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U.S. Army Reserve: the journey to psychological health resources

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U.S. Army Reserve: the journey to psychological health resources

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U.S. Army Reserve: The Journey to Psychological Health Resources

Katherine T. Alegado

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

December 2022

© Copyright by Katherine T. Alegado 2022
All Rights Reserved

The Committee for Katherine T. Alegado certifies the approval of this Dissertation

Diane Harney
Brian Adibe
Patricia Elaine Tobey, Committee Chair

Rossier School of Education
University of Southern California
2022

iv
Abstract
This qualitative study evaluated the interfering factors uniquely experienced by U.S. Army
Reserve (USAR) soldiers throughout their psychological health journeys. Bronfenbrenner's
(1977) ecological systems theory was applied as a theoretical and conceptual framework to
evaluate soldiers’ interactions with myriad levels of their environments that affected their ability
to maintain their mental health while serving in the USAR. Data was collected from 10
interviews with USAR veterans discharged between 2016 and 2022 and 11 public domain
documents relating to mental health and suicide in the military. This data revealed
misconceptions regarding USAR soldiers’ archetypical characteristics through preconceived
ideas how USAR soldiers are similar to active-duty soldiers. Denying the identity of a soldier
results in the ineffectiveness of policies, programs, and resources intended to prevent suicide.
Despite the protective factors described and offered through official channels, an inadequate
support system further decreases the overall effectiveness of efforts to enhance a soldier’s mental
health stability. This research helps mitigate the dearth of psychological health studies
exclusively concerning USAR soldiers in relation to cultural and transitional stressors and
continued barriers to resource access.
Keywords: U.S. Army Reserve, Bronfenbrenner, military suicide, mental health care.
v
Dedication
To those who have faced and overcome the overwhelming challenges life brings.
To those who are enduring life’s challenges and who seek support and belonging.
To the families, friends, and communities who have experienced the loss of a loved one and who
bear visible or invisible wounds.
To my family for their endless love, encouragement, and inspiration.
vi
Acknowledgments
We enter this world into a life that is unknown to us and, some would say, predestined for
us. We all share the experience of facing life’s challenges despite our differences. It is essential to
remember that we can overcome the most difficult challenges through support and resilience.
I would like to recognize my brother, Kristian Alegado, and my sister, Kristin Alegado,
for being my inspiration throughout my journey studying psychological health. Their
vulnerability and resilience taught me that the loss of life could be prevented through a safe
environment, open communication, genuine presence, and wholesome understanding. Thank you
both for being an inspiration to all.
I would also like to thank my wife, Marly Janes, for her unwavering accountability in
keeping me on track, helping me pace myself when I felt the weakest, and motivating me to
remain strong through the finish line. To my parents, Yolanda, and Jose Alegado, thank you for
your encouragement and belief in me. You taught me to be disciplined and to tackle challenging
work diligently from an early age; through these attributes, I have continued to aspire to be the
kind person you made me into and to make positive changes for others.
This study would not be possible without the guidance of my dissertation committee. Dr.
Patricia Tobey, your positivity in our weekly check-ins exerted an immensely positive impact on
my progress; Dr. Brian Adibe, your expertise in the field of wellness and health policy proved to
be a guiding framework throughout my research; Dr. Diane Harney, this journey would not be
possible without your recommendation for me to pursue a doctoral degree in our last advisor
meeting before earning my bachelor’s degree. Thank you all for your mentorship. May this study
enable positive change and inspire all to be the people we need at our weakest and darkest
moments. May we seize each day with the desire to live tomorrow.
vii
Table of Contents
Abstract .......................................................................................................................................... iv
Dedication ....................................................................................................................................... v
Acknowledgments.......................................................................................................................... vi
List of Tables ................................................................................................................................... x
List of Figures ................................................................................................................................ xi
Chapter One: Overview of the Study .............................................................................................. 1
Background to the Problem of Practice .............................................................................. 2
Statement of the Problem .................................................................................................... 4
Purpose of the Study ........................................................................................................... 4
Significance of the Study .................................................................................................... 5
Definition of Terms ............................................................................................................. 6
Organization of the Study ................................................................................................... 8
Chapter Two: Review of the Literature ......................................................................................... 10
A Soldier’s Identity ............................................................................................................11
Network and Environmental Influences ........................................................................... 12
Army Reserve Culture and Social Context ....................................................................... 15
Theoretical Framework ..................................................................................................... 19
Conceptual Framework ..................................................................................................... 22
Conclusion ........................................................................................................................ 24
Chapter Three: Methodology ........................................................................................................ 26
Research Questions ........................................................................................................... 27
Sample and Population ..................................................................................................... 27

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Instrumentation ................................................................................................................. 28
Data Collection ................................................................................................................. 28
Data Analysis .................................................................................................................... 29
Credibility and Trustworthiness ........................................................................................ 30
Ethics................................................................................................................................. 31
Positionality ...................................................................................................................... 32
Limitations and Delimitations........................................................................................... 32
Conclusion ........................................................................................................................ 33
Chapter Four: Findings ................................................................................................................. 34
Documents ........................................................................................................................ 34
Participants ........................................................................................................................ 38
Findings for Research Question 1 ..................................................................................... 42
Research Question 1: Document Analysis ........................................................................ 43
Research Question 1: Interview Analysis ......................................................................... 44
Summary for Research Question 1 ................................................................................... 46
Findings for Research Question 2 ..................................................................................... 46
Research Question 2: Document Analysis ........................................................................ 46
Research Question 2: Interview Analysis ......................................................................... 48
Summary of Research Question 2..................................................................................... 50
Findings for Research Question 3 ..................................................................................... 51
Research Question 3: Document Analysis ........................................................................ 51
Research Question 3: Interview Analysis ......................................................................... 53
Summary for Research Question 3 ................................................................................... 61

ix
Conclusion ........................................................................................................................ 61
Chapter Five: Discussion and Recommendations......................................................................... 63
Overview of the Study ...................................................................................................... 63
Discussion of Findings ...................................................................................................... 64
Implications of the Study .................................................................................................. 75
Practice Recommendations ............................................................................................... 76
Recommendations for Future Research ............................................................................ 81
Conclusion ........................................................................................................................ 82
References ..................................................................................................................................... 83
Appendix A: Informed Consent for Research ............................................................................... 94
Appendix B: Theoretical Framework Alignment Matrix (Qualitative) ........................................ 99
Appendix C: Pre-Survey Protocol .............................................................................................. 100
Appendix D: Interview Protocol ................................................................................................. 102
Appendix E: Mental Health Resources ....................................................................................... 105
Appendix F: A Priori Codes for Data Analysis ........................................................................... 106

x
List of Tables
Table 1: Public Domain Documents Information 35
Table 2: Participant Biographic Information 38
Appendix B: Theoretical Framework Alignment Matrix (Qualitative) 99
Appendix F: A Priori Codes for Data Analysis 106

xi
List of Figures
Figure 1: Suicide Prevention Strategies 18
Figure 2: Ecological Systems Theory—Theoretical Framework 21
Figure 3: Ecological Systems Theory—Conceptual Framework 24
Figure 4: Coding Collection and Analysis Process 30
Figure 5: Ecological Systems Theory—Findings 65

1

Chapter One: Overview of the Study
The Department of Defense (DoD) loses over 500 military service members to suicide
yearly, and the rate continues to increase (U. S. Department of Defense [DoD], 2021). Veterans
are 1.5 times more likely to die by suicide than the general population, with an average of 17
suicides each day (Peterson et al., 2022). On January 28, 2020, the United States Congress
reported that “suicide is the tenth leading cause of death among people in the U.S. and the
second-leading cause of death for young people between the ages of 15 and 34” (Advancing
Research to Prevent Suicide Act, 2020). This elevated risk affects service members between the
ages of 17 and 30, primarily enlisted and male (DoD, 2021). Studies continue to yield similar
demographic data each year. The continued increase in suicides has prompted questions about
the impact of social influences, accessibility, and the effectiveness of psychological health
resources.
Understanding how influential factors, such as a basic knowledge of neural, cognitive,
and environmental conditions, affect the military suicide rate is critical to identifying
preventative measures (Advancing Research to Prevent Suicide Act, 2020). Since 2018,
psychological health resources have expanded and evolved to accommodate services for patients
facing geographic disparities and mandatory quarantine during the COVID-19 pandemic. Active-
duty soldiers living on or near military installations are endowed with psychological health
resources provided by behavioral health clinics. However, service members living in remote
areas or distant from military installations face barriers to psychological health services (Mohatt
et al., 2018). Although telemedicine has been increasingly relied upon, Luitel et al. (2019)
suggests that the degree of help an Army Reserve soldier needs may not be provided through
2

telehealth. As the challenges related to the provision of support continue to proliferate in an
evolving and complex Army Reserve environment, the suicide rate will continue to increase.
According to Reimann and Mazuchowski (2018), “Any suicide among Service Members
is one too many; it not only affects the individual’s family and friends, but it also affects military
readiness (p. 1).” The suicide rate has increased in spite of the policies, regulations, and training
resources made available by the U.S. Army Reserve Command (USARC) for soldiers.
Furthermore, organizational barriers further delay the time for an Army Reserve soldier to
receive psychological health support. While many current empirical pieces of literature
concerning U.S. Army suicides primarily focus on active-duty soldiers and the impacts of
suicides on families and surviving service members, minimal studies have focused on Army
Reserve soldiers’ treatment-seeking behavior and the accessibility of psychological health
resources that influence suicide rates (Peterson et al., 2022).
Background to the Problem of Practice
The rates of military and civilian suicides have undergone an alarmingly similar trend.
Annual DoD suicide reports indicate conditions including the sex, age group, race, and rank of
service members and the corresponding method of suicide, such as firearm or asphyxiation
(DoD, 2021). Accounting for these conditions can enable further research analyzing the
contributing causes of suicide such as genetic, psychological, and environmental factors (Isaak et
al., 2010; Mohatt et al., 2018). The DoD Office of the Under Secretary of Defense for Personnel
and Readiness (OSD(P&R)) established the Defense Suicide Prevention Office (DSPO) in 2011
to prevent military suicide. The mission of DSPO is to “advance holistic, data-driven suicide
prevention in our military community through policy, oversight, and engagement to positively
impact individual beliefs and behaviors, as well as instill systemic culture change” (Defense
3

Suicide Prevention Office [DSPO], 2022). DSPO works with non-profit organizations and non-
governmental agencies by integrating holistic training and resources to fortify military suicide
prevention, intervention, and postvention (i.e., LivingWorks Applied Suicide Intervention Skills
Training, Tragedy Assistance Program for Survivors, and Give An Hour).
The Army Reserve accounts for 40% of the Department of the Army (DA), with a
congressional authorization of 189,000 soldiers assigned across 2,075 units throughout 30
countries. Army Reserve soldiers fulfill different service statuses, serving part-time in Troop
Program Units (TPU) or as Individual Mobilization Augmentees (IMA), as full-time temporary
activated soldiers for operational support, mobilizations, or deployments, or as full-time Active
Guard Reserve (AGR) soldiers. The mission of the Army Reserve is “to provide combat-ready
units and Soldiers to the Army and the Joint Force across the full spectrum of conflict” (U.S.
Army Reserve [USAR], 2022). Additionally, Army Reserve soldiers must be prepared to respond
to capable and sophisticated high-end threats quickly, conduct sustained counter-terrorist
operations, and deter aggression in multiple regions of the world while simultaneously defending
the homeland (USAR, 2022).
In response to the increasing suicide rate, the Secretary of Defense established the
Defense Health Board Task Force, which culminated in the development of the Army Reserve
Suicide Prevention Program in 2010. In 2012, to support the Army Reserve Suicide Prevention
Program, the USAR Psychological Health Program (PHP) was established to serve as a liaison in
addressing program referrals, providing command consultations, and managing traumatic events.
In 2015, The DA published Army Regulation 600-
63, Army Health Promotion, requiring annual suicide prevention training and Ask, Care,
Escort (ACE) training for all Army soldiers. Each completed training is recorded in the Digital
4

Training Management System (DTMS) within each soldier’s training record. The training data
proves that soldiers possess the necessary knowledge to identify suicidal behavior and the skills
to prevent suicide through intervention.
The Army Reserve has dedicated significant resources to addressing the complex factors
and systems that influence soldiers’ suicide behaviors, as presented throughout the years. Despite
additional mental health resources, the continued increase in suicide warrants concerns about the
cost-effectiveness and efficiency of prioritizing healthcare policies and interventions (Jo, 2014;
Schaughency et al., 2021). Undertaking the financial burden associated with the soldier’s suicide
can enable Army Reserves leaders and policymakers to formulate effective suicide prevention
and intervention strategies.
Statement of the Problem
Despite the policies, regulations, and training resources made available by the DoD for its
service members, the suicide rate continues to increase annually. U.S. Army Reserve (USAR)
soldiers, an unrepresented population in studies concerning mental health, experience unforeseen
challenges and added stressors when seeking and receiving psychological health resources.
These challenges relate to the timeliness of psychological health support, eligibility
requirements, administrative procedures, funding allocation, and proximity to authorized
treatment centers (Hummer et al., 2021). Added stressors can increase the risk of suicidality
(Luitel et al., 2019).
Purpose of the Study
This study aimed to examine the factors that influence a soldier’s ability to seek and
receive mental health care while serving in the USAR. Understanding the unique stressors
deriving from unforeseen or understudied events experienced by USAR soldiers may help
5

improve existing policies, programs, and resources to prevent soldier suicide.
The following three research questions guided this study:
1. How does access to psychological health resources impact U.S. Army Reserve
soldiers’ success throughout their service?
2. How do the U.S. Army Reserve’s policies and regulations affect an Army Reserve
soldier’s psychological health experience?
3. What challenges do U.S. Army Reserve soldiers experience throughout their health-
seeking endeavors?
Significance of the Study
Despite the funding made available for improvements in suicide prevention throughout
the DoD, the stigma attached to suicide and the lack of organizational support continue to
contribute to suicidality in the Army Reserve. This study is significant because it revealed the
relationship between the attitudes and self-perceptions of Army Reserve soldiers in relation to
suicide and the level of support soldiers receive within their environments when seeking and
undergoing psychological health services (Johnson & Christensen, 2017).
As emphasized in the 2020 DoD Annual Suicide Report (Defense Suicide Prevention
Office, 2022), the “DoD is committed to preventing suicide and reducing stigma for seeking help
within our military community” (p. 4). Suicidality is a complicated matter to understand. While
self-awareness in performance and capabilities is vital for a soldier's and unit's success, an Army
Reserve soldier’s life is complex. Not only must a soldier meet the demands related to their
responsibilities in the Army Reserve, but they must also meet the demands of their civilian career
and personal responsibilities. Understanding the multifaceted lifestyle of an Army Reserve
soldier, the immense influences of an Army Reserve soldier's immediate environments, and the
6

inadequacies in an organization’s use of psychological health resources may lead to the
continued increase of Army Reserve suicides.
A report from the U.S. Government Accountability Office (2018) noted that of the $6.2
million dedicated to the Veterans Health Administration in 2018 for suicide prevention outreach,
only $57,000 was spent. Similar services provided by Veterans Affairs are critical to increasing
service members’ knowledge and awareness regarding the resources available to them to
alleviate hardships that contribute to suicidality. On May 25, 2018, the DA headquarters issued a
memorandum eliminating the requirement for annual suicide prevention training (Esper, 2018).
This change reduced the knowledge and impetus of soldiers to remain knowledgeable about
suicide prevention and intervention practices. It further influenced the already prevalent suicide
stigma; for instance, it made it more difficult for survivors to talk about suicide or the reluctance
to seek help (Schaughency et al., 2021).
Since past studies have focused on the DA as a whole entity and further concentrated on
active-duty soldiers or soldiers’ post-deployment, minimal studies have focused on Army
Reserve soldiers and their complexities. This study explored an Army Reserve soldier's pursuit to
receive psychological health resources by assessing accessibility, support-related influences, and
barriers from entry to completion. The DoD addressed service-specific efforts in combatting
suicide within its 2020 Annual Suicide Report; however, this report neglected to present
component-specific suicide prevention strategies (Schaughency et al., 2021).
Definition of Terms
The following list of key terms and specific notes will help promote an understanding of
the narrative within this study:
• Active Guard Reserve is a soldier on active military status who supports U.S. Army
7

Reserve units (U. S. Department of the Army [DA], 2019).
• Basic training refers to the mandatory initial entry training for non-prior service
individuals (DA, 2004).
• Discharge is the end of a contract, enlistment, or induction from a military status
(DA, 2019).
• Enlisted status applies to soldiers who entered the U.S. Army Reserve with non-prior
service and prior service (DoD, 2021).
• Initial entry training is the mandatory specialty or branch training upon initial entry
into the U.S. military (DA, 2004).
• Intervention is the strategy or approach intended to prevent an outcome or alter the
course of an existing challenge or stressor, also known as “secondary prevention”
(DoD, 2021).
• Military community refers to a person’s affiliation and involvement with a group of
military servicemembers and family members through their unit, organization, or
community (DoD, 2021).
• A military treatment facility is a military medical facility on a military installation
(DoD, 2021).
• Officers are individuals in the ranks of commissioned officers, warrant officers, and
commissioned warrant officers (DA, 2004).
• Postvention means responding to the immediate aftermath of a suicide impacting
units and families (DoD, 2021).
• Prevention reduces an individual’s risk of harmful behavior (DoD, 2021).
• Protective factors enhance an individual’s resilience through attitudes, values,
8

relationships, and norms related to suicide (DoD, 2021).
• A reserve component of the Army is composed of U.S. military service members
serving in the U.S. Army Reserve or National Guard (DA, 2019)
• Risk factors stem from an individual’s environment and from social, biological, and
psychological factors that could cause the individual to engage in high-risk harmful
behaviors (DoD, 2021).
• A soldier is a member of the U.S. Army serving as a commissioned officer,
commissioned warrant officer, warrant officer, noncommissioned officer, or enlisted
soldier (DA, 2019).
• Stigma is an individual’s negative perception of mental health care, the effects, and
the potential end of their careers (DoD, 2021).
• Suicidal behavior encompasses high-risk behaviors, acts, or attempts related to
suicide (DoD, 2021).
• Suicide ideation refers to thoughts, considerations, or plans related to suicide (DoD,
2021).
• Troop Program Units refer to Army Reserve units that are assigned a mobilization
mission or that serve as mobilized units (DA, 2019).
Organization of the Study
This research is structured into a five-chapter qualitative study exploring Army Reserve
soldiers’ help-seeking behavior and their experiences with receiving psychological health
support. Chapter One summarizes the overview of the study, the problem of practice, information
concerning the organization, guiding research questions, and definitions of critical terms.
Chapter Two presents a cross-analysis of emerging themes from the empirical literature using
9

Bronfenbrenner's ecological systems theory (1979) to discuss Army Reserve soldiers’ identities,
stressors from their immediate environments, the Army Reserve culture and social context, and
policies and regulations related to psychological health. Chapter Three describes the
methodology and research design of the study, presents the interview protocol for the selected
sample population, and defines limitations and delimitations. Chapter Four presents a thorough
qualitative analysis of the responses of the interviewed participants. Chapter Five discusses the
findings and provides recommendations for future research.
10

Chapter Two: Review of the Literature
The existing literature emphasizes that suicide among veterans and service members
continues to be a significant concern in public health (Peterson et al., 2022). One study
conducted in Japan examined the need for suicide reduction efforts through frequent, accessible,
and high-quality suicide prevention and awareness resources (Hashimoto et al., 2016). Despite
the increased efforts of task forces and training programs to reduce suicide since 2010 (Schuman
et al., 2022), the Army Reserve continues to require a more sophisticated response to its rising
suicide rate. Army Reserve soldiers experience unique environmental conditions, since
populations living in remote geographic locations are susceptible to specific impacts, such as the
inability to drive to and from a clinic or office to receive services (Mohatt et al., 2018). The
literature also discusses similar conditions and disparities in access to psychological health
services among Army Reserve soldiers in relation to civilian suicide rates, accessibility, health
provider shortages, social and economic disadvantages, and cultural stigma. According to the
most recent studies, service members screened for mental health concerns continue to face
stigma and organizational barriers, preventing them from seeking psychological health services
(Comtois et al., 2019).
While many studies have addressed suicidality in the military, particularly among soldiers
serving on active duty in the U.S. Army, minimal literature has discussed Army Reserve soldiers
and their psychological health. Previous studies have focused on perceived support but have not
defined the makeup of the support as emotional, informational, or instrumental, which influences
suicidality (Blais et al., 2021). The literature discussed below addresses the following emerging
themes: Army Reserve soldiers’ identities, immediate environmental stressors, the cultural and
social context within the Army Reserve, and policies and regulations impacting the
11

psychological health of soldiers. In alignment with the emerging themes, this study's theoretical
and conceptual framework applies Bronfenbrenner’s ecological systems theory (1979), which is
explained after the literature review.
A Soldier’s Identity
An Army Reserve soldier serving part-time participates in a two-day monthly training
with an additional 14-day annual training. In addition to their Reserve duty obligations, they are
responsible for concurrently fulfilling their civilian career and family responsibilities. Under
circumstances of war or immediate mandated activation, Army Reserve soldiers are expected to
immediately commit to serving full-time, requiring them to cease or limit their ability to fulfill
their civilian and familial obligations.
Psychological Health and Suicide History
The rising rates of suicidality and mental disorders occurring early in soldiers’ Army
Reserve careers have elicited preventative interventions (Bernecker et al., 2018). Suicide risk can
encompass a person’s history of attempts and their risk of future attempts (Blais et al., 2021).
Addressing suicide risk can be challenging because risk and historical behavior are often not
visible to others. Prospective soldiers, whether they are entry-level soldiers, enlisted soldiers, or
officers, must have their mental health accessed before entering the military (Office of the Under
Secretary of Defense for Personnel and Readiness, 2022). However, prospects are often guided
to withhold information that may impede them from joining the Army Reserve. The
administrative process of reporting historical behavior, psychological health behavior, or
treatments can be concerning, as reports sometimes lack accuracy regarding a soldier’s
qualifications for entry into the military (Bernecker et al., 2018).
One flaw in the system of U.S. Army recruitment for entry into the Army Reserve is the
12

discouragement of help-seeking behavior. Studies by Bryan et al. (2018), Hom et al. (2019), and
Peterson et al. (2022) have linked suicidality to suicide exposure. New Army Reserve soldiers
face additional risks during military training, where they are equipped and trained to gain the
capability to end a life. Schuman et al. (2022) posit that soldiers who experience psychological
health challenges during repeated exposure to combat training, such as weapons training, may
develop an increased proclivity toward suicide.
Treatment-Seeking Behavior
The effects of suicide exposure on veterans emerged in three themes throughout the study
by Peterson et al. (2022), including veterans’ perspectives on psychological health treatment-
seeking behavior, psychological health risks, and suicide risks. The effects of suicide exposure
influence a person’s perception on suicide and on mental health treatment. Chen et al. (2019)
contended that individuals exposed to suicide gain the responsibility to openly speak about
suicide and to encourage their peers to receive treatment. Peterson et al. (2022) further posit a
correlation between suicide exposure and an increased receptiveness to psychological health
treatment.
Network and Environmental Influences
Understanding the identity and psychological health history of an Army Reserve soldier
is the first stage of identifying the practical applications of prevention and intervention methods.
Unexpected stressors can be caused by unforeseen events, from natural disasters to the COVID-
19 pandemic. Everyday stressors due to inherited responsibilities are frequently experienced and
expected, while added stressors are experienced through social exchanges. Life-changing
experiences, such as joining the Army Reserve and the major transitions from home to training,
then returning home, and integrating into unit environments are new stressors experienced by
13

new soldiers. The following section presents literature addressing the potential and immediate
stressors experienced by Army Reserve soldiers.
COVID-19
In their research, Wang et al. (2020) and Chew et al. (2020) asserted that the intense
impact of the COVID-19 pandemic throughout the world also caused a mental health crisis in the
general population, especially among healthcare professionals. The psychological health impacts
during the COVID-19 pandemic resulted in an unprecedented intensification of psychological
health challenges, including medical provider burnout. Army Reserve soldiers undergoing
psychological health treatment faced unexpected challenges with continued in-person treatment.
During the COVID-19 pandemic, providers experienced a substantial increase in caseloads and
complex cases. Soldiers who continued receiving treatment during the pandemic may have
experienced a decline in effective treatment outcomes. The negative impact of inadequate
treatment experiences may have caused soldiers to endure additional stressors and to develop
negative attitudes toward psychological health treatments. Meeting the demands for
psychological health providers may require altering the ratio of providers to patients.
Unlike soldiers who served full-time in their Army Reserve units, part-time Army
Reserve soldiers faced the unprecedented predicament of losing their civilian jobs and enduring
the challenge of increased responsibilities as frontline COVID-19 workers in their civilian
careers to immediate activation in support of COVID-19 operations throughout the nation.
Moreover, Miller et al. (2022) assert that the deteriorating mental health conditions of individuals
with pre-existing psychological health issues put them at significant risk of psychological
difficulties as Army Reserve soldiers. Access to social support networks and regular routines are
essential aspects of treatment. Supportive behaviors result in individuals facing amplified
14

stressful events (Miller et al., 2022).
Social Stressors
Army Reserve soldiers experience stressors in various environments. Newsom et al.
(2005) and Blais et al. (2021) posit that social exchanges are integral contributors to an
individual’s behavior. Blais et al. (2021) further emphasize that hostile social exchanges and their
relationship to suicide risk among soldiers continue to be minimally studied. Among veterans,
minority populations, especially those of Asian American and Pacific Islander descent,
experience a more acute psychological health stigma, resulting in reduced help-seeking behavior
(Chu et al., 2021). The Army Reserve is a vastly diverse organization; continued studies
regarding cultural relationships with suicide may help the Army Reserve identify effective
psychological health services for soldiers within at-risk groups (Schuman et al., 2022). Soldiers
who join the Army Reserve with preconceptions about suicide can influence the culture within
Army Reserve units, resulting in positive or negative social exchanges. Individuals within at-risk
groups who finally seek psychological health treatment often experience their problems more
severely rather than addressing the issue in its earlier stages (Schuman et al., 2022).
Transitional Stressors
The transitions experienced by soldiers joining the Army Reserve are complex and multi-
faceted. Schaughency et al. (2021) delineate the following transition stages within the first year:
“civilian to military life, from basic to advanced training, from training to first duty station, and
finally integration into the duty station” (p. 913). Transitioning from civilian to military life can
entail drastic environmental changes, such as soldiers transitioning from unstructured
environments to rigid structures with drill sergeants and army instructors. Transitions from
primary to advanced training force soldiers to leave yet another community to integrate
15

themselves into an unfamiliar environment and create new relationships. The final transition
stage for an Army Reserve soldier consists of three coincidences: integration into a soldier’s
civilian career, home environment, and Army Reserve unit. Acknowledging transitional stressors
through advocacy in help-seeking behaviors can further mitigate suicidality among soldiers.
Army Reserve Culture and Social Context
The culture and climate of an organization differs within each industry. Despite its
ostensible condemnations through policies and regulations, Schuman et al. (2022) posit that the
U.S. Army power structure contributes to the amplification and adverse effects of the bullying
and hazing of soldiers despite the historical significance of perceived initiations. A soldier’s
military experience is enhanced through camaraderie and acceptance. In the infantry, soldiers
strive to earn the esteemed ranger badge, and if soldiers are not successful, they are often
ostracized by their peers and leadership. In their research, Zedlacher and Koeszegi (2018) further
highlight the convergence of power and balance and how it creates an environment that permits
the victimization of soldiers.
Mental Health Stigma
Camaraderie in the military has been found to enhance the cohesion of a person’s social
network. Buffers between an Army Reserve soldier's life and suicide may include grit and
gratitude, which can be improved through the shared responsibility of the affected person and
their surrounding community members (White et al., 2017). As a community enhances its
awareness and attitudes toward suicide while simultaneously minimizing mental health issues,
soldiers are further encouraged to seek psychological health support. Harrison et al. (2017) assert
that social connectedness is the strongest predictor of suicide behavior. Environments that
cultivate a culture of inclusion further alleviate isolation and ostracization.
16

The facilitation and implementation of changed behavior by leaders is essential to
sustaining change and shifting the sense of change into a norm (Eisenbach et al., 1999).
Unresolved unit cohesion concerns prevent progress toward reducing suicide stigma. According
to Harrington-LaMorie et al. (2018), a suicide is perceived as a dishonorable death in the
military. Family members affected by soldier suicide emphasize the importance of reducing
mental health stigma (LaCroix et al., 2018). The perceived mental health stigma in the Army
Reserve negatively impacts soldiers’ units, families, and local communities.
Policies and Regulations
Soldiers are inclined not to seek mental health support, fearing that doing so may impact
their military career. Milkman et al. (2021) conducted a study highlighting the collaborative
efforts between policymakers and psychological health experts in developing guidance to
improve outcomes. Policies and regulations influence an Army Reserve unit’s climate and a
soldier’s perception of their ability to continue to serve. A study by Stecher and Kirby (2004)
addressed concerns about bureaucratic accountability by highlighting the lack of accountability
methods, such as audits and inspections, to evaluate organizational deficiencies. Performance
evidence has become a resource for developing organizational solutions and improvements. The
systematic guidance associated with security clearances and a soldier’s ability to deploy is
strongly associated with a soldier’s mental health while serving in the military.
Suicide Prevention Program
Three offices manage the DoD suicide prevention program, each serving a critical and
specialized role. DSPO (2019) is responsible for systemic culture change. The Defense Human
Resources Activity (n.d.) ensures that service members receive care and support through direct
support programs aimed toward risk reduction. The Office of Force Resiliency (2019) oversees
17

the resiliency program for all service members in the DoD. While each office focuses on suicide
prevention differently, all three are responsible for developing, implementing, and overseeing
policies. These same offices provide the tools and resources to prevent service member suicides.
Stecher and Kirby (2004) emphasize the importance of stakeholders possessing a shared
understanding of how policy impacts organizations. Soldiers and leaders share responsibility for
reporting inefficacies in organizations. In December 2021, the Army Reserve announced a new
suicide prevention initiative through a public health approach. The improved initiative intends to
provide soldiers with a comprehensive understanding of using the available resources to enhance
their psychological health. Figure 1 provides a graphical representation of the protective factors
encompassed within the suicide prevention strategies developed by DSPO (Lopez, 2019).

18

Figure 1
Suicide Prevention Strategies

Note. Adapted from DOD Releases Report on Suicide Among Troops, Military Family Members
by C. T. Lopez, 2019 (https://www.defense.gov/News/News-
Stories/Article/Article/1972793/dod-releases-report-on-suicide-among-troops-military-family-
members). In the public domain.

19

Resource Effectiveness
The DoD partners and coordinates with organizations to reduce service members' risks;
these organizations include the Veteran/Military Crisis Line and Military One Source. However,
the suicide prevention initiative relies on resources and training, which require time and funding
(Lim et al., 2013). Research by Schaughency et al. (2021) has demonstrated that there is a lack of
cost-effectiveness across all the available programs that address suicide. Army Reserve soldiers
face additional challenges when receiving suicide risk reduction services, which depend on the
availability of DoD funding and further conflicts with the long-term success of preventing
suicide. Schaughency et al. (2021) have further asserted that the direct costs involved in medical
costs, such as treatment; nonmedical costs, such as transportation; and indirect costs, such as
declines in productivity, affect the outcomes of interventions and the current standard of care.
Allocating funding and ensuring that the budget is dedicated to behavioral health treatment is a
critical point to address to promote and enable program coordination in the context of suicide
prevention efforts.
Theoretical Framework
This study applied the ecological systems theory by Bronfenbrenner (1979) as its
theoretical framework. Bronfenbrenner (1974) examined environmental interactions and effects
on human development. He recognized that a child’s interactions with their parents and strangers
are not linear but dynamic (Bronfenbrenner, 1974; Rosa & Tudge, 2013). The interactions
observed were discovered within multiple nested structured environments surrounding the child,
including their microsystem, mesosystem, exosystem, and macrosystem (Bronfenbrenner, 1974).
The nested environmental structure posed by Bronfenbrenner provides a graphic representation
of a child in the center, encircled by the microsystem, mesosystem, exosystem, macrosystem,
20

and chronosystem (Figure 2).
The microsystem encompasses the activities and interactions between the developing
child and their immediate networks, such as parents and teachers. The interactions are bi-
directional or mutual, causing a child’s ability to be influenced by other people or to change
other people’s beliefs and actions, as the mesosystem is comprised of multiple microsystems
(Bronfenbrenner, 1974). The mesosystem is where a person functions dependently through
interconnection and asserts their influence upon others. The exosystem incorporates formal and
informal social structures and indirectly influences them, as they affect one of the microsystems.
The macrosystem focuses on how cultural elements, such as socioeconomic status, wealth,
poverty, and ethnicity, affect a child's development. The chronosystem refers to the proximal
process that relies on the continued reciprocal interactions between a person and their
environment (Rosa & Tudge, 2013).

21

Figure 2
Ecological Systems Theory—Theoretical Framework

Note. Adapted from Bronfenbrenner’s Ecological Systems Theory, by O. Guy-Evans, 2020,
Simply Psychology (https://www.simplypsychology.org/Bronfenbrenner.html). In the public
domain.

22

Conceptual Framework
The ecological systems theory is further applied as the conceptual framework for this
study to identify factors affecting an Army Reserve soldier’s pursuit of psychological health
resources. Through a cross-analysis of the literature, interviews, and public domain documents
addressing influences on a soldier’s psychological health, the ecological systems theory
conceptualizes the dynamic and ever-changing interconnected environments surrounding a
soldier (Figure 3).
The microsystem is a soldier’s immediate environment. Soldiers engage in personal
interactions in environments including their homes, civilian workplace, religious institutions, and
the Army Reserve unit. This study revealed soldiers’ positive and negative sentiments and
interactions surrounding mental health. The mesosystem encompasses the intersections of
multiple microsystems, such as the interpersonal connection between a soldier’s civilian and
military workplace. Furthermore, it includes any additional microsystems that a soldier is part of,
such as faith-based institutions and community organizations.
In the exosystem, soldiers are not active participants but are affected by policies and
regulations that influence the climate surrounding mental health. Barriers to psychological health
resources that are perceived to be beyond the soldier’s control or influence. The macrosystem
describes the overall cultural context surrounding a soldier. In this study, culture is nurtured
within a soldier’s Army Reserve unit and its higher echelons based on ideologies, values, and
beliefs related to mental health.
Soldiers’ ethics, values, and beliefs are developed in the chronosystem and continue to
evolve. The mesosystem also comprises a soldier’s beliefs about their reality, which influences
how they align with their professional and personal lives. In this study, the mesosystem consists
23

of a soldier's help-seeking behavior. The third environment, the exosystem, consists of the
interactions between soldiers and information received through various communication channels,
such as mass media and social media. The impacts on a soldier exerted by policies, regulations,
and the establishment of psychological health-related programs reside within the fourth
environment, the macrosystem. The continued observation and monitoring of a soldier in the
chronosystem may help determine their mental health outcomes.

24

Figure 3
Ecological Systems Theory—Conceptual Framework

Note. Adapted from Bronfenbrenner’s Ecological Systems Theory, by O. Guy-Evans, 2020,
Simply Psychology (https://www.simplypsychology.org/Bronfenbrenner.html). In the public
domain.

Conclusion
This literature review examined the factors that contribute to an Army Reserve soldier's
experience when seeking and receiving psychological health resources. The elements uncovered
include a soldier’s identity, immediate environmental stressors, the culture and social context of
the Army Reserve, and psychological health-related policies and regulations. I applied
25

Bronfenbrenner’s ecological systems theory (1979) as this study's theoretical and conceptual
framework to further allow an in-depth analysis of each system and to identify emerging
elements impacting soldier suicide.
26

Chapter Three: Methodology
This chapter presents the research design and methodology guiding the exploration of
Army Reserve soldiers’ help-seeking behavior and mental health pursuits through the lens of
Bronfenbrenner’s ecological systems theory (1979). The explorative approach allowed for an
understanding of how the barriers to access and the stigmatization of suicide within an
environment affect soldiers. The qualitative design permitted this study to employ an inductive
style that focuses on meaning and acknowledges interpretations of situations and their
complexities (Merriam & Tisdell, 2016). Furthermore, this chapter discusses ethical
considerations, limitations, and delimitations of the approach and data sources.
The inquiry process integrates constructivism and pragmatism. Constructivism prioritizes
the realities and beliefs of individuals (Maxwell, 2013). Pragmatism highlights the value of
knowledge and ideas that influence actions (Saunders, 2019). The axiology focuses on the Army
Reserve soldier’s belonging through a social construct and social role inquiry paradigm and on
their positionality within their environment through values and ethics (Creswell, 2014; Saunders,
2019). The ontology involves the nested structure of Bronfenbrenner’s ecological systems theory
(1979). The emphasis is on the mesosystem layer, which encompasses the perspectives and
assumptions of a person’s realities and how they align with their lives (Creswell, 2014; Saunders,
2019). Soldiers are more susceptible to suicidality when they lack knowledge of preventative
care. Furthermore, the Army Reserve connects with soldiers about suicidality through their
applied suicide prevention methods, which are taught by suicide prevention experts and driven
by policymakers (Saunders, 2019).
27

Research Questions
1. How does access to psychological health resources impact U.S. Army Reserve
soldiers’ success throughout their service?
2. How do the U.S. Army Reserve’s policies and regulations affect an Army Reserve
soldier’s psychological health experience?
3. What challenges do U.S. Army Reserve soldiers experience throughout their health-
seeking endeavors?
Sample and Population
The population of this study consists of Army Reserve soldiers discharged between 2016
and 2022. The selection of this population within a five-year timeframe was intended to address
the impacts of the COVID-19 pandemic and organizational influences that led to the U. S. Army
Reserve Command’s (2021) implementation of a new suicide prevention initiative. The goal was
to achieve 15 to 20 interviews with participants in the enlisted, warrant officer, and officer ranks.
Cha et al. (2018) posit that demographic characteristics, including age, gender identity, sexual
orientation, race, and ethnicity, guide interpretations and findings throughout research. Moreover,
the uniqueness of the Army Reserve is its geographic diversity, with soldiers serving in units
within their state of residence or in units in a different state or country. Purposeful network
sampling was used to obtain a diverse sample encompassing the broadest range of Army Reserve
soldiers’ identities (Merriam & Tisdell, 2016).
The hierarchical structure of the Army Reserve comprises a rank disparity of soldiers
developing help-seeking behaviors. In a study by Clark-Hitt et al. (2012), high-ranking officers
with a history of psychological health services were used as examples within their organizations
to assist in destigmatizing help-seeking behavior. The 2021 DoD Annual Suicide Report
28

indicated that the highest suicide rate within the Army Reserve was that of enlisted soldiers, at
88.3%; of those soldiers, 50.6% held the ranks of E1–E4. Consistent with previous reports and
studies, suicides by service members were committed by enlisted males between the ages of 17
and 30 (DoD, 2021). Interviews with a diverse sample within this study may result in evidence of
influences of suicidality affected by policy and regulation changes since 2016, including the
integration of women in combat arms and the implementation of transgender military service.
Instrumentation
This qualitative evaluation of Army Reserve soldiers’ psychological health journeys was
conducted by interviewing 10 qualified veterans discharged from the Army Reserve between
2016 and 2022 to capture historical events, such as the COVID-19 pandemic and the integration
of women into combat arms. The Qualtrics survey platform determined participants'
qualifications. A pre-survey link was dispersed through the network of Army Reserve suicide
prevention program managers, Veteran Affairs, and public Army Reserve social forums. The pre-
survey (Appendix C) consisted of 11 qualifying questions. Qualified participants conducted a
virtual interview through the Zoom video conference platform. Each participant abided by the
interview protocol and answered 15 open-ended questions (Appendix D) within a 60-minute
interview. The three research questions aligned with the theoretical framework, as shown in
Appendix B.
Data Collection
This study followed a high standard for data collection integrity and privacy practices
(Appendix A). Data collection for this study was derived from participants’ interviews and
document analysis. Due to the sensitive nature of suicidality, data collection was conducted once
with each participant. Ten participants were screened for their qualifications for this study and
29

were asked for consent in conducting a one-on-one interview via Zoom. The benefit of
conducting virtual interviews was the feasibility of collecting data from a geographically
dispersed target population. During the interview, participants selected a pseudonym to maintain
their anonymity. They were given a choice to skip any questions they preferred not to answer and
to halt the interview at any point (Creswell, 2014). Data from interview questions not answered
were collected through document analysis involving public domain documents relating to mental
health in the military, which consisted of official government documents and blog articles.
Applying the flexible thematic analysis approach enabled the quick identification of critical
features of perspectives and unforeseen insights, as presented in Chapter Four.
Data Analysis
The data analysis was conducted in five phases for this study. After the data collection,
data from interview transcriptions were coded and analyzed immediately after each interview
and classified into topical categories. Themes, events, and conditions were identified and
categorized into the nested environments of Bronfenbrenner’s ecological systems theory (1977).
The perspectives and experiences described within each interview were thoroughly examined by
cross-tabulating participants' sociodemographic characteristics and interview codes to identify
emerging themes (Merriam & Tisdell, 2016). Figure 4 illustrates the flow of collection and
analysis applied within this study.

30

Figure 4
Coding Collection and Analysis Process

Note. Adapted from Qualitative analysis: Deductive and inductive approaches, by A.J. Bingham
and P. Witkowsky, 2022 (https://www.andreajbingham.com/resources-tips-and-tricks/deductive-
and-inductive-approaches-to-qualitative-analysis). In the public domain.

Credibility and Trustworthiness
To maximize the credibility and reliability of the study, several approaches assessed the
accuracy of the findings by applying strategies that included triangulation, member
31

checks/respondent validation, and peer review/examination (Merriam & Tisdell, 2016).
Comparing the data from the interviews to other studies with similar target populations enabled
triangulation to assess the study’s relevance (Creswell, 2014). The alignment of interview
questions with the study’s research questions guided the data collection from interview
participant responses and document analysis for this qualitative study.
Ethics
Transparency and confidentiality are ethical factors that are vital to address in this
research study on suicide (Merriam & Tisdell, 2016). Participants were provided an informed
consent form to address confidentiality concerns (Appendix A). The degree of sensitivity of the
topic was reduced by conducting interviews with discharged Army Reserve soldiers to align with
the exempt category of the IRB process. The issues that are important to consider in the study
surround the context of the organization's bureaucratic culture and hierarchical structure. While
conducting each interview, I distanced myself from identifying as a soldier, which would impose
a perceived hierarchy, a threat based on the rank and position of the participant (Robinson &
Leonard, 2019).
Since participants range in rank, age, experiences, and cultural background (personal and
professional), these factors confer the opportunity to better understand the participant's
perspectives and insights from their position. More importantly, mitigating these challenges will
require protecting participants' right to privacy by obtaining their consent and complying with
the interview guidelines, further establishing a trusting and safe interview process (Merriam &
Tisdell, 2016).
This study serves the Army Reserve suicide prevention program and DSPO, which
govern the implementation of the suicide prevention program. Soldiers receive a no-cost benefit
32

from using any of the suicide prevention resources listed in Appendix E. Soldiers’ minimal usage
of available suicide prevention resources can prevent the continual commitment of organizations
in the future.
Positionality
My assumptions, perceptions, and prejudices throughout this study are significant in that
they have influenced the study’s findings and recommendations (Merriam & Tisdell, 2016). My
background as an Army Reserve soldier and Applied Suicide Intervention Skills Training
instructor framed the research and interview questions. I approached this study with a social
constructivist philosophical worldview by examining the complexities of lived experiences
through participant interviews using open-ended questions (Creswell, 2014). Additionally, to
minimize my biases from my personal lived experiences in seeking psychological health
services, I applied phenomenological research to create a cross-analysis of multiple participants’
experiences (Creswell, 2014). I explored the ebbs and flows of lived experience when dealing
with psychological health. I hope that this study helps the Army Reserve implement programs
that create a supportive organization for soldiers to seek psychological health resources.
Limitations and Delimitations
This study was affected by limitations related to time, participants’ transparency, and
probable triggering events. Time limitations were affected by two constraints: efficiently finding
a minimum of 10 qualified participants and the quality of participants' responses within 60-
minute interviews. The likelihood of participants not skipping any question was unknown.
Specific delimitations provided firm boundaries to prevent participants from feeling pressured or
unsafe during the interview. Participants may not have been willing to elaborate on their answers
when asked.
33

Furthermore, triggering events experienced by the participants during the interviews
could have caused participants to opt to limit their responses or conclude the interview. The
study’s value depends on the quality of the participant’s willingness, transparency, and resilience.
The design of this study, through the selection of veterans who no longer serve in the Army
Reserve, narrowed the scope of participants, leading to the limitation of qualified and willing
participants (Ross & Bibler Zaidi, 2019). However, selecting participants through the qualifying
survey further ensured a diverse pool of participants and psychological health experiences.
Conclusion
The qualitative research design in this study enabled the problem of practice to further
explore the experiences and beliefs of Army Reserve Soldiers related to stressors within their
units, civilian careers, and personal responsibilities. Chapter Four elucidates the findings of the
data collected through interviews and document analysis. Chapter Five presents the analysis of
the findings to provide recommendations for implementation and implications for future
research.

34

Chapter Four: Findings
This study explored the factors that U.S. Army Reserve (USAR) soldiers encountered
when attempting to access psychological health resources and their experiences surrounding
mental health stigma while serving in the Army Reserve. This study's use of Bronfenbrenner’s
ecological systems theory as its theoretical and conceptual framework called attention to the
coexistent and synchronized external factors affecting a soldier’s health-seeking behavior. The
questions guiding the research and data collection were as follows:
1. How does access to psychological health resources impact U.S. Army Reserve
soldiers’ success throughout their service?
2. How do the U.S. Army Reserve’s policies and regulations affect an Army Reserve
soldier’s psychological health experience?
3. What challenges do U.S. Army Reserve soldiers experience throughout their health-
seeking endeavors?
Documents
Public domain documents were analyzed for this study, including 11 published
psychological health-related news articles, blogs, memorandums, reports, policies, and
regulations addressing military suicide and the mental health of service members (Table 1). The
contents of the documents were applicable to military service members, psychological health
professionals, policymakers, and stakeholders affected by the military suicide rate.

Table 1
Public Domain Documents Information
Type Title Location Completeness Target audience Content
News article
A General Fights to
Illuminate Mental
Health Issues in the
Military
www.nytimes.com
/2022/03/19/us/politics/milit
ary-mental-health.html
General
information
Military service
members,
psychological health
professionals,
policymakers
A senior military
leader destigmatizes
mental health
issues.
News article
Reducing the
stigma and
encouraging mental
health care in the
military
https://www.health.mil/New
s/Articles/2021/05/18/Redu
cing-the-stigma-and-
encouraging-mental-health-
care-in-the-military
General
information
Psychological health
professionals and other
stakeholders
Barriers to mental
health care
Blog article
Guard, Reserve
Work to Improve
Mental Health Care
https://www.ausa.org/news/
guard-reserve-work-
improve-mental-health-care
General
information
Policymakers and other
stakeholders
Mental health care
improvements for
Guard and Reserve
soldiers
Instruction
Command
Notification
Requirements to
Dispel Stigma in
Providing Mental
Health Care to
Service Members
https://www.usar.army.mil/P
ortals/98/DoDI%206490_08
%20Command%20Notificat
ion%20Requirements%20to
%20dispel%20stigma%20in
%20providing%20mental%
20health%20care%2017%2
0Aug%2011_1.pdf
Program
guidance and
instruction
Military service
members
Requirements to
reduce mental
health care stigma

35

Type Title Location Completeness Target audience Content
Instruction
Commander’s
Talking Points
Overview
https://www.usar.army.mil/P
ortals/98/Commander%27s
%20Talking%20Points-
%20Overview%20-
%20July%202021_1.pdf
Program
guidance and
instruction
U.S. Army Reserve unit
leadership
Communication
guidance addressing
the U.S. Army
Reserve mental
health program
News article
Army Reserve
Commands focus
on connectedness in
suicide prevention
to make people first
https://www.army.mil/article
/247100/army_reserve_com
mands_focus_on_connected
ness_in_suicide_prevention
_to_make_people_first
General
information
Military service
members,
psychological health
professionals, and other
stakeholders
Suicide prevention
program training
overview
Memorandum
Establishment of
the Suicide
Prevention and
Response
Independent
Review Committee
[Memorandum]
https://media.defense.gov/2
022/mar/22/2002961288/-
1/-1/0/establishment-of-the-
suicide-prevention-and-
response-independent-
review-committee.pdf
General
information
Military service
members,
psychological health
professionals, and other
stakeholders
Committee
establishment to
address military
suicide
Report
Military Suicide
Prevention and
Response
https://crsreports.congress.g
ov/product/pdf/IF/IF10876
Research
report
Psychological health
professionals,
policymakers, and other
stakeholders
Overview of the
2019 military
suicide rates and
legislative
initiatives
Blog article
What About our
Junior Officers: An
Examination of
Mental Health in
the Army
https://juniorofficer.army.mi
l/what-about-our-junior-
officers-a-examination-of-
mental-health-in-the-army/
General
information
Military service
members,
psychological health
professionals, and other
stakeholders
The mental health
of junior officers
36

Type Title Location Completeness Target audience Content
News article
VA releases mental
health and suicide
prevention toolkit
for former Guard
and Reserve
members
https://news.va.gov/58631/v
a-releases-mental-health-
and-suicide-prevention-
toolkit-for-former-guard-
and-reserve-members/
General
information
Former military service
members and other
stakeholders
Establishment of a
suicide prevention
toolkit
Fact sheet
Mental Health and
Security Clearances
https://www.dcsa.mil/Portal
s/91/Documents/pv/DoDCA
F/resources/DCSA-
FactSheet_Mental-
Health.pdf
General
information
Military service
members,
psychological health
professionals, and other
stakeholders

Security clearance
guidance related to
mental health care

Note. This table provides detailed information regarding each public domain document used for data collection through the document
analysis conducted in this study.

37
38

Participants
Ten interviews with USAR soldiers, discharged between 2016 and 2022, chronicle four
decades of cultural change by conveying their experiences around psychological health in the
Army Reserve. Participants shared historical events that influenced their ideas related to
emotional and cognitive mental health. Such events included the September 11 terrorist attacks
in 2001, the integration of women into combat arms in 2015, and the COVID-19 pandemic in
2020. The participants interviewed created a balance through their diversity in rank, component
affiliation, and time in service (Table 2).

Table 2
Participants’ Biographical Information
Name Age Ethnicity Gender
Time in
service
Rank
category
Ashley 34 White/Caucasian Female 8 Enlisted
Eric 55 White/Caucasian, Hispanic Male 30+ Officer
Gabriela 29 Hispanic Female 10 Enlisted
Jessica 30 Asian-Eastern Female 8 Enlisted
Joanna 41 Hispanic Female 30+ Enlisted
Lana 52 Hispanic Female 30+ Officer
Melissa 40 African American Female 10 Officer
Ryan 35
White/Caucasian, Asian-Eastern,
Mixed race
Male 8 Officer
Stephanie 43 White/Caucasian Female 8 Enlisted
Vince 56 Hispanic Male 30+ Enlisted

39

Ashley
Ashley served eight years of combined service in the active Army and Army Reserve.
She was voluntarily discharged from the Army Reserve as a specialist. She served as a TPU
soldier in a unit based in Florida and had an overseas deployment. Ashley joined the Army
Reserve immediately after transitioning from active duty. She enjoyed her time in the Army
Reserve and viewed the opportunity as a brief vacation. She overcame challenging events in her
personal life through her communities of military friends and her softball team. Ashley received
psychological health support through Veteran Affairs. At the time of the interview, Ashley was
still receiving psychological health support.
Eric
Eric is a retired lieutenant colonel with over 30 years of service in the Army Reserve. He
served as a TPU and on active-duty orders in Colorado, Florida, and South Dakota. Eric had
multiple overseas deployments. Eric joined the Army Reserve due to the obligation to serve the
United States and to pay for his college tuition. He described his experiences during the past 10
years; overall, his career was highly fulfilling. However, he faced challenging times and
contemplated suicide. Eric’s primary method of overcoming challenging moments was to “just
let it go away on its own.” Eric sought mental health-related support during personal and
professional challenges through private practice while serving and through the Veterans Affairs
while transitioning into retirement. At the time of the interview, he was no longer receiving
psychological health support.
Gabriela
Gabriela served for 10 years and was voluntarily discharged from the Army Reserve as a
specialist. She served as a TPU and TPU on active-duty orders soldier in a Florida-based unit.
40

She joined the Army Reserve after serving on active duty. Her transition from active duty to the
Army Reserve was the juncture at which Gabriela struggled the most. To practice self-care, she
went to the gym regularly. She sought psychological health support during personal challenges
through the Veteran Affairs in two states. At the time of the interview, Gabriela continued to
receive psychological health support through the VA.
Jessica
Jessica served for eight years and was voluntarily discharged from the Army Reserve as a
corporal. She served as a TPU and TPU on active-duty orders soldier in a California-based unit.
Jessica always had a deep respect for the military. She decided to enlist in the Army Reserve
after feeling that she was hitting a glass ceiling in her professional career. She expressed that her
experience during her time in service was “overall, challenging.” She sought psychological
health support to overcome challenging moments through multiple private practices using her
civilian company’s health insurance. At the time of the interview, Jessica was no longer receiving
psychological health support.
Joanna
Joanna is a retired master sergeant with over 30 years of combined service in the active
Army and Army Reserve. She served as a TPU, TPU on active-duty orders, and AGR soldier in
units based in Florida, Kansas, Oregon, Puerto Rico, Virginia, and Washington. Joanna joined the
Army Reserve to adhere to the family tradition of her parents and family members before she
served. She disclosed that her professional life was smooth but that she faced challenges in her
personal life. To cope with and overcome the challenging moments, she received support from
family members and from Military One Source. At the time of the interview, Joanna was not
receiving psychological health support.
41

Lana
Lana is a retired lieutenant colonel with over 30 years of combined service in the active
Army and Army Reserve. She served as TPU, TPU on active-duty orders, and AGR soldier in
units based in California, Illinois, Kansas, North Carolina, and Texas. Lana had multiple
overseas deployments. She joined the Army Reserve immediately after she transitioned from the
active Army. Lana coped with challenging events throughout her service by contacting her old
active Army friends. She sought a women’s group through the Veterans Affairs for psychological
health support. At the time of the interview, Lana was still receiving support regularly.
Ryan
Ryan served eight years and was voluntarily discharged from the Army Reserve as a
captain. He served in Texas as an active-duty officer and subsequently transferred into the Army
Reserve as a TPU officer. He joined the Army Reserve after being out of active duty for five
years. Ryan shared how his Army Reserve unit had absentee officers. He sought psychological
health support to overcome his personal and professional challenges through the Veterans
Affairs. He faced gender bias in his interactions with a male therapist earlier in his treatment,
prompting Ryan to seek treatment elsewhere. At the time of the interview, Ryan continued to
receive psychological health support and was an advocate of deconstructing the stigma
surrounding men’s mental health.
Stephanie
Stephanie served eight years and was voluntarily discharged from the Army Reserve as a
specialist. She served as a TPU soldier in units in California, Nevada, and Texas. She had
multiple overseas deployments. Stephanie joined the Army Reserve to leave home. She shared
that her time in service involved a combination of great and challenging times. She depended on
42

the community she built and family members who also served in the Army Reserve during
challenging times. Stephanie sought psychological health support from private practices through
her health insurance and expressed that she “did not have much patience to deal with the VA.” At
the time of interview, Stephanie was not receiving psychological health support.
Vince
Vince is a retired master sergeant with over 30 years of service in the Army Reserve. He
served as a TPU, TPU on active-duty orders, and AGR soldier in units based in Florida, New
Jersey, New York, Pennsylvania, and Puerto Rico. Vince had multiple overseas deployments. He
joined the Army Reserve for financial incentives but continued to serve after gaining a sense of
duty, purpose, and belonging. Vince revealed that 85% of his time in service was suffused with
negative sentiments: “I was angry and unhappy at work.” He applied self-care to overcome the
challenges by exercising and seeking psychological health support. He received resources from
the closest military installation, an Air Force base, and the Veteran Affairs office nearest to his
residence. At the time of the interview, Vince continued to receive support through a mental
health program.
Findings for Research Question 1
The first research question asked the following: “How does access to psychological
health resources impact Army Reserve Soldiers' success throughout their service?” As addressed
in Chapter Two, soldiers experience suicidality and mental disorders before they even join the
Army and during the preliminary stages of their Army careers (Bernecker et al., 2018). Two
themes emerged throughout the interviews and document analysis to answer Research Question
1: access to resources and transitioning into the Army Reserves.
43

Research Question 1: Document Analysis
The documents analyzed revealed similar concerns and efforts related to adapting to
environments while highlighting the challenges of preexisting mental health conditions among
newly joined soldiers.
Theme 1: Access to Resources
Efforts to support the mental health of USAR soldiers and their families are an ongoing
project. Steinhauer (2022) shared the concern of a senior military leader, Maj. Gen. Litynski,
who called attention to the lack of medical insurance for the Guard and Reserve soldiers and
further attributed the rising number of suicides to the lack of access to resources. The Association
of the United States Army (2021) highlighted the efforts to expand access to care through
community partnerships and telehealth for soldiers living in areas with limited resources,
presenting a concerning barrier for a large population of the USAR. In 2019, Veterans Affairs
announced the release of a suicide prevention toolkit specifically for Guard and Reserve soldiers
and their families (Moon, 2019). All three sources emphasized the continued concerns regarding
access to mental health care despite efforts made in previous years.
Theme 2: Transitioning Into the Army Reserve
The document analysis highlighted the expectations and demands placed on new soldiers
when adapting to new and unknown environments, especially as they transition from civilian
environments and between training environments. Alford and Campbell (2022) uncovered the
realities of young soldiers experiencing new challenges for the first time. These same soldiers are
immersed in ideologies of self-reliance and expected to overcome challenges with limited time.
They shared their uncompromising emotions regarding being inundated with requirements and
the feeling of inevitable failure. One soldier shared that these pressures bled into their personal
44

life, causing them to become ill (Alford & Campbell, 2022). One challenge Steinhauer (2022)
highlighted in a news article concerned how soldiers enter the military with preexisting mental
health issues not revealed in their medical screening. The unfamiliar stressors of adapting and
coping exert lasting impacts on soldiers with preexisting mental health issues that could become
worse over time.
Research Question 1: Interview Analysis
Participants revealed how rank-related prejudices affected their ability to receive
necessary support. Furthermore, participants transitioning from active duty into the Army
Reserve experienced unexpected transition challenges.
Theme 1: Access to Resources
Three of the 10 interview participants raised concerns about rank biases during their
service that prevented them from seeking mental health resources. Jessica conveyed that the
perception of junior soldiers is as follows: “If you are young and you are low ranking, you are
nobody.” Gabriela shared her experience when she held the rank of specialist or E-4 of rank
biases among her leadership:
Rank could have influenced her. If I had been higher ranking because, unfortunately, at
least from my point of view, I was in a very pro-officer environment, whereas, like me as
a little E-4, they will [leadership] say, “You are fine, what are you doing? Go hang out or
something.” They brushed off quickly. I do not know if I had been higher ranking, not
even NCO-wise, just officer-wise, it would have been taken a little more seriously.
Melissa, also a specialist at the time of her experience, shared the following:
Not all of them, but a good portion of the leadership I was working with then did
not want to let me leave. It was more so out of, I felt, spite, and I was incredibly stressed
45

with that because I was a specialist. I do not think I had the proper verbiage to express
how I was feeling while maintaining my military bearing and to find the regulations and
the wording to say.
Theme 2: Transitioning Into the Army Reserve
Five of the 10 interview participants served on active duty before transitioning to the
Army Reserve as a Troop Programs Unit (TPU) soldier, serving one weekend per month, and
completing a 14-day annual training. Based on the interviews, the transition between components
were challenging when adapting to the Army Reserve culture and business practices.
Ryan transitioned into the Army Reserve five years after leaving active duty. He shared
that his time in the Army Reserve was short because of “Absentee officers. It felt like they did
not care. I was just a number, and anything I asked for help with, I was told to ‘figure it out on
my own, but those were the same people who were supposed to help me. So, I ended up leaving
after two years.”
The challenge involved in transitioning into the Army Reserves, especially immediately
after leaving active duty, is losing one’s benefits while on active duty, such as housing allowance
and medical insurance. Ashley, Gabriela, Joanna, and Ryan transitioned out of active duty with
minimal challenges in obtaining employment and received benefits from their respective
employers. On the other hand, Lana described her transition in 1996 as a predicament by sharing
that she had no medical care: "I had no insurance. I was living straight off my savings.” Even in
2022, Lana represents a population of transitioned soldiers facing these same medical care and
financial concerns.
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Summary for Research Question 1
In summary, the documents and interview participants revealed that challenges to
accessing psychological health resources are still prevalent today, as in the 1990s. Additionally,
soldiers' environments continue to be barriers to access, due to ideologies that do not support a
soldier's ability to practice self-care, leaders dismissing soldiers who are undoubtedly asking for
help, and unexpected transition challenges. As the documents and participants revealed, many
challenges are frequently experienced by soldiers for the very first time.
Findings for Research Question 2
The second research question asked the following: “How do the Army Reserve’s policies
and regulations affect an Army Reserve Soldier’s psychological health experience?” Chapter
Two addressed how culture and resources drive changes in policies and regulations. Two themes
emerged through the thematic data analysis to address Research Question 2: perceived impacts
on a soldier’s career and transparent supportive narratives. The document analysis revealed
similar concerns and efforts, as well as misconceptions and miscommunications in soldier
management and the USAR mental health program.
Research Question 2: Document Analysis
The documents revealed the military’s efforts to change how service members are
supported to help them access mental health care and to eliminate stigma surrounding mental
health.
Theme 1: Perceived Impacts on a Soldier’s Career
The mental health stigma in the military was described as a misrepresentation that a
service member must be capable of fulfilling a mission with no deficiencies (Sanchez-
Bustamante, 2021). This perception deters soldiers from seeking help. They fear the inability to
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deploy, judgments of their ability by members of their units, and the possibility of their military
career ending. Examples of these career-impacting conditions are the possibility of losing or the
inability to obtain a security clearance and the simple fear of having mental health treatment in
one’s medical record. However, the Defense Counterintelligence and Security Agency (2020)
explained in a fact sheet that the condition of receiving mental health support is not a
disqualifying factor that impacts a soldier's career. Less than 1% have lost their clearance for
mental health-related concerns. However, not complying with receiving mental health support or
completing treatment are disqualifying factors.
Theme 2: Transparent Supportive Narrative
The communication method in the military is intended to convey clear and concise
information that is understood at all levels, from the highest-ranking military leaders to the
lowest-ranking soldiers. However, the method by which soldiers receive information through
training in suicide prevention continues to exhibit a degree of ineffectiveness. An Army Reserve
suicide prevention program exposed how the dissemination of information through program
cards, resource lists, and directories exerted a minimal impact on soldiers’ ability to prevent
suicide in their formations (Taylor, 2021). The suicide prevention program further illustrated how
the spiritual, intellectual, and physical self must be integrated into training. Through their
observations, soldiers who understood themselves enhanced their ability to overcome some
leading causes of suicide, from managing relationships to finances. Integrating the training
methods further aligns with the Army People strategy that prioritizes soldiers and acknowledges
them as the Army’s most vital asset.
Military leaders of all ranks understand that it is acceptable to receive help to create a
safe environment predicated on trust. The Secretary of Defense emphasized that “mental health
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is health” (Austin, 2022) in the memorandum regarding the establishment of the Suicide
Prevention and Response Independent Review Committee. They further highlighted that there is
no difference from another soldier seeking care for other medical concerns. Moreover, they
emphasized the importance of healing wounds, as some wounds are inevitably visible. Campbell,
a clinical psychologist, shared the following: “In a nutshell, mental health is invisible, and people
tend not to believe [in] things that they can’t see” (Sanchez-Bustamante, 2021). The consistency
and transparency of mental health narratives at all service levels are driving factors in mitigating
suicidality.
Research Question 2: Interview Analysis
Participants revealed their fears and concerns when being transparent about their mental
health needs to their chain of command and further shared their experiences with the changes in
the military’s narratives and outreach around mental health.
Theme 1: Perceived Impacts on a Soldier’s Career
Participants disclosed their fears when they first considered seeking mental health
support. Apprehensive at the beginning when asked about her thoughts regarding seeking help
early in her career, Joanna shared the following: “I did not. I was too scared to. I did not want to
get kicked out because that would happen if I could not control my emotions. Then you cannot
be in the service.” Lana expressed the same sentiment by explaining the following:
It was a stigma that if you asked for help, there was something psychologically wrong
with you or mentally wrong with you, that you were not strong enough. Many people
who did come forward with something lost their clearances, and when you see that
happening, you do not want to say anything.
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When asking for help, Vince revealed soldiers' fears of being flagged. He explained that flagging
actions guided by the policy are inputted into a government system indicating any administrative,
medical, and legal concerns that prevent a soldier from being promoted, transferred between
units, or deployed. Two participants shared their fears related to administrative and medical
flagging actions. Eric expressed the following: “I was very reluctant to engage with the military
mental health support structure. I was worried about things like getting promoted and stuff like
that.”
Focusing on medical evaluations, Stephanie opined that “you do not want to say anything
because if it goes in your record, they are going to make you a three in the mental health part of
your PULHES.” Soldiers are medically evaluated in five categories, indicated by the PULHES:
physical capacity/stamina, upper extremities, lower extremities, hearing and ear, eyes, and
psychiatric. Soldiers are then coded from one through four. One and two indicate that a soldier
can deploy, and three and four indicate a soldier’s inability to deploy.
Theme 2: Transparent Supportive Narrative
In earlier research, participants emphasized the importance of a supportive environment
throughout a soldier's mental health journey. Today, soldiers of all ranks create environments that
deter soldiers from seeking help. Reluctant to ask for help initially, Ashley stated the following:
“The only time that I did not, before I ever sought out help, was because I did not trust anybody
in my unit.” Furthermore, participants asserted that having a leader’s support can impact a
struggling soldier. Gabriela remembered seeing videos of high-ranking soldiers, including the
Sergeant Major of the Army, sharing their mental health experiences: “They would not go into
detail, but they said, if I can do it, you can do it.” Eric shared his personal experience with his
leader while at a field exercise:
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When I had those low moments, my commander said, “Hey, you know we are in the field.
Stress is high. You know not to make decisions here. Let things sort of calm down, and
then decide whether you want to continue or not.”
Witnessing more leaders display a degree of empathy and vulnerability exerted an impact by
encouraging soldiers to seek the help they needed. Jessica shared that her leadership would stand
before the formation to say the following: “Soldiers take care of yourself. Take care of your
family. We are only as strong as our weakest link, and if you are not okay at home, then you are
not okay here.”
Eric acknowledged the improvement in the Army’s language when addressing mental
health: “The language is much more encouraging. You do not have to worry about whether you
are going to get promoted. It is more important that you are a healthy person.” Melissa shared the
same sentiment: “I feel like there are a lot more than only resources but people to reach out to
and share experiences with and to hear about their perspectives.”
Lana acknowledged the improvements made by the military with its messaging and
outreach. However, she emphasized the following: “It is instructed to call this hotline number,
but it is not about numbers. It is about one-on-one reaching out to somebody and saying, ‘You
know what? I care, and I want to make sure you get the help that you need.” Even with these
changes, Lana explained that “People are still scared. Even as more people are coming forward,
they are still scared.”
Summary of Research Question 2
In summary, the documents and interview participants revealed the challenges involved
in ensuring that the military's priorities related to mental health were transparently adhered to by
all soldiers. The mental health risk levels intensify as soldiers continue to be exposed to counter-
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narratives, especially by their leaders, regarding the importance of health; they should thus not
fear of seeking help. Despite the efforts made by the military to improve perceptions surrounding
mental health, there continues to be tension between the expectations of soldiers fulfilling their
military duties and supporting their desire to use the mental health resources available to them
without repercussions.
Findings for Research Question 3
The third research question asked the following: “What challenges do U.S. Army Reserve
soldiers experience throughout their health-seeking endeavors?” Chapter Two addressed how the
lack of access to social support networks and the presence of supportive behaviors can negatively
impact individuals facing amplified stressful events (Blais et al., 2021; Miller et al., 2022).
Additionally, an environment that allows the victimization of soldiers is created by the
convergence of power and balance (Zedlacher & Koeszegi, 2018). The analysis of documents
and participant interviews highlighted the following emergent themes and subthemes to answer
Research Question 3: treatment stressors, cultural influences, support systems, and the transitions
between a soldier's life and civilian life.
Research Question 3: Document Analysis
The documents analyzed illustrated cultural influences related to the persistent presence
of mental health stigma in the military. Service members quoted in the documents called
attention to the perceived portrayal of U.S. Army Reserve soldiers and the influences of an Army
Reserve unit's culture around a soldier receiving mental health treatment.
Theme 1: Treatment Stressors
The Association of the United States Army (2021) emphasized that Army Reserve
soldiers are frequently negatively judged by other military components and services. However,
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these same parties neglect that Army Reserve soldiers are more than their military duty: “These
Army Reserve [soldiers] that support America and support our active-duty and our sister
services, but… they also have to maintain a job, maintain their family, possibly go to school,”
said Col. Mitravich (Association of the United States Army [AUSA], 2021).
Theme 2: Cultural Influences
Sanchez-Bustamante (2021) asserts that at the individual level, understanding from their
family, friends, and communities is critical to eliminating the stigma associated with mental
health. However, suicide stigma in some cultures can be uncompromising and challenging for
individuals to navigate in addressing their mental health needs. As gender biases are nurtured
within a person’s culture, Scott Alsup shared, “Being a man, you don’t talk about your feelings”
(Steinhauer, 2022). Cultural influences continue to impact a soldier’s mental health and can
influence military culture.
Highlighting the directness of the military culture, retired Marine officer Gillum shared
that service members are taught to conceal their problems, adapt, and overcome (Steinhauer,
2022). Furthermore, military leaders perceived help-seeking behaviors by service members as
liabilities to their mission. As a culture permeated with values of “winning above all else,”
leaders developed under this mantra are exposed to heightened stress levels, unable to display
any degree of weakness or the opportunity for failure (Alford & Campbell, 2022). Sharing
similar sentiments, a junior officer expressed that they believed that seeking help is tantamount
to career suicide, further confirming the persistence of mental health stigma in today’s military
and Army Reserve.
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Theme 3: Support Systems
Current military leaders have developed a military culture focused on metrics to measure
their unit’s readiness to determine their ability to accomplish a mission. The DoD Instruction
addressing the requirements to dispel mental health care stigma emphasized that support is
critical to the success of soldiers seeking mental health assistance (Under Secretary of Defense
for Personnel and Readiness [USD(P&R)], 2011):
The DoD shall foster a culture of support in the provision of mental health care and
voluntarily sought substance abuse education to military personnel in order to dispel the
stigma of seeking mental health care and/or substance misuse education services.
Similarly, soldiers seeking any other medical treatment can also experience a lack of support
from their leadership. Under challenging environment conditions, mental health stigma remains a
prevailing concern related to soldiers’ mental health needs. Unforeseen environmental
conditions, such as the COVID-19 pandemic, revealed the importance of connectedness, as
soldiers did not attend drills in person for a prolonged period (AUSA, 2021). It is already
challenging for an Army Reserve unit to collectively meet in person for only two days each
month to develop a trusting and supportive culture.
Research Question 3: Interview Analysis
Through the analysis of participant interviews, the sub-themes of civilian and military
cultures emerged. The distinct differences between the two environments influence a soldier's
attitudes and beliefs regarding mental health and how these attitudes and beliefs affect a soldier's
ability to safely navigate their personal, professional, and military lives. Furthermore,
participants reflected and shared their most vulnerable experiences when confronting their
mental health concerns. Events ranged from managing personal obligations and the support of
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their immediate network to struggles with the type of treatment from their assigned mental health
professional. These challenges prompted the more significant concern of added stress for
individuals already enduring many stressors.
Theme 1: Stressors During Mental Health
One of the 10 participants raised awareness of the additional stress she experienced while
receiving treatment. Even with a support system, which included her family and softball team,
Ashley shared that the “stress of graduate school, on top of what I was already going through,
was just making it worse.” As Ashley represents the population of soldiers who pursue their
education in addition to existing obligations, other populations with additional obligations were
not addressed in participant interviews.
Four of the 10 participants received mental health support through a civilian practice.
One participant paid out of pocket due to their fear of having the treatment placed in their
military records. The timeframe between participants contacting an organization for support and
their first appointment ranged from one week to six months.
The Veterans Affairs was a resource for seven of the 10 participants. Stephanie, who did
not receive treatment from the Veterans Affairs, expressed that she “did not have much patience
to deal with the VA. It is a lot of you waiting on hold and then being unable to get help; I just
could not.” She further conveyed the importance of a safe and trusting environment with a
mental health professional: “After my second deployment, I tried to see a counselor just through
my health insurance. For me, it is a relationship, even if you are paying for it, so if it did not feel
right or I could not click with the person I was talking to, I did not go.”
Other participants shared the same sentiments about concerns regarding the treatment
they received from a mental health professional. Jessica had to change her therapist because of
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her changing jobs and her insurance not covering the treatment. She took ample time to seek out
a new therapist. She relied on her immediate network for recommendations, researched online,
and read reviews. She finally identified a therapist despite how expensive they were. Her
progress in overcoming her mental health obstacles was more important than the money she
would have to spend. Unfortunately, after being assigned to the new therapist, Jessica stated the
following: “I get to my therapist’s office, and he says, ‘You are not depressed. Your hair is
combed, you are showered, and you have well-kept shoes.’” She was in disbelief to hear those
words from a therapist, which resulted in her undergoing another iteration of finding a new
therapist, causing even more frustration.
Gabriela communicated her concerns about her assigned therapist to Veterans Affairs and
was informed that they would need to talk to her provider: “But if I am telling you I do not like
her, I should not have to go through 500 hoops to change her,” Gabriela expressed with
frustration.
Concerns about how the Veterans Affairs manages multiple participants raised their
mental health services. Ryan shared his experience at a Veterans Affairs facility, where he was
admitted for intensive mental health treatment. After sharing the immediate safety concerns and
the emotional abuse he experienced from his partner, Veterans Affairs, upon his discharge, signed
him over to his partner. He further expressed his frustration and confusion about what he was
experiencing.
In another treatment experience, Ryan expressed that he experienced gender bias with a
male therapist provided by another Veterans Affairs facility. He felt that at any time during his
sessions, when he would make statements such as “She is saying these things” or “She is
demeaning about this,” the therapist would abruptly stop him without allowing him to fully share
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his thoughts. Ryan related this experience to how his father would respond to his same concerns.
This trauma, he found, resulted in him seeking help from organizations not affiliated with the
military.
Changing therapists while making treatment progress by choice or by necessity was a
common concern shared by participants. Ashley was the only participant who shared an
experience with needing to move between states. Having made positive progress with her mental
health support team, she stressed the importance of the following: “You should continue getting
help from that person because especially now since we are virtual. Why can’t we see each other,
especially with a psychiatrist, because that is important? It can be detrimental to your mindset.”
Other participants shared that they felt that they were only addressing an agenda by
having the professional see them. Unlike other participants, Eric sought help from organizations
not affiliated with the military. He first shared that his concern about obtaining mental health in
the private sector is “thinking if they [mental health professionals] are going to start proselytizing
me.” This thought stemmed from his first encounter with a mental health professional while
residing in the Bible Belt. His first and only session with this therapist consisted of biblical
references, and Eric further shared that he identified as an atheist.
Conversely, Melissa sought support from the military chaplain, as she struggled with her
leadership and the treatment she received while on a mission. After waiting two weeks to see a
chaplain due to other mission requirements, she shared the following: “When I finally saw a
chaplain, I felt like they were checking a box so that they could cover the basis for my
leadership.” She felt the lack of genuine support from a spiritual confidant.
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Theme 2: Cultural Influences
Stephanie shared how her upbringing influenced her feelings about handling mental
health support: “I made a choice not to say anything just because it was a social norm when I
was younger. As I got older, my choices to not say anything was more of ‘it is none of your
business, you do not need to know about my personal life.’” Sharing the same sentiments as
Stephanie, Lana conveyed the following:
The stigma is still being taught at home, and new soldiers bring it into the military. The
stigma gets in the way, or they [soldiers] do not want their friends knowing about it, or
you know you look weak, you are asking for help.
Ryan expressed his concern about how the current stigma surrounding psychological health is
“probably worse.” Transparent about his struggles, he shared the following: “I do not think you
understand the pushback. I say this. After all, I fight the taboo of having suicidal episodes
because I have post-traumatic stress disorder (PTSD).” Like Ryan, Vince, who also struggles
with PTSD, shared the following:
The stigma for us who are diagnosed with PTSD is terrible. When people see a container
of medication, they think you are crazy and push back. When you are diagnosed, they
[family and friends] do not understand. It is a stigma. Every time you say you have
PTSD; they push you away.
The feeling of isolation and being ostracized from their closest family and friends was shared
among the interview participants as they faced mental health obstacles. Interview participants
further shared how the culture they have been immersed in throughout their civilian lives closely
relates to the military culture surrounding mental health stigma. Lana described misconceived
portrayals of Army Reserve soldiers:
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People fail to realize that Reserve soldiers are civilians in uniform, so we are double
serving. We are serving the community, and we are serving our country. Moreover, we
must always maintain strict military boundaries, rules, and regulations in our
communities. Reserves are different; you are working with civilians wearing a uniform,
so a different frame of mind is different.
Acknowledging the expected behavior of soldiers, Lana indicated that the military culture
heavily stigmatizes soldiers who seek help. She shared the following: “If there is something
psychologically wrong with you or mentally wrong with you, you are not strong enough.” She
further discussed her recent overseas deployment:
You still have women who should not be in combat stigma. When I was in Iraq in 2020,
the female next door to me was a second lieutenant, and her troops would harass her. She
was the only female, and her executive officer (XO) would allow it, so every night, I
could hear her in her room crying.
Recognizing the need for change in the military culture, Melissa shared the following: “With all
the decades of culture consisting of, ‘You have got to man up, you got to put your best foot
forward and emotions later, just do the job.’ It will take a lot to rewire the culture to where it is
okay to say I need mental and emotional assistance.”
Theme 3: Support Systems
Immediate network levels of support varied throughout the 10 participants. Of the 10
interviewed, five participants faced challenges in receiving support when seeking medical health
support and treatment. Vince broached his mental health support to his Army Reserve unit only
to be ostracized:
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After asking for help, no one cared, not even the commander and the entire chain of
command. It hurts, you know. Everyone said, “I do not want to deal with him.” The
commander said, “I do not want to deal with him; we have too many issues with AGRs.”
They sent me to a different office to work out of because nobody wanted to deal with me.
There was only one person that took me under their wings.
Due to the lack of support they received early in their help-seeking journey, Eric and Lana
shared that they chose to shield much of what they were experiencing from their immediate
networks. Stephanie shared a similar sentiment:
I did not talk to my family often about when things were hard or if I was having a
difficult time during my deployment; I never told them. I just dealt with it there and kept
it away from it. I leaned on the friends that I made and counted on them to get me through
until it was not so horrible anymore.
For participants who did receive support, their immediate networks identified changes in their
behavior and made them aware of their concerns. Ashley expressed the following:
After returning from deployment, I noticed I was not the same, and everybody else started
noticing. I started not showing up for work and stuff, so I had to do something that
initiated my receiving support. I noticed how my mom and son were noticing that I was
getting worse. Regarding attitude, I was not a good person to be around.
Participants shares positive support systems while receiving treatment. Gabriela conveyed how
difficult it was to undergo her first-time treatment, yet she shared the following, “The second
time, I had the support of my partner, so that was super easy.” Jessica divulged the same
sentiment: “I lucked out with my parents, my siblings, my friends, and eventually met my
husband; I had a great support system.”
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However, Jessica further expressed that even through the positive support she received
from her immediate networks, she still experienced challenges related to them understanding her
mental health obstacles. Jessica explained, “It helps; what matters at the end of the day is your
walk, and whether people support you, they can only support you to a certain extent, but you
have to walk.”
Theme 4: Transitions Between Military and Civilian Life
Three of the 10 participants sought psychological health support after their overseas
deployments. Stephanie, one of three, stated the following: “I do not think people talk enough
about Reserve soldiers who came back from a deployment and cannot adapt back to their regular
life.”
When Eric returned from his deployment, he shared that he lied when answering
questions during the mandatory post-deployment survey regarding his thoughts about killing
himself so that he could go home. Sharing a similar sentiment to the desire to transition back to
civilian life after deployment, Stephanie shared the following: “You go home, and then you get
home and you kind of get past the honeymoon phase of being back, and it is ‘oh man, I really
should have told them this or I should tell them that.”
Jessica did not deploy during her service; however, she still recognized the challenges of
transitioning between her military and civilian life. After returning from basic training, Jessica
shared her experience transitioning back to her civilian job: “If I can transition into something I
never knew, I can easily transition back to what I knew. I went back to work right away. I sat in
front of my computer, and I had to remind myself how to type again.” To convey differences in
transitions, she further explained that attending drills can be challenging under an unhealthy
environment created by military leadership: “I would not sleep the week going into drill because
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of much anxiety. I would go to drill tired and frustrated.” The emotional toll endured by Jessica
led her to share that she “could not wait for my contract to end, and so I started counting down.”
Summary for Research Question 3
In summary, the documents and interview participants revealed how a soldier's help-
seeking behavior is influenced by their immediate environment. A soldier’s immediate network,
consisting of family and friends, can cause that soldier to feel unsupported and ostracized for
their desire to become healthy. The stigma surrounding mental health struggles in particular that
is prevalent in a soldier’s culture transfers to the military, further compounding the existing echo
chambers of soldiers surrounding the mental health stigma. The heightened risk a soldier faces
when seeking and receiving mental health support was further revealed, including the
unexpected negative experiences and increased stressors. Those stressors are amplified when
undergoing ineffective treatment, leaving a soldier to seek support elsewhere, causing frustration
or leading a soldier to refuse further help. Research Question 3 exposed the unknown conditions
that hinder a soldier’s opportunity to overcome mental health obstacles when providing them
with a safe and effective support environment is critical.
Conclusion
The archetype of a soldier is often described as a selfless warrior willing to sacrifice their
life for their nation’s security (Kaspersen, 2021). Often perceived as detached from society,
soldiers are deeply rooted in their communities and environments, rendering their identities
multifaceted. Participants and documents revealed the Army Reserve soldiers’ frustrations with
misconceptions regarding their identities and responsibilities as only soldiers and civilians. They
possess multiple titles, such as soldier, civilian, caregiver, student, and member of various
organizations. As members of society, these soldiers, when called for duty, are removed from
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their communities and are expected to adapt to various military environments effortlessly. They
are then expected to return to their communities upon completing their duty, anticipating that
they will be called upon again.
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Chapter Five: Discussion and Recommendations
Active-duty military suicides have been tracked and analyzed since the early 19th century
(Smith et al., 2019). Studies regarding mental health have focused primarily on active-duty
soldiers and those deployed to combat zones. Reports mentioning Army Reserve suicides did not
appear until the early 2000s. Moreover, there continues to be a lack of research focusing on the
Army Reserve’s culture surrounding mental health. Recent studies have revealed the importance
of an Army Reserve soldier’s identity to address the mental health challenges unique to them
compared to their active-duty counterparts. Hummer et al. (2021) delineated the added barriers
that Army Reserve soldiers experience when receiving quality mental health care, raising
concerns about the increased stress caused by secondary consequences. The DoD (2021)
recognizes in its annual suicide report that secondary consequences can manifest through
managing relationships and financial difficulties, dealing with mental health care stigma, and
fulfilling military obligations. This chapter discusses the research findings presented in Chapter
Four, the study’s implications, and recommendations for future research.
Overview of the Study
This study evaluated soldiers' journeys with psychological health resources while serving
in the U.S. Army Reserve (USAR). A qualitative evaluation approach was applied to collect data
through interviews and document analysis. One-on-one interviews with 10 participants were
conducted on Zoom's computer-mediated communication tool. Participants were selected
through the qualification survey (Appendix C) to determine their eligibility for this study.
Additionally, 11 public domain documents were selected via purposeful sampling based on
publication type, year, and organization-level criteria. Recognizing the sensitivity surrounding
mental health, primarily through the lived experiences shared by the participants in this study, a
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data analysis was conducted using constructivist and interpretivist paradigms. The paradigms
revealed the intangible realities in relation to social and personal constructs (Creswell, 2014).
The findings from Chapter Four identified emergent themes to answer this study’s research
questions:
1. How does access to psychological health resources impact U.S. Army Reserve
soldiers’ success throughout their service?
2. How do the U.S. Army Reserve’s policies and regulations affect a soldier’s
psychological health experiences?
3. What challenges do U.S. Army Reserve soldiers experience throughout their health-
seeking endeavors?
Discussion of Findings
The ecological systems theory was applied as the theoretical framework for this study,
placing the soldier in the center of their ecosystem, as presented in Figure 5. This theoretical
perspective revealed the dynamic interactions surrounding a soldier’s five systems. To better
understand these interactions, data collection through interviews and document mining, as
presented in Chapter Three, and the empirical literature, as presented in Chapter Two, were
analyzed to identify emergent themes and subthemes for this study. Ten USAR veterans
discharged from 2016 to 2022 were interviewed to gain an understanding of the journeys they
each endured to maintain their mental health while serving. Eleven public domain documents
relating to mental health in the military, from news articles to official policy documents, were
analyzed to highlight the factors shared across participants’ lived experiences and identify factors
that were unaddressed. This chapter presents the triangulations of the findings in Chapter Three
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and the literature review in Chapter Two through the theoretical framework of the ecological
systems theory (Bronfenbrenner, 1979).

Figure 5
Ecological Systems Theory—Findings

Note. Adapted from Bronfenbrenner’s Ecological Systems Theory, by O. Guy-Evans, 2020,
Simply Psychology (https://www.simplypsychology.org/Bronfenbrenner.html). In the public
domain.

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Findings for Research Question 1
Research Question 1 explored how access to psychological health resources impacted
USAR soldiers’ success throughout their service. Two themes, access to resources and
transitioning into the USAR, emerged throughout the interviews and document analysis. As
depicted by the lens of the ecological systems theory (Figure 5), the soldier, centered, is
influenced by the interactions within their immediate environment, known as the mesosystem.
This structure highlights the lack of studies concerning positive and negative social exchanges
among service members regarding suicide risk, as posed by Blais et al. (2021) and presented in
Chapter Two. Their study demonstrated that the consistency of negative social exchanges with
fewer positive social exchanges increased suicide ideation and risk.
Regarding the theme of transitioning into the USAR, participants interviewed for this
study shared that they missed the sense of service, structure, and camaraderie after leaving the
active-duty Army. They decided to join the USAR to reclaim those factors missing in their lives.
Ryan, who only served two years in the USAR, shared that immediately upon his assignment to
his unit, he often felt alone and struggled to receive help from members of his unit. He shared
that “It felt like they [unit members] did not care.” He felt like more of a number than a human,
leading to his short service with the USAR. Ryan was one of four participants who transitioned
from active duty into the USAR.
Another prior service participant, Lana, revealed the disturbing reality of losing all of her
benefits when leaving the active-duty Army. Benefits include medical insurance, which is often
required to receive mental health care. The environmental interactions between available
resources and soldiers falls within the exosystem of the ecological systems theory (Figure 5).
Findings from the document analysis revealed senior leaders’ concerns about the lack of medical
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insurance in the Reserve force, further presenting a barrier for soldiers seeking help. The mental
health care resources provided by the DoD that do not require medical insurance pose another
concern. The study by Burke et al. (2013) highlighted the estimation of behavioral health staff
needed at community health centers. Considering that these community health centers are likely
to service USAR soldiers who do not reside near a military medical facility center, Burke et al.
(2013) contended that to serve 40 million medical patients, more than 27,000 behavioral health
providers are needed. However, the high ratio of providers to patients can lead to provider
burnout, which affects treatment quality and outcomes (Stearns et al., 2018). The principal
concern presented from Lana’s lived experienced is the causal sequence of events when
psychological health resources not requiring medical insurance are made available but are
limited to behavioral health providers.
In summary, Ryan and Lana’s transition into the USAR was vastly different, yet it
presented stressors from environmental influences, a lack of medical benefits, and demands from
unfamiliar conditions. These three stress factors become foundational conditions for soldiers in
similar circumstances relative to Ryan and Lana. Until the culture of all USAR units changes to
be more supportive, access to mental health will no longer be associated with additional
stressors. Until soldiers are thoroughly assessed and evaluated throughout their service, suicide
will continue to exist throughout the formation.
Findings for Research Question 2
Research Question 2 explored how USAR policies and regulations affect a soldier’s
psychological health experience. Two themes, namely perceived impacts on a soldier’s career
and transparent supportive narratives, emerged through interviews and document analysis to
answer Research Question 2. This area of interaction with a soldier is focused on the exosystem
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of the ecological systems theory (Figure 5). Since this research question focuses on policies and
regulations, soldiers impacted by standards make little to no contribution to its development. The
study by Milkman et al. (2021) highlighted how the insights from behavioral science regarding
the improvements of decisions and outcomes by citizens are sought out by policymakers.
In this study, annual suicide reports from the DSPO became foundational data for
changing mental health-related policies and regulations developed by the DoD. However,
modifications or new policy developments face challenges related to bureaucratic accountability,
dismissing methods of frequent audits and inspections to evaluate the performance of the
guidance provided (Stecher & Kirby, 2004).
Unclear and conflicting guidance continues to resonate throughout the U.S. Army
Reserve formation. Interview participants Vince and Stephanie shared that soldiers do not seek
mental health treatment despite desiring it, since they fear the consequential impact on their
military career. Vince raised the familiar concern of a soldier fearing an administrative or
medical flag. Further providing insight into medical evaluation reporting, Stephanie shared the
following: “You do not want to say anything because if it goes in your record, they are going to
make you a three in the mental health part of your PULHES,” which signals restrictions such as
the inability to deploy, change units, or be promoted. The document analysis presented a 2020
report stating that soldiers receiving mental health care is not a condition for disqualifying a
soldier to serve or that impacts their careers. However, not complying with or completing
treatment leads to possible service discharge. Another popular misconception prohibiting soldiers
relates to losing their security clearance. However, a news article affirmed that 1% of soldiers
lose their security clearance for mental health-related issues. These fears are perceived as
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stressors by soldiers influenced by past and existing policies and regulations. They will continue
to be viewed without clear guidance and exemplified by military leaders.
What continues to compound the fears presented is mental health stigma. Practicing
policies and regulations to eliminate this stigma depends on transparent narratives supporting
mental health care. Leaders' facilitation and implementation of changed behaviors are essential to
sustaining change and transferring the difference into a norm (Eisenbach et al., 1999). Many
efforts to implement policies and regulations entail the execution of programs, such as the U.S.
Army Reserve suicide prevention program. However, a suicide prevention program manager
shared in a news article that the information disseminated to soldiers regarding suicide
prevention was considered to have a minimal impact on a soldier’s ability to prevent suicide.
Information such as program cards and resource lists during training was often discarded
or dismissed. These soldiers’ interactions with suicide prevention program representatives and
military leaders, found in the microsystem of the ecological systems theory, are fundamental to
their relations to the policies and regulations in place. The interview participant Eric shared that
“the language [on mental health] is much more encouraging. You do not have to worry about
whether you are going to get promoted. It is more important that you are a healthy person.”
Removing barriers related to fear and flags is critical to a soldier’s health and well-being. Lana,
another interview participant, further highlighted the importance of supportive outreach by
soldiers as opposed to the suicide hotline number: “It is instructed to call this hotline number, but
it is not about numbers. It is about the one-on-one reaching out to somebody and saying, ‘You
know what? I care, and I want to make sure you get the help that you need.”
In summary, the consensus shared between interview participants and stakeholders
identified in the document analysis emphasizes the importance of eliminating the apprehension
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of mental health care and the importance of the clarity of existing policies and regulations that
guide soldiers’ ability to maintain their mental health. The disparity will continue to grow if a
soldier’s desire to continue serving in the USAR and the barriers presented remain unresolved.
As presented in Chapter Two, the recent change in the USAR’s approach to suicide prevention
through a public health approach has precipitated a new beginning for opportunities for
evaluations of program effectiveness. Despite this change, a growing concern regarding the
process of changes in support for mental health is the concern about counter-narratives in units
where prevalent stigma is the area of focus for the USAR and future studies.
Findings for Research Question 3
Research Question 3 explored the challenges experienced by USAR soldiers throughout
their health-seeking journey. Multiple themes and subthemes, including cultural influences,
support systems, treatment stressors, and frequent military and civilian transitions, emerged in
participant interviews and the document analysis to answer Research Question 3. This area of
interactions presented in each theme hyper-focused on the degree of influence in the
microsystem within the ecological systems theory (Figure 5). However, a soldier’s beliefs,
ideologies, and values developed through these interactions extend into the macrosystem and
chronosystem, rendering change and acceptance difficult. Briefly addressed in Research
Question 1 was the importance of the awareness of a candidate’s history with mental health
struggles. However, as emphasized, they are often not visible to others. Research Question 3 asks
how those wounds developed or why soldiers are reluctant to accept the normality of maintaining
their mental health.
The foundation of Bronfenbrenner’s (1977) ecological systems theory is the study of
human development. His original research focused on child development and the various
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interactions a child experiences in their environments. The diversity of the USAR is immense, as
it is composed of soldiers from diverse backgrounds in terms of culture, values, and beliefs, all
developed since birth. Through document analysis, a blog article highlighted that gender bias
regarding mental health was prevalent in a stakeholder’s culture and that men could not talk
about their feelings.
Ryan, an interview participant, shared his experiences dealing with gender biases from
his family and therapist. When Ryan spoke about his concerns, he shared that his father and
therapist would stop him from expressing his thoughts. This made Ryan feel that his concerns
were irrelevant to his overall health. Both countering stakeholders agreed that a man should take
the emotional wounds and live with them. Ryan represents one example of the different types of
stigmas that soldiers endure in their lives. In his shared experience, he only revealed the stigma
imposed by his family and therapist, not by his USAR unit.
Schnyder et al. (2017) studied the association between mental health-related stigma and
active help-seeking. The study posits a direct association between stigma related to mental illness
and mental health services; however, the type of stigma will determine the strength of the
association (Schnyder et al., 2017). In theory, Ryan being culturally influenced by gender bias
stigma could apply that same belief in any environment he is part of, especially as a soldier in a
USAR unit. Influenced by their USAR environments, Lana, another interview participant,
expressed her frustration with the help-seeking stigma she experienced in her USAR unit: “if
there is something psychologically wrong with you or mentally wrong with you, you are not
strong enough.” Melissa made similar testaments regarding the expectation to do the job and
push emotions aside. She further asserted that it would require substantial effort to rewire a
culture built upon this ideology.
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A culture built on a stigma that resists evolving over time poses risks related to soldiers'
mental health needs. Through the document analysis, a directive published by the DoD
emphasized the necessity for military leaders to equally prioritize the overall health of their
soldiers with their persistent determination to maintain the metrics of their unit. Vince, an
interview participant, shared that when he asked for support from his USAR unit to meet his
mental health care needs, “no one cared, not even the commander and the entire chain of
command.” He continued to hear the phrase, “I do not want to deal with him,” causing an
increase in his helplessness and suicide risk. Fortunately, Vince found a confidant who supported
him through his mental health care journey.
Unlike Vince, interview participants such as Eric and Lana opted not to tell their
immediate networks about their mental health care needs; they instead chose to keep their care
private between them and their therapists due to their fear of cultural stigma and judgments of
their character from their communities. However, a study by Kalvesmaki et al. (2022) that
analyzed the gaps in policy and practice to end veteran suicide posited the need for veterans to
have greater connections with broader communities as opposed to merely clinical relationships,
further affirming the importance of a support system not merely from an individual but a network
of supporting stakeholders to help reduce the risk of soldier suicide.
The types of support soldiers gain from their immediate networks are risk reduction
factors. However, even with a supportive network, as highlighted in the document analysis and
participant interviews, soldiers endure additional stressors, including personal obligations, such
as pursuing advanced degrees that demand additional time previously allocated to family and
community engagements. As expressed by Ashley, an interview participant, these stressors were
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endured in addition to the mental health care she received, conceivably posing a risk in care
completion.
A study by Stearns et al. (2018) concerning the burnout of U.S. military behavioral health
providers posits that a decline in treatment experience affected patients' attitudes toward the
effectiveness of their care. As Ashley’s attitude declined from additional stressors, other
participants, such as Jessica, Eric, Ryan, and Gabriela, faced challenges with their discomfort in
their interactions with their therapists, prompting them to end their care and seek other therapists.
No participant in this study was directly affected by the COVID-19 pandemic.
However, a study by Miller et al. (2022) regarding the impacts on a person’s
psychological health during the COVID-19 pandemic posited that disruptions in routines can
increase the risk of mental health conditions—further demonstrating that individuals with mental
health issues need essential loss aspects of their treatments to include face-to-face care during the
pandemic. Structure and routine are essential aspects of mental health care, but this also applies
to a soldier’s daily life.
In Research Question 1, we learned about Ryan and Lana’s transition experiences when
they entered the US. However, with the familiarity of the military culture and its benefits, they
shared a degree of comfort. The reality is that most USAR soldiers enter without prior service
experience. This study further revealed the importance of recognizing historical and immediate
mental health behaviors before entering the military and in the developing stages of a soldier.
The Office of the Under Secretary of Defense for Personnel and Readiness (2022) asserted that
mental health behaviors might not be visible to others early during a soldier’s entry into the
USAR.
Document analysis further revealed the demands and expectations placed on new soldiers
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to adapt to unfamiliar environments, which poses an increased strain on a soldier’s ability to
overcome the challenges new to them through their initial and advanced training before their
official assignment to their unit. In this circumstance, the interaction of a person and their
environment through adaptation is presented through the mesosystem of the ecological systems
theory (Figure 5). Consider Jessica’s experience as she transitioned from a civilian into a soldier.
It was a culture shock when she reported to basic training, as with many other service members.
Jessica had to immediately adapt to demanding and high-stress environments that
deprived her of the daily luxuries familiar to her. Upon completing her training in a highly
structured environment, she transitioned back into her civilian life with the following
expectation: “If I can transition into something I never knew, I can easily transition back to what
I knew. I went back to work right away. I sat in front of my computer, and I had to remind myself
how to type again,” Jessica stated. Even with the simple task of typing again, the effect on a
soldier is one minor example of the many transitional challenges a soldier will continue to
experience throughout their career.
Major transitional events, such as deployments, pose even more acute mental health risks
for soldiers. Upon Eric and Stephanie’s return from their deployments, they both neglected to tell
the truth about their mental health to their respective military medical staff to fulfill their desire
to return home. Stephanie claimed that it is not until after the “honeymoon phase of being back”
that you develop a sense of regret for not informing the military medical staff that you need
mental health care. The study by Schaughency et al. (2021) regarding the financial costs of
newly enlisted soldiers’ suicides highlighted the stressors involved in transitions and the
integration of soldiers throughout their training. These stressors may become familiar events to
developing soldiers.
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However, based on the study by Miller et al. (2022), routine and structural changes result
in increased stressors. Often uncontrolled by soldiers, sudden changes to meet unit requirements
fall within the macrosystems of the ecological systems theory (Figure 5). USAR soldiers
experience unexpected and abrupt changes throughout their careers, including changes in their
monthly training that conflict with family functions and events, short- to long-term missions
requiring their absence from their civilian careers, and fiscal constraints related to the income
difference between soldiers’ USAR pay and their civilian career. These stressors further induce a
degree of internal conflict with a soldier’s desire to continue serving in the USAR.
In summary, challenges experienced by soldiers through the contexts of cultural
influences, support systems, treatment stressors, and frequent military and civilian transitions
exert significant impacts on their health-seeking endeavors. However, where USAR soldiers
experience the most significant stress throughout their military career is during transitions.
Soldiers are removed from their daily routines, disrupted in accomplishing projects and
aspirations in their civilian careers, and expected to make personal sacrifices, to miss significant
family events, to put on the uniform, and to prioritize their duty to protect their nation.
Implications of the Study
This study evaluated soldiers’ journeys toward psychological health resources in the U.S.
Army Reserve (USAR). The empirical literature regarding military suicide and the DoD’s annual
suicide reports continues to convey that death by suicide affects the whole military community,
from a unit’s formation to family and friends. As described by USAR veterans in Chapter Four, a
community for USAR soldiers extends beyond their military community, as they occupy roles as
civilian employees and members in various civilian organizations. They fulfill many roles, which
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can lead to conflicting responsibilities, further challenging the mental health state of a soldier
(Hummer et al., 2021).
This research revealed barriers affecting a soldier’s ability to maintain their mental health
while serving part-time in the USAR. Barriers highlighted were the archetype of a USAR soldier,
the stigma surrounding mental health, the lack of support systems, and the challenges
experienced by mental health providers. Continued efforts by the U.S. Army Reserve leaders
through transparent narratives and as exemplars of maintaining mental health continue to be a
catalyst behind change throughout the formation. Moreover, the emphasis is that mental health is
health; as with any other health concern, mental health concerns must also be addressed to
continue living.
Practice Recommendations
The stigma surrounding mental health in the U.S. Army Reserve (USAR) continues to
evolve each year by design through the implementation of policies and cultural influences.
However, to change centuries’ worth of mental health stigma will require centuries of eliminating
mental health stigma. Understanding that the number of soldier deaths is not merely from years
of war dating back to the 19th century to present-day conflicts in the 21st century, deaths also
include soldier suicides. It was not until 1843 that the U.S. Army published annual reports of
soldier suicides (Smith et al., 2019). The continued efforts to report soldier suicide statistics have
improved the reports’ refinements, addressing all branches and components, including military
family members. Each evolution in reports, policies, and cultural norms continues to positively
influence the small steps toward eliminating mental health stigma and soldier suicide.
From this study, three recommendations emerged to continue further efforts toward the
improvement of soldiers’ abilities to maintain their mental health: (a) making the most of
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intergenerational influences; (b) implementing preventive care training instead of the continued
use of the term “suicide prevention;” and (c) improved monitoring of a soldier’s mental health
through frequent evaluations. Considering the challenges the USAR faces in recruiting new
soldiers and the retention of its current formation, a steady rate in the reduction of forces presents
a national security concern. In that same view, every soldier’s death, especially by suicide,
threatens the stability of U.S. national security.
Intergenerational Shift
The first recommendation is to implement a bi-annual unit health and wellness survey for
all USAR units to address the factors that matter most to soldiers. Survey questions would
highlight opportunities for unit training, promotability, professional development, administrative
efficiency, and the resource utilization rate. A unit report would then be generated to present the
results of the survey in a manner that is accessible to all USAR soldiers and leaders. Unit health
and wellness reports allow transparency for soldiers to review the culture of an organization.
Furthermore, USAR leadership can assess underperforming units for necessary improvements
and monitoring.
This practice is based on the benchmarking method, a tool used for organizational
improvements by comparing organizations based on the highest standards of excellence (Bhutta
& Huq, 1999). Through this practice, USAR units are compared to one another, allowing for a
clear and holistic review of the culture of each unit from the perspective of assigned soldiers.
Maj. Gen. Ernest Litynski shared that there has been an intergenerational shift in today’s military
and that young people value themselves as humans first before their uniform and weapon
(Steinhauer, 2022). When asked about the mental health stigma in USAR units, Joanna shared
the following:
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The younger generation is easier to talk to about that stuff. Soldiers in their early 30s, I
feel that generation comprehends and does not think badly about it. However, for people
closer to like the 40s and older, I feel it is hard to be open because of all the stereotypes
growing up and everything we saw and heard. It was not so talked about, you know.
A soldier’s voice continues to evolve the military culture as each generation enters the USAR.
Moreover, the DoD is faced with recruitment and retention challenges (Lopez, 2022). While
financial incentives continue to be prevalent as a tool for recruiting and retaining soldiers, the
culture of the USAR continues to pose a barrier to entry.
It is critical to understand that new soldiers joining USAR units harbor various beliefs,
ideologies, and cultural norms. Soldiers are far more expressive and have increased self-
awareness compared to past generations. The USAR continues to face challenges in its
recruitment and retention because potential recruits today have far more choices than past
generations offered through technological advances and cultural changes in the workplace.
USAR soldiers of younger generations not only seek opportunities tailored to their lifestyles but
have higher emotional cognition than their senior leaders, which leads them to pursue USAR
units that meet their professional, personal, and emotional desires.
Preventative Care Training
The second recommendation involves modifying the USAR suicide prevention training
using two methods. The first change entails deviating from specified suicide prevention training
and integrating the prevention and intervention teachings into a series of preventative care
training. This change focuses on the root causes of treatment stressors, cultural influences,
support systems, and the transitions between a soldier's life and civilian life, as presented in
Research Question 3, which are the influences that lead to the most significant amount of stress
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for USAR soldiers. When asked for recommendations to decrease soldier suicide, Vince shared
the following: “It does not matter if you have the suicide prevention program; people will still
commit suicide because others do not know how to read red flags.” Sharing this same sentiment,
another interview participant, Lana, further expressed the following:
It is a shame that they [Army Reserve] only require two people per unit to be trained
when everybody in the unit should be trained because you are an asset to your community
if you are fully trained. If at least all the full-time people in the units were trained. You
know, at least they can identify those more minor issues and maybe help. Get help to the
people that need the help that can see the red flags.
Vince and Lana affirmed the ineffectiveness of the current suicide prevention training offered by
the USAR’s suicide prevention program by recognizing that in-depth instruction regarding
suicide prevention is limited to a predetermined number of soldiers. Furthermore, the unit suicide
prevention training is conducted annually within a one-and-a-half-hour instruction period, often
viewed as a check-the-block item for soldiers.
The second change is that instead of an annual instruction, prioritizing and integrating the
root causes of stress experienced from transitions, fiscal responsibilities, relationship
management, time management, and effective communication through frequent preventative care
training will assist in changing the culture surrounding addressing issues in their earliest stages.
It is also essential to consider the quality of information shared by instructors who are soldiers as
opposed to subject matter experts in fields such as behavioral health, finance, business
management, and family science. The USAR may experience a more effective cultural change in
applying the frequency and quality of preventative care rather than suicide prevention.
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Quality Azimuth Check
The third recommendation is to enhance one-on-one counseling by improving the quality
of dialogue between a subordinate and leader to identify and monitor the stress factors a soldier
is experiencing. As the azimuth check is a common term used in the Army to assess and verify
the direction a soldier travels, it is also a self-assessment tool managed by the Army Resilience
Directorate. This tool, which is required annually, consists of a confidential 10-minute survey
that soldiers complete, often quickly and not thoughtfully, further challenging the authenticity
and accuracy of the result.
However, formal and informal counseling allow for a more intimate environment to
assess a soldier’s performance and concerns with genuine care from the leader. Guided by the
Army Techniques Publication (ATP) 6-22.1, counseling is the review process by a leader
concerning the performance and potential of a subordinate (DA, 2014). Personal issues are often
neglected with the oversight of duty performance. Starting a discussion focused on the soldier’s
health and well-being allows a leader and subordinate to build a working relationship built upon
trust. When asked for a recommendation to improve a unit’s culture, Joanna shared the
following:
It should be like a one-on-one conversation, like when you do your quarterly counseling.
You should pick up if you are really talking and counseling this soldier, not just telling
them, ‘Hey, this is what I see you doing at work, and you could improve that.’ If you
really talk to them, then I think that would open the dialogue for mental health and an
opportunity for the soldier to ask for help.
Leaders may have limitations related to helping in areas requiring third-party assistance or may
experience resistance from subordinates to discuss personal matters. These challenges may
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present opportunities to assess the relationship quality between a subordinate and a leader, such
as the lack of trust and support. Other undisclosed conditions may produce an unhealthy unit
environment, influencing other soldiers’ perspectives. With a firsthand review of detailed reports
of soldier suicides, Vince shared the following:
Everything was after the fact, ‘Let's do an investigation. What was the reason for this?’ It
was only after someone killed themselves that the leadership wanted to know what was
wrong, not before. Leaders need to check what's going on in that command. Leaders need
to know why people are not happy.
The inefficacy of identifying warning signs and cultivating a supportive environment has
precipitated soldier suicides. Fundamental and genuine interactions between leaders and their
subordinates promote a healthier working environment that encourages the vulnerability of
soldiers through help-seeking behavior and a genuine sense of care by leaders.
Recommendations for Future Research
This study revealed veterans’ journeys as they sought mental health support while serving
in the Army Reserve. The literature used in this study referenced research addressing the mental
health concerns of soldiers serving on active duty and in the Reserves. However, the literature
that addressed the Reserve encompassed the National Guard and Army Reserve. Therefore, this
limited the understanding of the distinct difference in service requirements for National Guard
and Army Reserve soldiers.
Future research should consider conducting a thorough study exclusively addressing
Army Reserve soldiers to identify specific conditions that affect their obligations beyond their
military duty. Studies focusing on the challenges that Army Reserve soldiers experience related
to progressing in their military careers can reveal areas of stressors that could lead to suicidality.
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Not addressed in this study was the evaluation of early mental health care, such as talk therapy,
in the initial stages of an Army Reserve soldier's career. Future studies evaluating the frequency
and effectiveness of early mental health care can reveal a soldier's ability to improve non-
cognitive attributes, such as grit and perseverance, to overcome stress (Southwick et al., 2019).
More focused studies examining the Army Reserve and National Guard as separate entities may
reveal unknown factors unique to each component that causes a decline in a soldier's will to live.
Conclusion
The U.S. military is an all-volunteer force. The U.S. Army Reserve (USAR) presents
itself to the American public as an organization that encourages the population to serve their
community and country while still having the ability to pursue a civilian career, academic
degree, and other personal aspirations (U.S. Army Reserve, 2022). Consequently, the USAR
lacks the capacity to clarify the physical, mental, and emotional requirements of entering the
formation. As asserted throughout this study, USAR soldiers experience stressors that are unique
to the formation compared to their active duty and National Guard counterparts. Acknowledging
these differences is critical to addressing the USAR’s suicidality and suicide rate.
According to the DoD, from 2011 to 2020, the average rate of Army Reserve suicide was
24.4 per 100,000 soldiers. Year over year, suicidality and soldier suicides will occur even through
changes in policies, program developments, and improved access to resources. Among all
stressors revealed in this study, transitional stress significantly impacted a soldier’s health and
well-being. Learning skills for daily application to resolve these stressors is the linchpin of a
healthier soldier and USAR. What cannot be dismissed are the efforts by all stakeholders, family,
friends, coworkers, and especially Army Reserve soldiers and leaders to recognize and support
the most critical assets in our Army Reserve: its people.
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Appendix A: Informed Consent for Research
Study Title: U.S. Army Reserve: A Soldiers Psychological Health Journey
Principal Investigator: Katherine T. Alegado
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 this study is to conduct a gap analysis to examine conditions that interfere
with an Army Reserve soldier’s ability to seek and receive psychological health resources. This
study is being conducted as part of requirement to complete the researcher’s dissertation for
Doctoral degree at USC. Knowledge gained from your lived experience will add to the existing
literature on the relationship between Army Reserve soldiers and psychological health resources.
We hope to learn more of how Army Reserve soldier’s environment and external influences
impacts their access and willingness to seek psychological health resources. You are invited as a
participant because your prior use of psychological health resources during your service in the
Army Reserve. About 15-20 participants will take part in the study.
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Procedures
If you decide to take part of this study, you will first be screened by the researcher for
suicidality and mitigations questions. You will then be required to fill out a consent form to
participate in the study. All participants are required to conduct a 60-minute recorded
audio/video interview on the cloud-based video conferencing platform, Zoom. All interviews
will be conducted via Zoom to allow access to transcript. You can choose to conduct the
interview without video and audio only recording. All transcripts from the interview will be
downloaded for analysis and deleted at the end of the study.
The interview will collect data through your lived experience in seeking and receiving
psychological health services. During the interview, no military title, command name, position,
or rank will be identified to protect confidentiality. The researcher will ask you 15 open-ended
questions, which you can skip or stop answering any questions that may make you feel
uncomfortable.
Risks and Discomforts
Risks and discomforts you could experience during this study include nervousness,
emotional discomfort, triggers from memories, or painful bereavement.
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 stores in a safe location and used only for this research purpose.
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Benefits
There are no direct benefits to you from taking part in this study. However, your
participation in this study may help us learn more on the complexities of Army Reserve soldiers
help-seeking behavior and psychological health service experience. Contribution to literature on
this topic may lead to improved and effective psychological health resources for Army Reserve
soldiers.
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, including
research study and medical records, 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 include Defense Suicide Prevention Office (DSPO), U.S.
Army Reserve (USAR) Psychological Health Program, and Veteran Affairs (VA).
Your data collected as part of this research will be used or distributed for future research
studies without your additional informed consent. Any information that identifies you (such as
your name) will be removed from the data before being shared with others or used in future
research studies.
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To understand the privacy and confidentiality limitations associated with using Zoom, we
strongly advise you to familiarize yourself with their privacy policies at
https://explore.zoom.us/en/privacy/.
Alternatives
An alternative would be to not participate in this study.
Payments/Compensation
You will not be compensated for your participation in this research. However, your
participation will help increase awareness through challenges faced by Army Reserve soldiers in
helps to create effective solutions to prevent 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 to which you are
otherwise entitled.
Participant Termination
You may be removed from this study without your consent for any of the following
reasons: you do not follow the study researcher’s instructions, at the discretion of the researcher,
or if you do not sign the consent form.
Contact Information
If you have questions, concerns, complaints, or think the research has hurt you, talk to
the study researcher Katherine Alegado at kalegado@usc.edu or the faculty advisor, Patricia
Tobey, PhD, at tobey@usc.edu.
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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 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
Person Obtaining Consent
I have personally explained the research to the participant using non-technical language. I have
answered all the participant’s questions. The participant understands the information described in
this informed consent and freely consents to participate.
____________________________________________________________________________
Name of Person Obtaining Signature Date Signed

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Appendix B: Theoretical Framework Alignment Matrix (Qualitative)
Research question Theoretical framework
Data instrument
questions
1. How does access to
psychological health resources
impact U.S. Army Reserve
soldiers’ success throughout
their service?
Ecological systems theory
(Bronfenbrenner, 1977)
mesosystem and
macrosystem
Document analysis
Interview questions:
3–4
2. How do the U.S. Army
Reserve’s policies and
regulations affect an Army
Reserve soldier’s psychological
health experience?
Ecological systems theory
(Bronfenbrenner, 1977)
mesosystem and
macrosystem
Document analysis
Interview questions:
12–13
3. What challenges do U.S. Army
Reserve soldiers experience
throughout their health-seeking
journey?
Ecological systems theory
(Bronfenbrenner, 1977)
microsystem, mesosystem,
macrosystem, and
chronosystem
Document analysis
Interview questions:
5–11

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Appendix C: Pre-Survey Protocol
Qualtrics qualification survey: https://usc.qualtrics.com/jfe/form/SV_00zqZRgwps8CmA6
Thank you for your interest in participating in the evaluation research on an Army
Reserve soldier’s journey when seeking and receiving psychological health support. To
participate in this research, you must answer the following qualifying and demographic
questions. You are required to answer all the questions to participate. Should you feel the need to
get help, the following resources are available for you:
National Suicide Prevention Lifeline
800-273-8255
suicidepreventionlifeline.org
Military Crisis Line
800-273-8255 (TALK) or Text to 838255 for crisis support
Qualifying Questions
1. Were you discharged from the Army Reserve from 2016 to 2022?
2. Did you seek psychological health resources while serving in the Army Reserve?
Soldier Affiliation Questions
3. What status in the Army Reserve did you serve in?
4. What was the rank you last held in the Army Reserve?
5. What years did you serve in the Army Reserve?
6. Which state(s) were your Army Reserve unit(s) located in?
Socio-Demographic Questions
7. What is your age?
8. What is your ethnicity?
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9. What is your gender identity?
10. What is your sexual orientation?
11. What is your religion?
12. Which states did you live in during your Army Reserve service?
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Appendix D: Interview Protocol
Thank you for joining me today. I am Kate Alegado, a doctoral candidate at the
University of Southern California. Your participation in today’s recorded interview is voluntary.
It will be used as a part of the research for a dissertation focused on the journey of U.S. Army
Reserve (USAR) Soldiers seeking psychological health support.
A little background on this study. While many studies continue to present the many
stressors leading to suicidality in military service members, studies lack in presenting the
stressors of USAR Soldiers and the complexities in receiving psychological health support.
Today’s interview is to learn about your psychological health journey while serving in
the USAR through your experiences and perspectives in each phase of deciding, seeking, and
receiving psychological health support.
At this time, I will need your consent to participate before we continue. I will now share
the consent form previously emailed to you to address any additional questions or concerns.
Please take this moment to review the form again.
This interview is a safe space, and any information shared here will not be traceable to
any person or unit. To ensure the confidentiality of your responses, you will be provided with an
alias. What alias would you like for me to use?
Please note that you do not have to answer every question, we can skip any or all you feel
uncomfortable answering, and you can end the interview or withdraw any of your responses at
any time.
I am going to begin the recording process now. The recording ensures the accuracy of
your responses during the data analysis process. Please note that we can stop the recording
anytime if you feel uncomfortable. Are you ready to proceed with the questions?
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Introductory Questions
1. Why did you serve in the Army Reserve?
2. How would you describe your time serving in the Army Reserve?
RQ1: The access to resources and its effect on a soldier’s success in service.
3. Think back at your time in the Army Reserve; how did you get through stressful
times?
4. What were your experiences in practicing self-care?
RQ3: The help-seeking influence from a soldier’s environment.
5. When did you decide to get psychological health support?
6. How did your immediate environments, such as home, civilian job, school, or Army
Reserve unit, affect your decision to seek help?
7. Can you share with me how your age and/or rank may have influenced your decision
to seek help?
8. What challenges, if any, did you face from your immediate environments while you
were waiting for support from a resource?
9. Can you share with me how much time you had to wait to hear back from a resource
and how it may have affected you?
10. What was your experience like when you were receiving help?
11. What challenges, if any, did you face from your immediate environments while
receiving help?
RQ2: The policies and regulations affecting a soldier’s psychological support experience.
12. In the past 5 years, since 2016, what changes have you observed or experienced in the
USAR changing the stigma of psychological health support?
104

13. What USAR policies or regulations affect your overall psychological health
experience?
Closing question
14. Before we conclude the interview, is there anything else you would like to share with
me about the psychological health support journey as a USAR Soldier?

105

Appendix E: Mental Health Resources
Should you feel triggered during the interview process, the organizations listed below are
meant to provide guidance and assistance for those seeking psychological health resources.
Crisis
National Suicide Prevention Lifeline
800-273-8255
suicidepreventionlifeline.org

Military Crisis Line
800-273-8255 (TALK) or Text to 838255 for crisis support
Go to VA.gov to find VA hospitals, homeless services, and more.
Community Providers (Direct Service/Therapy)
Cohen Veterans Network
cohenveteransnetwork.org/backtobetter
Mental health care for National Guard and Reserve Soldiers, Marines, Sailors, Airmen, Coast
Guardsmen, and their families through Cohen Veterans Network military family clinics and
face-to-face video therapy: CVN Telehealth

Give an Hour
giveanhour.org/military
Click on “Get Help”
Non-military, licensed therapists volunteer to provide FREE to Service Members and families
for up to a year.
Vet & Peer Support
Vets 4 Warriors
vets4warriors.com
855-838-8255 (TALK) 24/7 telephonic, confidential peer-to-peer support by veterans to help.

Real Warriors
realwarriors.net
Information and resources, including several excellent phone apps such as PTSD Coach,
Breathe2Relax, Virtual Hope Box, and Dream EZ.

The information above was retrieved from the U.S. Army Reserve Psychological Health Program
website, https://www.usar.army.mil/BehavioralHealthResources/.
106

Appendix F: A Priori Codes for Data Analysis
Code name Description Files References
Deployment
Psych health influences from
deployment experience
5 6
Army Reserve
A soldier who served their full
military career in the Army
Reserve
5 5
Prior active duty
A soldier who served on
active duty before serving in
the Army Reserve
5 5
Personal development
Obligations that do not pertain
to the family, civilian
profession, or a military career
1 1
Relocation
A soldier needed to move
from one physical location to
another
3 5
Stigma
The personal and cultural
biases on managing
psychological health
12 32
USARC psych health guidance
U.S. Army Reserve policies
and regulations addressing the
management of soldier’s
psychological health
13 26
Federal psych health guidance
Federal policies and
regulations addressing the
management of soldier’s
psychological health
4 4
USARC psych health resource
Psychological health resources
provided by or affiliated with
the U.S. Army Reserve
10 18
107

Code name Description Files References
Civilian psych health resource
Psychological health resources
covered by civilian health
insurance or were paid out of
pocket by the soldier
5 6
Civilian culture
Influences outside of the
military that affects a soldier’s
psychological health
6 13
Military culture
Influence within the military
that affects a soldier’s
psychological health
17 48
Religion
A soldier’s personal belief
affects their psychological
health
1 3
Rank biases
The external influences
affecting a soldier’s
psychological health based on
their rank
5 6
Treatment experience
Experiences during treatment,
such as rapport with the
therapist or effects from
unexpected treatment changes
7 11
Time frame
The duration which a Soldier
had to wait to attend their first
appointment
7 11
Transition
A change in an environment
requiring a soldier to integrate
5 9
Military coworkers
Influences from in/direct
interactions with service
members
14 33
108

Code name Description Files References
Civilian coworkers
Influences from in/direct
interactions at a soldier’s
civilian employment
5 6
Family
Influences from family
members, biological and non-
biological
10 15
Friends
Influences from persons who
are trusted agents
7 9

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Creator Alegado, Katherine (author)

Core Title U.S. Army Reserve: the journey to psychological health resources

School Rossier School of Education

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Degree Program Organizational Change and Leadership (On Line)

Publication Date 11/21/2022

Defense Date 11/03/2022

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