mental health problems and
substance abuse disorders are major barriers hindering the success of suicide prevention
programs in the military. Similarly, prolonged grief disorder affected 10% of adults experiencing
bereavement and trauma caused after losing someone to suicide and is associated with mental
disorders and suicide behavior (Harfmann, 2020; Szuhany et al., 2021). This aligned with SCT
and the conceptual framework that described human beings as change agents that actively
participate in changing their conditions and are changed by their environment that constrains
human performance to produce responses and behaviors (Bandura, 2005).
The lack of access to healthcare and constraints on time to properly grieve increased
mental health problems, leading to suicidal behaviors and suicide among the active-duty military
124

population. The literature revealed that participants who used professional support were better
prepared to live with the uncertainty of their loss and heal emotionally; professional support
helped change participants’ cognition from feeling guilty for losing someone to suicide to
achieving self-control and healing (Sajan et al., 2021). A recent study showed that flexible
working hours are essential to managing mental illness effectively. The research results indicated
that providing sufficient manpower and a flexible duty schedule increased resilience and the
ability to overcome negative emotional disturbances among nurses during the COVID-19
pandemic (Rahman, 2022).

125

Table 10
Recommendation 3: Implementation Plan and Evaluation Criteria
Resources Activities Outputs Short/long-term
outcomes
Impact
Designate time
for personnel.
Change policy to
allow time to
grief and
attend medical
appointments.
Command
implemented
policy with an
integrated
timeline for
personnel to
grief and
attend medical
appointments.
Adequate time to
grief properly,
Increased
access to care
and support
services.
Command
psychologist,
chaplain
service
reported
decreased
number
mental health
problems and
military
suicide rates.

Designate time
for personnel.
Unit commander
draft new
policy
allowing
personnel
affected by
loss time off to
grief properly
and attend
medical
appointments.
Command
Administrative
department
updated and
retain policy to
support
personnel
affected by
loss with time
to grief.
Increased
awareness and
knowledge the
use of
resources by
personnel
affected by
loss.

Note. Adapted from Using Logic Models to Bring Together Planning, Evaluation, and Action:
Logic Model Development Guide, 2004, by the W.K. Kellogg Foundation. © 1998 by the W.K.
Kellogg Foundation.

Equity Evaluation Framework
The Equity Evaluation Framework (EEF) is an effective assessment tool integrated into
the research to ensure that proposed recommendations for the practice meet DEI standards to
126

sustain change. Accordingly, the framework consists of three principles such as (a) evaluation
work contributes to equity, (b) evaluation work is consistent with equity work, and (c) evaluative
work should answer critical questions. The number of military personnel who seek help to treat
mental illness and psychological trauma is low because of fear of stigma, loss of security
clearance, and social isolation (Krunnfusz, 2018). Consequently, military culture exacerbates
stigma and marginalization, leading to a lack of access to care and support for people affected by
loss (Ran et al., 2021). Integrating the EEF model aligns with recommendations for practice to
highlight disparities in access to healthcare and identify how military leadership can reduce these
disparities and provide equitable access to healthcare and support for people affected by loss.
Inclusion authentically brings traditionally excluded individuals and or groups into processes,
activities, and decision making (Dean-Coffey, 2018). The goal is to use the evaluation
framework to remove barriers and cultural practices and implement policies to facilitate
equitable access to care and resources to support all personnel regardless of their medical
condition or mental health status. Thus, the social and psychological needs of military personnel
affected by loss must be understood and met to motivate them to complete the mission (Singh,
2013).
The guiding principles of EEF are
1. Equity work is in service of and contributes to equity
2. Evaluative work should be designed and implemented in a way that is commensurate
with the values underlying equity work;
a. Culturally competent
b. Multiculturally valid
c. Oriented toward participant ownership
127

3. Evaluative work can and should answer critical questions about the
a. Effect of a strategy on different populations
b. Effect of a strategy on the underlying system drives of inequity
c. Ways in which history and cultural context are tangled up with the structural
condition and the change initiatives itself.
Evaluation Work Contributes to Equity
Evaluating the three recommendations through the lens of equity is essential to achieving
sustainable change and justice for all military personnel. Equity will address and justify
integrating qualified medical personnel to facilitate suicide awareness and prevention training to
determine whether the training increased awareness and knowledge among personnel. Also,
psychoeducation training to increase awareness of mental illness and stigma will be assessed and
evaluated through the equity lens. Likewise, access and the delivery of care to people affected by
loss may be evaluated and compared with access and delivery of care to people without mental
health issues for quality. For change to be successful, a sophisticated approach that meets
complexities within the organization must be implemented (Williams et al., 2005).
Evaluative Work Is Consistent With Equity Work
If transformational leaders wish to institute change inside the organization, their
leadership styles must be strategically aligned to accommodate the organization's culture (Singh,
2013). Consistency in assessing practice recommendations is critical to achieving equity and
sustaining changes inside the organization. Integrating EEF will increase evaluators’ knowledge
about military tradition, communications and training, cultural competency, and leadership
structure. The evaluation process will be aligned with multicultural perspectives for validity and
authenticity to accommodate people affected by loss into practice recommendations.
128

Constituents will become willingly involved to the extent that they believe in those sponsoring
the change (Singh, 2013).
Evaluative Work Should Answer Critical Questions
Assessing recommendations for the practice may provoke answers to critical questions
such as the perceived culture of stigma, effectiveness of the practice, and organizational norms.
Also, EEF will investigate the effect of the practice recommendations on different populations,
such as LGBTQ, African Americans, and Asian Americans, to examine whether implementing
the recommendation will impede their access to care. Often diversity plans produce changes that
are superficial or isolated. As a result, high-profile plans are quickly forgotten, shelved, or
abandoned as the realities of implementation short-circuit the change process. (Williams et al.,
2005). The effect of the changes on military culture and the impact on society also will be
examined. Table 11 shows using EEF to assess three practice recommendations.

129

Table 11
Equity Evaluation Framework and Three Practice Recommendations
EEF principles Use qualified medical
person for training
Provide training
(psychoeducation)
Strengthen access and
delivery of care
Contributes to equity Does the practice
contribute to
equity?
Does the practice
contribute to
equity?
Does the practice
contribute to
equity?
Consistent with
equity work
Is the evaluation
multiculturally
valid?
Is the evaluation
multiculturally
valid?
Is the evaluation
multiculturally
valid?
Answers critical
questions
How will this
practice impact
organizational
culture?

How will this
practice impact
social conditions?
How will this
practice impact
organizational
culture?

How will this
practice impact
social conditions?
How will this
practice impact
organizational
culture?

How will this
practice impact
social conditions?

130

Recommendations for Future Research
This research centered on the behavioral effect of exposure to suicide events on active-
duty members across military organizations. Future research on the military warrior culture and
toughness and how it impedes seeking help and treatment for mental health problems would add
value to the literature on suicide prevention. Culture is pervasive and influences all aspects of the
organization (Schein & Schein, 2017). Also, an extensive study on grief strategies will increase
knowledge and benefit the literature. It is important to understand differences in people’s values
and cultures in organizations to achieve job satisfaction and organizational goals (Burke, 2018).
Conclusion
Suicide is a public health problem and a social issue that affects 48,000 Americans and
800,000 people around the world every year. Death by suicide manifests in different settings,
affecting people, families, and the military’s operational readiness. Exposure to a suicide event
affects behavior among the social group of the deceased, causing emotional pain and
psychological trauma and increasing mental health problems and suffering, which leads to
suicidal behaviors and suicides when untreated. Mitigating military suicides requires effective
prevention programs to identify and support the people affected. Perceived stigma toward mental
illness increased fear and discourages help-seeking behavior.
Given the complexity surrounding suicide, a multifaceted approach and framework is
recommended as solution to mitigate the high rates of suicide among the active-duty military
population. Destigmatizing stigma is critical to increasing help-seeking behavior and mental
health problems. It is time to examine the military’s culture of stigma and create connectedness,
unit cohesion, and a more inclusive culture that values and respects all personnel regardless of
medical condition or mental status. Integrating qualified medical personnel to facilitate suicide
131

prevention training engenders trust and encourages help-seeking behavior. Providing
psychoeducation leadership training increases awareness and understanding of mental illness,
enabling access to resources and delivery of care to support people affected by loss. It is possible
to create a military environment where personnel feel psychologically safe without fear of stigma
or discrimination and are ready to fight tonight.

132

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Appendix A: Interview Protocol
The following research questions guided this study:
1. How does the experience of losing someone to suicide influence behaviors of active-
duty military personnel?
2. What role does stigma play in seeking help from mental health among active-duty
military personnel?
3. What are the recommended methods used by retired military personnel to cope with
the loss of someone to suicide while on active duty?
The respondents were retired military personnel from the Marine Corps, Army, Navy,
and Air Force
• Male and female
• Experienced exposure to a suicide event
• Sign consent form
• Volunteered to participate
• Complete screening for suicidality

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Appendix B: Suicidality Prevention Assessment
I anticipate the greatest risk to participation in this study to be triggers from earlier
suicide ideation. To ensure that all college students who participate in this study will be
appropriately referred to help services, all potential participants will be assessed for suicidality
before participation.
Contact information will be collected from all potential participants of this study. This
information will not be used unless the researcher feels the potential participant needs more
assistance than the researcher is able to provide during this assessment.
Phone number of potential participants _________________________
Question Response/Score
1. Are you currently having suicidal thoughts?
a. If the answer is “No”; the interview may begin (Score 1)
b. If the answer is “Yes”; ask Question 2 (Score 2)
c. If the answer is ambiguous; ask Question 2 (Score 2) _______________
2. Are you currently thinking about a specific way to kill yourself?
a. If the answer is “No”; ask if the participant still wants to be interviewed (Score 0)
b. If the answer is “Yes”; ask Question 3 (Score 1)
c. If the answer is ambiguous; ask Question 3 (Score 1) _______________
3. When are you thinking about killing yourself?
a. If the answer is within the next 48 hours (Score 1)
b. If the answer is ambiguous (Score 1)
c. If there is no timeframe (Score 0) _______________
Total Score________
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Ambiguous answers include
• I don’t know Sometimes
• Maybe
• I’m not sure
• Every now and then.”
For ambiguous responses, use probing questions
• Can you tell me more about this
• What do you mean by ____
Interpreting the Total Score
Risk level <3: Proceed with the next step; begin the interview
Risk Level 3: Inform the participant: Thank you very much for your interest in being part
of this research study. However, I am not comfortable proceeding with the interview with you at
this time. I would like to recommend some help services to you. Would you like me to share
some of these help services with you?
Risk Level 4: Inform the participant: Thank you very much for your interest in being part
of this research study. However, I really want you to speak with someone at the VA. Can I share
your phone number with the counselors so that someone who is qualified to help you can call
you back?
Resources
For chat contacts: Use confidential online chat at session at
www.Veteranscrisis.line.net/chat. or National suicide prevention lifeline 1800-273-8255.
For phone contacts: Call Military Crisis Line (1800-273-8255) number to schedule a call-
back.
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Contact Veterans Military Crisis Line at 1877 995 5247, National Suicide Prevention
Lifeline 1800 273 8255.
For text messages: Send text message to 838255 to connect to a VA responder.

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Appendix C: Introduction and Conclusion of the Interview
My name is Andy Nyeche, I am a student at USC OCL program and research team.
Thank you for accepting my invitation to participate in my study today. As you know,
purpose of this interview is to contribute information for research intended to better understand
how exposure to a suicide event affect the behaviors of active-duty military population. Today,
the goal of the interview is to learn from your personal experience of being exposed to a suicide
event so to better understand the problem and create effective solutions to prevent suicide in the
military and across the world. This interview is confidential, and all information provide today
will be secured and used for this research purpose only. Also, nobody from the University of
Southern California will have access to your story and responses, your name, rank, tile,
command, and position in the military will not be discussed during the interview; no identifying
information about you will be shared in any reports. You have already signed an informed
consent form to participate today, but as a reminder, you may decline to answer any questions
that makes you uncomfortable and withdraw from the interview at any time you wish. After the
interview, the command chaplain, clinical psychologist, and deployed resiliency program
coordinator is available to provide intervention counseling and support. This interview will take
45 minutes. With your permission, I will record the interview for note taken and analysis
purposes. Do I have your permission to record? Do you have any questions before we begin?
Thank you for your time today. I deeply appreciate your contribution to the study and
sharing your experience of how exposure to a suicide event affect the behaviors of active-duty
military personnel. May I contact you if I need any clarifications of the information provided?

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Appendix D: Interview Questions
Interview questions Potential probes RQ
Addressed
Key concept
addressed
Question
type
Tell me about what you
did (job) while on
active duty in the
military?
How long did you
serve in the
military?
RQ1 Influence of
environmental
risk factors on
behavior
Open-ended
Describe how losing
someone to suicide
affected you as a
person?
Tell me more about
how the
experience
affected:
Emotions
Reasoning
RQ3 Changes in
cognition
influences
behavior and
attitudes
Open-ended
Describe your
experience, if any,
with dealing with the
stigma of seeking
help for mental
health during this
period?
How did you
manage the
situation?
What are the things
you did to cope
with the loss
during this
period?
RQ2, RQ3 Perceived
stigma
directly
affects
helping
seeking
behavior
Open-ended
Describe changes, if
any, in your
behaviors during this
period?
Explain how the
experience
affected your
decision-making
skills?
Tell me more?
RQ1, RQ3 Changes in
personality,
cognition, and
values due to
loss
Open-ended
Discuss the support
you received from
command suicide
prevention program?
Explain how the
support helped
increase your
resiliency?
RQ2, RQ3 Programs and
policy,
military
structure, and
leadership
affect
behavior and
response
Open-ended
Discuss how the
experience affected
you mentally during
this period?
Tell me more about
how the
experience
changed your
perspectives on
life?
RQ1, RQ2 Ability to self-
regulate
behavior
depends on
personal
values and
beliefs
Open-ended
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Interview questions Potential probes RQ
Addressed
Key concept
addressed
Question
type
Discuss some of the
things inside the
command
environment that was
helpful?
How supportive
was the
command
leadership?
Your supervisor?
RQ2, RQ3, Culture, norms,
and military
structure
influences
response to
using
resource
Open-ended
Discuss how the
experience affected
your relationships
with others?
Your willingness to
make new
friends at work?
Work well in a
group?
Relationship with
family?
RQ1, RQ2,
RQ3
Connecting
with others
increase
protective
factors to
cope with loss
Open-ended
Discuss how the
experience affected
what you value?
Describe how you
feel about people
who commit
suicide?
Tell me more about
blame and
feeling?
RQ1, RQ3 Exposure
affects
changes in
cognition and
behavior
Open-ended
Discuss the military
warrior culture of
toughness?
How did you
manage the
disappointments?
Keep your morale
up?
Seek helped during
this period?
RQ1, RQ2,
RQ3
Behavior is
learned inside
the
environment,
impact on
help-seeking
behavior
Open-ended
What can we do at the
command level to
prevent suicide?
How can we best
support active-
duty members
affected by
exposure to a
suicide event?
RQ1, RQ2,
RQ3
Environment,
programs,
policy,
culture,
leadership
Open-ended

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Appendix E: Theoretical Framework Alignment Matrix
Research question Theoretical framework Data instrument questions
How does the experience of
losing someone to suicide
influence behavior of
active-duty military
personnel?

Social cognitive theory
(Bandura, 2005)

Interviews questions:

Questions 1, 3, 4, 6, 7, 8, 9,
10, 11, and 12

What role does stigma play
in seeking help from
mental health among
active-duty personnel?

Social cognitive theory
(Bandura, 2005)

Questions 1, 3, 5, 7, 8, 9, 10,
11, and 12
What are the recommended
methods used by retired
military personnel to cope
with the loss of someone
to suicide while on active
duty?

Social cognitive theory
(Bandura, 2005)
Questions 1, 2, 4, 5, 6, 9, 11,
12
Demographic questions Questions 9–12

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Appendix F: Recruitment Email Message for Research
My name is Anderson Nyeche, and I am a doctoral candidate at the University of
Southern California. I invite you to participate in my research study focusing on how exposure to
a suicide event (losing someone due to suicide) affect the behavior of military personnel. This
study is under the guidance of Dr. Pat Tobey as part of my doctoral studies at the Rossier School
of Education at the University of Southern California. This study seeks to understand how
exposure to a suicide event affect the behavior of military personnel. Criteria to participate in the
research is that you are (a) retired from active-duty military service, (b) volunteered to
participate. (c) experienced the loss of someone by suicide, (d) sign informed consent form.
I understand your time is limited and valuable, and the interview will take forty-five minutes via
zoom. Your voluntary participation is appreciated and would provide important data to
understand how suicide affect the behaviors of military personnel as requirement to complete my
dissertation and add to the existing literature in the hope to increase knowledge and support to
people who experience loss.
If you are interested, please contact me at nyeche@usc.edu for questions. Thank you in
advance for your time.

Sincerely,
Anderson Nyeche
Researcher and Doctoral Candidate
Nyeche@usc.edu

155

Appendix G: Code Book
Name Description Files References
Changes in behaviour Changes that occurred after exposure to
suicide event, mental health issues,
behavioural disorder, psychological
trauma, suicidal ideation, suicidal
attempts
8 18
Changes in cognition Changes in reasoning, thoughts, and
perspectives of a person
8 12
Changes in emotions Emotions that were displayed by a
person after exposure
7 25
Effect of stigma How stigma influenced behaviour to
seek help and treatment
8 19
Lessons learned Additional lessons learned from
participants beyond literature
9 14
Lack of support Lack of support from members
command or immediate supervisor
5 6
Supported Members who received support from
their leadership
6 9
Recommended coping
methods
Different ways each participants
recommended uses as mechanisms
8 20
Negative coping methods Such as excessive drinking, substance
and alcohol abuse, recklessness
2 3
Recommended solutions Ways recommended to prevent suicide
in the military and support people
who experienced loss
9 29

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Appendix H: Informed Consent for Research
Study Title: High Rates of Suicides Among Active-Duty Military Population: How Exposure to
a Suicide Event Affect Behaviors
Principal Investigator: Anderson A. Nyeche
Faculty Advisor: Patricia Tobey. PhD
Department: Rossier School of Education
24-Hour Telephone Number: 1-800-273-8255
Introduction
We invite you to take part in a research study. Please take as much time as you need to
read the consent form. You may want to discuss it with your family, friends, or your personal
Doctor. If you find any of the language difficult to understand, please ask questions. If you
decide to participate, you will be asked to sign this form. A copy of the signed form will be
provided to you for your records.
Detailed Information
Purpose
The purpose of the study is to understand how exposure to a suicide event affect the
behaviors of active-duty military personnel. The study is being conducted as part of a
requirement to complete the researcher’s dissertation for Doctoral degree at USC. Knowledge
gained from your lived experience will add to the existing literature about how suicide affects the
behaviors of people who experience loss. Lack of a comprehensive and inclusive understanding
of the effect of suicide on survivor behaviors may result in increases in death by suicides in the
military. We hope to learn if exposure to a suicide event increases suicidal behavior among
activity duty military population. You are invited as a participant because of your prior exposure
157

to a suicide event while on active-duty military service, which is a valuable experience to the
study. About 10-12 participants will take part in the study.
Procedures
If you decide to take part, you will be screened by the researcher for suicidality and
mitigation assessment by answering three questions. Then you will fill out a consent form to
participate in the study. All participants are required to participate in audio/video recorded
interview for 45minutes through zoom website to collect data and lived experiences of their
exposure to a suicide event. During the interview, no military title, command name, position, or
rank will be identified to protect confidentiality. Participants will be allowed to use only audio
recording without video if they choose. The researcher will ask 12 open-ended interview
questions, which participants are encouraged to answer. However, participants are allowed to
skip any questions that make them uncomfortable and to stop the answer whenever they choose.
All interviews will be conducted via Zoom to allow access to transcript. All transcripts from the
interview will be downloaded for analysis and deleted at the end of the study.
Risks and Discomforts
Possible risks and discomforts you could experience during this study include
• Nervousness
• Emotional discomfort from answering personal questions
• Personal questions regarding suicide may trigger painful memory of loss
• Participants with recent exposure to a suicide event could be experiencing the loss of
their friend, and painful bereavement during the interviews.

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Interviews
Some of the questions may make you feel uneasy or embarrassed. You can choose to skip or stop
answering any questions you don’t want to.
Breach of Confidentiality
There is a small risk that people who are not connected with this study will learn your identity or
your personal information. All information shared with the researcher will be private and stored
in a safe location and used only for this research purpose.
Benefits
There are no direct benefits to you from taking part in this study. However, your participation in
this study may help us learn how exposure to a suicide event affects behaviors of active-duty
military personnel. Contribution to literature on this topic may lead to better care and support to
prevent suicide in the military.
Privacy/Confidentiality
We will keep your records for this study confidential as far as permitted by law. However, if we
are required to do so by law, we will disclose confidential information about you. Efforts will be
made to limit the use and disclosure of your personal information to people who are required to
review this information. We may publish the information from this study in journals or present it
at meetings. If we do, we will not use your name. The University of Southern California’s
Institutional Review Board (IRB) and Human Subject’s Protections Program (HSPP) may review
your records. Organizations that may also inspect and copy your information includes:
The Department of Defense (DOD) or Federal representatives may also access research records
for the purpose of protecting human subjects. Officials of the U.S. Army Research Protections
Office and the Army Research Laboratory’s Human Research Protection Program are permitted
159

by law to inspect the records obtained in this study to ensure compliance with laws and
regulations covering experiments using human subjects. Your data collected as part of this
research will not be used or distributed for future research studies, even if all your identifiers are
removed. To understand the privacy and confidentiality limitations associated with using Zoom,
we strongly advise you to familiarize yourself with their privacy policies.
Payments/Compensation
You will not be compensated for your participation in this research. However, your participation
will help to increase knowledge on how exposure toa suicide event affects the behaviors of
active-duty military personnel; and may help create effective solutions to care and prevention of
suicide.
Voluntary Participation
It is your choice whether to participate. If you choose to participate, you may change your mind
and leave the study at any time. If you decide not to participate, or choose to end your
participation in this study, you will not be penalized or lose any benefits that you are otherwise
entitled to.
Participant Termination
You may be removed from this study without your consent for any of the following reasons: If
you do not follow the study researcher’s instructions, do not complete the suicidality prevention
assessment, or fill out and sign the consent form.
Contact Information
If you have questions, concerns, complaints, or think the research has hurt you, talk to
the study researcher at Anderson Nyeche at nyeche@usc.edu or the faculty advisor, Patricia
Tobey, PhD at tobey@usc.edu
160

This research has been reviewed by the USC Institutional Review Board (IRB). The
IRB is a research review board that reviews and monitors research studies to protect the rights
and welfare of research participants. Contact the IRB if you have questions about your rights
as a research participant or you have complaints about the research. You may contact the IRB
at (323) 442-0114 or by email at irb@usc.edu
Statement of Consent
I have read the information provided above. I have been given a chance to ask questions. All my
questions have been answered. By signing this form, I am agreeing to take part in this study.

Name of Research Participant Signature Date Signed/Time
Person Obtaining Consent
I have personally explained the research to the participant using non-technical language. I
have answered all the participant’s questions. I believe that the participant understands the
information described in this informed consent and freely consents to participate.

Name of Person Obtaining Signature Date Signed/Time

Abstract (if available)

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University of Southern California Dissertations and Theses

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Asset Metadata

Creator Nyeche, Anderson A. (author)

Core Title High rates of suicides among active-duty military population: how exposure to a suicide event affects behaviors

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Degree Conferral Date 2022-08

Publication Date 06/24/2022

Defense Date 05/02/2022

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

Tag active-duty personnel.,exposure,OAI-PMH Harvest,suicide event

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Tobey, Patricia (committee chair), Canny, Eric (committee member), Phillips, Jennifer (committee member)

Creator Email nyeche@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC111352075

Unique identifier UC111352075

Legacy Identifier etd-NyecheAnde-10789

Document Type Dissertation

Format application/pdf (imt)

Rights Nyeche, Anderson A.

Type texts

Source 20220706-usctheses-batch-950 (batch), University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the author, as the original true and official version of the work, but does not grant the reader permission to use the work if the desired use is covered by copyright. It is the author, as rights holder, who must provide use permission if such use is covered by copyright. The original signature page accompanying the original submission of the work to the USC Libraries is retained by the USC Libraries and a copy of it may be obtained by authorized requesters contacting the repository e-mail address given.

Repository Name University of Southern California Digital Library

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

Repository Email cisadmin@lib.usc.edu