Mindfulness and resilience: an investigation of the role of mindfulness in post-9/11 military veterans' mental health-related outcomes

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Mindfulness and Resilience: An Investigation of the Role of Mindfulness in Post-9/11 Military
Veterans’ Mental Health-Related Outcomes

by
Nicholas Barr
August 2018 Degree Conferral
Doctor of Philosophy (SOCIAL WORK)
FACULTY OF THE USC GRADUATE SCHOOL

Dissertation Guidance Committee
Carl A. Castro, PhD (Chair)
John Brekke, PhD
Chih Ping Chou, PhD

MINDFULNESS, MENTAL HEALTH, AND SERVICE USE ii

Dedication
This dissertation is dedicated to the U.S. military veterans whose generosity with their
time and experience made this research possible. I also dedicate this work my mentors, friends,
and colleagues at USC – I would not have made it through this process without your humor,
support, and wisdom. Thank you!
I also take this opportunity to thank my mother and sisters; growing up around such
strong, smart, talented women has improved my life immeasurably. To my father, I do my best to
live up to your example and hope you would be proud. To my friends and colleagues in the
doctoral program, thank you for keeping me sane and more or less on track. Finally, to the
special tribe of friends I’ve joined here in Los Angeles, thank you for helping me keep things in
perspective and for putting up with my predictable response to even the most trivial claim: “ok,
but where is the evidence?”

MINDFULNESS, MENTAL HEALTH, AND SERVICE USE iii
Acknowledgments
To Dr. Carl Castro, for your steadfast support, colorful anecdotes, wisdom, and strategic vision,
and for encouraging me to think critically about and vigorously pursue my interests.
To Dr. John Brekke, for your sagacity, guidance, and for sharing your deep understanding of the
social work research process.
To Dr. Chih Ping Chou, for your patience, humor, and for showing me the elegance and utility of
structural equation modeling.
To Dr. Concepcion Barrio, for your grace, kindness, and for embodying the compassion of the
clinical perspective in research and teaching.
To Dr. Jeremy Goldbach, for including me in interesting projects and for your invaluable, candid
advice about negotiating the PhD program and beyond.
To Dr. Eric Rice, for your generosity with your time, expertise, and data, and for encouraging me
to think differently about social context.
To Dr. Michael Hurlburt, for your excellent teaching and for modelling the highest standards of
rigor, forthrightness, and ethics; I am inspired by your example.
To Malinda Sampson, for your unending help and patience, and for keeping the ship afloat!
To the USC Suzanne Dworak-Peck School of Social Work PhD program and Dr. Michalle Mor
Barak, for believing in me and giving me the freedom and support to pursue my interests and
goals. I am so grateful to have had this opportunity.
And finally, to my cohort, Andi, Cheung, Gordon, Jaih, Kate, Missy, and Rebecca; I cannot
believe my good fortune in meeting and working with such a brilliant, talented, industrious,
committed, supportive group. I am excited to see the impact your work will have in our field and
the world. I could not have made it through this program without you!
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE iv

Table of Contents
Dedication ....................................................................................................................................... ii
Acknowledgments.......................................................................................................................... iii
List of Figures and Tables.............................................................................................................. vi
Abstract ......................................................................................................................................... vii
Chapter 1: Overview of the Three Studies ...................................................................................... 1
Rationale ................................................................................................................................... 1
Background ............................................................................................................................... 2
Mindfulness and Resilience ................................................................................................ 3
Risk Factors and Outcomes ................................................................................................ 9
Study Goal and Structure ........................................................................................................ 13
Conceptual Framework ........................................................................................................... 13
Method .................................................................................................................................... 14
Participants ........................................................................................................................ 14
Procedures ......................................................................................................................... 15
Summary ................................................................................................................................. 16
References ............................................................................................................................... 17
Chapter 2: Mindfulness is Associated with Less Severe Symptoms of PTSD and Depression in
Post-9/11 Veterans ........................................................................................................................ 35
Background ............................................................................................................................. 35
Method .................................................................................................................................... 38
Participants ........................................................................................................................ 38
Procedures ......................................................................................................................... 39
Measures ........................................................................................................................... 40
Analyses ............................................................................................................................ 41
Results ..................................................................................................................................... 42
Discussion ............................................................................................................................... 43
References ............................................................................................................................... 47
Chapter 3: Examining Direct and Indirect Effects of Mindfulness, PTSD, and Depression on
Self-Stigma in Modern Veterans .................................................................................................. 62
Background ............................................................................................................................. 62
Method .................................................................................................................................... 65
Participants ........................................................................................................................ 65
Procedures ......................................................................................................................... 65
Measures ........................................................................................................................... 66
Analyses ............................................................................................................................ 68
Results ..................................................................................................................................... 69
Discussion ............................................................................................................................... 70
References ............................................................................................................................... 74
Chapter 4: Can Mindfulness Aid in Predicting Veterans’ Mental Health Service Utilization? ... 88
Background ............................................................................................................................. 88
Method .................................................................................................................................... 90
Participants ........................................................................................................................ 90
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE v
Procedures ......................................................................................................................... 90
Measures ........................................................................................................................... 91
Analyses ............................................................................................................................ 93
Results ..................................................................................................................................... 94
Discussion ............................................................................................................................... 95
References ............................................................................................................................... 99
Chapter 5: Conclusion................................................................................................................. 113
Introduction ........................................................................................................................... 113
Major Findings ...................................................................................................................... 115
Limitations and Future Directions ........................................................................................ 117
Implications........................................................................................................................... 120
Conclusion ............................................................................................................................ 122
References ............................................................................................................................. 123

MINDFULNESS, MENTAL HEALTH, AND SERVICE USE vi
List of Figures and Tables
Figure 1.1. Conceptual Model of Risk and Protective Factors and Outcomes ............................. 33
Figure 1.2. Sample Composition Flow Chart ............................................................................... 34
Table 2.1. Descriptive Statistics.................................................................................................... 58
Table 2.2. Unstandardized and Standardized Parameter Estimates for the Effects of Predictors
and Covariates on PTSD and Depression ..................................................................................... 60
Figure 2.1. Sample Composition .................................................................................................. 61
Table 3.1. Descriptive Statistics.................................................................................................... 82
Table 3.2. Full Model Factor Loadings and Residual Correlations .............................................. 84
Figure 3.1. Sample Composition .................................................................................................. 86
Figure 3.2. Structural Equation Model of Relationships among Mindfulness, PTSD, Depression,
Education Covariates, and Self-Stigma ........................................................................................ 87
Table 4.1. Descriptive Statistics.................................................................................................. 106
Table 4.2. Odds Ratios and 95% Confidence Intervals of Predictors and Covariates of Mental
Health Service Use in the Last 12 Months.................................................................................. 108
Figure 4.1. Sample Composition ................................................................................................ 110
Figure 4.2. Average Marginal Effects of PTSD at Representative Levels of Mindfulness with
95% Confidence Intervals ........................................................................................................... 111
Figure 4.3. Conditional Marginal Effects of PTSD above the Clinical Cutoff with 95%
Confidence Intervals at Representative Levels of Mindfulness ................................................. 112

MINDFULNESS, MENTAL HEALTH, AND SERVICE USE vii
Abstract
Military veterans of the post-9/11 era conflicts in Iraq and Afghanistan are at high risk of
developing symptoms of mental health disorders, including posttraumatic stress disorder (PTSD)
and depression. However, these veterans are likely to report stigmatizing mental health-related
beliefs that reduce their likelihood of receiving mental health treatment. Together, these findings
point to a need for research that can be leveraged to promote resilience across the continuum of
veterans’ mental health experiences to enhance prevention, reduce stigma, and increase the
likelihood of mental health service use.
This three-study dissertation aimed to improve understanding of risk and protective
factors that contribute to post-9/11 era veterans’ mental health symptoms, stigmatizing beliefs,
and treatment decisions. By applying a risk and resilience framework to investigate associations
between mindfulness, combat experiences, PTSD and depression, self-stigma, and mental health
service use, each of the three studies sought to explain mental health-related outcomes at
interrelated cross-sections of veterans’ mental health continua.
Chapter 1 provides an overview of post-9/11 veterans’ mental health risks and treatment
obstacles and develops the links among the three studies, introducing key study constructs and
describing the overarching conceptual framework and individual study goals. Chapter 2 (Study
1) examines and compares main effects of combat experiences and mindfulness on PTSD and
depression to improve understanding of how these risk and protective factors contribute to the
development of veterans’ mental health symptoms. Chapter 3 (Study 2) examines direct and
indirect effects of mindfulness, PTSD, and depression on self-stigma of mental illness to develop
an integrated risk and resilience model of veterans’ self-stigma. Chapter 4 (Study 3) examines
main and interaction effects of mindfulness, PTSD and depression, and self-stigma on mental
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE viii
health service use to develop a holistic model of predictors of service use in this population.
Chapter 5 discusses conclusions yielded by each study, the broader importance of the study
findings, and implications for training, prevention, intervention, service delivery, and future
research.

MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 1
Chapter 1: Overview of the Three Studies
Rationale
The Department of Veterans Affairs (2016) estimated that close to 3 million post-9/11
military veterans existed as of 2014. Evidence indicates that this large and growing cohort will
require significant health and mental health services. In particular, the high operational tempo
that characterized the major post-9/11 conflicts in Iraq (Operation Iraqi Freedom; OIF) and
Afghanistan (Operation Enduring Freedom; OEF) is associated with high rates of mental health
symptoms among OEF/OIF veterans. Since 2001, the percentage of Veterans Health Authority
(VHA) service users with mental health or substance use disorders has grown from nearly 27%
to more than 40% (VHA, 2016). Although this is a substantial increase, the number of post-9/11
veterans who could benefit from mental health services is likely much larger. Many veterans
endorse negative mental health- and treatment-related beliefs that interfere with accessing mental
health services, and evidence suggests that most OEF/OIF veterans who screen positive for
mental health problems do not pursue treatment (Fox, Meyer, & Vogt, 2015; Garcia et al., 2014;
Hoge et al., 2004; Vogt, 2011). These findings shed light on two related problems. First, veterans
of the recent high-tempo, unconventional conflicts demonstrate high rates of mental health
problems when they return home. Second, these veterans demonstrate internal barriers, including
self-stigma, that reduce the likelihood of accessing mental health services.
To address these problems and develop effective prevention and intervention strategies to
improve veterans’ mental health-related outcomes, we must understand contributing factors at
multiple points along a mental health continuum characterized by a dynamic balance of risk and
protective factors. This research framed this need in terms of interrelated research questions at
two critical points along veterans’ mental health continua. First, how can we understand the
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 2
contributions of risk and protective factors to the development of mental health symptoms in
OEF/OIF veterans? Second, how can we understand the contributions of risk and protective
factors to informing attitudes toward mental health symptoms and mental health service use in
this population?
To answer these questions, this dissertation research examined relationships among five
interrelated constructs: mindfulness, combat experiences, mental health symptoms, self-stigma of
mental illness, and mental health service use. Although these constructs and some of their
associations have been investigated, the proposed project is unique in its conceptualization of
mindfulness as a stable protective factor and mental health symptoms and internalized stigma as
both outcomes and risk factors contingent on their relationships to other study constructs at
critical cross-sections of the mental health continuum. According to this framework, a combat
experience risk factor and the mindfulness protective factor contribute to mental health symptom
outcomes. Downstream, mental health symptoms are risk factors that interact with the protective
mindfulness factor to contribute to internalized stigma of mental illness. Further along the
continuum, mental health symptoms and internalized stigma act as risk factors that interact with
the protective mindfulness factor to predict mental health service use.
Background
Although evidence indicates that most OEF/OIF veterans cope well with their military
experiences (Kang & Bullman, 2009; Kang et al., 2015), they are also at elevated risk of mental
health disorders including PTSD and depression (Bruce, 2010; Kang et al., 2015; Seal et al.,
2009). There is almost no published data regarding prevalence rates for mental health disorders
among members of this cohort who have not received VHA services (Vaughan, Schell,
Tanielian, Jaycox, & Marshall, 2014), but among OEF/OIF VHA service users, the overall
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 3
prevalence of posttraumatic stress disorder (PTSD) has been estimated at 23% (Fulton et al.,
2015). Most studies have estimated the prevalence rate of depression in this cohort to be 11% to
16% (Holdeman, 2009; Killgore, Melba, Castro, & Hoge, 2006), with some recent studies
showing rates as high as 21% (Vaughan et al., 2014). PTSD and depression are among the most
salient predictors of poor psychosocial outcomes in veterans, including social and economic
dysfunction, risky behavior, and suicide (Barr, Sullivan, Kintzle, & Castro, 2016; McFall &
Cook, 2006; Ramchand, Rudavsky, Grant, Tanielian, & Jaycox, 2015).
As more OEF/OIF-era military service members to transition to veteran status,
researchers and service providers will face a substantial challenge in meeting their mental health
needs. This challenge is compounded by the fact that OEF/OIF veterans endorse internalized and
perceived public stigma and a preference for self-management of symptoms, which reduces their
likelihood of using mental health services (Adler, Bliese, & Castro, 2015; N. B. Brown & Bruce,
2016; Pietrzak, Johnson, Goldstein, Malley, & Southwick, 2009; Vogt, 2011; Wright et al.,
2009). To improve the lives of veterans at high risk of mental illness and concurrently reluctant
to seek mental health services, more research is needed to investigate modifiable psychological
processes amenable to intervention and associated with resilience. Ideally, such processes are
efficient intervention targets and protect against both proximal and distal risk factors to reduce
mental health symptom severity and stigma and contribute to adaptive mental health service use.
Mindfulness and Resilience
Psychological resilience has been the focus of much attention in both the civilian (Agaibi
& Wilson, 2005; Fletcher & Sarkar, 2013; Luthar, Cicchetti, & Becker, 2000; Masten, 2001) and
military-focused (Adler et al., 2011; Britt, Adler, & Castro, 2005; Bonanno, 2004; Bonanno et
al., 2012; L. A. King, King, Vogt, Knight, & Samper, 2006; Lee, Sudom, & Zamorski, 2013;
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 4
Meredith et al., 2011) research literature. In the mental health context, psychological resilience
refers to environmental and individual factors associated with hardiness or vulnerability to
negative posttraumatic symptoms outcomes such as PTSD following adverse experiences
(Thompson, Arnkoff, & Glass, 2011). Definitions of resilience have ranged from a strict
resistance model allowing for only transitory psychological symptoms following adverse
experiences (Bonanno, 2004) to more inclusive criteria encompassing concepts of recovery and
posttraumatic growth, characterized by cognitive, behavioral, and emotional adaptations to
overcome trauma symptoms following adverse experiences (Lepore & Revenson, 2006). In the
military context, consensus has emerged regarding a view of resilience that includes both
resistance and recovery concepts defined as “the sum total of dynamic psychological processes
that permit individuals to maintain or return to previous levels of well-being and functioning in
response to adversity” (Technical Cooperation Program, 2012, p. 4; also see Lee et al., 2013).
Based on this definition, psychological processes associated with resilience buffer against
adverse experiences and other risk factors to contribute to outcomes consistent with return to or
maintenance of functioning or well-being. Although the cross-sectional data employed in this
dissertation study did not permit longitudinal analyses required to investigate maintenance or
return to well-being over time, the logic of resilience theory as previously outlined supports the
view that cross-sectional outcomes associated with more resilience would include fewer, less
severe, or subthreshold mental health symptoms; less internalized mental health stigma; and
adaptive mental health service use, because these outcomes are consistent with better functioning
and well-being. In the context of these studies, resilience is not an indexed variable; rather,
resilience theory provides a framework for understanding contributions of risk and protective
factors to veterans’ mental health-related outcomes.
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 5
Defining mindfulness. The core protective factor under investigation in this dissertation
research is mindfulness. Mindfulness has been described in the literature as many things,
including a theoretical construct, psychological trait, mode of awareness, set of meditation
practices, and range of psychological processes (Black, Sussman, Johnson, & Milam, 2012;
K.W. Brown, Ryan, & Creswell, 2007; Chambers, Yee Lo, & Allen, 2008; Williams & Kabat-
Zinn, 2013). Most commonly, mindfulness is conceptualized as a special way of paying attention
to internal experience, on purpose, in the present moment, and without judgment (Kabat-Zinn,
1994; Linehan, 1993; Marlatt & Kristeller, 1999).
In a widely cited paper proposing an operational definition of the mindfulness construct,
Bishop and colleagues (2004) suggested that mindfulness involves two components: (a) self-
regulation of attention focused on present-moment experiences and (b) a nonjudgmental
acceptance of the experience. It is evident a priori, however, that the second component is
predicated on the first; sustained nonjudgmental orientation toward mental content is
fundamentally dependent on attentional control. As a result, this study took the narrow view that
core mindfulness is best defined and measured as the process of engaging in present-centered
attention and awareness. This approach also allowed for measurement of mindfulness using
items querying about attention, which scholars have argued are more likely to be familiar to
nonmeditators than items querying about nonjudgmental acceptance of mental events. (K. W.
Brown & Ryan, 2003).
Similar to physical fitness, mindfulness is present in a greater or lesser degree in all
individuals at any given time, but it can also be enhanced through training. Typically,
mindfulness training exercises involve focusing attention on moment-to-moment physical
sensations or activities, like breathing, and redirecting attention back to the sensation or activity
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 6
when it wanders to strengthen attentional control. Although both mindfulness and physical
fitness have been described as traits, logical examination reveals this term to be ontological
shorthand consistent with the incremental or malleable view of psychological traits described in
the social psychology literature (Levy & Dweck, 1998). According to this view, psychological
traits reflect a stable propensity to employ particular psychological processes in response to
environmental stimuli. In this account, an individual who tends to respond with more present-
focused attention on internal experience more of the time can be described as demonstrating the
propensity to act mindfully. Dispositional mindfulness scales like the Mindful Attention and
Awareness Scale employed in this study (K. W. Brown & Ryan, 2003) index the propensity to
engage in the psychological process of mindfulness.
Integrating mindfulness and resilience. An emerging theoretical and empirical
literature has begun to investigate links between mindfulness and resilience in the context of risk
factors for PTSD and depression (Johnson et al., 2014; Smith et al., 2011; Thompson et al.,
2011). Theories of PTSD posit that dissociation, defined as disturbances in consciousness,
perception, and memory, and avoidant coping, defined as efforts to avoid thoughts, emotions,
and memories related to traumatic experiences, are instrumental in the development and
maintenance of PTSD symptoms (Batten, Orsillo, & Walser, 2005; Foa, Steketee, & Rothbaum,
1989; Follette, Palm, & Pearson, 2006; Walser & Hayes, 2006). Empirical studies have
supported this view and suggested that experiential avoidance, avoidant coping, thought
suppression (Gil, 2005; Morina, Stangier, & Risch, 2008; Silver et al., 2002; Tull, Gratz, Salters,
& Roemer, 2004), and dissociation (Briere, Scott, & Weathers, 2005; McCaslin et al., 2008) are
associated with increased PTSD and depressive symptoms following traumatic experiences.
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 7
Conversely, mindful attention applied to present-moment experiences, regardless of their
agreeable or aversive nature, represents a functional contrast to dissociation and avoidant coping
(Thompson et al., 2011). Rather than avoiding or suppressing aversive thoughts or emotions,
mindfulness entails paying attention to those experiences as they arise. As a result, the propensity
to act mindfully is hypothesized to exert a protective effect in individuals exposed to adverse
experiences (Vujanovic, Niles, Pietrefesa, Schmertz, & Potter, 2011). Evidence suggests that in
addition to working against avoidant and dissociative psychological processes, mindfulness may
support individual-level factors associated with resilience. A RAND review (Meredith et al.,
2011) of resilience in military service members identified information processing, refocusing
after distraction, and the ability to monitor, tolerate, and modify emotional reactions as
individual-level resilience factors. These processes appear to be contingent on the ability to focus
and maintain attention on present-moment experiences without avoidance, suppression, or
dissociation, and can be understood to emerge from a psychological substrate of mindfulness.
The empirical literature examining relationships among mindfulness, risk factors, and
PTSD and depressive symptoms in military populations is in its infancy, but preliminary results
have suggested some utility for mindfulness in treating and preventing these symptoms.
Mindfulness has been shown to be a significant predeployment predictor of postdeployment
distress, anxiety, and arousal in National Guard soldiers (Call, Pitcock, & Pyne, 2015). In
addition, a study conducted with Marine infantry platoons investigating the effects of
Mindfulness-based Mind Fitness Training (Stanley, 2014), a mindful attention training
intervention designed for high-stress cohorts, showed that it altered heart and breathing rate
recovery after military training exercises designed to induce stress. Further, neuroimaging
suggested that the intervention affected brain regions linked to information processing about the
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 8
body’s response to stress (Johnson et al., 2014). Small studies have also shown that mindfulness-
based interventions including Mindfulness-Based Cognitive Therapy (Segal, Williams, &
Teasdale, 2012) and Mindfulness-Based Stress Reduction (Kabat-Zinn, 1990) are linked to
reductions in self-reported PTSD and depressive symptoms in combat-exposed veterans
(Bhatnagar et al., 2013; Kearney, McDermott, Malte, Martinez, & Simpson, 2012; A. P. King et
al., 2013). Taken together, these findings suggest that deficits in mindfulness may help explain
the etiology and maintenance of PTSD and depressive symptoms, and that enhancing
mindfulness may protect against or reduce PTSD and depressive symptoms following adverse
experiences, including combat.
However, as noted in the literature, the need for effective interventions for PTSD and
depression is only one part of the problem; the other is convincing veterans to take advantage of
these services (Elnitsky et al., 2013; Koo & Maguen, 2014). To improve veterans’ mental health
outcomes, research examining risk and protective factors not only in the context of mental health
symptoms but also with regard to mental health stigma and mental health service use is urgently
needed. Although no study has directly investigated relationships between these constructs and
mindfulness, correlates of mindfulness have been linked to reduced mental health stigma and
adaptive mental health service use (Corrigan, Watson, & Barr, 2006; Masuda et al., 2007), which
are outcomes consistent with the return to functioning or well-being criteria employed in
resilience theory. Applying focused attention and awareness to present-moment experiences may
decrease shame, guilt, and nonacceptance related to mental health symptoms, thereby affecting
internalized stigma, and more mindful individuals may also be more open to discussing thoughts
and emotions with mental health service providers (Henning & Frueh, 1997; Vujanovic et al.,
2011).
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 9
Risk Factors and Outcomes
Combat experiences. OEF/OIF veterans are likely to have experienced prolonged
deployments characterized by exposure to combat experiences with infrequent breaks (Belasco,
2007; Hosek, Kavanagh, & Miller, 2006). Combat experiences are robustly linked to negative
mental health outcomes in both active-duty personnel and veterans, and this risk increases with
the amount and intensity of combat experience (Castro & McGurk, 2007; LeardMann et al.,
2013), such that combat exposure and PTSD demonstrated a dose–response relationship in many
studies (Guyker et al., 2013; Mayeux et al., 2008). Combat experiences like exposure to killing,
wounding of service members by friendly fire, seeing a friend being wounded or killed, exposure
to dead or dying people, and being fired upon are most closely associated with PTSD (Guyker et
al., 2013; Hoge et al., 2004; Stretch et al., 1996).
PTSD and depression. PTSD and depression are the most common mental health
diagnoses for OEF/OIF veterans (N. B. Brown & Bruce, 2016; VHA, 2016); up to 24% of this
cohort is estimated to meet criteria for one or both diagnoses (Elbogen et al., 2013; Holdeman,
2009; Seal et al., 2009; Skidmore & Roy, 2011). Symptoms of PTSD are distributed across four
domains: re-experiencing, avoidance, arousal and reactivity, and cognitive and emotional
responses (National Institute of Mental Health, 2018). The change from the previous three-factor
model of PTSD to the current four-factor model in the Diagnostic and Statistical Manual of
Mental Disorders (5th ed., or DSM-5; American Psychiatric Association, 2013) reflects the
evolving view of PTSD symptomology as fundamentally inclusive of depressive symptoms. The
empirical literature shows considerable overlap between the cognitive and emotional domain of
PTSD and symptoms consistent with diagnosis of a depressive disorder, including depressed
mood, anhedonia, and negative thoughts. These disorders are highly comorbid in military
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 10
populations (Campbell et al., 2007; Stander, Thomsen, & Highfill-McRoy, 2014). Evidence
indicates that comorbid PTSD and depression is a core feature of chronic expressions of
posttraumatic illness (O’Donnell, Creamer, & Pattison, 2004).
Risk factors for PTSD and depression in veterans include traumatic experiences prior to
military service, younger age, female gender, lower educational attainment, and unmarried
status, as well as more cumulative and severe combat experiences, perceived life threat, negative
emotional responses, and physical injury; posttrauma risk factors include lack of postdeployment
social support and subsequent life stress (Call et al., 2015; Koren, Norman, Cohen, Berman, &
Klein, 2005; Pietrzak et al., 2009; Ramchand et al., 2015). Psychological factors that may protect
against PTSD and depression and that have demonstrated responsiveness to previous
modification efforts have been understudied in OEF/OIF veterans, but they may include
constructs such as a sense of personal control, acceptance of changes, and psychological
flexibility (Elliot et al., 2015), in addition to those identified in the mindfulness and resilience
literature reviewed previously. In the large body of civilian research examining PTSD resilience,
protective psychosocial factors include emotional regulation skills, openness, cognitive
reappraisal, attentional control, and availability of and willingness to accept social support (Fani
et al., 2012; Feder, Nestler, & Charney, 2009; Naim et al., 2015; Southwick & Charney, 2012).
Stigma of mental illness in the military context. Research has suggested that 17%–33%
of OEF/OIF soldiers meet criteria for a DSM-5 disorder following return from deployment, but
only 20% of these endorsed recent mental health treatment (Hoge et al., 2004; Kim, Britt,
Klocko, Riviere, & Adler, 2011). A robust body of evidence supports the view that public and
internalized stigma associated with having a mental illness are core barriers to mental health
service use (N. B. Brown & Bruce, 2016; Gould et al., 2010; Hoge et al., 2004; Kim et al., 2011;
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 11
Valenstein et al., 2014). Public stigma is defined as the negative judgments, attitudes, and beliefs
that an individual believes society holds regarding a characteristic, whereas internalized stigma is
defined as negative judgments, attitudes, and beliefs that inform an individual’s view of that
characteristic and its meaning (N. B. Brown & Bruce, 2016; Corrigan & Watson, 2002).
Literature shows that public stigma of mental illness leads to self-stigma or internalized stigma
as individuals incorporate the stigmatizing views of mental illness that appear to be held in
society at large or in salient social contexts into their own belief systems (Corrigan, 2004; Link,
1987; Link & Phelan, 2001). This process appears to hold true among veterans; internalized
concerns about mental health service use are grounded in public stigma toward mental health
problems that informs military cultural norms, which frame disclosure of mental health problems
as potentially career-ending violations of military expectations of self-sufficiency and toughness
(N. B. Brown & Bruce, 2016; Greene-Shortridge, Britt, & Castro, 2007).
Although evidence indicates that both mental health symptoms and public and
internalized stigma are barriers to care, the relationship among symptoms, stigma, and mental
health service use is complex. Studies have shown that veterans who meet criteria for a mental
health problem are substantially more likely to endorse internalized mental health stigma (Hoge
et al., 2004; Kim et al., 2011), and those who endorse more internalized stigma are less likely to
report seeking care (Kim, Thomas, Wilk, Castro, & Hoge, 2010). But the literature also shows
that veterans who report more severe mental health symptoms are more likely to seek mental
health services (Vogt, 2011). Taken together, these findings suggest that although mental health
symptoms are linked to a stigma barrier for mental health service use, severe symptoms may
overcome public and internalized stigma and lead to mental health service use.
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 12
Evidence shows that external variables like leadership and unit cohesion reduce
perceived public stigma and perceived barriers to care (Greene-Shortridge, Britt, & Castro, 2007;
Wright et al., 2009), but there is a lack of research examining internal psychological processes
that buffer against the development of internalized stigma in military veterans. This dissertation
research examined the hypothesis that mindfulness may buffer against internalized stigma due to
its association with nonjudgment, cognitive flexibility, and acceptance of aversive mental states.
Although this pathway of influence has not been investigated in military populations, the civilian
literature suggests that mindfulness is associated with less stigmatized beliefs toward individuals
with mental illness (Masuda et al., 2007) and that mindfulness may moderate the relationship
between mental health symptoms and internalized stigma in individuals with mental health
symptoms (Chan & Lam, 2017; Yang & Mak, 2017).
Mental health service use. The military mental health service use literature is largely
concerned with the themes previously reviewed, including the contributions of mental health
problems and public and internalized stigma of service-seeking behavior. As previously noted,
most OEF/OIF veterans who screen positive for mental health problems do not seek services
(Elnitsky et al., 2013; Hoge et al., 2004; Pietrzak et al., 2009; Schell & Marshall, 2008). In
addition, among recently diagnosed veterans with PTSD who initiate mental health treatment,
most do not complete the recommended number of treatment sessions (Seal et al., 2010). In
addition to public and internalized stigma, factors associated with decreased likelihood of service
utilization in the context of mental health needs among OEF/OIF veterans include a preference
for self-management of mental health symptoms and doubts about the effectiveness of mental
health treatment, in addition to external barriers like difficulty making appointments or finding
reliable transportation (Elbogan et al., 2013; Hoge et al., 2004; Kim et al., 2011; Ouimette et al.,
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 13
2011; Pietrzak et al., 2009; Vogt, 2011). Positive predictors of mental health service utilization
are understudied in this population but may include more severe mental health symptoms,
perceived similarity to other VHA care users, knowledge of the right to access VHA services,
and less internalized and perceived public stigma (Fox et al., 2015).
Study Goal and Structure
The overarching goal of this three-study dissertation is to improve understanding of how
risk and protective factors interact and contribute to mental health-related outcomes at critical
points along veterans’ mental health continua. Each of the three studies was informed by the
perspective that the development of mental health symptoms, attitudes toward mental health
service use, and receipt of mental health services are influenced by a dynamic balance of adverse
experiences and protective psychological processes. Specific questions examined in each study
are as follows:
Study 1: What are the main effects of combat experiences and mindfulness on veterans’
symptoms of PTSD and depression?
Study 2: What are the direct and indirect effects of PTSD, depressive symptoms, and
mindfulness on veterans’ internalized mental health stigma?
Study 3: What are the main and interactive effects of mindfulness, PTSD and depression,
and self-stigma on veterans’ mental health service use?
Conceptual Framework
To better understand associations between risk and protective factors for OEF/OIF
veterans’ mental health outcomes and to answer the aforementioned questions, this dissertation
research employed a conceptual framework informed by resilience theory (Agaibi & Wilson,
2005; Bonanno et al., 2012; Lee et al., 2013; Pietrzak, Russo, Ling, & Southwick, 2011).
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 14
Consistent with this framework, it was assumed that an evolving picture of mental health and
illness emerges in the context of dynamic interaction between salient risk and protective factors
at work in a larger ecology of measured and unmeasured social and cultural processes and
individual characteristics. Although it is understood that these factors develop and interact
longitudinally, they exist in relation to one another at any given point of time (see Figure 1.1).
Study 1 investigated the main effects of combat experiences and mindfulness on
outcomes of PTSD and depressive symptoms. Study 2 conceptualized these symptoms as risk
factors informing additional outcomes at a related cross-section of veterans’ mental health
continua and investigated the direct and indirect effects of mindfulness, PTSD, and depressive
symptoms on veterans’ internalized mental health stigma. Embedded in this investigation was
the assumption that mental health symptoms function as both outcomes of prior stressors and
predictors of related mental health constructs like attitudes toward mental illness and mental
health service use behaviors, and that protective factors exert buffering effects at these junctures.
Consistent with the view that mental health symptoms and attitudes function as both outcomes
and predictors, Study 3 leveraged variables investigated as outcomes in the previous studies to
develop a nuanced model of mental health service use behavior by investigating additive effects
of PTSD and depressive symptoms, mindfulness, and internalized stigma on mental health
service use.
Method
Participants
Data for this dissertation were collected from OEF/OIF veterans recruited from a
sampling frame of veterans who participated in the Los Angeles/Orange County, Chicago, and
Bay Area Veterans’ Surveys (Castro, Kintzle, & Hassan, 2015; Kintzle, Rasheed, & Castro,
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 15
2016; Castro & Kintzle, 2017). Veterans who agreed to be contacted for future research during
these surveys were invited to take part in the current study. Screen-in criteria were current
veteran status and separation from the military after September 11, 2001; respondents who did
not endorse these two categories were unable to proceed with the survey. In addition, because
valid participants shared the survey link with individuals not included in the original sampling
frame, the investigators screened all surveys to confirm that they were associated with Internet
Protocol (IP) addresses linked to verified participant email addresses included in study
recruitment emails. This ensured that only survey responses from invited participants who met
inclusion criteria were included in the final dataset (N = 577).
Procedures
The investigators constructed the survey instrument in Qualtrics and created a
MailChimp account to facilitate survey distribution. A second survey instrument capturing
participant email addresses was created and linked to the end of the survey instrument to allow
disbursement of the $15 electronic incentive and to verify that participant email addresses were
included in the sampling frame while ensuring participant survey data remained anonymous.
The investigators sent a bimonthly email with the survey link to participants who had
agreed to be contacted in previous veterans surveys after first removing email addresses of those
who had already completed the survey, those who requested to be removed from the mailing list,
and those who endorsed either of the two initial exclusion items. Following survey distribution,
the investigators followed a two-step process to verify that raw surveys had been completed by
valid participants. First, the investigators examined IP addresses associated with invited
participant email addresses in the survey incentive link. Second, these IP addresses were
compared to IP addresses associated with completed raw surveys. Surveys with IP addresses
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 16
linked to invited participant email addresses were considered valid and included in the final
dataset. Incentives were then emailed to valid participants. Data collection was conducted from
July 2016 to February 2017 until the target of 1,000 completed raw surveys was reached. A
flowchart detailing sample composition is presented in Figure 1.2. All procedures were approved
by the University of Southern California Institutional Review Board.
Summary
Numerous studies have shown that many OEF/OIF veterans return from deployments
with mental health problems, including PTSD and depression (Bruce, 2010; Kang et al., 2015;
Seal et al., 2009; VHA, 2016). However, few of these veterans engage mental health services
(Hoge et al., 2004; Kim et al., 2011). Although previous research has investigated risk factors for
mental illness and barriers to mental health service use, no study has jointly modeled effects of
risk factors and the protective factor of mindfulness on mental health-related outcomes in this
population, despite evidence suggesting that mindfulness may buffer against development of
both mental health problems following adverse experiences and self-stigma, which serves as a
core barrier to mental health service use (Hoge et al., 2004; Johnson et al., 2014; Kim et al.,
2011; Smith et al., 2011; Thompson et al., 2011).
By investigating associations among combat experiences, mindfulness, mental health
symptoms, self-stigma, and mental health service use, these three dissertation studies contributed
independently to building a more comprehensive picture of OEF/OIF veterans’ mental health-
related outcomes and supporting the risk and resilience literature aimed at enhancing training,
prevention, intervention, and service delivery in this vulnerable population.

MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 17
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MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 33
Figure 1.1. Conceptual Model of Risk and Protective Factors and Outcomes

MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 34
Figure 1.2. Sample Composition Flow Chart

MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 35
Chapter 2: Mindfulness is Associated with Less Severe Symptoms of PTSD and Depression
in Post-9/11 Veterans
Background
Nearly 3 million veterans of the Operation Enduring Freedom (OEF) and Operation Iraqi
Freedom (OIF) military conflicts are eligible to receive Veterans Health Administration (VHA)
services (VHA, 2016). Although evidence indicates that OEF/OIF veterans generally cope well
with their military experiences and are likely to be healthier than their civilian counterparts
(Kang & Bullman, 2009; Kang et al., 2015), they are at risk of mental health disorders including
PTSD and depression (Bruce, 2010; Kang et al., 2015; Seal et al., 2009). Prevalence estimates in
this cohort are 23% for PTSD and 11% to 16% for depression (Holdeman, 2009; Killgore,
Melba, Castro, & Hoge, 2006), although some recent studies showed depression rates as high as
21% (Vaughan, Schell, Tanielian, Jaycox, & Marshall, 2014).
PTSD and depression are among the most robust predictors of negative psychosocial
outcomes in veterans, including social and economic problems, risky behavior, and suicide (Barr,
Sullivan, Kintzle, & Castro, 2016; McFall & Cook, 2006; Ramchand, Rudavsky, Grant,
Tanielian, & Jaycox, 2015). Risk factors for PTSD and depression in veterans include
characteristics such as traumatic experiences prior to military service, younger age, female
gender, lower educational attainment, and unmarried status, as well as more cumulative and
severe combat experiences, perceived life threat, negative emotional responses, and physical
injury (Call, Pitcock, & Pyne, 2015; Koren, Norman, Cohen, Berman, & Klein, 2005; Pietrzak,
Johnson, Goldstein, Malley, & Southwick, 2009; Ramchand et al., 2015).
Adverse deployment experiences are believed to be particularly salient predictors of
mental health problems in OEF/OIF veterans and are linked to negative mental health outcomes
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 36
in both active-duty personnel and veterans; this risk increases with the amount and intensity of
combat experience (Castro & McGurk, 2007; LeardMann et al., 2013). Frequency and intensity
of combat experiences like exposure to killing, wounding of service members by friendly fire,
and a friend being wounded or killed, are closely associated with PTSD (Guyker et al., 2013;
Hoge et al., 2004; Killgore et al., 2008; Killgore et al., 2006; Stretch et al., 1996).
In addition to risk factors for mental health problems, the construct of psychological
resilience has been the focus of much attention in the military research literature (Adler, Bliese,
& Castro, 2011; Bonanno, 2004; Bonanno et al., 2012; Britt, Adler, & Castro, 2005; L. A. King,
King, Vogt, Knight, & Samper, 2006; Lee, Sudom, & Zamorski, 2013; Meredith et al., 2011).
The study of resilience in the military context is concerned with environmental and individual
factors associated with vulnerability or resilience to PTSD following adverse experiences
(Thompson, Arnkoff, & Glass, 2011). The consensus view of resilience includes both resistance
and recovery concepts, defined as “the sum-total of dynamic psychological processes that permit
individuals to maintain or return to previous levels of well-being and functioning in response to
adversity” (Technical Cooperation Program, 2012, p. 4; also see Lee et al., 2013).
Based on this definition, psychological processes associated with resilience can be
described as protective factors that buffer against adverse experiences and other risk factors to
contribute to outcomes consistent with return to or maintenance of functioning or well-being. In
the current study, resilience theory provided a framework for understanding contributions of risk
and protective factors to veterans’ mental health-related outcomes.
The core protective factor under investigation in the current study is mindfulness, which
is conceptualized as a special way of paying attention to internal experience. For example,
Linehan’s (1993) definition involves observing, describing, and participating in cognitive and
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 37
emotional experience without judgment. Others have described mindfulness as “bringing one’s
complete attention to the present experience on a moment-to-moment basis” (Marlatt &
Kristeller, 1999, p. 68) and as paying attention on purpose, in the present moment,
nonjudgmentally (Kabat-Zinn, 1994).
An emerging theoretical and empirical literature has begun to investigate links between
mindfulness and resilience in the context of risk factors for PTSD and depression (Johnson et al.,
2014; Smith et al., 2011; Thompson et al., 2011). Theories of PTSD posit that dissociation,
defined as disturbances in consciousness, perception, and memory (American Psychological
Association, 2013), and avoidant coping, defined as efforts to avoid thoughts, emotions, and
memories related to traumatic experiences, are instrumental in the development and maintenance
of PTSD symptoms (Batten, Orsillo, & Walser, 2005; Foa, Steketee, & Rothbaum, 1989;
Follette, Palm, & Pearson, 2006). Empirical studies have supported this view and suggested that
experiential avoidance, avoidant coping, thought suppression (Gil, 2005; Morina, Stangier, &
Risch, 2008; Silver, Holman, McIntosh, Poulin, & Gil-Rivas, 2002; Tull, Gratz, Salters, &
Roemer, 2004), and dissociation (Briere, Scott, & Weathers, 2005; McCaslin et al., 2008) are
associated with increased PTSD and depressive symptoms following traumatic experiences.
Several small pilot studies investigating the effects of mindfulness training on mental
health outcomes for active-duty military service members suggests that improvements in
mindfulness are linked to reductions in self-reported PTSD and depressive symptoms (Bhatnagar
et al., 2013; Kearney, McDermott, Malte, Martinez, & Simpson, 2012; A. P. King et al., 2013).
Observational studies have also shown links between mindfulness and stress correlates in active-
duty military service members (Call et al., 2015; Johnson et al., 2014; Stanley, 2014). These
findings suggest that deficits in mindfulness may help explain the etiology and maintenance of
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 38
PTSD and depressive symptoms and that enhancing mindfulness may protect against or reduce
PTSD and depressive symptoms following adverse experiences including combat.
Despite the growing evidence linking mindfulness to resilience against the development
of mental health symptoms in combat-exposed active-duty military service members, no study
has directly compared the effects of deployment experiences and mindfulness on PTSD and
depression in OEF/OIF-era military veterans. The current study aimed to address this gap in the
literature in two ways: (a) by examining and comparing the main effects of mindfulness and
deployment experiences on OEF/OIF veterans’ symptoms of PTSD and depression and (b) by
investigating the additive explanatory potential of mindfulness in models examining
relationships among deployment experiences, demographic covariates, and mental health
outcomes.
Method
Participants
Participants were recruited from a sampling frame featuring veterans who participated in
the Los Angeles/Orange County, Chicago, and Bay Area Veterans’ Surveys conducted by the
Center for Innovation and Research on Veterans & Military Families at the University of
Southern California (Castro & Kintzle, 2017; Castro, Kintzle, & Hassan, 2015a; Kintzle,
Rasheed, & Castro, 2016). All those who agreed to be contacted for future research were invited
to take part in the study. Initial screen-in criteria were current veteran status and separation from
the military after September 11, 2001; respondents who did not endorse these two categories in
the survey were automatically blocked from proceeding. In addition, because participants shared
the survey link with individuals not included in the original sampling frame, the investigators
screened all surveys to confirm that they were associated with Internet Protocol (IP) addresses
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 39
linked to verified participant email addresses included in study recruitment emails. This ensured
that only survey responses from invited participants who met inclusion criteria were included in
the final dataset (N = 577 ). Descriptive statistics are shown in Table 2.1.
Procedures
The investigators built the survey instrument in Qualtrics and created a MailChimp
account to distribute the survey. A second survey instrument capturing participant email
addresses was created and linked to the end of the survey instrument to facilitate disbursement of
the $15 electronic incentive and to verify that participant email addresses were included in the
sampling frame while ensuring participant survey data remained anonymous.
Approximately twice per month, the investigators emailed the survey to participants who
had agreed to be contacted after first removing email addresses of those who had already
completed the survey, requested to be removed from the mailing list, or endorsed either of the
two initial exclusion items. Following survey distribution, the investigators followed a two-step
process to verify that raw surveys had been completed by valid participants. First, the
investigators examined IP addresses associated with invited participant email addresses in the
survey incentive link. Second, these IP addresses were compared to IP addresses associated with
completed raw surveys. Surveys with IP addresses linked to invited participant email addresses
were considered valid and included in the final dataset. Incentives were then emailed to valid
participants. Data collection was conducted from July 2016 to February 2017, until the target of
1,000 completed raw surveys was reached. A flowchart detailing sample composition is
presented in Figure 2.1. All procedures were approved by the University of Southern California
Institutional Review Board.
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 40
Measures
Demographic covariates. Demographic covariates included age, gender, race, marital
status, and level of education.
Deployment experiences. Impactful deployment experiences were measured using the
13-item short version of the Combat Experiences Scale (Hoge et al., 2004). Scale items are
dichotomous and capture common impactful deployment-related experiences like receiving
enemy fire and seeing dead bodies.
Mindfulness. Mindfulness was measured using the Mindful Attention and Awareness
Scale (MAAS; Brown & Ryan, 2003), a unidimensional 15-item measure with a 6-point Likert-
type scale. The MAAS exhibited strong internal consistency across clinical, college-age
nonclinical, and adult samples and in these data (α = .93). The MAAS was designed to measure
the inverse of mindfulness, or “mindlessness,” because the scale authors hypothesized that
mindless states would be more familiar and thus easier to recognize for most individuals. Higher
MAAS scores indicate more mindful attention. Items include: “I find myself doing things
without paying attention” and “I find myself preoccupied with the future or the past.” In these
data, MAAS scores averaged 3.33 (SD = 0.99). This is lower than the mean typically found in
community adult (M = 4.20, SD = 0.69) and college age (M = 3.83, SD = 0.70) samples (Brown
& Ryan, 2003; Carlson & Brown, 2005).
Posttraumatic stress disorder. PTSD was measured using the PTSD Checklist for
DSM-5 (Weathers et al., 2013), a 20-item measure with a 5-point Likert-type scale. The
instrument is a four-factor measure indexing disturbances in intrusive thoughts, physical arousal,
cognitive, and avoidance symptoms. Responses to the 20 items result in a score from 0–80, with
cutoff point of 33 (National Center for PTSD, 2017). The scale demonstrated strong internal
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 41
consistency in the current study (α = .96). Items include: “In the past month, how much were you
been bothered by: repeated, disturbing, and unwanted memories of the stressful experience?” and
“In the past month, how much were you been bothered by: feeling jumpy or easily startled?”
Depression. Depression was measured using the Patient Health Questionnaire 9 (PHQ-9;
Kroenke, Spitzer, & Williams, 2001), a unidimensional 9-item measure with a 4-point Likert-
type scale. Scores on the PHQ-9 range from 0 to 27, with a cutoff point of 10. The PHQ-9
demonstrated strong internal consistency in these data (α = .89). Items include a question stem of
“In the past two weeks, how often have you been bothered by the following symptoms?”
followed by specific experiences such as “feeling down, depressed or hopeless” and “trouble
concentrating on things, such as reading the newspaper or watching television.”
Analyses
Two multivariate ordinary least squares regression models were specified to examine and
compare main effects of mindfulness and deployment experiences on veterans’ mental health
symptoms. Model 1 examined main effects of mindfulness, deployment experiences, and
covariates including age, race, marital status, and education on PTSD symptoms. Model 2
examined main effects of these predictors and covariates on symptoms of depression. Regression
diagnostics showed that the mindfulness and deployment experiences variables were skewed
slightly to the right, although examination of residual plots and the Breusch-Pagan test (Zeileis &
Hothorn, 2002) for homoscedasticity of residuals, χ
2
(1) = 0.02, prob > χ
2
= 0.88, supported
regression assumptions regarding homoscedasticity. To facilitate interpretation of effects,
mindfulness and deployment experience variables were centered on the mean and no linear
transformations were performed. Covariates were operationalized using dichotomous variables.
Modeled race categories included Black, Latino, and a combined category for all other races,
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 42
with a contrast category of White. Male gender was modeled with the contrast category of
female. Marital status categories included divorced or separated from a partner, with a contrast
category of being married or cohabitating with a partner. Education categories were no degree
and advanced (master’s or doctoral) degree, with a contrast category of bachelor’s or associate’s
degree. All analyses were performed in Stata version 14.1.
Results
Model 1 demonstrated a negative main effect of mindfulness (β = -.67, p < .001) and a
positive main effect of deployment experiences (β = .18, p < .001) on PTSD symptoms.
Comparison of standardized coefficients indicated that the magnitude of effect for mindfulness
was approximately 3.5 times the effect for deployment experiences. In addition, Latino ethnicity
(β = .09, p < .01), age (β = .11, p < .001), and no college degree (β = .07, p < .05) were
significantly and positively associated with PTSD symptoms. Model 1 explained 60% of the
variance in PTSD symptoms in these data. The addition of mindfulness to a model examining the
effects of deployment experiences and covariates on PTSD symptoms yielded a significant
increase in the model R
2
, from .24 to .60, F(1, 506) = 469.07, p < .001.
Findings for Model 2 investigating the main effects of predictors and covariates on
symptoms of depression were also consistent with study hypotheses. Model 2 showed a
significant negative main effect of mindfulness (β = -.69, p < .001) and a positive main effect of
deployment experience (β = .10, p < .001) on symptoms of depression. As with PTSD
symptoms, mindfulness was a substantially stronger predictor of symptoms, with higher
mindfulness scores linked to lower PHQ-9 scores. Among Model 2 covariates, only divorce or
separation from a cohabitating partner was significantly associated with depressive symptoms (β
= .09, p < .01). Model 2 explained 57% of the variance in depressive symptoms in these data. As
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 43
in Model 1, adding mindfulness to a model examining effects of deployment experiences and
covariates on depressive symptoms yielded a significant increase in the model R
2
, from .18 to
.57, F(1, 510) = 455.56, p < .001. All standardized and unstandardized coefficients and standard
errors are presented in Table 2.2.
Discussion
Rates of PTSD and depressive symptoms endorsed by study participants were higher than
prevalence estimates reported in other studies. This may be because deployment rates in this
sample were close to 90% and because respondents with more pronounced symptoms could have
been more motivated to participate in the study, which was described in participant information
materials as focusing on these disorders. In addition, not all respondents who met cutoff points
for PTSD and depression measures would be expected to meet full criteria for these disorders.
Finally, although elevated rates in the current sample may limit this study’s generalizability to
the larger veteran population, they may nevertheless assist with improving understanding of the
subset of veterans who suffer from clinically significant PTSD and depression.
This study was the first to directly compare the effects of deployment experiences and
mindfulness on symptoms of the two most common mental health disorders associated with
OEF/OIF military service. For both PTSD and depressive symptoms, mindfulness demonstrated
a strong negative association several times the magnitude of deployment experiences, a robust
predictor of mental health symptoms well-documented in the veteran mental health literature
(Hoge et al., 2004; Vogt, Pless, King, & King, 2005). Consistent with previous studies (Guyker
et al., 2013; Mayeux et al., 2008), deployment experiences demonstrated a linear relationship
with both PTSD and depressive symptoms. However, mindfulness demonstrated an even
stronger negative relationship with these symptoms. Furthermore, accounting for the role of
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 44
mindfulness in both models resulted in a large and significant increase in the variance explained
by each. This suggests that mindfulness may be a critical and overlooked determinant of mental
health outcomes in the context of military deployment experiences.
The robust negative effect of mindfulness on symptoms of PTSD and depression also
provides empirical support for the predictions of resilience theory, which posits that better
mindfulness skills will be associated with less severe mental health symptoms. These data
suggest that enhancing dispositional mindfulness in military service members prior to
deployment may provide a protective effect against mental health symptoms associated with
adverse deployment experiences. This finding has important implications for prevention.
Previous veteran mental health research has often focused on risk and protective factors that are
either inseparable from the military’s core mission or for which efficacious interventions have
not been developed, as is the case for many of the psychological processes described in the
military resilience literature (Ramchand et al., 2015; Schultz, Glickman, & Eisen, 2014). In
addition, many previously examined risk factors, like adverse deployment experiences,
preexisting mental health conditions, or adverse experiences prior to military service, are
difficult to modify after enlistment. For example, it is unlikely that service members deployed to
combat zones or unpredictable operating theatres will be able to effectively limit their exposure
to adverse experiences directly related to their military role.
Consistent with previous studies (Hoge et al., 2004; Seal et al., 2009), other significant
contributors to mental health symptoms in these data included age, Latino ethnicity, divorce or
separation, and not having a college degree. As found in previous studies (Dohrenwend, Turner,
Turse, Lewis‐ Fernandez, & Yager, 2008), Latino respondents in the current sample tended to be
younger, which may account for a portion of their increased risk. Some of these characteristics or
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 45
their underlying mechanisms of effect on mental health symptoms may be addressed through
intervention, but others, like divorce, will for a variety of reasons likely prove difficult to address
at scale. However, study results show that the magnitude of effect for risk variables is
substantially lower than the effect for mindfulness. In addition, mindfulness is a highly
modifiable characteristic (Chiesa & Serretti, 2010; Keng, Smoski, & Robins, 2011) targeted by
existing evidence-based interventions with robust empirical support (Hayes & Feldman, 2004;
Hofmann, Sawyer, Witt, & Oh, 2010; Jha, Stanley, Kiyonaga, Wong, & Gelfand, 2010; Linehan,
1993; Miller, Fletcher, & Kabat-Zinn, 1995; Segal, Williams, & Teasdale, 2012).
Consistent with previous theoretical accounts of the role of mindfulness in the
development of mental health symptoms, the ability to pay nonjudgmental attention to internal
states might be a necessary component of self-regulation, particularly when they are unpleasant,
as is the case for symptoms of PTSD and depression. Conversely, deficits in mindfulness are
associated with maladaptive approaches to coping with distress, like avoidance and suppression,
which are linked to more severe symptoms (Gil, 2005; Morina et al., 2008; Silver et al., 2002;
Tull et al., 2004). The large and significant proportion of variance in symptoms of PTSD and
depression explained by mindfulness in this study supports the view that mindfulness is a critical
determinant of adaptive coping in the context of adverse experiences. More research
investigating the role of mindfulness in the development of mental health symptoms in the
military context seems warranted to enhance resilience in this population.
It is important to note that some researchers and clinicians have argued that mindful style
of engagement diverges conceptually and practically from culturally determined approaches to
managing distressing emotions that characterize military coping styles, particularly among
individuals with combat arms specialties most likely to encounter adverse deployment
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 46
experiences (Castro, Kintzle, & Hassan, 2015b). Consistent with recent approaches (Stanley,
2014), mindfulness-based approaches to prevention and intervention in the military context
should be framed as practical behavioral tools for assisting with management of thoughts and
emotions associated with adverse experiences in an adaptive way.

MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 47
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Table 2.1. Descriptive Statistics
n % M SD
Age
21–29 66 11.87
30–39 273 49.10
40–49 150 26.98
50–59 51 9.17
60+ 16 2.88
Race
White 273 49.10
Black 59 10.61
Latino 144 25.90
Other 80 14.39
Gender
Male 444 79.86
Female 111 19.96
Transgender 1 0.18
Education
No degree 183 32.91
College degree 294 52.88
Advanced degree 77 14.21
Marital status
Single 97 17.48
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 59
Married or cohabitating 362 65.22
Separated 96 17.29
Deployed 486 87.52
Combat experiences 553 6.50 4.02
PCL-5 530 38.16 20.26
PHQ-9 535 11.52 6.75
MAAS 538 3.33 1.00
Note. PCL-5 = PTSD Checklist for DSM-5; PHQ-9 = Patient Health Questionnaire 9; MAAS = Mindful Attention
and Awareness Scale.

MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 60
Table 2.2. Unstandardized and Standardized Parameter Estimates for the Effects of Predictors
and Covariates on PTSD and Depression
Model 1 PTSD Model 2 Depression
b SE β b SE β
Mindfulness -13.64*** 0.63 -0.67 -4.70*** 0.23 0.69
Combat experiences 0.88*** 0.16 0.18 0.16** 0.05 0.10
Age 0.25*** 0.07 0.11 0.04 0.02 0.05
Male -1.20 1.49 -0.02 -0.13 0.51 -0.01
Race
Black 3.42 1.97 0.05 1.24 0.69 0.06
Latino 4.14** 1.41 0.09 0.40 0.50 0.02
Other 0.61 1.72 0.01 0.59 0.02
Marital status
Single 1.01 1.60 0.02 0.92 0.55 0.05
Divorced or separated 1.93 1.63 0.03 1.63** 0.56 0.09
Education
No college degree 2.85* 1.30 0.07 0.65 0.45 0.05
Advanced degree 0.10 1.78 0.00 -0.37 0.61 -0.02
R
2
.61 .57
Note. Reference categories were White for race; married or cohabitating with a partner for marital status; and
college degree for education.
*p < .05. **p < .01. ***p < .001.

MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 61
Figure 2.1. Sample Composition

MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 62
Chapter 3: Examining Direct and Indirect Effects of Mindfulness, PTSD, and Depression
on Self-Stigma in Modern Veterans
Background
Since the beginning of the recent military conflicts in Afghanistan (Operation Enduring
Freedom; OEF) and Iraq (Operation Iraqi Freedom; OIF), the percentage of Veterans Health
Administration (VHA) service users with mental health or substance use disorders has increased
from nearly 27% to more than 40% (VHA, 2016). Two of the most common and costly mental
health diagnoses for this cohort are posttraumatic stress disorder (PTSD) and depression (Bruce,
2010; Kang et al., 2015; Seal et al., 2009). Despite the substantial proportion of OEF/OIF
veterans who separate from the military with mental health needs, very few engage with mental
health services. Research has suggested that 17% to 33% of OEF/OIF soldiers meet criteria for a
diagnosed disorder following return from deployment, but that only 20% of those individuals
endorse recent mental health treatment (Hoge et al., 2004; Kim, Britt, Klocko, Riviere, & Adler,
2011).
A robust literature has explored veterans’ barriers to mental health service use (Adler et
al., 2015; N. B. Brown & Bruce, 2016; Gould et al., 2010; Hoge et al., 2004; Kim et al., 2011;
Ouimette et al., 2011; Valenstein et al., 2014; Vogt, 2011). This research indicated that barriers
can be divided into external and internal categories that contribute to veterans’ low rates of
accessing mental health care. External barriers include difficulty making appointments or finding
reliable transportation, whereas internal barriers include public and self-stigma related to mental
illness (Hoge et al., 2014; Oumiette et al., 2011). Public stigma is defined as the negative
judgments, attitudes, and beliefs that an individual believes society holds regarding a
characteristic, and internalized stigma is defined as negative judgments, attitudes, and beliefs that
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 63
inform an individual’s view of that characteristic and its meaning (N. B. Brown & Bruce, 2016;
Corrigan & Watson, 2002). The literature shows that public stigma of mental illness leads to
self-stigma as individuals incorporate the stigmatizing views of mental illness that appear to be
held in society at large or in salient social contexts into their own belief systems (Corrigan, 2004;
Link, 1987; Link & Phelan, 2001).
Self-stigma related to mental illness is evident in military context, wherein veterans’
internalized concerns about mental health service use are grounded in public stigma toward
mental health problems, which informs military cultural norms. Concerns about disclosing
mental health problems in the military are not unfounded; among service members and
reservists, internalized stigma is linked to legitimate worries about promotion (N. B. Brown &
Bruce, 2016; Greene-Shortridge, Britt, & Castro, 2007).
Despite significant VHA investment in mental health infrastructure to address external
barriers, internal barriers, particularly public and self-stigma related to mental illness, remain
core obstacles to veterans’ mental health service use (N. B. Brown & Bruce, 2016; Gould et al.,
2010; Hoge et al., 2004; Kim et al., 2011; Valenstein et al., 2014). Studies have demonstrated
that veterans who met criteria for a mental health problem were substantially more likely to
endorse internalized mental health stigma (Hoge et al., 2004; Kim et al., 2011), and those who
endorsed more internalized stigma were less likely to report seeking care (Kim, Thomas, Wilk,
Castro, & Hoge, 2010). In addition, a recent meta-analysis revealed that interventions targeting
internalized stigma in the military have been largely ineffective (Griffiths, Carron-Arthur,
Parsons, & Reed, 2014).
To improve veterans’ mental health outcomes, more must be done to understand
processes that both protect against the development of mental health problems like PTSD and
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 64
depression and buffer against self-stigma that interferes with accessing services in the context of
mental health needs. Mindfulness, defined as “bringing one’s complete attention to the present
experience on a moment-to-moment basis” (Marlatt & Kristeller, 1999, p. 68) and “paying
attention in a particular way: on purpose, in the present moment, and nonjudgmentally” (Kabat-
Zinn, 1994, p. 4), may be such a process.
Reviews of the mindfulness literature suggested that mindfulness is a highly modifiable
process (Chiesa & Serretti, 2010; Keng, Smoski, & Robins, 2011) targeted by existing evidence-
based interventions with empirical support (Hayes & Feldman, 2004; Hofmann, Sawyer, Witt, &
Oh, 2010; Jha, Stanley, Kiyonaga, Wong, & Gelfand, 2010; Linehan, 1993; Miller, Fletcher, &
Kabat-Zinn, 1995; Segal, Williams, & Teasdale, 2012). Although associations between
mindfulness and mental health related self-stigma have not been investigated in military
populations, the civilian literature suggests that mindfulness is associated with less stigmatized
beliefs toward individuals with mental illness (Masuda et al., 2007). Correlates of mindfulness
have also been linked to reduced mental health stigma and adaptive mental health service use
(Corrigan, Watson, & Barr, 2006; Masuda et al., 2007). Research has suggested that focusing
attention and awareness on present-moment experiences may decrease shame, guilt, and
nonacceptance related to mental health symptoms and that mindful individuals may also be more
open to discussing thoughts and emotions with mental health service providers (Henning &
Frueh, 1997; Vujanovic, Niles, Pietrefesa, Schmertz, & Potter, 2011). In the context of these
findings, this study employed a structural equation modeling (SEM) approach to test the
following hypotheses:
1. Mindfulness will demonstrate a negative direct effect on PTSD and depression.
2. PTSD will demonstrate positive direct effects on self-stigma and depression.
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 65
3. Depression will demonstrate a positive direct effect on self-stigma.
4. Mindfulness will demonstrate a negative direct effect on self-stigma.
5. Mindfulness will demonstrate a negative indirect effect on self-stigma.
Method
Participants
Participants were recruited from a sampling frame featuring veterans who participated in
the Los Angeles/Orange County, Chicago, and Bay Area Veterans’ Surveys conducted by the
Center for Innovation and Research on Veterans & Military Families at the University of
Southern California (Castro & Kintzle, 2017; Castro, Kintzle, & Hassan, 2015a, 2015b; Kintzle,
Rasheed, & Castro, 2016). Participants who agreed to be contacted for future research were
invited to take part in the study. Initial screen-in criteria were current veteran status and
separation from the military after September 11, 2001; respondents who did not endorse these
two categories in the survey were automatically blocked from proceeding. In addition, because
participants shared the survey link with individuals not included in the original sampling frame,
the investigators screened all surveys to confirm that they were associated with Internet Protocol
(IP) addresses linked to verified participant email addresses included in study recruitment emails.
This ensured that only survey responses from invited participants who met inclusion criteria
were included in the final dataset (N = 577). Descriptive statistics are shown in Table 3.1.
Procedures
The investigators built the survey instrument in Qualtrics and created a MailChimp
account to distribute the survey. A second survey instrument capturing participant email
addresses was created and linked to the end of the survey instrument to facilitate disbursement of
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 66
the $15 electronic incentive and verify that participant email addresses were included in the
sampling frame while ensuring participant survey data remained anonymous.
Approximately twice per month, the investigators sent the survey to participants who had
agreed to be contacted after first removing email addresses of those who had already completed
the survey, requested to be removed from the mailing list, or endorsed either of the two initial
exclusion items. Following survey distribution, the investigators followed a two-step process to
verify that raw surveys had been completed by valid participants. First, the investigators
examined IP addresses associated with invited participant email addresses in the survey incentive
link. Second, these IP addresses were compared to IP addresses associated with completed raw
surveys. Surveys with IP addresses linked to invited participant email addresses were considered
valid and included in the final dataset. Incentives were then emailed to valid participants. Data
collection was conducted from July 2016 to February 2017, until reaching the target of 1,000
completed raw surveys. A flowchart detailing sample composition is presented in Figure 3.1. All
procedures were approved by the University of Southern California Institutional Review Board.
Measures
Demographic covariates. Demographic covariates included age, gender, race, marital
status, and level of education.
Mindfulness. Mindfulness was measured using the Mindful Attention and Awareness
Scale (MAAS; K. W. Brown & Ryan, 2003), a unidimensional 15-item measure with a 6-point
Likert-type scale. The MAAS exhibited strong internal consistency across clinical, college-age
nonclinical, and adult samples and in these data (α = .93). The MAAS was designed to measure
the inverse of mindfulness, or “mindlessness,” because the scale’s authors hypothesized that
mindless states would be more familiar and thus easier to recognize for most individuals. MAAS
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 67
scores were reverse coded so higher scores indicated more mindful attention. Items include: “I
find myself doing things without paying attention” and “I find myself preoccupied with the
future or the past.”
Posttraumatic stress disorder. PTSD was measured using the PTSD Checklist for
DSM-5 (PCL-5; Weathers et al., 2013), a 20-item measure with a 5-point Likert-type scale. The
PCL-5 is a four-factor measure indexing disturbances in intrusive thoughts, physical arousal,
cognitive, and avoidance symptoms. Responses to the 20 items result in a score from 0–80, with
cutoff point of 33 (National Center for PTSD, 2017). The PCL-5 demonstrated strong internal
consistency in the current study (α = .96). Items include: “In the past month, how much were you
been bothered by: repeated, disturbing, and unwanted memories of the stressful experience?” and
“In the past month, how much were you been bothered by: feeling jumpy or easily startled?”
Depression. Depression was measured using the Patient Health Questionnaire 9 (PHQ-9;
Kroenke, Spitzer, & Williams, 2001), a unidimensional 9-item measure with a 4-point Likert-
type scale. Scores on the PHQ-9 range from 0 to 27, with a cutoff point of 10. The PHQ-9
demonstrated strong internal consistency in these data (α = .89). Items include a question stem
of: “In the past two weeks, how often have you been bothered by the following symptoms?”
followed by specific symptoms such as: “feeling down, depressed or hopeless” and “trouble
concentrating on things, such as reading the newspaper or watching television.”
Self-stigma. Self-stigma of mental health help-seeking was measured with the widely
used Self-Stigma of Seeking Help Scale (SSOSH; Vogel, Wade, & Haake, 2006). The SSOSH is
a unidimensional 10-item measure with a 5-point Likert-type scale ranging from 1 (strongly
disagree) to 5 (strongly agree). The SSOSH demonstrated good internal consistency in these
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 68
data (α = .80). Items include: “I would feel inadequate if I went to a therapist for psychological
help” and “If I went to a therapist, I would feel less satisfied about myself.”
Analyses
Descriptive statistics and bivariate correlations between study variables were computed in
Stata 14.1. Next, confirmatory factor analysis was conducted for MAAS, PHQ9, and SSOSH
instruments to compute measurement models for mindfulness, depression, and self-stigma latent
factors in these data. The best-performing items for each scale were retained and used as
indicators for latent factors in a full SEM. Both substantive and statistical strategies were
employed in this process. Items with factor loadings less than .60 were excluded from initial full-
scale confirmatory factor analyses. Model fit was assessed with indexes including the chi-square
statistic, comparative fit index (CFI), Tucker-Lewis index (TLI; Bentler, 1990), and root mean
square error of approximation (RMSEA; Steiger, 1990). Values for CFI and TLI > .90 and
RMSEA < .08 indicate good model fit (Hu & Bentler, 1999; Kline, 2011). Because the goal was
to understand the contribution of PTSD to self-stigma rather than to compute a measurement
model for individual PTSD subscale factors, this study involved parceling PCL-5 items across
the four subscales and employing subscale means as indicators of the PTSD latent factor. This
approach has empirical and theoretical strengths, particularly when applied to well-validated
scales with firm theoretical grounding (Little, Rhemtulla, Gibson, & Schoemann, 2013). Final
measurement models were specified as follows: MAAS Items 7–10, 13, and 14 constituted
mindfulness; PHQ-9 Items 1–8 represented depression; the four parceled PCL-5 subscale items
constituted PTSD; and SSOSH Items 1, 3, 6, 8, and 10 reflected self-stigma.
Next, a full SEM was specified to examine associations between study variables. The
model examined direct effects of mindfulness on PTSD, depression, and self-stigma; direct
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 69
effects of PTSD on depression and self-stigma; and direct effects of depression on self-stigma.
Indirect effects of mindfulness on self-stigma were also examined. Consistent with Muthén and
Muthén (2015), only level of education was included as a covariate because of its significant
correlation with both exogenous and endogenous predictors and the dependent variable of self-
stigma. Education was modeled as two dummy variables indexing advanced degree and no
college degree status with the contrast category of college degree. Confirmatory factor analysis
and SEM were performed in Mplus 1.4 (Muthén & Muthén, 2015).
Results
Final measurement models showed significant standardized factor loadings > .64 for all
scale indicators. The mindfulness model indicated good fit to the data, χ
2
(9, 550) = 38.8, p <
.001, CFI = .98, TLI = .97, and RMSEA = .08 (90% CI: .05, .10). To improve model fit for
depression and PTSD measurement models, the Lagrange multiplier test was applied to facilitate
model respecification through inclusion of additional parameters that may account for shared
method variance (Cole, Ciesla, & Steiger, 2007). For depression, residuals were allowed to
correlate for Items 2 and 6 and Items 4 and 5. This improved model fit indexes from χ
2
(9, 550) =
38.80, CFI = .95, TLI = .93, and RMSEA = .10 (90% CI: .08, .12) to CFI = .98, TLI = .97, and
RMSEA = .07 (90% CI: .05, .09). For PTSD, residuals were allowed to correlate for Items 2 and
6 and Items 4 and 5. This improved model fit from χ
2
(2, 549) = 23.90, p < .001, CFI = .98, TLI =
.96, and RMSEA = 0.14 (90% CI: .09, .19) to χ
2
(2, 549) = 23.6, p < .001, CFI = 1.00, TLI =
1.00, and RMSEA = .00 (90% CI: .00, .10). The measurement model for self-stigma
demonstrated good fit to the data, with χ
2
(5, 552) = 10.40, p < .001, CFI = 1.00, TLI = .99, and
RMSEA = .04 (90% CI: .00, .08).
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 70
The full SEM examined direct and indirect effects among study variables. All reported
parameters are standardized. Hypotheses 1, 2, and 5 were supported. Mindfulness had a negative
direct effect on PTSD ( β = -.74, p < .001) and depression ( β = -.14, p < .01). PTSD had a
positive direct effect on self-stigma ( β = .40, p < .001). Mindfulness also had a negative indirect
effect on self-stigma through the PTSD pathway ( β = -.47, p < .001). The total effect of
mindfulness on self-stigma was β = -.33, p < .001. Hypotheses 3 and 4 were not supported; the
direct effects of mindfulness and depression on self-stigma were not significant in this model.
Having no college degree was negatively associated with mindfulness ( γ = -.22, p < .01) and
having an advanced degree was negatively associated with depression ( γ = -.06, p < .05). The
model demonstrated good fit to the data, χ
2
(259, 552) = 956.71, p < .001, CFI = .92, TLI = .91,
RMSEA = .07 (95% CI: .07, .08). Factor loadings and standard errors for the full model are
presented in Table 3.2. Direct effects are presented in Figure 3.2.
Discussion
Sample descriptive statistics show that the rates of PTSD and depressive symptoms
endorsed by study participants were higher than prevalence estimates in other studies. This may
be because respondents with more pronounced symptoms were more motivated to participate in
the study, which was described in participant information materials as focusing on these
disorders, and because of the high deployment rate in the current sample (87.5%). However, not
all respondents who met cutoff points for PTSD and depression measures would be expected to
meet full criteria for these disorders. Finally, although elevated rates in the current sample may
limit this study’s generalizability to the larger veteran population, they may help with improve
understanding of challenges to mental health help-seeking for the subset of veterans who suffer
from significant symptoms of PTSD and depression.
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 71
This study yielded noteworthy findings regarding associations among mindfulness,
mental health symptoms, and self-stigma in veterans. This is a critical area of investigation
because most OEF/OIF veterans who screen positive for mental health problems do not seek
mental health treatment (Hoge et al., 2004; Kim et al., 2010), and research has suggested that
self-stigma is the most salient internal barrier (Kim et al., 2011). This study advanced research
investigating associations between these constructs and is the first to model direct and indirect
effects for mindfulness on mental health symptoms and self-stigma in this population.
Findings were largely in line with study hypotheses and supported by prior research;
mindfulness was negatively associated with PTSD and depression, and PTSD was positively
associated with self-stigma. The nonsignificant direct effect of depression on self-stigma may
reflect high rates of comorbid PTSD and depression in military populations (Campbell et al.,
2007; Stander, Thomsen, & Highfill-McRoy, 2014). Evidence suggests that comorbid PTSD and
depression are indistinguishable from PTSD in chronic expressions of posttraumatic illness
(O’Donnell, Creamer, & Pattison, 2004), and the discrete depression factor in these data may not
account for variance in self-stigma beyond what was captured by PTSD.
The negative indirect effect of mindfulness on self-stigma through the PTSD pathway is
novel in the veterans mental health literature, although the direct effect of mindfulness on self-
stigma was not significant despite a negative bivariate association between these variables. This
may be because of the large proportion of variance in self-stigma explained by PTSD and
additional unmeasured constructs. However, the negative indirect effects of mindfulness on self-
stigma through the PTSD and depression pathways suggest that even when mental health
symptoms exert a strong influence on self-stigma, mindfulness may buffer against these effects.
Although these associations have not previously been investigated in a veteran population, they
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 72
are consistent with civilian studies that have shown that mindfulness is associated with less
stigmatized beliefs toward individuals with mental illness (Masuda et al., 2007) and that
mindfulness may influence the association between mental health symptoms and internalized
stigma in individuals with mental health symptoms (Chan & Lam, 2017; Yang & Mak, 2016).
This pattern of associations supports the view that better mindfulness skills may reduce
the intensity of PTSD and depressive symptoms in veterans. In addition, mindfulness skills may
have the added effect of buffering against self-stigma associated with mental health symptoms in
this population. Observing thoughts and emotions nonjudgmentally and without avoidance or
reactivity may assist with keeping automatic thoughts related to stigmatizing value judgments
linked to mental health symptoms at arm’s length.
In addition, consistent with previous civilian research, lower educational attainment was
negatively associated with mindfulness in these data, whereas higher educational attainment was
negatively linked to depression (K. W. Brown & Ryan, 2003; Lorant et al., 2003). Although
various interpretations of these findings exist, it seems plausible that individuals with more
refined attentional control may perform better in formal educational settings. It is also possible
that learning to regulate attention and emotion are secondary skills acquired through participation
in formal educational practices.
Together, study findings suggest that enhancing mindfulness skills in veterans and
military service members may serve two important functions. First, mindfulness may provide a
primary protective effect against PTSD and depression; improving mindfulness skills can be
expected to reduce the incidence of these mental health problems. Second, mindfulness may act
indirectly against self-stigma by reducing the intensity of mental health symptoms and related
judgments and aversive cognitions, thereby working against a critical barrier to accessing mental
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 73
health services in this population. More research investigating the role of mindfulness in
veterans’ mental health outcomes seems warranted.

MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 74
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MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 82
Table 3.1. Descriptive Statistics
n % M SD
Age
21–29 66 11.87
30–39 273 49.10
40–49 150 26.98
50–59 51 9.17
60+ 16 2.88
Race
White 273 49.10
Black 59 10.61
Latino 144 25.90
Other 80 14.39
Gender
Male 444 79.86
Female 111 19.96
Transgender 1 0.18
Education
No degree 183 32.91
College degree 294 52.88
Advanced degree 77 14.21
Marital status
Single 97 17.48
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 83
Married or cohabitating 362 65.22
Separated 96 17.29
Deployed 486 87.52
PCL-5 530 38.16 20.26
PHQ-9 535 11.52 6.75
MAAS 538 3.33 1.00
SSOSH 547 26.04 6.40
Note. PCL-5 = PTSD Checklist for DSM-5; PHQ-9 = Patient Health Questionnaire 9; MAAS = Mindful Attention
and Awareness Scale; SSOSH = Self-Stigma of Seeking Help Scale.

MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 84
Table 3.2. Full Model Factor Loadings and Residual Correlations
Estimate SE p
Mindfulness
MAAS Item 7 .78 .02 < .001
MAAS Item 8 .85 .01 < .001
MAAS Item 9 .74 .02 < .001
MAAS Item 10 .76 .02 < .001
MAAS Item 13 .69 .03 < .001
MAAS Item 14 .80 .02 < .001
Depression
PHQ-9 Item 1 .82 .02 < .001
PHQ-9 Item 2 .80 .02 < .001
PHQ-9 Item 3 .70 .02 < .001
PHQ-9 Item 4 .68 .03 < .001
PHQ-9 Item 5 .65 .03 < .001
PHQ-9 Item 6 .75 .02 < .001
PHQ-9 Item 7 .69 .02 < .001
PHQ-9 Item 8 .65 .03 < .001
PTSD
PCL-5 Item B .88 .01 < .001
PCL-5 Item C .81 .02 < .001
PCL-5 Item D .96 .01 < .001
PCL-5 Item E .84 .01 < .001
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 85
Self-stigma
SSOSH Item 1 .75 .02 < .001
SSOSH Item 3 .76 .02 < .001
SSOSH Item 6 .85 .02 < .001
SSOSH Item 8 .80 .02 < .001
SSOSH Item 10 .64 .03 < .001
Residual correlations
PHQ-9 Item 2 and Item 6 .27 .05 < .001
PHQ-9 Item 4 and Item 5 .20 .04 < .001
PCL-5 Item C and Item E -.15 < .01
Note. PCL-5 = PTSD Checklist for DSM-5; PHQ-9 = Patient Health Questionnaire 9; MAAS = Mindful Attention
and Awareness Scale; SSOSH = Self-Stigma of Seeking Help Scale.

MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 86
Figure 3.1. Sample Composition

MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 87
Figure 3.2. Structural Equation Model of Relationships among Mindfulness, PTSD, Depression,
Education Covariates, and Self-Stigma

MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 88
Chapter 4: Can Mindfulness Aid in Predicting Veterans’ Mental Health Service
Utilization?
Background
The high operational tempo that characterized the military conflicts in Afghanistan,
(Operation Enduring Freedom; OEF) and Iraq (Operation Iraqi Freedom; OIF) is associated with
high rates of mental health problems, including posttraumatic stress disorder (PTSD) and
depression, among OEF/OIF service members. A meta-analysis of 33 studies published between
2007 and 2013 estimated a PTSD prevalence rate of 23% for OEF/OIF veterans who use
Veterans Health Administration services (Fulton et al., 2015); most studies have estimated the
prevalence rate of depression in this cohort to be 11% to 16% (Holdeman, 2009; Killgore,
Melba, Castro, & Hoge, 2006), although some recent studies showed rates as high as 21%
(Vaughan, Schell, Tanielian, Jaycox, & Marshall, 2014). However, many veterans endorse
negative mental health- and treatment-related beliefs that represent barriers to mental health
service use (MHSU), and evidence suggests that most OEF/OIF veterans who screen positive for
mental health problems do not pursue treatment (Fox, Meyer, & Vogt, 2015; Garcia et al., 2014;
Hoge et al., 2004; Vogt, 2011).
Research has suggested public and internalized or self-stigma associated with having a
mental illness represent core barriers to veterans’ MHSU (N. B. Brown & Bruce, 2016; Gould et
al., 2010; Hoge et al., 2004; Kim, Britt, Klocko, Riviere, & Adler, 2011; Valenstein et al., 2014).
Scholars have defined public stigma as the negative judgments, attitudes, and beliefs that an
individual believes society holds regarding a characteristic and self-stigma as negative
judgments, attitudes, and beliefs that inform an individual’s view of that characteristic and its
meaning (N. B. Brown & Bruce, 2016; Corrigan & Watson, 2004). Studies have shown that
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 89
public stigma related to mental illness leads to self-stigma as individuals incorporate the
stigmatizing views held in their broader social contexts into their own personal views (Corrigan,
2004; Link, 1987; Link & Phelan, 2001). This appears to be true in the military, wherein
veterans’ self-stigma toward mental illness and MHSU are grounded in an institutional stigma
toward mental health problems that informs military cultural norms (Greene-Shortridge, Britt, &
Castro, 2007).
Although evidence indicates that both mental health symptoms and public and self-
stigma are barriers to care, the relationship among symptoms, stigma, and MHSU is complex.
Studies have shown that veterans who meet criteria for a mental health problem are substantially
more likely to endorse internalized mental health stigma (Hoge et al., 2004; Kim et al., 2011),
and those who endorse more internalized stigma are less likely to report seeking care (Kim,
Thomas, Wilk, Castro, & Hoge, 2010). But veterans who report more severe mental health
symptoms are also more likely to seek mental health services (Vogt, 2011). Together, these
findings suggest that although mental health symptoms are linked to a self-stigma barrier for
MHSU, symptom severity is nevertheless the prime driver of veterans’ MHSU. To reduce
barriers to MHSU, it is important to explore constructs that may play an unexamined role in
associations among mental health symptoms, self-stigma, and MHSU.
Mindfulness, defined as the purposeful application of present-moment attention to
internal states without judgment (Bishop et al., 2004; Kabat-Zinn, 1994), may be such a
construct. Associations among mental health symptoms, self-stigma, and mindfulness have not
been investigated in veterans, but correlates of mindfulness have been linked to reduced mental
health stigma and increased MHSU in civilian populations (Corrigan, Watson, & Barr, 2006;
Masuda et al., 2007). Mindfully examining distressing thoughts and feelings related to mental
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 90
health symptoms may decrease shame, guilt, and nonacceptance related to those symptoms,
affecting internalized stigma, and more mindful individuals may also be more open to discussing
thoughts and emotions with mental health service providers (Henning & Frueh, 1997; Vujanovic
et al., 2011). In light of these findings, the specific aims of this study were (a) to examine the
main effects of PTSD, depressive symptoms, self-stigma, and mindfulness on MHSU and (b) to
examine the interaction effects of mindfulness, PTSD, and depressive symptoms on MHSU.
Method
Participants
Participants were recruited from a sampling frame of veterans who participated in the Los
Angeles/Orange County, Chicago, and Bay Area Veterans’ Surveys (Castro & Kintzle, 2017;
Castro, Kintzle, & Hassan, 2015; Kintzle, Rasheed, & Castro, 2016). Veterans who agreed to be
contacted for future research during these surveys were invited to take part in the current study.
Screening criteria were current veteran status and separation from the military after September
11, 2001; respondents who did not endorse these two categories were unable to proceed with the
survey. In addition, because valid participants shared the survey link with individuals not
included in the original sampling frame, the investigators screened all surveys to confirm that
they were associated with Internet Protocol (IP) addresses linked to verified participant email
addresses included in study recruitment emails. This ensured that only survey responses from
invited participants who met inclusion criteria were included in the final dataset (N = 577).
Descriptive statistics are presented in Table 4.1.
Procedures
The investigators constructed the survey instrument in Qualtrics and created a
MailChimp account to facilitate survey distribution. A second survey instrument capturing
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 91
participant email addresses was created and linked to the end of the survey instrument to allow
disbursement of the $15 electronic incentive and to verify that participant email addresses were
included in the sampling frame while ensuring participant survey data remained anonymous.
The investigators sent a bimonthly email with the survey to participants who had agreed
to be contacted in previous veterans surveys after first removing email addresses of those who
had already completed the survey, requested to be removed from the mailing list, or endorsed
either of the two initial exclusion items. Following survey distribution, the investigators followed
a two-step process to verify that raw surveys had been completed by valid participants. First, the
investigators examined IP addresses associated with invited participant email addresses in the
survey incentive link. Second, these IP addresses were compared to IP addresses associated with
completed raw surveys. Surveys with IP addresses linked to invited participant email addresses
were considered valid and included in the final dataset. Incentives were then emailed to valid
participants. Data collection was conducted from July 2016 to February 2017, until reaching the
target of 1,000 completed raw surveys. A flowchart detailing sample composition is presented in
Figure 4.1. All procedures were approved by the University of Southern California Institutional
Review Board.
Measures
Demographic covariates. Demographic covariates included age, gender, race, marital
status, and level of education. Gender effects were modeled for women, with the contrast
category of male gender. Race effects were modeled for Black, Latino, and other races, with the
contrast category of White. Marital status effects were modeled for single or divorced or
separated, with the contrast category of married or cohabitating. Education effects were modeled
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 92
for no degree or advanced degree status, with a contrast category of bachelor’s or associate’s
degree.
Mindfulness. Mindfulness was measured using the Mindful Attention and Awareness
Scale (MAAS; K. W. Brown & Ryan, 2003), a unidimensional 15-item measure with a 6-point
Likert-type scale. The MAAS exhibited strong internal consistency across clinical, college-age
nonclinical, and adult samples and in these data (α = .93). The MAAS was designed to measure
the inverse of mindfulness, or “mindlessness,” because the scale’s authors hypothesized that
mindless states would be more familiar and thus easier to recognize for most individuals. Higher
MAAS scores indicate more mindful attention. Items include: “I find myself doing things
without paying attention” and “I find myself preoccupied with the future or the past.” In these
data, the average MAAS score was 3.33 (SD = 0.99), lower than the mean typically found
community adult (M = 4.20, SD = 0.69) and college-age (M = 3.83, SD = 0.70) samples (K. W.
Brown & Ryan, 2003; Carlson & Brown, 2005).
Posttraumatic stress disorder. PTSD was measured using the PTSD Checklist for
DSM-5 (PCL-5; Weathers et al., 2013), a 20-item measure with a 5-point Likert-type scale. The
PCL-5 is a four-factor measure indexing disturbances in intrusive thoughts, physical arousal,
cognitive, and avoidance symptoms. Responses to the 20 items result in a score from 0–80, with
a cutoff score of 33 (National Center for PTSD, 2017). The PCL-5 demonstrated strong internal
consistency in the current study (α = .96). Items include: “In the past month, how much were you
been bothered by: repeated, disturbing, and unwanted memories of the stressful experience?” and
“In the past month, how much were you been bothered by: feeling jumpy or easily startled?”
Depression. Depression was measured using the Patient Health Questionnaire 9 (PHQ-9;
Kroenke, Spitzer, & Williams, 2001), a unidimensional 9-item measure with a 4-point Likert-
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 93
type scale. Scores on the PHQ-9 range from 0 to 27, with a cutoff point of 10. The PHQ-9
demonstrated strong internal consistency in these data (α = .89). Items include the question stem
of: “In the past two weeks, how often have you been bothered by the following symptoms?”
followed by specific symptoms such as “feeling down, depressed or hopeless” and “trouble
concentrating on things, such as reading the newspaper or watching television.”
Self-stigma. Self-stigma of mental health help-seeking was measured with the widely
used Self-Stigma of Seeking Help Scale (SSOSH; Vogel, Wade, & Haake, 2006). The SSOSH is
a unidimensional 10-item measure with a 5-point Likert type scale ranging from 1 (strongly
disagree) to 5 (strongly agree). The SSOSH demonstrated good internal consistency in these
data (α = .80). Items include: “I would feel inadequate if I went to a therapist for psychological
help” and “If I went to a therapist, I would feel less satisfied about myself.” SSOSH scores of
10–22 indicate low stigma, 23–32 indicate moderate stigma, and 32–50 indicate high stigma.
Mental health service use. MHSU was measured with a dichotomous item: “Have you
sought help for a mental, emotional, or stressful problem in the last year from a mental health
professional (e.g., psychiatrist, psychologist, social worker, VA clinician)?” Response categories
were 1 (yes) or 0 (no).
Analyses
A logistic regression modelling strategy was employed to examine associations between
mindfulness, PTSD, depression, self-stigma, demographic covariates and the outcome of MHSU
relative to the previous year. Continuous variables were centered on the mean and all variables
were entered simultaneously in Model 1 to examine main effects of predictors and covariates.
Model 2 introduced a conditional effect by modeling the interaction of mindfulness and PTSD.
The conditional effects model was compared to Model 1 using Akaike information criterion
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 94
(AIC), Bayesian information criterion (BIC), and the additional substantive utility of the
interaction term in explaining MHSU in the previous year. Smaller AIC and BIC values
indicated a better-fitting model (Hosmer, Lemeshow, & Sturdivant, 2013). Average marginal
effects for PTSD at representative margins of mindfulness were plotted to facilitate interpretation
of the interaction term. A final plot examined conditional marginal effects for PCL-5 scores
above the clinical cutoff point of 33. All analyses were conducted in Stata 14.1.
Results
Sample means were above the clinical cutoff points for PTSD and depression; mean
SSOSH and MAAS scores indicated moderate self-stigma and low mindfulness. Approximately
52% of the sample reported MHSU in the last year. Model 1 indicated a significant positive main
effect of PTSD (OR = 1.04, 95% CI: 1.02, 1.06) on MHSU. Mindfulness (OR = 0.68, 95% CI:
0.48, 0.95) and self-stigma (OR = 0.90, 95% CI: 0.87, 0.94) demonstrated significant negative
main effects on MHSU. Among covariates, age (OR = 1.04, 95% CI: 1.01, 1.07), female gender
(OR = 2.36, 95% CI: 1.35, 4.10), and unmarried status (OR = 2.07, 95% CI: 1.14, 3.77)
demonstrated positive associations with MHSU, whereas being Black (OR = 0.23, 95% CI: 0.11,
0.48), being Latino (OR = 0.47, 95% CI: 0.28, 0.78), or having an advanced degree (OR = 0.38,
95% CI: 0.20, 0.89) demonstrated negative associations.
For Model 2, there was a significant interaction effect (OR = 1.03, 95% CI: 1.01, 1.03) of
mindfulness and PTSD on MHSU. The main effects of PTSD and self-stigma remained
significant, as did effects of age; being female, Black, or Latino; and having an advanced degree.
An additional significant main effect emerged for being separated or divorced (OR = 1.95, 95%
CI: 1.02, 3.74). The negative main effect of mindfulness was no longer significant after
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 95
accounting for the interaction between mindfulness and PTSD. All parameter estimates for both
models are presented in Table 4.2.
Comparison of AIC and BIC indexes showed smaller values for Model 2 and a
magnitude difference of 4.85 in BIC, which provided positive support for better fit to the data in
Model 2 (Raftery, 1995). Average marginal effects of PTSD on the probability of MHSU were
plotted across the range of mindfulness values from 2 standard deviations below to 2 standard
deviations above the mean. Results, shown in Figure 4.1, indicate nonsignificant marginal effects
of PTSD at mindfulness values 1 or more standard deviations below the mean. Above this value,
higher mindfulness scores were associated with significantly greater probability of MHSU per
unit increase in PCL-5 score. With mindfulness held constant at 1 standard deviation above the
mean, each unit increase in PCL-5 score was associated with a 1% increase in the probability of
MHSU. The conditional marginal effects plot for PCL-5 scores above the clinical cutoff point
showed that mindfulness below the mean was associated with reduced probability of MHSU,
whereas mindfulness above the mean was associated with increased probability of MHSU
(Figure 4.2).
Discussion
This study yielded results consistent with previous research and novel findings regarding
associations among mindfulness, PTSD, and MHSU. Sample descriptive statistics show that the
mean PTSD and depressive symptoms endorsed by study participants were higher than the
clinical cutoffs for both disorders. This may be because nearly 90% of respondents endorsed at
least one deployment and those with more pronounced symptoms may have been more
motivated to participate in study. However, not all respondents who met cutoff points for PTSD
and depression measures would be expected to meet full diagnostic criteria for these disorders
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 96
after full clinical interviews. Finally, although elevated rates in the current sample may limit this
study’s generalizability to the larger veteran population, they may nevertheless assist with
improving understanding of challenges to mental health help-seeking for the subset of veterans
who suffer from severe symptoms of PTSD and depression.
Consistent with previous research, increased PTSD symptoms were associated with
increased odds of reporting MHSU in the last year, whereas self-stigma was associated with
decreased odds (Elbogen et al., 2013; Kim et al., 2010). The main effect of depressive symptoms
was nonsignificant, although it is important to note that the PCL-5 includes a depressive
symptoms factor, and the empirical literature largely supports the view that PTSD includes
depressive symptoms like low mood, anhedonia, and negative thoughts (Campbell et al., 2007;
O’Donnell, Creamer, & Pattison, 2004; Stander, Thomsen, & Highfill-McRoy, 2014). Thus,
although the main effect of depression is important to account for, the more inclusive PTSD
construct may explain most of the mental health symptom-related variance in outcomes.
In addition, veterans in the current cross-sectional sample who sought mental health
services in the last year may still have been experiencing substantial PTSD symptomology at the
time of survey completion. Most OEF/OIF veterans who initiate PTSD treatment typically do not
complete it (Elnitsky et al., 2013; Hoge et al., 2004; Pietrzak, Johnson, Goldstein, Malley, &
Southwick, 2009; Schell & Marshall, 2008), and a recent meta-analysis showed that 60% to 70%
of veterans who complete one of the Veterans Health Administration’s gold-standard PTSD
therapies retain their PTSD diagnoses (Steenkamp, Litz, Hoge, & Marmar, 2015).
More work is needed to develop and improve PTSD treatments, but the problem of low
rates of MHSU in veterans remains. From the service engagement perspective, the question is
what differentiates those with PTSD symptoms who seek help from those who do not? The
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 97
interaction effect of mindfulness on the association between PSTD and MHSU in these data may
prove informative. Examining the average marginal effects of PTSD showed that below the
sample mean of mindfulness, increases in PTSD symptoms were not significantly associated
with increased probability of MHSU. However, at and above the mean of mindfulness, PTSD
was associated with increased probability of MHSU. Substantively, this indicates an increase of
1 standard deviation on the PCL-5 at mean mindfulness was associated with an approximately
20% increase in the probability of MHSU. This finding suggests a buffering effect of
mindfulness in the context of service seeking for PTSD symptoms such that increasingly above
mean mindfulness but not below it, the probability of MHSU increases as PTSD symptoms
increase.
This effect is more pronounced for clinically significant PTSD symptoms. Regarding
PCL-5 scores above the clinical cutoff point, respondents 1 or more standard deviations below
the mean on mindfulness were 20%–40% less likely to endorse MHSU, whereas those 1 or more
standard deviations above the mean on mindfulness were 20%–60% more likely to endorse
MHSU. These marginal effects suggest that mindfulness may be an overlooked determinant of
MHSU in veterans with clinically significant PTSD symptoms.
Findings for demographic covariates were largely consistent with previous research.
Minority race and ethnicity was associated with decreased MHSU, which may indicate
additional internal or external barriers to MHSU for minority veterans (Rosenheck & Fontana,
1996), although other studies have found nonsignificant associations between veterans’ minority
status and MHSU (Elhai, Reeves, & Frueh, 2004). Having an advanced degree was also
negatively associated with MHSU, although this may be because those with advanced degrees
were less likely to endorse PTSD symptoms in these data and previous studies (Magruder et al.,
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 98
2004). Women in this study were more than twice as likely to report MHSU than were men. This
may reflect previous findings showing that negative attitudes toward treatment were more salient
for male veterans and that perceptions of service availability were more influential in facilitating
MHSU among female veterans (Vogt, 2011). Consistent with previous studies, age was
positively associated with MHSU (Seal et al., 2010). Finally, being single or divorced or
separated was associated with nearly twice the odds of reporting MHSU in the last year
compared to being married or cohabitating with a partner, which may reflect the increased risk of
PTSD associated with belonging to these groups and interactions with other variables, like age.

MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 99
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MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 105
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Table 4.1. Descriptive Statistics
n % M SD
Age
21–29 66 11.87
30–39 273 49.10
40–49 150 26.98
50–59 51 9.17
60+ 16 2.88
Race
White 273 49.10
Black 59 10.61
Latino 144 25.90
Other 80 14.39
Gender
Male 444 79.86
Female 111 19.96
Education
No degree 183 32.91
College degree 294 52.88
Advanced degree 77 14.21
Marital status
Single 97 17.48
Married or cohabitating 362 65.22
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 107
Separated 96 17.29
MHSU in last 12 months 554 51.87
MAAS 538 3.33 0.99
PCL-5 530 38.16 20.26
PHQ-9 535 11.52 6.75
SSOSH 547 26.04 6.40
Note. PCL-5 = PTSD Checklist for DSM-5; PHQ-9 = Patient Health Questionnaire 9; MAAS = Mindful Attention
and Awareness Scale; MHSU = mental health service use; SSOSH = Self-Stigma of Seeking Help Scale.

MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 108
Table 4.2. Odds Ratios and 95% Confidence Intervals of Predictors and Covariates of Mental
Health Service Use in the Last 12 Months
Model 1 Model 2
OR 95% CI OR 95% CI
Depression 1.02 0.96, 1.08 1.02 0.96, 1.09
PTSD 1.04 1.02, 1.06 1.04 1.02, 1.06
Mindfulness 0.68 0.48, 0.95 0.78 0.54, 1.12
Self-stigma 0.90 0.87, 0.94 0.90 0.87, 0.94
Mindfulness × PTSD 1.03 1.01, 1.03
Age 1.04 1.01, 1.07 1.04 1.02, 1.07
Female 2.36 1.35, 4.10 2.39 1.36, 4.20
Race
Black 0.23 0.11, 0.48 0.22 0.10, 0.47
Latino 0.47 0.28, 0.78 0.46 0.28, 0.78
Other race 0.83 0.44, 1.56 0.85 0.45, 1.62
Marital status
Single 2.07 1.14, 3.77 2.03 1.10, 3.74
Separated or divorced 1.79 0.94, 3.43 1.95 1.02, 3.74
Education
No degree 0.89 0.55, 1.44 0.93 0.57, 1.51
Advanced degree 0.38 0.20, 0.89 0.40 0.21, 0.75
AIC × n 584.70 575.63
BIC -71.34 -76.19
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 109
Note. Reference categories were male for gender, White for race, married for marital status, and associate’s or
bachelor’s degree for education. AIC = Akaike information criterion; BIC = Bayesian information criterion.

MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 110
Figure 4.1. Sample Composition

MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 111
Figure 4.2. Average Marginal Effects of PTSD at Representative Levels of Mindfulness with
95% Confidence Intervals

MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 112
Figure 4.3. Conditional Marginal Effects of PTSD above the Clinical Cutoff with 95%
Confidence Intervals at Representative Levels of Mindfulness

MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 113
Chapter 5: Conclusion
Introduction
United States military veterans are a well-studied population for good reason; they have
been subject to uniquely challenging social and cultural pressures and expectations. Especially in
the context of extended, high-tempo combat deployments of the sort that characterized the
Operation Enduring Freedom and Operation Iraqi Freedom conflicts, the consequences of
veterans’ military experiences can include social, economic, physical, spiritual, and
psychological difficulties that continue long after their transition to veteran status (Bruce, 2010;
Kang et al., 2015; Seal et al., 2009). Despite substantial resources devoted to improving mental
health outcomes for veterans, a significant minority experience persistent psychological
problems. For post-9/11 veterans in particular, high rates of posttraumatic stress disorder
(PTSD), depression, and suicide have resisted attempts by researchers, clinicians, and
administrators to identify and ameliorate causes and develop and deliver effective prevention and
intervention services (Fox, Meyer, & Vogt, 2015; Garcia et al., 2014). In addition to elevated
rates of mental illness compared to the civilian population and previous generations of veterans,
mental health stigma and low rates of mental health service use continue to be significant
problems in post-9/11 veterans (Hoge et al., 2004; Vogt, 2011).
Much of the research devoted to improving mental health outcomes in veterans has
rightly focused on identifying risk factors for PTSD and depression; these have included
intensity and number of combat experiences, prior traumatic events, and physical injury (Castro
& McGurk, 2007; Guyker et al., 2013; Hoge et al., 2004; LeardMann et al., 2013). More
recently, the resilience-focused literature has investigated characteristics associated with factors
that protect against negative outcomes despite exposure to stressors. But much of this literature
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 114
has focused on constructs like social support, acceptance of change, emotional stability, and
conscientiousness, for which few evidence-based interventions exist (DeViva et al., 2016; King,
King, Vogt, Knight, & Samper, 2006; Tsai, Harpaz-Rotem, Pietrzak, & Southwick, 2012). In
addition, few studies have examined veterans’ mental health outcomes through the lens of
integrative models that include main, interactive, and indirect effects of both risk and protective
factors, more closely mirroring the real-life constellation of social and psychological processes
that determine mental health-related behaviors and outcomes. This dissertation research
contributed to the veteran mental health literature by examining integrated models including both
risk factors and a protective mindfulness factor to better understand critical, interrelated mental
health outcomes: mental health symptoms, self-stigma of mental health symptoms, and mental
health service use.
Because of theoretical and empirical support in the mental health literature for its role in
enhancing resilience, mindfulness was the core protective factor under investigation in this study.
Mindfulness acts in direct opposition to cognitive and affective processes, like avoidance,
suppression, and dissociation, hypothesized to perpetuate PTSD and depressive symptomology.
In addition, nonjudgment is a critical correlate of mindfulness. The link between mindfulness
and nonjudgmental perceptions supports the view that enhancing mindfulness may diminish self-
stigma, which by definition consists of negative judgements about the meaning of mental health
symptoms (Corrigan & Watson, 2002). In addition, mindfulness is an efficient intervention
target; a robust literature supports mindfulness-based interventions for a wide range of mental
health and stress-related conditions (Bhatnagar et al., 2013; Kabat-Zinn, 1990; Kearney,
McDermott, Malte, Martinez, & Simpson, 2013; King et al., 2013; Segal, Williams, & Teasdale,
2012).
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 115
This final chapter presents major findings from the three empirical papers and discusses
the limitations of the studies and areas for future research. The chapter concludes with
implications for training, prevention, intervention, and service delivery with this population.
Major Findings
At the heart of this dissertation research was an investigation of two related problems: the
high rates of PTSD and depression among post-9/11 veterans and the low rates of mental health
service use among those who screen positive for mental health problems. Findings from these
studies provide strong support for mindfulness as protective factor for these problems.
Mindfulness demonstrated a significant protective effect against PTSD and depressive symptoms
in Study 1. The negative main effect of mindfulness on PTSD ( β = -.67) was nearly 4 times the
magnitude of the positive main effect of combat experiences ( β = .18). Regarding depression, the
effect of mindfulness ( β = -.69) was nearly 7 times the effect of combat experiences ( β = .10). In
addition, these models accounted for a substantial amount of the variance in PTSD (R
2
= .61) and
depression (R
2
= .57). Adding mindfulness to bivariate models of associations between combat
experiences and mental health outcomes explained an additional 39% of the variance in PTSD
and 41% of the variance in depression. This study was the first to jointly investigate effects of
these variables on PTSD and depression in veterans, and results suggest that mindfulness may be
a highly salient and overlooked predictor of mental health symptoms in this population. Findings
further support the view that more mindful individuals are more resilient to PTSD and depression
in the context of combat experiences.
Study 2 was the first investigation of associations among mindfulness, mental health
symptoms, and self-stigma in veterans. In addition to direct effects of mindfulness on PTSD and
depression, findings show a negative indirect effect of mindfulness on self-stigma of mental
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 116
illness through the PTSD pathway ( β = -.47, p < .001). This effect was of greater magnitude than
the positive direct effect of PTSD on self-stigma ( β = .40, p < .001). This is particularly
noteworthy because self-stigma is a core barrier to accessing mental health services in this
population, and existing interventions designed to reduce self-stigma in the military context have
been largely unsuccessful (Griffiths, Carron-Arthur, Parsons, & Reed, 2014). Although the
negative direct effect of mindfulness on self-stigma did not meet the threshold of statistical
significance, findings suggest that mindfulness, in addition to its primary effect on mental health
symptoms, may indirectly reduce self-stigma in the context of PTSD symptoms. This is
consistent with previous research showing that enhancing mindfulness reduces self-judgment and
improves acceptance toward thoughts and feelings (Thompson, Arknoff, & Glass, 2011;
Vujanovic, Niles, Pietrefesa, Schmertz, & Potter, 2013). Mindfulness in the context of mental
health symptoms may have a double buffering effect; more mindful individuals have less severe
symptoms of PTSD and depression and fewer stigmatizing views about those symptoms.
Despite substantial effort on the part of veterans service organizations to expand the
availability of mental health services, many veterans do not access care. Study 3 demonstrated
novel findings related to risk and protective factors in the context of mental health service use
and showed that although an overall positive association existed between PTSD symptoms and
mental health service use (OR = 1.04, 95% CI: 1.02, 1.06), the interaction effect of mindfulness
and PTSD (OR = 1.03, 95% CI: 1.01, 1.03) adds a critical explanatory layer. At low levels of
mindfulness, the average marginal effect of PTSD on mental health service use is nonsignificant.
Substantively, this means the increased probability of mental health service use associated with
PTSD symptoms was significant only as mindfulness neared the mean, and this probability grew
in magnitude as mindfulness increased above the mean. Perhaps more importantly, for veterans
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 117
above the PTSD clinical cutoff, PTSD symptoms were negatively associated with mental health
service use below mean mindfulness and increasingly positively associated with service use as
mindfulness increased above the mean. For those most in need of mental health services, these
associations indicate that low levels of mindfulness reduce the probability of receiving services,
whereas high levels of mindfulness dramatically increase that probability. This effect persisted
even when accounting for the influence of self-stigma on service use.
Taken together, these findings suggest that mindfulness exerts a protective effect on a
range of interrelated mental health outcomes in post-9/11 veterans with high rates of deployment
and clinically significant PTSD and depression. In these studies, protective effects of
mindfulness were larger in magnitude than effects of salient risk factors identified in the
veterans’ mental health literature. In addition, mean mindfulness in this sample (M = 3.33, SD =
1.00) was below that reported in samples of college students (M = 3.83, SD = 0.70) and adults in
the general population (M = 4.20, SD = 0.69; Brown & Ryan, 2003). This suggests that the
sample as a whole was unlikely to have received training in mindfulness practices and indicates
that there may be substantial room to improve mindfulness skills in similar groups of veterans.
Limitations and Future Directions
These studies had several limitations that also represent areas for future research. First,
these data were cross-sectional; thus, assumptions regarding causal effects between variables
cannot be made. In addition, although study participants were vetted by the veterans’ service
organizations that linked them to the larger studies from which the sampling frame was drawn,
no additional vetting regarding the veracity of veteran status was performed in the context of
these studies. This is typical of veterans’ survey-based literature that has included participants
not recruited directly through U.S. Department of Veterans Affairs (VA) databases and linkages
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 118
(Kintzle et al., 2015; Matthieu, Lawrence, & Robertson-Blackmore, 2017; O’Toole, Conde‐ Martel, Gibbon, Hanusa, & Fine, 2003). Nevertheless, it is possible that some nonveteran
respondents were able to slip through initial agency verification procedures and were motivated
to complete both this survey and the previous surveys from which the current sampling frame
was derived. This survey had a verified participant response rate of 38%, which is commensurate
with other veterans surveys (U.S. Department of Veterans Affairs, 2010). However, it is possible
that nonrespondents had different experiences than those who elected to respond.
More than 87% of respondents reported an overseas deployment, 59.63% met the clinical
cutoff for depression on the 9-item Patient Health Questionnaire, and 60.20% met the clinical
cutoff for PTSD on the PTSD Checklist for DSM-5. These rates are higher than those reported
for the overall population of veterans by VA agencies (Fulton et al., 2015; Veterans Health
Administration, 2016) and likely reflect the high deployment rate in this sample. Although these
descriptive statistics suggest that this sample may not be representative of the overall population
of post-9/11 veterans, results may be generalizable to those with combat deployments and
higher-than-average rates of PTSD and depression. A related limitation is that it is not known
how many survey respondents had any lifetime contact with the VA. Additional efforts should be
made in future studies to sample from non-VA-connected veterans; little is known about this
population compared to VA-connected veterans (Vaughan et al., 2014).
Previous studies have noted a pattern of symptom overreporting among Vietnam-era
veterans seeking service-connected compensation from the VA (Freeman, Powell, & Kimbrell,
2008; Frueh, Gold, & Arellano, 1998) and those with more pronounced dissociative and
anhedonic symptoms (Kashdan, Elhai, & Frueh, 2007; Merckelbach, Boskovic, Pesy, Dalsklev,
& Lynn, 2016), although the same pattern has not been observed in post-9/11 veterans. Other
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 119
studies have observed that a variety of underreporting and overreporting biases may be present
for veterans in different contexts (Maguen et al., 2011). However, because these data were
anonymous, respondents had little to lose or gain by inaccurately reporting mental health
symptoms.
Beyond sample-related considerations, future studies would benefit from including
multiple measures of complex constructs like mindfulness, stigma, and mental health service use
behavior, in addition to self-report questionnaires of the sort used in these studies. For
mindfulness, these might include both objective attention tasks like the selective attention
response test and convergent measures of nonjudgment and acceptance toward thoughts and
emotions. In addition, more must be done to disentangle mental health stigma from self-reliance
and a preference for self-management of symptoms evinced by many veterans (Adler, Bliese, &
Castro, 2011; Pietrzak, Johnson, Goldstein, Malley, & Southwick, 2009). From the perspective
of understanding service use, accessing objective indicators through linkages to VA and
community agency administrative data will be critical for robust investigation of this complex
behavior. Although evidence shows that few veterans who initially access mental health services
complete treatment (Seal et al., 2010), little is known about why this is the case. A mixed-
methods approach leveraging administrative data, psychometric scales, and perhaps qualitative
interviewing seems appropriate for advancing understanding of this nuanced and difficult issue.
Finally, beyond demographic covariates, this study did not account for the larger ecology
of social and contextual variables that might affect veterans’ mental health-related processes and
outcomes. Understanding social context is critically important for veteran research, not least
because the military bears many of the hallmarks of a total institution (Goffman, 1961) and
exerts powerful social conditioning on its members. Despite the intensely social nature of
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 120
military organizational units (Ingraham, 1984), no studies involving military veterans have used
social network analysis methods. Future research should endeavor to collect both egocentric and
sociometric network data to better understand network-level influences on veterans’ mental
health-related predictors, mediators, moderators, and outcomes.
Implications
The development of mental health symptoms and decision making about mental health
service use is personal, nuanced, and contextual; improving mindfulness skills in military service
members and veterans will not eliminate PTSD and depression related to combat stress or
dissolve the stigma barrier rooted in military and broader cultural norms. Although mindfulness
will not be a panacea for the complex, dynamic, and interdependent problems under
investigation in these studies, enhancing mindfulness can be thought of much like enhancing
physical fitness. Physical fitness does not prevent all injury, but it does reduce overall risk of
injury and improves duration and quality of recovery in civilian, first responder, and military
populations (Bullock, Jones, Gilchrist, & Marshall, 2010; Cady, Bischoff, O’Connell, Thomas,
& Allan, 1979; Haskell et al., 2007; Kaufman, Brodine, & Shaffer, 2000). The military includes
a physical fitness requirement for all branches because fitness enhances mission preparedness by
improving physical capabilities and resilience. The current study findings, and the larger
mindfulness literature, suggest that there is a similar salutary effect of mindfulness on mental
health and fitness. Enhancing mindfulness in veterans is likely to enhance psychological
resilience across a range of mental health outcomes.
From a prevention perspective, it seems a good investment to train military service
members in mindfulness skills, emphasize the importance of these skills for mission
preparedness, and incentivize ongoing mindfulness practice. Fitness is a core military value and
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 121
training domain—its definition should be explicitly broadened to include up-to-date methods for
enhancing both psychological and physical resilience. Emerging research has suggested
mindfulness-based interventions like Mindfulness-Based Mind Fitness Training, designed
specifically for military and other high-stress cohorts, may be effective in reducing stress
indicators following exposure to stressful events (Meland et al., 2015; Stanley, Schaldach,
Kiyonaga, & Jha, 2011). Although additional investigations of these interventions should be
conducted, existing findings support inclusion of mindfulness-based techniques in basic training
and potentially top-up training offered at additional intervals—for example, prior to deployment.
As is the case with Mindfulness-Based Mind Fitness Training, it will be critical to tailor these
interventions to fit military cultural norms and expectations.
In addition to prevention, a mindfulness-based approach to enhancing psychological
resilience through training might also have implications for intervention and service delivery.
Evidence shows that prolonged exposure and cognitive processing therapy, the current gold-
standard interventions for PTSD, are less effective than previously thought for improving PTSD
symptoms in veterans; nonresponse rates among patients receiving these therapies are high, and
many patients still meet diagnostic criteria following treatment (Steenkamp, Litz, Hoge, &
Marmar, 2015). More investigation of novel, evidence-based interventions is required to improve
outcomes for veterans with PTSD. Mindfulness-based approaches have shown promise, and they
should be included in such investigations. In addition, enhancing acceptance and nonjudgment
skills associated with mindfulness may more effectively address moral dimensions of military
trauma than exposure-based therapies (Farnsworth, Drescher, Nieuwsma, Walser, & Currier,
2014).
MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 122
Conclusion
This dissertation aimed to develop a body of empirical evidence examining the protective
value of mindfulness in the context of identified risk factors in post-9/11 military veterans’
mental health-related outcomes. These studies contribute to the growing mindfulness- and
resilience-focused literature and have implications for prevention and intervention with military
veterans, service members, and perhaps other high-stress cohorts at risk of exposure to traumatic
events.
In rigorous non-Western philosophical traditions, mindfulness practice has long been
understood to produce benefits in mental health and resilience—the growing empirical literature
investigating mindfulness largely supports these findings. Although the traditional definition of
mindfulness is difficult to distill from its complex cultural and historical roots, the simplified,
empirically supported definition employed in these studies nevertheless has important
implications for enhancing mental health and resilience in veterans. Paying attention to present-
moment mental experiences with nonjudgmental acceptance is a teachable skill. It can be
improved through practice using relatively straightforward techniques. It presents low risk and
seems to have significant mental health benefits. Scholars and practitioners interested in
improving mental health-related outcomes for veterans and other high-risk cohorts should
vigorously pursue this line of research.

MINDFULNESS, MENTAL HEALTH, AND SERVICE USE 123
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Asset Metadata

Creator Barr, Nicholas Upton (author)

Core Title Mindfulness and resilience: an investigation of the role of mindfulness in post-9/11 military veterans' mental health-related outcomes

Contributor Electronically uploaded by the author (provenance)

School School of Social Work

Degree Doctor of Philosophy

Degree Program Social Work

Publication Date 07/19/2018

Defense Date 05/31/2018

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

Tag Mental Health,Military,mindfulness,OAI-PMH Harvest,PTSD,resilience,Veterans

Format application/pdf (imt)

Language English

Advisor Castro, Carl Andrew (committee chair), Brekke, John (committee member), Chou, Chih Ping (committee member)

Creator Email nicholub@usc.edu,nuptonbarr@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-20566

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Legacy Identifier etd-BarrNichol-6424.pdf

Dmrecord 20566

Document Type Dissertation

Format application/pdf (imt)

Rights Barr, Nicholas Upton

Type texts

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Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

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Abstract (if available)

Abstract Military veterans of the post-9/11 era conflicts in Iraq and Afghanistan are at high risk of developing symptoms of mental health disorders, including posttraumatic stress disorder (PTSD) and depression. However, these veterans are likely to report stigmatizing mental health-related beliefs that reduce their likelihood of receiving mental health treatment. Together, these findings point to a need for research that can be leveraged to promote resilience across the continuum of veterans' mental health experiences to enhance prevention, reduce stigma, and increase the likelihood of mental health service use. ❧ This three-study dissertation aimed to improve understanding of risk and protective factors that contribute to post-9/11 era veterans' mental health symptoms, stigmatizing beliefs, and treatment decisions. By applying a risk and resilience framework to investigate associations between mindfulness, combat experiences, PTSD and depression, self-stigma, and mental health service use, each of the three studies sought to explain mental health-related outcomes at interrelated cross-sections of veterans' mental health continua. ❧ Chapter 1 provides an overview of post-9/11 veterans' mental health risks and treatment obstacles and develops the links among the three studies, introducing key study constructs and describing the overarching conceptual framework and individual study goals. Chapter 2 (Study 1) examines and compares main effects of combat experiences and mindfulness on PTSD and depression to improve understanding of how these risk and protective factors contribute to the development of veterans' mental health symptoms. Chapter 3 (Study 2) examines direct and indirect effects of mindfulness, PTSD, and depression on self-stigma of mental illness to develop an integrated risk and resilience model of veterans' self-stigma. Chapter 4 (Study 3) examines main and interaction effects of mindfulness, PTSD and depression, and self-stigma on mental health service use to develop a holistic model of predictors of service use in this population. Chapter 5 discusses conclusions yielded by each study, the broader importance of the study findings, and implications for training, prevention, intervention, service delivery, and future research.