Fall 2021

RESEARCH ON THE WELL-BEING OF HISTORICALLYSERVICE MEMBERS, BLACK VETERANS,COLLEGES DEPENDENTS AND SURVIVORS AND UNIVERSITIESBY SERVICE MEMBERS, VETERANS, DEPENDENTS AND SURVIVORS Shaping Lives: The Everyday Hero as TransformativePut Yourself Agent inPage My 22 Combat Boots: Autoethnographic Reflections on Forms of Life as a Soldier and VeteranPage 81 Copyright © 2021 by The University of Alabama Division of Community Affairs. All rights reserved. ISSN 1944-1207. Publisher Associate Editor, Production Editor/Web Producer Samory T. Pruitt, PhD Special Issues Karyn Bowen Vice President Rhoda Reddix, PhD Marketing Manager Division of Community Affairs Associate Professor, Program Division of Community Affairs The University of Alabama Director, Service Learning The University of Alabama Franciscan Missionaries Editor of Our Lady University Assistant to the Editor Marybeth Lima, PhD Violet Nkwanzi, Doctoral Student Cliff and Nancy Spanier Editorial Assistant School of Social Work Alumni Professor Edward Mullins, PhD The University of Alabama Louisiana State University Director, Communication and Research, Center for Associate Editor Community-Based Partnerships Andrew J. Pearl, PhD The University of Alabama Director, Community Engagement Research and Publications Editorial Assistant The University of Alabama Diane Kennedy-Jackson Associate Editor, Student Publications Coordinator and Community Engagement Division of Community Affairs Katherine Rose Adams, PhD The University of Alabama Assistant Professor of Higher Education Leadership and Practice University of North Georgia

EDITORIAL BOARD

Marsha H. Adams, PhD Delicia Carey, PhD Sandra De Urioste-Stone, PhD Dean, College of Nursing Statistician, Centers for Disease Assistant Professor, Center for The University of Alabama-Huntsville Control and Prevention Research on Sustainable Forests, Atlanta, Georgia School of Forest Resources Andrea Adolph, PhD The University of Maine Director, Academic Affairs, and Doyle Carter, PhD Associate Professor of English and Professor and Director of the Quality David J. Edelman, PhD Women’s Studies Enhancement Plan/Center for Professor and Master of Community Department of Women’s, Gender, Community Engagement Planning Coordinator, Urban and and Sexuality Studies Department of Kinesiology Regional Planning Penn State-New Kensington Angelo State University University of Cincinnati Katrice A. Albert, PhD Richard L. Conville, PhD Hiram E. Fitzgerald, PhD Vice President, Equity and Diversity (retired) Associate Provost, University University of Minnesota Professor, Communication Studies Outreach and Engagement, The University of Southern and Professor of Psychology Anna Sims Bartel, PhD Mississippi Michigan State University Associate Director, Engaged Learning and Research Virginia Cope, PhD Nancy Franz, PhD Cornell University Assistant Dean and Associate Professor Emeritus, School Professor, Department of English of Education Lola Baydala, MD, MSc, FRCP Ohio State University-Newark Iowa State University Professor of Pediatrics Faculty of Medicine Susan Curtis, PhD Philip A. Greasley, PhD University of Alberta Professor, School of Associate Provost, University Interdisciplinary Studies Engagement Constance Beecher, PhD Purdue University University of Kentucky Associate Professor, School of Education Iowa State University Mary Elizabeth Curtner-Smith, Sulina Green, PhD PhD Professor, Department of Social Work Alice M. Buchanan, PhD Associate Professor, Department Stellenbosch University Associate Professor, School of of Human Development and Kinesiology, College of Education Family Studies, College of Human Valerie Holton, PhD Auburn University Environmental Sciences Director, Community-Engaged The University of Alabama Research Virginia Commonwealth University

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 2 EDITORIAL BOARD (CONTINUED) Susan S. Jakes, PhD Mary Ann Murphy, PhD Sunil Saigal, PhD Extension Assistant Professor and Professor, Dyson College of Arts Professor, Department of Civil and Associate State Program Leader and Sciences, Department of Environmental Engineering for Community Development Communication Studies New Jersey Institute of North Carolina State University Pace University Technology Kimberly L. King-Jupiter, PhD dt ogilvie, PhD Nick Sanyal, PhD (retired) Professor, College Professor, Center for Urban Professor, Natural Resources of Education Entrepreneurship, Saunders and Society Alabama State University College of Business University of Idaho Rochester Institute of Technology William Kisaalita, PhD Amilcar Shabazz, PhD Professor, College of Engineering Jacob Oludoye Oluwoye, PhD Professor, Department of University of Georgia Associate Professor, Community Afro-American Studies Planning and Urban Studies University of Massachusetts- J. Robert Krueger, PhD Alabama A&M University Amherst Associate Professor and Director, Timothy Shaffer, PhD Environmental and Sustainability Michael E. Orok, PhD Assistant Professor, Department Studies; Co-director, London Dean, School of Humanities of Communication Studies Project Center; and Director, and Social Sciences Kansas State University Worcester Community Project Virginia Union University Center Cassandra Simon, PhD Worcester Polytechnic Institute Judith Owens-Manley, PhD Associate Professor Director, Center for Community School of Social Work James Leeper, PhD Engagement & Learning and The University of Alabama Chair, Civic Engagement Professor, Community and Rural Certificate Program Medicine, College of Community L. Steven Smutko, PhD University of Alaska Anchorage Health Sciences Professor and Spicer Chair of The University of Alabama Collaborative Practice, Haub Linda Pei, PhD School of Environment and Robert C. Liebman, PhD Assistant Professor in Natural Resources, Department Professor, Department of International Education of Agricultural and Applied Sociology Shanghai Urban Construction Economics Portland State University Vocational College University of Wyoming Antoinette Lombard, PhD Josephine Pryce, PhD Jessica Averitt Taylor, PhD Professor and Head of the Associate Professor, School of Associate Professor, Department Department of Social Work Social Work of Counseling, Social Work, and Criminology The University of Alabama and Leadership University of Pretoria Northern Kentucky University Scott Reed, PhD (retired) Kimberley Mangun, PhD Vice Provost, Division of Outreach Kim L. Wilson, PhD Associate Professor, and Engagement Professor and Director of the Department of Communication Oregon State University Landscape Architecture Program The University of Utah and Community and Regional Susan Reiser, MS Planning, College of Architecture Lee Miller, PhD Associate Dean of Natural University of Nebraska-Lincoln Associate Professor, Department Sciences of Sociology University of North Carolina Sam Houston State University at Asheville Robert L. Miller, Jr., PhD Howard B. Rosing, PhD Associate Professor, School of Executive Director, The Irwin W. Social Welfare Steans Center for Community- University of Albany-SUNY Based Service-learning and Community Service Studies DePaul University

The Journal of Community Engagement and Scholarship is published at The University of Alabama by the Division of Community Affairs to advance the scholarship of engagement worldwide. To reach the editor, send an email to [email protected] or call 205-348-4480. See also www.jces.ua.edu.

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 3 RESEARCH ON THE WELL-BEING OF SERVICE MEMBERS, VETERANS, DEPENDENTS AND SURVIVORS BY SERVICE MEMBERS, VETERANS, DEPENDENTS AND SURVIVORS

Special Issue Introduction Page 5 Put Yourself in My Combat Boots: Autoethnographic Reflections on Forms “I remember the skills we learned and of Life as a Soldier and Veteran Page 81 put them into practice”: An Evaluation Shawn Dunlap of a Peer Support Training Program for Veterans Page 11 Profoundly Changed: The Homecoming Karen Besterman-Dahan, Jacqueline Sivén, of Veterans from Iraq and Afghanistan Kiersten Downs, and Tatiana Orozco Page 95 Kelly Wadsworth “If You Don’t Name the Dragon, You Can’t Begin to Slay It:” Participatory How Veterans Make Meaning of Action Research to Increase Awareness the College Choice Process in Around Military-Related Traumatic Brain the Post-9/11 Era Page 104 Injury Page 25 Derek M. Abbey Gala True, Ray Facundo, Carlos Urbina, Sawyer Sheldon, J. Duncan Southall, and Military Culture and Its Impact Sarah S. Onon on Mental Health and Stigma Page 116 A. Ganz, Chikako Yamaguchi, Bina Parekh FROM THE FIELD Gilly Koritzky, and Stephen E. Berger Motivations of Older Veterans and Dependents in a Physical Activity Benefits of Brazilian Jiu-Jitsu in Program Page 41 ManagingPost-Traumatic Stress Candace S. Brown, Ismail Mustafa Disorder: A Longitudinal Study Page 129 Aijazuddin, and Miriam C. Morey Kelly Weinberger and Tracey Burraston Creating Community for Women Teaching Military Cultural Competency Veterans Through Social Networking to Clinicians and Clinical Students: Organizations: A Secondary Analysis Assessing Impact and Effectiveness of Team Red, White, and Blue New Page 138 Member Surveys Page 52 Nancy Isserman and James Martin Kate Hendricks Thomas, Caroline M. Angel, Nicholas J. Armstrong, Michael S. Erwin, U.S. Veterans Experience Moral Injury Louis P. Nemec, Brandon B. Young, John M. Differently Based on Moral Foundations Pinter, Blayne P. Smith, and Justin T. McDaniel Preferences Page 151 Daniel Perez, Paul Larson, and John Bair Culturally Informed Interventions for Military, Veteran and Emergency Structural Examination of Moral Injury Service Personnel: The Importance and PTSD and Their Associations With of Group Structure, Lived Experience Suicidal Behavior Among Combat Facilitators, and Recovery-Oriented Veterans Page 161 Content Page 66 Allison R. Battles, Jeremy Jinkerson, Jonathan Lane, Miranda Van Hooff, Ellie Michelle L. Kelley, and Richard A. Mason Lawrence-Wood, and Alexander McFarlane

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 4 Special Issue Introduction: Research on the Well-being of Service Members, Veterans, Dependents and Survivors by Service Members, Veterans, Dependents and Survivors

SPECIAL ISSUE EDITORS Karl Hamner, Barton Buechner and Christopher Gill

Introduction It was a cold day in November of 2007 when the town of Brunswick, Maine, held its annual Veterans Day ceremony in a picturesque park adjacent the parish church. It was my last day in town before moving down south for a new job. As I took stock of the group of people surrounding me, I began to retreat into myself. To my left were mostly civilian onlookers who came to pay their respects. On the stage were several Vietnam veterans talking about things that seemed so foreign to my recent experience. They talked about recovery from the postwar years, repairing relationships with loved ones, and the hope they found in sharing their experiences. In the rest of the crowd, a smattering of World War II veterans leaned on canes or sat in wheelchairs, along with a few Desert Storm veterans with the obligatory black biker vests denoting their service. There were no other War on Terror veterans that I could see. I believed these other veterans had somehow moved on in a way I could not. They seemed to have it together and to have put the war behind them, while I stood there as my life crumbled around me. A short distance away, the sum of my 30 years of life, in the form of all my belongings, sat in a rusty old pickup. They represented war, a broken marriage, and a diffused sense of self that left me rudderless and adrift after 11 years of service in the Marine Corps. The truck’s incessant rattling taunted me with echoes of my failure to find sustainable work, hold my marriage together, and deal with the unrelenting images of war. The next day, the truck would take me from the brutal familiarity of Maine to the vast unknown of south Alabama. For the moment, however, I shivered in a park full of people unaware of the spiral I was in, with no notion of the challenges I would face in the coming months in a new town with no friends, no support. Everything I thought I was had proved transitory. I felt stuck in a liminal space, trying to outrun the haunting specter of “what was,” peering over the void of “what is,” with no hope of connecting to “what will be.” I was attending my first Veterans Day event as a certified veteran. I had no hope or desire of connecting to the civilians in the crowd, but I should have at least been able to feel like a part of this brotherhood around me and proud of my service. Instead, I was alone in a crowd of people. Fourteen years on, I find myself on a new path as an aspiring researcher in the veteran space. I was given the privilege of joining the scholarly effort to produce this special military and veterans’ edition of JCES. Having the opportunity to help provide a place for my fellow veterans to add their voices to the body of research is a vital step toward ensuring that future veterans will be able to navigate transition to civilian life with greater support and connection. — Christopher M. Gill, veteran, USMC

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 5 Background Given the tendency of clinical, This special edition of the Journal of academic, and other institutional researchers to Community Engagement and Scholarship focus on prevalent veteran stereotypes, scholars (JCES) is the result of a 2-year effort to identify, have paid insufficient attention to family and compile, and publish scholarly research about community social dynamics, alternative forms military-to-civilian transitions conducted by of mental health support, and the salutary service members, veterans, and their families benefits of community-based integration (SMVF). It gives these SMVF voices center stage programming for veterans. Most importantly, by representing a lived experience that speaks a the authentic voices of veterans and family truth to the scientific literature that bears careful members have not had a large role in the research and thoughtful consideration. This special literature. Accordingly, we sought to bring to the edition was inspired by the awareness that many fore a multitude of SMVF perspectives through a of the programs, policies and processes intended wide range of scholarship. These voices speak to facilitate social readjustment, transition, and with clarity about the context of the transition mental health intervention for the SMVF experience, their vision for social change, community are largely based upon clinical evidence-based models for engagement, and research. Yet this research has historically cultural competency for researchers as applied limited the participation of individuals with to SMVF issues. lived experience in SMVF social worlds. As a This special edition reflects a range of topics result, scholarly representations have left out the and contexts, with scholarship drawn from both full nature and diversity of the veteran seasoned individuals and teams and those newer community and the voices of the oft forgotten to the field. The research approaches that appear military family. As the project continued, we in this edition are diverse—from qualitative and came to understand another compelling reason reflective analyses by individual scholars based on to publish this work. Scholarship reflecting the methods of autoethnography and phenomenology experiences of military veterans and their to participative empirical quantitative studies families (as a largely marginalized population) conducted by teams composed of SMVF scholars also holds valuable lessons for a society that and experienced researchers. Each of the 13 struggles broadly with issues of identity, values, studies included here is unique in its approach and belonging, including the balance between and design. However, for purposes of organization, unity and diversity. we have found that the studies fit into several The genesis of this project was a broad categories, which we have defined as conversation between two of this issue’s editors at follows: (1) models for engagement of SMVF an America’s Warrior Partnership (AWP) annual scholars in participatory research, (2) symposium about the apparent absence of a forum contextualizing of veterans’ lived experience, (3) for publishing work—particularly socially engaged, systems - focused research for driving social community-based participatory research—by change, and (4) projects emphasizing cultural emerging SMVF scholars. Since this type of competency and moral injury. research often crosses traditional academic disciplines, it has been challenging to locate and Article Summaries disseminate. Additionally, many veteran-scholars Section 1: Models for Engagement of SMVF who are coming of age in the era of the Post-9/11 Scholars in Participatory Research GI Bill are just now reaching the point of creating These articles exemplify research practices original research and have not yet become well that integrate SMVF perspectives in diverse and versed in the ins and outs of academic publishing. often multidisciplinary teams. The studies in Thus, the necessary pathways and processes of this section are focused on evaluation of mentoring are neither fully established nor well- community programs intended to serve the known to them. We are grateful for the assistance social and mental health needs of veterans. and support of student veteran advocacy In the jointly authored piece “I Remember organizations, particularly the Student Veterans of the Skills We Learned and Put Them Into America and the National Association of Student Practice: An Evaluation of a Peer Support Program Administrators, in putting out the call for Training Program for Veterans,” coauthors proposals and helping us to locate a good sampling Karen Besterman-Dahan, Jacqueline Sivén, of these emerging scholars.

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 6 Kiersten Downs, and Tatiana Orozco describe to support more public–private initiatives (or an experimental and participatory research hybridized programs) following this model. design that provides a multiperspective evaluation of a skills training intervention. The last study in this category, “Creating While the purpose of the training was to enhance Community for Women Veterans Through peer advisement skills, the evaluation comments Social Networking Organizations,” was authored also revealed transformed perspectives among by a team led by Kate Hendricks Thomas, the participants, who were a mix of veterans and Caroline Angel, and Nicholas Armstrong, with nonveterans. This piece offers a good example of Michael Erwin, Louis Nemec, Brandon Young, the use of an ethnographic research method to John Pinter, Blayne Smith, and Justin McDaniel. capture the lived experiences of veterans, and it The study includes both comparative and also models community-based engagement aggregate findings about the improvements in through a public–private partnership approach. mental state experienced by men and women In reflexive terms, this study makes significant veterans who voluntarily participate in observations about the importance of community-based social/recreational activities. self-awareness, mindfulness, and communication This research recognizes further potential for skills to the transition process, noting that these gender-specific services while acknowledging skills are not only critical in peer advisement but the role and value of single-sex programming also transferable to family, work, and social and outreach in such recreational programs. situations. In this sense, it provides an excellent counterpoint to other pieces in this edition that Section 2: Contextualizing of Veterans’ Lived deal with military and veterans’ cultural Experience competence. This section contains articles that contribute The next study in this section, with the to an understanding of military culture through intriguing title “If You Don’t Name the Dragon, the authentic voice and lived experience of You Can’t Begin to Slay It,” represents the efforts veterans and the analysis of contextual of Gala True, Sarah Ono, Ray Facundo, Carlos symbology and sensitivities that shape the SMVF Urbina, Sawyer Sheldon, and J. Duncan Southall. experience from formation, to operational Their adaptation of participatory action realities, through periods of transition. research, grounded theory, and the photovoice The Australian research team of Jonathan technique offers a novel approach for building Lane, Miranda Van Hooff, Ellie Lawrence- knowledge of veterans’ lived experiences of Wood, and Alexander McFarlane provides the traumatic brain injury (TBI) among the veteran lead article for this section, titled “Culturally and caregiver community. Their collaborative Informed Interventions for Military, Veteran, effort resulted in “community-informed and Emergency Service Personnel: The solutions” for reintegration of veterans into the Importance of Group Structure, Lived community and models the practice of Experience Facilitators, and Recovery-Oriented “partnered dissemination” of study results. Content.” The study takes a mixed-methods “Motivations of Older Veterans and approach to examining the effectiveness of Dependents in a Physical Activity Program” culturally informed group therapy for military reports on community-based mixed methods and first responders. It frames the distinction research conducted by Candace Brown, Ismail between clinical and community (recovery- Mustafa Aijazuddin, and Miriam Morey. The oriented) approaches to mental health and helps participatory framing of this study, which details to answer the question of why active-duty the structure and evaluation of community service members and veterans tend not to engagement among veterans in an exercise complete many evidence-based therapies despite program, results in a culturally sensitive their documented efficacy. This insightful work assessment of an important medical/mental argues for the dual need to (1) develop military health issue. The study foregrounds the issue of cultural competence among mental health and motivation and long-term participation, and it social service providers and (2) undertake also documents a novel partnership between a psychoeducation of military clients to help make private health club and a veteran-serving them more equal partners in their therapeutic nonprofit organization, Team Red, White, and interactions. Blue. The evidence provided here may be useful

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 7 Shawn Dunlap’s thoughtful, reflective piece, automated tools that may make research projects “Put Yourself in My Combat Boots: of this type more accessible to beginning Autoethnographic Reflections on Soldiers and veteran-scholars. His paper outlines a replicable Veterans as a Form of Life,” reveals the potential method that could be used at other college of an individual veteran-scholar using the campuses to help create a shared understanding reflective discipline of autoethnographic of the college selection and motivation process research. Dunlap combines an analysis of his for student veterans. own lived experience with other academic studies in history and the social sciences to Section 3: Systems - Focused Research for Driving provide an intriguing firsthand account of how Social Change his lived experience is situated within a broader Articles in this section consider the bridging political-military context. Dunlap introduces of values and social dynamics between service the conceptual model of “community culture and the community setting via a systems ethnography” as a means of unlocking the perspective. Such a broadened view of the underlying meanings and symbologies within complexity of military-civilian relationships the military and veteran community. He encompasses the international scope of research positions this model as a way of interpreting into the contemporary experience of veterans, as these meanings and symbologies for others well as offering profound implications for local outside of the veteran experience. Dunlap’s work community settings. Among these are ideas for also touches on the therapeutic nature of this increasing cultural competency in interaction with type of self-reflective writing from a mental veterans, and “normalizing” mental health care by health perspective. identifying and providing forms of self-care that Kelly Wadsworth’s study, “Profoundly are consistent with military values and culture. Changed: The Homecoming of Veterans from These are types of approaches that may lead to a Iraq and Afghanistan,” offers substantive decrease in social isolation and marginalization of insights into the essential structure underlying returning veterans, and work to reduce the stigma the lived experiences of transitioning veterans, associated with seeking help. analyzed through the lens of both essential and The study “Military Culture and Its Impact lifeworld versions of phenomenology. Her on Mental Health and Stigma,” by Alexis Ganz, article provides a rigorous, accessible view of Chikako Yamaguchi, Bina Parekh, Gilly Koritzky, phenomenological methods, and it reveals and Stephen Berger, makes a strong contribution some of the subtle yet profound changes in to our understanding of both military culture’s consciousness and perception that take place impact on help-seeking and cultural and for returning veterans. Wadsworth considers intercultural aspects of service as they relate to the “expanded self” of a postservice veteran transition and postservice community that includes both challenges to identity and reintegration. The introduction and testing of a enhanced awareness. She also explores the scale that measures both in-service and reflexive nature of this shift in identity and postservice identification with military cultural perception in community settings. Wadsworth’s values stands as an important addition to the work challenges the commonly held notion military psychology literature, but the bridging that veterans reintegrate into a “static society” of these concepts to a nonmilitary context is our without the society itself being changed or focus here. Ganz and team’s research suggests impacted by their return. that there is less of a difference than is generally The final article in this category, Derek believed between active-duty service members/ Abbey’s “How Veterans Make Meaning of the veterans and those who have not served with College Choice Process in the Post-9/11 Era,” regard to attitudes about mental health. The similarly contributes to a deeper understanding study also suggests that a strong response to of the student veteran experience by using values (either acceptance or rejection) appears qualitative interview data to critique an to provide something of a protective factor, established theory of college selection particularly with respect to suicide risk. These (Gallagher’s college choice theory). It also gives findings have strong implications for reimagining voice to the lived experiences of student veterans ways to help separating veterans, especially in a meaningful way, illustrating how qualitative those who may have struggled to fit in with research can be effectively conducted using

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 8 military culture, “find their tribe” in the misconceptions and stereotypes. Particularly community after service. promising is Isserman and Martin’s concept of “reciprocal cultural competency,” which “The Benefits of Brazilian Jiu-Jitsu in addresses the mutually strengthening effect of Managing Post-Traumatic Stress Disorder,” by giving veterans tools to translate their military Kelly Weinberger and Tracey Burraston, presents experience while expanding the community’s empirical evidence from a longitudinal capability to engage people from diverse or assessment of how Brazilian Jiu-Jitsu (BJJ) nonmainstream backgrounds. affects the management of post-traumatic stress The contribution by Daniel Perez, Paul disorder (PTSD) symptoms over time. It also Larson and John Bair, “U.S. Veterans Experience considers how veterans experience the practice Moral Injury Differently Based on Moral of BJJ in community settings. BJJ is described as Foundation Preferences,” seeks to advance a somatically based practice that can serve in understanding of moral injury. This study takes conjunction with supervised mental health a novel approach by applying moral foundations support or as a freestanding wellness activity for theory to the psychological consequences of those not inclined to seek formal help. This difficult and challenging experiences. This study framing situates BJJ (and other martial arts) as adds a great deal to our understanding of the complementary and alternative medicine (CAM) “moral” aspect of moral injury, which has been approaches for helping veterans manage their less explored (at least in the United States) than PTSD symptoms. The article also discusses the “injury” aspect. The authors’ attention to cultural adaptations of practice facilities to “what is injured in moral injury” may help create more “veteran-friendly” environments. veterans assess for themselves the underlying nature of troubling experiences beyond the symptoms they are experiencing, which may in Section 4: Projects Emphasizing Cultural turn guide them in subsequent meaning making Competency and Moral Injury around these events. There is a growing awareness in the social The innovative study “Structural sciences of moral injury as a complex construct Examination of Moral Injury and PTSD and that includes elements of identity, culture, and Their Associations With Suicidal Behavior values as factors contributing to well-being—­ Among Combat Veterans,” by Jeremy Jinkerson, which can be damaged by events that challenge Allison Battles, Michelle Kelley, and Richard deeply held concepts of self and worldview. Mason, examines possible connections between Many of the articles elsewhere in this special symptoms associated with moral injury and edition touch on how cultural factors can suicide risk. Their research offers evidence that contribute to moral injury among veterans, but symptoms associated with both PTSD and moral those in this section are particularly focused on injury can be indicators of suicide risk, and it making these connections. Additionally, these suggests ways that military and unit culture may articles invite readers to consider how factors affect the lenses through which individual underlying moral injury among veterans in service members interpret potentially morally community settings can be reciprocally injurious events. This contribution is significant addressed in ways that are potentially in the sense that actions, perceptions, and transformative for the community as well as intentions may become misaligned across helpful to veterans. cultural differences, either during service or in “Teaching Military Cultural Competency to transition. Clinicians and Clinical Students: Assessing Conclusion Impact and Effectiveness,” by Nancy Isserman As the introduction to this special edition and James Martin, documents and evaluates a suggests, there is a sense of urgency to better community-based collaboration between mental understand the lived experiences of military health practitioners, academia, and nonprofit members, veterans, and families in order to organizations for developing military cultural improve their well-being. There is an irony to the competence. This study accounts for the alienation often felt by those who have served complexity of the military and veteran their country, distancing them in many ways experience, including the impact on families and from other citizens despite their communities’ the barriers to communication created by best intentions to welcome them home. It is our

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 9 hope that this collection of research articles by, Acknowledgment of Reviewers about, and for members of the SMVF community We would like to thank the reviewers will inspire further exploration in these and who lent their expertise and credibility to the other areas. While the articles represented here evaluation and enhancement of the articles only begin to capture the diversity of the SMVF that appear in this special edition. Without the experience, they do capture the passion and valuable insight and guidance they offered to innovation of researchers from a wide range of our authors, this project would not have been disciplinary areas who have an interest in the possible. well-being of those who have served and those David Chrisinger, MA close to them. Maybe just as importantly, many of these studies also reveal some of the potential Joseph Currier, PhD reciprocal value to society (at both the system and the community level) of understanding the Paula Dabovich, PhD nature of the SMVF experience. Luann Fortune, PhD Barton Buechner, PhD Zeno Franco, PhD Karl Hamner, PhD Katinka Hooyer, PhD Christopher Gill, BA Coeditors Jeremy Jinkerson, PhD

Zieva Konvisser, PhD

Harold Kudler, MD

Matt Louis, MBA

Lauren MacKenzie, PhD

Travis Martin, PhD

Bret Moore, PhD

Deedee Myers, PhD

Sarah Plummer Taylor, MSW

Sierra Rodgers-Farris, MA

Howard Rosing, PhD

Susan Steen, PhD

David Walker, PhD

David Willis, PhD

Joel Zimmerman, PhD

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 10 “I remember the skills we learned and put them into practice”: An Evaluation of a Peer Support Training Program for Veterans

Karen Besterman-Dahan, Jacqueline Sivén, Kiersten Downs, and Tatiana Orozco

Abstract Community-based organizations (CBOs) are critical sources of support for veterans. CBOs offer innovative and informed initiatives and are often nexuses that allow veterans and their allies to gather. Out of a commitment to veteran reintegration, Growing Veterans (GV), a veteran-founded CBO located in western Washington, created and implemented an evidence-based peer support training program (PST) for veterans and their allies. Building upon years of collaboration, GV partnered with the Veterans Health Administration (VHA) to conduct a formative evaluation of GV’s PST program, funded through the Bob Woodruff Foundation. The evaluation revealed that participants described the PST in largely positive ways and reported using learned skills with both veterans and nonveterans across their personal and professional lives. Specifically, participants reported learning tools through the PST that increased their patience, mindfulness, awareness, empathy, and confidence, resulting in improved interpersonal relationships and communications across multiple domains. The success of this community-engaged collaboration was due in part to the inclusion of veterans, allies, GV employees, and VHA evaluators throughout the evaluation, from grant applications to the final analysis. Using ethnographic methods of participant observation, in-depth interviews, focus groups, and surveys, VHA evaluators were able to gain a deep understanding of participants’ experiences of the PST as well as the program’s perceived usefulness.

Community reintegration poses many post-traumatic stress disorder, and substance challenges for veterans, yet community-based abuse resulting from or exacerbated by combat organizations (CBOs) can be critical sources exposure and transition stress, have been well of support (Crocker et al., 2014; Demers, 2011; documented in the literature (Amdur, 2011; Drebing et al., 2018; J.A. Gorman et al., 2018; Crocker et al., 2014; Hoerster et al., 2012; Sayer L.A. Gorman et al., 2011; Sayer et al., 2010, 2014). et al., 2011, 2014; Seal et al., 2007). Critical to Growing Veterans (GV) is a veteran-founded CBO mediating reintegration is that veterans learn committed to cultivating veteran reintegration how to negotiate norms in the communities to and reducing isolation through farm-based and which they are returning or moving (Demers, peer support initiatives with veterans and their 2011; Romaniuk & Kidd, 2018). Often these civilian allies. GV’s vision is “to end the isolation norms differ from what veterans were used to that leads to veteran suicide” (Growing Veterans, in the military (Cogan, 2016). Differences in 2021). To support this vision, GV developed an cultural norms, a lack of preparation for what to innovative, evidence-based peer support training expect after leaving the military, and the loss of a program (PST). With funding from the Bob social network can all contribute to reintegration Woodruff Foundation (BWF), the PST curriculum challenges for both servicemembers and their was designed and piloted by a group of GV families. A growing body of reintegration members, including veteran peers, mental health research supports decreased social support as a professionals, and educators. A mutual desire to major challenge for veterans (J.A. Gorman et al., improve reintegration resources led GV to partner 2018). To help ease servicemembers’ transitions, with Veterans Health Administration (VHA) there has been a surge of reintegration program evaluators to conduct an independent evaluation development over the past decade, especially of the PST via funding from the BWF. in the nonprofit sector. However, evidence bases for such programs, rigorous evaluation Introduction to determine what programs provide for Reintegration challenges faced by servicemembers, and evaluation of the programs’ servicemembers, including anxiety, depression, impacts are often lacking.

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 11 Programming focused on community their veteran service organizations (VSOs) and engagement can help ease postmilitary transitions. communities across the country to subsequently Community engagement within Western culture, support over 1,400 veteran peers (Besterman- however, has declined over the past 50 years, Dahan et al., 2019). In follow-up surveys, trainees including downturns in overall participation in (n = 24) overwhelmingly agreed that the PST community organizations, volunteering, voting, encouraged their own self-care as well as increased and knowing one’s neighbors (Putnam, 1995). their confidence in recognizing PTSD symptoms, Given this decline, returning veterans are likely serving as peer supporters, and making appropriate to find fewer partners in the community looking referrals to mental health care providers. GV then to engage with them, reducing the chance that partnered with the VHA evaluators to develop they will find social support and ultimately a proposal for continued funding from BWF for contributing to the “military-civilian divide.” (a) GV to continue its PST program and (b) VHA However, current data indicate a positive trend evaluators to conduct a rigorous, independent in veterans’ potential for social engagement. program evaluation of the GV PST from 2017 to 2019. In comparison to their civilian counterparts, This evaluation used a community-engaged veterans are more likely to trust and talk with their framework. In public health literature, community neighbors, to participate and serve as leaders in engagement has been broadly defined as “involving civic organizations, and to be politically engaged communities in decision-making and in the (Tivald & Kawashima-Ginsberg, 2015). Veterans planning, design, governance and delivery of share a number of common values, including services” (Swainston & Summerbell, 2008, p. 11). having a sense of community, wanting to give Community engagement activities can take back, and wanting to be a part of something bigger many forms and are usually described in terms than oneself. CBOs such as GV are important of five levels of engagement (from least to most to veteran reintegration because they employ engaged): information-giving, consultation, joint innovative community-building initiatives that decision-making, acting together, and supporting involve peer support, which helps ease isolation independent community interests (Wilcox, 1994). and cultivate common ground between veterans In this evaluation, the VHA evaluators implemented and civilian communities. community engagement through their partnership with GV, continued communication with GV, A Framework for Community Engagement: and periodic feedback between VHA and GV. In Collaboration between VHA and GV addition, veterans were included as participants in This evaluation of GV’s PST program the PST itself and as participants in the completion stemmed from a previous collaboration between of the evaluation, and one coauthor of this article the VHA and GV. In 2014, the Veterans Affairs is a veteran. Office of Rural Health funded a VHA-led mixed-methods case study evaluation of GV in Methods an effort to better understand the veteran health VHA evaluators conducted an independent and reintegration outcomes of GV’s agricultural formative evaluation of the PST program using program (Besterman-Dahan et al., 2018). At that a community-engaged framework. The project time, GV was in the process of developing its PST was designated a quality assurance activity program (Brown et al., 2016). With funding from by the local VHA Research and Development the BWF, GV went on to create its innovative Committee; institutional review board approval PST based on best practices and elements was not required. Evaluators used a mixed-method delineated by the Defense Centers of Excellence for design that employed ethnographic methods of Psychological Health and Traumatic Brain Injury participant observation, in-depth interviews, (DCOE) as essential to a successful military/ focus groups, and surveys. Ethnography is a veteran peer support program (Money et al., 2011). hallmark of anthropological research that is used GV’s PST is a 3-day workshop in which veterans to explore the lived experiences of others. The and allies of veterans (family members, care VHA evaluation data collection team consisted providers, people who work with veterans) learn of two PhD-level applied anthropologists, both and practice the skills necessary to be effective peer with extensive knowledge and applied research supporters for other veterans. During 2016 and experience utilizing ethnographic methods in 2017, GV conducted four PST sessions, resulting community-based research with veterans. The in 54 trained peer supporters who returned to study’s principal investigator, an applied medical

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 12 anthropologist, had worked in collaboration with Relationship building and collaboration GV since 2014. The PST program was evaluated with the GV community, including PST for its content, delivery, usefulness, quality, and participants, were critical components of the alignment with VSO values. The evaluation team evaluation. Of additional importance when also examined barriers and facilitators to attending employing community-engaged ethnographic the training and influence of PST on participants’ methods is acknowledgment of the power knowledge, attitude, and intention. The program’s dynamics intrinsic to ethnographic projects and implementation was also assessed via a post writing. Methodological approaches inherent to training focus group and survey with PST trainers. ethnographic research allow researchers to engage Collaboration is central to community with both the academic concerns of their discipline engagement and was crucial to the success of this and the broader structural and cultural factors that program evaluation. GV staff and the evaluation perpetuate systems of inequality (Pacheco-Vega & team worked closely with one another from Parizeau, 2018). proposal development through implementation The nature of the PST required trust between of the evaluation. This collaboration began early. all those present at the sessions hosted by GV. The VHA collaborated with GV in obtaining Because the evaluators were active participants in funding to both run the PST program and conduct the PST during data collection, they held the safety a complementary formative evaluation. Evaluators and needs of PST participants as a top priority. The facilitated a continuous cycle of feedback by PST data collection process allowed participants conducting ongoing discussions via weekly team to decide whether or not they welcomed the meetings before each peer support workshop, in presence of the evaluators at their sessions. This addition to meetings during each workshop while element of choice was especially important during on breaks, and after each session closed for the parts of the curriculum when participants were evening. Upon completion of each PST workshop, invited to share their personal experiences with the evaluation team and GV staff would meet for one another, often revealing sensitive information a brief focus group, which also led to an organic related to their personal accounts with traumatic process of debriefing with all team members and experiences. Evaluators and GV staff carefully additional debriefing among the evaluation team. prioritized gathering participants’ consent with Evaluators gathered feedback from workshop regard to the attendance of the project team during participants through observation, conversations the PST, frequently checking in with participants with participants, and focus group results, and individually, during group exercises, and via they both shared this feedback with GV staff daily anonymous qualitative feedback gathered from and included it in final reports. Open dialogue and survey data. There were no instances in which transparency built trust between the evaluation participants asked for the project team not to team and GV staff. The return on the investment of participate with them in the PST. time spent in debrief sessions, staff focus groups, During the 2017–2019 evaluation period, GV and informal conversations during each workshop hosted four PST sessions, one each in February, allowed PST trainers to make small course April, September, and October of 2018. Each adjustments in real time or in preparation for the cohort of PST participants completed a pretraining following workshop. focus group and survey, a post training focus Investigating and conducting evaluation and group and survey, and an interview and survey 90 research with vulnerable communities demands days after the conclusion of training. PST trainers the use of specific methods that not only engage the were asked to participate in a post training focus scholars involved but also protect the well-being group or debriefing and to complete a post training and livelihoods of target populations (Pacheco- survey after each PST cohort. Table 1 summarizes Vega & Parizeau, 2018). Ethnography as a research the sources of data gathered from participants. methodology offers a unique opportunity to understand social phenomena that occur within Focus Groups vulnerable populations while maintaining a A total of eight focus groups were conducted rigorous research process (McGranahan, 2014; with PST participants. Four focus groups (one per Warren, 2014). Engaged ethnography also requires cohort) were conducted with PST participants researchers to pay attention to the relationships (one per cohort) prior to starting the program they are building with the communities they are to determine participants’ baseline knowledge working alongside. of peer support and their expectations for the

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 13 Table 1. Participant Sampling Frame

Participant Participant Participant Time Frame focus groups surveys 90-day interviews

Pretraining 4 38

Posttraining 4 24

90-day 13 14 training. Four focus groups (one per cohort) were in all PST activities in all four PST sessions, conducted with PST participants immediately after which allowed for reflection on the activities training (one per cohort) to elicit their thoughts and modules. By participating in the PST, the and reflections on the overall PST as well as the project team was able to build rapport with other perceived usefulness, facilitators and barriers to participants and gain additional insight through understanding, and influence of the training. A casual conversations about the PST activities. post training focus group was also conducted The project team took detailed field notes with PST trainers to elicit their reactions to and during all aspects of the PST, and evaluators reflections on the program. carefully observed group dynamics, emotions, Focus groups were either led or co-led by and environmental stimuli throughout the PST members of the project team, one of whom served as and evaluation process. For instance, participants focus group moderator while another team member engaged in storytelling and sharing with each took notes. Focus groups were audio-recorded other throughout the PST, which sometimes put with permission, and salient themes from the focus them in vulnerable positions. Both evaluators groups were identified and grouped for analysis. took care not to take notes at these moments, as 90-Day interviews. Fourteen participants doing so could be observed by the participants spanning all four cohorts were interviewed 90 days as insensitive and intrusive and likely would after their PST using a semi structured, in-depth have resulted in a breach of trust between the interview protocol. All participants had agreed to researchers and the participants. In turn, this be contacted for a 90-day interview at the original could have caused an unwelcome power imbalance training. Interviews were conducted via telephone in group settings. The evaluators were committed and recorded with verbal permission. Salient to active, participatory engagement in the PST themes were identified and grouped for analysis. alongside participants. When it felt inappropriate Participant observation. Participant to take field notes, such as during the storytelling observation is an ethnographic research method circles, evaluators took time to debrief with each used to gain a holistic and in-depth understanding other after the conclusion of the day’s session, of how individuals and communities “describe and actively reflecting on their experiences with the structure their world” (Creswell, 2014, p. 207). In a group, then writing their field notes. traditional sense, this usually entails the researcher Surveys. The baseline surveys administered engaging in the lives of the research participants to PST participants collected data on their general for a long period of time, utilizing data collection demographics, history of military service, and activities such as direct observation, interviewing, VA service connection. Post-PST surveys asked document analysis, reflection, analysis, and participants to rate the PST modules and activities interpretation. With the development of faster in terms of their usefulness and included 11 approaches to qualitative inquiry, participant open-ended questions regarding the impact observation can be successfully conducted over of the training, reactions to the training, and shorter periods of time while still meeting rigorous respondents’ intention to use the skills they learned academic research standards of thorough data during training. Similarly, the post-PST surveys collection, analysis, and reporting. Following for trainers asked respondents to rate the PST anthropological methods, field notes were taken modules and activities in terms of their usefulness during participant observation, compiled, and and rate their perceptions of how impactful the analyzed. Evaluation team members participated training was for participants.

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 14 The 90-day participant surveys asked duty service member. Notably, participants could participants to describe the most and least useful identify in more than one category (veteran, civilian modules, how they had implemented PST skills in ally, family/partner of veteran/service-member). their lives since the training’s end, and the same The average age was 46.4, with a median age of 47 standardized measures as the baseline survey. and a standard deviation of 10.3. In descending All surveys were administered in person in order of frequency, participants identified as hard copy or electronically via a link to Qualtrics White (71%), Asian (5.3%), Black or African survey software. Responses were self-reported. American (5.3%), Hispanic or Latino (2.6%), Native Hawaiian or other Pacific Islander (2.6%), Analysis or Other (chose not to specify; 2.6%), with 10.5% Quantitative data (from the baseline, declining to respond. The majority of participants post, and 90-day surveys) were analyzed using identified as women (60.5%), with the remainder Microsoft Excel and IBM SPSS. Qualitative data identifying as men (39.5%). All respondents (from focus groups, field notes from participant identified as cisgender (i.e., their biological sex observation, and 90-day interviews) were analyzed and gender identity matched). Participants tended using rapid analysis to describe participant and to be married or have a partner (53%), though trainer experiences; perspectives of the program relationship status was unknown or not reported for satisfaction; barriers to and facilitators of for 26.3% of participants. The median household participation; and suggestions for program size was two. Across all cohorts, all participants improvement, dissemination, and sustainability. had at least some college or vocational school Qualitative rapid analysis uses matrices to education, and a majority, 74%, had a bachelor’s systematically organize and streamline data. degree or higher. Half of the participants reported These matrices, or compact displays, enhance the an annual household income of more than $45,000, accessibility of voluminous qualitative data by with 21.1% reporting incomes of $35,001–$45,000, condensing major findings and facilitating prompt 2.6% reporting $25,001–$35,000, 7.9% reporting assessment of similarities and differences within $15,001–$25,000, 5.3% reporting $10,001–$15,000, the data (Averill, 2002; Miles & Huberman, 1994). and 5% declining to respond. Matrices are formatted based on the purpose of the Participants cited a number of reasons for analysis; in this project, matrices were organized wanting to attend the PST, including being a veteran, according to the different waves of data collection. working with veterans, wanting to help veteran A matrix within Microsoft Excel was used to families, working with teens who have attempted organize data from transcripts around domains suicide, wanting to serve the community, wanting to of interest established at the start of the program address their own personal issues, wanting to build evaluation, and thematic analysis was conducted. communication skills, wanting to build/improve As this was a formative evaluation, evaluation peer support programs or collaborate with other team members shared their findings with GV programs, having completed another PST program through biweekly calls, debriefing meetings that “wasn’t good,” and wanting to get more immediately after each PST session, and a involved in GV. written list of specific suggestions and findings Overall, participants described the PST in delivered after each PST. This process provided largely positive terms, noting that it improved their GV the opportunity to implement the evaluation’s knowledge of peer support and peer support skills recommendations for improvement as they as well as their confidence and willingness to use emerged. Additionally, data-driven suggestions these skills. As a Cohort 2 participant stated: and strategies for improving the PST program were compiled and provided in the final report once all [The PST] completely opened my mind to data were analyzed. “peer support” as a technique for helping friends, family, coworkers, supervisees, Findings and children work through issues for The PST program included a total of 38 themselves rather than always be the veterans and nonveterans across four cohorts. A person coming up with ideas to fix the majority of all participants, 63%, reported veteran problem and therefore take on the burden status, while 29% identified as civilian allies. 35% of solving the issue. It really frees up the of participants identified as the spouse, partner load one carries. or other family member of a veteran or active

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 15 Knowledge, Expectations, and Impressions they learned in everyday life. As one participant Pretraining. Participants’ baseline understanding said, “You can apply these skills to just about any of peer support was at varying levels before conversation. Peer support is not unique for just the training. Some defined the term as being veterans. This is a life skill.” about listening, understanding, and/or equality Finally, though some participants had attended or a lack of hierarchical relationships. Several peer support trainings before, they still described participants specified that peer support is not GV’s PST as generating new knowledge for them. about solving other people’s problems or putting Participants stated that the new information one’s own problems on someone else. However, (described as being 50% new), communication several participants related that they did not know strategies, and veteran-centered nature of the anything about peer support when they came to program made the PST useful and that their the training. “perception of peer support has been broadened.” PST participants expected the program to One participant also said that the GV’s PST have potential impacts across their personal and “modules are the best I have received.” Participants professional lives. In terms of their personal lives, also noted that the training format—particularly they expected to gain the skills they needed to “get its provision of a safe space for participants to be back to being me again,” improve their emotional vulnerable— improved their use of PST skills. resiliency, improve their social skills, help break Participants described using these new skills in a down walls, encourage a parent who is a veteran variety of areas in their lives, including at work, and other older veterans, fine-tune their listening when volunteering, and with family and friends. skills, and avoid secondary trauma from listening. In terms of their professional lives, they expected to Use of PST Skills learn skills that would help them improve suicide Plans to use PST skills. Participants were prevention, “reach someone who is frozen,” assist very motivated to use the PST skills across people without getting stuck in their own heads, their personal and professional lives. Of those help homeless veterans get back on track, support who completed the post training survey, 100% student veterans, and generally better understand of participants across all cohorts answered the people with whom they work. affirmative to the question, “Do you plan to use Post training. In post-PST focus groups and the PST when you return to your organization?” surveys, participants talked about the PST in overall As one participant said, “I can use this just about positive terms, describing it as “transformative,” anywhere, school, work, my family. I love being “powerful stuff,” and “incredibly enlightening” able to support, even if the way I do it seems small.” and saying that they were “impressed” by the Several participants stated that they planned to use training. They also described the PST as having the skills they gained from the PST in personal had a positive impact on themselves and/or the ways (e.g., to be “more self-aware,” to “dial things community, said that GV is “making an impact down,” and to “check-in”), with their family (e.g., in the community” through the training, and to teach the skills to their children), with their professed that the training “actually solved a couple coworkers (e.g., to help teachers at their college of really big problems for me.” connect with veterans), and in their communities Some participants described the PST in terms (e.g., to address teen suicide). Several participants of skill building, stating that the PST was a “useful also planned to use the skills to create or bolster tool set” and “provided us with a structure we can their own peer support programs, including a peer use.” They also said that it “explained what peer support program for veterans. A male veteran from support is and why it is important” and that they Cohort 3 reported, “The PST helped me recognize liked the structure of the curriculum. that every interaction I have with a veteran is an When asked what surprised them most about opportunity to be better. We grew up in a culture the PST, emergent themes in focus groups and [where] everyone is taking stabs at each other.” surveys centered around the camaraderie and Post training use of PST skills. Surveys closeness participants felt to each other and the and 90-day interviews were conducted with PST ease and comfort they felt in sharing personal participants (n = 14) to assess the extent to which stories. Furthermore, participants were surprised they had used the PST skills in their communities not only at their own openness to sharing but and organizations since the conclusion of the also at how others have had similar experiences. program. These measures revealed that the PST Participants also noted the ability to use the skills not only influenced how participants interacted

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 16 at work and with family and friends but also the conversation switches to “well I was influenced participants’ own ways of thinking. in Iraq…,” then that is when I find myself Work. Of those interviewed 90 days post putting on my peer support hat. training, the majority of participants described using the skills that they gained from the PST Family and friends. The PST also affected professionally in both volunteer and paid work. participants’ personal lives. Most of the 90-day They shared the PST exercises and activities with interviewees described using PST skills with family individuals and groups, including with support and friends or in other informal relationships. groups and in staff trainings. Participants also They described improvements in communication described the PST skills as improving their daily skills, mindfulness, awareness, patience, empathy, professional interactions with increased patience and confidence, and some said they had used the and an enhanced ability to build relationships. As a skills to support friends in crisis. A male veteran female nonveteran from Cohort 4 explained: participant from Cohort 1 said:

I have had numerous veterans reach [The PST] gave me more confidence out to me. I am trying to get my own [with] how to deal with these issues, not to organization going. Oftentimes what be afraid to confront it; so it gave me more ends up as conversations about building confidence, ’cause I was afraid if I talk to business ends up being a conversation [a] veteran who has been in combat, is about our lives. That is where I find myself this going to set him off, but now I feel using the peer support skills. As soon as more confident and understand.

Table 2. Influence of PST on Participants

Domain Themes Illustrative quote

“I use it at work too—I work with Improved daily professional veterans…like when one of my peers interactions needs someone to listen to them, I have a lot more patience with that Work Increased patience type of thing. I’m more understanding; I feel like overall I’m more calm and Enhanced ability to build patient and understanding than I used relationships to be.” (Female, veteran, Cohort 1)

Improvements to interpersonal “The peer support training changed interactions, including: how I communicate with my boy. It • communication skills Family has been transformational in that • mindfulness and respect. It is in us to be that support • awareness friends system for others, but we need some • patience training to bring it out.” • empathy (Female, nonveteran, Cohort 1) • confidence

Increased self-empowerment and connection to the outside world, including: “I felt really helpless and really stuck • confidence for a long time. I felt really painted • communication into a corner…I am starting to realize Self • mindfulness I can make changes when things • new relationships aren’t working.” • feelings of empowerment (Female, veteran, Cohort 4) • empathy • connection to the natural world • recognizing veterans as leaders

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 17 Self. Many of the 90-day interviewees that a major barrier to using PST seemed to be a described the PST as positively impacting their lack of organizational sponsorship. ways of thinking. This included becoming more Once participants gained sponsorship, it confident communicators, being more mindful, seemed that organizations were on board with becoming more open to new relationships, implementing the PST in some manner. The one experiencing feelings of empowerment, feeling participant sponsored by an organization outside an improved ability to relate to others and an of GV stated that their organization has accepted improved connection to the natural world, and the PST, that they had not had to tailor or change recognizing veterans as leaders. As one male any part of the PST skills/practices, that the PST veteran participant from Cohort 2 shared: was a powerful tool, and that they believed their organization could improve delivery of training I’ve been going through a lot of therapy to veterans and families. The three interviewees and drug counseling over the years, but sponsored by GV stated that the PST had made I feel like since I took that course, it’s a difference, that it allowed them to care for each helped me open up and not be so closed other, and that they were using the PST in their off. I don’t feel so nervous about talking own organizations outside of GV. to strangers like I used to. And I’ve always The optimal way to assess barriers to and been extremely shy for the most part. facilitators of PST implementation at other organizations, as well as overall organizational Peer support recipients. Interviewees used willingness, is to interview organizational leaders their PST training in formal and informal to determine if their perspectives align with capacities. Peer support recipients included those of PST participants. However, during this veterans and their families, students, clients, evaluation, none of the interviewees provided coworkers, fellow PST participants, parents evaluators with contact information for their of children with mental illness, and, generally organizational leadership. It was also not possible speaking, anyone with whom PST participants to evaluate the effects of receiving peer mentoring interacted. One female nonveteran participant from a PST trainee, as participants did not provide from Cohort 4 described the PST as helping her contact information for those they had supported. in her suicide awareness work: Long-term PST benefits. Several major themes emerged concerning long-term benefits of I talk to people that are going through a the PST: clarification of the definition of and skills lot. I use the skills informally. And these needed for peer support, improved communication are more parents who have children who skills, increased confidence with providing peer are suicidal. But I remember the skills we support, and a sparked desire to help others. learned and put them into practice about

once or twice a month. Clarification of the Definition of The vast majority of 90-day interviewees and Skills Needed for Peer Support described using their PST skills with some Participants overwhelmingly expressed frequency or regularity. For example, one female positive reactions to the PST during the nonveteran interviewee from Cohort 4 explained 90-day interviews. Much of this favorable that she uses the PST skills “almost daily, or at least response stemmed from participants’ improved multiple times a week where I am finding someone understandings of what constituted peer support to use them [the PST skills] with.” and the skills required to provide it. This included an understanding that peer support is not about Barriers to Use of PST Skills “trying to fix” someone, as a female veteran The evaluation revealed that cost can be a participant from Cohort 1 explained, but more barrier for individuals seeking to enroll in the PST, about being there for them: and the program’s cost may also impede buy-in Instead of listening to [people] and from small organizations with tight budgets. Most thinking, “Oh I need to help this person participants stated in the 90-day interviews that and I need to do something for them,” they were self-motivated to attend the PST; only a now it’s more of, “Well if they ask me few interviewees stated that their organization had for help or have something they want sponsored their attendance. Interviews revealed me to do, I’m willing to be there for

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 18 Table 3. Long-Term Impacts of GV PST

Themes Illustrative quote

“There is a large group of veterans similar to me who tend to tough it out. If just ‘being there’ is enough—I can be there. Clarification of I don’t need to super analyze anything—I don’t need to solve definition and skills anyone’s problem or think I should solve the problem. for peer support All I need to be is empathetic to the issue.” (Male, veteran, Cohort 3)

“It [the training] opened up my personal perspective on the fact that I do not know why people behave the way they do. Improved It is just counterproductive to assume why they do. We can communication skills be supportive even if we initially don’t understand them.” (Female, nonveteran, Cohort 1)

“I was making things way complicated in my [peer support] prior to the training. [Since training] I am able to Increased confidence communicate with people and ask them those open-ended to provide peer questions…by asking the open-ended questions and listening. support It increased my ability to listen and my courage to do well and hold a space for another veteran.” (Female, veteran, Cohort 2)

“I used to work with traumatized populations. [The training] allowed me to see I desired to help on this level and I have Sparked desire experience that can [be] useful in this world….The workshop to help others was really good for me.” (Female, nonveteran, Cohort 4)

Connection to network of like-minded community Other Provided understanding of veterans’ struggles

them if it’s something I am capable of taking it personally, thinking they are doing.” Otherwise I listen, I don’t take it judging me; and the part where—the into myself as a part of myself. Which is effective listening aspect. Hold space probably way healthier. without losing my own value.

Improved Communication Skills Increased Confidence with Providing Peer Support This clearer understanding of the elements Several participants explained that learning necessary for peer support (e.g., empathy, and mastering these communication skills boundaries, etc.) as well as what is not needed improved their confidence in their peer support (e.g., solving other people’s problems) translated ability, skills, and effectiveness. This increased into multiple other long-lasting benefits of the confidence was facilitated by improving their PST. Chief among these was improvement in understanding of how to implement peer support professional and personal communication skills. in a structured way. As one female veteran Several participants also described learning the participant from Cohort 1 explained: valuable skill of listening without judgment and “holding space” for other people, which improved [The PST] taught me what I’ve been their communication and ability to provide seeking—it reinforced what I theorized peer support. According to one female veteran what people needed—love, validation, participant from Cohort 1: structure. I felt like the training reinforced and showed me how to apply it in a more Learning how to sit with my feelings structured way instead of just winging it, and let people say what they need to say which is what I had been doing. without me putting judgment in it or

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 19 Sparked Desire to Help Others relatively small, ranging from 10 to 14 participants Having a clear understanding of the elements per workshop setting. Evaluation team members of peer support and the necessary communication were cognizant of how their presence would skills provided several participants with a spark of affect group dynamics. Even though ethnographic hope for their own potential contribution to peer research methods aim to cultivate transparency support. As one female veteran participant from and trust between participants and researchers, Cohort 4 explained, “[the training] gave me a sense power dynamics are always present and must be of hope I would really like to use to help other handled with care. As a best practice, GV staff people; it was just a positive force.” A male veteran informed all workshop participants prior to their from Cohort 3 described this spark as follows: enrollment in the program and again prior to their arrival at the workshop site that the organization [The training] illuminated the idea was participating in a program evaluation. Before that vets can play the role of NCO the start of each peer support workshop, the [noncommissioned officer] to people in evaluation team always asked permission to attend their life; a great way to look at what a the workshops alongside trainers and participants. vet can be beyond the traditional role of This allowed the evaluation team to be active a veteran. A network of others who have participants in the PST process as opposed to gone through the training. being passive participants observing and collecting data. There was never a situation in which Other Long-Term Benefits participants did not approve of the evaluation Another long-term effect of the PST was the team’s participation. connection it provided to a network of like-minded Building rapport through participant people. As one participant, a male veteran from observation was essential to this evaluation, as it Cohort 3, stated, “[most impactful] was the eased any awkwardness that might have occurred network of folks I went to training with. I run into in such in an intimate setting. Participant and connected with them, and that is valuable. observation involved meeting with participants They are all veterans.” Participants who were not the night before the PST to answer any questions veterans also described how the PST helped them they might have about the evaluation, attending better understand the struggles veterans face. PST breakfasts alongside participants, and attending the PST sessions. Evaluation team Discussion members agreed that spending extra time to Reintegration research has noted that a lack of build rapport with participants opened the door social support is a key barrier to veterans’ efforts for the establishment of trust and the free flow of to reenter civilian life (J. A. Gorman et al., 2018). information between evaluation team members, Programming focused on community engagement GV staff, and workshop participants. can help ease postmilitary transitions. GV’s The evaluation team also found strength in evidence-based PST is particularly critical, given the intersectional identities of the team members. that it draws upon what the DCOE has determined The fact that one evaluator openly identified as a are best practices and elements essential to a woman veteran provided the researchers with an successful military/veteran peer support program insider’s perspective on the military-connected (Money et al., 2011). Indeed, the results of this community. Her perspective was especially evaluation indicate that this PST provided the important when issues arose with minority service skills that participants needed to successfully and members, particularly women veterans. Her confidently connect with, engage, and support experience as a woman veteran and expertise in veterans. From better understanding their roles working with women veterans—including having and goals as peer supporters, to active listening written a feminist ethnography on women veterans’ and having empathy, participants not only experiences with the transition out of military reported feeling more confident in their ability to service (Downs, 2017)—provided critical insight communicate and connect but also expressed an into how women veterans reacted to the PST. increased desire to do so, ultimately increasing the For example, after this evaluator drew attention community engagement opportunities available to how participants’ experience of the PST might for veterans. be affected by experiences of various traumas, The content and format of the PST trainings including those perpetrated by other service was very personal and intimate. Group sizes were members; feelings of isolation; and disconnection

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 20 from “pride in service,” GV made course corrections before the first session while participants were that opened a conversation on understanding and gathered for breakfast. The challenge with this respecting differences in military experiences. The method was that some participants showed up transparent, collaborative relationship between late, so several uncompleted surveys needed to be the evaluators and GV allowed for changes to finished prior to the start of the PST workshop. be made in real time to address input shared after In order to collect the survey data, GV changed the PST sessions. the schedule to allow participants to complete the GV made several other course corrections pretraining survey at the beginning of the agenda during the evaluation, including a change to on the first day. the popular “council circle” activity, in which Other limitations may also have affected the participants commonly discussed emotionally data. For example, a potential issue inherent in difficult or traumatic experiences. The council focus groups is that the desire to belong and/or circle was meant to bring people together in a maintain social standing within the group may circle to bear witness and share with each other influence participants’ responses. These focus authentically (Growing Veterans Peer Support groups covered several personal topics, and as part Training Manual, 2018). Though an experienced of this group dynamic participants may have felt the mental health counselor facilitated the activity, need to focus their responses on experiences that evaluators noted that it could be overwhelming for they might not have shared otherwise. However, the counselor to both be attentive to participants’ the key to good focus group facilitation is the art emotions and facilitate the workshops; upon of allowing participants to share their experiences, evaluators’ recommendations, GV added a feelings, and perspectives while guiding the group cofacilitator and an emotions monitor to observe to stay on topic. Within this evaluation, a desire the room during activities that might elicit sensitive to compare traumatic experiences occasionally stories from participants. seemed to arise, which some participants found to A number of suggested modifications to the be detrimental to the group dynamic; this feedback PST emerged from the collaborative process and was provided to GV. partnership between the VHA and GV, and GV The demographics of the PST participants also incorporated several of these suggestions into the necessarily limit these evaluation findings. Most program. Participants provided positive feedback participants were White, women, and veterans, on many modifications, including council circle so their responses do not capture the broadest and self-care and boundary modules. Participants possible scope of perspectives. It is not clear why also noted that the program helped them feel safe, more diverse participants did not enroll in the PST allowed for vulnerability and sharing, and provided at similar rates, but this is worth investigation. a clear understanding of peer support and required Inclusion of more diverse perspectives would peer support skills. By being open to feedback help researchers better understand the potential and incorporating suggestions, GV continuously impact of the PST program and areas where it improved its PST to be more impactful and can be improved. Evaluators did provide GV with effective. The evaluators made additional resources to widen its outreach to diverse veteran recommendations in the final report, including populations. consideration of a web-based or long-distance PST. This suggestion stemmed from the finding Conclusion and Future Directions that cost can be a barrier to PST participation, with Partnerships between the VHA and CBOs most participants self-funding PST participation such as GV are a valuable means of expanding and desiring alternative methods of enrollment. support for veterans. This value is evident in PST The barrier of cost was largely related to travel participants’ descriptions of their experiences costs and the fact that the PST required several with the program. Overall, participants reported days of in-person participation. By offering web- that the PST had a positive impact on their well- based or other long-distance participation, GV being, with implications for both their personal could greatly improve the reach of the program. and professional lives. Their positive feedback demonstrated the power of the PST, and their Challenges and Limitations suggestions for change make it possible to expand So as not to overburden participants or take the program. GV’s PST trainers adapted workshop time away from workshops to collect survey data, content based on participant feedback immediately attempts were made to collect pretraining surveys after the completion of the first training workshop.

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 21 A new trainer and participant manual were Train-the-Trainer program and the impact of the also produced as a result of the evaluation and suggested changes to both programs. participant feedback. This partnership also exemplifies how References the VHA and CBOs can improve veteran care Amdur, D., Batres, A., Belisle, J., Brown, J.H., by including veterans in program formation, Jr., Cornis-Pop, M., Mathewson-Chapman, M., implementation, and evaluation. Veterans Harms, G., Hunt, S.C., Kennedy, P., Mahoney- participated in the PST itself, participated Gleason, H., Perez, J., Sheets, C., & Washam, T. in the completion of the evaluation, and are (2011). VA integrated post-combat care: A systemic coauthor to this article. Having a community approach to caring for returning combat veterans. insider on the research team provided benefits Social Work in Health Care, 50(7), 564–575. https:// and subjective knowledge production. Having a doi.org/10.1080/00981389.2011.554275 native anthropologist (an anthropologist who Averill, J.B. (2002). Matrix analysis as a is a member of the population being evaluated, complementary analytic strategy in qualitative in this case veterans) on the team allowed inquiry. Qualitative Health Research, 12(6), 855– for an easier time developing rapport with 866. https://doi.org/10.1177/104973230201200611 program participants and facilitated a deeper Besterman-Dahan, K., Chavez, M., & Njoh, understanding of certain dimensions of cultural E. (2018). Rooted in the community: Assessing behavior that non-native evaluators may have the reintegration effects of agriculture on rural struggled to comprehend, especially in veteran- veterans. Archives of Physical Medicine and centered evaluation and research where acronyms Rehabilitation, 99(2), S72–S78. https://doi. are often used when discussing work and service org/10.1016/j.apmr.2017.06.035 history. Given that evaluators participated in the Besterman-Dahan, K., Downs, K.H., Siven, J., PST as both observers and participants, rapport & Orozco, T. (2019). Evaluation of the Growing Veterans’ was developed rather quickly; this can serve Peer Support Training program [Technical report]. as a useful model in future veteran-centered Brown, C., Besterman-Dahan, K., Chavez, M., evaluation and research. Njoh, E., & Smith, W. (2016). “It gave me an excuse Findings from this evaluation indicate that, to get out into society again”: Decreasing veteran overwhelmingly, participants reported the GV isolation through a community agricultural peer PST to be a powerful, transformative, and positive support model. Journal of Veterans Studies, 1(1), experience. Importantly, this includes those 163–204. http://doi.org/10.21061/jvs.v1i1.42 participants who had previously attended other Cogan, A.M. (2016). Community peer support trainings. PST participants reported reintegration: Transition between the figured implementing their peer support skills in all areas worlds of military and family life. Journal of of their life, both formally and informally, and Occupational Science, 23(2), 255–265. https://doi. described an increased understanding of the steps org/10.1080/14427591.2015.1114509 and skills that peer support requires. Crucially, Creswell, J. W. (2014). A concise introduction they noted that they do not need to “fix” anyone. to mixed methods research. SAGE Publications. Finally, this evaluation gathered a few Crocker, T., Powell-Cope, G., Brown, L. M., unintended consequences of note: & Besterman-Dahan, K. (2014). Toward a veteran- • Participants reported using their peer centric view on community (re)integration. Journal of support skills with all different populations, Rehabilitation Research & Development, 51(3), 11–17. veterans and nonveterans; many even say Demers, A. (2011). When veterans return: The that they have been able to use the peer role of community in reintegration. Journal of Loss support skills among their families to and Trauma, 16(2), 160–179. https://doi.org/10.10 improve relationships. 80/15325024.2010.519281 • Several nonveteran participants noted that Downs, K.H. (2017). “Beautifully awful”: A a benefit of the PST was to heighten their feminist ethnography of women veterans’ experiences awareness of veterans’ struggles. with transition from military service [Doctoral GV will be utilizing the findings from dissertation, University of South Florida]. this evaluation to further refine the PST and University of South Florida Scholar Commons. develop a new program (Train-the-Trainer). https://scholarcommons.usf.edu/etd/7018/ Future activities should include continued rigorous evaluation of the implementation of the

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 22 Drebing, C.E., Reilly, E., Henze, K.T., Kelly, Romaniuk, M., & Kidd, C. (2018). The M., Russo, A., Smolinsky, J., Gorman, J., & Penk, psychological adjustment experience of W.E. (2018). Using peer support groups to enhance reintegration following discharge from military community integration of veterans in transition. service: A systemic review. Journal of Military and Psychological Services, 15(2), 135–145. https://doi. Veterans Health, 26(2), 60–73. org/10.1037/ser0000178 Sayer, N.A., Carlson, K.F., & Frazier, P.A. Gorman, J.A., Scoglio, A.A.J., Smolinsky, (2014). Reintegration challenges in U.S. service J., Russo, A., & Drebing, C.E. (2018). Veteran members and veterans following combat Coffee Socials: A community-building strategy for deployment. Social Issues and Policy Review, 8(1), enhancing community reintegration of veterans. 33–73. https://doi.org/10.1111/sipr.12001 Community Mental Health Journal, 54, 1189–1197. Sayer, N.A., Frazier, P., Orazem, R.J., https://doi.org/10.1007/s10597-018-0288-y Murdoch, M., Gravely, A., Carlson, K.F., Hintz, Gorman, L.A., Blow, A.J., Ames, B.D., & Reed, S., & Noorbaloochi, S. (2011). Military to civilian P.L. (2011). National Guard families after combat: questionnaire: A measure of postdeployment Mental health, use of mental health services, and community reintegration difficulty among veterans perceived treatment barriers. Psychiatric Services, 62(1), using Department of Veterans Affairs medical care. 28–34. https://doi.org/ 10.1176/ps.62.1.pss6201_0028 Journal of Traumatic Stress, 24(6), 660–670. https:// Growing Veterans Peer Support Training doi.org/10.1002/jts.20706 Manual. (2021). https://growingveterans.org/peer- Sayer, N.A., Noorbaloochi, S., Frazier, P., support-training Carlson, K., Gravely, A., & Murdoch, M. (2010). Hoerster, K.D., Lehavot, K., Simpson, T., Reintegration problems and treatment interests McFall, M., Reiber, G., & Nelson, K.M. (2012). among Iraq and Afghanistan combat veterans Health and health behavior differences: U.S. receiving VA medical care. Psychiatric Services, military, veteran, and civilian men. American 61(6), 589–597. https://doi.org/10.1176/appi. Journal of Preventive Medicine, 43(5), 483–489. ps.61.6.589 https://doi.org/10.1016/j.amepre.2012.07.029 Seal, K.H., Bertenthal, D., Miner, C.R., Sen, McGranahan, C. (2014). What is ethnography? S., & Marmar, C. (2007). Bringing the war back Teaching ethnographic sensibilities without home: Mental health disorders among 103 788 fieldwork.Teaching Anthropology, 4, 23–36. https:// US veterans returning from Iraq and Afghanistan doi.org/10.22582/ta.v4i1.421 seen at Department of Veterans Affairs facilities. Miles, M.B., & Huberman, A.M. (1994). Archives of Internal Medicine, 167(5), 476–482. Qualitative data analysis: An expanded sourcebook https://doi.org/10.1001/archinte.167.5.476 (2nd ed.). SAGE Publications. Swainston, K., & Summerbell, C. (2008). The Money, N., Moore, M., Brown, D., Kasper, effectiveness of community engagement approaches K., Roeder, J., Bartone, P., & Bates, M. (2011). and methods for health promotion interventions. Best practices identified for peer support programs National Institute for Health and Clinical [White paper]. Defense Centers of Excellence for Excellence. Psychological Health and Traumatic Brain Injury. Tivald, J., & Kawashima-Ginsberg, K. (2015). https://www.mhanational.org/sites/default/files/ America’s greatest assets: How military veterans are Best_Practices_Identified_for_Peer_Support_ strengthening our communities (2015 veterans civic Programs_Jan_2011.pdf health index). Got Your 6. https://ncoc.org/wp- Pacheco-Vega, R. & Parizeau, K. (2018). content/uploads/2016/08/VetsCHI_2015_FINAL. Doubly engaged ethnography: Opportunities pdf and challenges when working with vulnerable Warren, S. (2014). “I want this place to thrive”: communities. International Journal of Volunteering, co-production and creative labour. Qualitative Methods, 17(1). https://doi. Area, 46(3), 278–284. https://doi.org/10.1111/ org/10.1177/1609406918790653 area.12112 Putnam, R.D. (1995). Bowling alone: America’s Wilcox, D. (1994). Community participation declining social capital. Journal of Democracy, 6(1), and empowerment: Putting theory into practice. 65–78. https://doi.org/10.1353/jod.1995.0002 RRA Notes, 21, 78–82.

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 23 About the Authors Karen Besterman-Dahan, PhD, RD is an applied medical anthropologist and registered dietitian. Her program of research focuses on veteran community reintegration, food insecurity, rural health, community engaged research and program evaluation. Jacqueline Sivén, PhD, MPH is an applied medical anthropologist whose research interests include behavioral health, worker safety and health, health equity, and migration. Her current work centers on COVID-related health inequities among underserved essential workers. Kiersten Downs, PhD is an applied anthropologist whose research portfolio leverages qualitative and quantitative methods to examine the military workplace as it is related to gender relations—specifically sexual assault and sexual harassment, race/ethnicity-based discrimination, and the workplace climate for the Department of Defense’s Office of People Analytics. Tatiana Orozco, PhD, is a statistician and research health scientist. Her interests focus on quantitative design, methods, and analysis in behavioral health.

Disclaimer The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States Government. This work was supported by the Bob Woodruff Foundation and the HSR&D Center of Innovation on Disability and Rehabilitation Research (CINDRR) at the James A Haley Veterans Hospital and Clinics, Tampa, FL.

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 24 “If You Don’t Name the Dragon, You Can’t Begin to Slay It:” Participatory Action Research to Increase Awareness Around Military-Related Traumatic Brain Injury

Gala True, Ray Facundo, Carlos Urbina, Sawyer Sheldon, J. Duncan Southall, and Sarah S. Ono

Abstract Hundreds of thousands of U.S. veterans and their families are significantly affected by traumatic brain injury (TBI), yet policy-makers and the general public often lack knowledge about TBI and other “invisible injuries” related to military service. Veterans may face delayed TBI diagnoses and trouble accessing needed health care, and they and their families may face stigma and misperceptions about TBI that impede successful community reintegration. Researchers in the Department of Veterans Affairs (VA) partnered with 45 veterans with TBI and 26 of their family caregivers on a participatory action research (PAR) study that used photovoice methods to explore and convey experiences of community reintegration after TBI. Interview data and images taken by participants were used to communicate stories, reflections, and insights. This paper reports participants’ reflections about (a) how they became aware of TBI-related symptoms and the impact of TBI on their lives and relationships, (b) challenges they have encountered—including misconceptions and stigma—when disclosing TBI and other “invisible injuries” to others, and (c) strategies and resources they draw upon to counter these challenges. The authors conclude by sharing participant-identified recommendations for supporting community reintegration after military service–related TBI. This work demonstrates the power of PAR to engage veterans and family caregivers in generating knowledge to inform the programs, policies, and public discourse that affect their lives. A priority for the dissemination of the study’s findings has been to raise awareness about TBI among veterans and military caregivers.

On January 8, 2020, Iran launched ballistic severity of TBI as “a major cause of death and missile attacks on two bases housing U.S. troops disability in the United States” (Brain Injury in Iraq. Despite early reports of no casualties, Association of America, 2020). At the same it was later revealed that at least 12 American time, the cochairs of the Congressional Brain servicemembers had sustained concussions and Injury Task Force released a bipartisan statement had been medically evacuated for evaluation and reiterating the nation’s commitment to providing treatment of possible traumatic brain injury, or “unqualified support and respect” to persons TBI (Lubold, 2020). At a press conference two impacted by TBI, noting, “Brain injury should weeks after the missile attacks, the U.S. president never be minimized. Unfortunately, too many described the injuries as “not very serious,” people, including elected leaders, are not familiar saying, “I heard they had headaches and a couple with the terrible realities of traumatic brain of other things.” He went on to characterize the injury” (Office of Congressman Bill Pascrell, servicemembers’ injuries as less severe than those 2020). The commander in chief’s remarks and of troops who lost limbs in roadside bomb attacks, the responses from brain injury advocates reveal noting, “I don’t consider them very serious injuries a central tension around “invisible injuries” such relative to other injuries that I’ve seen…I’ve seen as TBI. While these injuries may have serious, people with no legs and with no arms. I’ve seen long-term negative impacts on an individual’s people that were horribly, horribly injured in that health and functioning, the fact that they often area, that war” (Donnelly, 2020). lack visible and physical manifestations can The Brain Injury Association of America, impede awareness of an injury and its effects in an advocacy and research organization focused the eyes of the injured person, those closest to them, on increasing the public’s awareness and and outside observers (Tanielian & Jaycox, 2008). understanding of brain injury, expressed concern In this paper we examine these tensions that the president’s remarks minimized the around awareness of TBI through a new lens by

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 25 bringing in the voices of veterans and their family to local and national policy discussions and interdisciplinary evaluation and care for persons inform policies, programs, and public awareness caregivers. Drawing on data from a participatory public discourse regarding TBI and community with TBI and comorbid conditions (National that directly affect veterans’ and families’ transition action research (PAR) study, we seek to address the reintegration (Minkler & Wallerstein, 2011). Academies of Science, Engineering, and from military service to civilian life. Three authors following questions: 1. How do veterans develop Medicine, 2019). While these measures have been of this paper (CU, SS, and JS) who participated in self-awareness around the lasting effects of TBI? Background highly successful in identifying veterans with the study and one (RF) who was project manager 2. What are the consequences for veterans and their It is estimated that nearly 400,000 U.S. TBI and connecting them with needed services, for the study have direct experience of military families when self-awareness of TBI is delayed? servicemembers have suffered a TBI since the not all post-9/11 veterans receive VA care (Tsai & service, combat deployments, living with TBI, 3. How does awareness (or lack of awareness) onset of the wars in Iraq and Afghanistan (National Rosenheck, 2016). Furthermore, an internal audit and navigating the transition from military service about military service–related TBI among family Academies of Science, Engineering, and Medicine, discovered that screening and evaluation policies to civilian life. members and outside observers affect veterans 2019). TBIs are typically caused by a blow or jolt had been inconsistently applied across the VA as they navigate community reintegration (e.g., to the head, or less often by a penetrating head during a crucial 10-year period; consequently, Methods personal relationships, education, and work)? injury, and their effects can range from short-term many post-9/11 veterans had not been evaluated Community-engaged research has been 4. How do veterans (and their family caregivers) symptoms that resolve over time to long-lasting by a designated TBI specialist (VA, 2018). Thus, conceptualized as a continuum that spans three pursue valued life activities despite the challenges and debilitating changes in cognitive and motor despite growing recognition of the importance models: an advisory model, in which members of of living with TBI? functioning, physical symptoms such as recurrent of appropriate diagnosis and treatment of TBI a community provide overall guidance and input Our work is informed by Paolo Freire’s headaches and photosensitivity, and/or significant in U.S. servicemembers, there is still a need for throughout the life of the project; an employment critical pedagogy, the theoretical framework that changes in behavior and mood (Sayer et al., 2008). increased awareness and understanding of the model, in which community members are underpins PAR (Freire, 2018). A goal of critical TBI has been associated with negative impacts condition and its impacts, advocacy efforts to salaried members of the research team; and a pedagogy is to help individuals develop critical on employment and relationship functioning and ensure that veterans receive appropriate treatment participatory model, in which people affected by consciousness around an issue affecting their lives, with increased risk of suicide (Brenner et al., 2011; for their symptoms, and services to support the research topic are collaborative partners in thereby facilitating their ability to create and share Madsen et al., 2018). Around 80% of military veterans’ community reintegration. the research (Roche et al., 2010). Our photovoice knowledge of their own history and experiences service–related TBIs are classified as “mild,” or mTBI, study employed all three. We had an advisory (Ada, 1990). We were guided by critical pedagogy and multiple studies have demonstrated strong Partnered Research to Support board that included three veterans and three and PAR’s recognition of researchers and associations between mTBI and post-traumatic Community Reintegration military caregivers, the study’s project manager participants as bringing different types of expertise stress disorder (PTSD; Bryant et al., 2010; Hoge et Our work was guided by the belief that was a veteran, and our veteran and caregiver to the research enterprise. Through the process al., 2008). partnerships between researchers, veterans, and participants were coresearchers throughout most of engaging participants as co-researchers—what Many U.S. servicemembers experience military caregivers will improve the relevance phases of the project, including the identification of Markham has called “respectful dialogue” (2019)— multiple lifetime TBI exposures, both prior to of research findings, lead to improvements in themes in the data and dissemination of findings. our goal was to connect their deeply personal military service and throughout training and health care, and better inform policy downstream In addition, before beginning study recruitment, experiences of living with TBI to the broader deployment, and these injuries often are not assessed (Minkler & Wallerstein, 2011). Between April we developed relationships with leadership and conversations around TBI that are happening in or treated until servicemembers separate from 2016 and March 2019, two VA researchers (GT staff at several veteran-serving nonprofits to research and the public sphere. military service (Brenner et al., 2010). Individuals and SO) with experience conducting veteran- facilitate the recruitment of participants and The work described in this paper is built on who have sustained multiple lifetime concussions engaged research and a combat veteran working the dissemination of findings back to veteran several years of collaboration between researchers (i.e., mTBIs) are at a higher risk for emotional in VA research (RF) collaborated with individual communities. Institutional review boards at the and veterans of the wars in Iraq and Afghanistan distress, decreased cognitive functioning, and veterans with TBI and their military caregivers Southeast Louisiana Veterans Health Care System and was funded by the Department of Veterans dementia (Barnes et al., 2018; Spira et al., 2014). across two regions of the United States with the goal and the VA Portland Health Care System reviewed Affairs (VA; True et al., 2015, 2021). We engaged Barriers to diagnosis and treatment include of developing community-informed solutions for and approved all study methods. veterans and caregivers in this study using servicemembers’ reluctance to request medical improving community reintegration for persons photovoice methods, which involves giving treatment and a military culture that emphasizes with TBI and their families. For the purposes of Recruitment people cameras and asking them to document, stoicism over seeking help (MacLeish, 2013; Smith our study, we definedcommunity reintegration as Veterans were eligible for study participation reflect on, and communicate their experiences & True, 2014); veterans may be hesitant to report encompassing the return of individual veterans if they had served in the post-9/11 service era and concerns to stimulate discussion and social a history of TBI or to attribute their symptoms to and military families to meaningful participation (Operations Enduring Freedom, Iraqi Freedom, change (Wang, 1999). Our goal was to illuminate TBI (Brenner et al., 2015). In addition, the overlap in social, community, and civic life; work, or New Dawn [OEF/OIF/OND]) and had a TBI and convey veteran and caregiver experiences of between TBI and PTSD in terms of etiology education, and volunteering; domestic and family diagnosis documented in their medical record. We community reintegration after TBI and to ascertain and symptoms often complicates TBI diagnosis life; leisure; self-care; and spirituality and faith identified eligible veterans via the VA’s electronic participant-identified advocacy goals to promote and treatment; psychological trauma often (Resnik et al., 2012). health record (EHR) and through referrals from recovery and improve TBI care processes, programs, co-occurs with physical injury, especially in In alignment with our theoretical framework, VA staff in relevant clinics and community-based and policies. In keeping with the principles of military populations, and both conditions are we have endeavored to disseminate our research nonprofits, as described above. To confirm the our theoretical framework, a goal of this work characterized by attentional problems and mood findings through multiple channels to reach a broad eligibility of those veterans referred to the study, we was to engage individuals with lived experience changes (Tanev et al., 2014). audience, with veteran and caregiver participants verified the presence of a TBI diagnosis in the EHR. of military service and service-related injuries in In 2007, the VA instituted universal co-presenting and coauthoring with members of Veterans were mailed or handed a study flyer, and generating scholarship and knowledge to inform screening of post-9/11 veterans for TBI the VA research team whenever possible (True et a member of the study team followed up by phone programs and policies that directly affect their exposures and developed an integrated network al., 2021). Partnered dissemination ensures that all or in person with each prospective participant to lives and, ultimately, to bring their perspectives of specialized rehabilitative programs to provide types of expertise, including lived experience, can describe the requirements of participation in more

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 26 interdisciplinary evaluation and care for persons inform policies, programs, and public awareness with TBI and comorbid conditions (National that directly affect veterans’ and families’ transition Academies of Science, Engineering, and from military service to civilian life. Three authors Medicine, 2019). While these measures have been of this paper (CU, SS, and JS) who participated in highly successful in identifying veterans with the study and one (RF) who was project manager TBI and connecting them with needed services, for the study have direct experience of military not all post-9/11 veterans receive VA care (Tsai & service, combat deployments, living with TBI, Rosenheck, 2016). Furthermore, an internal audit and navigating the transition from military service discovered that screening and evaluation policies to civilian life. had been inconsistently applied across the VA during a crucial 10-year period; consequently, Methods many post-9/11 veterans had not been evaluated Community-engaged research has been by a designated TBI specialist (VA, 2018). Thus, conceptualized as a continuum that spans three despite growing recognition of the importance models: an advisory model, in which members of of appropriate diagnosis and treatment of TBI a community provide overall guidance and input in U.S. servicemembers, there is still a need for throughout the life of the project; an employment increased awareness and understanding of the model, in which community members are condition and its impacts, advocacy efforts to salaried members of the research team; and a ensure that veterans receive appropriate treatment participatory model, in which people affected by for their symptoms, and services to support the research topic are collaborative partners in veterans’ community reintegration. the research (Roche et al., 2010). Our photovoice study employed all three. We had an advisory Partnered Research to Support board that included three veterans and three Community Reintegration military caregivers, the study’s project manager Our work was guided by the belief that was a veteran, and our veteran and caregiver partnerships between researchers, veterans, and participants were coresearchers throughout most military caregivers will improve the relevance phases of the project, including the identification of of research findings, lead to improvements in themes in the data and dissemination of findings. health care, and better inform policy downstream In addition, before beginning study recruitment, (Minkler & Wallerstein, 2011). Between April we developed relationships with leadership and 2016 and March 2019, two VA researchers (GT staff at several veteran-serving nonprofits to and SO) with experience conducting veteran- facilitate the recruitment of participants and engaged research and a combat veteran working the dissemination of findings back to veteran in VA research (RF) collaborated with individual communities. Institutional review boards at the veterans with TBI and their military caregivers Southeast Louisiana Veterans Health Care System across two regions of the United States with the goal and the VA Portland Health Care System reviewed of developing community-informed solutions for and approved all study methods. improving community reintegration for persons with TBI and their families. For the purposes of Recruitment our study, we definedcommunity reintegration as Veterans were eligible for study participation encompassing the return of individual veterans if they had served in the post-9/11 service era and military families to meaningful participation (Operations Enduring Freedom, Iraqi Freedom, in social, community, and civic life; work, or New Dawn [OEF/OIF/OND]) and had a TBI education, and volunteering; domestic and family diagnosis documented in their medical record. We life; leisure; self-care; and spirituality and faith identified eligible veterans via the VA’s electronic (Resnik et al., 2012). health record (EHR) and through referrals from In alignment with our theoretical framework, VA staff in relevant clinics and community-based we have endeavored to disseminate our research nonprofits, as described above. To confirm the findings through multiple channels to reach a broad eligibility of those veterans referred to the study, we audience, with veteran and caregiver participants verified the presence of a TBI diagnosis in the EHR. co-presenting and coauthoring with members of Veterans were mailed or handed a study flyer, and the VA research team whenever possible (True et a member of the study team followed up by phone al., 2021). Partnered dissemination ensures that all or in person with each prospective participant to types of expertise, including lived experience, can describe the requirements of participation in more

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 27 detail and to answer questions. For each veteran active duty military, and 22% had served in the who expressed interest in study participation, National Guard or military reserves. Participants we asked, “Can you identify a family member or represented four branches of military service, with friend who is involved in supporting you in your a majority having served in the U.S. Army or U.S. health care and/or community reintegration?” We Marine Corps. contacted these veteran-identified caregivers to Of the 26 caregivers who enrolled in the see if they were interested in participating in the study, most were women (88%) and non-Hispanic study with the veteran. Veterans who could not White (85%). Most were the spouse or partner identify a caregiver were eligible to participate solo of a participating veteran (81%); the remaining (i.e., without a study partner). Caregivers were caregivers were parents, adult children, or siblings not eligible to participate without a veteran study of the veteran participants. partner. Participants provided written informed consent and were compensated $40 for each Photovoice Procedures in-person study visit they completed. The study sought (a) to encourage veterans and caregivers to reflect on their experiences with Sample health, illness, and community reintegration after A total of 45 veterans enrolled in the study, military service and (b) to engage them in advocacy of which 26 had a caregiver study partner. Most for supportive services and environments designed veterans identified as male (89%) and ranged in to help them and other veterans and their families age from 24 to 56 years (mean = 37). Nearly three pursue valued life goals. We framed photovoice quarters (73%) were White and non-Hispanic. as a PAR method that has the potential to bring By design, all veteran participants had a TBI the lived experiences of veterans and caregivers diagnosis; the majority also had a diagnosis of to policy-makers and to raise awareness about PTSD (91%) and/or depression (67%). About three the challenges facing individual patients and quarters of the veteran participants had served as communities (Wang, 1999). We used a graphical

Figure 1. Photovoice Methods

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 28 representation adapted from Lorenz (Figure 1) to For Visit 4, we invited participants to outline study methods for participants (Lorenz & attend one of six small-group meetings. The goal Chilingerian, 2011). of these discussions was to support community Study participation involved four distinct building and co-construction of knowledge visits. During Visit 1, members of the research (Minkler & Wallerstein, 2011; Tang Yan et al., team met with veteran participants or with 2019). The researchers presented preliminary veteran–caregiver participant pairs (dyads) to themes identified in the data and displayed discuss the principles of PAR and the goals of illustrative excerpts from participants’ photo the study. Participants were given cameras and narratives on the walls to facilitate sharing and asked to take photographs to illustrate their daily discussion. Researchers asked participants to lives and experiences with TBI and community reflect on what themes felt most relevant to their reintegration. Between Visits 1 and 2, a period experiences and to consider whether there were of approximately two weeks, participants took themes they felt were missing or underdeveloped. photographs or selected relevant photos from their Researchers and participants discussed priorities personal collections. for the dissemination of the study’s findings, At Visit 2, a member of the research team including preferred formats for dissemination trained in qualitative methods met with each (e.g., public exhibits and presentations) and participant one-on-one to collect photographs target audiences (e.g., VA administrators and and conduct a photo-elicitation interview, where policy-makers, other veteran and caregiver photographs taken by the participant were used as groups). At these meetings, many participants prompts to generate reflections and evoke stories. spontaneously connected with each other, sharing For this interview, we used a semistructured knowledge of resources and exchanging contact interview guide adapted from Wang’s SHOWeD information so they could stay in touch outside method (1999). At the end of Visit 2, each of the research project. These meetings often laid participant reviewed their photographs and the groundwork for papers such as this one. shared with the researcher any special instructions regarding how a specific photograph could be Data Analysis used and how they wanted to be identified in the We used a grounded theory approach dissemination of findings (e.g., by their full name, (Chun Tie et al., 2019; Strauss & Corbin, 1998) by their first name only, or by a pseudonym). These to analyze data, which we modified to suit health interviews were digitally recorded and transcribed. services research conducted in a grant-based Once transcripts were available, a member system. A modified grounded theory approach of the research team developed a photo narrative allows for analysis that involves initial open for each participant by matching text (i.e., what coding, the combination of a priori codes with the person said about their photographs) with any data-driven inductive codes that emerge, each photograph. Photo narratives were laid out and iteration throughout the analysis process. in Microsoft Publisher to resemble picture books, Drawing upon two sources—(a) the preliminary and these “books” were mailed to participants to coding of individual photographs and transcripts make edits as needed until they were satisfied that that we used to develop photo narratives and (b) the books captured their perspectives. This process an iterative review of eight randomly selected provided an opportunity for member checking, transcripts of photo-elicitation interviews— whereby data are shared with participants to check members of the research team (including three for accuracy and resonance with their intentions of the coauthors [GT, RF, and SO]) developed a and experiences (Birt et al., 2016). Veterans and codebook consisting of codes (i.e., brief labels caregivers who were participating together were assigned to a selection of text), code definitions, also asked to share their photo narratives with each and examples from transcripts. Each transcript was other sometime between Visits 2 and 3. coded in Atlas.ti by a primary coder who applied During Visit 3, researchers met with veteran– codes to the transcript and a secondary coder who caregiver dyads and conducted semi-structured “audited” the coded transcript and noted any areas interviews to elicit joint reflections on how of disagreement in the application of codes. Coding reading each other’s photo narratives affected their disagreements were tracked through written knowledge and understanding of one another’s memos and discussed and resolved by consensus perspectives and experiences. These interviews at biweekly coding meetings (Cascio et al., 2019). were audio-recorded and transcribed.

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 29 Through the iterative process of (a) creating I feel anxious in social situations. I feel photo narratives by linking photographs to anxious about meeting obligations. I feel quotations from transcripts, (b) member checking anxious about not being able to focus with participants to refine the photo narratives, on things. It feels like I’m always doing (c) gaining input from participants though something wrong, and everything I do small-group discussions, and (d) team coding of wrong feels like the end of the fucking transcripts, we identified recurrent themes around world. Half of my problems are from my veterans’ and caregivers’ experiences of living TBI. You feel stupid when you used to be with TBI and other “invisible injuries” related to a writer, an English major, and now you military service. These themes included barriers can’t find your vocabulary. You’re looking and facilitators to community reintegration as well somebody in the eye and don’t remember as recommendations for policy and programmatic their name. change to support veterans and their families in postmilitary life. To develop the current paper, Image 1. I feel anxious about everything. You we supplemented our previous analysis with two feel stupid when you can’t find your vocabulary. 60-minute phone calls during which researchers and coauthor veterans identified the themes and associated data (both illustrative images and quotations) that we wished to highlight and include in this manuscript.

Results Many themes emerged from the larger photovoice study. Elsewhere, we have published the insights we gained into the experiences of family caregivers of veterans with TBI (Abraham et al., 2021; Wyse et al., 2020). In this paper, we chose to focus on themes relevant to different dimensions of TBI awareness, including (a) veterans’ reflections on how they became self-aware of TBI-related symptoms and the impact of TBI on their lives and relationships; (b) the challenges veterans and family caregivers encountered—including misconceptions and stigma—when disclosing “invisible injuries” to others, and how these challenges may be compounded by civilian-held stereotypes of veterans as homogeneous; and (c) strategies and resources that veterans and caregivers draw upon to counter these challenges. We included photographs and quotations to illustrate each theme; all identifiers used here were selected by participants.

Developing Self-Awareness of TBI Many veterans described their recognition of TBI’s lasting impacts on their lives and relationships as a process that unfolded over multiple years post– Veterans and their caregivers recounted military service. A veteran who identified herself how TBI diagnoses helped the caregivers better by the name “Feral” provided a photograph of her understand their veterans’ initially frustrating bitten-down fingernails to convey the anxiety and behavior. One example came from John, who shared frustration she experienced as she grew more self- a photo of groceries to illustrate how his memory aware of cognitive impairments related to her TBI: issues strained his relationship with his wife:

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 30 My wife asked me to get butter. I came Veterans like Josh described how seeing back with everything besides butter. themselves through the eyes of their loved ones At first, she was annoyed. She didn’t helped them become self-aware of their TBI understand why I wasn’t paying attention, symptoms. Through photovoice, these veterans [that] I’m not doing it to spite her. Then illustrated the negative consequences that she found out about the TBI because she accompanied their delayed self-awareness of their came for the MRI with me…She was like, own TBI symptoms and their inability to access “Wow, that makes so much more sense!” adequate care and support. Eddie, for example, provided two photographs to illustrate the painful Image 2. My wife asked me to get butter. I loss of his family: came back with everything besides butter. This is what happens when you don’t deal with what you need to deal with. You think everything is okay, and you put everything that’s bothering you on the back burner…I was so used to the isolation that I didn’t give [my wife] enough attention. This picture was taken when I was still with my son and his mom. This is us starting something new, trying to become a family, making plans. [But] there were so many unresolved issues, as far as my PTSD and TBI, I had so much going on in my brain and in my life, that it resulted in this photo of me In contrast to John’s experience, in which his standing alone. TBI diagnosis helped his wife accept changes in his memory and cognition, other veterans described Image 3. This is what happens when you the challenges they faced in getting their TBI don’t deal with what you need to deal with. recognized in a health care setting, even as their TBI symptoms created problems in their personal lives. As Josh relayed:

I feel there are a lot of guys that are missing out on their TBI diagnosis. When I went to talk with [the VA doctor], he was like, “Nah, you’ve got PTSD.” And I was like, “Okay, is it possible I have both?” He looked at the scan of my brain and said there was no permanent physical damage, so I didn’t have TBI. I can’t argue with him, because if he don’t think I got it, he ain’t interested in treating it. But it’s the inability to stay on track that drives me nuts now. I forget where I put my keys, I forget that I’m supposed to be somewhere. I had a relationship with a girl that was living with me, and she said, “I feel like I’m living with an old man who Other veterans who developed self-awareness has dementia.” through observing the impact of their illness on their loved ones were able to access health Josh eventually received a TBI diagnosis care and begin the recovery process before those from a different VA doctor, but by that time his relationships were irretrievably lost. As Carlos relates: relationship had ended.

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 31 My rock bottom was when my wife was misconceptions about “invisible injuries” such as crying almost every day. She was telling TBI. Many veterans took photographs to illustrate me all the things I needed to notice the challenges they faced in social situations at about myself, and it went in one ear work and school when others did not perceive and out the other. I finally took a step them as injured, trust that they were experiencing back and listened…and really dug deep TBI-related symptoms (e.g., photosensitivity or and said, “Why is my wife crying? She’s chronic migraines), or believe that they needed crying because of me.” It opened my eyes special accommodations (e.g., closed window to, “I’m not who I want to be. If I want shades, dim lighting, or wearing sunglasses to work towards my goal, that person I indoors). JD shared his experience with an am supposed to be, then I need to start employer who, despite being a veteran, lacked a now…The doctors are there, telling me basic understanding of TBI: something, so why don’t I start taking notes?” After that, every time I went to I was trying to explain my own TBI to my an appointment, I would say, “Well, can employer, who was a military guy who I come next week? Can I come twice a didn’t see combat. And he said, basically, week? Can I come three times a week?” he doesn’t understand why I can’t get over They would recommend or suggest it. Because people can get over alcoholism, things, and I would jump to them. and he related it to alcoholism. I mean, it’s just frustrating. Finally, some veterans shared how the process of engaging in the study itself—of reflecting on Caregivers also shared how ignorance about their daily lives or hearing about the experiences “invisible” military-related injuries caused stress in of other veterans and families through study the course of their daily lives. As Sharon, caregiver participation—led to increased self-awareness to her Marine veteran husband, described: and a desire to educate others about symptoms and impacts of TBI. Ray, a combat veteran with The first time we went to the airport, I multiple TBI exposures who was also the study’s was terrified. There were no resources project manager, observed: for me to reach out [for help], because he looks normal on the outside. He stands It was astonishing how much I didn’t realize by himself. He can smile. When I went about TBI and the symptoms and the to the desk to ask if we could board first, signs that I was feeling and going through I said, “I will sit in the back of the plane during my transition. Hearing others’ even though it’s more uncomfortable, so stories made me reflect on the experiences there is nobody behind him. He doesn’t I had in school, my relationships, my social feel comfortable [with someone behind life, and my professional life. It really took him].” But [the gate agent] pushed back, me aback. I struggled a lot more than I saying, “He’s not disabled. He doesn’t look should have. It would have been less of a disabled.” struggle if people understood more about what TBI is. Another caregiver, Jennifer, contributed a photograph of a ripped coffee filter to represent A common goal emerged from our study how her husband’s TBI and decreased tolerance for participants: to educate veterans, their families, alcohol resulted in his having a “torn filter,” which health care providers, and other civilians about led to challenges in social situations even with symptoms and impacts of TBI and to ensure that close family: other veterans and families are able to access the resources they need to support their health and My friends and family are understanding, quality of life. but there are times when [my husband] says stuff. On New Year’s Eve, we were Coping With Misconceptions and all drinking and he started going off Stigma Around Disclosure of TBI about something. I could tell my family Veterans and caregivers shared their was getting kind of angry with him and frustrations and negative experiences with public I said, “You have to remember [he] has

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 32 a brain injury, he does not mean it this due to concerns about stigma. Veterans shared way.” This is one of the things I deal with experiences of hearing civilian student colleagues on a daily basis because it is not going to repeat stereotypes about veterans with TBI and change…The brain injury is not going to PTSD as “damaged.” As Sawyer recounted: repair itself and he is not going back to a hundred percent again. I would like for In grad school, a classmate of mine kept people to be more understanding and take talking about veterans dealing with TBI a step back and not get so easily offended. that she was working with, she kept talking about veterans like we were puppies. Like, Image 4. You have to remember he has a “They don’t know how to get help and brain injury; he does not mean it this way. they are so confused and they don’t know how to advocate for themselves.” And I finally snapped in class one day…There’s a section of the population that thinks we’re stupid because we had our brains scrambled.

Participants also observed how civilians tend to characterize veterans as a homogeneous community rather than as individuals with diverse backgrounds and perspectives. This general lack of awareness about individuals’ intersecting identities compounded the negative effects of stigma and misconceptions about TBI and thwarted participants’ efforts to connect with In addition to expressing their frustrations potentially helpful resources. Feral, a transgender with others’ misconceptions and lack of knowledge woman, described her struggle to be recognized about TBI, veterans spoke of how stigma and bias and accepted for her intersecting identities as both negatively affected their ability to engage in work a combat veteran with a TBI and a transgender and school. JD, who worked as a child welfare activist. JD, who served in the Marine Corps and advocate after separation from military service, later in the Army, shared two photographs—one faced professional challenges related to public of his Quran alongside his service medals and knowledge of his service-related injuries: dog tags and another of his Marine Corps portrait and medals—to illustrate his multiple identities Unfortunately, the situation I was in as a Muslim and a self-identified “queer, Marine- [when injured], it was highly publicized looking, bald male.” He shared the challenges he so I’m in three or four different books and faced when navigating educational and professional all these articles about what I did. If you settings where he does not always feel recognized Google my name, PTSD or TBI comes or welcomed by other veterans: up…People will use that against me in court when I testify, [saying], “This guy You go to school or to an employment shouldn’t have been around my children resource center, and there’s a bunch of because he has PTSD and TBI, and he’s veterans. But when you mention that going to swipe my kids.” I get that all the you’re queer, you know then that you’re time, so I fight on many different levels. no longer part of that sect or whatever. You’re not just in a personal fight with You lose that camaraderie… I understand having TBI, but the populace itself is so there’s prejudice in the world, but that’s prejudiced they can’t see people like me. another aspect of this; that we’re out in the professional world and we’re being judged Many veteran participants were using their not just for TBI but for being veterans. Post-9/11 GI Bill benefits to attend school after And then we have a lot of stigmas to separation from military service. Some reported overcome. a reluctance to disclose their TBI or to seek disability accommodations in school settings

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 33 Image 5. We have a lot of stigmas to overcome.

Sawyer echoed and expanded on these sentiments; Sawyer’s observations also touch upon a as a woman who returned to school after separation common thread present in participants’ photo from military service, she pointed out that not narratives: Many veterans, especially women or all veterans experience the idealized notion of members of racial or sexual minority groups, “camaraderie” emphasized in popular culture, and experienced institutional betrayals and traumas this can leave many veterans feeling unsupported during military service that may complicate even in spaces intended to serve student veterans: community reintegration.

Some veterans are going to be completely Living With TBI and different [in terms of] their needs Navigating Community Reintegration and wants and desires. What [women Veteran–caregiver pairs described the veterans] want from the veterans resource important role that caregivers played in recognizing center may be different than a lot of the and helping their veterans manage challenging male soldiers, Marines, airmen. When situations. For example, Sean, caregiver to his I was in the Army, there is no band of Army veteran wife, Sawyer, shared a photograph brothers when you’re the only woman and from when he and his wife encountered crowds 156 dudes. I never got that camaraderie. and other stressors while sightseeing and he That doesn’t exist when you’re the only recognized the need to cut their trip short: one of your gender. There’s institutional trauma that continues on in a lot of ways Sawyer can’t enjoy herself, because she’s in for women after we leave the service. So, that headspace where crowds are bad and when you walk into a resource center not something she is comfortable being and you get told “one place fits all,” it’s in. It’s like, “Alright, we’re gonna have to definitely frustrating. vacate the premises, go home, and feed our puppies.”

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 34 Image 6. Alright, we’re gonna have to vacate Image 7. It takes me a while to understand… the premises, go home, and feed our puppies. I just sit there quiet and try to catch what I can.

Reflecting on the experience of participating in the study with her husband, Sawyer was surprised to realize how much her husband had absorbed the impact of her symptoms and helped her to manage them by anticipating potential triggers and adapting with her:

My husband participated [in the photovoice study] and seeing and hearing things he said that I had never heard him say Veterans explained how they came to terms before, that was really eye-opening for with their own and others’ views of changes in me. He has become hyperaware of things their cognitive functioning and adjusted their that will upset me. I had never considered expectations for professional pursuits post-TBI. that he would become considerate of that. JD shared photographs of two cars he was in the It’s like a secondary learned trait that my process of rebuilding and said: trauma has brought; he had to learn, just from adapting to me. I was on my way to be an academic… I am changing my path because of the In the face of these challenges, veterans and cognitive delays I face. People that meet caregivers described strategies and resources they me now, they don’t see any problems with used to manage symptoms and pursue valued life me. But people that knew me before say, activities. Participants often used humor to relate “Oh, wow, you’re not as witty, you’re not their frustrations and coping mechanisms. Ben, a as fast.” I know I can’t go back and get my veteran with a collection of T-shirts poking fun at PhD and do what I wanted to do before stereotypes of combat veterans (e.g., as “dangerous” the war. But I’ve always enjoyed working or “medicated”), provided a photograph of himself on cars, and this is something with my “giving the finger” to the camera to illustrate his deficits I can still do. difficulties with understanding people and his advice to people who want to communicate with him: It is important to note that the veteran participants also described strategies that helped Speak slowly. It takes me a while to them pursue career and educational goals despite understand what you’re talking about, cognitive challenges. JD went on to a career in and it helps so you can communicate to child welfare, and at the time of this writing Carlos me and I can relay it back to you. When and Sawyer were both pursuing higher education. you’re talking to me, I’m more focused on the words than on what’s being said, Discussion and I have to break it down for myself. We value photovoice for its rootedness in It frustrates me that my mind works like critical consciousness, which fosters in-depth that. A lot of times, I just sit there quiet understanding of social and political worlds and try to catch what I can. through the eyes of people who have experienced

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 35 stigma, oppression, or suffering in order to expose TBI diagnoses, and they shared their stories in contradictions and help reframe public and policy hopes that other veterans would recognize shared conversations (Bowleg, 2017; Freire, 2018). experiences and seek out a TBI evaluation if they As evidenced by recent public discourse had not yet had one or pursue a second opinion and the personal experiences of our veteran and if they felt an initial medical evaluation had been caregiver collaborators, TBI is still a misunderstood incomplete. Likewise, caregivers shared insights condition. Participants’ narratives illuminated about their growing awareness that “something how delays in getting a diagnosis and developing was going on” with their loved one. They explained self-awareness of TBI symptoms negatively affected how their own research or education from health their relationships, health, and quality of life. In care providers helped them understand how their this way, our findings build on previous studies of veteran’s symptoms were related to TBI, and they the impacts of TBI and other invisible injuries on wanted other military caregivers to have access to family caregivers (Griffin et al., 2012; Moriarty et knowledge and resources before their relationships al., 2015, 2018; Voris & Steinkopf, 2019). deteriorated beyond repair. A priority area for the Even after veterans and caregivers gained dissemination of findings from our study has thus insight into TBI, they still had to contend with the been raising awareness about TBI among veterans invisibility of the injury, the public’s general lack of and military caregivers. knowledge about TBI, and stigma when navigating Second, participants had recommendations valued activities and life goals in community, for improving veterans’ experiences in employment work, and educational settings. Previous research and educational settings. They observed that many has associated TBI with negative changes in self- veterans were reluctant to disclose their TBI and concept, depression, and decreases in self-esteem other invisible injuries to employers, instructors, (Carroll & Coetzer, 2011). Although participants and school administrators out of embarrassment in our study used photovoice to share journeys that or concerns about being stigmatized. As one included periods of grief and loss as they became consequence, veterans often missed out on aware of TBI-related changes in themselves, services and accommodations that could help their stories also included acceptance, growth, them succeed. Other researchers have reported and finding new purpose. After their injuries, similar findings among veterans seeking higher veterans found support in their caregivers, coped education (Rattray et al., 2019). An important goal through humor and self-awareness, advocacy for for future education and advocacy work includes themselves and other veterans, and adopted new destigmatizing the disclosure of invisible injuries life goal. Many veterans noted the limitations of and ensuring that veterans are aware that their resources and services that treated veterans as a disclosures are confidential by law. homogenous community and failed to account Participants also noted the need for for veterans’ intersecting identities and diverse well-resourced veteran student centers with staff experiences of military service. trained to help facilitate difficult conversations Veteran and caregiver participants had between veterans and faculty or veteran and specific advice and recommendations with respect civilian students. They emphasized the importance to policies and practices that could best support of maintaining these centers as welcoming community reintegration. First, they emphasized spaces for veterans with diverse experiences and how important it is for veterans to recognize their identities, and they noted that campus resources potential exposure to repeated concussions as an for women and sexual and gender minorities occupational hazard of military service and to (i.e., LGBTQ students) could be important disclose any relevant history fully to their health potential collaborators in program development care providers. Our participants acknowledged for veteran student centers. Many participants exposure to a wide range of concussive events, in our study had gone into service professions from “getting your bell rung” during basic training, or were pursuing education with the intention to whiplash incurred by jumping out of airplanes, of helping other veterans; they emphasized their head trauma from falling equipment such as commitment to creating safe spaces for veterans to dislodged metal from makeshift up-armored share their experiences, disclose their needs, and vehicles, blast exposures from improvised explosive receive support. devices and rocket attacks, and overpressure from firing large weapons. Many veterans in our project faced years-long delays in getting their

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 36 Limitations been challenging to put into words. These methods We analyzed photovoice data using a also allowed participants to convey their views to PAR framework, with a focus on identifying policy-makers, program managers, and members participant-informed goals for advocacy and of the wider public. Photovoice holds great education. Data analysis through a different lens promise as a research approach that can be led or may have yielded different interpretations. We co-led by military servicemembers, veterans, and drew our study participants from two regions of their family members to challenge misconceptions the United States, and most (although not all) were about and misrepresentations of their experiences. receiving care from a VA medical center. Veterans Furthermore, we see photovoice and other forms and caregivers drawn from a larger national sample, of PAR as a potential tool for veterans and military including more veterans who do not receive VA families affected by invisible injuries, helping them care, would likely provide additional experiences to move toward healing and develop a new sense of and perspectives on TBI and community mission and purpose through engaging in critical reintegration. We focused on themes that we reflection on their reintegration experiences and identified as important and relevant to most study advocating for social change in their communities. participants based on data collected through photo narratives and small-group discussions (Visit 4). References We also consciously incorporated the personal Abraham, T.H., Ono, S.S., Moriarty, H., examples of our veteran-participant coauthors Winter, L., Bender, R.E., Facundo, R., & True, G. (CU, SS, and JS) to illustrate the selected study (2021). Revealing the invisible emotion work of findings. The investigators leading this research caregivers: A photovoice exploration of informal share a background in feminist theory and an care provided by family caregivers for post-9/11 appreciation for standpoint theory, reflexivity, veterans with traumatic brain injuries. Journal of and positionality, as these affect the perspectives Head Trauma Rehabilitation, 30(1), 25–33. https:// that each contributor brings to a collaboration doi.org/10.1097/HTR.0000000000000589 such as writing with study participants (Closser Ada, A.F. (1990, April 21–25). The educator as & Finley, 2016). Although the themes presented researcher: Principles and practice of participatory are grounded in the study data, a different research [Paper presentation]. Annual National combination of authors would likely foreground Association of Bilingual/Bicultural Education different examples while including additional Conference, Tuscon, AZ, United States. participants as coauthors could have broadened Barnes, D.E., Byers, A.L., Gardner, R.C., the diversity of views represented. We have Seal, K.H., Boscardin, W.J., & Yaffe, K. (2018). developed a traveling exhibit that includes photo Association of mild traumatic brain injury with narratives from every veteran and caregiver who and without loss of consciousness with dementia contributed to the study, and we continue to find in US military veterans. JAMA Neurology, opportunities to co-present study findings with a 75(9), 1055–1061. https://doi.org/10.1001/ variety of collaborators to make sure that as many jamaneurol.2018.0815 voices and perspectives as possible are represented. Birt, L., Scott, S., Cavers, D., Campbell, C., & Walter, F. (2016). Member checking: Conclusion A tool to enhance trustworthiness or merely Veterans’ and caregivers’ contributions and a nod to validation? Qualitative Health insights demonstrate the power of using photovoice Research, 26(13), 1802–1811. https://doi. to engage persons with direct experience of living org/10.1177/1049732316654870 with invisible injuries related to military service Bowleg, L. (2017). Towards a critical health in generating knowledge to inform the programs, equity research stance: Why epistemology and policies, and public discourse that affect their methodology matter more than qualitative methods. lives. Photovoice is a PAR approach that facilitates Health Education and Behavior, 44(5), 677–684. co-ownership of data and research findings and https://doi.org/10.1177/1090198117728760 makes engaging participants in data analysis, Brain Injury Association of America. (2020). interpretation, and dissemination of findings BIAA responds to Trump’s statement about service more feasible and equitable. In this study, visual- members with traumatic brain injury. https://www. narrative methods enabled participants to reflect biausa.org/public-affairs/public-awareness/news/ on and articulate experiences related to TBI and biaa-responds-to-trumps-disregard-for-service- community reintegration that may have otherwise members-with-traumatic-brain-injury

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SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 39 Acknowledgments About the Authors We wish to acknowledge the veterans and Gala True is an investigator with the South family caregivers who collaborated on this work Central Mental Illness Research, Education, and with us and shared their stories, experiences, and Clinical Center at the Southeast Louisiana Veterans perspectives because of a desire to learn more Health Care System and an associate professor about themselves and to be of service to others. in the Section on Community and Population We would also like to thank our families and loved Medicine at the Louisiana State University School ones for their support of us and of this work. We of Medicine. Ray Facundo is a project manager acknowledge the important contributions of other with the Southeast Louisiana Veterans Health research team members over the years, especially Care System and a U.S. Army veteran (OIF). Traci Abraham, PhD, for her involvement in coding Carlos Urbina is a BS candidate in psychology transcripts from photo-elicitation interviews, at Southeastern Louisiana University and a U.S. Mary Frances Ritchie, MPH, and Ryan Bender, Marine Corps veteran (OIF/OEF). Sawyer Sheldon MSW, who collected data, coded, and maintained is an MA candidate in applied psychological communication with participants. We thank the sciences at Pacific University and a U.S. Army anonymous reviewers for their helpful comments. veteran (OIF). J. Duncan Southall is a child welfare The study was supported by VA HSR&D award IIR specialist and a veteran of the U.S. Army and the 14-399. Gala True also receives support from the U.S. Marine Corps (OIF/OEF). Sarah Ono is an South Central Mental Illness Research, Education, investigator with the Center to Improve Veteran and Clinical Center (SC MIRECC). At the time Involvement in Care at the VA Portland Health of this research Sarah Ono was supported by the Care System and an associate professor at Oregon Center to Improve Veteran Involvement in Care Health & Science University. (CIVIC).

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 40 Motivations of Older Veterans and Dependents in a Physical Activity Program

Candace S. Brown, Ismail Mustafa Aijazuddin, and Miriam C. Morey

Abstract Motivation to engage in physical activity (PA) is of research interest due to the United States’ failure to achieve significant gains in the rates of individuals meeting national PA recommended guidelines. Veterans have physical deficiencies at a greater rate than the general population, and older veterans (> 65 years) are the least physically active of all veteran cohorts. The purpose of this pilot study was to ascertain the motivations of older veterans participating in an ongoing exercise program supervised and supported by the Department of Veterans Affairs. Participants (N = 63) self-reported their preferred exercises within the program and completed the Motives for Physical Activity Measure–Revised (MPAM-R), which assessed their exercise motivations in terms of interest/enjoyment, fitness, appearance, social factors, and competence. The most performed aerobic activity was walking, and the most popular anaerobic activity was yoga. Mean results of the MPAM-R indicated fitness as the highest rated motivation (M = 6.53, SD = 1.1), with a strong desire among participants for veterans to maintain health and well-being. The lowest rated statements were those related to social factors (M = 4.96, SD = 1.8), specifically, spending time with others. Fitness was statistically significant to interest/enjoyment, competence, and appearance (p < .01) but not to social motivation. However, interviews (n = 4) with participants of 10+ years revealed social factors to be a strong motivator for long-term participation in the exercise program. Exploring participants’ motivations produces valuable information that may broadly impact the development of future exercise programs.

The benefits of physical activity (PA) are that only 53.6% of U.S. older adults are achieving well established, but veterans’ motivations for the recommended minutes of aerobic activity, engaging in PA are of research interest due to and only 23.7% are carrying out the recommended the United States’ failure to achieve significant muscle-strengthening exercises (CDC, 2020). gains in the rates of older veterans meeting Although veterans are generally more engaged national recommended PA guidelines over the in PA than civilians are (Bouldin & Reiber, past decade. Older veterans represent the largest 2012; Littman et al., 2009), they consistently segment of the veteran population (Amaral et report poorer health (Schult et al., 2019), with al., 2018), and they are the least physically active only 43.1% of veterans age 50 and older meeting of all veteran age cohorts (Pebole & Hall, 2019). the CDC’s recommendations (Littman et al., The Centers for Disease Control and Prevention 2009). Following military discharge, many (CDC, 2020) recommends that all older adults veterans adopt a more sedentary lifestyle that, (age 65 and older) complete between 75 and coupled with the stress of returning to civilian 300 minutes of PA per week, including both life, increases their risk of becoming overweight moderate-intensity and vigorous-intensity or obese leading to concerningly high rates aerobic PA. For additional health benefits, the of disease and disability (Batch et al., 2020) CDC encourages weekly muscle strengthening that are likely to continue to increase as the of all major muscle groups on two or more days. population ages (Amaral et al., 2018; Dattilo et However, the most recent data available indicate al., 2014).

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 41 Behavioral intervention research focused on (Brown, 2019). Because motivation drives intent group exercise has demonstrated to be an effective toward a goal, this behavioral construct is key to strategy for increasing PA and decreasing the understanding why older people engage in PA. number of sedentary veterans. These interventions Drawn from theoretical perspectives including and programs have evaluated the potential effects social identity theory (Pelssers et al., 2018, 2019), of PA on function (Bulat et al., 2007; Morey et al., economic theory (Farooqui et al., 2014), and 2002; Paden et al., 2017), post-traumatic stress personal investment theory (Sullivan et al., 2002), disorder (Hall et al., 2016), and depression (Harada research indicates that older adults who participate et al., 2013). in PA interventions have increased levels of Team Red, White, and Blue, a nonprofit, autonomous motivation guided by their desire to veteran-led organization, establishes supportive be healthier. However, time, finances, weather, and relationships among civilians and veterans the opportunity for participation in other activities through physical and social activities. Bringing can serve as barriers to continued PA once the civilian community members together with interventions have ended (Van Roie et al., 2015). veterans reintegrating into civilian life allows space Self-Determination Theory (SDT), a macro for veterans to strengthen their physical health theory of human motivation, describes how through community social networks as opposed both intrinsic and extrinsic motivations relate to to veteran-exclusive networks (Angel et al., 2018). psychological, physical, and social domains of life The national evidence-based management (Deci & Ryan, 2008). It examines the differential program MOVE! was introduced by the Veterans effects of personal choice and/or outside influence Health Administration in 2006 to support on individuals’ motivation to engage in PA (Deci self-management of diet and PA among veterans & Ryan, 2008; Teixeira et al., 2012). Because (Romanova et al., 2013). Thousands of veterans behavior is not always intrinsically motivated, have participated in the program and various certain external pressures (e.g., social factors) studies have explored its impact on veterans with may motivate individuals to participate in PA. mental illness (Goldberg et al., 2013; Harrold The purpose of this exploratory study was to find et al., 2018), post-traumatic stress disorder out what motivates veterans who participate in an (Goldstein et al., 2018), and programs adjacent to ongoing VA exercise program. MOVE! (Fletcher et al., 2017; Harrold et al., 2018; Rosenberger et al., 2011). Methods While the health benefits of these Design interventions have been established, less work has We used a dual-method design in which been done to understand the factors of motivation quantitative and qualitative data were collected that compel veterans to join and remain in these and analyzed independently. This approach helped exercise programs. Recent research focusing on us to obtain different yet complementary data to the MOVE! program has highlighted motivation answer the research questions. Quantitative and and the importance of the program’s social impact qualitative data are reported separately in the on veterans. Participants’ desires to improve results and then merged in the discussion to give both their health and their laboratory reports an overall interpretation of the findings. (e.g., their cholesterol numbers) served as intrinsic and extrinsic motivators, respectively, Training Program for losing weight. Participants indicated they Established in 1986 at the Veterans were more successful in the program when they Affairs Medical Center (VAMC) in Durham, attended group classes more regularly as they North Carolina, Gerofit is an ongoing exercise had other veterans encouraging them to show intervention program for veterans age 65 and up (Batch et al., 2020). The extension program older (Peterson et al., 2004). Currently, there MOVE OUT provided peer leaders for the veteran are 17 nationally recognized Gerofit locations exercise program, and participants reported that that span the country from Miami, Florida, to camaraderie, commitment, and regular meeting Honolulu, Hawaii. Program enrollment occurs times motivated them to stay in the program on a rolling basis. Before veterans can participate, (Fletcher et al., 2017). their primary care providers must confirm their Motivation is defined as the internal and stable health and their ability to independently external factors that stimulate a person to function physically and cognitively in a group initially direct and sustain action toward a goal setting. Occasionally, when participation has been

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 42 low, enrollment has been opened to veterans of about the week’s events, and even join the any age. Spouses of veterans can also participate program’s biannual celebrations. in the program if a current primary care One of the Gerofit team members (who is physician confirms their independent physical both a veteran and the lead author on this paper) and cognitive function. volunteered with Gerofit and became interested Upon joining the program, participants in understanding what motivated the older undergo a physical function assessment that veterans to participate and remain in the program. includes the 8-foot up-and-go and a 6-minute An earned postdoctoral fellowship from Duke walk. In addition, body height, weight, and waist University’s Center for the Study of Aging and circumference are recorded, and veterans respond Human Development supported this interest, to a series of questionnaires that assess their and she remained with the Gerofit program while overall health, quality of life, current levels of PA, completing that fellowship and a subsequent and comorbidities and symptoms. Based on this research position in Duke’s Motivated Cognition information, participants receive an individually and Aging Brain Lab. tailored exercise prescription that focuses on improving any identified functional impairments. Data Collection The full assessment is repeated at the third and The Durham VAMC institutional review sixth month of the first year and then annually board reviewed and approved the protocol for this afterward to facilitate continuous updates and ancillary study annually (MIRB# 02021/0027). monitoring of the exercise program for as long as Gerofit staff invited veterans active in the program the veteran participates (Morey et al., 2006). to participate in this study, and they informed Supervised exercise sessions are offered three prospective participants that the study included times a week, with session times divided into two a 30-item survey. Once survey data collection groups that each comprise 60 to 75 participants. was complete, Gerofit staff asked long-term Exercise-health professionals lead group exercise participants if they would agree to an in-depth, classes (e.g., stretching and floor exercises) and follow-up interview. Only those who had been in monitor personalized aerobic (e.g., elliptical, the program for longer than 10 years at the start of treadmill) and muscle strengthening (e.g., free the study were eligible to participate in this stage of weights) activities. These exercises both help the research. Purposive sampling was used to select participants meet national PA guidelines and participants for these semi-structured interviews. target their functional deficits as identified by the All Gerofit participants provided written annual assessments. Sessions occur year-round, consent to have their clinical data entered into a and veterans are encouraged to attend as often as research database for use in future investigations. possible. Veterans’ active status in the program Each interviewee consented to an audio recording is changed to inactive following two months of and field notes of the face-to-face interview. The unexplained absence (Brown et al., 2019). quantitative data were collected starting in 2017, Gerofit’s mission is to promote physical and the qualitative data were collected in April exercise among older-adult veterans. Initially, 2018 following the quantitative data analysis. The the Durham branch of Gerofit held its classes quantitative data guided qualitative development at the Durham VAMC. However, due to space of the semi-structured interview guide. constraints at the medical center campus, the VAMC contracted with a local, private, Measures community-based fitness gym to provide access A demographic questionnaire captured to the program for 2.5 hours on three days of the self-identified information, including age, race, week. Gerofit participants share equipment and gender, and the exercises prescribed and executed space with community members, and, because on a weekly basis. Exercises were separated into there is no cost associated with being in Gerofit, individual activities—including the treadmill, older civilian gym members are welcome to join weights, stationary bike, and recumbent stepper— Gerofit’s group-based classes. Several civilian and group activities—stretching or floor exercises, gym members have consistent interaction with balance or dance class, and tai chi. program participants. Gerofit members and Motives of physical activity measure–revised civilian gym members will walk next to one (MPAM-R). The MPAM-R survey was used to another on treadmills, assist one another with assess the strength of five motives for exercise weights, spend time standing around talking in physically active veterans. These motives

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 43 are described by the measure’s Appearance, modified version of survey transformation was Competence, Fitness, Interest/Enjoyment, and performed, including four of the five original Social subscales. The Appearance subscale MPAM-R subscales (Interest/Enjoyment, measures respondents’ motivation to stay Appearance, Competence, and Social). Twelve physically active to maintain or improve their open-ended questions were developed to capture physical attractiveness, such as by developing deeper explanations of participants’ motivations. defined muscles or achieving/maintaining For example, the MPAM-R survey asks a desired weight. The Competence subscale respondents about the degree to which they relate measures respondents’ desire to stay physically to certain social motives for exercise, including active to improve, meet a challenge, or learn a “being with friends,” “being with others,” “meeting new skill. The Fitness subscale refers to wanting new people,” “friends want me to,” and “enjoy to be physically healthy, strong, and energetic. spending time with others doing this activity.” To The Interest/Enjoyment subscale measures PA further understand these social motivations, this completed because it provides good feelings open-ended question was added to the interview and makes the participant happy. Finally, the guide: “Some people talk about exercise as being Social subscale assesses respondents’ desire to another way to connect with people and make be physically active so that they can be with friends. What role does exercise play in your friends and/or meet new people (Ryan et al., social life or connecting you with others?” This 1997). Thirty statements covering these types of semistructured question allowed the interviewer motives are set to a Likert scale ranging from 1 to explore social motives of interest and allowed (Not at all true for me) to 7 (Very true for me). interviewees to discuss issues that the interviewer MPAM-R semi-structured interview guide. may not have anticipated. We used the newer approach to qualitative methods, survey transformation, to develop Analysis an interview guide (Brown et al., 2018). By Quantitative analysis. We used descriptive transforming the statements of the MPAM-R we statistics to analyze the participant demographics aimed to gain a more in-depth understanding of (i.e. race/ethnicity, exercise modality) and means why veterans participate in the Gerofit exercise and standard deviations to report the MPAM-R program. Interviewees first answered four results. Next, t tests between the Fitness subscale questions related to their experience with exercise, and the other subscales were conducted to compare the consistency of their past exercise regimen, the means. The significance threshold was set at .05. time they have spent in the current program, and Qualitative analysis. We used a predominantly their reasons for beginning the Gerofit program. inductive thematic approach to analyze the Survey transformation allows researchers qualitative data (Braun et al., 2017). The lead author to develop semistructured interview questions conducted the interviews and transcribed the directly from surveys. This method saves time and data. Pseudonyms were provided to help protect resources, as it is not always feasible to develop the identities of the participants. Codes were a qualitative survey for a new population. The generated transcript by transcript; codes developed difference between the formative grounded theory and applied to earlier transcripts were applied to approach, which is used to develop new surveys, subsequent transcripts, and earlier transcripts were and survey transformation, which transforms a revisited as new codes were generated. Themes valid survey into a qualitative guide, is that the were then identified and reviewed by rereading transformation method retains the original scales coded material and the full data set. Qualitative and statements of the survey and thus takes into analyses were completed before the quantitative account the general implications already believed analyses to minimize interpretation biases. to exist within the concepts of the survey. The open-ended questions created through survey Results transformation allow respondents to provide Quantitative Results a more in-depth explanations of their beliefs of Of all participants (N = 63), 57 were men the statements from the survey (Brown et al., and six were women. Four of the six women were 2018). In a full version of the transformation, veteran dependents, one was a veteran, and one was all 30 statements from the MPAM-R would be a volunteer who had a long-standing relationship categorized into their respective categories and with the program. Participants self-identified 30 questions would be written. For this study, a as being Black/African American (n = 32) or

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 44 White/Caucasian (n = 28). One participant (n = 43) on the treadmill or outside (when weather identified as being more than one race, and two permitted), and the least performed individual veterans identified as being part of the “human aerobic activity was using a recumbent bicycle race.” The average age of the participants was 75; (n = 21). The group activity with the most the youngest participant was 58 years old, and the participation was the stretching group exercise oldest was 93 years old. (n = 26), and the dance class had the least Because exercise is individually tailored, participation (n = 7), as seen in Table 1. many participants engaged in more than one Response means for individual MPAM-R individual and/or group activity focused on statements ranged from 3.66 to 6.86 with fitness aerobic and muscle strengthening activities. Based and social statements ranked highest and lowest, on participants’ self-reports, the most performed respectively (Table 2). Specifically, participants individual aerobic activity was walking or jogging rated motivation statements representing the

Table 1. Descriptive Metrics as Reported by Participants

Number of participants by demographics

Race/ethnicity No. of women (%) No. of men (%) Total

Black or African 2 (6%) 31 (94%) 33 American

White 4 (13%) 26 (87%) 30

More than one 0 (0%) 1 (100%) 1 race/ethnicity

Not reported 0 (0%) 2 (100%) 2

Total 6 (9%) 60 (91%) 66

Note. Mean participant age was 75 years old, with a range of 58–93 years old.

Number of participants by exercise modality

No. No. Individual participating Group exercises participating exercises (%) (%) Walking/ 43 (65%) Stretching exercises 26 (39%) jogging

Weights 41 (62%) Floor exercises 20 (30%)

Stationary 30 (45%) Tai chi 17 (26%) bike Recumbent 21 (32%) Balance class 13 (20%) bike

Dance class 7 (11%)

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 45 desire to “maintain health and well-being” and “to motivations. The interviewees included two White have energy” as highest. While there is not a large veteran participants, interviewed separately, and disparity between the means for each subscale, a Black couple (a male veteran and his wife) who the lowest rated statements were those related were interviewed together. We audio-recorded to social motivation, indicating that participants the interviews to keep verbatim accounts and were not motivated to exercise to “[spend] time took field notes during the interviews to assist in with others” or “because friends wanted [them] formulating relevant follow-up questions in the to be physically active.” moment (Galli, 2009). The recorded interviews To determine the statistical significance of were transcribed, and out of 21 codes, two main the relationship between the Fitness subscale themes were gleaned. and the other subscales, a one-tailed paired Maintaining health and wellness was a t test was performed. Results indicated no primary motivation to begin the Gerofit program. statistical significance between the Fitness and All the interviewees had previous experiences with Social subscales (t[4] = 2.4, p = .02); however, exercise, ranging from jogging, hunting, playing there was significance with Interest/Enjoyment, semipro baseball, and being part of other gyms Competence, and Appearance (p < .01), providing to doing home workouts with Jack LaLanne. The strong evidence that the population means are interviewees had all learned about the Gerofit different (Table 3). program (i.e., from other physicians or other veterans) at a time in their lives when they were not Qualitative Results active, and the idea of participating was desirable. Four participants who had been in the Chris joined the program because of physical program for more than 10 years were interviewed issues, stating, “I had been going to VA about my to gain a more in-depth understanding of knees and the doctor here recommended Gerofit… how motivations influenced their long-term I’ve been there ever since.” Sam gave his account of participation. Since the results of the MPAM-R joining the program, stating, “I had a friend [and] indicated fitness as the highest motivation he thought it was an excellent program. He said quantitatively, questions for the interview guide it was a ‘good way to exercise instead of sitting were directed toward themes of competence, around and feeling sorry for yourself.’” It was not appearance, interest/enjoyment, and social difficult to convince Sam’s wife, Sarah, to join the

Table 2. MPAM-R Results of Veterans

Number M Highest M Lowest M Subscales of (SD) rated (SD) rated (SD) questions total statement highest statement lowest

Maintain 6.54 6.66 To have more 6.41 Fitness 5 health and (1.1) (1.0) energy (1.1) well-being

Interest/ 5.75 Enjoy this 6.04 5.20 7 It’s interesting Enjoyment (1.4) activity (1.3) (1.7)

Keep up Want to 5.61 5.98 4.76 Competence 7 current skill obtain new (1.5) (1.4) (1.9) level skills

Lose or 5.17 Feel physically maintain 5.88 3.96 Appearance 6 (1.9) unattractive if weight so I (1.6) (2.0) I don’t look better

Enjoy 4.97 spending 5.79 Friends want 3.06 Social 5 (1.8) time with (1.5) me to (1.9) others

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 46 Table 3. Fitness MPAM-R Subscales t Tests

Subscale t(df) t stat p

Interest/Enjoyment 7 4.62 .001

Competence 8 4.16 .001

Appearance 7 4.44 .001

Social 6 2.44 .02 program when it opened up to spouses because she from James. He said that he did not know if the “was already interested in exercise.” program helped spouses and thought that it was While fitness was the main reason why an unnecessary expense to allow them to join. His participants began the program, social interaction point of view was based on personal experience; he was a key motivator for interviewees continued noted that his wife “was in it for a while…I don’t and/or long-term participation participation. know why she didn’t like it,” and he attributed her When asked about competence and interest/ decision to leave to her inability to successfully enjoyment motivations, participants responded perform some of the exercises. However, Sarah, with explanations related to social motivation. the spouse of a veteran and a current participant, When describing what he had learned through said that she looks forward to the program because participation in the program (competence), Sam she knows, “I’m going to see certain people…After answered: I miss Mike, after several days I have an attitude, [I’m] more cranky.” I realize that if you participate you develop The interviewees all believed that their a circle of friends. It’s not just exercising, continued engagement in the program had a big it’s a way to socialize. You develop a circle impact on their health and wellness. They enjoyed of friends. It’s a way of socializing and the camaraderie and the opportunity to learn I think that’s what keeps a lot of people relatable health information from another, which coming back—the camaraderies. added to their social interactions. Sarah also spoke of how important it was for her to be welcomed James said, “[You] learn about people by the veterans. She suggested that the program’s [through] conversations. What they did for a social and physical aspects were equal, stating, living. Amazing what you learn if you let people “You can’t separate the two. Both are cherished.” talk. Different attitudes, different politics. You learn about that.” Discussion The interviewees were also asked specifically The benefits of exercise are well known, and what they enjoyed about exercising. For Sarah, it to increase the number of active older veterans, was “the way y’all reach out.” She gave a lot of credit the Department of Veterans Affairs (VA) offers to the program director, who consistently reached various exercise programs. While information has out to follow up with participants. She continued, been reported regarding the barriers (Pebole & “The special holidays [are important]. We are Hall, 2019), facilitators (Hoerster et al., 2015), and not just coming to exercise. When somebody is self-efficacy (Brown et al., 2019) of exercise among missing, we know. We all feel like family.” Sam older veterans in various VA programs, previous followed up by reiterating how being around a research has not addressed their motivations for certain type of people is what makes the difference, participation. To our knowledge, we are the first to saying, “I enjoy all of it—the activities and the explicitly collect primary data on the motivations socializing. And the relationship I maintain with of older veterans who participate in the VA exercise the staff. I like all of it.” intervention program Gerofit. The question of how the program helped participants stay connected (related to social motivation) elicited an unexpected answer

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 47 According to our quantitative analysis, since.” Although people may begin an exercise fitness (mean = 6.54) was the most noted intervention program because of their interest motivation in both surveys and interviews. in changing their current health or fitness status, This was not a surprise, considering that most our data suggests that it may be the additional people who choose to participate in exercise connection, found through social motivation (i.e., programs do so because they have a vested camaraderie), that is associated with continuous interest in sustaining their physical health participation. (Etnier et al., 2017). Extrinsic motivations In sum, the results from this study indicate can be self-directed or other-directed and that veterans’ high levels of extrinsic motivation are dependent on the attainment of extrinsic to participate in Gerofit were driven by fitness, outcomes for maintenance. In this study, fitness maintenance of their health and well-being, and was considered an extrinsic motivation because the social opportunity to spend time with others. the veterans were exercising for outcomes (e.g., The highest rated intrinsic motivation (second to have more energy) apart from participation overall) was interest/enjoyment, indicating that itself (Ryan et al., 1997). However, the overall future research is needed to test how these and results for the Interest/Enjoyment subscale the other collected motivations (i.e., competence, indicated that exercise and the purpose of the appearance) may influence participation rates program also promoted intrinsic motivation in group exercise programs aimed at older (Deci & Ryan, 2008). adults. Additionally, since the current study was An innovation of our study was the survey limited in its number of participants (both men transformation (Brown et al., 2018) of the and women), its results cannot be generalized MPAM-R, which expanded our understanding to the general population. With the increased of some of the participants’ personal views on number of Gerofit programs around the country, motivation. Social factors were the least likely to an expanded research agenda may be feasible. be indicated as motivators on the survey. When Using convenience recruitment methods to the questions from the MPAM-R were asked target participants, we could assess differences in aloud, however, qualitative results confirmed that participation rates based on program descriptions social factors (e.g., social support, reinforcement) (as they differ) and locations. Environment has provided extrinsic motivation and were important been shown to play a part in self-efficacy as it to the long-term participants of the exercise relates to participating in Gerofit (Brown et al., program. This is consistent with other findings 2019), it and would likely have a direct effect from the literature that note the importance of on motivation. Filling gaps in knowledge by social motives for exercise among civilians (Etnier exploring the motivations of exercise program et al., 2017; Rivera-Torres et al., 2019). participants will produce valuable information Regarding the development of future VA that may help those who design exercise programs programming that promotes long-term exercise, retain participants for a longer number of years. our results suggest that a program may attract continuous participation if it is built around both References fitness and social aspects that are important to the Amaral, E.F.L., Pollard, M.S., Mendelsohn, participants. Social motivation cannot be forced, J., & Cefalu, M. (2018). Current and future but opportunities for organic social processes that demographics of the veteran population, 2014– promote camaraderie may allow for more social 2024. Population Review, 57(1). https://doi. interaction and, thus, motivation. An inability org/10.1353/prv.2018.0002 to connect with others may support why James’s Angel, C.M., Smith, B.P., Pinter, J.M., Young, wife did not continue the program who was B.B., Armstrong, N.J., Quinn, J.P., Brostek, D.F., primarily concerned with fitness but unsuccessful Goodrich, D.E., Hoerster, K.D., & Erwin, M.S. at developing social connections. Exemplifying (2018). Team Red, White & Blue: A community- the organic social motivation that grew out of based model for harnessing positive social networks Gerofit, a group of five program participants to enhance enrichment outcomes in military regularly visited McDonald’s for breakfast after veterans reintegrating to civilian life. Translational working out. Chris said, “I was in Gerofit, being a Behavioral Medicine, 8(4), 554–564. https://doi. loner, minding my own business, and [a member] org/10.1093/tbm/iby050 here asked if I wanted to come to McDonald’s… and we’ve been coming to McDonald’s ever

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SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 49 Hoerster, K.D., Millstein, R.A., Hall, K.S., Peterson, M.J., Crowley, G.M., Sullivan, R J., & Gray, K.E., Reiber, G.E., Nelson, K.M., & Saelens, Morey, M.C. (2004). Physical function in sedentary B.E. (2015). Individual and contextual correlates and exercising older veterans as compared to of physical activity among a clinical sample national norms. Journal of Rehabilitation Research of United States veterans. Social Science & and Development, 41(5), 653–658. https://doi. Medicine, 142, 100–108. https://doi.org/10.1016/j. org/10.1682/JRRD.2003.09.0141 socscimed.2015.07.034 Rivera-Torres, S., Fahey, T.D., & Rivera, M.A. Littman, A.J., Forsberg, C.W., & Koepsell, (2019). Adherence to exercise programs in older T.D. (2009). Physical activity in a national sample adults: Informative report. Gerontology & Geriatric of veterans. Medicine and Science in Sports Medicine, 5, Article 2333721418823604. https:// and Exercise, 41(5), 1006–1013. https://doi. doi.org/10.1177/2333721418823604 org/10.1249/MSS.0b013e3181943826 Romanova, M., Liang, L.J., Deng, M.L., Li, Z., Morey M.C., Ekelund, C., Pearson, M., & Heber, D. (2013). Effectiveness of the MOVE! Crowley, G., Peterson, M., Sloane, R., Pieper, C., multidisciplinary weight loss program for veterans McConnell, E., & Bosworth, H. (2006). Project in Los Angeles. Preventing Chronic Disease, 10, LIFE: A partnership to increase physical activity Article 120325. https://doi.org/10.5888/pcd10.120325 in elders with multiple chronic illnesses. Journal Rosenberger, P.H., Ruser, C., & Kashaf, S. of Aging and Physical Activity, 14(3), 324–343. (2011). MOVE! multidisciplinary programs: https://doi.org/10.1123/japa.14.3.324 Challenges and resources for weight management Morey, M.C., Pieper, C.F., Crowley, G.M., treatment in VHA. Translational Behavioral Sullivan, R.J., & Puglisi, C.M. (2002). Exercise Medicine, 1(4), 629–634. https://doi.org/10.1007/ adherence and 10‐year mortality in chronically s13142-011-0092-5 ill older adults. Journal of the American Ryan, R. M., Frederick, C.M., Lepes, D., Rubio, Geriatrics Society, 50(12), 1929–1933. https://doi. N., & Sheldon, K.M. (1997). Intrinsic motivation org/10.1046/j.1532-5415.2002.50602.x and exercise adherence. International Journal of Paden, L., Addison, O., Giffuni, J., & Katzel, L.I. Sport Psychology, 28(4), 335–354. (2017). Continued improvement and maintenance Schult, T.M., Schmunk, S.K., Marzolf, J.R., & in older veterans after two years of Gerofit exercise Mohr, D.C. (2019). The health status of veteran program: 2148 Board #161 June 1 2. Medicine & employees compared to civilian employees in Science in Sports & Exercise, 49(5S), 594. https:// Veterans Health Administration. Military Medicine, doi.org/10.1249/01.mss.0000518555.77177.25 184(7–8), e218–e224. https://doi.org/10.1093/ Pebole, M.M., & Hall, K.S. (2019). milmed/usy410 Insights following implementation of an Sullivan, V., Montgomery, I., Summers, J., & exercise intervention in older veterans with Sullivan, V. (2002). Personal investment predictors PTSD. International Journal of Environmental of exercise motivation among adolescents and Research and Public Health, 16(14), Article 2630. older adults. Journal of Science and Medicine in https://doi.org/10.3390/ijerph16142630 Sport, 5(4supp1), 26. https://doi.org/10.1016/ Pelssers, J., Hurkmans, E., Scheerder, J., S1440-2440(02)80087-1 Vanbeselaere, N., Vos, S., Smits, T., & Boen, F. Teixeira, P.J., Carraça, E.V., Markland, D., (2018). Acting one’s age in physical exercise: Silva, M.N., & Ryan, R.M. (2012). Exercise, Do perceived age norms explain autonomous physical activity, and self-determination theory: motivation among older adults? Journal of Aging A systematic review. International Journal of and Physical Activity, 26(4), 521–529. https://doi. Behavioral Nutrition and Physical Activity, 9, Article org/10.1123/japa.2016-0290 78. https://doi.org/10.1186/1479-5868-9-78 Pelssers, J., Fransen, K., Vanbeselaere, N., Van Roie, E., Bautmans, I., Coudyzer, W., & Boen, F. (2019). The effect of descriptive age Boen, F., & Delecluse, C. (2015). Low- and high- norms on the motivation to exercise among older resistance exercise: Long-term adherence and adults. Health Promotion International, 34(3), 400– motivation among older adults. Gerontology, 61(6), 409. https://doi.org/10.1093/heapro/dax092 551–560. https://doi.org/10.1159/000381473

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 50 Hoerster, K.D., Millstein, R.A., Hall, K.S., Peterson, M.J., Crowley, G.M., Sullivan, R J., & About the Authors Gray, K.E., Reiber, G.E., Nelson, K.M., & Saelens, Morey, M.C. (2004). Physical function in sedentary Candace S. Brown, PhD, is an assistant B.E. (2015). Individual and contextual correlates and exercising older veterans as compared to professor at the University North Carolina, of physical activity among a clinical sample national norms. Journal of Rehabilitation Research Charlotte and research collaborator with the of United States veterans. Social Science & and Development, 41(5), 653–658. https://doi. Motivated Cognition and Aging Brain Lab at Duke Medicine, 142, 100–108. https://doi.org/10.1016/j. org/10.1682/JRRD.2003.09.0141 University. She is a Navy veteran whose research socscimed.2015.07.034 Rivera-Torres, S., Fahey, T.D., & Rivera, M.A. focuses on understanding the motivation to Littman, A.J., Forsberg, C.W., & Koepsell, (2019). Adherence to exercise programs in older exercise among aging adults. Ismail Aijazuddin is T.D. (2009). Physical activity in a national sample adults: Informative report. Gerontology & Geriatric a Duke University graduate and an incoming MD of veterans. Medicine and Science in Sports Medicine, 5, Article 2333721418823604. https:// candidate at the Wayne State University School of and Exercise, 41(5), 1006–1013. https://doi. doi.org/10.1177/2333721418823604 Medicine in Detroit, MI. Miriam C. Morey, PhD, is org/10.1249/MSS.0b013e3181943826 Romanova, M., Liang, L.J., Deng, M.L., Li, Z., the Associate Director of Research of the Durham Morey M.C., Ekelund, C., Pearson, M., & Heber, D. (2013). Effectiveness of the MOVE! VA Geriatric, Research, Education and Clinical Crowley, G., Peterson, M., Sloane, R., Pieper, C., multidisciplinary weight loss program for veterans Center (GRECC) and a professor of medicine at McConnell, E., & Bosworth, H. (2006). Project in Los Angeles. Preventing Chronic Disease, 10, Duke University School of Medicine. She directs LIFE: A partnership to increase physical activity Article 120325. https://doi.org/10.5888/pcd10.120325 the national implementation of the VA Gerofit in elders with multiple chronic illnesses. Journal Rosenberger, P.H., Ruser, C., & Kashaf, S. exercise program which has been declared a VA of Aging and Physical Activity, 14(3), 324–343. (2011). MOVE! multidisciplinary programs: Best Practice. https://doi.org/10.1123/japa.14.3.324 Challenges and resources for weight management Morey, M.C., Pieper, C.F., Crowley, G.M., treatment in VHA. Translational Behavioral Sullivan, R.J., & Puglisi, C.M. (2002). Exercise Medicine, 1(4), 629–634. https://doi.org/10.1007/ adherence and 10‐year mortality in chronically s13142-011-0092-5 ill older adults. Journal of the American Ryan, R. M., Frederick, C.M., Lepes, D., Rubio, Geriatrics Society, 50(12), 1929–1933. https://doi. N., & Sheldon, K.M. (1997). Intrinsic motivation org/10.1046/j.1532-5415.2002.50602.x and exercise adherence. International Journal of Paden, L., Addison, O., Giffuni, J., & Katzel, L.I. Sport Psychology, 28(4), 335–354. (2017). Continued improvement and maintenance Schult, T.M., Schmunk, S.K., Marzolf, J.R., & in older veterans after two years of Gerofit exercise Mohr, D.C. (2019). The health status of veteran program: 2148 Board #161 June 1 2. Medicine & employees compared to civilian employees in Science in Sports & Exercise, 49(5S), 594. https:// Veterans Health Administration. Military Medicine, doi.org/10.1249/01.mss.0000518555.77177.25 184(7–8), e218–e224. https://doi.org/10.1093/ Pebole, M.M., & Hall, K.S. (2019). milmed/usy410 Insights following implementation of an Sullivan, V., Montgomery, I., Summers, J., & exercise intervention in older veterans with Sullivan, V. (2002). Personal investment predictors PTSD. International Journal of Environmental of exercise motivation among adolescents and Research and Public Health, 16(14), Article 2630. older adults. Journal of Science and Medicine in https://doi.org/10.3390/ijerph16142630 Sport, 5(4supp1), 26. https://doi.org/10.1016/ Pelssers, J., Hurkmans, E., Scheerder, J., S1440-2440(02)80087-1 Vanbeselaere, N., Vos, S., Smits, T., & Boen, F. Teixeira, P.J., Carraça, E.V., Markland, D., (2018). Acting one’s age in physical exercise: Silva, M.N., & Ryan, R.M. (2012). Exercise, Do perceived age norms explain autonomous physical activity, and self-determination theory: motivation among older adults? Journal of Aging A systematic review. International Journal of and Physical Activity, 26(4), 521–529. https://doi. Behavioral Nutrition and Physical Activity, 9, Article org/10.1123/japa.2016-0290 78. https://doi.org/10.1186/1479-5868-9-78 Pelssers, J., Fransen, K., Vanbeselaere, N., Van Roie, E., Bautmans, I., Coudyzer, W., & Boen, F. (2019). The effect of descriptive age Boen, F., & Delecluse, C. (2015). Low- and high- norms on the motivation to exercise among older resistance exercise: Long-term adherence and adults. Health Promotion International, 34(3), 400– motivation among older adults. Gerontology, 61(6), 409. https://doi.org/10.1093/heapro/dax092 551–560. https://doi.org/10.1159/000381473

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 51 Creating Community for Women Veterans Through Social Networking Organizations: A Secondary Analysis of Team Red, White, and Blue New Member Surveys Kate Hendricks Thomas, Caroline M. Angel, Nicholas J. Armstrong, Michael S. Erwin, Louis P. Nemec, Brandon B. Young, John M. Pinter, Blayne P. Smith, and Justin T. McDaniel

Abstract In an effort to better understand mental health and enrichment differences between veteran women and men in a veteran service organization (VSO), a research team conducted secondary analysis of assessment data from Team Red, White, and Blue (Team RWB) veteran members who joined between 2014 and 2016. In this secondary analysis of the 2014–2016 Team RWB initial member survey data, frequencies and crosstab analyses were conducted for veteran respondents (N = 10,015), a portion of whom (31.5%) identified as former servicewomen n( = 3,152). Women were statistically overrepresented by a factor of 2–3 times in organizational membership. Gender-correlated differences were found with levels of enrichment; at baseline, women reported lower levels of social support as described by the subcategory of belonging (p < .001) and lower levels of sense of purpose as measured by two subcategories (p < .002 and p = .03). Primary findings from this study indicate an opportunity for future research on mental health and enrichment when a member joins a service or social networking organization. is indicated. Lower levels of mental health and enrichment among new Team RWB members who are female veterans indicates an opportunity for the organization to actively focus programs and resources on this fast-growing subpopulation of veterans to enhance retention and the overall participant experience.

In the United States, veterans experience when analysis controls for age and time in service higher rates of mental health concerns than do (Bossarte, 2013). Internationally, numbers indicate nonveterans (Wilcox et al., 2013). A major issue the same. A British study of recent combat veterans affecting transitioning veterans’ mental health found the risk of suicide to be 2–3 times higher outcomes is the process of community reintegration for former military members than for the general during departure from active service (Thomas & population, with the year immediately following Plummer Taylor, 2015). Transition is a challenging discharge being a particularly risky time (Ilgen et time for military personnel, many of whom al., 2012). These mental and social health challenges self-report significant issues as they leave active are found both globally and across regions in the duty to resume civilian life (Demers, 2011; Pease et United States, with research indicating an intimate al., 2016). A strong body of literature supports such connection between social well-being and mental self-reported data (Friedman, 2015), with much of health (Thomas & Albright, 2018). In a time of the research focusing on mental health outcomes transition, veterans may experience struggles and the issues that often occur alongside mental with finding a sense of purpose, both individual health challenges, such as substance misuse, and shared, and can have difficulty relating even suicide, employment challenges, family disruption, to well-meaning loved ones who have not “been and other psychosocial impairments (Thomas, there” or shared similar experiences (Hoge, 2010; Turner et al., 2015). Thomas & Plummer Taylor, 2015).

Suicide Risk Social Cohesion Careful study of suicide risk in the veteran Veterans of all backgrounds report difficulty population shows that suicide risk is almost four with social cohesion–related behaviors. times higher among young veterans than it is Such behaviors, including awareness and among their peers in the general population, a communication of personal feelings, staying in difference made more statistically significant close communication with friends and family,

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 52 connecting easily with civilians, acquiring and numerically overrepresented in the membership Creating Community for Women Veterans maintaining a job, and practicing self-care, numbers of some types of civic organizations Through Social Networking Organizations: promote well-being and protect against adverse (in comparison to their representation in the A Secondary Analysis of Team Red, White, mental health outcomes (Hoge, 2010; Jakupcak military), suggesting unique opportunities to et al., 2007). After separation from the military, reach this at-risk population. For these reasons, and Blue New Member Surveys rates of interpersonal conflict increase, as do outreach to servicewomen is uniquely important maladaptive coping techniques that can create to veteran service organizations (VSOs) like Team Kate Hendricks Thomas, Caroline M. Angel, behavioral health issues (Murray, 2013). Red, White, and Blue (RWB), where servicewomen Nicholas J. Armstrong, Michael S. Erwin, (active duty as well as guard, reserve, and veteran) Louis P. Nemec, Brandon B. Young, John M. Pinter, Gender comprise a third of new registrants. Blayne P. Smith, and Justin T. McDaniel Gender is a potential demographic risk factor for anxiety, depression, and substance Team RWB misuse (Ramchand et al., 2015; Thomas et al., Team RWB is a 501(c) nonprofit with the Abstract 2016). Women constitute approximately 15% of mission of enriching veterans’ lives by connecting In an effort to better understand mental health and enrichment differences between veteran women the armed services (Murdoch et al., 2006) and them to their community through physical and social and men in a veteran service organization (VSO), a research team conducted secondary analysis of represent the fastest growing segment of the activity; it was founded to meet a perceived gap in assessment data from Team Red, White, and Blue (Team RWB) veteran members who joined between veteran population (Carlson et al., 2013). Meeting military transition services (Angel & Armstrong, 2014 and 2016. In this secondary analysis of the 2014–2016 Team RWB initial member survey data, and addressing the needs of female veterans, 2016). Since its inception in 2010, Team RWB frequencies and crosstab analyses were conducted for veteran respondents (N = 10,015), a portion of particularly when they are leaving active duty has grown to over 200 locations and 195,000 whom (31.5%) identified as former servicewomen n( = 3,152). Women were statistically overrepresented or returning from deployment, is important members, representing an intergenerational by a factor of 2–3 times in organizational membership. Gender-correlated differences were found with because of their increased risk for adverse health community of 75% veterans or active duty levels of enrichment; at baseline, women reported lower levels of social support as described by the outcomes (Levahot & Simpson, 2013). In general, servicemembers and 25% civilians (Team Red, subcategory of belonging (p < .001) and lower levels of sense of purpose as measured by two subcategories female veterans are more likely than their male White, and Blue [Team RWB], 2019). Team RWB (p < .002 and p = .03). Primary findings from this study indicate an opportunity for future research counterparts to report mental health concerns offers a range of local, consistent, and inclusive on mental health and enrichment when a member joins a service or social networking organization. such as post-traumatic stress (PTS), depression, activities to military-connected personnel and is indicated. Lower levels of mental health and enrichment among new Team RWB members who are and suicidal thoughts (Duhart, 2012; Koo & civilian community members in an effort to female veterans indicates an opportunity for the organization to actively focus programs and resources on Maguen, 2014), and they use mental health provide routine opportunities for veterans to this fast-growing subpopulation of veterans to enhance retention and the overall participant experience. services at higher rates than men (Albright et engage with each other and their mostly civilian al., 2017). They also report higher percentages of communities (Angel, Smith, et al., 2018). Some In the United States, veterans experience when analysis controls for age and time in service adverse experiences while serving; specifically, examples of Team RWB outreach activities higher rates of mental health concerns than do (Bossarte, 2013). Internationally, numbers indicate servicewomen commonly experience feelings include social events that invite families and nonveterans (Wilcox et al., 2013). A major issue the same. A British study of recent combat veterans of alienation and decreased unit cohesion members to get to know one another around affecting transitioning veterans’ mental health found the risk of suicide to be 2–3 times higher (Washington & Yano, 2013). Additionally, a leisure activity, gatherings centered around outcomes is the process of community reintegration for former military members than for the general disproportionately high rates of female a fitness activity, and even leadership camps during departure from active service (Thomas & population, with the year immediately following servicemembers (20–40%) experience military designed to pull members together in retreat-like Plummer Taylor, 2015). Transition is a challenging discharge being a particularly risky time (Ilgen et sexual trauma (MST) such as unwanted sexual settings. The purpose is always to forge strong time for military personnel, many of whom al., 2012). These mental and social health challenges advances, harassment, or assault, though this issue social ties. The organization has a wide reach self-report significant issues as they leave active are found both globally and across regions in the is still understudied and underreported (Kelly et geographically, and in 2018, Team RWB duty to resume civilian life (Demers, 2011; Pease et United States, with research indicating an intimate al., 2011). For institutional, social, and cultural sponsored a total of 29,100 physical events, 6,049 al., 2016). A strong body of literature supports such connection between social well-being and mental reasons, female, racial- and ethnic-minority, and social events, and 3,247 service events (Team self-reported data (Friedman, 2015), with much of health (Thomas & Albright, 2018). In a time of sexual-minority veterans have higher rates of RWB, 2019). In late 2019, TeamRWB rolled the research focusing on mental health outcomes transition, veterans may experience struggles poor outcomes related to reintegration (Pelts & out a mobile app and added opportunities for and the issues that often occur alongside mental with finding a sense of purpose, both individual Albright, 2015; Wilcox et al., 2013). members to engage in virtual events. health challenges, such as substance misuse, and shared, and can have difficulty relating even Team RWB works to operationalize its stated suicide, employment challenges, family disruption, to well-meaning loved ones who have not “been Community Engagement mission to “enrich lives.” In 2013, Team RWB and other psychosocial impairments (Thomas, there” or shared similar experiences (Hoge, 2010; The literature indicates that interventions defined enrichment as “quality relationships and Turner et al., 2015). Thomas & Plummer Taylor, 2015). working to increase social connections and facilitate experiences that contribute to life satisfaction and the cultivation of resource networks among overall wellbeing” (Angel et al., 2018). As such, Suicide Risk Social Cohesion veterans offer protective effects against isolation, early assessments of member “enrichment” focused Careful study of suicide risk in the veteran Veterans of all backgrounds report difficulty loneliness, mental and physical health problems, on social support (Cohen, 2004), satisfaction population shows that suicide risk is almost four with social cohesion–related behaviors. and suicidality (Bossarte, 2013), but women with life (Diener et al., 1985), and sense of shared times higher among young veterans than it is Such behaviors, including awareness and veterans take advantage of such programming at purpose (Lynn, 2014). In subsequent years, Team among their peers in the general population, a communication of personal feelings, staying in lower rates than their male peers do (Thomas et al., RWB developed the “Enrichment Equation,” which difference made more statistically significant close communication with friends and family, 2017). However, military-connected women are describes an enriched life as an ideal combination

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 53 of health (“health”), genuine relationships An interdisciplinary research team began (“people”), and sense of individual and shared a secondary analysis of the data in September purpose (“purpose”; Angel et al., 2020). Consistent 2017. The purposes of the present study are (a) to with a trend toward asset-based approaches to examine demographic differences in new members promoting well-being in military-connected by gender and service era, (b) to examine gender populations (Thomas, Plummer Taylor, et al., differences in veterans’ self-reported mental health 2015), the Enrichment Equation conceives of and (anxious and depressed mood) upon joining Team measures welfare in terms of physical and mental RWB, and (c) to examine gender differences in health, social engagement, and sense of purpose veterans’ enrichment levels (measured by social (Angel, Smith, et al., 2018; Angel, Woldetsadik, et support, purpose, and satisfaction with life) upon al., 2020; Jeste et al., 2015). Growing evidence that joining Team RWB. resilience is the predominant response to military service supports this approach (Angel, 2016; Measures Tedeschi & Calhoun, 1996; Thomas & Plummer In 2014, Team RWB staff began to Taylor, 2015). Viewing reintegration solely conduct initial accession assessments for new through the limited lens of adverse outcomes registrants to support organizational aims. limits program efficacy (Angel & Armstrong, 2016; Organizational leadership and the research Kobau et al., 2011). team designed the instrument and conducted initial reviews with subject matter experts. After Methods finalizing the instrument, the team formatted Study Purpose it using SurveyMonkey software. The resulting Each year since Team RWB’s inception, SurveyMonkey assessment was then pilot tested thousands of male and female veterans have signed to determine its completion time and overall up to join the organization. The purpose of this functionality. Using information from the pilot study is to explore differences in mental health (as test, a format for the instrument was finalized measured by self-reported feelings of anxiety or for use with new members. depression) and levels of enrichment (as measured Data for this study were originally collected by social support, sense of purpose, and satisfaction beginning in December 2014. Military-connected with life) between veteran men and women who members signing up to join the organization self-selected participation in Team RWB at initial completed an informational survey, incentivized sign-up between 2014 and 2016. This analysis of by the opportunity to receive a free Team differences in baseline levels of mental health and RWB shirt. In addition to incentivizing survey enrichment was conducted in hopes of tailoring completion, providing a T-shirt to new members future programming and communication efforts. immediately gave them a visual marker of team membership, regardless of whether they could Study Design participate in a local chapter on a daily basis. The present study analyzed new member The purpose of the survey was to gather baseline sign-up survey data gathered from 2014 to 2016. information about new members. At the close Specifically, this research sought to answer two and completion of the survey, all data were de- primary questions: identified and collected in aggregate to protect 1. Do differences in levels of baseline respondents’ privacy. mental health exist between veteran men Since 2016, the organizational leadership and women who self-select participation in team has revised the survey several times to collect Team RWB at initial sign-up? different enrichment data. These changes reflected 2. Do differences in levels of baseline enrichment an organizational interest in a new core concept of exist between veteran women and men who enrichment as a program outcome and resulted in self-select participation in Team RWB at a very different new-member assessment survey. initial sign-up? For the purposes of consistent reporting, the The study protocol was submitted to the data source for the present study includes only institutional review board of Syracuse University responses from December 2014 to August 2016 for review. Because the proposed analyses were (Angel & Armstrong, 2016). secondary in nature and did not involve contact with human subjects, this study received exemption from the review process.

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 54 of health (“health”), genuine relationships An interdisciplinary research team began Procedures served in the most recent conflicts in Iraq and (“people”), and sense of individual and shared a secondary analysis of the data in September The sampling time frame for the current study Afghanistan are those between the ages of 18–34 purpose (“purpose”; Angel et al., 2020). Consistent 2017. The purposes of the present study are (a) to was between December 14, 2014, and August 2, and were coded Operations Enduring Freedom with a trend toward asset-based approaches to examine demographic differences in new members 2016. During this period, approximately 37,229 and Iraqi Freedom (OEF/OIF). This age range also promoting well-being in military-connected by gender and service era, (b) to examine gender individuals, including active duty servicemembers, includes veterans who served during Operation populations (Thomas, Plummer Taylor, et al., differences in veterans’ self-reported mental health National Guard or reserve personnel, and New Dawn, the American operations in Iraq after 2015), the Enrichment Equation conceives of and (anxious and depressed mood) upon joining Team military veterans, signed up to join Team RWB. 2010. Respondents between the ages of 35–55 were measures welfare in terms of physical and mental RWB, and (c) to examine gender differences in Of these individuals, 19,443 completed the coded to the Gulf War category, while veterans health, social engagement, and sense of purpose veterans’ enrichment levels (measured by social online questionnaire implemented through age 55 and older were assigned to the Vietnam (Angel, Smith, et al., 2018; Angel, Woldetsadik, et support, purpose, and satisfaction with life) upon SurveyMonkey (a response rate of 52%). A limiting and Korean War era (Thomas, Turner, et al., al., 2020; Jeste et al., 2015). Growing evidence that joining Team RWB. feature of the reported response rate involves a 2015). Veterans of a given era often report having resilience is the predominant response to military record-keeping gap in total sign-up numbers; similar experiences that are affected heavily by the service supports this approach (Angel, 2016; Measures data on the total number of new members joining conflict that dominated their time in service and Tedeschi & Calhoun, 1996; Thomas & Plummer In 2014, Team RWB staff began to was missing for the two-week period between the government resources and policies prevalent Taylor, 2015). Viewing reintegration solely conduct initial accession assessments for new December 14, 2014, and December 31, 2014. during their service and reintegration period (U.S. through the limited lens of adverse outcomes registrants to support organizational aims. For the present study, 225 respondents who Bureau of Labor Statistics, 2017). limits program efficacy (Angel & Armstrong, 2016; Organizational leadership and the research self-identified as never having served in the military Kobau et al., 2011). team designed the instrument and conducted were dropped from the analyzed sample, yielding Mental Health: Anxiety initial reviews with subject matter experts. After a resulting sample size of 19,218 new Team RWB Symptom overlap between depressive Methods finalizing the instrument, the team formatted sign-ups. Additionally, new members who were conditions and anxiety, including stress injuries, Study Purpose it using SurveyMonkey software. The resulting in the Guard or Reserves or still on active duty often leads to misdiagnosis or confusion about Each year since Team RWB’s inception, SurveyMonkey assessment was then pilot tested were removed to isolate veteran respondents only co-occurring conditions (Hoge & Castro, 2012; thousands of male and female veterans have signed to determine its completion time and overall (N = 10,015). Service-connected women veterans U.S. Department of Veterans Affairs, 2017). up to join the organization. The purpose of this functionality. Using information from the pilot represented 31.5% of that sample. This percentage Self-reporting is useful for indicating the presence study is to explore differences in mental health (as test, a format for the instrument was finalized is significantly higher than national estimates, of a possible anxiety condition, the symptoms of measured by self-reported feelings of anxiety or for use with new members. which indicate that women comprise 10% of the which include anxious mood, nervousness, or being depression) and levels of enrichment (as measured Data for this study were originally collected American veteran population (U.S. Department of “on edge” (Hoge, 2010). A survey item derived by social support, sense of purpose, and satisfaction beginning in December 2014. Military-connected Veterans Affairs, 2017). from the Patient Health Questionnaire–4 (PHQ-4), with life) between veteran men and women who members signing up to join the organization a four-item measure of anxiety and depression self-selected participation in Team RWB at initial completed an informational survey, incentivized Study Variables (Kroenke et al., 2009), asked for a Likert scale sign-up between 2014 and 2016. This analysis of by the opportunity to receive a free Team Covariates response on a 5-point scale ranging from strongly differences in baseline levels of mental health and RWB shirt. In addition to incentivizing survey Variables were chosen to highlight possible disagree to strongly agree to the following question: enrichment was conducted in hopes of tailoring completion, providing a T-shirt to new members differences in service era, mental health, and “In the past month, I have felt nervous, anxious, future programming and communication efforts. immediately gave them a visual marker of team enrichment levels of new team members (based upon or on edge.” To code the variable for analysis, membership, regardless of whether they could the definition of “enrichment” and measurement respondents who answered agree or strongly agree Study Design participate in a local chapter on a daily basis. items that existed in 2014). Researchers were were characterized as self-reporting noticeable The present study analyzed new member The purpose of the survey was to gather baseline specifically looking for gender-correlatedfeelings of potential anxiety. Respondents who sign-up survey data gathered from 2014 to 2016. information about new members. At the close differences that may predict an intention to join answered disagree or strongly disagree were coded Specifically, this research sought to answer two and completion of the survey, all data were de- Team RWB in veteran men and women. Mental as reporting a low level of anxiety. For descriptive primary questions: identified and collected in aggregate to protect health indicators included questions meant to analyses, neutral responses were coded as neutral. 1. Do differences in levels of baseline respondents’ privacy. detect the presence of possible feelings of anxiety mental health exist between veteran men Since 2016, the organizational leadership or depression. Enrichment indicators included Mental Health: Depression and women who self-select participation in team has revised the survey several times to collect questions meant to ascertain respondents’ self- Self-reported symptoms are commonly used Team RWB at initial sign-up? different enrichment data. These changes reflected reported perceptions of social support, purpose, to diagnose depression in clinical settings (Martin 2. Do differences in levels of baseline enrichment an organizational interest in a new core concept of and life satisfaction levels. et al., 2006). A survey question specifically asking exist between veteran women and men who enrichment as a program outcome and resulted in respondents whether they had felt down or self-select participation in Team RWB at a very different new-member assessment survey. Age depressed in the last month, also from the PHQ-4 initial sign-up? For the purposes of consistent reporting, the Because Department of Defense personnel (Kroenke et al., 2009), was coded to indicate that The study protocol was submitted to the data source for the present study includes only numbers indicate that most servicemembers fall respondents who chose agree or strongly agree were institutional review board of Syracuse University responses from December 2014 to August 2016 within a given demographic age range, veterans displaying a possible depressed mood, and those for review. Because the proposed analyses were (Angel & Armstrong, 2016). were grouped into service eras based on their ages. who chose disagree or strongly disagree were not secondary in nature and did not involve contact (Defense Manpower Data Center, 2012). Recoding exhibiting symptoms of depressed mood/feelings. with human subjects, this study received exemption age involved taking the survey’s continuous For descriptive analyses, neutral responses were from the review process. age variable and categorizing it. Veterans who coded as neutral. Although depression symptoms

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 55 are varied and present differently in each individual, for analysis, respondents who answered agree or perception of overall poor mental health is a useful strongly agree were characterized as self-reporting indication of the condition (Mayo Clinic, 2018). a high level of satisfaction with life. Respondents who answered disagree or strongly disagree were Enrichment: Social Support coded as reporting a low level of satisfaction with Several survey questions asked about life. Neutral responses were coded as neutral. people and resources that contribute to veterans’ perceived social support levels. Social Data Analysis relationships play an important role in promoting All data were analyzed using the Statistical better health and alleviating symptoms of Package for the Social Sciences (SPSS) version diseases (Rankin, 2013). While not all kinds 23 for Windows. Descriptive statistics—that is, of social interactions produce such health percentages—were generated in SPSS for the benefits, close friendships and partnerships are demographic variables of gender and service era considered reliable indicators of social support and for the dependent variables measuring mental (Cohen et al., 2000). Survey questions asked for health and enrichment. After dropping neutral Likert scale responses to the following items on responses to create dichotomous variables, a 5-point scale from strongly disagree to strongly crosstab analyses checked for the practical agree: “I feel a sense of brotherhood/sisterhood significance of the independent variable (gender) in my life,” “I have people I can turn to for on dependent variables in order to provide information,” and “I have people I can turn to macro-level practical significance information for resources.” To code the variables for analysis, (Hosmer & Lemeshow, 2000). The dependent respondents who answered agree or strongly variables used to indicate baseline mental health agree were characterized as self-reporting high included measures of feelings of anxiety and levels of belonging, social support, or resources. depression, and the variables used to indicate Respondents who answered disagree or strongly baseline enrichment levels included measures disagree were coded as reporting low levels of the of social support, purpose, and satisfaction with same. For descriptive analyses, neutral responses life. Odds ratios, which provide an estimate of the were coded as neutral. association between categorical/binary variables in logistic regression analysis, were assessed Enrichment: Purpose for statistical significance with 95% confidence Self-reporting high levels of purpose has been intervals (Szumilas, 2010), with significance shown to be a protective factor against mental levels set a priori at p < .05 (Chatterjee & Siminoff, illness in military populations (Malmin, 2013; 2012). The chi-square test, χ2, was used to assess Thomas, Turner et al., 2015). Survey questions model significance (Hosmer et al., 1991). asked for Likert scale responses to the following items on a 5-point scale ranging from strongly Results disagree to strongly agree: “I feel a part of something Descriptive statistics were calculated for bigger than myself” and “I have opportunities veteran service era, mediated by gender (see Table 1). to inspire.” To code the variables for analysis, Of Team RWB’s 10,015 veteran respondents, respondents who answered agree or strongly agree 31.5% were women (n = 3,152). Of the survey were characterized as self-reporting a high level participants who answered the age question (male of purpose. Respondents who answered disagree n = 6,783, female n = 3,137), 28.0% of responding or strongly disagree were coded as reporting a low women served or were serving during the OEF/ level of purpose. For descriptive analyses, neutral OIF era, 63.4% served during the Gulf War era, responses were coded as neutral. and 8.5% served during the Vietnam and Korean War era. Of responding men, 24.5% served or were Enrichment: Satisfaction with Life serving during the OEF/OIF era, 61.1% served Satisfaction with life is important to well-being during the Gulf War era, and 14.4% served during and has been well studied as it relates to optimized the Vietnam and Korean War era. mental health (Hoge, 2010; Rankin, 2013). Survey A higher percentage of women than of men questions asked for a Likert scale response to the signing up for Team RWB reported poor mental statement “I am satisfied with my life” (quality of health and low levels of the three examined life) on a on a 5-point scale ranging from strongly enrichment variables (by subcategory) at baseline disagree to strongly agree. To code the variable (see Table 3).

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 56 Crosstabs with chi-square tests of (anxious mood/depression symptoms) were not independence then further explored statistically significant. Both male and female gender-correlated linkages between these two respondents self-reported symptoms of anxiety and mental health and three enrichment variables depression, however. Of new members, 47.1% of in respondents. Specifically, univariate logistic men and 45.4% of women joined the organization regression analysis explored effect size linkages with generalized symptoms of anxiety, and between the two mental health and three 32.1% of men and 31.4% of women joined with enrichment variables in male and female veteran symptoms indicating possible depression. These respondents to see if baseline levels upon joining prevalence data are interesting when considering differ by gender. the work of researchers who think that indicators Differences in male and female veterans’ of depression (such as black-and-white thinking, responses to the mental health outcome measures perfectionist standards and mental rigidity,

Table 1. Summary of Frequency Statistics for Sample of New Veteran

Variable Male n Male % Female n Female % Total Total sample of 6,863 68.5 3,152 31.5 10,015 veteran members Service era 9,920 5,781

OIF/OEF 1,662 24.5 879 28.0 3,137

Gulf 4,147 61.1 1,990 63.4 6,137

Vietnam/Korea 974 14.4 268 8.5 1,242

Table 2. Summary of Mental Health and Enrichment Levels by Variable for All Veterans (N = 10,015)

Variable n Low % Neutral % High %

Mental health

Anxiety 9,973 35.7 17.7 46.6

Depression 9,973 31.8 19.2 49.0

Social support

I feel a sense of brotherhood/ 9,979 63.9 19.9 16.2 sisterhood in my life. I have people I can 9,982 81.3 11.3 7.4 turn to for information. I have people I can 9,967 72.5 17.8 9.7 turn to for resources. Purpose I feel part of something 9,977 63.2 20.8 16.0 bigger than myself.

I have opportunities to inspire. 9,980 72.5 17.2 10.2

Satisfaction

I am satisfied with my life. 9,981 63.7 21.4 15.0

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 57 Table 3. Summary of Veterans’ Mental Health and Enrichment Levels Upon Joining: Gender Differences 61 45.4 31.4 68.5 80.5 71.3 64.0 High % 72.1 17.6 18.5 22.1 11.4 21.6 17.7 22.1 Neutral % 8.1 37.1 50.2 18.0 17.4 11.1 13.9 10.3 17.6 Low % 3,139 3,140 3,142 3,142 3,142 3,148 3,138 3,139 Female n 47.1 32.1 65.8 81.7 64.2 73.1 63.5 High % 72.7 17.7 19.5 18.9 11.2 20.5 17.0 18.0 21.0 Neutral % 7.1 9.8 9.4 35.1 48.5 15.4 15.3 15.5 Low % n 6,834 6,833 6,837 6,840 6,835 6,832 6,828 6,843 Male

Variable Mental health Anxiety Depression Depression Social support brotherhood/ of sense a feel I life. my in sisterhood I have people I can turn to turn can I people have I information. for Purpose something of part feel I myself. than bigger to opportunities have I inspire. I have people I can turn to turn can I people have I resources. for Satisfaction my life. I am satisfied with

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 58 Table 3. Summary of Veterans’ Mental Health and Enrichment Levels Upon Joining: Gender Differences emotional suppression, and an overdeveloped reports of feelings of depression and anxiety sense of responsibility) are actually inculcated warrant further organizational attention and during military service and may contribute to research. These results are not surprising. Rates postservice mental health issues (Whelan, 2016). of poor mental health outcomes vary wildly, but 61 45.4 31.4 68.5 80.5 71.3 64.0 For the outcome variable of social support, they are known to be an issue among the veteran High % 72.1 with a p value equal to or greater than .05, population; many of the behaviors and mindsets gender was not statistically significant in the that are adaptive in the service environment are subcategories indicating that respondents have less functional in the civilian sector (Hoge, 2010; access to people who provide information Whelan, 2016). 17.6 18.5 22.1 11.4 21.6 17.7 22.1 (p = .05) or who provide resources (p = .166). Results of the present study indicate that The relationship between gender and social while veteran women self-selected joining Team Neutral % support as indicated by feelings of brotherhood RWB at rates higher than their overall proportion or sisterhood was statistically significant of the veteran population, they were also more (p < .001), however, as was gender’s relationship likely to have slightly lower levels of enrichment 8.1 37.1 50.2 18.0 17.4 11.1 13.9 with each purpose subcategory. The correlation at the time they entered the program. Veteran 10.3 17.6 Low % of gender with variable subcategories indicating women exhibited lower levels of social support purpose through connection to something and a lower sense of purpose—both of which greater than self (p < .002) and through the contribute to enrichment—than veteran men. existence of opportunities to inspire others The brotherhood/sisterhood subcategory of (p = .03) were statistically significant (p < .05). social support indicates respondents’ sense 3,139 3,140 3,142 3,142 3,142 3,148 3,138 3,139 With an alpha level greater than .05, the variable of belonging. The purpose variables indicate Female n of satisfaction with life lacked significance. respondents’ sense of connectedness and the Though gender was statistically significant self-reported existence of opportunities to in social support’s brotherhood/sisterhood make a difference to other people. Both of these subcategory and in purpose models, it was not a are important indicators of social cohesion, an 47.1 32.1 65.8 81.7 64.2 73.1 63.5

High % predictor at practically significant levels, meaning important contributor to mental and physical 72.7 important to the individual in terms of effect (odds health (Thomas & Albright, 2018). Collectively, ratios of 1.5 or higher). However, belonging was the challenges women veterans face with financial likely to be lower for new female members, with stability, family caregiving responsibilities, and odds ratios of 1.2 for the brotherhood/sisterhood social support upon reintegration contribute to 17.7 19.5 18.9 11.2 20.5 17.0 18.0 21.0 category (see Table 4). stress injury and depression rates that are over 2.3 times higher than rates of incidence among male Neutral % Discussion veterans (Thomas et al., 2016; Thomas, Turner, et Across male and female veterans, men al., 2015; Washington & Yano, 2013). represented a majority of sign-ups. However, When considering ways to enable successful 7.1 9.8 9.4 women signed up at a higher rate than they are reintegration for veterans in general and for female 35.1 48.5 15.4 15.3 15.5

Low % represented in the military, a finding consistent veterans in particular, a high level of social support with current Team RWB new-member data. inevitably emerges as a predictor of successful

n The veteran women who joined Team RWB transition and self-reported well-being (Egolf et between 2014 and 2016 were more likely to be al., 1992; Friedman, 2015). Studies have shown 6,834 6,833 6,837 6,840 6,835 6,832 6,828 6,843 younger members of the Gulf War and OIF/ that there is an inverse correlation between social Male OEF/Operation New Dawn service eras. Many support and depression symptoms, comorbid veterans who joined Team RWB during these years depression and anxiety, decreased scores for self-reported the presence of mental health health measures, and suicide attempts, specifically symptoms. Though not all gender differences were for female veterans (Lehavot & Simpson, 2013; significant in the present study, overall percentages Thomas et al., 2016). That is, as social support of new members with possible depressed mood decreases, the latter outcomes all increase. (49.0% of new veteran members) and anxious The service experiences of veteran women mood (46.6% of new veteran members) were differ from those of their male peers (Cox &

Variable noteworthy (Whelan, 2016). This finding does Albright, 2014; Thomas, 2016). Team RWB not represent a clinical diagnosis of depression or and other VSOs can play an important role anxiety, as the nonprofit-created, PHQ-4-inspired in rebuilding eroded social support levels assessment items are limited without substantial and creating a social bridge for transitioning Mental health Anxiety Depression Depression Social support brotherhood/ of sense a feel I life. my in sisterhood I have people I can turn to turn can I people have I information. for Purpose something of part feel I myself. than bigger to opportunities have I inspire. I have people I can turn to turn can I people have I resources. for Satisfaction my life. I am satisfied with psychometric validation. However, such high veterans (Hoge & Castro, 2012). In this way, an

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 59 Table 4. Risk Estimate: Relationship of Gender to Likelihood of Veteran’s Low Mental Health or Enrichment Upon Joining

Enrichment Variable p CI 95% Odds Ratio

Mental health: Anxiety .052 .830, 1.001 .911

Male .971, .943 1.0

Female 1.00, 1.136 1.136

Mental health: Depression .254 .859, 1.041 .946

Male .953, 1.013 .982

Female .973, 1.11 1.039

Social support: < .001 .693, .873 Brotherhood/sisterhood

Male .887, .958 .922

Female 1.098, 1.280 1.2

Social support: People to 0.05 .728, 1.0 turn to for information

Male .899, 1.0 .968

Female 1.002, 1.234 1.112

Social support: People to 0.166 .784, 1.03 turn to for resources

Male .923, 1.01 .969

Female .973, 1.17 1.07

Purpose: Part of .002 .742, .936 something larger than self

Male .907, .98 .943

Female 1.047, 1.22 1.131

Purpose: Opportunities to .03 .753, .993 inspire others

Male .910, .999 .954

Female 1.006, 1.21 1.103

Satisfaction with life .072 .990, 1.267

Male .998, 1.07 1.035

Female .897, 1.008 .924

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 60 Table 4. Risk Estimate: Relationship of Gender to Likelihood of Veteran’s organization like Team RWB that is attracting Conclusion Low Mental Health or Enrichment Upon Joining a large number of women veterans is uniquely The findings of our study support the broader poised to create higher levels of social support research literature that the prevalence of mild, Enrichment Variable p CI 95% Odds Ratio for this group of members. To retain and engage moderate, and major depressed and anxious Mental health: Anxiety .052 .830, 1.001 .911 the large numbers of veteran women joining moods are significant problems for both male Team RWB, understanding the characteristics and female military veterans (Miller & Cano, Male .971, .943 1.0 of this subpopulation and targeting outreach 2009; Thomas et al., 2016). The present data differ to them should be considered an important slightly from the literature in that, based on the Female 1.00, 1.136 1.136 organizational aim. odds ratios in this study, depression and anxiety did not appear to be practically significant risk Mental health: Depression .254 .859, 1.041 .946 Limitations factors among women veterans who self-selected Male .953, 1.013 .982 When considering the findings of this membership in Team RWB. Though some exploratory report, a number of limitations statistical significance indicates that women enter Female .973, 1.11 1.039 must be acknowledged. Secondary analysis of the organization with lower enrichment rates, new-member survey data, while providing a odds ratios did not exceed 1.2. Previous research Social support: < .001 .693, .873 large sample, limited the scope of questions has indicated that women veterans are much Brotherhood/sisterhood that could be asked to only those included more likely (1.5 times more likely than their male Male .887, .958 .922 in the 2014 instrument. Subsequently, Team peers) to exhibit poor mental health outcomes or RWB has built upon its original data collection risks (Duhart, 2012; Haskell et al., 2011; Thomas Female 1.098, 1.280 1.2 instrument, resulting in a psychometric et al., 2018; Thomas et al., 2016). The sample may Social support: People to instrument, the Enriched Life Scale (Angel et indicate that male veterans joining Team RWB 0.05 .728, 1.0 turn to for information al., 2020), that clarifies and extends these early have higher than average risks for depressed concepts. Additionally, the sample was delimited and anxious mood states, though understanding Male .899, 1.0 .968 to respondents not in medical institutions, prevalence rates for all levels of these conditions which may have had the effect of excluding or is a challenge; conditions are often co-occurring Female 1.002, 1.234 1.112 underrepresenting enrichment issues among and undiagnosed (Hoge, 2010; Paykel & Priest, Social support: People to veterans. Hospitalized veterans, particularly 1992). In total, 46.6% of all respondents indicated 0.166 .784, 1.03 turn to for resources those hospitalized for mental health treatment, high levels of potentially mild, moderate, or would likely have lower levels of enrichment major anxiety, and 49% indicated high levels of Male .923, 1.01 .969 than the respondents considered in the present potentially mild, moderate, or major depression. study. Data were self-reported, which could be This may indicate risk in the population generally Female .973, 1.17 1.07 problematic due to respondent recall or reluctance and suggests a need for models that focus on Purpose: Part of to truthfully answer sensitive, personal questions. assets and enrichment in the member base. .002 .742, .936 something larger than self However, the use of self-reporting in survey- The Department of Defense and Department of based research in the field is both accepted and Veterans Affairs have prioritized combating both Male .907, .98 .943 common (Alvarez et al., 2012). anxiety (including possible stress injury) and Female 1.047, 1.22 1.131 The variables of anxiety and depression depression specifically because they are known considered in this study are broad, as questions predictors of suicide (Bossarte, 2013). Purpose: Opportunities to .03 .753, .993 asked in the survey capture self-reported The findings of the present study conclude inspire others information that indicates the likelihood of mild, what the literature also does – namely that social Male .910, .999 .954 moderate, and major levels of each condition support and feelings of purpose are known (Crum-Cianflone et al., 2016; Thomas, Turner, et contributors to health and longevity, with recent Female 1.006, 1.21 1.103 al., 2015). As a result, the present study’s prevalence studies indicating that high levels of both add 7.5 rates indicate symptom self-report at a broad years to the average American’s life expectancy Satisfaction with life .072 .990, 1.267 range of severity levels. The variable of veteran (Egolf et al., 1992; Rankin, 2013). Perhaps Male .998, 1.07 1.035 service era is also limited. Some respondents may because the service experiences of women differ fall into more than one service era, and all active from those of their male peers in key ways, levels Female .897, 1.008 .924 duty respondents are automatically categorized as of social support and feelings of purpose are post-9/11 based on ongoing service, regardless of lower in military women (Thomas et al., 2016). age. There is precedent for grouping age variables Though the results of the present study indicate into service era in the literature (Thomas, Turner, that women veterans who joined Team RWB et al., 2015; Thomas et al., 2016). between 2014 and 2016 came in at a higher risk for low social support and purpose levels, the fact that they are overrepresented in the community

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 61 of military-connected personnel who self-select such tailored programming across the United participation in a VSO like Team RWB indicates States. Outreach must be thoughtful, peer-led, an interesting opportunity for engagement. mindful of baseline enrichment differences, The current study’s finding is important and considerate of the culture of women because it suggests value in potentially warriors (Richardson, 2002; Thomas, Plummer expanding the scope of programming to serve Taylor, et al., 2015). Team RWB members beyond gender-neutral social support at the community/chapter level. References It proposes new avenues to explore targeted, Albright, D.L., Fletcher, K.L., Pelts, M.D., & culturally informed programming that is Taliaferro, L. (2017). Use of college mental health organizationally-prioritized. Gender norms services among student veterans. Best Practices in and differences in gendered experiences are Mental Health, 13(1), 67–79. incredibly valuable for contemporary military Alvarez, J., Canduela, J., & Raeside, R. (2012). service organizations (MSOs) and VSOs to Knowledge creation and the use of secondary data. understand. Within this subpopulation of Journal of Clinical Nursing, 21(19), 2699–2710. veterans, women-only programming has been https://doi.org/10.1111/j.1365-2702.2012.04296.x demonstrated to be an appealing and effective Angel, C.M. (2016). Resilience, post-traumatic outreach technique that creates feelings of stress, and post-traumatic growth: Veterans’ belonging and may serve as a bridge to larger and active duty military members’ coping organizational participation (Godfrey et trajectories following traumatic event exposure. al., 2018). The findings of the present study Nurse Education Today, 47, 57–60. https://doi. present important feedback for Team RWB, an org/10.1016/j.nedt.2016.04.001 organization committed to reaching, engaging, Angel, C., & Armstrong, N.J. (2016). Enriching and retaining women members. veterans’ lives through an evidence based approach: Understanding the service challenges that A case illustration of Team Red, White & Blue many of these women are more likely to have (Measurement and Evaluation Series, Paper 1). or face can inform programming. Culturally Institute for Veterans and Military Families, competent programming could include Syracuse University. https://teamrwb.org/wp-content/ enrichment-informed offerings in a single-gender uploads/2017/11/IVMF-Case-Illustration.pdf environment that introduce members to the Angel, C.M., Smith, B.P., Pinter, J.M., Young, organization and encourage them to participate B.B., Armstrong, N.J., Quinn, J.P., Brostek, D.F., further in large-group settings. Gender norms in Goodrich, D.E., Hoerster, K.D., & Erwin, M.S. military family life could also be considered in (2018). Team Red, White & Blue: A community- VSO programming. Women are more likely to based model for harnessing positive social be the primary caregivers to dependent children networks to enhance enrichment outcomes in (Mankowski & Everett, 2016), and not offering military veterans reintegrating to civilian life. childcare at events could create a barrier to Translational Behavioral Medicine, 8(4), 554–564. participation (Thomas et al., 2017). https://doi.org/10.1093/tbm/iby050 The broad literature on VSOs indicates that Angel, C.M., Woldetsadik, M.A., Armstrong, programming should consider gender-based N.J., Young, B.B., Linsner, R.K., Maury, R.V., & norms and recognize that barriers exist to Pinter, J.M. (2020). The Enriched Life Scale (ELS): women veterans’ participation in VSOs (Held Development, exploratory factor analysis, and & Owens, 2013; Rogers & Kelly, 2011; Thomas, preliminary construct validity for U.S. military 2016). Team RWB is already positioned through veteran and civilian samples. Translational its successful recruitment of military-connected Behavioral Medicine, 10(1), 278–291. https://doi. women to consider investing more proactively org/10.1093/tbm/iby109 in this membership segment. Comparable Bossarte, R. M. (Ed.). (2013). Veteran suicide: initiatives, such as Veteran Women Igniting A public health imperative. American Public Health the Spirit of Entrepreneurship (V-WISE) Association. at the Institute for Veterans and Military Carlson, B.E., Stromwall, L.K., & Lietz, C.A. Families at Syracuse University, which offers (2013). Mental health issues in recently returning training in small business ownership to active women veterans: Implications for practice. Social duty women, women veterans, and military Work, 58(2), 105–114. https://doi.org/10.1093/sw/ spouses, have experienced rising demand for swt001

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SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 64 Thomas, K.H., Albright, D.L., Shields, M.M., About the Authors Kaufman, E., Michaud, C., Plummer Taylor, S., An interdisciplinary team led by Kate & Hamner, K. (2016). Predictors of depression Hendricks Thomas of George Mason University diagnoses and symptoms in United States female contributed to this research. Reach her with veterans: Results from a national survey and inquiries at www.DocKate.com. Researchers implications for programming. Journal of Military included leaders of Team RWB including and Veterans’ Health, 24(3), 6–17. Caroline M. Angel, Michael S. Erwin, Louis Thomas, K.H., Haring, E.L., McDaniel, J., P. Nemec, Brandon B. Young, John M. Pinter, Fletcher, K.L., & Albright, D.L. (2017). Belonging and Blayne P. Smith. Nicholas J. Armstrong of and support: Women veterans’ perceptions of Syracuse University and Justin T. McDaniel veteran service organizations. Journal of Veterans of Southern Illinois University also contributed to Studies, 2(2), 2–12. the project. Thomas, K.H., McDaniel, J.T., Haring, E.L., Albright, D.L., & Fletcher, K.L. (2018). Mental health needs of military and veteran women: An assessment conducted by the Service Women’s Action Network. Traumatology, 24(2), 104–112. https://doi.org/10.1037/trm0000132 Thomas, K.H., & Plummer Taylor, S. (2015). Bulletproofing the psyche: Mindfulness interventions in the training environment to improve resilience in the military and veteran communities. Advances in Social Work, 16(2), 312– 322. https://doi.org/10.18060/18357 Thomas, K.H., Plummer Taylor, S., Hamner, K., Glazer, J., & Kaufman, E. (2015). Multi-site programming offered to promote resilience in military veterans: A process evaluation of the Just Roll With It Bootcamps. Californian Journal of Health Promotion, 13(2), 15–24. https://doi. org/10.32398/cjhp.v13i2.1820 Thomas, K.H., Turner, L.W., Kaufman, E.M., Paschal, A., Knowlden, A.P., Birch, D.A., & Leeper, J.D. (2015). Predictors of depression diagnoses and symptoms in veterans: Results from a national survey. Military Behavioral Health, 3(4), 255–265. https://doi.org/10.1080/21635781.2015.1085928 U.S. Bureau of Labor Statistics. (2017). www. bls.gov U.S. Department of Veterans Affairs. (2017). www.va.gov Washington, D.L., & Yano, E.M. (2013). PTSD women veterans’ prevalence of PTSD care. Journal of General Internal Medicine, 28, Article 1265. https://doi.org/10.1007/s11606-013-2488-z Whelan, J.J. (2016). Ghost in the ranks: Forgotten voices and military mental health. Friesen Press. Wilcox, S.L., Finney, K., & Cedarbaum, J.A. (2013). Prevalence of mental health problems among military populations. In B.A. Moore & J.E. Barnett (Eds.), Military psychologists’ desk reference (pp. 187–196). Oxford University Press.

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 65 Culturally Informed Interventions for Military, Veteran and Emergency Service Personnel: The Importance of Group Structure, Lived Experience Facilitators, and Recovery-Oriented Content Jonathan Lane, Miranda Van Hooff, Ellie Lawrence-Wood, and Alexander McFarlane

Abstract There is little available research on what constitutes a culturally informed program to treat mental health conditions among military, veteran, and emergency services personnel. The current study presents the qualitative participant evaluations of a modified group Skills Training in Affective and Interpersonal Regulation (STAIR) program. Participants were grouped with either lived-experience facilitators or non-lived-experience clinicians for the program, and 93 textual responses to a series of qualitative questions were analyzed. The findings suggest strong support for the postulated three primary components of a culturally informed program: a group structure; facilitation by peers with lived experience; and functional, skills-based, and recovery-oriented content.

There has been increasing interest over the less focus on and promotion of other, adjunctive last decade in the cultural competence of clinicians interventions that can assist in the reduction who manage military and veteran personnel. of PTSD symptom severity but do not fit the Military and veteran personnel form a distinct criteria above. These include generalized subset of society that is shaped by members’ service “recovery-oriented” interventions for mental experiences, including training and deployment health and well-being, mind–body interventions, experiences, norms, traditions, and values (Atuel physical therapies, other psychotherapies, and & Castro, 2018). The high rates of mental health psychosocial interventions. Another range of conditions among active and veteran military interventions and programs targets the issues that personnel have received significant attention in arise during specific stages of military members’ Australia (Van Hooff et al., 2018) as well as the careers (i.e., the transition into civilian life). United States, and commonly reported conditions Unfortunately, there are also concerns about the include post-traumatic stress disorder (PTSD), efficacy of the mainstream care and interventions depression, anxiety, and substance abuse, among that are frequently offered (and promoted) others (Hoge et al., 2004). Physical symptoms to military personnel and veterans. Problems and conditions such as chronic pain are also more may arise from a one-size-fits-all approach prevalent among military and veteran personnel to treatment that doesn’t necessarily work for compared to civilians (Graham, K., 2019), and all (Steenkamp & Litz, 2014). In particular, they have been reported to have major impacts the evidence-based treatments recommended on individuals’ quality of life and mental health by PTSD guidelines (Steenkamp et al., 2015; (Ahmadian et al., 2019). Steenkamp et al., 2020) have had relatively poor Current clinical practice guidelines for the clinical outcomes, particularly over the long prevention and treatment of PTSD recommend term for these populations. Researchers have also both individual trauma-focused psychotherapies argued that treatments should be formulated to and pharmacotherapy for service members address the different stages of PTSD and their and veterans (Hamblen et al., 2019; Ostacher & associated physical and psychiatric comorbidities Cifu, 2019). Most of these guidelines, however, (McFarlane et al., 2017). are based on results from randomized control Lack of clinician cultural competence is trials with moderate to large sample sizes considered to add to the barriers that service investigating reductions in PTSD symptom members and veterans face in accessing and severity as the primary outcome of interest, with remaining engaged with care, especially mental psychological and pharmacological treatment health services (Atuel & Castro, 2018). For these as the target interventions. In contrast, there is reasons, many clinicians with service experience

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 66 have promoted the need for, and elements of, insights into the dynamics of teams (Gooch, 1998). cultural competence among clinicians in the Rickman and Bion’s therapeutic communities American and Australian contexts (Atuel & minimized patient –practitioner hierarchical Castro, 2018; Burek, 2018; Coll et al., 2011; Gayton differences, creating a culture of inquiry that & Kehoe, 2016; Lane & Wallace, 2020). These calls promoted self-investigation and awareness. They to action also raise the question, however, of what also created a culture of mutual support, whereby a culturally informed program or intervention all members within the community united to for the treatment of mental health conditions support themselves and others within those among service members and veterans might look communities (Mills & Harrison, 2007). Rap groups like in terms of its structure, format, and content. played a critical role in early self-generated support Several recent peer-led, community-based efforts for U.S. Vietnam war veterans and led to interventions have shown promising results in the emergence of counseling services, in which reducing mental health symptoms among military veterans played a key role in providing support, as veterans. Examples of such programs include an alternative to formal therapy (Egendorf, 1975; Buddy-to-Buddy, a peer support program for Shatan, 1973). U.S. National Guard and reserve service members Modern-day group intervention programs for (Greden et al., 2010), and the Team Red, White veterans and emergency service personnel have a & Blue community-based model for developing similar ethos. They offer a format and structure positive social networks to enhance outcomes in that reflect normal service culture, defined by such military veterans reintegrating into civilian life tenets as a team-oriented approach to problem (Angel et al., 2018). Another study examined the resolution. Such group interventions involve relationship between peer support, self-efficacy, several people gathering together on a regular and PTSD symptoms in combat veterans after basis and engaging in the social connectedness an intensive weekend program run by the that is essential to service life. These meetings offer community support group Vets4Vets (MacEachron opportunities to normalize stress and distress, & Gustavsson, 2012). A range of peer outdoor and they challenge perceived stigmas about support therapy (POST) programs have also been having mental health conditions and engaging evaluated, and all of these programs indicate with services for help with those problems. some beneficial outcomes for PTSD despite being Through their provision of mutual support and nonclinical interventions (Bird, 2014). understanding, group interactions help to validate These programs share several common participants’ traumatic experiences and therefore features: They are based on a group structure; they reduce potential shame (Schwartze et al., 2019), do not involve individual one-on-one therapy just as happens in a normal service environment. from a clinician to a patient; they include peers Working as a part of a team and sharing a sense with lived experiences of military culture and/or of loyalty, pride, camaraderie, and brotherhood mental health conditions; and they emphasize are fundamental aspects of service and hence are psychosocial functioning from within a recovery- often lost upon transition out of service (Burek, oriented framework rather than just “treatment.” 2018). Group interventions’ potential to restore These factors are all worth examining in detail in these feelings might help explain the popularity of terms of how they relate to military culture and the format among veterans. therefore why they should be considered essential for culturally informed practice. Peer Support The desire for community explains why many Group Structure service members naturally gravitate toward others There are a number of elements of group who have shared experiences, values, norms, programs that are reminiscent of military culture. attitudes, beliefs, and expectations of behavior, In fact it was John Rickman and Wilfred Bion, both during service and beyond, when creating both British Army psychiatrists during World psychosocial bonds (Lifton, 1976). This affinity War II, who originally pioneered the therapeutic for others who have the same “lived experience” community model that is considered today also helps explain the attraction and power to be the forebearer of group programs (Mills of peer-driven programs for veterans and the & Harrison, 2007). Bion himself was a highly benefits that culturally specific group programs decorated World War I veteran who had fought can offer. Typical veteran attitudes include beliefs in the tank corps, which gave him particular such as “If you haven’t been there, you don’t get

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 67 it,” “We believe in taking care of our own,” and Another aspect of military culture is the “Other veterans can be trusted.” In contrast, many concept that performance of one’s task and veterans mistrust mainstream clinical services mission is central to a positive sense of self (Lane and clinicians (Blank, 1982; Greden et al., 2010). & Wallace, 2020). A task- or mission-oriented As such, military personnel are used to relying on approach allows for sublimation of distress, peers for support, consider them more trustworthy especially emotional distress, and therefore than other authority figures, and identify with becomes an effective coping mechanism: leaders with similar experiences to model adaptive Individuals derive a sense of purpose from their growth and change (Hundt et al., 2015). Peer vocational tasks that allows them to push through support programs therefore meet an inherent need their distress. Unfortunately, service members of service personnel. and veterans lose these adaptive coping They are also becoming increasingly mechanisms as their cognitive and motor popular because they can improve outcomes in functions decline due to mental health injuries. inpatient programs, as evidenced by their formal The reality of these functional losses represents introduction in the U.S. Veterans Affairs medical a direct challenge to the positive self-concept system (Jain et al., 2016). Additionally, when characteristics described above; the individual employed in a paraprofessional role, veterans loses the ability to demonstrate high performance, themselves can augment existing services in is no longer a part of a team, and may have been low-resource communities (Jain, 2010). Finally, discharged from the military as unfit for service. programs led by peers with lived experiences of However, the drive for individual improvements both service culture and recovery from mental in effective functioning and positive identity health conditions can augment and cement the improvements through teamwork can therefore group bonding and cohesion process because also be used as components of a culturally they mimic the general training and occupational appropriate, recovery-oriented program. format of service life—that of a leader with more Functional losses often include difficulties with experience and knowledge who serves as a role emotional regulation (ER), which are commonly model, instructor, and guide for a group of others, seen in service members and veterans. Stanley and within a task or purpose-oriented frame. Larsen (2019) described how the typical military attitude to emotional distress is to “suck it up” Recovery-Oriented Content and “drive through,” which ends up resulting in Recovery is defined in this context as “gaining emotional suppression and therefore further distress and retaining hope, understanding of one’s and disability. They argue that high accumulated abilities and disabilities, engagement in an active chronic stress loads from occupational, operational, life, personal autonomy, social identity, meaning and organizational factors of service increase ER and purpose in life, and a positive sense of self” challenges and maladaptive coping mechanisms, (Australian Government Department of Health, therefore increasing the risk of psychological 2010). This definition of recovery fits well with distress and suicidality among both service the positive attributes of military culture, values, members and veterans. Considering these risk beliefs, norms, and behaviors. The concepts of factors in combination with personal societal self-efficacy, striving for excellence, and high- stigmas against mental health diagnoses and performance standards, all of which are facets treatment, which are linked to treatment avoidance of recovery, are also essential to military identity and poor adherence (Vogt, 2011), it is not surprising (Burek, 2018). Finally, the three characteristics that there are such high rates of mental health (or values) of “integrity,” “team worker,” and morbidity within this population. “good judgment” were all ranked significantly Mainstream mental health treatment above random assignment in Gayton and Kehoe’s programs may further aggravate these problems. (2016) work with Australian Army Special As described earlier, traditional interventions Forces soldiers. These characteristics seem to have been criticized because they are generally drive recovery-oriented behaviors—as also seen administered on an individual basis (one-on-one in the work of Dabovich et al. (2019) on values with a therapist and client) and provided within and identity redevelopment during rehabilitation an institutionalized framework that defines and transition—hence the popularity of a clinicians as “experts” who deliver “treatment” recovery-oriented approach with military and to patients because they have a “disorder” veteran personnel. (Lifton, 1976). This medical model disempowers

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 68 consumers, ignores their cultural context, The Skills Training in Affective and and has the disheartening effect of dismissing Interpersonal Regulation (STAIR) program by any of the consumers’ strengths (Brende, Cloitre et al. (2002) was originally developed to 1981). In effect, mainstream services reinforce target ER among individuals with complex PTSD. a negative sense of self-identity by reaffirming STAIR is a manualized, skills-based program individuals’ lack of functional capacity and designed to educate individuals with PTSD on the minimizing their sense of efficacy except within a personal impacts of trauma, and it uses various narrow focus of trauma-focused psychotherapy. psychological tools (primarily dialectical behavior Indeed, Steenkamp et al. (2020) argued that therapy) to help participants develop the skills trauma-focused psychotherapies may have low they need to improve their own ER capability and success and high dropout rates because veterans the quality of their interpersonal relationships. with PTSD typically struggle to cope with the It has primarily been used in the context of sexual prescribed, emotionally demanding therapies. trauma, with the psychoeducation and skill phase This is not surprising given the difficulties with being followed by a narrative exposure therapy ER described by Stanley and Larsen (2019), but phase (a form of trauma-focused psychotherapy it should also be recognized that veterans and treatment), and it has been shown to improve service members are engaging in these therapies both distress symptoms and functional outcomes without the support of their peers and without in participants (Cloitre et al., 2014; Cloitre et any leveraging of the inherent strengths and al., 2016). STAIR has also been adapted to a capabilities they developed during their service group format (Cloitre et al., 2015), which has careers. In contrast, the adjunctive interventions the added benefit of maximizing social support that seem to be increasing in popularity among (Charuvastra & Cloitre, 2008). As such, group veterans do not have the same hierarchical STAIR provides the perfect platform for creating structures, do not pathologize psychological a culturally relevant intervention delivered by distress, and focus on leveraging the strengths peers whose lived experiences could help model and positive characteristics of the veterans functional recovery. themselves to move them toward functional Finally, programs that deliver skills-based, recovery. In other words, as stated earlier, function-oriented content with the goal of these therapies have several key components: improving ER, social supports, and interpersonal They involve peers; are goal-oriented toward relationships are also likely to appeal to the service functional improvement (recovery); and leverage member and veteran audience because they align the values, norms, and conditioned behaviors with their predisposition to want to perform and expected by military and veteran personnel. succeed at given tasks within a recovery-oriented framework. A Potential Culturally Informed Model of Intervention Summary and Current Research Project The discussion above suggests that a While there is growing interest in the culturally informed intervention for active cultural competence of clinicians working with military personnel, veterans, and other service service members and veterans, there is little personnel should have three main factors: It published research on what constitutes a culturally should be group-based, with minimal hierarchy; it informed structure, format, and content for an should be delivered and facilitated by leaders with intervention for mental health conditions among lived experience ; and it should have functional, this population group. The purpose of this paper is recovery-oriented content. This model also implies therefore to examine the participants’ perspectives that “treatment” for psychological disorders of a culturally informed and modified pilot STAIR should have a staged approach, depending on the program. This intervention was informed by the severity of participants’ symptoms and functional three key principles that we have so far discussed: disability (McFarlane et al., 2017). This staged It was conducted in a group format, the content approach should also include a primary skills- of the program was functional and recovery- based stabilization stage, preferably including oriented, and it was delivered by facilitators with an ER component, prior to active treatment. It lived military and mental health experience. is at this early intervention point that culturally specific interventions are considered to be most relevant, achievable, and effective.

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 69 Methods The Program This study is part of a larger mixed-methods The modified group STAIR program by Cloitre effectiveness trial of a group STAIR program et al. (2015) consisted of once-weekly 90-minute conducted with current and veteran military and sessions, which were run as closed groups over the emergency service personnel in Australia. This course of 12 weeks in 2018 and 2019. Six sessions larger, modified group STAIR evaluation consisted covered emotional regulation, and six sessions of a range of common mental health inventories covered interpersonal relationships. The group and open-ended questions in the form of a STAIR program was modified by the author (a written survey. It was approved by the Australian clinician with 30 years’ Army experience as an Departments of Defence and Veterans’ Affairs enlisted soldier, medical doctor, and psychiatrist) Human Research Ethics Committee (DDVA to make it more culturally specific and relevant to 030-18) and the University of Adelaide Human military, veteran, and emergency service personnel. Research Ethics Committee (H-2018-114) and was Modifications included using appropriate language conducted as a real-world effectiveness trial over a and providing detailed psychoeducation on 24-month period. the impacts of service and culture on identity, behaviors, patterns of maladaptive coping Participants mechanisms, and relationships. The sample evaluated in this paper was The program was delivered through two restricted to participants’ responses to the separate Australian nongovernmental community four open-ended questions at the end of the service organizations. These were The Road Home survey. Responses were collected from the 93 (TRH), a leading South Australian veteran and participants who completed the entire program. emergency services charity in Adelaide, South All participants were current or former military Australia, and Mates4Mates (M4M), another or emergency service personnel who were ex-service organization with Family Recovery experiencing difficulties with their mental health. Centres in Hobart, Brisbane, and Townsville. Participants were excluded if they had active The TRH groups (n = 62) consisted of a mix of psychosis or suicidal ideation with a plan to carry active military, veteran, police, and fire brigade out self-harm. Emergency services personnel personnel, and they were led by the primary were actively recruited to the project because they author with an ex-policeman and a current have similar cultural norms, attitudes, beliefs, military peer as cofacilitators. The M4M groups and behaviors to military personnel. In addition, (n = 31) only had military and veteran participants in Australia they have similarly high rates of and were led by clinical psychologists with no mental health conditions but much more limited lived military experience. access to care, especially culturally informed care (Harman, 2019). Participant Mental Health Status All participants completed a baseline battery Procedure of self-report mental health questionnaires Participants for this study were referred prior to commencement of the STAIR program into the modified group STAIR program by in order to provide initial measures of mental their community care clinicians, but they also health symptoms and prior trauma history. These continued to receive care as normal from their included the Kessler 10 (K10), a 10-item screening clinicians during the program. Psychometric measure of psychological distress (Kessler et evaluations (not reported in detail here) and al., 2002); the seven-item Generalized Anxiety qualitative evaluations were administered at four Disorder (GAD-7) scale to screen for anxiety time points: (1) immediately before the program, symptoms (Spitzer et al., 2006); the nine-item (2) immediately at the end of the program Patient Health Questionnaire (PHQ-9) to screen (3 months), then at 6 months (3) and at 12 months for depressive symptoms (Kroenke et al., 2001); (4) following commencement of the program. the 20-item PTSD Checklist for DSM-5 (PCL-5) The qualitative data reported in this paper were to screen for PTSD symptoms (Wortmann et collected from the immediate post program survey. al., 2016); the Dimensions of Anger Reactions The project procedures were approved through (DAR-5) scale, a five-item screening measure to the Australian Departments of Defence and assess anger frequency, intensity, and duration Veterans’ Affairs (DDVA) and University of and anger’s perceived negative impact on social Adelaide (UA) human research ethics committees. relationships (Forbes et al., 2004); and four items

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 70 Methods The Program to examine suicidal ideation, plans, and behavior The data analysis process used qualitative content This study is part of a larger mixed-methods The modified group STAIR program by Cloitre adapted from the Australian National Survey of analysis (Drisko, 2015) to derive common effectiveness trial of a group STAIR program et al. (2015) consisted of once-weekly 90-minute Mental Health and Wellbeing (Australian Bureau descriptive themes from the written responses to conducted with current and veteran military and sessions, which were run as closed groups over the of Statistics, 2007). The Lifetime Exposure to the four separate review questions. For the purpose emergency service personnel in Australia. This course of 12 weeks in 2018 and 2019. Six sessions Traumatic Events scale was taken from the CIDI of this paper, responses were coded for three larger, modified group STAIR evaluation consisted covered emotional regulation, and six sessions V3 (Haro et al., 2006). The 28 questions covered themes. These themes represent the three factors of a range of common mental health inventories covered interpersonal relationships. The group a range of potentially traumatic events and suggested earlier to be implicit in the development and open-ended questions in the form of a STAIR program was modified by the author (a were endorsed by either “yes” or “no” answers of a culturally informed intervention for military written survey. It was approved by the Australian clinician with 30 years’ Army experience as an from participants. The total number of times personnel, veterans, and emergency service Departments of Defence and Veterans’ Affairs enlisted soldier, medical doctor, and psychiatrist) that participants were exposed to each of the 28 workers: group structure, lived experience peer Human Research Ethics Committee (DDVA to make it more culturally specific and relevant to traumatic events was also obtained. support, and recovery-oriented content. Identified 030-18) and the University of Adelaide Human military, veteran, and emergency service personnel. subthemes will also be discussed and illustrated by Research Ethics Committee (H-2018-114) and was Modifications included using appropriate language Qualitative Component the inclusion of direct quotes from participants. conducted as a real-world effectiveness trial over a and providing detailed psychoeducation on Qualitative data was obtained from written 24-month period. the impacts of service and culture on identity, responses to the following questions: Results behaviors, patterns of maladaptive coping Demographics Participants mechanisms, and relationships. 1. In what way do you feel the clinician Ninety-three of the 130 participants who The sample evaluated in this paper was The program was delivered through two who facilitated your STAIR Program enrolled in the study between January 2018 and restricted to participants’ responses to the separate Australian nongovernmental community helped you understand yourself and December 2019 completed the qualitative measures four open-ended questions at the end of the service organizations. These were The Road Home some of the problems you might have and hence were included in the sample for the survey. Responses were collected from the 93 (TRH), a leading South Australian veteran and experienced? current study. Of those 93 participants, 83% were participants who completed the entire program. emergency services charity in Adelaide, South current or ex-serving Australian Defence Force All participants were current or former military Australia, and Mates4Mates (M4M), another 2. Were you able to relate to the facilitator? members, and 17% were current or ex-serving or emergency service personnel who were ex-service organization with Family Recovery If so, what made this possible, and why? Australian emergency services personnel. Table 1 experiencing difficulties with their mental health. Centres in Hobart, Brisbane, and Townsville. provides detailed demographic and occupational 3. Do you think it’s worthwhile training Participants were excluded if they had active The TRH groups (n = 62) consisted of a mix of information for this sample. people to be Counsellors to help their psychosis or suicidal ideation with a plan to carry active military, veteran, police, and fire brigade The total number of times each participant Peers? If yes, then why? out self-harm. Emergency services personnel personnel, and they were led by the primary reported exposure to a different traumatic event were actively recruited to the project because they author with an ex-policeman and a current 4. What do you think the main potential and the proportion of the sample exposed to each have similar cultural norms, attitudes, beliefs, military peer as cofacilitators. The M4M groups benefits of having Peer Counsellors are? type of traumatic event are summarized in Figures and behaviors to military personnel. In addition, (n = 31) only had military and veteran participants 1 and 2. The figures show that the occupational in Australia they have similarly high rates of and were led by clinical psychologists with no and lifetime risk of exposure to traumatic events mental health conditions but much more limited lived military experience. Table 1. Participant Occupational Demographics is high among military and access to care, especially culturally informed care emergency services personnel, (Harman, 2019). Participant Mental Health Status Demographics No. of participants with the mean level of exposure All participants completed a baseline battery (N=93) % being six separate events. When Procedure of self-report mental health questionnaires Gender looking at the specific types of Participants for this study were referred prior to commencement of the STAIR program trauma, 70% of participants Male 79 85 into the modified group STAIR program by in order to provide initial measures of mental endorsed witnessing death, their community care clinicians, but they also health symptoms and prior trauma history. These Female 14 15 45% of participants reported continued to receive care as normal from their included the Kessler 10 (K10), a 10-item screening Age witnessing the death of clinicians during the program. Psychometric measure of psychological distress (Kessler et someone they were close to, and evaluations (not reported in detail here) and al., 2002); the seven-item Generalized Anxiety Range (22–73) SD=11.82 M=46 40% reported being in combat. qualitative evaluations were administered at four Disorder (GAD-7) scale to screen for anxiety Currently working 50 54 time points: (1) immediately before the program, symptoms (Spitzer et al., 2006); the nine-item Mental Health Emergency services 14 15 (2) immediately at the end of the program Patient Health Questionnaire (PHQ-9) to screen Baseline scores on each (3 months), then at 6 months (3) and at 12 months for depressive symptoms (Kroenke et al., 2001); Defence 19 20 of the mental health measures (4) following commencement of the program. the 20-item PTSD Checklist for DSM-5 (PCL-5) Health and community services 8 9 according to the standard The qualitative data reported in this paper were to screen for PTSD symptoms (Wortmann et scoring bands are provided collected from the immediate post program survey. al., 2016); the Dimensions of Anger Reactions Other 9 10 in Table 2. Overall, 30% of The project procedures were approved through (DAR-5) scale, a five-item screening measure to Retired 43 46 participants scored in the severe the Australian Departments of Defence and assess anger frequency, intensity, and duration range for anxiety, with 36% Emergency services 8 9 Veterans’ Affairs (DDVA) and University of and anger’s perceived negative impact on social scoring greater than 50 on the Adelaide (UA) human research ethics committees. relationships (Forbes et al., 2004); and four items Defence 35 38 PCL-5 and 30% scoring above

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 71 Figure 1. Frequency of Participants’ Total Lifetime Exposures to Trauma

Figure 2. Percentage of Participants Who Endorsed a Specific Trauma Type

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 72 15 on the GAD-7, both of which are indicative of learning and understanding behaviour” and “It a probable disorder. Severe levels of psychological was good to discuss other people’s situations and distress based on K10 scores were reported in coping mechanisms.” The group format allowed for 48% of the sample, 49% reported some form of interaction and engagement, which participants suicidality (either suicidal ideation or attempt), and appreciated. One participant noted, for example, 49% reported problematic levels of anger (a score the “opportunity to pass on knowledge and of 12 or greater on the DAR-5). The quantitative understanding, share personal experience and results of the changes in the clinical measures are reflect on those.” Finally, the notion of support not reported in this paper as they will be presented from others within the group was very strongly in a separate article. identified; participants wrote, for example: “understanding of the issues each other face, mutual Qualitative Question Results support” and “Good to have that peer support.” The participants’ responses were evaluated It appeared that people felt they could relate to to derive their perspectives, perceptions, each other because of their shared experiences and opinions of the following three themes: and shared understandings of similar problems, (a) the importance of the group format; (b) peer and they felt “more likely to open up about each support/lived experience; and (c) skills-based, other’s experiences” because there was “trust” and recovery-oriented content. Direct quotes from “understanding and connection within the group.” participants that illustrate the derived themes are The fact that these comments came from all the also included. participant groups suggests that incorporating emergency services personnel within the groups Theme 1: Group Format did not diminish the trust, rapport, and sense of There were no specific questions that asked connection that participants felt with each other, participants about their perceptions of the and these factors emerged regardless of whether or group format. However, spontaneous answers not groups had lived-experience facilitators. demonstrated positive regard for the format, such as “Group situation good.” Most of the other Theme 2: Lived Experience relevant comments addressed the benefits of Lived experience of military/service life and normalizing difficult experiences during service mental health conditions were the most prominent and within the treatment process, such as “Sharing themes to emerge in participant responses,

Table 2. Participant Mental Health Characteristics (N=93)

Test (range) K10 (0–50) Well Mild Moderate Severe M=28.2 (SD=8.4) 16 (18%) 12 (13%) 20 (21%) 45 (48%)

GAD-7 (0–21) Well Mild Moderate Severe M=9.9 (SD=5.9) 19 (20%) 29 (32%) 17 (18%) 28 (30%)

Suicidality Screen (y) Ideation Plan Attempt 45 (48%) 32 (34%) 5 (34%) 2 (2%)

Probable PHQ-9 (0–27) Well Sub-syndromal disorder M=12.6 (SD=6.8) 23 (25%) 51 (55%) 19 (20%)

Probable PCL-5 (0–80) Low Sub-syndromal disorder M=36.9 (SD=20.9) 35 (37%) 35 (38%) 34 (36%)

Probable DAR-5 (5–24) No disorder disorder M = 12.2 (SD=4.7) 46 (51%) 47 (51%)

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 73 particularly in response to Question 1. For understanding, shared experiences, and therefore example, the majority of the participants from the also a perception that peers were likely to be groups led by the facilitators with lived experience more effective counselors. Examples included: (n = 62) spontaneously mentioned the importance “Very useful to have peers that already have of shared experiences and similar personal some rapport with personnel and can provide characteristics in relation to how they related to immediate assistance. Often means there is no the facilitator or how they felt the facilitator related barriers [stigma],” “Yes, they can relate as they to them. This suggests the importance of the have been in the same situation,” and “We can all facilitator’s lived experience in developing rapport relate to each other, we have instant rapport and both on a personal level as well as clinically. a level of trust, especially as peers in the military. Responses included: “Service-related background We “get” each other.” Modeling recovery was established rapport, respect and confidence to also mentioned: “Yes. 100%. Because it helps the disclose vulnerable information of myself,” “He peers to relate to personnel that have first-hand was very familiar with what we were talking about experience in what they are feeling and going and didn’t have to have everything explained to through. They are not alone. Also shows them him,” “He was familiar with military and policing that there is light at the end of the tunnel.” terms which is generally lacking in therapists,” Other themes to emerge in relation to the “Via Military speak, true understanding of why benefits of having peer counselors were equality, I am thinking mostly the military way,” “Always shared experiences, and common backgrounds made examples that were relatable,” “Related well. and therefore more trust, rapport, and relatability With his background in defence it made it easier between counselors and participants. These to connect with him. And somehow could read subthemes also encompassed stronger perceived my mind,” “Yes being in the ADF [Australian psychosocial bonds between facilitators and Defence Force] and the examples used, and the participants as well as the benefits of normalizing language and situations automatically built a trust difficulties and modeling recovery. Examples of and a relationship. So much respect,” and finally, these sentiments included: “Familiarity, shared “As a veteran who has served and then become experiences, shared understanding, trust, not a a psychiatrist [he] truly understands the issues doctor,” “They've lived your problems and can facing veterans because he has lived the military empathize,” “Shared experience and understanding life. If you don’t get it you don’t get it, it’s not just that others have been through it,” “Relatable trauma from service it’s training and culture.” experiences & see people as normal,” and “Like Shared language, culture, behavioral norms, minded individuals who share a common beliefs, and attitudes were also very influential experience of having experienced trauma, been on participants’ opinions of the lived-experience diagnosed with it, and sought help through their facilitators. The use of culturally informed relevant organisation, and the STAIR program.” language, although directly referenced by only a few participants, is likely to have influenced this Theme 3: Functional and as well. Participants noted, for example, that the Recovery-Oriented Content facilitator “spoke in a manner that was so clearly Although there was not a specific question understood—spoke layman’s language and not a asking participants about the importance of lot of confusing jargon,” “Yes, down to earth, in functional and recovery-oriented content, several layman’s terms not medical, very approachable, themes emerged in participants’ responses that understanding etc.,” and “being in the ADF and supported the importance of such content. For the examples used and the language and situations example, participants’ answers to Question 1 automatically built a trust and a relationship.” In often referred to the skills components of the contrast, none of the participants in the groups content in explicit detail and described how this led by the facilitators without lived experience content benefited them in functional terms: “My (n = 31) mentioned anything about lived experience understanding of emotions and relationships or relating to the clinicians on a personal level has improved as well as tools to deal with my because of their shared experiences. anxiety,” “Helped me understand my feelings are Questions 3 and 4 both addressed normal. Change starts with me,” “ability to break participants’ opinions and perceptions of using complex human thoughts and emotions down peers in facilitation and/or counseling roles. The via explanation so that I was able to analyse and dominant themes to emerge here were shared understand/interpret them. This info could then

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 74 particularly in response to Question 1. For understanding, shared experiences, and therefore be used to consciously change thoughts/feelings/ content to participants. Facilitators were tasked example, the majority of the participants from the also a perception that peers were likely to be behaviours moving forward allowing for greater with educating participants about the degree groups led by the facilitators with lived experience more effective counselors. Examples included: understanding of self and others and therefore to which their mental health conditions and (n = 62) spontaneously mentioned the importance “Very useful to have peers that already have opening the door to improved relationships,” “Easy functional problems are consequences of of shared experiences and similar personal some rapport with personnel and can provide to apply the learning to my everyday life. Made the exposure to chronic stress, trauma, as well as the characteristics in relation to how they related to immediate assistance. Often means there is no information very relatable and understood our conditioning effects of military and other service the facilitator or how they felt the facilitator related barriers [stigma],” “Yes, they can relate as they lives and work,” and “It was presented in a way that experiences, and they were also charged with to them. This suggests the importance of the have been in the same situation,” and “We can all made it real and relevant to the context I live and providing participants with skills to address these facilitator’s lived experience in developing rapport relate to each other, we have instant rapport and work in. He helped me understand that a lot of challenges. The skills-based content primarily both on a personal level as well as clinically. a level of trust, especially as peers in the military. the issues I have are normal human responses and targeted the ER deficits identified by Stanley and Responses included: “Service-related background We “get” each other.” Modeling recovery was there are ways to combat the negative ones.” Larsen (2019). Participants’ answers to Question established rapport, respect and confidence to also mentioned: “Yes. 100%. Because it helps the Improved self-efficacy in ER, especially anger, 1 showed support for the functional ER skills disclose vulnerable information of myself,” “He peers to relate to personnel that have first-hand was another strong theme to emerge in relation obtained from the intervention, with a number of was very familiar with what we were talking about experience in what they are feeling and going to content. Participants wrote, for example: “By respondents reporting better perceived self-efficacy and didn’t have to have everything explained to through. They are not alone. Also shows them breaking down the basic mechanics, so by getting to manage themselves, their emotions, and their him,” “He was familiar with military and policing that there is light at the end of the tunnel.” myself to recognise my own emotions and how to daily functioning. This finding is important given terms which is generally lacking in therapists,” Other themes to emerge in relation to the regulate them. How my feelings in situations can that the modified group STAIR content made it “Via Military speak, true understanding of why benefits of having peer counselors were equality, affect my reactions to situations,” “helped me gain a psychoeducation and skills-based intervention I am thinking mostly the military way,” “Always shared experiences, and common backgrounds control of my life back. Reduced anger and awareness rather than a typical “treatment” or trauma-focused made examples that were relatable,” “Related well. and therefore more trust, rapport, and relatability of what’s going on in my head, and how to control psychotherapeutic intervention. With his background in defence it made it easier between counselors and participants. These that,” “Helped me deal with anger and dealing with However, a striking aspect of participants’ to connect with him. And somehow could read subthemes also encompassed stronger perceived situations,” “I have been able to address my issues answers to Question 1 was how respondents my mind,” “Yes being in the ADF [Australian psychosocial bonds between facilitators and with conflict and realising that sometimes the pain related to and spontaneously praised the lived Defence Force] and the examples used, and the participants as well as the benefits of normalizing of conflict is worth the conflict itself,” “Gained a lot experiences of their facilitators in terms of making language and situations automatically built a trust difficulties and modeling recovery. Examples of of knowledge, and understanding about feelings the content relatable. They also commented and a relationship. So much respect,” and finally, these sentiments included: “Familiarity, shared emotions, helped improve communication within on how this helped them develop knowledge “As a veteran who has served and then become experiences, shared understanding, trust, not a the family home.” All of these quotations imply a sense and understanding of their own emotions and a psychiatrist [he] truly understands the issues doctor,” “They've lived your problems and can of mastery through skills acquisition, which had identified their rapport with the facilitator as a facing veterans because he has lived the military empathize,” “Shared experience and understanding broader implications for participants’ psychosocial large factor in how they were able to normalize life. If you don’t get it you don’t get it, it’s not just that others have been through it,” “Relatable well-being, functioning, and self-identity. and understand their experiences so they could trauma from service it’s training and culture.” experiences & see people as normal,” and “Like regain functionality. Shared language, culture, behavioral norms, minded individuals who share a common Discussion The increased rapport that developed beliefs, and attitudes were also very influential experience of having experienced trauma, been This investigation aimed to explorebetween the participants and the lived-experience on participants’ opinions of the lived-experience diagnosed with it, and sought help through their participants’ perceptions of using lived-experience facilitators is important because this sits apart facilitators. The use of culturally informed relevant organisation, and the STAIR program.” facilitators to deliver a small-group, skills-based from the intervention content and has to do language, although directly referenced by only a intervention to improve emotional regulation and entirely with the frame of the intervention. few participants, is likely to have influenced this Theme 3: Functional and interpersonal relationships. It was hypothesized Participants’ responses to Questions 3 and 4 also as well. Participants noted, for example, that the Recovery-Oriented Content that this intervention met the requirements to reflected these attitudes; these questions were facilitator “spoke in a manner that was so clearly Although there was not a specific question be considered a culturally informed intervention aimed at exploring participants’ opinions of understood—spoke layman’s language and not a asking participants about the importance of because it used a group format, was facilitated by whether it is important and potentially beneficial lot of confusing jargon,” “Yes, down to earth, in functional and recovery-oriented content, several peers with lived experience, and was composed of to have peers with lived service and mental layman’s terms not medical, very approachable, themes emerged in participants’ responses that skills-based and recovery-oriented content. The health experience in therapeutic leadership understanding etc.,” and “being in the ADF and supported the importance of such content. For qualitative results suggest that the participants roles. Responses were overwhelmingly favorable the examples used and the language and situations example, participants’ answers to Question 1 viewed the intervention and its outcomes toward this proposition. The themes of increased automatically built a trust and a relationship.” In often referred to the skills components of the favorably. Participants’ answers to all four understanding, trust, and rapport engendered by a contrast, none of the participants in the groups content in explicit detail and described how this questions also demonstrated positive regard for common language, experiences, and histories were led by the facilitators without lived experience content benefited them in functional terms: “My the three themes in question: the group format; prominent, as was the idea that the therapeutic (n = 31) mentioned anything about lived experience understanding of emotions and relationships lived-experience facilitators; and functional, process would be more effective if peers with lived or relating to the clinicians on a personal level has improved as well as tools to deal with my skills-based, recovery-oriented content. experience more commonly facilitated them. because of their shared experiences. anxiety,” “Helped me understand my feelings are The concept of peers being able to normalize Questions 3 and 4 both addressed normal. Change starts with me,” “ability to break Lived Experience and Role psychological injuries from service was also participants’ opinions and perceptions of using complex human thoughts and emotions down Modeling of Functional Recovery prominent, suggesting that participants had peers in facilitation and/or counseling roles. The via explanation so that I was able to analyse and Question 1 was aimed at exploring how well previously felt abnormal or “different” in some dominant themes to emerge here were shared understand/interpret them. This info could then the facilitator was able to transfer the program way because of their operational stress injuries.

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 75 Similarly, peers (similar to the lived-experience clinician–client relationships. Nor were there clinician facilitators) were identified as modeling power dynamics inherent to the program, which, and demonstrating recovery and post-traumatic again, is likely to have improved rapport and growth, therefore challenging negative beliefs relatability among facilitators and participants. and stigma about both mental illness and Participants’ interpersonal relationships the potential for recovery. Responses thus were further strengthened by the group format demonstrated the importance of lived experience of the intervention, with cultural service factors within the interventional frame and a strong desire encouraging members of the group to rapidly come from the participants for their facilitators to have together and rely on each other for mutual support. this lived experience. Participants’ shared behavioral norms, attitudes, The finding that peers are important in terms of and beliefs promoted positive attitudes toward culture and context for increasing positive attitudes each other, their facilitator, and engagement with toward engagement is consistent with previous the program content. However, the group format research, especially studies examining correlates also mimicked participants’ previous educational and predictors of whether veterans initiate and or training experiences; the context of the program remain engaged in care. In a comprehensive review was familiar, which again improved participants’ of these factors, Johnson and Possemato (2019) rapport and relatability among each other and with argued that positive valence of veterans’ beliefs their facilitators. about mental health care consistently predicted Finally, it would seem that the structure and more initiation and engagement in care. Hundt format of the program represented the positive et al. (2015) has also supported the idea that qualities of Rickman and Bion’s earlier programs perceived benefits from increased social support, in terms of reflecting a therapeutic community purpose and meaning, normalization of symptoms, with a strong alliance between facilitators and and actual therapeutic benefits are all factors participants. This is likely why it was popular with that motivate veterans to engage in ongoing care these participants, who potentially felt isolated and use skills-based interventions. Participants within the wider civilian community because in the current study spontaneously recognized their loss of employment had entailed the loss of and favorably commented on these aspects of the a meaningful service community. Their losses in program, potentially suggesting that the frame of terms of community, role, purpose, functioning, the intervention was at least as important as the and identity were significant, and participation in specific content. the modified STAIR groups gave them back this Finally, Kumar et al. (2019) identified that sense of community, a shared set of values, and a peer support is also fundamentally important to sense of mutual purpose in terms of working with the concept of global recovery in that it can help other participants toward the goal of improved individuals with PTSD and other mental health functioning in their daily lives. conditions integrate their symptoms into their daily life and functioning, thereby reducing the Summary distress they feel . This statement is effectively the The demographic and mental health data definition of “recovery” used in this study and was in tables 1 and 2 demonstrate the morbidity of identified as a goal for the majority of participants. mental health conditions in this population group and therefore establish the need for care. The Lived Experience and the Cultural primary themes that emerged from this study’s Relevance of the Group Format qualitative data show strong support for the Military and emergency service is largely postulated factors of group-based interventions, centered around interpersonal relationships. In leadership by those with lived experiences, and the context of this study, the lived experience functional, recovery-oriented content as being of the facilitators helped enhance interpersonal culturally appropriate for a cohort of service relationships among the participants in each group. members, veterans, and emergency services This was observed among both the emergency personnel. It could also be argued that it is services and military personnel, highlighting difficult to separate these factors out because the translatability of military experience to they appear to be fundamentally interdependent the first responder context. It also emphasizes on each other, as demonstrated by the overlaps in how the relationships that lived-experience participants’ comments. However, more research facilitators developed with participants were not is clearly needed to quantify what constitutes

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 76 Similarly, peers (similar to the lived-experience clinician–client relationships. Nor were there the frame of a culturally informed or culturally content, and integration into mainstream mental clinician facilitators) were identified as modeling power dynamics inherent to the program, which, appropriate intervention and to measure the nature health services would help clarify the necessary and demonstrating recovery and post-traumatic again, is likely to have improved rapport and and impact of the factors identified in this study, components of a culturally informed intervention growth, therefore challenging negative beliefs relatability among facilitators and participants. let alone whether all three factors are required or and allow for more specific interventions to be and stigma about both mental illness and Participants’ interpersonal relationships to what degree they are each required for such a developed and evaluated. the potential for recovery. Responses thus were further strengthened by the group format program to be effective. demonstrated the importance of lived experience of the intervention, with cultural service factors Conclusions within the interventional frame and a strong desire encouraging members of the group to rapidly come Other Community Engagement Potential This paper supports the position that from the participants for their facilitators to have together and rely on each other for mutual support. The results suggest that a culturally appropriate, context and empathy are critical to mental health this lived experience. Participants’ shared behavioral norms, attitudes, skills-based, functional program delivered by peers interventions because treatment is not just The finding that peers are important in terms of and beliefs promoted positive attitudes toward with lived experience in a group format is highly about specific techniques. Culturally informed culture and context for increasing positive attitudes each other, their facilitator, and engagement with attractive to the military, veteran, and first responder interventions for mental health conditions toward engagement is consistent with previous the program content. However, the group format population. This raises the question of whether for military, veteran, and emergency services research, especially studies examining correlates also mimicked participants’ previous educational similar culturally unique population groups would personnel are best undertaken in a group format, and predictors of whether veterans initiate and or training experiences; the context of the program also benefit from this approach. High-level athletes, when delivered by facilitators with relevant remain engaged in care. In a comprehensive review was familiar, which again improved participants’ musicians, and health care personnel are often more lived experience, and with skills-based and of these factors, Johnson and Possemato (2019) rapport and relatability among each other and with vocational than simply occupational populations, recovery-oriented content. The qualitative argued that positive valence of veterans’ beliefs their facilitators. as they have similarly strong attachments to evaluation of the modified group STAIR about mental health care consistently predicted Finally, it would seem that the structure and performance-related self-identities; hence they may intervention demonstrated the inherent more initiation and engagement in care. Hundt format of the program represented the positive be other suitable target populations for these forms psychosocial benefits of group programs and et al. (2015) has also supported the idea that qualities of Rickman and Bion’s earlier programs of community-based, adjunctive mental health showed that participants appreciated this perceived benefits from increased social support, in terms of reflecting a therapeutic community interventions. Similarly, other social or cultural format. Participants’ strong identification of purpose and meaning, normalization of symptoms, with a strong alliance between facilitators and groups should also be identified to determine the benefits of working with others with similar and actual therapeutic benefits are all factors participants. This is likely why it was popular with whether the postulated factors of lived experience and lived experience reinforces the important role that motivate veterans to engage in ongoing care these participants, who potentially felt isolated group/community are transferable. of cultural expertise in delivery to maximize and use skills-based interventions. Participants within the wider civilian community because positive regard, and therefore minimize in the current study spontaneously recognized their loss of employment had entailed the loss of Limitations both stigma and barriers to care. Finally, the and favorably commented on these aspects of the a meaningful service community. Their losses in The primary limitation of this area of participants’ positive regard for the functional, program, potentially suggesting that the frame of terms of community, role, purpose, functioning, investigation is the lack of recognition of skills-based, and recovery-oriented content, the intervention was at least as important as the and identity were significant, and participation in the importance of interventions that deliver along with the ability of participants to identify specific content. the modified STAIR groups gave them back this culturally specific structure and content to and explain the perceived personal benefits of Finally, Kumar et al. (2019) identified that sense of community, a shared set of values, and a military and emergency service personnel. the program, also suggests that it is an effective peer support is also fundamentally important to sense of mutual purpose in terms of working with Results from this study provide a starting point intervention content modality. the concept of global recovery in that it can help other participants toward the goal of improved for further explorations in the field. Limitations individuals with PTSD and other mental health functioning in their daily lives. of this intervention evaluation include the small References conditions integrate their symptoms into their scale of the intervention, the limited qualitative Ahmadian, A.J., Neylan, T.C., Metzler, T., daily life and functioning, thereby reducing the Summary data gained from participants, and the limited & Cohen, B.E. (2019). Longitudinal association distress they feel . This statement is effectively the The demographic and mental health data length of time of the evaluation. Quantitative of PTSD symptoms and self-reported physical definition of “recovery” used in this study and was in tables 1 and 2 demonstrate the morbidity of data analysis demonstrating efficacy has yet functioning among veterans. Journal of Affective identified as a goal for the majority of participants. mental health conditions in this population group to be published but would be beneficial for Disorders, 250, 1–8. https://doi.org/10.1016/j. and therefore establish the need for care. The comparison to the more typical trauma-focused jad.2019.02.048 Lived Experience and the Cultural primary themes that emerged from this study’s psychotherapeutic interventions. The group Angel, C.M., Smith, B.P., Pinter, J.M., Young, Relevance of the Group Format qualitative data show strong support for the STAIR program had to be extensively modified B.B., Armstrong, N.J., Quinn, J.P., Brostek, D.F., Military and emergency service is largely postulated factors of group-based interventions, to incorporate a culturally relevant structure and Goodrich, D.E., Hoerster, K.D., & Erwin, M.S. centered around interpersonal relationships. In leadership by those with lived experiences, and content, and it might therefore be more effective (2018). Team Red, White & Blue: A community- the context of this study, the lived experience functional, recovery-oriented content as being to develop a new program incorporating the based model for harnessing positive social of the facilitators helped enhance interpersonal culturally appropriate for a cohort of service recovery-oriented features of ER and interpersonal networks to enhance enrichment outcomes in relationships among the participants in each group. members, veterans, and emergency services relationship skills alongside the necessary issues military veterans reintegrating to civilian life. This was observed among both the emergency personnel. It could also be argued that it is of identity, values, service history, conditioning, Translational Behavioral Medicine, 8(4), 554–564. services and military personnel, highlighting difficult to separate these factors out because and transition that veterans and service personnel https://doi.org/10.1093/tbm/iby050 the translatability of military experience to they appear to be fundamentally interdependent face. Finally, further identification of similar Atuel, H.R., & Castro, C.A. (2018). Military the first responder context. It also emphasizes on each other, as demonstrated by the overlaps in programs (such as the specific peer-support cultural competence. Clinical Social Work Journal, how the relationships that lived-experience participants’ comments. However, more research programs identified previously) and systematic 46(2), 74–82. https://doi.org/10.1007/s10615-018- facilitators developed with participants were not is clearly needed to quantify what constitutes review of their structures, modes of delivery, 0651-z

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SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 79 Shatan, C.F. (1973). The grief of soldiers: About the Authors Vietnam combat veterans’ self-help movement. The Jonathan Lane is a 30-year Australian Army American Journal of Orthopsychiatry, 43(4), 640–653. veteran who has served as a soldier, medical https://doi.org/10.1111/j.1939-0025.1973.tb00834.x officer, and psychiatrist in full-time and part- Spitzer, R.L., Kroenke, K., Williams, J.B.W., time roles. He is also an Afghanistan veteran and & Löwe, B. (2006). A brief measure for assessing works as a clinician, educator and consultant is generalized anxiety disorder: The GAD-7.Archives now completing his Ph.D. through the University of Internal Medicine, 166(10), 1092–1097. https:// of Adelaide looking at culturally informed skills- doi.org/10.1001/archinte.166.10.1092 based interventions for military, veteran and Stanley, E.A., & Larsen, K.L. (2019). Difficulties emergency services personnel. Miranda Van Hooff with emotion regulation in the contemporary U.S. is a career researcher with a long history of interest armed forces: Structural contributors and potential and expertise in military, veteran, and emergency solutions. Armed Forces & Society, 47(1), 77–105. services personnel who is widely published in the https://doi.org/10.1177/0095327X19848018 field. She is now the director of the Military and Steenkamp, M.M., & Litz, B.T. (2014). One- Emergency Services Health Australia organization, size-fits-all approach to PTSD in the VA not which is dedicated to innovative research, program supported by the evidence. American Psychologist, delivery and services for these personnel and their 69(7), 706–707. https://doi.org/10.1037/a0037360 families. Ellie Lawrence-Wood is now working Steenkamp, M.M., Litz, B.T., Hoge, C.W., & for Phoenix Australia, the largest research Marmar, C.R. (2015). Psychotherapy for military- and education organization for trauma within related PTSD: A review of randomized clinical Australia. Alexander McFarlane is Australia’s trials. Journal of the American Medical Association, pre-eminent academic and researcher in the field 314(5), 489–500. https://doi.org/10.1001/ of PTSD. He was the founding director of the jama.2015.8370 Centre for Traumatic Stress Studies at the Steenkamp, M.M., Litz, B.T., & Marmar, University of Adelaide and has served in the Royal C.R. (2020). First-line psychotherapies for Australian Air Force Reserve. He is internationally military-related PTSD. Journal of the American renowned for his work in PTSD for military, Medical Association, 323(7), 656–657. https://doi. veterans and emergency services personnel over org/10.1001/jama.2019.20825 the last five decades. Van Hooff, M., Lawrence-Wood, E., Hodson, S., Sadler, N., Benassi, H., Hansen, C., Grace, B., Avery, J., Searle, A., Iannos, M., Abraham, M., Baur, J., & McFarlane, A. (2018). Mental health prevalence, mental health and wellbeing transition study (Publication No. P03371). Department of Defence and Department of Veterans’ Affairs, Canberra. https://www.dva.gov.au/mental-health- prevalence-report Vogt, D. (2011). Mental health-related beliefs as a barrier to service use for military personnel and veterans: A review. Psychiatric Services, 62(2), 135– 142. https://doi.org/10.1176/ps.62.2.pss6202_0135 Wortmann, J.H., Jordan, A.H., Weathers, F.W., Resick, P.A., Dondanville, K.A., Hall-Clark, B., Foa, E.B., Young-McCaughan, S., Yarvis, J.S., Hembree, E.A., Mintz, J., Peterson, A.L., & Litz, B.T. (2016). Psychometric analysis of the PTSD Checklist-5 (PCL-5) among treatment-seeking military service members. Psychological Assessment, 28(11), 1392– 1403. https://doi.org/10.1037/pas0000260

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 80 Put Yourself in My Combat Boots: Autoethnographic Reflections on Forms of Life as a Soldier and Veteran

Shawn Dunlap

Abstract The link that current and former service members have with the governments they serve is unique. Following Giorgio Agamben’s work on forms of life, this paper argues that those who choose to take part in military service exist as a unique, emergent form of life. This form of life often stands at the intersection of nationalistic mythmaking and the lived realities of service members prior to, during, and after their service. The author employs content relevant non-fiction vignettes. These sections follow Leon Anderson’s notion of “analytic autoethnography.” Topics explored include liminal experiences in military service and military operational realities. The paper also explores mechanical allegories of the soldier and veteran their implications on the life of the veteran. This research was conducted between August 2016 and May 2017. The author is a veteran and sole researcher for this work. Through the autoethnographic method, the work decodes and organizes the author’s personal military experience, highlighting service member and veteran voices that are often filtered through more traditional academic work on the topic as a means of demystifying military service and experience. The author concludes that by developing our understanding of service members and veterans as a form of life we can make the notions surrounding them more intimate and contextual, allowing us space to understand those individuals outside of the images and myth that often precede them.

Introduction define, for many, the proper exercise of state power For many Americans, current and former and civic citizenship, two concepts that have become service members historically represent the best linked in the modern era. More graphically, they values that they identify as being important exist to kill and die for our security at home and in society. Military values like loyalty, duty, abroad. This aspect is paramount, since, as Anna honor, integrity, and selfless service are ideas Simons (1999) tells us, “security remains the raison the nation is supposed to aspire to individually d'être of states” and these states “will continue to and collectively. In the contemporary War on support militaries in order to protect their citizenry Terror, the service member exists as a symbolic and/or themselves from being overrun, absorbed, representative of those values. They are placed, and conquered” (p. 91). literally and metaphorically, in opposition to the entities that sovereign governments identify Purpose and Method as threats to peace and security. We often know The goal in this paper is to describe the these enemies as state and non-state actors or experiences of U.S. service members and veterans terrorists and insurgents, all of whom we are told in the War on Terror to explore how, more threaten our way of life. Relative to these enemies, generally, those who perform military service exist service members are mechanistic and necessary in relation to the governments they serve and, more implements of conflict. Their bodies work to stem importantly, in relation to themselves, their service, the real and perceived tide of external state and and the reality that often entails. This examination non-state (and, therefore, illegitimate) violence. of soldiering focuses on the experiences as a form In the national narrative of the United States, of life specifically aimed at to demystifying military service members are said to sacrifice themselves service in our larger societal narratives, exposing for the people, their freedoms, and their way of the functional realities of governments with their life. Their lives are sacrificed for ideas the nation citizens. As is often the case, the actual material values or, in the minds of some citizens, particular and social nature of military service can undercut political views. They lionize service members larger narratives of civil engagement, whose and their service to the nation. The real rhythm fidelity is frequently referenced in policy making at of soldiers’ lives are starkly temporal, marked by the highest levels. More troubling, however, are the deployments and training around the world. They real results of conflict: injury and death, doubts,

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 81 fears, moral and emotional pain are downplayed (p. 375). My involvement in the community is clear in the wider narratives our society creates about through my directly stated and described military military service. These consequences are almost service. My research agenda’s goal is to bring a always reserved for the individual, the veteran, closer understanding to the experiences of service their family, and their healthcare providers to members and veterans through an in-depth deal with. The results of conflict represent a discussion of their being as a form of life. Military whole breadth of experiences that it seems can service members and veterans have injected their only be waded through in the past tense, often experiences, wittingly or unwittingly, into our leaving the veteran feeling isolated from others, social and academic discourses. These writings and many fail to negotiate these highly charged (both fiction and non-fiction) seem to pop up in histories in ways that are productive, healthy, and the aftermath of conflicts as those individuals, not harmful. Although this paper is critiquing myself included, seek to process their experiences. modern-day military service in the United States, it is not intended to be a wholesale indictment of Significance of Lived Experiences it. Military service can be a source of great pride The accounts I present in this paper happened and meaning for service members and veterans, several years ago. This was before I knew what something that is inextricably linked to them as anthropology was or what and how its preferred they move forwards in their lives. research methodologies are performed. The scenes Giorgio Agamben (2013) finds that a form of are ones I’ve replayed in my head in the ensuing life is characteristically defined by a set of norms. years, scenes which stand out to me as watershed These norms, he says, are “constitutive,” meaning moments in my larger experiences in the military. that they “do not prescribe a certain act or regulate It should be understood that because of this lack of a preexisting state of things, but themselves bring vocational rigor at the time the events happened into being the action or state of things” (p. 71). that I did not document my experiences in any Forms of life are generally granted to ways of methodical way. What I do remember can only be being that we recognize as unique based on how bracketed in terms of things like rank, deployment their inherent rules dictate the expressiveness of location, or even weather. These specifically those involved. This analysis also follows the work reflect an idea Birgitte Sørensen (2015) has called of Didier Fassin et al. (2017) on immigrants as a “ontological narratives,” which are representative form of life, who experience power in many more of the complex negotiation that every veteran bleak and diffuse ways than service members must go through as they seek to contextualize and veterans, but who are also receptacles of it, their experiences in relation to the state, public nonetheless. This paper seeks to interpret service opinion, and actual on-the-ground realities of members’ experiences as they emerge in military military service, especially abroad (p. 231). These service and labor and their collective aftermath memories are ontological exactly because forms in the veteran’s life. It also describes the unique of life themselves spring from specific forms of relationship modern warfare has with the tools knowledge. The creation of these narratives conveys used to enact it and the soldier’s agency in using certain meanings about a veteran’s experiences those tools, and conceives of soldiering, meaning while also working to create shortcuts through the specific act of someone engaged in military explanations for military service to society at service and its aftermath, as a specific form of life, large. They are war stories that reference the tools a way of knowing, for its participants in a way that of war, injury, and life itself. My negotiation with avoids deconstructing its various parts. the meaning of the vignettes is thus ongoing and My own experiences in the military influence my feelings toward them continue to evolve. It is how I conduct my research and form my conclusions. through these vignettes, war stories, that I attempt I will employ Leon Anderson’s (2006) conception to analytically acknowledge the realities of service of analytic autoethnography to acknowledge this members’ shared experience. fact. Anderson defines analytic autoethnography The majority of the uncited data about military as “ethnographic work in which the researcher is structure and practice comes from my personal (1) a full member in the research group or setting, experiences in the United States Army from 2006 (2) visible as such a member in the researcher’s until 2014, appearing within the text as the uncited published texts, and (3) committed to an analytic data about military practice and habit—the sorts of research agenda focused on improving theoretical information that become so engrained in soldiers’ understandings of broader social phenomena” minds as they serve, sacrifice, and are sacrificed.

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 82 My experiences include two deployments in experience and knowledge serve as a lens through support of Operation Enduring Freedom to which I view military service and its ensuing form Afghanistan in 2008 and 2009. Later, between 2011 of life. Throughout the text I use the term “soldier” and 2014, I was in the Army Reserves assigned to as representative of all service members, which an aviation company. Both groups of soldiers with is interchangeable with other common terms for whom I served taught me different things about members of the military like troop, sailor, marine, the military. Though the missions of the units and or airman—the only difference being their branch my roles within them were very different from of service, not their relationship to the government one another, the continuity of those experiences and the public. in my mind and their contributions to my lived

Basic Combat Training, July–September 2006; Fort Jackson, SC Arriving at Fort Jackson for United States Army Basic Combat Training (BCT) was a jarring experience. The in-processing center at Fort Jackson is best described in one word: chaotic. Upon arrival I was issued my first round of uniforms, which included clothes for physical training (PT) and fatigues (i.e., the Army Combat Uniform (ACU) blouse and pants, matching cover, desert tan boots, tan belt, tan underwear, tan shirts, and olive-green socks). Every recruit also gets a new haircut, several vaccinations, and new running shoes. Rumors swirl about what we should expect. It almost seems like a requirement that the information never be first-hand. There is a lot of what I later learned was called “hurry up and wait.” As the first few weeks came and went, I adjusted to my surroundings. The uniform requirements for specific tasks and the schedule began to sink in and become more routine. For the record, the ACU is not complete without a belt, and when you are given a formation time, they really mean 15 minutes earlier than that. For us new soldiers, BCT seemed to operate at a company and platoon level, with drill sergeants running the daily trainings and offering guidance. They led us through our first trainings on military etiquette, directed us on the proper way to complete the Land Navigation course, and hastily educated us on the proper use and wear of the M40 gas masks before unceremoniously running us through the gas chamber. Together as a group of recruits we started to memorize the Army Creed and the Army Song (both of which are inspectable) packed our first rucksack, and learned the ins and outs of road marching. Within the first month we were issued our weapons without live ammunition and a blank firing adapter, which remained on our weapons at all times when we were not on the firing range. We fired what felt like an infinite number of blanks while learning about buddy movement and spent an inordinate amount of time cleaning our weapons and the barracks. At some point in this seemingly endless stream of training, you start to buy into what you’re actually there to do and turn a corner. For me, that corner was the bayonet assault course. While not the deadliest weapon in the United States Army arsenal (in fact, they aren’t even issued regularly anymore to many units, even in deployment settings), the bayonet symbolizes the terror of face-to-face combat. As I learned later, if you come to the situation where you are using your sidearm you are already having a bad day. The bayonet brings this notion to an even closer meaning. It is the last weapon before unarmed combat, the last force multiplier available to a soldier to subdue the enemy. The bayonet course was no different from many of the other trainings I had and would receive in basic training and afterwards in my active duty unit, less intense than some, more intense than others. Somewhere someone checked a box on a training log with my name on it. As I lined up, bayonet fixed to the end of my M-16, I was ready to attack. The target was a sandbag, already full of holes, hung on a post. A switch in my mind seemed to click. I knew what I had to do and where the power had to come from: grab the weapon tightly on the narrow part of the buttstock. Firmly grasp the hand guards on the barrel, just above the slip ring. Muster up your strength and rush toward the enemy, thrusting the weapon into the meatiest part of the body. Withdraw, repeat, continue on past the post. It helps to get angry. Return to that feeling as necessary.

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 83 Service and Citizens of my service, my agency in making those BCT is one of the universal, liminal rites of decisions, and the fact that I still do find some passage that all military service members and pride in the experiences. It could be summed up veterans share. Rites of passage, as defined by like this: I wouldn’t do it again but I would not Arnold Van Gennep (1960), are identified by their (and cannot) change a thing. three phases: separation, margin, and aggregation. While discussing rites of passage as defined by Conceptions of Military Uniform(ity) Van Gennep, Victor Turner (1969) points out that on Forms of Life as the neophytes pass through the experience, In his discussion of what constitutes a form they “among themselves…tend to develop an of life, Agamben (2013) describes how the habits intense comradeship and egalitarianism. Secular and practice of a monastic way of life constitute distinctions of rank and status disappear or are an example of it. Describing the origin of the root homogenized” (p. 95). Basic training follows term “habitus,” he tells us that the term originally this example closely as it serves to sever, both “signified a way of being or acting”, noting that socially and functionally, your former self among the Stoics it “became synonymous with from your newer military self in the same ways virtue” (p. 13). Classically defined by Pierre that many cultures use rites of passage to mark Bourdieu (1977), “habitus” are “systems of adulthood. Through the completion of a series of durable, transposable dispositions, structuring basic soldiering tasks, the individual arriving at structures predisposed to function as structuring basic training is transformed into the uniformed structures” of which he says that “even when they soldier, someone who can be relied upon to follow appear as part of the realization of the explicit, the orders of their superiors and train tirelessly in and explicitly stated, purposes of a project or the defense of the duly elected government that plan” produce practices which enable “agents they serve. This marking of the service member is to cope with unforeseen and ever-changing the first key to the discussion of military service situations” and “are only apparently determined as a form of life. It is also the first understanding by the future” (p. 72). Agamben’s discussion of of how nation-states mark and unmark different the monk’s habit suggests that a great deal of categories of people to achieve political goals how we morally understand different actors can and exert political force. Obliquely speaking, the come from their dress. The monk’s leather belt categorization of citizens and non-citizens into specifically denotes the actor “as a warrior of different legal statuses by the state is an archaic Christ.” The sight and symbol of the leather belt form of exclusion used by sovereign governments is directly connected to its sacred meaning, which to justify their uses of force internally and Agamben (2013) calls a “sacred sign,” marking externally (Agamben, 1998, p. 9). when the “neophyte takes off his secular clothes A citizen’s qualification through social to receive the monastic habit” (p. 15). Without categories like “service member” and “veteran” invoking the full meaning of religious sacrality further atomizes these distinctions. These onto the soldier, a service member’s uniform acts categories are granted what Catherine Lutz as a marker that conveys to the viewer details (2001) calls “supercitizenship” as they are seen about the rites of passage the individual has gone to exceed the public in discipline, virtue, and through as well as their likely allegiance to the moral authority (p. 236). This image lands in the state. It also tells the viewer how the person might core of soldiering as a form of life. It is what is react to different stimuli and how their lives might added to and taken from to produce the notion be structured both in and after their enlistment that there may even be something identifiable ends. The fatigues, the tan shirt and tan boots, the and reproduceable in those experiences of cover, are all shorthand for this. These ideas are soldiering. However, as Lutz herself implies, it bound up with the uniform and its wearer and is something given to the servicemember, and is continue for the veteran indefinitely as their own the precursor, I think, of endless waves of “thank habitus, an integral part of the form of life they you for your service.” Moreover, the part of my now embody. mind that could be labeled “veteran” is wary of The understanding that dress can represent any individual who would actively solicit these both morals and lifestyle should be seen as a part hierarchal distinctions between themselves and of the state-building project itself. State creation, the service member. The ambivalence I feel is, as Phillip Corrigan and Derek Sayer (1985) for me, tied to mixed feelings about the purpose tell us, is “always accompanied by the moral

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 84 Service and Citizens of my service, my agency in making those regulation of society,” creating classifications of resonance” as the act of “giving something up” or BCT is one of the universal, liminal rites of decisions, and the fact that I still do find some citizens as a byproduct of their relations to the the act of “a giving of” is what “makes something passage that all military service members and pride in the experiences. It could be summed up means of productions in capitalistic societies holy” (p. 8). This social aspect, again bordering on veterans share. Rites of passage, as defined by like this: I wouldn’t do it again but I would not (p. 4). Military service’s connecting of morality a sort of sacrality, is what makes military service a Arnold Van Gennep (1960), are identified by their (and cannot) change a thing. and citizenship, much like Lutz’s (2001) powerful force in politics and other national and three phases: separation, margin, and aggregation. discussion of “supercitizenship,” is a defining way social discussions. It has weight. While discussing rites of passage as defined by Conceptions of Military Uniform(ity) to understand the modern state’s economic and The notion that military service and sacrifice Van Gennep, Victor Turner (1969) points out that on Forms of Life political goals. Moreover, the connection between is a social act ties that act to our own cultural as the neophytes pass through the experience, In his discussion of what constitutes a form dress and morality, combined with the access prejudices, coloring how the military is used and they “among themselves…tend to develop an of life, Agamben (2013) describes how the habits to arms defines how we think of soldier’s labor the context in which it is read. Sacrifice, who can intense comradeship and egalitarianism. Secular and practice of a monastic way of life constitute and what it means to us. Soldiering as a form of make it, and in what context act as “the primary distinctions of rank and status disappear or are an example of it. Describing the origin of the root life is defined by the tasks contained within it. means, by which we give meaning to the world homogenized” (p. 95). Basic training follows term “habitus,” he tells us that the term originally As the first vignette shows, these tasks are often around us; they allows us to interpret what we see, this example closely as it serves to sever, both “signified a way of being or acting”, noting that physical in nature. They also work to build mental and indeed, what we are” (Kertzer, 1988, p. 4). If socially and functionally, your former self among the Stoics it “became synonymous with toughness and resolve in the recruit. The ability to the soldier does sacrifice themselves willingly, from your newer military self in the same ways virtue” (p. 13). Classically defined by Pierre be precise in uniform wear and proficiency in the then the goals of the state are validated. Their that many cultures use rites of passage to mark Bourdieu (1977), “habitus” are “systems of use of military equipment is continually pressed coffins return home draped in an American flag adulthood. Through the completion of a series of durable, transposable dispositions, structuring into the mind of the soldier. This information and the soldier thereafter becomes a synecdoche basic soldiering tasks, the individual arriving at structures predisposed to function as structuring is shorthanded in the image of the soldier. The for the state and its sacred goals (Kertzer, 1988, basic training is transformed into the uniformed structures” of which he says that “even when they uniformed body of the soldier is a transformed p. 7). Telling of this, as Kenneth MacLeish (2013) soldier, someone who can be relied upon to follow appear as part of the realization of the explicit, object. This uniform body is then used by the points out of modern combat casualties, is the the orders of their superiors and train tirelessly in and explicitly stated, purposes of a project or state to create cohesive national narratives. fact that “even in death, one can’t be human” as the defense of the duly elected government that plan” produce practices which enable “agents most casualties in contemporary conflicts “just they serve. This marking of the service member is to cope with unforeseen and ever-changing Meaning and Sacrifice happen, unceremoniously” (pp. 88–90). This the first key to the discussion of military service situations” and “are only apparently determined This shift in status from civilian to soldier allows for both their easy absorption into the as a form of life. It is also the first understanding by the future” (p. 72). Agamben’s discussion of dictates how we should begin to understand conflict’s political narrative and the completion of how nation-states mark and unmark different the monk’s habit suggests that a great deal of service members’ experiences in the military. At of their sacred duty to the public. These deaths categories of people to achieve political goals how we morally understand different actors can the deepest level, they do serve as tools of the are often stark and violent. It solidifies the service and exert political force. Obliquely speaking, the come from their dress. The monk’s leather belt state, made to die if necessary, for its purposes member’s status, transitioning them into a categorization of citizens and non-citizens into specifically denotes the actor “as a warrior of and policies. More important, though, is to have permanent status in death. different legal statuses by the state is an archaic Christ.” The sight and symbol of the leather belt that person sacrifice willingly for the state. This form of exclusion used by sovereign governments is directly connected to its sacred meaning, which agentive action helps to create viable national Homecoming and Transition to justify their uses of force internally and Agamben (2013) calls a “sacred sign,” marking narratives and supports claims made by states The transition from service member to veteran externally (Agamben, 1998, p. 9). when the “neophyte takes off his secular clothes for continued legitimacy. The agentive difference is often invisible, however. As Sørensen (2015) A citizen’s qualification through social to receive the monastic habit” (p. 15). Without between “being sacrificed” and “sacrificing” is an describes, rather than experiencing homecoming categories like “service member” and “veteran” invoking the full meaning of religious sacrality important one. By sacrificing themselves with in explicit ritual terms of death and living, modern further atomizes these distinctions. These onto the soldier, a service member’s uniform acts agency for the security of the state, the soldier Danish veterans experience homecoming as a categories are granted what Catherine Lutz as a marker that conveys to the viewer details becomes part of a narrative which lends legitimacy “displacement into an unsettling environment,” (2001) calls “supercitizenship” as they are seen about the rites of passage the individual has gone to the actions that government has chosen to which “constitutes a ‘critical event’ that requires to exceed the public in discipline, virtue, and through as well as their likely allegiance to the undertake. As Veena Das (2008) suggests, this new social practices and relationships” inside an moral authority (p. 236). This image lands in the state. It also tells the viewer how the person might vying for the soldier’s consent is mostly to “claim “entirely new narrative” (p. 231). United States core of soldiering as a form of life. It is what is react to different stimuli and how their lives might legitimacy for a nation’s own wars” as it “creates military personnel experience a similar disconnect added to and taken from to produce the notion be structured both in and after their enlistment boundaries between so called civilized warfare after service as they move from a visibly marked that there may even be something identifiable ends. The fatigues, the tan shirt and tan boots, the and savage violence” (p. 287). category, the soldier, to the unmarked veteran. and reproduceable in those experiences of cover, are all shorthand for this. These ideas are Thus, the problematic notion of sacrifice for Even more ambiguity exists in this transition soldiering. However, as Lutz herself implies, it bound up with the uniform and its wearer and the state is key to our understanding of the life when considering those service members and is something given to the servicemember, and is continue for the veteran indefinitely as their own associated with it, especially its aftermath. This veterans whose bodies are permanently physically the precursor, I think, of endless waves of “thank habitus, an integral part of the form of life they seems to fall in line with more modern narratives or mentally altered by their experiences. The you for your service.” Moreover, the part of my now embody. of soldiers who “put themselves in harm’s way,” presence or seeming absence of these changes mind that could be labeled “veteran” is wary of The understanding that dress can represent which as Lutz (2002) points out, “reverses the again re-inscribes veterans’ bodies to society at any individual who would actively solicit these both morals and lifestyle should be seen as a part image of soldiers as warrior-killers and [elides] large, marking them with assumed mental health hierarchal distinctions between themselves and of the state-building project itself. State creation, the state’s role in their movements” (p. 725). As diagnoses and other categories that fit into the the service member. The ambivalence I feel is, as Phillip Corrigan and Derek Sayer (1985) Ivan Strenski (2003) suggests, “sacrifice is not cultural understandings of what and how the form for me, tied to mixed feelings about the purpose tell us, is “always accompanied by the moral just a social deed,” it also “has potent religious of life exists.

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 85 Sørenson (2015) also describes how there soldiers did not know and were not encouraged seems to be a taboo among many former service to know. They shared uniforms, especially winter members’ of speaking openly about the extent of boots, as the seasons and our missions changed. their combat experiences to outside questioners To truly understand the landscape in which who only seek to know the explicit details of their soldiers act, we must understand the nature of military experience. “Such questions,” she tells us, warfare and how the bodies in both sides of a “are typically felt as an assault, a transgression of conflict are reshaped to meet its task. Talal Asad a moral boundary, that robs the Veteran of the (2007) defines the term “war” as “a defined privilege of controlling silence and disclosure activity in international law” that has “a formal about this most sensitive matter” (p. 234). The cause and formal conclusion,” though one which discussion of warfare and the individual’s role should not be mistaken for the “beginning and in it is thus a taboo for soldiers as they attempt end of organized killing by the state” (p. 26). This to leave the military and transition into civilian definition suggests that warfare can be legitimate life. They feel trapped in the context of trying to and ostensibly morally justified. It also suggests decode those experiences for people who do not a level of (a)temporality to the event that is war. share them and whose lives offer very little context Modern conflicts have shown how complicated for their discussion. This is when they must begin this situation can be on the ground, however, as to control the narratives about their service and they create quagmires of meanings surrounding themselves, creating the war stories they choose to the purpose of specific military operations, share with others while negotiating their meanings often spanning multiple theaters, decades, and to themselves. generations of service members. The vignettes included in this paper are the The soldier is especially wrapped up in ones I felt I could share—they are coherent to me this violence. We are imagined to be constantly and their meanings have crystallized. The subtext, vigilant, kicking in doors, conducting convoy as I mention above, is steeped in deep ambivalence and dismounted patrols, finding the enemy and about my role in these experiences. As I explain defusing the source of political violence thought later, those experiences are both anonymous to be being perpetrated against all United States and intimately familiar to me. As a part of the Citizens. The reality for many of us, however, is discussion around a form of life, however, we see a slow negotiation with goals and policies that that the making of this life extends from the deeply often begin high above us. They echo down chains personal through to the broadest examples of the of command and intelligence, leading us to social, cultural, and political world. blacked-out planes and runways. The next vignette is an example of my own involvement Soldiers and Warfare in violence. However, I was so far removed from The social nature of conflict and how we the decision-making that led me there that I define it to exclude certain forms of violence and was not even deemed as a need-to-know person life, like chemical weapons and the intentional in the events of my own life. As an image to our targeting of civilians, is bound to the fact that we enemies, however, I did represent the powers understand warfare as social action. All military necessary to have them detained in their own conflict is tied to this notion as it disrupts, realigns, countries and essentially disappeared. As often is and forever alters social landscapes in the places the case, soldiers are also themselves disappeared. where it occurs. The operational reality of these The policies and practices that brought me to ideas in places like Afghanistan, however, has that intersection in time are easier to track. become more opaque as both sides of the conflict The veterans and, more troublingly the Local balance violence in terms that are both efficient Nationals, slip offstage, leaving unresolved and, seemingly, short term. Words like “detainee,” experiences in their wakes. “insurgent,” and “Local Nationals” seemed to blend together. The long-term status of any one person could not be guaranteed as those groups shifted and changed, often in response to the time of year and our own actions. In Afghanistan, I saw Local Nationals hired to be gate guards, cleaners, and cooks in endless cycles of individuals who we as

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 86 Operation Enduring Freedom, August–September 2008; Bagram Airbase, Afghanistan I got orders from my NCOIC, the non-commissioned officer in charge of my section, to go over to Ops at 1600 for a detail. When I arrived, the sergeant on duty told me where to be and when and with what gear: body armor, weapons, Kevlar helmet, ear pro. Full battle rattle. We were going to pick up a high-value target one of our teams had recently captured. I wasn’t told which team had captured the person, the person’s identity, or relative importance to our mission. I wasn’t “read-in,” meaning I didn’t need to know, for that level of information and it was not pertinent to the detail. I was joined by three other soldiers from different sections. Two non-commissioned officers (NCO) drove us to the flight line. We flew out on a C-130 that evening after dark, landing about an hour later at a firebase I had been to before. The plane idled on the blacked-out runway while we waited for the prisoner to be handed off and prepared for transport. “Transport” in this context means zip tying the person’s hands, blindfolding them with goggles that had been painted black, covering their ears with hearing protection, sitting them on a dog pee pad, and using a tow strap to strap them to the aircraft. The pee pad was there in case the detainee decided to soil themselves in a last-ditch protest, a situation the flight crew prepared for since it had happened frequently enough in the past. The entire transaction lasted less than ten minutes. The plane taxied quickly, turning at the end of the short runway, and made a hasty exit. We flew with the ramp of the plane open, which undoubtedly created an unwanted sensory experience for our detainee exacerbated by his sensory deprivation. We arrived back at Bagram less than an hour later. We waited on the dimly lit flight line for the truck, a white Toyota Hilux, to arrive. We loaded the detainee into the back of it, maintaining positive control to direct him into a kneeling position. The four of us, still wearing all our gear, got into the back with him, sitting on the edges of the truck bed as he knelt between us. We drove in silence down a small back road of the air base. We were taking him to be processed into the prison located on the base. We wouldn’t see him again after that. I was picked up for another guard detail a few weeks later. I was assigned to guard a detainee who one of our teams had recently brought in after a less-than-effective exchange of fire with one of our helicopters. The helicopter crew’s report stated that the detainee shot at the Apache, an advanced attack helicopter, with an AK-47, the assault weapon of choice for enemy combatants in Afghanistan. The standing ROE (rules of engagement) required us to render aid because he hadn’t been killed in the lopsided exchange of weapons fire. The information relayed to me was that the man was already apparently a single amputee before this incident. He was remarkably unscathed overall, I thought, considering the disparity in combat power between himself and the aircraft. He did, however, lose his second leg below the knee as a result of this encounter with U.S. forces. He was unconscious when I arrived at the main base hospital in full gear to guard him. The NCO in charge gave me brief instructions on what I should expect and sat me down in a plastic chair facing the foot of the detainee’s bed. A sucking sound periodically emitted from the machine that pulled fluid off the newly amputated leg. I was meant to guard him in case he “got out of control,” though even I knew there wasn’t much he could do in his current state. The room was dimly lit and had no windows. The door was closed. The nurses weren’t fazed by my presence there. I sat in the chair; it was night outside. I read a mystery novel that had been left there by some guard before me. Every few lines were punctuated by the sucking noise coming from the direction of his leg. He regained consciousness at some point. He looked down at his second leg, now lost. He didn’t seem to notice me and I couldn’t offer any consolation; I didn’t speak any of the Afghani languages and nobody else was in the room.

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 87 Wars: Soldiers as Objects and violence and acts of this sort, things like massacres Locations of Violence and, more broadly, genocide, are socially and As Lawrence Freedman (2005) suggests, the culturally remembered as failures of leadership at wars we fight now are no longer wars over national every level, inhumane, and morally indefensible. territories, what he calls “wars of necessity,” but, This is an important inflection point as we instead, modern wars are “wars of choice” as states continue to interrogate forms of life in this vein, attempt to police other countries’ spaces from especially when we consider generational changes within and outside their borders. These missions, in how the military recruits and retains its forces. often tied to the political clout of the leader in I joined the military as a means to an end, a fact charge at the time, are, as Harald Müller (2012) that colors how I weigh my experiences and how observes, “complex” as “soldiers are expected to I subsequently tell those stories. As mentioned fight insurgents, protect civilians, and perform above, war itself is a social action. So much of the non-military tasks within environments where reality of soldiering as a form of life appears to be lines of distinction between ‘friend’ and ‘foe’ are violence visited upon and by the service member. increasingly blurred” (p. 283). “Force projection” This leaves less space to interrogate the soldier’s is itself a regular activity for units operating in own motives in seeking out enlistment and modern theaters of war, though the targets of these motives themselves should be understood that force are never fully described and are not to be within social and economic contexts. In intended to be. They are objects with which we their study of recruiting tactics in Sweden and interact. Shows of force are meant to dissuade the United Kingdom, Sanna Strand and Joakim local nationals and enemies from continuing their Berndtsson (2015) identify several methods insurgent and supporting activities through a currently used to persuade new recruits to join demonstration of military might. those militaries. Recruitment rhetoric in both The soldier’s role is identifiable in these countries, they observe, promises new recruits exchanges. Their appearance signals their “that they will grow as individuals” thereby involvement in the military, like the uniform making them more “employable and attractive and standardized haircut. We use militaristic to private labor markets” (p. 234). As Strand and jargon. As Carol Cohn (1987) describes, the use Berdntsson (2015) further point out, modern of sanitized language by members of the military military recruitment exists within the context of is a linguistic technique used to change humans a long list of military transformations as soldiers into objects that can be killed more easily (p. now enter a “redefined global security arena” 691). Throughout writing this series of vignettes, whose weapons, tactics, and premises are different I often translated terms and meanings for the sake from the wars of the past (p. 234). of clarity. The act of recoding often seemed to Set within this roiling social context, forms sanitize the events and remove me from them, as of life and ontological narratives seem to become if I were hidden behind the orders and decisions more convoluted. The question of how we made by those few who had a need to know. reconcile these realities is hard to answer. This Further, as historian John Keegan (1978) tells confusion is key, however, as we, the outsiders of us, the rise of “thing-killing” weapons like heavy personal experience, look in on the experiences artillery, whose purpose is to remotely destroy of others. Soldiers like myself are recruited objects with the side effect of killing people, from small towns with long affiliations with the so-called “collateral damage,” is the genesis of military, plucked, as it were, straight from our this type of speech. Its purpose is, arguably, the high school classrooms. We are sent to fight wars creation of bare life, meaning life that is reduced that no longer even make it onto the news. The to its biological fact only and ignores how it terms for resolving these conflicts is ambiguous at might be lived (pp. 329–330). Using language best. We do so for economic, political, and social in this way is also a method of euphemistically reasons. The reality of the experiences, however, masking violence and, as Das (2008) suggests, are often morally gray and amorphous in their this “discursive technique” allows “certain kinds apparent larger purpose. As a view into the form of violence by dominant groups” to “disappear” of life, the unevenness itself is the most telling. (p. 289), thus allowing violence to continue while It complicates easy narratives about war and masking actual military practice with increasing peace, sacrifice and honor, and forces individual jargon and self-reference. The social implications service members and veterans to continually of this are well known. Dehumanization of the weigh their own position in their own social enemy is often the first step to more expansive worlds and beyond.

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 88 Operation Enduring Freedom, September 2009; Forward Operating Base Farah, Afghanistan Our repair team was being sent out again. For this and most missions the repair team consisted of myself, one private, and a box of items that we thought we might likely need on-site. Functionally this meant components of our units preferred radio and night vision, the tools to fix them, a length of cable with its associated adapters, and the paperwork to document our work. Our mission this time was to Farah, a small firebase in southern Afghanistan. To get there we first had to fly to Kandahar, then catch a second Chinook flight further out to Camp Bastion, and then, finally, convoy a small distance further to reach our destination. We arrived with the knowledge that the group at Farah had recently lost a team member to an IED, an improvised explosive device, less than a month prior. We had been sent out by the battalion for routine equipment repair, meaning we’d check their radios and fix any broken NVGs (night- vision goggles) and probably make some radio cables for them. The movement to the firebase took about a day and a half. When we arrived, however, our point of contact told us that there wasn’t much for us to do. A team from 2nd Battalion had been out to the base not long before us. The only thing they had for us was the grim task of trying to get the secure equipment, things like radios and the jammer, out of the rack of the truck that had been hit a few weeks before. The “truck,” in this case was a GMV, a ground mobility vehicle, which is a Humvee that has been modified to the specs needed for the missions our unit carried out. They were favorites of the teams for a few reasons: they were easy to drive, had large stable wheelbases, and were familiar to most soldiers. The GMV, which shared a flat bottom with its predecessor, the Humvee, had by 2009 been deemed by the Army (and the enemy) to be an easy target for IEDs. The 120mm Howitzer shells preferred by the Taliban and the Mujahideen in their construction of IEDs could effectively punch a hole straight through the bottom of the vehicles, killing, maiming, or ejecting all the occupants inside. This would often lead to additional casualties as the enemy often set ambushes at these chokepoints, wounding additional troops as they rolled out of the trucks disoriented and injured. Not unsurprisingly, the United States Army had started to train its soldiers to identify the signs of IED emplacement while on mounted patrol. By 2009, the various United States military branches had begun to replace GMVs with MRAPs, or Mine Resistant Ambush Protected vehicles, which, as the name implies, were designed to try and overcome some of the glaring weaknesses of the flat-bottomed GMV and Humvee. The MRAP was designed with a V-shaped hull and higher ride height, which lessened the intensity of the blast while also deflecting it, thereby protecting the vehicle’s passengers. The entire vehicle could be buttoned up, making it a harder target than the vehicles it was meant to replace. The enemy responded in an almost ingenious way to this change in our military hardware. Rather than giving up on manufacturing IEDs or using other non- conventional tactics, they did something much simpler: they canted the angle at which they buried their explosives, instead placing the IED in the ground at a 45-degree angle, effectively nullifying the supposed protection of the hull. Thus, we found ourselves in a GMV which had no chance of surviving the encounter in which it had been placed. The equipment in question had melted and become fused with its rack and still sat where it had been left when the blast hit the vehicle. The mangled remains of the vehicle had inoperable doors, and so we had to go in through the top, where the turret had been. The inside smelled of rust, like a nosebleed. It smelled of smoke. The smell burned in your nose. We weren’t able to get the equipment out that day. We only had tools for radio and night-vision repair: screwdrivers and Allen keys. Nothing meant to cut metal or chisel out equipment that had effectively been fused to its rack. We added the relevant details about the situation to the paperwork. The truck, I can only assume, would be sent to the junk yard to be dismantled and processed by an army of military contractors.

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 89 Men and Machines to harm. As a soldier, I was explicitly aware of Soldiering and militaries have historically the shifts in armor technology and the resulting been at least partially defined by their armed contracts the government would use to help reduce nature, the nature of the armaments they employ, death tolls. But I, like many other service members and to what success. The tools of contemporary and veterans, was also aware of the futility of the soldiering materially compound and exponentially process in which I found myself. From flak jackets increase the body’s effectiveness for the realities of that dated to the Desert Storm era, to more modern modern warfare. The tools of a given conflict shape interceptor body armors (IBA) that use ceramic a battle’s rhythm and expectations. Innovations in plates as their main method of survivability, I felt battlefield medicine and the widespread adoption as though I understood the material evolution of ceramic body armor to replace older flak jackets, of protecting soldiers from small arms fire and an innovation that dates back to the Vietnam War other anti-personnel weaponry and the logic era but whose premise goes back much further, surrounding it. The result of this type of warfare have led to decreasing numbers of service members offers what MacLeish (2013) calls a false sense being killed by combat actions while weapons such of “technomagical invincibility” to the troops, at as drones have increasingly removed the act of least in the United States military, which belies the killing from the actor. Soldiering, as a form of life, number of ways in which it can fail, resulting in derives a large part of its mandate from this. the death of the individual soldier (pp. 53–54). As Underscoring this focus on the material a form of life marker, there are few things closer to nature of the tools of conflict and their connection a soldier’s heart as they train and toil. It pervades to the acts themselves, Woodward and Jenkings the stories we tell ourselves about who will win, (2011) observed that when British soldiers who will lose, and what our odds of coming back were asked to describe the act of soldiering, alive from deployment are for any one of us. The they focused on its materiality as a means of results of thinking of oneself in these terms is what measuring success in that role. Using the soldiers’ MacLeish (2013) describes as a state “biological own descriptions of personal photographs, the precarity” for the soldier, as they are “the agents authors identifies several key concepts linked and instruments of sovereign violence, but also to this, noting that for some “these skills were its objects: equipped and trained to kill, kept alive clearly identifiable as military tasks,” such as in extreme circumstances, and placed deliberately “accuracy in marksmanship” and “surveillance in harm’s way” (p. 54). Thus, the greatest irony and observations skills,” or “the deployment of the soldier, and the resulting cynicism, is that of technical knowledge in the act of patrolling they exist as lives “kept alive” by great bulwarks of hostile urban areas” (p. 258). These are the factors technology that are “fundamentally linked to the that the soldiers themselves bring to the fore to logic that endangers them in the first place” (p. 54). explain their service and their success or failure Often, however, the discussion of war itself is in it. Through this it becomes clear that military limited to this discussion of machinery. War in the identities, as Woodward and Jenkings (2011) mechanical context suggests a certain scalability, suggest, “have a materiality to them in that they functionality, and modularity to the body of the are constituted and expressed through the use of soldier. It lends a notion of replicability to the equipment,” extending all the way to weapons, soldier’s body. Machine-centered thinking is also the key part of what makes a soldier a soldier, a tool for the soldier, though, as “cyborg” thinking and “the trained ability to correctly handle and allows soldiers to interact with their weapons in use them” (p. 259). This connection to the proper more useful and meaningful ways. As Gusterson use and deployment of military technology is (1996) points out, “the figure of the cyborg does not paramount to understanding soldiering as a form so much describe a literal phenomenon as provide of life. However, as MacLeish (2013) tells us, a metaphor for the increasing technicization of “modern warfare does not ensure the protection daily life and interdependence of humans and of the human body so much as it subjects it to machines” (p. 121). The notion of cyborgism previously unimaginable forms of harm and is related to soldiers, Gusterson continues, as it exposure—levels of violence…” (p. 53). “makes symbolic connections” between weapons Much like the discussion of thing-killing as and bodies, allowing the creation of metaphors a language device, the actual act of killing is now that allow the soldier to “make sense of the world” facilitated by the implements of war that variously (p. 123). These connections build into stories and and simultaneously protect and expose the soldier ontologies. Haraway (1991) concurs by telling

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 90 us that the “cyborg is a condensed image of both a shot at an enemy combatant”. Depressingly, imagination and material reality, the two joined he continues, “at the end of it, though things centres structuring any possibility of historical may seem to have changed strategically or transformation” (p. 150). It is through this politically for better or worse wherever he was, understanding that we see how the image of the the war typically has been neither won nor lost” soldier, their material being, and their meaning (pp. 14–15). This sort of slow encounter with the and purpose, create the hierarchies of meaning possibility of death creates feelings of being stuck in necessary to a form of life being formed, with the slow time, where every ping of a rock or shake of the weapons of war being references for the violence ground can mean the death of you or your comrade. level of the conflict and, often, how we as soldiers and the public expect or imagine death to arrive to Community Engagement and Forms of Life ourselves and our enemies. In a larger sense, the discussion around forms Referencing the last vignette, the presence of life is a chance to reflect on shared notions of the wrecked Humvee and my knowledge of its about groups with which increasingly few people shortcomings as a platform allowed and allows engage. In a time where “thank you for your me to frame its destruction and the death of the service” seems almost reflexive for many people, soldiers in it into a larger personal and political the ability to peer deeply into what that experience commentary and understanding. In doing so, it is or might be is crucial. The personal stories used becomes part of the ontological narrative I create to frame the discussion in this paper are unique for myself and others about the meaning of the to my experience, but they are also universal for conflict and my place within it. It is the memory many veterans across many generations of conflict. work of soldiers and veteran’s, however, that tells us Autoethnography can then be seen as a point of how these machines work. Reflecting on his own departure from theory into experience. ethnographic information, MacLeish (2013) notes As a form of community engagement, how they concurrently inform us of the effects of disclosing my own experiences creates spaces war that are “necessary and worthy” and those into which other service members, veterans, and that are “abhorrent and avoidable” (p. 10). There is their families can inject their own knowledge. often a great deal of moral ambiguity about which This then begins to flesh out our larger communal actions represent each category. understandings of their lives in relation to military violence and its aftermath. The decision to do so Time and Horizons stems from my desire to describe experiences Inasmuch as soldiers can be approximated that, far from heroic, represent the laborious to machines, they should also be understood nature of military service. While service members regarding the temporal nature of their and veterans are far from marginalized, in the experiences. As MacLeish (2013) accurately contemporary sense of the word, they are at risk tells us, soldiers experience their service as an of something much worse: being taken for granted. unfinished present. In the case of his informants, As so many other communities work to get their he describes how they are “repeatedly shuttling stories into a mainstream consciousness, so do between home and Iraq,” often returning home many veterans feel great isolation from a lack of with the foreknowledge of their next deployment appropriate cultural spaces available for them to (p. 8). However, this same precarity seems to be process their own experiences. a defining feature when we think of what makes This work further seeks to engage researchers soldiering a form of life. I have a sense of what in fields related to military and veteran studies in time of year I was in the truck, my futile attempts the social sciences with first-hand accounts from at trying to pry out the sensitive equipment so members of that community. The decision to use that our unit could do the necessary paperwork autoethnography allows the readers from those to make sure it was taken off of the inventory, but fields of study to understand very clearly where I that is not my focus. My focus is on the heat of am drawing my conclusions from, thus allowing the sun, the jagged metal, and the smell of rust them to challenge and expand on those findings and smoke generated by the bodies lost in the while demystifying military service realities that vehicle. MacLeish (2013) details this sentiment they often do not share with their subjects. This thoroughly, describing how “the soldier goes translation, so to speak, is the major draw for to war, and labors at it for months and months, researchers who are also community members, perhaps in a job in which he never even takes like myself, who find gaps in the literatures

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 91 surrounding their own experiences. The use that the experiences necessary to define it are of forms of life compliments this, working as a as much a set of activities as they are political concept that allows the topic to be understood in imaginings. The continued use of ideas like forms more contextual way, as veterans’ lives continue of life are calls for stakeholder engagement in well after their military service but always, and research to disentangle those two incarnations of in many intangible ways, relative to it. As one life from each other. An acknowledgement of this veteran said to me, “[in my mind] there is no time call, in turn, points towards an alternate future to before the Army, and while you’re in, there isn’t the categories of service member and Veteran, one any time after.” where they are understood more representatively As a vehicle for researchers who seek to by the individuals which inhabit them. The work with the military and veteran communities, uncoupling of this relationship between image the usefulness of understanding the layered and reality is, most importantly, the path forward experiences of military service cannot be in truthfully speaking to the realities and needs of understated. The very notion that there may service members and veterans. exist something recognizable as a discrete form As a form of life, soldiers are trapped of life opens up the possibilities of what types of between dichotomies of logic. They are wedged research might benefit both the community and between our ideas of individual responsibility the researcher. Qualitatively speaking, it expands and institutional practice. They also straddle the many things we already know about the benefits intersections between harm, biological precarity, of interviews, ethnographic, and other more and strength. They are equipped with the most subjective and contextual types of data collection. modern weapons, disciplined to endure pain and For those who work with more quantitative data, hardship, and taught to create stories out of these models, and frameworks, this work allows those difficult experiences that define them as veterans researchers to reflect on more confounding issues and people throughout their lives. Service that might not yet have been accounted for in members are expected to, if necessary, commit their work. acts that, outside the context of military service, One limitation inherent in this paper is the exact the highest forms of penal punishment. fact that I do not speak for all service members or They assent to all of this for what could be seen as veterans, each with their own unique experiences. purely personal gain, such as a college education, The work I produce, especially in regard to this healthcare, and financial stability. All the veterans topic, is biased by my education, worldview, (myself included) who I spoke with felt that time in service, time of service, and the sheer their military service was a beneficial stepping- opportunity to work in this space. What is needed stone for their careers and personal lives. Service, for true community engagement, beyond the accordingly, becomes very linked closely to our premise of forms of life, are opportunities for narratives about ourselves. other members of this community to speak their Conversely, our understanding of the actual truths. Many of those stories will be far from my lived realities of soldiers and those who would own, influenced, like mine, by political narratives become soldiers undermines our notions of honor and personal beliefs. My assumption, however, and sacrifice. They confound our understanding is that their confluences and the meanings for of the military as a body that represents the those individuals will reflect and build on the public it serves. Soldiers’ day-to-day experiences discussion here even as the details are parsed out. in combat zones, MacLeish (2013) says, demand True community engagement thus moves forward a “complex synthesis of practical knowledge, from this as dialogues and concepts are created for emotional discipline, and bodily discipline” those discussions to take place. This is echoed by (p. 77). This habitus remains with them long after Shalowitz et al. (2019) because, as they point out, their service ends, creating meaning and trauma “the process of engaging community members… for the veteran as they attempt to make sense of the represents the necessary ‘first step’ in conducting a lives lost around them for politically ambiguous research project” (p. 353). goals. They return to a climate that concurrently venerates their “service” while placing them into Conclusion stigmatized mental health categories. Forms of life, as a concept, presupposes a I use an autoethnographic method in this generalizable notion of the service member and paper to discuss the realities as a form of life veteran and calls it into contention. It acknowledges to reveal the heterogeneous nature of military

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 92 experience. Intriguingly, beyond that, is that the References universality of those experiences can be made Agamben, G. (1998). Homo sacer: Sovereign into any one coherent notion like a form of power and bare life. Stanford University Press. life. It changes the service member and veteran Agamben, G. (2013). The highest poverty: from passive beings into active creators of their Monastic rules and form-of-life. Stanford University own experiences as the activities concomitant to Press. their service define their social intelligibility to Anderson, L. (2006). Analytic autoethnography. others. There is no vignette describing my life as a Journal of Contemporary Ethnography, 35(4), 373– veteran after my military service. As a category of 395. https://doi.org/10.1177/0891241605280449. my experience, the time in it is marked by normal Asad, T. (2007). On suicide bombing. Columbia experiences that need no explication: college University Press. graduation, relationships, changing vehicles, Bourdieu, P. (1977). Outline of a Theory of moving to different cities and states. These are Practice (Cambridge Studies in Social and Cultural universal experiences, but they are framed by my Anthropology) (R. Nice, Trans.). Cambridge military service in ways of which even I am only University Press. doi:10.1017/CBO9780511812507 slowly becoming conscious. Cohn, C. (1987). Sex and death in the rational It is arguably this process of reflection world of defense intellectuals. Signs, 12(4), that truly marks soldiering as a form of life. By 687–718. https://doi.org/10.1086/494362 understanding the processes that bring about the Corrigan, P., & Sayer, D. (1985). The great “soldier” category in modern armies as an act arch: English state formation as cultural revolution. that itself creates a form of life, we are better able Blackwell. http://eprints.lancs.ac.uk/49214/ to see how these experiences fuse into what we Das, V. (2008). Violence, gender, and recognize as a person, rather than an object or subjectivity. Annual Review of Anthropology, image. This recognition of a soldier’s humanity 37(1), 283–299. https://doi.org/10.1146/annurev. outside of a category is what will enrich the anthro.36.081406.094430 discourse surrounding them for some time to Fassin, D., Wilhelm-Solomon, M., & Segatti, A. come. The veterans’ acknowledgment that their (2017). Asylum as a form of life: The politics and body was and is the currency upon which the experience of indeterminacy in South Africa. state makes its calculations when contemplating Current Anthropology, 58(2), 160–187. https://doi. new and existing wars causes waves in that org/10.1086/691162 person’s life that they must endure. We can and Freedman, L. (2005). The age of liberal wars. do know that through different intersecting Review of International Studies, 31(S1), 93–107. subjectivities, service members are made to act https://doi.org/10.1017/S0260210505006807 as controlled but agitative agents, at once docile Gusterson, H. (1996). Nuclear rites: A weapons while also enfolding the projection of sovereign laboratory at the end of the Cold War. University of military power. They are recruited by the state California Press. for both physical security and to reinforce Haraway, D. (1991). Simians, cyborgs, and hegemonic and gendered civic ideals. The shared women: The reinvention of nature. Routledge. cultural ideas we associate with soldiering are Keegan, J. (1978). The face of battle: A study of themselves often weaponized to create new forms Agincourt, Waterloo, and the Somme. Penguin. of media that appeal to the use of overwhelming Kertzer, D.I. (1988). Rituals, politics, and force and technology. These are then used to create power. Yale University Press. national narratives of freedom and democracy, Lutz, C. (2001). Homefront: A military city and suggest how they might be achieved, and the American 20th century. Beacon Press. reinforce the role of the United States military in Lutz, C. (2002). Making war at home in the the realization of these goals. The service member United States: Militarization and the current crisis. and veteran are intertwined in these facts. The American Anthropologist, 104(3), 723–735. https:// task beyond this work, in this light, becomes how doi.org/10.1525/aa.2002.104.3.723 to understand the intersections of these forces as MacLeish, K.T. (2013). Making war at Fort they emerge in service members’ experiences as Hood: Life and uncertainty in a military community. they negotiate the mediated, ongoing meanings Princeton University Press. of those realities while also attempting to move forward with their lives.

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About the Author Shawn Dunlap is a Health Science Specialist and anthropologist at the Center for Healthcare Organization and Implementation Research. His most recent work involves engaging veterans experiencing homelessness using ethnographic methods aimed at identifying transitions into and out of housing and using those findings to create a mobile application that reproduces their detail. His research interests include the implications of policy on Veterans experiencing homelessness, moral economies surrounding healthcare, stakeholder engagement, and the use of technology to facilitate healthcare engagement and research.

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 94 Profoundly Changed: The Homecoming of Veterans from Iraq and Afghanistan Kelly Wadsworth

Abstract This phenomenological research study, conducted from 2017 to 2018, rigorously and methodologically investigated Iraq and Afghanistan (OIF/OEF) veterans’ first-person accounts of their experiences of profound change after war. This study explored the existential themes of homecoming, betrayal, grief, guilt, meaning, and truth-telling through the lens of OIF/OEF veterans. This existential investigation built on the methods of Husserl’s phenomenology, which explored human consciousness, and Heidegger and others, who deepened the phenomenological exploration to address the question of human existence. Key to the investigation of human phenomena is allowing the core encounter to emerge through rich, authentic description. In this study, OIF/OEF veterans described an experience in which they recognized that they had been profoundly changed by war. In-person interviews were recorded and transcribed. Data was analyzed using Colaizzi’s (1978) seven-step approach. The findings highlighted how profound change after war was a matrix of psychological and spiritual expansion for both the individuals and their communities. The fundamental structure of this phenomenon had three essential facets. First, experience, awareness, and impact collectively constituted one another in a circle of influence. Second, a before-deployment self stood in stark contrast to an expanded after-deployment self. Finally, profound change was enduring and had wide-sweeping implications throughout many levels of each veteran’s life. Psychological-spiritual growth may result in symptomatic behaviors that are easily attributed to psychological disorders. These results also illuminate the need for social support at the community level as well as the need for veterans to cultivate self-awareness as part of the transition process.

The Iraq and Afghanistan conflicts of the are recognized and integrated into both the 21st century have ushered in a new generation of personal and the collective narrative. A transition war veterans. For many, these encounters will bring that is arrested or inadequate can leave veterans about psychic changes so profound that the war ill-prepared to face the war-related phenomena itself will pale in comparison to what lies ahead. that may emerge in their lives 2, 5, 10, or 20 years There is no guarantee whether a transformative down the road. maturity or a regressive disintegration will Descriptive phenomenology is a comprehensive emerge. What happens in the short span of the approach to qualitative research that accounts homecoming years, often when veterans are at their for the complexity of consciousness, and it is most vulnerable, can have lasting effects on their therefore a particularly vital tool in veteran-related health and efforts at reintegration. Experiences of research. This research sought to uncover the combat and related phenomena may resist easy essential structure of profound change after war as quantification and are subject to ongoing debates encountered by Operation Iraqi Freedom (OIF)/ about their place in the human psyche as well as Operation Enduring Freedom (OEF) veterans. The their proper role in society at large. The political, essential structure is the scaffolding that makes the economic, social, and personal implications of phenomenon at hand what it is. It describes the combat experience may complicate matters even features and contours of a cohesive mental process further. More robust approaches to transition that are shared between those experiencing it. are needed that can address the multifaceted The phenomenologically informed conceptual and multilayered realities of veterans’ wartime model of profound change after war offers a clear experiences. It can be a disservice to both veterans structure of awareness, expansion, and impact that and society when only piecemeal or partial shapes and defines the nature of homecoming for understandings of veterans’ combat encounters returning veterans.

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 95 Brief History phenomena can cast multidirectional shadows In 2008, the number of U.S. servicemembers and shape life in a multitude of ways. A previous deployed to Iraq and Afghanistan peaked at over battlefield experience can influence and color a two million combined troops (Belasco, 2009). veteran’s world by shaping how they see their future Operation Enduring Freedom began in late 2001 on the horizon. Similarly, Relph (1976) advanced when U.S. military personnel arrived in Afghanistan that the physical aspects of space do not stand in response to the attacks of September 11, 2001. alone but instead coexist alongside the perceptual Troop numbers hit their peak a decade later in qualities of how we imagine and remember space. 2011 at over 30,000, and the operation officially Individuals are more than timelines of events, and ended in 2014 with a shift to Operation Freedom’s people embody physical space carrying with them a Sentinel (OFS), an ongoing training and advisory whole host of accompanying worlds rather than as mission of 5,000–10,000 personnel (Torreon, a blank slate. For the veteran, physical presence at 2016). Operation Iraqi Freedom began in 2003, hit home carries with it the previous world of combat. its peak in 2008, and then officially transitioned to Schuetz (1945) recognized early that communities an advisory and support mission with Operation and veterans underwent significant changes in New Dawn (OND; Torreon, 2016). Taking into their time apart and that a successful homecoming account OEF/OIF/OFS/OND and the more recent required deep cooperation from both parties. For Operation Inherent Resolve (OIR), which began example, civilians steeped in the war propaganda in 2014, the U.S. military has steadily deployed an issued by the U.S. State Department to raise money all-volunteer force to the Middle East for nearly for World War II war bonds would need to adjust 20 consecutive years. As those troops separate their expectations so that they could welcome or retire, the transfer of personnel from military to home their veterans, whose military service civilian status has real-world implications for both often was nothing like what had been depicted the returning individuals and the community at large. in radio and film (Schuetz, 1945). Homecoming as a discrete, physical act, rather than as a mythic Homecoming journey, remains the normative approach for Homecoming is a critical juncture and OIF/OEF veterans. Tick (2005) warned against generally refers to major transitions from understanding war in terms of isolated facts and deployment to home, from active duty to reserve/ figures as opposed to an entire world to be grasped guard status, or from military service to civilian and faced by the entire community. Beshai and status. Even though each of these transitions has Tushup (2006) argued for the recognition of psychological, emotional, social, and spiritual combat as a complex world where questions of life’s implications, the physical tends to be emphasized. sanctity and societal responsibility were treated There are departure ceremonies when a unit as foremost concerns rather than secondary deploys; battlefield rituals for valor, heroism, and afterthoughts. death; as well as redeployment celebrations upon In the autobiographical milieux of memoir, return. Rites of passage that highlight psychological journals, and poetry, veterans themselves articulate or psychic transformations tend to be limited similar critiques of homecoming: that there is (Demers, 2011). Servicemembers engaged with not enough emphasis on existential concerns or the existential tasks of homecoming, such as societal responsibility (Harris, 2014; Holmstedt, moral reflection, consciousness raising, or spiritual 2007; Jones, 2013). There have also been calls reckoning, are likely to find fewer resources to for post-traumatic stress disorder (PTSD) to guide them through these transitions than they can be applied to the wider society and not just the find for their physical transition home. This can individual (Tick, 2005). The dominant framework result in alienation from critical social support and currently assumes that the reintegration of veterans perpetuate a cycle of distress (Ahern et al., 2015). into a static society, one that does not change itself, The challenge of alienation has been articulated is psychologically healthy and personally desirable, in a number of different ways over the past half when it may in fact be neither (Marlantes, 2011). century. Merleau-Ponty (1968) emphasized the Too often, the wider culture forgoes the possibility ways that people perceive entire worlds rather than that the veteran might have something to offer that simply discrete things. In his work, he implored the the civil sector may need, like the hero’s boon or wider community to recognize the importance gift earned along the journey (Campbell, 2012). of the whole and not just the parts. In this vein, how things appear in front of us matters because

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 96 Design Background origin, sources, and meaning of meaning and First-person OIF/OEF accounts often tackle meaningfulness” (van Manen, 2014, p. 74). In the phenomena such as ineffable experiences, the early 20th century, Husserl (1913/1983) advocated presence of the soul, and the human community for the importance of the relationship between the as chief postwar concerns (Tick, 2014; Williams mind and objects rather than solely the objects & Staub, 2005). Existential-phenomenological themselves and called for human consciousness to themes touching on meaning, identity, belonging, be explored with all the rigor and gravitas that had death, guilt, and shame have been endorsed by been afforded to the scientific pursuit of the natural veterans across geography, gender, rank, and age world. He understood phenomenology to be “the (Castner, 2012; Gordon, 2014; Luttrell, 2007). science of the essence of consciousness” (p. 33), or These first-person voices, however, often fall the systematic study of subjectivity, and he argued outside of academic and medical research, which that it was necessary because the natural sciences drive veteran-related policies and programs. had become untethered from their philosophical Overreliance on the empirical scientific method as roots and were therefore incapable of adequately performed by these institutions confines the field addressing human concerns (Husserl, 1936/1970). and restricts its knowledge base. As a result, the The rise of phenomenology, in which human limits of reality have frequently been assumed to experience was foundational and prioritized, be synonymous with the limits of method (Giorgi, challenged the “sensation-bound positivism” that 1970). More bridges are needed to connect veterans’ had infused modernism and shaped how and what self-identified concerns with the programs that was studied (Spiegelberg, 1972, p. xxviii). are designed for them. Since the self-observer has In this study, veterans were asked to describe greater access to the intricacies of their experience an experience of profound change after war— than does the external, third-person observer one in which they came to understand their whose lens is more restricted, first-person accounts postcombat lives in a new way. The concept of are an essential and irreducible perspective (Von “profound change” allowed for a wide range of Eckartsberg, 1989). Descriptive phenomenology experiences to emerge beyond the traditional and its focus on first-person experiences does categories of trauma or psychological injury. not “wish for third person, ostensibly objective In this way, the method aligned with the goal of accounts of our lifeworld to wear the mask of uncovering veterans’ existential interests, concerns truth to dominate the field of lived-experiences” which tend to be highly interconnected and not (Steinbock, 2012, p. 594). always discretely categorized. Clinical settings, This study sought to excavate the lived particularly the Department of Veterans Affairs, experiences of Iraq and Afghanistan veterans which is traditionally called the VA, capture only through the lens of descriptive phenomenology a small fraction of both veterans themselves and in order to strengthen the conceptual foundation the challenges, distress, and reintegration hurdles of homecoming. By prioritizing subjectivity, that they face (Demers, 2011). By investigating at descriptive phenomenology shifts the veteran the deeper level of profound change—rather than from the object of research to the subject (Colaizzi, through the lens of a specific diagnosis like PTSD, 1978) and in this way allows veterans to reclaim spiritual distress, or moral injury—this research the primary voice in postwar reflection. was equipped to capture the ways in which the sum of veteran experience is greater than its parts. Methodology In addition to the overarching directive Descriptive phenomenology is the to “describe an experience of profound change methodological framework for this study. after war,” veterans were also asked a set of Phenomenology is the exploration of the lived phenomenological interview questions (Barrell et experience and a study of how events show al., 1987), including: themselves to the human person amid the complex 1. Briefly describe the setting of your experience. layers and intricacies of life. As a methodological Where were you? What were you doing? approach, phenomenology emerged in the Western 2. Attempt to get back to a short interval of time philosophical tradition as scholars wrestled when you experienced the phenomenon. with questions of authentic knowledge about As you relive this brief interval, share your humanity and the surrounding world. The study of first-person, present tense experience. phenomena can be understood as “a philosophically 3. Report both what you were experiencing and consuming fascination with the question of how you were experiencing it.

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 97 This pilot study aimed to uncover the shared hand. The extracted significant statements were structure of profound change among six OIF/ then compiled into a complete list. In Step 3, the OEF veterans. Priority was given to saturation meanings of the significant statements were drawn and alignment of the data over the number of out and highlighted. The analysis moved from what participants. This research was designed to allow the participants said to what they meant and thus veterans’ concerns to emerge in their own language illuminated meanings that might have otherwise and to guide the outcome. Participants who could remained hidden. In Step 4, the formulated describe in detail an experience with profound meanings were gathered into clusters of themes. change after war were selected, and participation Validation took place in this step, as the themes was limited to Iraq or Afghanistan servicemembers were referred back to the original descriptions who were able to engage in a 45–60 minute interview to ensure that the findings remained rooted in in a public setting. Prospective participants who and closely tied to the raw data and that they were not able to describe or who did not report did not contain anything foreign to the original having had an experience of profound change descriptions. Likewise, the themes were allowed were not eligible for the study. Participants were to stand in whatever contradictions or ambiguity recruited until a full accounting, or saturation, of that arose, and any discrepancies were noted. In the phenomenon was reached. Variety was sought Step 5, an exhaustive description pulled together in terms of participants’ age, gender, veteran status, all of the findings into an integrative account of the and time in service. Specific medical or mental phenomenon. In Step 6, an exhaustive description diagnoses were neither inclusive nor exclusive and of the phenomenon offered “as unequivocal a were not asked about. Physical ability, substance statement of identification of its fundamental use, and/or employment status likewise were not structure as possible” (Colaizzi, 1978, p. 61). In limiting factors. A service-connected disability or Step 7, the final phase, the researcher returned to a particular military occupation specialty (MOS) the participants and inquired about the findings, was not required, although at least one post-9/11 asking, “How do the descriptive results compare combat deployment to Afghanistan or Iraq was a with your experiences?” (Colaizzi, 1978, p. 62). necessary qualification. The Saybrook University New data that emerged in this step was integrated institutional review board approved and oversaw into the analysis and the final outcome. In this study. The interviews were professionally descriptive phenomenology, the goal of analysis is transcribed for analysis. Table 1 presents to create an essential structure of the phenomenon biographical data for all participants (P). that outlines its mental contours and psychological features. Data Analysis Data was analyzed using Colaizzi’s (1978) Summary of Findings seven procedural steps for phenomenological The phenomenon of being profoundly analysis of a qualitative inquiry. Step 1 was the changed after war incorporated an important first, full read through the transcripts to get a sense circle of experience, recognition, and impact. The of the collective body of data. Step 2 focused on experience of the change occurred first. Then came extracting significant statements that were in the the ability to recognize it, followed finally by the data that were pertinent to the phenomenon at ongoing impact of the event. In the findings, this

Table 1. Participant Demographics

P Branch Overseas Age MOS Family Employment Gender 1 Army Iraq 30–40 Chaplain Married/Children Employed M

2 Army Iraq 30–40 Infantry Married/Children Unemployed M

3 Army Iraq 20–30 Signal Single Unemployed M 4 Navy Iraq 40–50 Chaplain Married/Children Employed M 5 Army Afghanistan 20–30 Armor Single Employed M 6 Marines Afghanistan 20–30 Infantry Single Unemployed M

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 98 This pilot study aimed to uncover the shared hand. The extracted significant statements were cycle repeated itself rather than being finite, and it nonordinary time, an encounter which drastically structure of profound change among six OIF/ then compiled into a complete list. In Step 3, the was not limited to just one sphere of life as veterans reformed P2’s understanding of the nature of OEF veterans. Priority was given to saturation meanings of the significant statements were drawn felt the cycle and its impacts in multiple places, reality. P3 and P4 had similar transcendental and alignment of the data over the number of out and highlighted. The analysis moved from what such as family, work, and school. Veterans came to moments, with the former able to “see sounds” participants. This research was designed to allow the participants said to what they meant and thus fresh recognitions about their experience of change and the latter “seeing pain and suffering” in an veterans’ concerns to emerge in their own language illuminated meanings that might have otherwise and saw the impacts of this change evolve, and energetic, third eye kind of way. P6 only began to and to guide the outcome. Participants who could remained hidden. In Step 4, the formulated they uncovered new aspects of their identity both recognize the depth of what had changed after his describe in detail an experience with profound meanings were gathered into clusters of themes. at the level of the self and at the communal level. discharge from military service. After a childhood change after war were selected, and participation Validation took place in this step, as the themes This created a marked contrast between the before- marked by “masculine betrayal and abuse,” P6’s was limited to Iraq or Afghanistan servicemembers were referred back to the original descriptions profound-change self and the after-profound- newfound trust in male peers as a result of service who were able to engage in a 45–60 minute interview to ensure that the findings remained rooted in change self. The interviewees’ endorsement in the Marine Corps was a source of deep healing. in a public setting. Prospective participants who and closely tied to the raw data and that they of “who I was before” versus “who I am after” were not able to describe or who did not report did not contain anything foreign to the original illuminated the rupturing quality of profound Before-Deployment Self and Expanded, having had an experience of profound change descriptions. Likewise, the themes were allowed change. This schism resulted from experiences After-Deployment Self were not eligible for the study. Participants were to stand in whatever contradictions or ambiguity that included but surpassed conventional The findings highlighted that veterans recruited until a full accounting, or saturation, of that arose, and any discrepancies were noted. In definitions of trauma and were marked by the experienced themselves as having a before- the phenomenon was reached. Variety was sought Step 5, an exhaustive description pulled together quality of expansion. The after-change self was not deployment self and an after-deployment self. in terms of participants’ age, gender, veteran status, all of the findings into an integrative account of the merely different or changed but was an expanded The profound changes that they encountered and time in service. Specific medical or mental phenomenon. In Step 6, an exhaustive description self with a greater capacity for sensory input, were often so extensive that they felt as if a new diagnoses were neither inclusive nor exclusive and of the phenomenon offered “as unequivocal a perspective, knowledge, or relationships. This person had been born. The data supported the were not asked about. Physical ability, substance statement of identification of its fundamental bigger and fuller self, however, was not always new self as being marked by an expansion and/ use, and/or employment status likewise were not structure as possible” (Colaizzi, 1978, p. 61). In accompanied by corresponding coping skills or or enlargement of sensory capabilities (i.e., limiting factors. A service-connected disability or Step 7, the final phase, the researcher returned to ego strength. Personal transformation that moved heightened hearing, smell, and perceptions), a particular military occupation specialty (MOS) the participants and inquired about the findings, more rapidly than either the individual’s mental empathy and spiritual sensing, or moral was not required, although at least one post-9/11 asking, “How do the descriptive results compare structures or social support could keep up with sensibilities. For some, this expansion was a combat deployment to Afghanistan or Iraq was a with your experiences?” (Colaizzi, 1978, p. 62). usually resulted in distress. In sum, the essential positive change marked by growth, maturity, necessary qualification. The Saybrook University New data that emerged in this step was integrated structure of profound change after war was (a) and perspective. For others, this expansion institutional review board approved and oversaw into the analysis and the final outcome. In an unpredictable and erupting awareness of the ushered in a breakdown of their coping skills this study. The interviews were professionally descriptive phenomenology, the goal of analysis is profound change; (b) a rapidly expanded self, and ego structure. On some occasions, growth transcribed for analysis. Table 1 presents to create an essential structure of the phenomenon regardless of corresponding ego strength or social and disintegration took place simultaneously. biographical data for all participants (P). that outlines its mental contours and psychological support; and (c) widespread implications in nearly Interviewees described the emergence of a new features. all spheres of life. self in a number of ways. For P1 it was “a major Data Analysis change,” and for P2 it was “something that’s Data was analyzed using Colaizzi’s (1978) Summary of Findings Awareness going to stick with me and it’s going to be a big seven procedural steps for phenomenological The phenomenon of being profoundly The awareness that profound change had even deal.” P1 described a “shaken faith” and said that analysis of a qualitative inquiry. Step 1 was the changed after war incorporated an important occurred was a key piece of the phenomenon’s “in the course of those experiences, the details first, full read through the transcripts to get a sense circle of experience, recognition, and impact. The essential structure. The awareness itself emerged of my life just lost all worth.” P3, knowing that of the collective body of data. Step 2 focused on experience of the change occurred first. Then came unpredictably and was often disruptive when he had experienced changes in perception and extracting significant statements that were in the the ability to recognize it, followed finally by the it arose. For some, awareness developed at the cognition, still “doesn’t know how to explain it data that were pertinent to the phenomenon at ongoing impact of the event. In the findings, this moment of a key experience, while for others to [my health care providers],” continuing “I still awareness took on more of a cumulative, unveiling can’t get help because they say I don’t have it.” effect. P1 had spent 4 out of 5 years on deployments P4’s transcendental “seeing” of the suffering and Table 1. Participant Demographics with significant losses and an increasing feeling pain of war while in the basement of a building of the “heaviness of what we experienced.” The immediately allowed him to start seeing that same P Branch Overseas Age MOS Family Employment Gender snowballing effect of loss and the long exposure suffering and pain in the “impact on civilians,” rate eventually culminated in a profound something which he could then not unsee. P5’s 1 Army Iraq 30–40 Chaplain Married/Children Employed M transformation. P5 endorsed a similar experience after-deployment self struggled with the “flow of 2 Army Iraq 30–40 Infantry Married/Children Unemployed M of key events “over time” rather than at “a specific civilian life,” and after experiencing the grit and time.” P2 and P4 both had discrete transcendental determination of his military peers, he found it 3 Army Iraq 20–30 Signal Single Unemployed M encounters that were immediately recognizable, difficult to interact with civilians who lacked such 4 Navy Iraq 40–50 Chaplain Married/Children Employed M but it was not until a later time that they more traits. P6’s expansion of self came in the form of fully understood the impacts of these encounters. new trust, an ability “to actually have faith that I 5 Army Afghanistan 20–30 Armor Single Employed M P2 experienced an “unexpected slowing of time” can trust another man in my life. And [that he] 6 Marines Afghanistan 20–30 Infantry Single Unemployed M amid “absolute confusion” as a first foray into isn’t like there to like crush you.”

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 99 Widespread Implications case, of the profound change. The interviewees’ The third piece of the essential structure was narratives seamlessly wove together combat the profound change’s widespread, continually exposure, trauma, grief, trust, betrayal, family, expanding implications. The effects of the change community, intimacy, spiritual encounters, implicated not only the veterans but also their transpersonal experiences, heightened sensory personal networks and their wider communities. perception, expanded perspectives, families Whether or not veterans were accepted and of origin, religious communities, theology, supported by their immediate friends and family psychological development, traumatic brain often made a big difference in the nature of their injury, mental illness, and physical injury, just to homecoming. Describing the return home, P1 name a few. Rather than disjointed collections of said, “like before, life was a bunker, and now it separate themes, the accounts were coherent and is just a lot of crushed stone.…I have absolutely connected. The findings at this subjective level of no shelter, no sense of protection or security.” In encounter produced a high-level accounting of the addition, P1 realized what “a gaping hole I was phenomenon that is closer to a conceptual model in this fabric” of a familiar community. P2 had or a cohesive system than to a diagnosis or set of internalized the ethical questions of combat and symptoms. Profound change after war could not found little outlet for them upon his return home, be reduced to experiences, symptoms, emotions, resulting in a pressure cooker–like internal life or coping skills, although it embraced all of these. that deteriorated beyond recognition. P3 had It also was not simplified to trauma, mental illness, managed to integrate a newfound sensitivity to grief, or moral injury, even though it incorporated sound by balancing an avoidance of “shopping at these as well. Walmart, football games, and musical concerts” This understanding of the phenomenon of with more time spent building a foundation “for profound change after war may thus contribute reimagining custody of my children.” P4 entered to a more nuanced and informed understanding homecoming with a “greater level of sensitivity of homecoming by equipping veterans ahead of to what was here” and reaffirmed the wisdom of time with realistic expectations and appropriate moving through life in an intuitive kind of way resources. The essential structure of profound rather than with strategic or intentional plans. P5 change, which includes continual awareness, an asked himself, “What rhythm am I supposed to expanded self, and ongoing implications, suggests march to now? Well, which ever one you want,” that an informed homecoming, rather than a which reflected the deep identity formation laissez faire one, is crucial. For the veterans who that was taking place. In the military, P6 had have encountered profoundly transformational experienced trust in personal relationships, experiences, understanding a map of the terrain to a departure from his preservice relationships come might be a central step toward an effective characterized by a lack of or broken trust. This homecoming. The landscape might not only contrast had a number of disorienting impacts; include traditional mental health services but P6 noted that homecoming was a time where also models of psychospiritual development that “things you don’t remember come up for you,” in have the potential to align with servicemembers’ reference to abuse that had occurred in his past. systems of making meaning (Harris et al., 2015). The ways in which veterans can be deeply and Discussion and Implications profoundly changed also shed light on practical With the data analyzed for its essential concerns, such as diagnosis and treatment structure, it becomes possible to look at the as defined by the VA. The work of preparing phenomenon of profound change after war servicemembers for the cycle of awareness, apart from medical diagnosis, psychological integration, and impact extends far beyond the categorization, or political influence. In this level health care traditionally offered by the VA. A of analysis, often called lived experience, the specific challenge in receiving adequate care participating subject is as close as can be to the is the task of demonstrating eligibility and the phenomenon and is able to provide a sweeping ways in which a servicemember must show that view of the encounter. Lived experience, when they are psychologically injured in connection described soon after the phenomenon itself, is with their military service. Such parsing may not freer of explanations or justifications. This kind be consistent with the integrated nature of the of proximity allows the subject to craft a cohesive phenomenon at hand. The findings from this study and internally organized accounting, in this show that veterans experiencing profound change

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 100 Widespread Implications case, of the profound change. The interviewees’ after war are engaged in critical psychological, legitimate factor, on its own it fails to account for The third piece of the essential structure was narratives seamlessly wove together combat spiritual, and social tasks on many levels and in a host of other influences. Quite a bit of time and the profound change’s widespread, continually exposure, trauma, grief, trust, betrayal, family, many areas at the same time. This raises questions life experience may elapse between combat and expanding implications. The effects of the change community, intimacy, spiritual encounters, about the degree to which the practical services of coming home, such that the conceptualization implicated not only the veterans but also their transpersonal experiences, heightened sensory the VA reflect the reality that veterans who have of postwar stress as a narrow linear equation personal networks and their wider communities. perception, expanded perspectives, families been profoundly changed may experience. in which A causes B has been shown to be Whether or not veterans were accepted and of origin, religious communities, theology, The findings also can provide insight for problematic (Paulson & Krippner, 2007). Likewise, supported by their immediate friends and family psychological development, traumatic brain practitioners who encounter Iraq and Afghanistan the operationalization of PTSD through the lens often made a big difference in the nature of their injury, mental illness, and physical injury, just to veterans throughout the course of their work. Such of the DSM-5 remains focused on the individual homecoming. Describing the return home, P1 name a few. Rather than disjointed collections of practitioners may include university professors, and does not address higher-order factors, such as said, “like before, life was a bunker, and now it separate themes, the accounts were coherent and clergy, counselors, medical personnel, veteran the fact that the rate of PTSD in veterans decreases is just a lot of crushed stone.…I have absolutely connected. The findings at this subjective level of service officers, social workers, mental health as cultural support for war increases (Greenberg no shelter, no sense of protection or security.” In encounter produced a high-level accounting of the professionals, and even family members, to name et al., 2008) or the argument that higher levels of addition, P1 realized what “a gaping hole I was phenomenon that is closer to a conceptual model a few. Profound change after war takes place moral attunement may signal an increased risk in this fabric” of a familiar community. P2 had or a cohesive system than to a diagnosis or set of on an iterative continuum whereby experience, of PTSD (Kempton, 2008). Sociological research internalized the ethical questions of combat and symptoms. Profound change after war could not recognition, and impact mutually inform one on the relationship between social abandonment found little outlet for them upon his return home, be reduced to experiences, symptoms, emotions, another, and a before-change self stands in contrast and PTSD-like symptoms raises questions about resulting in a pressure cooker–like internal life or coping skills, although it embraced all of these. to an expanded, after-change self, with ongoing the proximate causes of trauma (Brown, 2012). If that deteriorated beyond recognition. P3 had It also was not simplified to trauma, mental illness, implications. Profound change after war involves homecoming and combat-related phenomena are managed to integrate a newfound sensitivity to grief, or moral injury, even though it incorporated the complex work of awareness and integration in primarily conceived of in individual terms, there sound by balancing an avoidance of “shopping at these as well. the midst of an expanded being; the phenomenon may be a failure to recognize the inevitable changes Walmart, football games, and musical concerts” This understanding of the phenomenon of could be described as one of development and that war has wrought on individuals and their with more time spent building a foundation “for profound change after war may thus contribute expansion. Psychological, moral, and spiritual society at large (Tick, 2005). An ethical diagnosis reimagining custody of my children.” P4 entered to a more nuanced and informed understanding developmental theories might be considered of PTSD must rely upon the clear articulation of homecoming with a “greater level of sensitivity of homecoming by equipping veterans ahead of essential tools when engaging with a veteran personal and communal sources where individual to what was here” and reaffirmed the wisdom of time with realistic expectations and appropriate who has experience with this phenomenon. The notions of disease and disorder are secondary to moving through life in an intuitive kind of way resources. The essential structure of profound movement of the psyche has been addressed societal notions of the same (Beshai & Tushup, rather than with strategic or intentional plans. P5 change, which includes continual awareness, an by a number of scholars, including Erikson’s 2006). Community engagement is critical for new asked himself, “What rhythm am I supposed to expanded self, and ongoing implications, suggests (1982/1997) psychosocial stages, Kohlberg’s conceptualizations of homecoming; specifically: march to now? Well, which ever one you want,” that an informed homecoming, rather than a (1984) moral development, Fowler’s (1981) stages which reflected the deep identity formation laissez faire one, is crucial. For the veterans who of faith, Steinbock’s (2009) structures of mysticism, Practical and theoretical anchors for that was taking place. In the military, P6 had have encountered profoundly transformational and Loder’s (1989) transformative growth. These understanding and treating PTSD rest on experienced trust in personal relationships, experiences, understanding a map of the terrain to models have the advantage of serving as a map deep, foundational social, psychological, a departure from his preservice relationships come might be a central step toward an effective and a guide to a rapidly changing interior life, philosophical, and existential questions characterized by a lack of or broken trust. This homecoming. The landscape might not only something which is lacking in the symptom …and the dangers associated with contrast had a number of disorienting impacts; include traditional mental health services but reduction approach that many veterans receive. the increased clinical attention to P6 noted that homecoming was a time where also models of psychospiritual development that the condition are that these difficult, “things you don’t remember come up for you,” in have the potential to align with servicemembers’ Community Engagement fundamental issues are overlooked in reference to abuse that had occurred in his past. systems of making meaning (Harris et al., 2015). Profound change after war shows that the favor of approaches that ignore important The ways in which veterans can be deeply and homecoming of veterans is neither an individual nuances and deal merely with symptoms, Discussion and Implications profoundly changed also shed light on practical pursuit nor simply a medical or diagnostic problem. approaches that offer respite from bad With the data analyzed for its essential concerns, such as diagnosis and treatment The phenomenon illuminates how an integrated dreams, or tranquilize a veteran who structure, it becomes possible to look at the as defined by the VA. The work of preparing conceptualization of homecoming should includde has been overrun by paranoia, without phenomenon of profound change after war servicemembers for the cycle of awareness, broad social involvement and community fully restoring the person. That kind of apart from medical diagnosis, psychological integration, and impact extends far beyond the engagement. The relationships among veteran profound recovery relies on an equally categorization, or political influence. In this level health care traditionally offered by the VA. A homecoming, the VA, PTSD, and the Diagnostic profound awareness of the circumstances of analysis, often called lived experience, the specific challenge in receiving adequate care and Statistical Manual of Mental Disorders (DSM- involved in a person’s life, as well as participating subject is as close as can be to the is the task of demonstrating eligibility and the 5; American Psychiatric Association, 2013) may the nature of the trauma. (Paulson & phenomenon and is able to provide a sweeping ways in which a servicemember must show that overly simplify experiences of profound change. Krippner, 2007, p. xvi) view of the encounter. Lived experience, when they are psychologically injured in connection For instance, combat-related PTSD has relied described soon after the phenomenon itself, is with their military service. Such parsing may not almost exclusively on cause-and-effect factors for freer of explanations or justifications. This kind be consistent with the integrated nature of the diagnosis, whereby a veteran’s distressing symptoms Conclusion of proximity allows the subject to craft a cohesive phenomenon at hand. The findings from this study at home are assumed to be the direct result of Profound change after war is a phenomenon and internally organized accounting, in this show that veterans experiencing profound change prior events in combat. While causality may be a that weaves together key experiences, awareness,

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 101 a new expanded self, and ongoing impact into an Beshai, J.A., & Tushup, R.J. (2006). Sanctity of integral narrative. Profound change is just that: human life in war: Ethics and post traumatic stress profound. It has qualities of entireness, fullness, disorder. Psychological Reports, 98(1), 217–225. and pervasiveness. It emerges, reemerges, and does https://doi.org/10.2466/PR0.98.1.217-225 not shy away from conflict. It brings about healing Brown, B. (2012). The power of vulnerability: just as it brings about disintegration, because when Teachings on authenticity, connection, & courage the self expands, ego strength and social support [Audiobook]. Sounds True. may or may not be in place. Key encounters in Campbell, J. (2012). The hero with a thousand combat, both traumatic and nontraumatic, bring faces (3rd ed.). New World Library. veterans onto sacred ground and into dreadful Castner, B. (2012). The long walk: A story of places. Profound change after war defies the easy war and the life that follows. Doubleday. dichotomy of good experiences versus bad ones Colaizzi, P.F. (1978). Psychological research and instead paints the homecoming landscape with as the phenomenologist views it. In R.S. Valle the full colors of a developmental leap. Profound & M. King (Eds.), Existential-phenomenological change echoes ancient homecoming myths and alternatives for psychology (pp. 48–71). Oxford yet roots the traveler within the confines of life as University Press. presently lived. Phenomenology conceives of the Demers, A. (2011). When veterans return: The hero’s journey as the hero sees it and conceives role of community in reintegration. Journal of Loss of homecoming as the veteran sees it. What is and Trauma, 16(2), 160–179. https://doi.org/10.10 clinically convenient, politically expedient, or 80/15325024.2010.519281 financially lucrative is set aside and attention is Erikson, E.H. (with Erikson, J.M.). (1997). The given to the essence of the things themselves and life cycle completed (Extended version). W.W. the evidence within them, “we want to go back Norton. (Original work published 1982) to the ‘things themselves’ … and thereby bring Fowler, J.W. (1981). Stages of faith: The ourselves to the evidence” (Husserl, 1901/1968, p. psychology of human development and the quest for 6). Homecoming as a mutual endeavor between meaning. HarperSanFrancisco. veterans and society bears out what William James Giorgi, A. (1970). Psychology as a human science: (1880/2009) described as how the “the community A phenomenologically based approach. Harper & Row. stagnates without the impulse of the individual. Gordon, K. V. (2014). Experiences in the war The impulse dies away without the sympathy of the zone, shared narratives, and shifting identities: community” (p. 50). The phenomenon of profound Systematic review of qualitative research. The change after war conceives of coming home as just Humanistic Psychologist, 42(4), 331–353. https:// the beginning, rather than the end, of the journey. doi.org/10.1080/08873267.2014.893514 Greenberg, N., Iversen, A., Hull, L., Bland, D., & Wessely, S. (2008). Getting a peace of the action: References Measures of post traumatic stress in UK military Ahern, J., Worthen, M., Masters, J., Lippman, peacekeepers. Journal of the Royal Society of S.A., Ozer, E.J., & Moos, R. (2015). The challenges Medicine, 101(2), 78–84. https://doi.org/10.1258/ of Afghanistan and Iraq veterans’ transition jrsm.2007.070024 from military to civilian life and approaches to Harris, J.I., Park, C.L., Currier, J.M., Usset, reconnection. PloS ONE, 10(7), Article e0128599. T.J., & Voecks, C.D. (2015). Moral injury and https://doi.org/10.1371/journal.pone.0128599 psycho-spiritual development: Considering the American Psychiatric Association. (2013). developmental context. Spirituality in Clinical Diagnostic and statistical manual of mental disorders Practice, 2(4), 256–266. https://doi.org/10.1037/ (5th ed.). American Psychiatric Association. scp0000045 Barrell, J.J., Aanstoos, C., Rechards, A.C., & Harris, S. (with Cox, R.O.). (2014). Steel will: Arons, M. (1987). Human science research methods. My journey through hell to become the man I was Journal of Humanistic Psychology, 27(4), 424–457. meant to be. Baker Books. https://doi.org/10.1177/0022167887274004 Holmstedt, K.A. (2007). Band of sisters: Belasco, A. (2009, July 2). Troop levels in the American women at war in Iraq. Stackpole Books. Afghan and Iraq wars, FY2001–FY2012: Cost Husserl, E. (1901/1968). Logical investigations: and other potential issues (Report no. 7-5700). volume 2. Investigations in phenomenology and the Congressional Research Service. https://fas.org/ theory of knowledge – part I (5th ed.). Max Niemeyer sgp/crs/natsec/R40682.pdf Verlag.

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 102 a new expanded self, and ongoing impact into an Beshai, J.A., & Tushup, R.J. (2006). Sanctity of Husserl, E. (1970). The crisis of European In D. Zahavi (Ed.), The Oxford handbook integral narrative. Profound change is just that: human life in war: Ethics and post traumatic stress sciences and transcendental phenomenology: An of contemporary phenomenology. Oxford profound. It has qualities of entireness, fullness, disorder. Psychological Reports, 98(1), 217–225. introduction to phenomenological philosophy (D. University Press. https://doi.org/10.1093/ and pervasiveness. It emerges, reemerges, and does https://doi.org/10.2466/PR0.98.1.217-225 Carr, Trans.). Northwestern University Press. oxfordhb/9780199594900.013.0029 not shy away from conflict. It brings about healing Brown, B. (2012). The power of vulnerability: (Original work published 1936) Spiegelberg, H. (1972). Phenomenology in just as it brings about disintegration, because when Teachings on authenticity, connection, & courage Husserl, E. (1983). Ideas pertaining to a psychology and psychiatry: A historical introduction. the self expands, ego strength and social support [Audiobook]. Sounds True. pure phenomenology and to a phenomenological Northwestern University Press. may or may not be in place. Key encounters in Campbell, J. (2012). The hero with a thousand philosophy: First book (F. Kersten, Trans.). Martinus Tick, E. (2005). War and the soul: Healing our combat, both traumatic and nontraumatic, bring faces (3rd ed.). New World Library. Nijhoff Publishers. (Original work published 1913) nation’s veterans from post-traumatic stress disorder. veterans onto sacred ground and into dreadful Castner, B. (2012). The long walk: A story of James, W. (2009). Great men, great thoughts, Quest Books. places. Profound change after war defies the easy war and the life that follows. Doubleday. and the environment. In M. Ruse (Ed.), Philosophy Tick, E. (2014). Warrior’s return: Restoring the dichotomy of good experiences versus bad ones Colaizzi, P.F. (1978). Psychological research after Darwin: Classic and contemporary readings soul after war. Sounds True. and instead paints the homecoming landscape with as the phenomenologist views it. In R.S. Valle (pp. 49–55). Princeton University Press. (Original Torreon, B.S. (2016, September 29). U.S. the full colors of a developmental leap. Profound & M. King (Eds.), Existential-phenomenological work published 1880) periods of war and dates of recent conflicts(Report change echoes ancient homecoming myths and alternatives for psychology (pp. 48–71). Oxford Jones, A. (2013). They were soldiers: How the no. RS21405). Congressional Research Service. yet roots the traveler within the confines of life as University Press. wounded return from America’s wars—The untold van Manen, M. (2014). Phenomenology presently lived. Phenomenology conceives of the Demers, A. (2011). When veterans return: The story. Haymarket Books. of practice: Meaning-giving methods in hero’s journey as the hero sees it and conceives role of community in reintegration. Journal of Loss Kempton, J.P. (2008). Extenuata gerens phenomenological research and writing. Taylor & of homecoming as the veteran sees it. What is and Trauma, 16(2), 160–179. https://doi.org/10.10 veteris vestigia poenae (Bearing the faded scars Francis. clinically convenient, politically expedient, or 80/15325024.2010.519281 of the ancient penalty): The moral development- Von Eckartsberg, R. (1989). The unfolding financially lucrative is set aside and attention is Erikson, E.H. (with Erikson, J.M.). (1997). The trauma link among combat veterans [Doctoral meaning of intentionality and horizon in given to the essence of the things themselves and life cycle completed (Extended version). W.W. dissertation, Pacifica Graduate Institute]. ProQuest phenomenology. The Humanistic Psychologist, the evidence within them, “we want to go back Norton. (Original work published 1982) Dissertations Publishing. https://search.proquest. 17(2), 146–160. https://doi.org/10.1080/08873267 to the ‘things themselves’ … and thereby bring Fowler, J.W. (1981). Stages of faith: The com/openview/eed8f6e183d2fa9c4f5ffac8f47d7a8 .1989.9976848 ourselves to the evidence” (Husserl, 1901/1968, p. psychology of human development and the quest for 8/1?pq-origsite=gscholar&cbl=18750&diss=y Williams, K., & Staub, M.E. (2005). Love my 6). Homecoming as a mutual endeavor between meaning. HarperSanFrancisco. Kohlberg, L. (1984). The psychology of moral rifle more than you: Young and female in the U.S. veterans and society bears out what William James Giorgi, A. (1970). Psychology as a human science: development: The nature and validity of moral Army. W.W. Norton. (1880/2009) described as how the “the community A phenomenologically based approach. Harper & Row. stages (Essays on moral development, volume 2). stagnates without the impulse of the individual. Gordon, K. V. (2014). Experiences in the war Harper and Row. About the author The impulse dies away without the sympathy of the zone, shared narratives, and shifting identities: Loder, J.E. (1989). The transforming moment. Kelly Wadsworth is a faith leader, a guest community” (p. 50). The phenomenon of profound Systematic review of qualitative research. The Helmers & Howard. lecturer, and a community speaker in the Pacific change after war conceives of coming home as just Humanistic Psychologist, 42(4), 331–353. https:// Luttrell, M. (with Robinson, P.). (2007). Lone Northwest. Her professional interests center on the the beginning, rather than the end, of the journey. doi.org/10.1080/08873267.2014.893514 survivor: The eyewitness account of Operation intersection of health, spirituality, and community Greenberg, N., Iversen, A., Hull, L., Bland, D., Redwing and the lost heroes of SEAL Team 10. life including the ways perspective-taking & Wessely, S. (2008). Getting a peace of the action: Little, Brown. fosters human growth and development. Using a References Measures of post traumatic stress in UK military Marlantes, K. (2011). What it is like to go to phenomenological lens, she seeks to explore both Ahern, J., Worthen, M., Masters, J., Lippman, peacekeepers. Journal of the Royal Society of war. Atlantic Monthly Press. inner and outer experiences of the sacred and the S.A., Ozer, E.J., & Moos, R. (2015). The challenges Medicine, 101(2), 78–84. https://doi.org/10.1258/ Merleau-Ponty, M. (1968). The visible and engagement with meaning-making. Kelly received of Afghanistan and Iraq veterans’ transition jrsm.2007.070024 the invisible (A. Lingis, Trans.). Northwestern her PhD from Saybrook University in 2018 with from military to civilian life and approaches to Harris, J.I., Park, C.L., Currier, J.M., Usset, University Press. a focus in existential psychology as well as her reconnection. PloS ONE, 10(7), Article e0128599. T.J., & Voecks, C.D. (2015). Moral injury and Paulson, D.S., & Krippner, S. (2007). Haunted M.Div from Princeton Theological Seminary https://doi.org/10.1371/journal.pone.0128599 psycho-spiritual development: Considering the by combat: Understanding PTSD in war veterans (2003). She served as an Army Chaplain from American Psychiatric Association. (2013). developmental context. Spirituality in Clinical including women, reservists, and those coming back 2001–2011 which included a deployment to Diagnostic and statistical manual of mental disorders Practice, 2(4), 256–266. https://doi.org/10.1037/ from Iraq. Praeger Security International. Balad, Iraq with the Washington State Army (5th ed.). American Psychiatric Association. scp0000045 Relph, E. (1976). Place and placelessness. Pion National Guard. She can be reached at Kelly. Barrell, J.J., Aanstoos, C., Rechards, A.C., & Harris, S. (with Cox, R.O.). (2014). Steel will: Limited. wadsworth.squarespace.com Arons, M. (1987). Human science research methods. My journey through hell to become the man I was Schuetz, A. (1945). The homecomer. American Journal of Humanistic Psychology, 27(4), 424–457. meant to be. Baker Books. Journal of Sociology, 50(5), 369 –376. https://doi.org/10.1177/0022167887274004 Holmstedt, K.A. (2007). Band of sisters: Steinbock, A.J. (2009). Phenomenology and Belasco, A. (2009, July 2). Troop levels in the American women at war in Iraq. Stackpole Books. mysticism: The verticality of religious experience. Afghan and Iraq wars, FY2001–FY2012: Cost Husserl, E. (1901/1968). Logical investigations: Indiana University Press. and other potential issues (Report no. 7-5700). volume 2. Investigations in phenomenology and the Steinbock, A.J. (2012). Evidence in the Congressional Research Service. https://fas.org/ theory of knowledge – part I (5th ed.). Max Niemeyer phenomenology of religious experience. sgp/crs/natsec/R40682.pdf Verlag.

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 103 How Veterans Make Meaning of the College Choice Process in the Post-9/11 Era

Derek M. Abbey

Abstract The Post-9/11 GI Bill was implemented in 2009. Since then, more than 1.9 million people have used the benefits afforded by the bill to attend college, and more than $90 billion has been paid to institutions of higher learning and Post-9/11 GI Bill beneficiaries. During this time, the types of colleges that veterans attend as well as the educational models they select have shifted. Veterans are more likely to utilize online or distance education models. Additionally, veterans attend for-profit universities at an increasing and greater rate than do their nonveteran counterparts. These shifts differ from the trends observed among the general population. The purpose of this study was to learn from veterans how they make sense of decision-making related to college choice prior to matriculation into a 4-year institution. Qualitative methods were utilized to examine the lived experiences of 12 post-9/11-era U.S. Navy and U.S. Marine Corps student veterans during the college choice process. The experiences shared by the participants in this study were used to further examine and critique an established theory of college selection. This study provides practitioners and academics with insight into how to better engage with this diverse and unique community of prospective students on and off campus through greater understanding of how they make meaning of the college choice process.

Since its inception, the United States military has increased, the overall percentage of student has represented a cross section of the American veterans who choose these school settings has community. In recent years, the veteran population decreased from 63% to 56%. Additionally, veterans has been shrinking because fewer citizens serve in are more likely to access higher education online the military today than served in previous decades when compared to their nonveteran independent (U.S. Department of Veterans Affairs, 2015). counterparts. Independent students are students Despite this trend, a steady stream of student over the age of 24 and those students under age 24 veterans continues to flow onto college campuses who are married, have dependents, were orphans (U.S. Department of Veterans Affairs, 2014). or wards of the courts, were homeless or at risk of Individuals who serve in the military become part homelessness, or are determined to be financially of a unique, rich culture that is present in varying independent by a financial aid officer using levels across the entire country and national professional judgment (Radford et al., 2016). The community. These potential students bring with factors influencing these changing enrollment them this culture and a set of experiences that can trends have yet to be thoroughly researched. The contribute positively to the breadth and depth of number of new Post-9/11 GI Bill students entering the diversity of campus communities. higher education averages 200,000 per year and is In 2009, the Post-9/11 GI Bill took effect. This forecast to remain the same in the coming years new version of the GI Bill significantly increased (U.S. Department of Veterans Affairs, 2015). the level of support provided to student veterans. The recruiting practices of many institutions Since its inception, more than 1.9 million people catering to veterans have been called into question have benefited from it, and more than $90 billion (Ochinko & Payea, 2018). In 2012, U.S. president has been paid to institutions of higher learning Barack Obama issued Executive Order 13607, and to Post-9/11 GI Bill beneficiaries. During which condemned colleges’ predatory practices this time, the types of colleges and universities of recruiting veterans and called for the creation that veterans attend as well as the educational of principles of excellence for colleges serving models they select have shifted. The number veterans. Despite widespread condemnation of veterans attending for-profit institutions of colleges’ practices and the establishment of has increased from 14% of the student veteran administrative boundaries to prevent them, population to 24%. Although the total number of evidence suggests that these practices continue veterans attending all models of public colleges (Ochinko & Payea, 2018). A 2018 brief released by

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 104 Veterans Education Success stated that six of the the frictions they face in the transition to the top 10 schools receiving Post-9/11 GI Bill payments higher education environment (Ackerman et al., “were being investigated by, sued by, or had reached 2009; DiRamio et al., 2008; DiRamio & Jarvis, settlements with federal or state law enforcement 2011; Heitzman & Somers, 2015). These studies agencies for actions such as misleading advertising are often prescriptive, offering best practices for and recruiting and fraudulent loan programs” serving these students once they are on campus. In (Ochinko & Payea, 2018). Additionally, ITT Tech, recent years, researchers have started to examine which received close to $1 billion in Post-9/11 the college choice process for veterans at specific GI Bill payments—the third-highest amount types of colleges (Circle, 2017; Hill, 2016; Ives, of Post-9/11 GI Bill funds received by any 2017; Vardalis & Waters, 2011). However, there institution—closed in 2016 while under remains a significant need for research in the post- investigation by multiple state attorneys general 9/11 era that explores the period before veterans and federal agencies (Ochinko & Payea, 2018). matriculate into a college. There is an understanding that first-generation In this study, the researcher used qualitative college students often lack the social and cultural research methods to develop a theoretical capital that helps prospective students efficiently understanding about how post-9/11 veterans make access the higher education system. The U.S. meaning of the college choice process, how they Department of Veterans Affairs has stated that 62% decide which universities or colleges to consider of veterans are first-generation college students and apply to, how they decide which educational (2015). This fact, combined with the significant model is right for them, and in what ways financial benefit for veterans who attend college emotions influence the college choice process. The using the Post-9/11 GI Bill, may explain why significance of this study is in providing data to institutions are using predatory practices to lure colleges and universities that could influence their veterans into their systems. Without data on the recruitment and outreach practices in order to factors that influence veterans’ college choice better serve these potential students. Additionally, decision-making processes, quality colleges and practitioners that work with veterans will be able universities have little information that they can to use these data to better inform their work with use to inform and adjust their recruiting methods student veterans. to meet the needs of veteran students. Academics have been examining the reasons Methodology why students choose the colleges that they attend Qualitative methodology was applied because since the middle of the 20th century. This research of the gap in current data related to the veteran initially focused on high school students and population during the college choice process and the impacts of counselors and parents on their the need to develop a theoretical understanding decisions. Over time, the theories have expanded to of the phenomenon. Semistructured interviews examine a broader range of factors and influences following an interview guide were used as the on college choices. In the 1980s, multistage models primary source of data collection. This approach of college choice theory were created, including allowed for flexibility in the interviews and gave Donald Hossler and Karen Gallagher’s college the researcher more opportunities to explore choice theory (Chapman, 1981; Chapman & topics as they emerged. The interview guide in Jackson, 1987; Hanson & Litten, 1982; Hossler & this study was based on several sources: Hossler Gallagher, 1987; Jackson, 1982; Litten, 1982). Since and Gallagher’s college choice theory (1987), it was created, Hossler and Gallagher’s theory has a review of interview guides used in other been used to examine the general population, studies based on the same theoretical framing and in recent years it has been used to study the (McWhorter, 2015), common influencing college choices of specific racial and ethnic groups factors as outlined in the Handbook of Strategic (Hurtado et al., 1997). However, this theory has Enrollment Management (Hossler & Bontrager, yet to be used thoroughly as a theoretical frame to 2014), and unpublished pilot studies (Abbey, explore the factors influencing veterans’ decision- 2016a; Abbey, 2016b) conducted in preparation making related to college choice. for this study. Additionally, as part of the daily A significant amount of research has focused requirements of working at a university and with on veterans in higher education. The majority appropriate approval, the researcher conducted of this research has explored the experiences of document analysis and worked as a participant veterans once they arrive on campus as well as observer with the student veteran population.

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 105 Participants in this study were a convenience in order to group the codes into the major themes sample of 12 student veterans from eight different of the study. Triangulation was used not only to 4-year universities (see Table 1). search for convergence across data sources to The 12 participants included three male support findings but also to note inconsistencies Marine Corps veterans, three female Marine and contradictions in the data (Mathison, 1988). Corps veterans, three male Navy veterans, and Data sources used for triangulation were the three female Navy veterans who were either participants, literature, and data gathered through attending a 4-year university or had attended and document analysis and observation. Member completed a 4-year degree during the Post-9/11 checking was conducted with all participants to GI Bill era, which spans from August 2009 to the further confirm findings and minimize bias. present. In keeping with institutional review board approval for this study, pseudonyms are utilized Findings throughout this article to protect the identities of College Choice Theory the participants. Hossler and Gallagher’s college choice theory All interviews were transcribed and uploaded (1987) was used as the theoretical framing for to NVivo for coding. A variety of first cycle coding this study. The interviews were conducted using methods were used, including initial, in vivo, this theory as a foundational guide. The questions emotion, longitudinal, and value coding (Saldaňa, were divided according to the theory’s three 2012). This initial coding identified the tentative phases: predisposition, search, and choice. The codes by highlighting verbatim quotations predisposition stage is when the student first decides from the interviews that represented emotions, to either attend college or pursue other routes, values, beliefs, knowledge, understandings, and such as entering the workforce or military service. respondents’ experiences through the college The search phase occurs next, once the student has choice process. Once all of the interviews and decided to attend college. In this stage, the student first cycle coding were complete, second cycle gathers information about the potential colleges in coding was conducted using holistic, focused, consideration and adds these colleges to a selection axial, and longitudinal coding (Saldaňa, 2012). pool. The choice stage is when the student applies The second cycle coding process examined both to one or multiple institutions and finally chooses the experiences of the participants as a whole one to attend. over time and the frequency of their experiences

Table 1. Participant Demographics

Name Gender Branch Race First Generation Amber Female Navy Multiracial Yes

David Male Marine Corps White No

Donald Male Navy Multiracial Yes

Hokage Male Marine Corps Black No

Jav Male Marine Corps Hispanic Yes

Jordyn Female Marine Corps White Yes

Kyle Male Navy Multiracial Yes

Lynn Female Navy White No

Melanie Female Navy Mexican Yes

Melinda Female Marine Corps Hispanic No

Persephone Female Marine Corps Hispanic Yes

Scott Male Navy White No

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 106 Predisposition whom participants had previously established All of the participants were veterans of the relationships, or perceived persons of authority. Navy or Marine Corps. However, five of the Persephone, a Hispanic female Marine Corps participants attended college prior to joining veteran attending a for-profit university, used a the military. Two of the five that started college social media platform for female Marines and directly out of high school struggled academically. sought guidance from her colleagues there. She When they did not find initial success in college, said, “I didn’t have an opportunity really to visit they enlisted in the military. Three of the five that places. I talked to other veterans, you know, the started college directly out of high school faced female Marines Facebook page. ‘Hey ladies,’ you additional life circumstances that interfered with know, ‘What have your experiences been at these desired college track. Of the seven participants universities?’” Figures of authority included that entered the military directly, all expressed professors or guidance counselors as well as leaders a desire to go to college. However, many did not in university or college veterans programs. The have the resources to pay for a college education. participants gave significant weight to the input of Additionally, some lacked the social and cultural these trusted relational partners, with some making capital associated with successfully applying to and decisions to apply for and attend a university based accessing college. on the guidance of a single person. Although all of the participants aspired to attend college, they were not always sure how to Choice achieve this goal. Both first-generation college Although most of the participants attended students and students whose parents had college more than one college, all of the participants degrees demonstrated a lack of knowledge about only applied to one university when accessing the college application process. A lack of cultural the institution from which they would ultimately and social capital obstructed these students early strive to attain their 4-year degree. The participants and also influenced some participants’ decisions to decided on the college they wanted to attend, join the military before going to college. confirmed that it had the degree they were seeking, and applied without a backup plan for their Search education. Kyle, a multiracial male Navy veteran This study focused on student veterans at attending a private, nonprofit university, only 4-year universities. However, all but one of the applied to one university, although he was aware participants attended multiple colleges, with that there was a chance he would not be accepted. seven of the 12 participants attending more than He said, “I chose to go with [this university] and two colleges. The search phase for these students I put all my eggs in that basket and took a leap of took many routes: from searching universities in faith and it worked out okay.” high school, to exploring courses offered through The participants in this study decided whether military programs, to starting at a community or not they were going to continue their education college after separating from the military. For at a university prior to applying. For these this study, the researcher examined how the participants, the scope of the choice phase was participants searched for their current university limited to this point. Since each student submitted or the university from which they graduated. an application to only one institution, choosing When exploring which university to attend in between multiple institutions was not part of the order to attain their 4-year degree, the participants process; they did not consider multiple options nor in this study did not conduct in-depth searches. compare them to each other after being admitted. The majority of the participants selected a region For the participants, the search and choice phases or city and then briefly researched local universities were thus blended together into one phase. This using online search engines or websites. When finding is notable because it suggests that a better asked how she searched for her college, Melanie, a theoretical framing could be developed or utilized Mexican female Navy veteran attending a private, to examine how the veteran population accesses nonprofit university, stated, “So I knew I wanted higher education. It appears that the factors that to move to San Diego and I literally just typed in influenced the college choice process for these ‘colleges in San Diego.’” In addition to or in concert participants encouraged them to follow a different with online research, most of the participants course than the one outlined by Hossler and received guidance from trusted relational partners. Gallagher’s college choice theory (1987). Advice came from relatives, other people with

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 107 Themes Influencing Meaning Making for even more difficult, as the participants expressed Veterans During College Choice a lack of understanding of higher education, their Numerous themes emerged throughout the benefits, and how the two systems work together. interview process. Through first and second cycle coding, these were combined and narrowed down Receiving Little Guidance and Lots of to seven major themes: lack of social and cultural Discouragement About Going to College capital, receiving little guidance and lots of Multiple participants expressed that the discouragement about going to college, using and resources available to them while they were seeking out trusted relationships when making actively serving were lacking in quality. In college choices, significant outside responsibilities addition, all of the participants either felt that they while selecting and attending college, joining were not provided guidance along the way or that the military as a means to education, fear and they were discouraged, directly or indirectly, from anxiety during the college choice process, and seeking higher education or certain options. This the influence of location and convenience when deterrence came from multiple sources. Donald, a selecting a college. multiracial male Navy veteran attending a private, nonprofit university, said that the Navy failed to Lack of Social and Cultural Capital inform him fully and completely about all of the All of the participants lacked social and cultural education benefits that were and would be available capital related to higher education. While 62% of to him. He indicated, “So that, I guess was…a veterans are first-generation college students, and failure, you know, on the Navy’s part.” Participants this sample closely mirrored that percentage, the were discouraged directly and indirectly not students that were not first-generation college only by military representatives but also, for two students also lacked capital related to higher participants, by a community college counselor education. For example, Melinda, a Hispanic and a university faculty advisor. For instance, female Marine Corps veteran attending a private, Melinda shared that her assigned faculty advisor nonprofit university, had several family members at her current university was very discouraging. who were college graduates, including her parents. She stated, “He told me I wouldn’t make it. It However, in explaining the steps she took to apply made me angry. I’m an ambitious person and to her current university, she said, “I honestly positive. I always want to achieve success. That’s did not know how to do that crap. I was just like, just my personality. It just made me angry and I why do you do this? And then I had to get these never went back to him.” Despite the participants’ stupid letters of recommendation…I just kinda eventual success, the limited amount of quality went with the motions.” Additionally, all of these resources, lack of guidance, and discouragement students lacked a thorough understanding of how that they described had a negative impact on their their veteran education benefits would work while educational pathways. they were attending college, or they maintained a complete lack of awareness of some benefits. This Using and Seeking Out Trusted Relationships general lack of awareness exacerbated the negative When Making College Choices effects of their lack of social and cultural capital Participants’ decisions to research colleges related to higher education. and ultimately select a college were often based on The deficit of cultural and social capital in the perceived relationships of trust. When asked how veteran population has been discussed significantly they heard about or why they selected a college, in the literature, primarily in relation to the large several of the participants expressed that their portion of the population that is composed of friend told them about the college or their friend first-generation college students. The fact that this attended the college. Participants placed a great lack of capital extends beyond first-generation deal of trust in the thoughts and input of these college students was noted in the pilot studies friends, enough to select the college they finally that preceded this study. In the role of observer, pursued. David, a White male Marine Corps the researcher noted that the staff of the military veteran attending a private, nonprofit university, and veterans program at their university regularly explained, “I got so much more support from peers worked with students who did not know how to and nontraditional advisors than I did from anyone access the university nor what the application whose job it was to help me.” Other times, students timelines were. The addition of complex military developed trusting relationships with professors or education benefits seemed to make this situation counselors on the campuses they were exploring.

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 108 Themes Influencing Meaning Making for even more difficult, as the participants expressed Hokage, a Black male Navy veteran attending a observer. Familial relationships that held the Veterans During College Choice a lack of understanding of higher education, their private, for-profit university, visited the campus he same commitment as blood relationships, strong Numerous themes emerged throughout the benefits, and how the two systems work together. was considering and found trust in a counselor that commitments to extended family, and obligations interview process. Through first and second cycle he consulted. He said, “I walked around the school to causes or beliefs all brought with them significant coding, these were combined and narrowed down Receiving Little Guidance and Lots of then visited a counselor. . . . She was really adamant commitments. The time required to meet the to seven major themes: lack of social and cultural Discouragement About Going to College about the school, so I took a leap of faith. Say just obligations of college, social interactions, formal capital, receiving little guidance and lots of Multiple participants expressed that the gave it a shot.” At times, students found trusted roles, work, family, and more maximized these discouragement about going to college, using and resources available to them while they were relationships in a veterans center on the campus students’ schedules. Given that the researcher had seeking out trusted relationships when making actively serving were lacking in quality. In or in students who were already attending the to probe for answers related to responsibilities, it college choices, significant outside responsibilities addition, all of the participants either felt that they college. In all, 10 of the 12 participants sought out appeared that the participants were not completely while selecting and attending college, joining were not provided guidance along the way or that and placed significant weight in these relationships conscious of how busy they were and how much the military as a means to education, fear and they were discouraged, directly or indirectly, from while going through the college choice process. responsibility they maintained. anxiety during the college choice process, and seeking higher education or certain options. This the influence of location and convenience when deterrence came from multiple sources. Donald, a Significant Outside Responsibilities While Joining the Military as a Means to Education selecting a college. multiracial male Navy veteran attending a private, Selecting and Attending College Nine of the 12 participants explained that they nonprofit university, said that the Navy failed to The study participants fell into the category were able to go to college because they served in Lack of Social and Cultural Capital inform him fully and completely about all of the of nontraditional students. One common the military. Some described how the intangible All of the participants lacked social and cultural education benefits that were and would be available characteristic of many such students is outside drive, confidence, and discipline that they gained capital related to higher education. While 62% of to him. He indicated, “So that, I guess was…a responsibilities. Given that nontraditional while serving allowed them to attempt to seek out veterans are first-generation college students, and failure, you know, on the Navy’s part.” Participants students, like the participants in this study, are higher education. For instance, Kyle shared that this sample closely mirrored that percentage, the were discouraged directly and indirectly not emancipated from their parents and have had the military provided him with the ambition and students that were not first-generation college only by military representatives but also, for two professional careers as well as families of their determination to face challenges like college and students also lacked capital related to higher participants, by a community college counselor own, the influence of these responsibilities is be successful. He stated, “I just feel I have the drive, education. For example, Melinda, a Hispanic and a university faculty advisor. For instance, predictable (Hossler & Bontrager, 2014). the perseverance. I have overcome the adversity. female Marine Corps veteran attending a private, Melinda shared that her assigned faculty advisor All of the participants maintained significant You know, in the military there’s a lot of adversity.” nonprofit university, had several family members at her current university was very discouraging. responsibilities outside of class. Half of the Education is one of the top reasons why who were college graduates, including her parents. She stated, “He told me I wouldn’t make it. It participants were married, and four of them people join the U.S. military today. The benefits However, in explaining the steps she took to apply made me angry. I’m an ambitious person and had children. The majority worked on or off earned through service provide a way for people to her current university, she said, “I honestly positive. I always want to achieve success. That’s campus. Additionally, these participants were very who may not have been able to afford the costs did not know how to do that crap. I was just like, just my personality. It just made me angry and I engaged in the various on-campus student veteran otherwise or who want to avoid being a financial why do you do this? And then I had to get these never went back to him.” Despite the participants’ organizations. These other responsibilities came burden on their families to pay for college. stupid letters of recommendation…I just kinda eventual success, the limited amount of quality with competing time commitments and stress in Additionally, the significant support provided went with the motions.” Additionally, all of these resources, lack of guidance, and discouragement addition to the regular strain of college life. Scott, by military education benefits like the Post-9/11 students lacked a thorough understanding of how that they described had a negative impact on their a White male Navy veteran attending a public, GI Bill expand education options to include their veteran education benefits would work while educational pathways. nonprofit university, said, “I am participating in universities with high attendance costs. When they were attending college, or they maintained a a federal work study and I also hold a leadership Donald was asked if he would be in college complete lack of awareness of some benefits. This Using and Seeking Out Trusted Relationships position in my college’s student veteran organization.” without the GI Bill, he stated, “Absolutely. But not general lack of awareness exacerbated the negative When Making College Choices Many of these responsibilities existed prior to here.” Donald is attending a private university and effects of their lack of social and cultural capital Participants’ decisions to research colleges attending their current university and would studying engineering. Each of the participants in related to higher education. and ultimately select a college were often based on remain upon leaving or graduating. Lynn, a White this study expressed that they would not have The deficit of cultural and social capital in the perceived relationships of trust. When asked how female Navy veteran attending an online, public, been able to attend the university that they were veteran population has been discussed significantly they heard about or why they selected a college, nonprofit university, shared, “You know, I kind of attending or had attended if not for their service in the literature, primarily in relation to the large several of the participants expressed that their anticipated, you know, the stress of, of working in the military and its attendant benefits. portion of the population that is composed of friend told them about the college or their friend full time and going to school full time. It was just first-generation college students. The fact that this attended the college. Participants placed a great a hard thing to learn to balance at first.” When Fear and Anxiety During the College Choice Process lack of capital extends beyond first-generation deal of trust in the thoughts and input of these asked about outside responsibilities, many of the Many of the participants expressed that they college students was noted in the pilot studies friends, enough to select the college they finally participants had to be asked multiple times about gained confidence, discipline, and drive from the that preceded this study. In the role of observer, pursued. David, a White male Marine Corps specific responsibilities before they acknowledged military. Yet, 10 of the 12 participants also voiced the researcher noted that the staff of the military veteran attending a private, nonprofit university, them, as though they had become so routine that substantial fear about the idea of going to college. and veterans program at their university regularly explained, “I got so much more support from peers they forgot that they were still responsibilities and Scott shared, “I was terrified, and it took a couple worked with students who did not know how to and nontraditional advisors than I did from anyone took up a significant portion of their time. years before I finally settled in.” This fear was access the university nor what the application whose job it was to help me.” Other times, students Beyond the participants’ underselling of based on the perceived potential for failure, doubts timelines were. The addition of complex military developed trusting relationships with professors or their outside responsibilities, they also held about their own aptitude, and the lack of a distinct education benefits seemed to make this situation counselors on the campuses they were exploring. responsibilities not readily apparent to the common pathway toward success. It should be noted that

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 109 the two participants that did not experience these settings. The two students that selected and emotions had previously attended college. continued their education at hybrid and online The participants were asked specifically about programs did so because the programs provided the emotions that they felt when going through the the flexibility to move and still continue their college choice process because fear had emerged education. Lynn needed the flexibility of an as a theme in previous pilot studies (Abbey, 2016a; online program. She shared, “It was really just the Abbey, 2016b). It proved to be common again in convenience of, you know, being able to live on this study. Given that this population is departing base, and do that degree on my computer and then a very structured system, the military, and now knowing that I could be sent away for something.” venturing into another system that, as the previous findings in this study show, they know little about, Factors Influencing College Choice it makes sense that there would be a fear of the Over the decades, college choice researchers unknown. The military system provides strict have examined the factors that influence college guidelines in the form of documented standard choice decisions among a variety of populations. operating procedures for everything from daily TheHandbook of Strategic Enrollment Management tasks to career progression. This strict guidance recognizes nine key predictors that influence is missing in the higher education environment. college choice (Hossler & Bontrager, 2014). The As an observer, the researcher witnessed several six factors that were noticeably present in this veterans display anxiety when seeking out a solid study were peer effect, social and cultural capital, pathway or specific answers at the university. This information sources, personal characteristics, anxiety increased when they discovered that the academic ability, and location and convenience. solid answers that they were seeking many times Three factors were missing as influencers in this did not exist. study: family income, high school attended, and cost of attendance and financial aid. The Influence of Location and Convenience When Selecting a College Peer Effect The study participants came from across As described in the previous section’s the nation and represented nine different states. discussion of common themes, peer effect Of the 12 participants, 10 attended colleges in significantly influenced college choice for the regions different from their home region. Many participants in this study. Multiple student veterans expressed that they joined the military as a means made the decision to apply for and attend a given to leave the area or circumstances in which they university based on the suggestion of a peer, found themselves. For instance, Hokage shared, sometimes without any previous knowledge of the “I lived in a really poor neighborhood…Okay. university. Additionally, participants emulated the And that's the only way out. Basically, sports paths taken by respected peers. and the military.” Often, the military represented a socioeconomic opportunity for veterans like Social and Cultural Capital Hokage in the form of a stable income, access The participants in this study lacked social and to higher education prospects, leaving negative cultural capital related to higher education. While surroundings, and more. the majority of the participants were first-generation In searching for and selecting higher college students, social and cultural capital education options, location was a common factor. were also lacking in the participants that were not Scott simply stated, “My current university was first-generation college students. Additionally, all of the closest four year [university]. So, it only the students lacked knowledge related to military made sense geographically and financially.” Of education benefits and how those benefits work the 12 participants, 10 focused their exploration with the variety of higher education institutions. on one region or city. While sometimes they This factor had a negative influence on the college conducted this focused search because they choice process for the participants. did not want to return to their home region, most of the participants had established ties to Information Sources their chosen region, including employment and Hossler and Bontrager’s Handbook of Strategic family commitments. These 10 students attended Enrollment Management (2014) states that “having resident programs where the majority of their information sources that can provide accurate classes were taught in traditional classroom college information is…associated with positive

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 110 college choice outcomes” (p. 54). It can be inferred, expected to move selected programs that allowed in turn, that not having quality information them to travel or move while continuing their sources may have a negative impact on these studies with the same institution, such as online or outcomes. In this study, the participants expressed hybrid programs. and displayed that they lacked information sources: They described the deficiencies in official Three Factors Not Found in This Study military education programs and displayed a Family income, high school attended, and the lack of knowledge about where to access quality cost of attendance are common predictors that information. Like social and cultural capital, this influence college choice (Hossler & Bontrager, factor had a negative impact on the college choice 2014), but they were not observed factors among process for these student veterans. these participants. The participants came from families with varying incomes and socioeconomic Personal Characteristics statuses. However, as nontraditional students, the Studies of college choice as it relates to participants had emancipated from their parents students’ personal characteristics have often and were no longer legal dependents. Although examined differences between male and female family income and cost of attendance did not students. Although gender was examined during affect the colleges participants attended, they were this study, no obvious differences between genders common reasons for joining the military. The were observed. Additionally, no differences participants came from various high schools across were observed between Navy and Marine Corps the nation, but their high schools did not appear veterans. However, veteran status itself appears to affect college choice. Cost of attendance did to be a unique characteristic that influences the not influence college choice for the participants, college choice process, as this paper has so far but some of the students noted that they would outlined. The study participants shared how the not have selected the college they were attending drive, maturity, and confidence they gained while if the cost to attend were not covered by military serving in the military influenced them on their education benefits. path toward attaining their higher education goals. Additionally, emotions of fear and anxiety were Limitations common across most of the participants. The sample used for this study is not representative of the entire veteran population, as Academic Ability it lacks participants from all of the military branches. Academic ability influenced participants’ Additionally, the demographic breakdown does not college choice processes in multiple ways. It most proportionally represent the veteran population directly affected students who were not eligible in terms of gender, ethnicity, race, and more. for some universities because of their grade point Although participants represented multiple 4-year averages and previous performance in college or universities from multiple regions, the sample is high school. In a more common but less direct way, heavily weighted in the southwest region of the the students’ negative perceptions of their own United States and primarily includes resident academic ability and resultant fear and anxiety programs where students attend most of their influenced them to narrow their searches to a courses in classrooms on a physical campus. Lastly, single institution. all participants were highly engaged students on their campuses, which is not representative of all Location and Convenience student veterans and could be connected to some Location and convenience significantly of the homogeneity in their responses. influenced the college choice process for the The researcher’s own social identities and study participants. Participants picked a location positionality must be named and acknowledged and restricted their search to a small region for how they might influence bias related to without considering universities outside of their eliciting biased responses and interpreting chosen location. As outlined previously, these participants’ answers. At the time of the study, the restrictions were based on personal, professional, researcher was a student veteran, first-generation or familial connections to the area. For those college student, veterans’ advocate, and the leader without a tie to their chosen region, convenience of a highly visible military and veterans program replaced relational influence. Participants striving at a large public university. These circumstances to complete their degree on active duty or who motivated the researcher to study this topic and

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 111 influences their views and beliefs connected to consumer can create a more integrated cognitive it. Subjectivity is always an issue in research. At structure that will inform their future research the beginning of all interviews, the researcher and work as a practitioner. announced their veteran status and explained their own personal experience to establish a bond Recommendations with the participants and create openness and Additional steps should be taken by the comfort in the interview process. These efforts Departments of Defense and Veterans Affairs to created an environment of trust that encouraged build active duty service members’ and veterans’ the participants to more quickly open up and share knowledge of the higher education system and their experiences. However, bias and positionality how to successfully access it. Although the general cannot be ignored, despite the efforts taken to nontraditional student population may lack social minimize them. and cultural capital related to higher education, Acknowledging researcher’s subjectivity these students do not have to also determine how related to this study was only one step that was to use complex benefits like the Post-9/11 GI Bill. taken to create awareness and minimize the impact The combination of complex military benefits and of bias. Although only one participant attended a convoluted higher education system exacerbates the university where the researcher worked, it the issue of access and makes this recommendation cannot be ignored that the researcher’s military even more important. background and position at the university had Understanding that active duty and veteran the potential to sway participants’ answers. Sound populations are generally lacking cultural and interview techniques were used to minimize social capital related to accessing higher education, the influence of these factors on the interview it is imperative that the people working with them responses. These included avoiding encouraging in mentorship and guidance roles on college or discouraging responses through voice or body campuses are knowledgeable of all education language. Additionally, member checking was models, how to access them, and how military utilized with the participants to ensure that their education benefits will work or may not work responses were interpreted accurately and not with specific systems. This knowledge is vital misrepresented. when recruiters and outreach specialists focus This was a qualitative study and therefore their efforts within a limited region, as location is not generalizable. However, it still provides and convenience are given significant weight by valuable and actionable data for the consumer. the population they are serving. Providing insight Donmoyer (2000) outlined how a single qualitative into all of the options available and how they are study does have value in providing vicarious similar and different will allow veteran students experience. Through processing this research, the to make more informed decisions when selecting

Figure 1. Study Theme Flow and Opportunity for Intervention Opportunity for Intervention

Significant Outside Fear and Anxiety Joining the Responsibilities During the College Military as While Selecting and Choice Process a Means Receiving Little Attending College to Education Guidance and Lots of Discouragement Student About Going to Veterans' College Using and Seeking The Influence and Lack of Out Trusted Convenience When Social and Relationships Selecting a College Cultural When Making Capital College Choices

Note. The shaded area indicates where opportunities for intervention exist.

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 112 universities to apply for. It is recommended that of the participants had early aspirations of going professionals working in recruitment roles receive to college but either were not initially successful appropriate training and guidance to better in college or utilized the military to mature or understand this information and the best ways to earn resources that would allow them to go to transfer it to their constituents. college. For several participants, the military and Universities and colleges that seek to conduct subsequently college provided an escape from their outreach among or recruit veteran students earlier circumstances. Participants’ overall lack of should ensure that lines of communication are social capital, cultural capital, and guidance added easily accessible and as open as possible. This is burdens to the process. Additionally, the college especially true for campus military and veterans choice process was exacerbated by discouragement programs. Facilitating communication allows and misinformation along the way. Without a potential students to connect and build trust strong understanding of the process or where to with individuals and teams on these campuses. find quality information—and scared of failing— As outlined in this study, trusting relationships the participants sought out perceived trusted carry significant weight as prospective students relational partners for information and guidance. decide which institutions to explore and attend. These relationships were one of the primary Additionally, these professionals can provide contributors to the direction participants would quality information to students who may lack take in searching for and selecting a college. Given information or find themselves confused as they their narrow searches and commitments early in the research universities. process to one institution, the participants limited Recruiters and practitioners on college the amount of risk they took on in their search for campuses need to be aware that student veterans and choice of a college. The college choice process are independent students with significant outside was further limited due to the circumstances that responsibilities. They should communicaterestricted their searches to specific locations. their mindfulness of students’ responsibilities in Colleges and universities are extensions recruiting practices, and steps should be taken to of their communities. By achieving a better address this on campuses. Beyond establishing a understanding of their own roles on and off college or university center for military-connected campus, these institutions can deepen their bond students, additional actions may help student with and understanding of the communities they veterans manage their increased responsibilities, serve and in which they participate. Results from including those associated with their education. this research demonstrate that veterans follow a These steps could include but are not limited to unique path through their college choice journey. childcare options, a commuter center, prioritized Certain distinctive characteristics influence parking privileges, and other things that help veterans’ decision-making as they consider and minimize the load associated with outside ultimately select a college to apply for and attend. responsibilities. With a greater awareness of how veterans make There are multiple opportunities to conduct meaning of the college choice process, college positive interventions along the pathway outlined recruiters and practitioners can open and maintain in this study. An intervention in the form of quality lines of communication while establishing providing quality information or building a relationships of trust with these potential students. positive relationship with veterans could be of This approach will ultimately minimize friction significant benefit. As seen in Figure 1, such an in the process and have a positive impact on the intervention could occur early in prospective campus and surrounding community. Veterans are students’ active duty careers as a counter to the present in all communities across the nation. The discouragement and lack of guidance they receive, recommendations listed provide opportunities for all the way to the point where veterans are deciding community engagement that are often missed by which university to apply for and attend. This type colleges and align with efforts on many campuses to of intervention and community engagement could connect with the nontraditional and independent provide the vital information many veterans are student population. seeking during the college choice process. Having led military and veterans programs at two separate universities, the researcher used Conclusion the data gathered from this research to influence The participants in this study struggled when their work as a practitioner. They implemented a making meaning of the college choice process. All policy of providing student-focused advising to

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 113 potential student veterans and military-connected Circle, K.C. (2017). College choice of veterans: students in both programs. This practice Variables affecting and factors veterans consider included asking the potential students about in choosing their institution of higher education their professional and higher education goals [Doctoral dissertation, Saint Louis University]. and from there recommending quality university ProQuest Dissertations & Theses Global. options that allowed them to efficiently pursue DiRamio, D., Ackerman, R., & Mitchell, R.L. those goals while getting the most out of the (2008). From combat to campus: Voices of student- education benefits they had earned through their veterans. NASPA Journal, 45(1), 73–102. https:// military service. Many times, the researcher and doi.org/10.2202/1949-6605.1908 their staff referred students to other colleges and DiRamio, D., & Jarvis, K. (2011). Veterans in universities. Despite referring students to other higher education: When Johnny and Jane come universities, upon implementing these protocols marching to campus. ASHE Higher Education at the first military and veterans program the Report, 37(3), 1–144. https://doi.org/10.1002/ researcher led, the student veteran population aehe.3703 increased by 30% within the first three semesters Donmoyer, R. (2000). Generalizability and the as student veterans began to refer their peers to single-case study. In R. Gomm, M. Hammersley, & the military and veterans program for guidance on P. Foster (Eds.), Case study method: Key issues, key higher education. By establishing relationships of texts (pp. 45–68). SAGE Publishing. trust and connecting with these students through Hanson, K., & Litten, L. (1982). Mapping the outreach, all of those involved in the process road to academia: A review of research on women, benefited, including student veterans, the campus men, and the college selection process. In P.J. military and veterans program, the university, and Perun (Ed.), The undergraduate woman: ISSUES in the greater community. This campus community educational equity. Lexington Books. was recognized as welcoming to the military Heitzman, A.C., & Somers, P. (2015). The population, and as a result they were trusted and disappeared ones: Female student veterans at a engaged by potential student veterans. Ultimately, four-year college. College and University, 90(4), this unique population of students became active 16–19. university participants once they matriculated, and Hill, R.L. (2016). Factors affecting college choice the university became more highly engaged with and transfer: A study of the decision-making process the surrounding community. of student veterans [Doctoral dissertation, Old Dominion University]. ODU Digital Commons. References https://digitalcommons.odu.edu/efl_etds/9/ Abbey, D. (2016a). Experiences, needs, desires, Hossler, D., & Bontrager, B. (2014). Handbook and motivations of veterans seeking higher education. of strategic enrollment management. John Wiley & [Unpublished doctoral paper]. University of San Sons. Diego. Hossler, D., & Gallagher, K.S. (1987). Studying Abbey, D. (2016b). Factors influencing student college choice: A three-phase model and veterans’ decision making when selecting a college. the implication for policy makers. College and [Unpublished doctoral paper]. University of San University, 62(3), 207–221. Diego. Hurtado, S., Inkelas, K.K., Briggs, C., & Rhee, Ackerman, R., DiRamio, D., & Mitchell, R.L. B.-S. (1997). Differences in college access and choice G. (2009). Transitions: Combat veterans as college among racial/ethnic groups: Identifying continuing students. New Directions for Student Services, barriers. Research in Higher Education, 38, 43–75. 2009(126), 5 –14. https://doi.org/10.1002/ss.311 https://doi.org/10.1023/A:1024948728792 Chapman, D.W. (1981). A model of student Ives, E.J. (2017). Understanding the college college choice. Journal of Higher Education, 52(5), choice process of United States military-affiliated 490–505. https://doi.org/10.1080/00221546.1981.1 transfer students [Doctoral dissertation, University 1778120 of California Los Angeles]. eScholarship. https:// Chapman, R.G., & Jackson, R. (1987). College escholarship.org/uc/item/9w49c7kb choices of academically able students: The influence Jackson, G.A. (1982). Public efficiency and of no-need financial aid and other factors. Research private choice in higher education. Educational monograph no. 10 (ED282467). ERIC. https://files. Evaluation and Policy Analysis, 4(2), 237–247. eric.ed.gov/fulltext/ED282467.pdf https://doi.org/10.3102/01623737004002237

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 114 potential student veterans and military-connected Circle, K.C. (2017). College choice of veterans: Litten, L.H. (1982). Different strokes in the students in both programs. This practice Variables affecting and factors veterans consider applicant pool: Some refinements in a model included asking the potential students about in choosing their institution of higher education of student college choice. The Journal of Higher their professional and higher education goals [Doctoral dissertation, Saint Louis University]. Education, 53(4), 383–402. https://doi.org/10.1080 and from there recommending quality university ProQuest Dissertations & Theses Global. /00221546.1982.11780470 options that allowed them to efficiently pursue DiRamio, D., Ackerman, R., & Mitchell, R.L. Mathison, S. (1988). Why triangulate? those goals while getting the most out of the (2008). 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College and University, 90(4), undergraduate and graduate education (NCES this unique population of students became active 16–19. 2016-435). U.S. Department of Education. https:// university participants once they matriculated, and Hill, R.L. (2016). Factors affecting college choice nces.ed.gov/pubs2016/2016435.pdf the university became more highly engaged with and transfer: A study of the decision-making process Saldaňa, J. (2012). The coding manual the surrounding community. of student veterans [Doctoral dissertation, Old for qualitative researchers (2nd ed.). SAGE Dominion University]. ODU Digital Commons. Publications. References https://digitalcommons.odu.edu/efl_etds/9/ U.S. Department of Veterans Affairs. (2014). Abbey, D. (2016a). Experiences, needs, desires, Hossler, D., & Bontrager, B. (2014). Handbook Education program beneficiaries. https://www. and motivations of veterans seeking higher education. of strategic enrollment management. 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SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 115 Military Culture and Its Impact on Mental Health and Stigma

A. Ganz, Chikako Yamaguchi, Bina Parekh Gilly Koritzky, and Stephen E. Berger

Abstract This article reports two studies that used the Ganz Scale of Identification with Military Culture (GIMC), developed for these studies, to evaluate the relationships between military culture and aspects of mental illness, such as stigma (Study 1), substance use, and trauma (Study 2). The first two authors are veterans of the United States Armed Forces. Study 1 found that active-duty military scored higher on the GIMC total score, and on the component values of duty, selfless service, honor, and personal courage than did a general population sample, but not on the values of loyalty, integrity, and commitment. Level of GIMC endorsement (low, moderate, high), was related to attitudes toward those suffering from mental illness. Additionally, level of GIMC endorsement was found to be either a risk or protective factor toward self-harm and suicide. Study 2 found that service personnel who had sought mental health treatment after joining the military reported less concerns about whether such treatment would hurt their careers than did those who did not seek mental health services. Combined, the results of the two studies indicate that acculturation to the military culture can have positive or negative effects, and mental health stigma and concern about one’s future in the military are impediments to service members obtaining mental health services.

As the wars in Iraq, Afghanistan, and with Alcohol and Substance Related Disorders elsewhere draw on, service members are often (DOD, 2019). This is concerning on account of the surviving what were once lethal incidents. This is ‘healthy soldier effect,’ which suggests that because largely due to improved war fighting technologies recruits are screened prior to enlistment, mental such as enhanced personal and vehicle protection, health rates in the military should be well below along with advances in medical care. The cost civilian norms. Also of concern is the fact that of increased survival of traumatic incidents is many military members do not report their mental represented by the growing number of service health symptoms or substance use issues, and men and women, and their families, who live with therefore go undiagnosed (Dabovich et al., 2019b). physical and behavioral health consequences. For This means that the statistics presented here may example, as of September 10, 2019, since 2001 a represent a small fraction of the military’s actual total of 52,981 military troops were physically mental health burden. wounded in action while deployed (Blum & In addition to elevated mental health diagnoses DeBruyne, 2019). These statistics represent a small in the military, suicide rates are the highest since fraction of those negatively impacted by their data from the recent wars have been collected service. The mental health concerns of service (Orvis, 2019). In 2018, a total of 325 active-duty members and veterans, including suicide, are military members completed suicide (Orvis, 2019), higher than ever experienced in the United States, with the suicide rate varying between 256 and 325 with epidemic levels of suicide, posttraumatic deaths annually since 2012. This represents an stress disorder (PTSD), traumatic brain injuries average of one service member completing suicide (TBIs), and other mental health-related injuries. every 30.5 hours (Orvis, 2019). Unlike physical For example, approximately 8.4% of the wounds, which are often visible and thereby overall military force (ranging from 6.8% to objectively validated, mental health issues and 10.0% across services) were formally diagnosed suicidal ideations are invisible, which means they with a mental health disorder in 2019, which are harder to recognize and validate in both the self accounted for 1.9 million outpatient encounters and others. This invisibility inhibits an individual’s (Department of Defense [DOD], 2019). Of these, willingness to engage in clinical care and 3.8% were formally diagnosed with PTSD, 7.3% community support (i.e., help-seeking behaviors) with anxiety, and 7.5% with depression, and 2.6% in the military, which may otherwise be of benefit.

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 116 Specifically, the reasons include concerns about et al. (2013) documented that military leaders Military Culture and Its Impact being seen as weak, being treated differently, losing believed service members with mental illness were on Mental Health and Stigma the confidence of fellow soldiers, and harming malingering. This skewed view increases stigma their own careers (Zinzow et al., 2013). Other toward help-seeking behavior within the unit, barriers to treatment are associated with issues of which poses a significant barrier to mental health A. Ganz, Chikako Yamaguchi, Bina Parekh trust and confidentiality among the individual, the treatment (Zinzow et al., 2013). Gilly Koritzky, and Stephen E. Berger military health system, and command structures Although the attitude of needing to “tough it (Miggantz, 2013; Quartana et al., 2014; Zinzow et out” or “push through” (Dabovich et al., 2019b) al., 2013), all of which amount to a loss of personal can be problematic to help-seeking behavior in Abstract agency when exposing personal vulnerabilities the military, it must be acknowledged that the This article reports two studies that used the Ganz Scale of Identification with Military Culture (Dabovich et al., 2019a). With these concerns in attitude is adaptive in context and begins during (GIMC), developed for these studies, to evaluate the relationships between military culture and aspects place, many service personnel choose to “tough it basic training (Dabovich et al., 2019a; Hsu, 2010), of mental illness, such as stigma (Study 1), substance use, and trauma (Study 2). The first two authors out” (Miggantz, 2013), which means they ignore when the core values are inculcated. For example, are veterans of the United States Armed Forces. Study 1 found that active-duty military scored higher on their symptoms and hope they will resolve on their the US Army has a core value of “Selfless Service,” the GIMC total score, and on the component values of duty, selfless service, honor, and personal courage own (Miggantz, 2013). Alternatively, some service which encourages putting the unit or the mission than did a general population sample, but not on the values of loyalty, integrity, and commitment. Level members report the practice of self-treatment and before the individual self. The other core values of GIMC endorsement (low, moderate, high), was related to attitudes toward those suffering from mental self-medication is common, which often includes among the military are “Loyalty,” “Duty,” “Respect,” illness. Additionally, level of GIMC endorsement was found to be either a risk or protective factor toward substance misuse (Dabovich et al., 2019b). “Honor,” “Integrity,” “Personal Courage,” and self-harm and suicide. Study 2 found that service personnel who had sought mental health treatment To highlight the extent of these problems, “Commitment” (www.army.mil/values; www.navy. after joining the military reported less concerns about whether such treatment would hurt their careers one study found that of returning service mil). Of these, the greatest barrier to treatment than did those who did not seek mental health services. Combined, the results of the two studies indicate members who screened positive for PTSD, 75% may stem from the core value of Personal Courage, that acculturation to the military culture can have positive or negative effects, and mental health stigma acknowledged they had mental health concerns, which encourages members to face fear, adversity, and concern about one’s future in the military are impediments to service members obtaining mental and only 40% of those were interested in seeking and danger with both physical and moral courage health services. help (Miggants, 2013). This is problematic (U.S. Army Center of Military History, 2011)—all because PTSD is often comorbid and also because of which are necessary for mission success. The As the wars in Iraq, Afghanistan, and with Alcohol and Substance Related Disorders it is widely accepted that early help-seeking degree to which this core value extends to enabling elsewhere draw on, service members are often (DOD, 2019). This is concerning on account of the behavior and interventions for mental health service members to ask for help when facing their surviving what were once lethal incidents. This is ‘healthy soldier effect,’ which suggests that because issues are one of the most reliable predictors of personal fears, adversity, or dangers, remains largely due to improved war fighting technologies recruits are screened prior to enlistment, mental recovery across a wide range of conditions. The underexplored. such as enhanced personal and vehicle protection, health rates in the military should be well below help-seeking barriers faced by military personnel along with advances in medical care. The cost civilian norms. Also of concern is the fact that and the behaviors they espouse suggest further Study 1: GIMC and Military Mental Health of increased survival of traumatic incidents is many military members do not report their mental examination of the military culture and its impact Stigma represented by the growing number of service health symptoms or substance use issues, and on help-seeking behaviors and outcomes. Study 1 was designed to identify the prevalence men and women, and their families, who live with therefore go undiagnosed (Dabovich et al., 2019b). A widely accepted component of the of negative attitudes and beliefs toward mental physical and behavioral health consequences. For This means that the statistics presented here may military culture is to “tough it out,” which has health services among military members who do example, as of September 10, 2019, since 2001 a represent a small fraction of the military’s actual also been described as the inclination to “push not seek mental health treatment. The targeted total of 52,981 military troops were physically mental health burden. through” limitations to achieve mission success sample was active-duty personnel who had not wounded in action while deployed (Blum & In addition to elevated mental health diagnoses (Dabovich et al., 2019a). Failures to “tough it sought mental health services, and an additional DeBruyne, 2019). These statistics represent a small in the military, suicide rates are the highest since out” and “push through”—that is, to unflaggingly sample of civilians (or general population) who fraction of those negatively impacted by their data from the recent wars have been collected perform one’s role in the military—are often had never been in the military was created as a service. The mental health concerns of service (Orvis, 2019). In 2018, a total of 325 active-duty associated with personal failure, weakness, and comparison. The essential component of Study 1 members and veterans, including suicide, are military members completed suicide (Orvis, 2019), therefor vulnerability, which can have devastating was the implementation of the GIMC, constructed higher than ever experienced in the United States, with the suicide rate varying between 256 and 325 psychosocial consequences for the individual, in for this study, along with two other measures that with epidemic levels of suicide, posttraumatic deaths annually since 2012. This represents an addition to the original physical or psychological assess mental health stigma between active-duty stress disorder (PTSD), traumatic brain injuries average of one service member completing suicide trauma (Dabovich et al., 2019a). This attitude, personnel and a non-military civilian sample. (TBIs), and other mental health-related injuries. every 30.5 hours (Orvis, 2019). Unlike physical and the culture it creates, is often strengthened For example, approximately 8.4% of the wounds, which are often visible and thereby by military leaders. For example, a major general Methods overall military force (ranging from 6.8% to objectively validated, mental health issues and (2-star General) at Fort Bliss, Texas, stated, Participants 10.0% across services) were formally diagnosed suicidal ideations are invisible, which means they “I have now come to the conclusion that suicide Samples of active-duty military personnel with a mental health disorder in 2019, which are harder to recognize and validate in both the self is an absolutely selfish act” (National Alliance and individuals from the general population were accounted for 1.9 million outpatient encounters and others. This invisibility inhibits an individual’s on Mental Illness [NAMI], 2012, p. 6). Such a recruited using snowball and purposive sampling. (Department of Defense [DOD], 2019). Of these, willingness to engage in clinical care and response reinforces the notion that psychological A snowball sample technique was used due to 3.8% were formally diagnosed with PTSD, 7.3% community support (i.e., help-seeking behaviors) or emotional suffering is akin to personal failure the close-knit nature of the military group, in an with anxiety, and 7.5% with depression, and 2.6% in the military, which may otherwise be of benefit. within the culture of the military. Indeed, Zinzow attempt to increase the flow of participation and

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 117 maximize authenticity of participants’ inclusion Measures criteria and eligibility (minimize hesitation on the Demographic questionnaire. The demographic part of the participants and maximize authentic questionnaire was included in the e-mail and responses). The two primary authors of this participants need to complete it as part of the online study initiated the snowball samples with their Qualtrics survey. All measures were anonymous personal contacts who then subsequently recruited and no personally identifiable information was additional military participants to complete the collected. The demographic questionnaire asked for survey. The inclusion criteria for Study 1 were the branch of service, the status of service (active, active-duty participants who were at least 18 years reserve, or national guard), rank, age, marital old. There were no restrictions regarding gender, status, number of dependents, occupational status, rank, or ethnicity. and gender. The respondents indicated whether Initial contact with all participants (both they had received treatment for mental health active-duty military and the general population) concerns, believed they needed treatment but did was made via e-mail through personal contacts. not get treatment, or did not need treatment. There were no known connections between Attribution questionnaire. The Attribution military and general population participants, and Questionnaire (AQ-27; Corrigan et al., 2003) was these were two separate snowball samples. The used to assess stigma. The AQ-27 consists of 27 e-mail contained information about informed items regarding attitudes toward individuals with consent, how to access the digital Qualtrics mental illness. Each statement has a 9-point Likert survey, the time requirements of the study, scale answer choice labeled from not at all to very what participation entailed, risks and benefits of much, indicating the respondent’s disagreement or participation, voluntary participation, and where agreement with the attitude toward an individual to seek additional information regarding the study. with mental illness. With permission from the Participants were required to complete the survey author of the AQ-27, the scale was adapted for the and give their consent. The participants were military population to include a vignette that was asked to forward the e-mail to other prospective more representative of mental illness within the participants. Additionally, the recruitment e-mail military culture and values. and a hyperlink to the Qualtrics survey were Scoring AQ-27 consists of using the AQ- posted to a social media website. The goal of 27 Score Sheet, which identifies the questions recruitment was to locate service members who loading onto each of the nine factors (Corrigan had not had professional mental health treatment. et al., 2012). Validity and reliability of the AQ-27 Participants from the general population needed were psychometrically tested by Brown (2008). It to be at least 18 years old, and they could not have was found to have an overall high reliability and any history of service in the United States Armed validity, and to have high convergent validity with Forces. The final active-duty sample was 129 other measures of stigma (Brown, 2008). participants; the final general population sample Self-stigma of mental illness scale–short was 80 participants. The mean age of active-duty form. The respondents completed the Self-Stigma personnel was 26.38 years (SD = 9.26, range 18 to of Mental Illness Scale–Short Form (SSMIS-SF; 60). The general population mean age was 43.65 Corrigan et al., 2012), which consists of 20 items years (SD = 13.07, range 19 to 72). that respondents rated on their level of agreement The sample included participants from the Air on a 9-point Likert scale from I strongly disagree Force (n = 23), Army (n = 18), Marine Corps (n = to I strongly agree. The SSMIS-SF is scored using 86), and Navy (n = 2). The rank breakdowns were: the SSMIS-SF Score Sheet, which identifies which Junior Enlisted (E1-E5; n = 86); Senior Enlisted questions load onto the four subscales: Awareness, (E6-E9; n = 26); Junior Officer (O1-O4;n = 10); Agreement, Application, and Hurts Self. Hurts Self and Senior Officer (O5-O9;n = 6), and one “no refers to whether the application of the stereotype answer.” Of the 129 active-duty participants, 49 to oneself is increasing harmful behavior. The (38%) indicated they had deployed to a combat higher the score, the more the individual endorses zone at least once and 80 (62%) indicated they negative beliefs and attitudes related to mental had never deployed to a combat zone. Twenty-five health stigma. Corrigan et al. (2012) conducted (19%) indicated they had received mental health psychometric analysis on the SSMIS-SF to treatment before serving, 103 (79%) indicated they psychometrically compare it to the original SSMIS, had not received treatment, and one participant and found internal consistency ranged from did not answer the question. α = .65 to α = .87 across the four subscales.

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 118 maximize authenticity of participants’ inclusion Measures Ganz scale of identification with military and the demographic questionnaire, in that criteria and eligibility (minimize hesitation on the Demographic questionnaire. The demographic culture. At the time this research was conducted, order. The total time for survey completion was part of the participants and maximize authentic questionnaire was included in the e-mail and there did not appear to be an existing instrument approximately 15 to 20 minutes. The final page of responses). The two primary authors of this participants need to complete it as part of the online measuring identification with the US military the online Qualtrics survey contained a Debriefing study initiated the snowball samples with their Qualtrics survey. All measures were anonymous culture. Therefore, a scale was created for this Statement that included general information personal contacts who then subsequently recruited and no personally identifiable information was study to address the extent to which the individual about the study and mental health resource additional military participants to complete the collected. The demographic questionnaire asked for endorsed the components of military culture core information in case the study caused any distress survey. The inclusion criteria for Study 1 were the branch of service, the status of service (active, values delineated in the literature (www.army. or participants were interested in seeking services. active-duty participants who were at least 18 years reserve, or national guard), rank, age, marital mil/values; www.navy.mil). The GIMC consists of Also, respondents were notified in the Informed old. There were no restrictions regarding gender, status, number of dependents, occupational status, eight statements that addressed eight core values Consent that their voluntary participation in this rank, or ethnicity. and gender. The respondents indicated whether of the armed forces without naming the value research study would result in a $5.00 donation to Initial contact with all participants (both they had received treatment for mental health on a 5-point Likert scale from Not at All to Very the Wounded Warrior Project for each completed active-duty military and the general population) concerns, believed they needed treatment but did Much. Table 1 shows the list of statements and survey, up to $750.00, as a token of appreciation was made via e-mail through personal contacts. not get treatment, or did not need treatment. corresponding core values. As this was the first for their participation. This study was approved There were no known connections between Attribution questionnaire. The Attribution use of the GIMC, its reliability and validity are by the Argosy University, Southern California military and general population participants, and Questionnaire (AQ-27; Corrigan et al., 2003) was currently unknown. This scale was given to the Institutional Review Board. these were two separate snowball samples. The used to assess stigma. The AQ-27 consists of 27 general population participants to begin to develop Statistical analyses for both studies were e-mail contained information about informed items regarding attitudes toward individuals with a validity indicator. Active- duty personnel scored conducted using the SPSS software (Version 2017) consent, how to access the digital Qualtrics mental illness. Each statement has a 9-point Likert significantly higher than the general population on package. survey, the time requirements of the study, scale answer choice labeled from not at all to very overall GIMC scores, thus supporting the validity what participation entailed, risks and benefits of much, indicating the respondent’s disagreement or of this measure. Study 2: Military Culture and Substance Use participation, voluntary participation, and where agreement with the attitude toward an individual Study 2 was designed to focus on the etiology to seek additional information regarding the study. with mental illness. With permission from the Procedures of substance misuse among service members, Participants were required to complete the survey author of the AQ-27, the scale was adapted for the The prospective participants who accessed as it relates to military culture and help-seeking and give their consent. The participants were military population to include a vignette that was the online Qualtrics Survey were first presented behaviors. asked to forward the e-mail to other prospective more representative of mental illness within the with an Informed Consent page on the screen. participants. Additionally, the recruitment e-mail military culture and values. Participants acknowledged consent by selecting Methods and a hyperlink to the Qualtrics survey were Scoring AQ-27 consists of using the AQ- “yes” at the bottom of the first page of the survey. Participants posted to a social media website. The goal of 27 Score Sheet, which identifies the questions Another way in which participants consented was The respondents were active-duty US Military recruitment was to locate service members who loading onto each of the nine factors (Corrigan by completing the survey. After indicating their service members, aged 18 or older, with at least one had not had professional mental health treatment. et al., 2012). Validity and reliability of the AQ-27 consent to participate, all sample participants year of time in service including boot camp and Participants from the general population needed were psychometrically tested by Brown (2008). It completed the GIMC, the AQ-27, the SSMIS-SF, military occupational specialty school. There were to be at least 18 years old, and they could not have was found to have an overall high reliability and any history of service in the United States Armed validity, and to have high convergent validity with Table 1. GIMC Items and Corresponding Core Values Forces. The final active-duty sample was 129 other measures of stigma (Brown, 2008). participants; the final general population sample Self-stigma of mental illness scale–short Item Statement Core Value was 80 participants. The mean age of active-duty form. The respondents completed the Self-Stigma personnel was 26.38 years (SD = 9.26, range 18 to of Mental Illness Scale–Short Form (SSMIS-SF; Believe in and devote yourself to something or someone; allegiance Loyalty 60). The general population mean age was 43.65 Corrigan et al., 2012), which consists of 20 items to others. years (SD = 13.07, range 19 to 72). that respondents rated on their level of agreement Fulfill obligations to the military, mission, and unit. Duty The sample included participants from the Air on a 9-point Likert scale from I strongly disagree Force (n = 23), Army (n = 18), Marine Corps (n = to I strongly agree. The SSMIS-SF is scored using Trust that all people have done their jobs and fulfilled their duty, Respect 86), and Navy (n = 2). The rank breakdowns were: the SSMIS-SF Score Sheet, which identifies which putting forth their best effort. Junior Enlisted (E1-E5; n = 86); Senior Enlisted questions load onto the four subscales: Awareness, Put the welfare and needs of the nation, the military, and your peers Selfless Service (E6-E9; n = 26); Junior Officer (O1-O4;n = 10); Agreement, Application, and Hurts Self. Hurts Self and subordinates before your own. and Senior Officer (O5-O9;n = 6), and one “no refers to whether the application of the stereotype answer.” Of the 129 active-duty participants, 49 to oneself is increasing harmful behavior. The Live by the military moral code and value system in everything you do. Honor (38%) indicated they had deployed to a combat higher the score, the more the individual endorses Do what is right, legally and morally. Integrity zone at least once and 80 (62%) indicated they negative beliefs and attitudes related to mental had never deployed to a combat zone. Twenty-five health stigma. Corrigan et al. (2012) conducted Face fear, adversity, and danger, with both physical and moral courage. Personal Courage (19%) indicated they had received mental health psychometric analysis on the SSMIS-SF to Exhibit the highest degree of moral character, technical excellence, Commitment treatment before serving, 103 (79%) indicated they psychometrically compare it to the original SSMIS, quality and competence in what I have been trained to do. had not received treatment, and one participant and found internal consistency ranged from did not answer the question. α = .65 to α = .87 across the four subscales. Note. GIMC items were scored on a Likert Scale from Not at all to Very Much.

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 119 no other restrictions. The sample was recruited that consisted of the demographic questionnaire, using snowball sampling for the same reason as along with other questions to identify participants’ specified for Study 1. An initial survey was sent beliefs, attitudes, and behaviors related to aspects of via email to a list of active-duty military personnel mental health, lifestyle, and GIMC. All information from personal contacts for further dissemination was anonymous as no identifying information to their personal contacts. The email included a was obtained. Once the survey was completed by recruitment letter that provided details about the a participant, each respondent received a digital expected time required to fill out the survey. A debriefing statement. Respondents were notified digital form of informed consent was attached to that their voluntary participation in this study the recruitment email and included instructions would result in a $5.00 donation to the Disabled on the SurveyMonkey survey. Completion of American Veterans Charitable Service Trust for the survey on SurveyMonkey indicated that the each completed survey as a token of appreciation informed consent was acknowledged and given by for their participation. This study was approved participants. by the Argosy University, Southern California A total of 90 service personnel completed a Institutional Review Board. portion of the questionnaires, with 81 members responding to every question. Of those 81, 17 Results were men and 64 were women. Three branches of A multivariate analysis was conducted for military service were represented: 2 Navy, 6 Army, gender differences between the military sample and 73 Marines. In terms of years of service, 44 had and general population sample. No significant 1–5 years, 21 had 6–10 years, 9 had 11–15 years, differences were found regarding gender on the and 7 had 16 or more years of service. GIMC (Pillai’s Trace = 1.864, p = .073), AQ-27 factors (Pillai’s Trace = 1.488, p =.162), or the Measures SSMIS-SF subscales (Pillai’s Trace = .228, p = .922). Demographic questionnaire. The demographic A multivariate analysis was also conducted to questionnaire was kept anonymous and did not determine whether age and gender combined collect any personally identifiable information. contributed to any significant differences between The demographic questionnaire asked for branch the military and general population samples on of service, status of service, rank, age, gender, the GIMC, AQ-27, and SSMIS-SF. No significant marital status, military occupation, time in interactions were found for any of the measures service, combat experience, and whether they used. Therefore, further analyses combined the had sought treatment for mental health concerns two genders. Age was assessed as a covariate when prior to or after joining the military, were open to differences were found and was indicated where mental health treatment, were open to physical necessary. health treatment, had used substances (such as alcohol and/or prescriptions prior to joining the Overall Differences between Active-Duty military), or had been diagnosed with or treated Military and General Population on the GIMC for substance-related disorders. Study 1 compared the scores for the general Ganz scale of identification with military population and active-duty military personnel culture. The GIMC (as described above and in on the GIMC, for which the means and standard Table 1) consists of eight statements that address deviations are presented in Table 2. As there was the eight core values of military service. Each a difference in the mean age between the two statement allowed the participant to identify groups (F = 11.201, p = .000), age was used as a their level of agreement with how each core value covariate in these analyses. Analyses of Variance affected their views or beliefs relevant to the (ANOVAs) were analyzed for the GIMC, with the military culture. A 7-point Likert scale was used active-duty military having significantly higher with ratings ranging from Not at All to Very Much scores for overall GIMC (identification with to indicate how each value applied to them. military culture), and the individual core values of Duty, Selfless Service, Honor, and Personal Procedures Courage. Interestingly, the general population had By accessing the survey, participants a statistically significantly higher score on Respect. acknowledged consent to participate. Participants then completed the Informed Consent form, then completed in sequence, the online survey

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 120 no other restrictions. The sample was recruited that consisted of the demographic questionnaire, Table 2. GIMC Statistics for Military vs. General Population using snowball sampling for the same reason as along with other questions to identify participants’ General specified for Study 1. An initial survey was sent beliefs, attitudes, and behaviors related to aspects of Active Duty Population via email to a list of active-duty military personnel mental health, lifestyle, and GIMC. All information from personal contacts for further dissemination was anonymous as no identifying information to their personal contacts. The email included a was obtained. Once the survey was completed by M SD M SD F (1, 197) p (α=.05) recruitment letter that provided details about the a participant, each respondent received a digital expected time required to fill out the survey. A debriefing statement. Respondents were notified Total GIMC 34.65 5.380 31.49 5.584 13.563 .000 digital form of informed consent was attached to that their voluntary participation in this study the recruitment email and included instructions would result in a $5.00 donation to the Disabled Loyalty 4.56 .904 4.50 1.052 - n.s on the SurveyMonkey survey. Completion of American Veterans Charitable Service Trust for Duty 4.69 .905 3.49 1.172 58.838 .000 the survey on SurveyMonkey indicated that the each completed survey as a token of appreciation informed consent was acknowledged and given by for their participation. This study was approved Respect 3.22 1.193 3.66 1.040 7.171 .008 participants. by the Argosy University, Southern California Selfless Service 4.36 .957 3.62 1.083 20.421 .000 A total of 90 service personnel completed a Institutional Review Board. portion of the questionnaires, with 81 members Honor 4.23 .972 3.37 1.056 40.213 .000 responding to every question. Of those 81, 17 Results Integrity 4.56 .839 4.55 .855 - n.s. were men and 64 were women. Three branches of A multivariate analysis was conducted for military service were represented: 2 Navy, 6 Army, gender differences between the military sample Personal Courage 4.57 .818 3.95 .965 10.862 .001 and 73 Marines. In terms of years of service, 44 had and general population sample. No significant 1–5 years, 21 had 6–10 years, 9 had 11–15 years, differences were found regarding gender on the Commitment 4.46 .769 4.36 .875 - n.s. and 7 had 16 or more years of service. GIMC (Pillai’s Trace = 1.864, p = .073), AQ-27 factors (Pillai’s Trace = 1.488, p =.162), or the Note. Active Duty, n= 129. General Population, n=80. n.s. = not significant. GIMC items Measures SSMIS-SF subscales (Pillai’s Trace = .228, p = .922). were scored on a Likert Scale from Not at all to Very Much. Demographic questionnaire. The demographic A multivariate analysis was also conducted to questionnaire was kept anonymous and did not determine whether age and gender combined collect any personally identifiable information. contributed to any significant differences between Further Analyses of GIMC Scores that the only effects were for the attitudes of help The demographic questionnaire asked for branch the military and general population samples on The active-duty service members were and coercion. of service, status of service, rank, age, gender, the GIMC, AQ-27, and SSMIS-SF. No significant classified into GIMC categories of low (total Because significant overall differences were marital status, military occupation, time in interactions were found for any of the measures score ≤ 24), moderate (total score 25–32), and found for the help and coercion factors, pairwise service, combat experience, and whether they used. Therefore, further analyses combined the high (total score ≥ 33) on the GIMC to determine comparisons were conducted to identify which had sought treatment for mental health concerns two genders. Age was assessed as a covariate when whether there were any differences on the separate levels of the GIMC differed from which other levels. prior to or after joining the military, were open to differences were found and was indicated where measures and endorsement of the GIMC. The With regard to the help scale, Table 3 shows that mental health treatment, were open to physical necessary. GIMC was used as an independent variable active-duty military members who were classified health treatment, had used substances (such as with three levels (i.e., high, medium, and low) as having the lowest identification with the military alcohol and/or prescriptions prior to joining the Overall Differences between Active-Duty along with the general population sample. These culture (low GIMC score) endorsed helping military), or had been diagnosed with or treated Military and General Population on the GIMC analyses are reported in the following sections. behaviors (e.g., talking to someone with mental for substance-related disorders. Study 1 compared the scores for the general health problems or helping them seek treatment) Ganz scale of identification with military population and active-duty military personnel Relationship of Levels of GIMC Endorsement to less frequently than both those who scored culture. The GIMC (as described above and in on the GIMC, for which the means and standard the AQ-27 moderate (p = .014) and those who scored high (p Table 1) consists of eight statements that address deviations are presented in Table 2. As there was An analysis was conducted to determine = .000) on GIMC endorsement. Additionally, the the eight core values of military service. Each a difference in the mean age between the two within-group differences of GIMC endorsement active-duty military personnel who were classified statement allowed the participant to identify groups (F = 11.201, p = .000), age was used as a on scores on the AQ-27. Results of a multivariate as having the highest identification with military their level of agreement with how each core value covariate in these analyses. Analyses of Variance analysis revealed a significant difference between culture (high GIMC score) endorsed helping affected their views or beliefs relevant to the (ANOVAs) were analyzed for the GIMC, with the levels of GIMC endorsement among active-duty behaviors more frequently than those who scored military culture. A 7-point Likert scale was used active-duty military having significantly higher military on the linear combination of the AQ-27 moderate (p = .003). Thus, those who scored with ratings ranging from Not at All to Very Much scores for overall GIMC (identification with constructs and the SSMIS-SF scales (Pillai’s Trace the highest in their endorsement of the military to indicate how each value applied to them. military culture), and the individual core values = 2.006, p = .003). culture endorsed helping behaviors higher than of Duty, Selfless Service, Honor, and Personal Follow-up univariate ANOVAs revealed a either the moderate or the lowest endorsers of the Procedures Courage. Interestingly, the general population had significant difference between the level of GIMC military culture. By accessing the survey, participants a statistically significantly higher score on Respect. endorsement on the AQ-27 attitudes of help and Taken together, the findings related to help acknowledged consent to participate. Participants coercion. Means and standard deviations for the and coercion indicated those who identified the then completed the Informed Consent form, three levels of GIMC endorsement and the factors least with the military culture endorsed lower then completed in sequence, the online survey of the AQ-27 are presented in Table 3, showing levels of helping behavior for people with mental

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 121 illnesses, but also endorsed less use of what measure (i.e., SSMIS-SF). Means and standard many would consider coercive behaviors toward deviations for each of the three levels of GIMC people obtaining treatment for mental illnesses endorsement and the subscales of the SSMIS- than did both those who scored moderate (p SF are presented in Table 4. A significant = .004) and those who scored high (p = .005) difference was found between levels of GIMC on GIMC endorsement. Coercive actions with and the SSMIS-SF subscale of Hurts Self. Post regard to treatments for mental illnesses could be hoc analysis revealed active-duty military with involuntary medication, involuntary treatment, the highest GIMC level scored lower than those and medical discharge of personnel with mental endorsing moderate identification with the illnesses. An alternative way to express these military culture with regard to supporting self- findings is that those who identified with higher injurious beliefs about mental illness (Hurts Self levels of endorsement of the military culture subscale; p = .003). The Hurts Self subscale finding endorsed higher ratings of providing help to people indicates active-duty military with moderate with mental illnesses, including actions that many identification with military culture believe if would consider coercive, such as forced treatment they had a mental illness they would be at fault or discharge from service. for having such an illness, and they would be dangerous, unpredictable, and unable to recover Relationship of Levels of GIMC Endorsement or take care of themselves. Those with the highest and the SSMIS-SF endorsement of the military culture asserted less Follow-up univariate ANOVAs were conducted than any other group that these negative beliefs to examine the relationships among the three (i.e., stigmas) would apply to them if they suffered levels of the GIMC and the mental illness stigma from mental illness.

Table 3. Military GIMC Endorsement and AQ-27 Attitudes

Moderate Low GIMC High GIMC GIMC Endorsement Endorsement Endorsement M SD M SD M SD F (2, 121) p (α=.05)

Help 16.20 10.085 21.32 5.588 24.13 3.207 11.856 .000

Coercion 7.00 3.808 13.92 4.663 13.31 4.919 4.408 .014

Note. Low GIMC, n=5. Moderate GIMC, n=25. High GIMC, n=94. AQ-27 items were scored on a Likert Scale from Not at all to Very Much.

Table 4. Military GIMC Endorsement and SSMIS-SF Scales

Moderate Low GIMC High GIMC GIMC Endorsement Endorsement Endorsement M SD M SD M SD F (2, 121) p (α=.05)

Awareness 21.20 2.490 26.16 6.421 25.35 8.475 - n.s. Agreement 20.80 6.099 20.36 5.859 18.93 6.541 - n.s. Application 19.40 6.580 20.36 8.225 17.05 7.286 - n.s. Hurts Self 24.20 5.933 28.24 10.441 21.14 10.367 4.781 .010

Note. n.s. = not significant. SSMIS-SF Subscales were scored on a Likert Scale from I Strongly Disagree to I Strongly Agree.

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 122 Endorsement of GIMC and Substance Use Comparing Service Members Who Did and Did Analyses were conducted to determine if there Not Have Mental Health Treatment after Joining were relationships between endorsement of the the Military military culture (GIMC scale) and the measures Of the 81 respondents, only 8 reported having reflecting substance use. None of those analyses had mental health treatment prior to entering the revealed significant results. military, while 50 reported having had mental health treatment after joining the military. In

Table 5. Means, Standard Deviations, and One-Way Analyses of Variance in Differences Between Service Members Who Sought Treatment and Those Who Did Not after Entering Military

Item Yes No Theme M SD M SD F (1, 77) p (α=.05)

Support within 2.98 1.220 2.19 1.078 8.26 .005 Command

Talking About Struggles 2.14 1.088 2.90 1.399 6.905 .010 is Weak

Exercise as Self-Care 2.32 1.133 1.74 0.999 4.987 .028

Self-medicating 3.46 1.297 4.13 1.147 5.972 .017 emotions

Negative Consequences 2.20 1.010 2.96 1.221 7.644 .007 for personal problems

Unfit for Duty if talk to 2.58 1.180 3.23 1.146 6.035 .011 Chaplain or Psychologist

Asking for help is 2.14 0.969 2.77 0.990 8.239 .005 looked down upon

Experienced lasting effects of traumatic 1.12 0.328 1.39 0.495 7.840 .006 event

Constant worry and 1.12 0.328 1.65 0.486 3.142 .000 anxiety

Note. Total n = 81, Service Members Who Sought Treatment: Yes n = 50; No n = 31. Participants responded to multiple choice questions based on agreeableness.

Table 6. Means, Standard Deviations, and One-Way Analyses of Variance in Relationship of Deployment and Military Culture (GIMC)

Loyalty Commitment Deployed M SD M SD

Yes (n= 38) 3.89 1.351 4.42 0.683

No (n= 45) 3.36 1.264 3.98 0.965

Note. Total n = 83, Service Members Who were Deployed: Yes n = 38; No n = 45. Participants responded to multiple choice questions based on agreeableness.

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 123 particular, some significant differences were shown honorable, and engage in acts of personal courage, on nine questions. The means, standard deviation, the wording is unique to military culture. F, and p values are presented in Table 5. Selfless service is the concept of putting the welfare and needs of the nation, military, peers, and Relationship of the Military Culture (GIMC) subordinates before one’s own. The idea of putting and Deployment an entire nation and military before one’s own needs Deployment is likely what bonds service members together. It is Two significant effects were found on the also possible that identification with this cultural GIMC for those who were deployed compared construct is a barrier to treatment. Identifying to those who were not. The means and standard as having a mental health problem that needs deviations for those two significant differences are treatment is contradictory to this military value. presented in Table 6. It can be seen in Table 6 that Honor is defined as living by the military those who were deployed more highly endorsed moral code and value system. The finding that the the military values of Loyalty (F (1, 81) = 6.54, active-duty military participants rated honor more p = .012) and Commitment (F (1, 81) = 6.54, highly than did the general population participants p = .019) than did those who were not deployed. may be the result of the wording, as it is likely that individuals in the general population who have Discussion strong religious or moral codes or who greatly In general, the results of the current studies value integrity would endorse this construct more support the finding that identification with strongly if it did not uniquely state the military military culture is related to beliefs about seeking moral code. mental health treatment. The military culture Personal courage is defined as facing fear, does not tend to foster an environment that is adversity, and danger with both physical and conducive to seeking mental health services. moral courage. This cultural value is unlikely to Service members are indoctrinated to “tough it be generalizable to the general population but out,” and to identify any sign of a problem as a may be generalizable to law enforcement and first weakness or vulnerability (Hsu, 2010; NAMI, responders; however, it is the basic understanding 2012). Interestingly, we found that those who that military personnel face danger and fear as a reported having obtained treatment since joining way of life. the military report less concern about negative The finding that the general population consequences from the military than those who participants endorsed the construct of respect reported not having mental health treatment. higher than did the active-duty participants This could be due to the fact that their individual may be an artifact of the idea that the military level of distress was strong enough to overcome is defined by a rank structure and power any stigma-related barriers to treatment. differentials. Therefore, lower-ranking individuals may not feel they have experienced respect from Differences between Active-Duty and General higher-ranking individuals. With regard to the Population Participants on GIMC military values identified as loyalty, integrity, and One of the first steps of these studies was commitment, these are not unique to the military to develop some validity data for the GIMC. A culture or lifestyle. Therefore, it makes sense that significant difference was found between the active- there were not statistically significant differences duty military personnel and the general population between the general population participants and participants with regard to the GIMC total score. the active-duty military participants regarding Active-duty military participants endorsed a these values. Our data shows that the military higher overall identification with military culture and the general population share some values than the general population participants, which equally. Specifically, the general population and supports the validity of the GIMC. the military sample both endorsed the same Concerning the individual military cultural (moderate) level of identification with military constructs, active-duty military endorsed those culture values. values that are seemingly more unique to military culture, such as duty, selfless service, honor, Differences between Levels of GIMC Endorsement and personal courage (Hsu, 2010; U.S. Army within Active-Duty Military Center of Military History, 2011). Though the The service members who had the lowest general population participants are likely dutiful, endorsement on the GIMC also had the lowest

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 124 endorsement of seeking help or talking with the service members who identified a moderate others regarding their mental health problems and level of endorsement (WHO, 2014). Additionally, helping them seek treatment. Those with the lowest Thompson et al. (2017) discuss the development identification with military culture may not think of identities while transitioning across major life of the military as a brotherhood and other service events, which include joining military service, members as family to the same extent as those who and that “identity crisis” and “culture shock” identified more strongly with the military culture. can occur when one struggles to adapt to the Consequently, they may not feel as compelled unfamiliar culture (e.g., military culture). They to help a fellow service member, as one would if argue that when an individual feels socially he or she considered that individual similar to isolated and has difficulty immersing in the new a family member. This was consistent with the culture, it can have profound negative effects finding that those with the lowest endorsement on mental and physical health and well-being of identification with military culture also had the (Thompson et al., 2017) lowest endorsement of coercion or using coercive means to force treatment (e.g., involuntary Effects of Having Received Mental Health Treatment medication, hospitalization, or medical discharge). after Joining the Military In contrast, those who endorsed a high level of Those who reported receiving mental health identification with military culture had the highest services after joining the military indicated that level of endorsement of helping behaviors as well they were less likely to use alcohol to deal with as forcing (i.e., coercing) treatment. their problems than service members who did Another significant difference is related to the not seek help, that they felt that the military had epidemic of suicide among military personnel and not been as much of an influence on them to self- veterans (Blum & DeBruyne, 2019; NAMI, 2012). medicate, and that they were more likely to use This study shows that individuals who endorsed physical exercise to “refresh” their minds. They a moderate level of identification with military reported feeling that someone in the chain of culture had a statistically significantly higher command understood them, that seeking mental endorsement of the Hurts Self subscale. TheHurts health services did not likely make them look unfit Self subscale reflects whether the application of for duty, that they were less likely to feel that telling the stereotype toward oneself increases the risk a superior about personal problems may lead to factors for harmful behavior, such as decreased a negative consequence, and that they were less self-esteem, increased depression, and decreased likely to feel that talking to a chaplain or military help-seeking efforts. The Hurts Self subscale psychologist may be perceived as unfit for duty. In consists of items that describe mental instability, addition, they also felt less concerned that asking including being dangerous, unpredictable, at fault for help will be looked down upon. for one’s mental illness, and unable to recover In contrast, those who had not obtained or take care of oneself. The belief that one is treatment after joining the military reported unpredictable, unable to take care of oneself, feeling that such action would be looked down unable to recover, and to blame for the mental upon, would cause them to be seen as unfit for illness could decrease self-esteem and increase duty, that even talking about such problems would depression. Our study suggests that a moderate make them look unfit, and even more so if they level of identification with military culture is talked to the chaplain or a psychologist. equivalent to feeling marginalized or isolated from any culture, which may be a key risk factor Effects of Deployment and the Military Culture for engaging in self-harm or suicidal behaviors (GIMC) and avoiding treatment. Research shows isolation Findings related to those who deployed to a and a lack of cultural identity are risk factors for combat zone and military culture indicate that suicide (Best Practices Advocacy Centre New those who had been deployed at least once indicated Zealand, 2010). The World Health Organization greater endorsement of the military values of (WHO, 2014) identifies a lack of social support loyalty and commitment. However, it is not possible and isolation (i.e., feeling disconnected from one’s to assert whether deployment itself increased their social circle such as partners, family, peers, and endorsement of loyalty and commitment. It is friends) as a contributing factor for suicide. Social possible that deploying to a combat zone would cohesion creates a sense of purpose, security, increase one’s loyalty to the mission, the unit, and connectedness, which may be lacking in and other service members because lives are at

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 125 stake. Therefore, seeking treatment for any mental treatment or medical settings, in conjunction health issues would be contradictory to loyalty and with other suicide risk factor screeners. commitment to others. One positive finding from the research Smith et al. (2008) find that self-reported suggests that service members who obtained symptoms of PTSD were significantly higher treatment after joining the service did not appear among service members with combat exposures to be as affected by treatment-seeking stigma in comparison with service members without than those who did not seek help. Seeking exposures. Moreover, a large longitudinal study treatment decreased self-medicating behaviors. of effects of military service in 2001 indicated that Requiring counseling sessions with mental there was a significant correlation between service health professionals as a routine activity would members who have deployed to combat areas and be beneficial. It would remove much stigma from substance abuse, especially alcohol abuse (Jacobson mental health services by including treatment in et al., 2008). McCabe et al. (2008) identified a rising the same way as any other basic training activity or trend of prescription misuse over the previous 20 medical physical. It is essential for military culture years in the general population of the US. This to mainstream mental health services to address is consistent with our findings from Study 2. issues before they become unmanageable and to A majority of service members who did not or support the well-being of all service members. could not seek mental health-related treatment This research found that job security is a reported using alcohol as coping mechanism. It concern regarding treatment-seeking behaviors. is crucial to recognize that a majority of service Prior to 2008, any mental health treatment had to members endorsed prescription use, which is an be reported for a security clearance, which then increasing problem. The high endorsement of changed in 2008 to no reporting requirement for loyalty and commitment could be contributing mental health treatment by reasons of “combat- to the misuse of substances, as drinking alcohol is related” and family/marital issues (Dingfelder, socially acceptable in the United States and widely 2009). It is important to note that this policy still condoned within the US military. limits which service members qualify for mental health services. Clinical Implications and Recommendations Based on our findings in these studies, those Limitations and Directions for Future Research working with active-duty personnel might want A limitation of the present research is that to be especially sensitive to identification with the a majority of potential participants were from values of military culture. Our findings suggest one branch of service (US Marines). Compared that the moderate endorsement of the military to other branches, the Marines have relatively culture (as reflected in the GIMC) may be a risk low mental illness diagnoses (DOD, 2019). The factor for suicide due to endorsing the Hurts Self relationship between identification with the subscale more than other levels of endorsement military culture and alcohol use may differ among of military culture. Moderate levels of the GIMC the branches of the military. Similarly, the study were also consistent with the themes of lower samples did not represent the genders equally or self-esteem, depression, and other mental health represented the gender breakdown within the risk factors, while high levels of endorsement military. Another limitation is that no independent of loyalty and commitment were associated data were available regarding participants’ actual with increased substance use and misuse of uses of substances. Additionally, although the new prescription medication. Therefore, the military GIMC does not yet have established reliability leaders who have expressed negative views toward and validity, it produced meaningful results in the mental health or who have expressed the opinion present studies. We hope it will be a useful tool for that suicide is a selfish decision (NAMI, 2012) can future work. be educated on the risk and protective factors for Future research may focus on finding ways to self-harm in relation to military culture. Educating overcome barriers to mental health help-seeking the Military Leadership on risk and protective that are introduced by the military culture. This factors for self-harm, especially as it pertains to may be done by highlighting other aspects of this military culture, will hopefully highlight how culture, such as the importance of peer-support mental health treatment contributes to the overall and reliance on peers’ assistance (Caddick et al., mission and readiness of the force. The GIMC 2015; Greden et al., 2010). Military members and can also be used as a screener in mental health veterans may be more willing to seek psychological

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 126 stake. Therefore, seeking treatment for any mental treatment or medical settings, in conjunction help if the therapist is also a veteran (Johnson et al., Blum, D.A. & DeBruyne, N. (2019). American health issues would be contradictory to loyalty and with other suicide risk factor screeners. 2018). If more veterans and service members are War and Military Operations Casualties: Lists and commitment to others. One positive finding from the research provided with psychotherapy, it might reconcile Statistics (CRS Report RL32492). Congressional Smith et al. (2008) find that self-reported suggests that service members who obtained the perception that service members who seek Research Service. https://fas.org/sgp/crs/natsec/ symptoms of PTSD were significantly higher treatment after joining the service did not appear mental health services are incompatible with RL32492.pdf among service members with combat exposures to be as affected by treatment-seeking stigma military culture. Brown, S.A. (2008). Factors and measurement in comparison with service members without than those who did not seek help. Seeking of mental illness stigma: A psychometric exposures. Moreover, a large longitudinal study treatment decreased self-medicating behaviors. Conclusion examination of the Attribution Questionnaire. of effects of military service in 2001 indicated that Requiring counseling sessions with mental Although there are many behavioral programs Psychiatric Rehabilitation Journal, 32(2), 89–94. there was a significant correlation between service health professionals as a routine activity would designed to address mental health concerns of https//doi.org/10.2975/32.2.2008.89.94 members who have deployed to combat areas and be beneficial. It would remove much stigma from service members and promote engagement in Caddick N., Phoenix C., & Smith, B. (2015). substance abuse, especially alcohol abuse (Jacobson mental health services by including treatment in mental health treatment, the rate of mental health Collective stories and well-being: Using a et al., 2008). McCabe et al. (2008) identified a rising the same way as any other basic training activity or problems is high and suicide rates are holding dialogical narrative approach to understand peer trend of prescription misuse over the previous 20 medical physical. It is essential for military culture alarmingly steady. More must be done to address relationships among combat veterans experiencing years in the general population of the US. This to mainstream mental health services to address negative mental health behaviors and substance post-traumatic stress disorder. Journal of is consistent with our findings from Study 2. issues before they become unmanageable and to misuse in the military from a cultural and Health Psychology, 20(3)286–299. https//doi. A majority of service members who did not or support the well-being of all service members. etiological perspective. org/10.1177/1359105314566612 could not seek mental health-related treatment This research found that job security is a This research adds to the body of literature Corrigan, P.W., Markowitz, F.E., Watson, reported using alcohol as coping mechanism. It concern regarding treatment-seeking behaviors. regarding the stigma related to mental health and A., Rowan, D., & Kubiak, M.A. (2003). An is crucial to recognize that a majority of service Prior to 2008, any mental health treatment had to treatment-seeking behaviors among active-duty attribution model of public discrimination towards members endorsed prescription use, which is an be reported for a security clearance, which then military personnel. This article presents a new tool persons with mental illness. Journal of Health increasing problem. The high endorsement of changed in 2008 to no reporting requirement for for evaluating the relationships between military and Social Behavior, 44(2), 162–179. https//doi. loyalty and commitment could be contributing mental health treatment by reasons of “combat- culture and aspects of mental illness, such as org/10.2307/1519806 to the misuse of substances, as drinking alcohol is related” and family/marital issues (Dingfelder, stigma (Study 1), substance use, and trauma (Study Corrigan, P.W., Michaels, P.J., Vega, E., Gause, socially acceptable in the United States and widely 2009). It is important to note that this policy still 2). Using the new Ganz Scale of Identification M., Watson, A.C., & Rusch, N. (2012). Self-stigma condoned within the US military. limits which service members qualify for mental with Military Culture (GIMC), we conducted two of mental illness scale —short form: Reliability and health services. studies to compare how samples from active-duty validity. Psychiatry Research, 199(1), 65–69. https// Clinical Implications and Recommendations military and the general population scored on the doi.org/10.1016/j.psychres.2012.04.009 Based on our findings in these studies, those Limitations and Directions for Future Research GIMC total score and on several values (e.g., duty, Dabovich, P.A., Eliott, J.A., & McFarlane, A.C. working with active-duty personnel might want A limitation of the present research is that selfless service, honor, and personal courage). (2019a). The meanings soldiers attach to health and to be especially sensitive to identification with the a majority of potential participants were from We find that level of GIMC endorsement (low, their impacts on primary health-care utilization values of military culture. Our findings suggest one branch of service (US Marines). Compared moderate, high) was related to attitudes toward and avoidance in an Australian high-risk combat that the moderate endorsement of the military to other branches, the Marines have relatively people with mental illnesses. Additionally, level of unit. Armed Forces & Society, 47(2) https://doi. culture (as reflected in the GIMC) may be a risk low mental illness diagnoses (DOD, 2019). The GIMC endorsement was found to be either a risk org/10.1177/0095327X19852652. factor for suicide due to endorsing the Hurts Self relationship between identification with the or protective factor toward self-harm and suicide. Dabovich, P.A., Eliott, J.A., & McFarlane, A.C. subscale more than other levels of endorsement military culture and alcohol use may differ among Specifically, individuals who identified moderately (2019b). Individuate and separate: Values and of military culture. Moderate levels of the GIMC the branches of the military. Similarly, the study with military culture endorsed a significantly identity re-development during rehabilitation and were also consistent with the themes of lower samples did not represent the genders equally or higher belief of self-harm. Our research finds that transition in the Australian Army. Social Science & self-esteem, depression, and other mental health represented the gender breakdown within the service personnel who had sought mental health Medicine, 222, 265–273. https://doi.org/10.1016/j. risk factors, while high levels of endorsement military. Another limitation is that no independent treatment after joining the military reported less socscimed.2019.01.012 of loyalty and commitment were associated data were available regarding participants’ actual concerns about whether such treatment would Department of Defense. (2019). Health of with increased substance use and misuse of uses of substances. Additionally, although the new hurt their careers than did those who did not the Force. Retrieved from https://health.mil/ prescription medication. Therefore, the military GIMC does not yet have established reliability seek mental health services. The results of the two Reference-Center/Reports/2020/11/24/DoD- leaders who have expressed negative views toward and validity, it produced meaningful results in the studies indicate that acculturation to the military Health-of-the-Force-2019 mental health or who have expressed the opinion present studies. We hope it will be a useful tool for culture can have positive or negative effects, and Dingfelder, S.F. (2009). The military’s war that suicide is a selfish decision (NAMI, 2012) can future work. mental health stigma and concern about one’s on stigma. 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SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 127 Hsu, J. (2010, September). Overview of military Thompson, J.M., Lockart, W., Roach, M.B., culture [Powerpoint slides]. Retrieved from http:// Atuel, H., Belanger, S., Black, T., Castro, C.A., sttpml.org/wp-content/uploads/2014/06/military- Cooper, A., Cox, D.W., de Boer, C., Dentry, culture.pdf S., Hamner, K., Shields, D., & Truusa, T-T. Jacobson, I.G., Ryan, M.A.K., Hooper, T.I., (2017, June 01). Veterans’ Identities and Well- Smith, T.C., Amoroso, P.J., Boyko E.J., Gackstetter, being in Transition to Civilian life – A Resource G.D., Wells, T.S., & Bell, N.S. (2008). Alcohol use and for Policy Analysts, Program Designers, Service alcohol-related problems before and after military Providers and Researchers. Report of the Veterans’ combat deployment. JAMA, 300(6), 663–675. https:// Identities Research Theme Working Group, apps.dtic.mil/dtic/tr/fulltext/u2/a493267.pdf Canadian Institute for Military and Veteran Johnson, T., Ganz, A., Berger, S., Ganguly, A., Health Research Forum 2016. Charlottetown PE: & Koritzky, G. (2018). Service members prefer Research Directorate, Veterans Affairs Canada. a psychotherapist who is a veteran. Frontiers Research Directorate Technical Report. https:// in Psychology, 9, 1068. https://doi.org/10.3389/ www.researchgate.net/publication/324606192_ fpsyg.2018.01068 Veterans%27_Identities_and_Well-being_in_ McCabe, S.E., Cranford, J.A., & West, B.T. Transition_to_Civilian_Life-A_Resource_for_ (2008). Trends in prescription drug abuse and Policy_Analysts_Program_Designers_Service_ dependence, co-occurrence with other substance Providers_and_Researchers use disorders, and treatment utilization: Results U.S. Army Center of Military History. (2011, from two national surveys. Addictive Behaviors, June 26). The seven Army values. Retrieved from 33(10), 1297–1305. https://doi.org/10.1016/j. http://www.history.army.mil/LC/The%20Mission/ addbeh.2008.06.005 the_seven_army_values.htm Miggantz, E.L. (2013). Stigma of mental health World Health Organization. (2014). Preventing care in the military. San Diego, CA: Naval Center suicide: A global imperative. World Health for Combat and Operational Stress Control. Retrieved Organization. Retrieved from https://apps.who.int/ from https://ia801300.us.archive.org/7/items/ iris/bitstream/handle/10665/131056/9789241564779_ StigmaWhitePaper/Stigma%20White%20Paper.pdf eng.pdf?sequence=1 National Alliance on Mental Illness. (2012). Zinzow, H.M., Britt, T.W., Pury, C.L.S., Parity for patriots: The mental health needs of military Raymond, M.A., McFadden, A.C., & Burnette, personnel, veterans, and their families. Arlington, C.M. (2013). Barriers and facilitators of mental VA: National Alliance on Mental Illness. Retrieved health treatment seeking among active-duty Army from https://www.nami.org/getattachment/About- personnel. Military Psychology, 25(5), 514–535. NAMI/Publications/Reports/ParityforPatriots.pdf https://doi.org/10.1037/mil0000015 Orvis, K. (2019). Department of Defense (DoD) quarterly suicide report (QSR) 4th quarter, About the Authors CY 2018. Department of Defense. https://www. All authors are associated with The Chicago dspo.mil/Portals/113/Documents/QSR_CY2018_ School of Professional Psychology. A. Ganz, Psy.D., Q4.pdf is a licensed clinical psychologist and a combat Quartana, P.J., Wilk, J.E., Thomas, J.L., Bray, veteran of the U.S. Army Reserves. C. Yamaguchi, R.M., Olmsted, K.L.R., Brown, J.M., Williams, J, Psy.D., is a clinical psychologist and is a combat Kim, P.Y, Clarke-Walper, K & Hoge, C. W. (2014). veteran of the U.S. Marine Corps. B. Parekh, Ph.D., Trends in mental health services utilization and is a licensed clinical psychologist with an emphasis stigma in US soldiers from 2002 – 2011. American in psychometrics. G. Koritzky. Ph.D., is a cognitive Journal of Public Health, 104(9), 1671–1680. psychologist. S.E. Berger, Ph.D., is a licensed clinical https://doi.org/10.2105/AJPH.2014.301971 psychologist, ABPP, and a forensic psychologist. Smith, T. C., Ryan, M.A.K., Wingard, D.L., Correspondence concerning this article should be Slymen, D.J., Sallis, J.F., & Kritz-Silverstein, D. addressed to A. Ganz, [email protected]. (2008). New onset and persistent symptoms of post-traumatic stress disorder selfreported after deployment and combat exposures: Prospective population based US military cohort study. British Medical Journal, 336(7640), 366–371. https://doi. org/10.1136/bmj.39430.638241.AE

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 128 Benefits of Brazilian Jiu-Jitsu in Managing Post-Traumatic Stress Disorder: A Longitudinal Study

Kelly Weinberger and Tracey Burraston

Abstract The longevity of the United States’ armed conflicts has resulted in a substantial portion of military personnel being at risk for post-traumatic stress disorder (PTSD). Fewer than half of veterans needing mental health services receive treatment for PTSD. For those who do receive treatment, less than one third are receiving evidence-based care. Additionally, one third of first responders develop PTSD. The need for additional treatment options is staggering. Brazilian Jiu-Jitsu (BJJ) is evaluated here as a complementary and alternative method (CAM) that promotes discipline, structure, camaraderie, concentration, and mind-body coordination. These effects are measured in terms of their impact on veterans’ capacity to manage PTSD symptoms. Participants for this longitudinal study include armed-service personnel, veterans, and first responders. There were 32 participants, ranging in ages from 25 to 50 years old, with no prior BJJ training. Participants completed five questionnaires both prior to starting the study and after every 20 hours of BJJ that they completed. All participants initially displayed symptoms of PTSD, which significantly reduced over the course of the study. Participants report that the therapeutic benefits of BJJ practice include assertiveness, self-confidence, self-control, patience, empathy, empowerment, improved sleep, and mindfulness. Qualitative data was used to determine impact of these beneficial capacities to manage PTSD symptoms, and to assess the attractors that allow veterans to initiate and stick with BJJ training in community settings. These findings suggest that the inclusion of opportunities and financial support for veterans to practice BJJ as a form of somatic psychotherapy would be highly beneficial.

Many U.S. veterans suffer from untreated The RAND Center for Military Health Policy post-traumatic stress disorder (PTSD). Long Research reported that only half of returning wait times and overcrowded facilities at U.S. veterans who needed mental health services Department of Veterans Affairs (VA) medical sought help from a provider, and of those receiving centers contribute to this problem, as does the treatment for PTSD, just slightly more than half social stigma regarding mental health. Since of them received minimally adequate treatment the attacks of September 11, 2001, the ensuing (Tanielian et al., 2008). Furthermore, a 2013 report conflicts in Iraq and Afghanistan have contributed from the VA and Department of Defense (DoD) to substantial visible and invisible wounds for states that veterans account for approximately U.S. soldiers. PTSD, which affects approximately 20% of the deaths from suicide in the United 8 million Americans each year, is far from a States, with estimates that 18–22 veterans die from military-only disorder (PTSD: National Center suicide each day. Veterans are also more likely for PTSD, 2018). But veterans have additional than their civilian counterparts to own firearms, challenges when facing this debilitating disorder which is a risk factor for suicide attempts being due to barriers in accessing adequate treatment more successful in this high-risk population. The (U.S. Department of Veterans Affairs, 2015). need for additional community-based treatment PTSD prevalence in returning service members options is therefore crucial. varies depending on wars, eras, and service branch. The use and optimization of non-traditional A 2014 VA study found that of the 60,000 Operation therapies, such as somatic psychotherapy, for Enduring Freedom (OEF) and Operation Iraqi active-duty service personnel, veterans, and first Freedom (OIF) veterans screened for PTSD, 13.5% responders with PTSD can provide this population of study participants screened positive (Dursa et al., with a community support base, structure, physical 2014). In addition, it is estimated that 30% of first fitness, and a means to complete mental, spiritual, responders develop behavioral health conditions and emotional healing. Somatic psychotherapy including, but not limited to, depression and PTSD utilizes the awareness of sensorial experience and (Abbot et al., 2015). embodiment to integrate the mind and body in

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 129 the process of healing (Peña, 2019). The practice Participants completed five questionnaires of martial arts promotes discipline, structure, both prior to starting the study and after camaraderie, self-control, concentration, and every 20 hours of BJJ that they completed. The mind-body coordination. Martial arts are carried following questionnaires were used: Primary Care out through ritualization of combat moves (katas), PTSD Screen (PC-PTSD), Trauma Screening the requirement of respect to the teacher (sensei), Questionnaire (TSQ), Generalized Anxiety to the practice space, and to one another. Martial Disorder 7-item (GAD-7) scale, Patient Health arts also highlight the importance of mindfulness Questionnaire-9 (PHQ-9), Generalized Anxiety meditation and teaching of philosophical Disorder (GAD) Screening Tool. concepts and values such as peace, benevolence, In addition to the quantitative questionnaires humanity, and self-restraint (Nosanchuk & listed above, participants took part in semi- MacNeil, 1989). The therapeutic benefits of structured qualitative interviews throughout martial arts for those experiencing PTSD have the course of the study, with an emphasis on been known to reduce anxiety and depression, discussing how BJJ works to manage PTSD, and while improving psychological well-being (Wang why. Furthermore, an additional qualitative survey et al., 2014). Martial arts are more than just sports was sent out through social media platforms to or avenues to physical fitness; they are paths to veterans across the United States who practiced better physical, mental, emotional, and spiritual Jiu-Jitsu. Recipients were asked if they had health and well-being, and studies find that experienced any of the following benefits from they promote empowerment, self-protection, and practicing Jiu-Jitsu: improved physical fitness, self- self-development (Phillips, 2011). defense skills, confidence, a sense of community, Brazilian Jiu-Jitsu (BJJ) is a form of martial reduced anxiety, increased calmness, structure, arts that has until recently been overlooked in focus, empathy, and improved sleep. terms of its therapeutic benefits for PTSD. Whereas The military-connected author involved in this many martial arts schools teach self-defense, BJJ study participated in the collection, analysis, and is mainly practiced as a combat sport. The aim of interpretation of both quantitative and qualitative BJJ is to bring the fight to the ground, control the data.2 opponent’s movements, and apply a submission hold (Pope, 2019). Although many people have Results of Quantitative Study espoused the psychological and physical benefits Analysis of overall data gathered from the of BJJ, as of 2021 there has been only one formal participants questionnaires are presented in the study on how BJJ reduces symptoms of PTSD1 following charts. Through comparison of the (Willing et al., 2019). Participants in this study spectrum of questionnaire types, we can view the demonstrated clinically meaningful improvements progression of symptoms reported throughout in their PTSD symptoms, decreased symptoms of the length of the study. All participants displayed major depressive disorder, decreased generalized evidence of significant symptoms of PTSD. anxiety, and decreased alcohol use. The present All of the participants' initial scores on study is intended to expand on this earlier work. all surveys demonstrated clinically significant PTSD symptoms. Throughout the study the Methodology questionnaires were repeated every 20 hours of Participants for this longitudinal study BJJ practice. The participants showed marked included 32 armed-service personnel, veterans, and decrease in scores on the questionnaires with first responders who resided in Arizona, who had each subsequent reporting. Figure 1 illustrates the not received previous BJJ training, and whose ages mean scores of all questionnaires for participants ranged from 25 to 50 years. Research for this study with corresponding hour of training completed. has been ongoing since it was first implemented in Further analysis of the individual questionnaires August 2016. The study was initially approved by with mean scores and standard deviations is Columbia University Institutional Review Board. broken down further in subsequent figures. Figure

1PTSD is characterized by four clusters of symptoms: (1) re-experiencing; (2) avoidance symptoms; (3) negative changes in cognitions and mood; and (4) alterations in arousal or reactivity symptoms after exposure to trauma. (Lancaster et al., 2016). 2As part of this Special Edition, research that has been undertaken under primary leadership of service members, veterans, dependents and survivors (SMVDS) students has been selected. Identification of SMVDS role is noted accordingly.

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 130 Figure 1. Mean Scores of Questionaire Data Figure 2. PC-PTSD Score Means with SD

PC-PTSD TSQ GAD-7 PHQ-9 GADQ-IV 0 Hours 20 Hours 40 Hours 60 Hours 4 50

40 3

30 2

20 1 10

0 0 0 Hours 20 Hours 40 Hours 60 Hours 0 Hours 20 Hours 40 Hours 60 Hours

Figure 3. TSQ Score Means with SD Figure 4. GAD-7 Score Means with SD

0 Hours 20 Hours 40 Hours 60 Hours 0 Hours 20 Hours 40 Hours 60 Hours 10 20

8 15

6 10 4

5 2

0 0 0 Hours 20 Hours 40 Hours 60 Hours 0 Hours 20 Hours 40 Hours 60 Hours

Figure 5. PHQ-9 Score Means with SD Figure 6. GADQ-IV Score Means with SD; CI 95%

0 Hours 20 Hours 40 Hours 60 Hours 0 Hours 20 Hours 40 Hours 60 Hours 25 70.00

60.00 20 50.00

15 40.00

10 30.00 20.00 5 10.00 0 0.00 0 Hours 20 Hours 40 Hours 60 Hours 0 Hours 20 Hours 40 Hours 60 Hours

Note. Figures demonstrate the decrease in symptoms/scores according to the various questionnaires through the hours of BJJ completed. The standard deviation is represented on the datapoints.

2 illustrates the PC-PTDS results which decreased 6.67 ± 4.25 at 60 hours. Figure 5 illustrates the 37% from a baseline of 3.5 ± .88 at zero hours, 2.83 mean PHQ-9 scores which decreased 39 % from ± 1.11 at 20 hours, 2.30 ± 1.25 at 40 hours, 1.3 ± a baseline of 14.90 ± 7.38 at zero hours, 10.16 ± 1.34 at 60 hours. Figure 3 illustrates TSQ scores 7.63 at 20 hours, 8.50 ± 6.31 at 40 hours, 5.10 ± which decreased 51% from a baseline of 7.31 ± 2.32 4.9 at 60 hours. Finally, Figure 6 illustrates the at zero hours, 5.75 ± 2.80 at 20 hours, 5.4 ± 2.46 at GAD-IV scores which decreased 49% from a 40 hours, 3.7 ± 2.54 at 60 hours. Figure 4 illustrates baseline of 42.13 ± 17.36 at zero hours, 36.17 ± that the participants' GAD-7 scores decreased 18.36 at 20 hours, 34.30 ± 13.99 at 40 hours, 20.80 52% from a baseline of 12.72 ± 5.57 at zero hours, ± 14.93 at 60 hours. 9.92 ± 5.76 at 20 hours, 8.00 ± 5.72 at 40 hours,

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 131 Results of Qualitative Study of habitual ways of responding and interacting The quantitative results presented above show (Phillips, 2011). that participants who regularly practice BJJ report Prior studies show that the practice of BJJ improved scores in standardized tests that measure can lead to the reduction or elimination of the PTSD symptoms. The purpose of the qualitative frequency of aggressive behavior (Wojdat & part of this study was to determine how BJJ practice Ossowski, 2019). As BJJ trainings teach forms of might support evidence-based therapies for PTSD, engagement appropriate to the situation and level and why the veterans involved in this study were of threat, participants who train learn how to able to stick with the practice in a community deal effectively with emotions rather than falling setting. The qualitative data was extrapolated from into panic. In fact, studies show that long-term multiple group and individual interviews with Brazilian Jiu-Jitsu practice significantly reduces participants through a process based on grounded levels of aggression for both men and women, theory. The authors coded the data, compared and that BJJ is suitable for preventing and treating data and codes, and identified analytic leads and excessive and uncontrolled aggression in social tentative categories to develop through further relations (Wojdat & Ossowski, 2019). Participant data collection (Charmaz & Belgrave, 2015). Both A stated: authors interpreted the data using keywords, and organized participant responses into the following BJJ has definitely decreased my PTSD themes; managing aggression, sublimation, symptoms. I sleep better than I have in submission, empowerment, discipline, social years. I’m less hypervigilant and I have support, and mindfulness. far less aggressive tendencies. I believe In addition, a qualitative survey with five this is due to what I refer to as ‘supervised questions was sent out via social media to veteran mutual aggressive expression’ all BJJ practitioners, prompting 16 responses. The bound together with consent and trust. questions included: Specifically, I can legally express my 1. Are you a veteran of the military or a first aggressive disposition with a partner responder? that gets to practice the same with me. So much in my experience with 2. Do you practice Brazilian Jiu Jitsu? psychiatry involves medications to pacify 3. Do you consider your gym/dojo/academy/ aggression. BJJ feeds and channels the center veteran friendly? aggressive nature in me to be productive. 4. What do you feel makes your center Veteran Sublimation friendly or not friendly? BJJ can be used as an effective tool that 5. How can other centers create a more veteran demonstrates Freud’s concept of sublimation, a friendly atmosphere? process in which socially unacceptable behaviors The authors eliminated one response from a are internally repressed and later channeled participant who did not affirm to be a veteran of into behaviors that can expel aggressive and the military or first responder. The authors then provocative drives in a manner that is socially extrapolated data from the remaining 15 responses acceptable (Collura, 2018). Many definitions of to incorporate suggestions for how BJJ academies violence assume a negative moral judgment and could better encourage, support, and promote the are viewed as fundamentally illegitimate. BJJ veteran community. allows participants to direct aggressive drives towards socially valued goals, including customary Benefits of the Practice of Brazilian Jiu Jitsu norms in times of war, rites of passage and Managing Aggression educational means in various cultures, and various Given the aggressive connotations associated medical, scientific, body care, entertainment, and with some martial arts, it may be counterintuitive other sports practices (Even-tzur & Hadar, 2019). to learn that BJJ is a useful resource for managing Participants reported that they could work the fight-or-flight response associated with through the fight-or-flight response associated with combat-related PTSD. As a philosophically PTSD using BJJ principles, in a manner similar to grounded somatic practice, martial arts training that accomplished by prolonged exposure therapy can be a powerful resource for learning how to (PE). PE is considered to be a highly efficacious and control the body while exploring ways to let go effective treatment for PTSD, ameliorating a wide

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 132 Results of Qualitative Study of habitual ways of responding and interacting variety of related symptoms, including anxiety, mental, emotional, spiritual, and physical The quantitative results presented above show (Phillips, 2011). depression, functional impairment, mild suicidal resources, or pre-conditions, to take action in/on that participants who regularly practice BJJ report Prior studies show that the practice of BJJ ideation, and anger (Brown et al., 2019). BJJ allows one's life and the agency to move forward, that is, improved scores in standardized tests that measure can lead to the reduction or elimination of the participants to explore the mental pathways of the ability to define one's goals and to act on them PTSD symptoms. The purpose of the qualitative frequency of aggressive behavior (Wojdat & “fight or flight” that were set in the military, and (Phillips, 2011). Participant D reported that the part of this study was to determine how BJJ practice Ossowski, 2019). As BJJ trainings teach forms of it re-conditions participants to fight within a set of physical activity associated with BJJ builds physical might support evidence-based therapies for PTSD, engagement appropriate to the situation and level conditions that serve as new “rules of engagement” and psychological strength: and why the veterans involved in this study were of threat, participants who train learn how to (Collura, 2018). able to stick with the practice in a community deal effectively with emotions rather than falling Brazilian Jiu Jitsu requires submission as the I have so much more confidence now setting. The qualitative data was extrapolated from into panic. In fact, studies show that long-term experience of being physically dominated cultivates than I ever did. I feel strong. BJJ teaches multiple group and individual interviews with Brazilian Jiu-Jitsu practice significantly reduces humility and understanding of one’s limits. Tapping balance, control, self-control, empathy, participants through a process based on grounded levels of aggression for both men and women, out is the ultimate admission of defeat because it trust, and faith. I first started Jiu Jitsu for theory. The authors coded the data, compared and that BJJ is suitable for preventing and treating signifies recognition that further application of the self-defense aspect of it. Later on it data and codes, and identified analytic leads and excessive and uncontrolled aggression in social the technique could have led to unconsciousness, became the camaraderie, discipline, and tentative categories to develop through further relations (Wojdat & Ossowski, 2019). Participant injury, or death (Pope, 2019). Participant B stated, all the other things I missed so much data collection (Charmaz & Belgrave, 2015). Both A stated: “In BJJ, you have some control in what would be about the military...I’m clean and sober authors interpreted the data using keywords, and an uncontrolled situation elsewhere, as you can almost five months, I’m in the best shape organized participant responses into the following BJJ has definitely decreased my PTSD tap out at any time.” This act of tapping on your of my life since being out of the military, themes; managing aggression, sublimation, symptoms. I sleep better than I have in training partner’s body with an open hand, is I’m far more confident, and I rarely get submission, empowerment, discipline, social years. I’m less hypervigilant and I have an admission that such techniques have been depressed or anxious. I’d say my quality support, and mindfulness. far less aggressive tendencies. I believe successfully applied, before unconsciousness or of life has improved to a point far beyond In addition, a qualitative survey with five this is due to what I refer to as ‘supervised injury occurs (Pope, 2019). what I ever thought it would. questions was sent out via social media to veteran mutual aggressive expression’ all When reflecting on the experiences in a recent BJJ practitioners, prompting 16 responses. The bound together with consent and trust. tournament, Participant C stated: Brazilian Jiu-Jitsu is goal-directed, providing questions included: Specifically, I can legally express my practitioners with the opportunity to set goals for nutrition, physical training, and scheduling. This 1. Are you a veteran of the military or a first aggressive disposition with a partner I was really concerned with hand-to-hand discipline transfers to everyday life. Participant responder? that gets to practice the same with combat, and I was afraid I was going to me. So much in my experience with lose it. In the military, we answered D also reported that through this empowerment, 2. Do you practice Brazilian Jiu Jitsu? psychiatry involves medications to pacify everything with “kill.” But in Jiu-Jitsu, he was able to return to school and excel due to 3. Do you consider your gym/dojo/academy/ aggression. BJJ feeds and channels the tunnel vision is counterproductive. the tools that he learned from BJJ. “It’s brought center veteran friendly? aggressive nature in me to be productive. You’ve got to be centered and just flow. discipline into my life. If I want something now, I go for it.” 4. What do you feel makes your center Veteran There is no room for ego. You can’t Sublimation friendly or not friendly? get mad because then you’ll just get BJJ can be used as an effective tool that smashed. You have to be controlled. It’s Social Support/Sense of Purpose 5. How can other centers create a more veteran demonstrates Freud’s concept of sublimation, a productive as opposed to destructive. In addition to the physical and psychological friendly atmosphere? process in which socially unacceptable behaviors This has really helped with my road rage. benefits of BJJ, the practice offers social support. The authors eliminated one response from a are internally repressed and later channeled Whenever someone cuts in front of me Participants in this study who experienced participant who did not affirm to be a veteran of into behaviors that can expel aggressive and now, I just take that breath and let it isolation—a classic symptom of PTSD—reported the military or first responder. The authors then provocative drives in a manner that is socially happen. You learn self-control and that that the BJJ unit mimicked the brotherhood that extrapolated data from the remaining 15 responses acceptable (Collura, 2018). Many definitions of you are responsible for your own safety. is traditionally found within the military. The to incorporate suggestions for how BJJ academies violence assume a negative moral judgment and I have far more patience than I used to. camaraderie, support, and accountability to the could better encourage, support, and promote the are viewed as fundamentally illegitimate. BJJ group motivated participants to attend regular veteran community. allows participants to direct aggressive drives The practice of BJJ requires a high degree classes and venture further out into society, towards socially valued goals, including customary of trust and builds confidence while teaching often together. Benefits of the Practice of Brazilian Jiu Jitsu norms in times of war, rites of passage and patience. BJJ encourages practitioners to live in Brazilian Jiu Jitsu provides participants with a Managing Aggression educational means in various cultures, and various the moment and deal with the immediate; when sense of purpose, the lack of which many veterans Given the aggressive connotations associated medical, scientific, body care, entertainment, and participants come onto the mat, they immediately struggle with when transitioning from the military. with some martial arts, it may be counterintuitive other sports practices (Even-tzur & Hadar, 2019). learn what they can and cannot control. It takes Learning BJJ etiquette and techniques involves to learn that BJJ is a useful resource for managing Participants reported that they could work trust, and it takes submission. ritualistic hurdles that participants undergo as their the fight-or-flight response associated with through the fight-or-flight response associated with competence progresses. The “tribal nature” that is combat-related PTSD. As a philosophically PTSD using BJJ principles, in a manner similar to Empowerment, Confidence, and Discipline found within respective BJJ academies demands grounded somatic practice, martial arts training that accomplished by prolonged exposure therapy “Empowerment” was a word that came allegiance, loyalty, and doing ones’ best in order can be a powerful resource for learning how to (PE). PE is considered to be a highly efficacious and up many times during qualitative interviews. to represent the credibility of the BJJ academy control the body while exploring ways to let go effective treatment for PTSD, ameliorating a wide Empowerment has been described as having (Collura, 2018). The representation of the senior

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 133 instructor, their lineage, and the etiquette that is learning how to use skills and strategies to suit the fostered within the respective school also foster students’ own style of practice; brown for refining cultural elements that resembles “mission-focused students’ techniques and learning how to think identity,” which is a core aspect of military culture conceptually; and black for those students who (Collura, 2018). Participant E reported: have achieved the highest levels of practice. The black belt levels are the start of students’ journeys One of the biggest struggles I had of mastery, teaching, and reflection of how the transitioning out of the military, was practice is applied to their daily lives. that I did not have anything to fight Although many practitioners utilize BJJ to for anymore, and I didn’t have that fulfill combative aspirations, practitioners often brotherhood and mission. Jiu-Jitsu, more find that the cultural rituals foster a strong sense than anything else, is a family unit, and of community that encourages healthy social brings that brotherhood back. It helped interactions, promotes understanding of both with reintegration so much. When I first stress and self, and contributes to positive physical went to tournaments, I expected this habits that can mitigate substance abuse as well as animosity from civilians, but everyone sedentary behavior (Collura, 2018). was shaking hands and hugging, which completely blew away the myth of “us Flow versus them.” We are more connected Perhaps one of the primary ways in which BJJ to the civilian community than we have manages PTSD is through the experience of “flow,” ever been. a state that occurs when a person maintains deep focus while performing an activity , becoming one Participants reported that this sense of with the activity while losing consciousness of time brotherhood increased their sense of purpose; as and being detached from the ego (Kohoutková they trained together, they trained harder for each et al., 2018). This flow state is often connected other. As they fought together, they fought harder with intrinsic motivation, and brings feelings of for each other. Participant A stated: happiness, pleasure, and satisfaction (Kohoutková et al., 2018). Participant F said, “We appreciate, It builds a bond between people, which or perhaps more important, get addicted to those is a remedy for isolation. It brings peace freeing moments, because with PTSD they are few and clarity to the mind, builds empathy and far between.” for your classmates and other people, As the practitioner’s competence in BJJ and the benefits to a person struggling progresses, the ritualized moves create muscle from PTSD-related aggression to have memory. To achieve flow state in BJJ, there needs grown in empathy is priceless! Empathy to be a balance between the level of the challenge and forgiveness for yourself, and others, and the grappler’s skill set, which need to match can prevent suicide and pointless acts of (Pope, 2019). Participant G reported: violence against other people. Jiu-Jitsu gives you amazing clarity. When Cultural Rituals I drive home every night, I’m more When military service members or BJJ centered than I’ve ever been. Nothing else practitioners wear their uniforms, it paints a works this way. It helped so much just picture of who they are and what their experiences getting out of my head. I was able to get are, and it symbolizes how they should conduct off all the meds I was prescribed and go themselves (Collura, 2018). Participants found back to school. that putting on their gi (a lightweight, two- piece garment traditionally worn in martial arts, Pope (2019) describes three ways that BJJ pronounced “gee”) with the corresponding belt provides practitioners with the opportunity provides the physical shifts and rituals necessary to embody spirituality. First, the engagement to frame their warrior identity; yet the gi is a in a physical activity reminds practitioners of reminder that BJJ is a sport rather than combat in embodiment of their spirituality and provides the militaristic sense. In BJJ, the various belt colors them with a corrective practice to replace “escapist correspond with certain levels or ranks; white for theology” (Pope, 2019, para. 39). Second, BJJ allows building the foundation of the BJJ practice; blue the practitioner to reach a flow state in which the for developing technical proficiency; purple for

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 134 pursuit of excellence matches the physical and Survey respondents also recommended that psychological challenges of the activity. Third, and gym owners and BJJ instructors who wish to make above all, BJJ teaches humility. their facilities more veteran-friendly consult with other instructors who run veteran-friendly BJJ Making BJJ Veteran Friendly programs and discuss what works, what is needed, Brazilian Jiu Jitsu academies can offer and why. One of the respondents suggested that structure for veterans that enhances the warrior representatives from their own program (not the ethos that was ingrained within service, while program where the study was implemented) be allowing veterans to restructure their perspective involved at every academy across America, no on how their understanding of violence, trauma, matter how small, to encourage veterans to train and combat plays out in civilian life (Collura, by offering free and/or discounted training. 2018). This section examines ways for how martial arts academies might offer more veteran-friendly Conclusion environments. Brazilian Jiu Jitsu promotes growth, encourages During the course of this study, a brief survey socialization, generates exercise, creates a healthy was sent through social media groups to veterans and acceptable outlet to build upon combative across the United States who practice BJJ. Survey identity, and provides a culture that is rooted in questions asked veterans if they considered their familiar notions of hierarchy that give purpose to gym/dojo/academy/center to be veteran-friendly, participants on the mat and subsequently in the and if so, to describe what aspects of the center civilian world (Collura, 2018). were veteran-friendly, and to suggest how other While BJJ does not replace cognitive therapies centers could create veteran-friendly atmospheres. and/or medications, it provides physical, social, Out of the 15 responses to this survey, 100% of psychological, emotional, and spiritual means to respondents considered their respective academies manage the components of PTSD, and it can be a to be veteran-friendly. Respondents reported highly effective form of somatic psychotherapy. As believing that their centers were veteran-friendly Csikszentmihalyi (1990) stated: because they allowed veterans to train alongside other veterans; hired instructors who understood The best moments in our lives are not the PTSD symptoms and offered space or support passive, receptive, relaxing times…The when needed; offered free or discounted training best moments usually occur if a person’s for veterans; provided open mats for veterans; body or mind is stretched to its limits in a permitted veterans to sew military patches on their voluntary effort to accomplish something gis; and were veteran-owned and -operated. difficult and worthwhile (p.2). In addition, survey respondent suggested that gyms could be made more veteran friendly The clinical approaches that are typically by offering safe and supportive environments that pushed at VA facilities can be foreign and avoid stigmatizing persons with PTSD. One survey intimidating for many veterans, compounded participant suggested: with social stigma associated with mental illness and difficulties getting timely and adequate care Just make veterans welcome. Offer a safe (Returning Home, 2014). BJJ offers an alternative place to train and let them know it’s ok means of stress and trauma mitigation that focuses to have physical and mental difficulties on physical fitness, interactions with peers, and this should not hold them back from biological and somatic release, social cultivation, trying something new. Let the veteran and reframing of the warrior identification know it’s not about fighting. It’s about (Collura, 2018). The results from this study show respect for BJJ. that the practice of BJJ is a powerful tool for alleviating the overwhelming symptoms of PTSD. Another survey respondent suggested that Going forward, we suggest that the VA explores gym owners should “treat veterans like everyone how to provide veterans with opportunities and else. They are there to train. Ask about service financial support to practice BJJ as a form of somatic and be a friend.” Respondents also suggested that psychotherapy. The physical and psychological encouraging veterans to assimilate to the culture of benefits of BJJ, along with the camaraderie and the gym at their own pace, would be beneficial. As identity reformation that are essential aspects of would discounted or free training for veterans. reintegration, provide an alternative to the more

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 135 expensive traditional clinical approaches and Lancaster, C.L., Teeters, J.B., Gros, D.F., & dependence on prescription medications. Back, S.E. (2016). Posttraumatic stress disorder: Overview of evidence-based assessment and References treatment. Journal of Clinical Medicine, 5(11), 105. Abbot, C., Barber, E., Burke, B., Harvey, J., https://doi.org/10.3390/jcm5110105 Newland, C., Rose, M., & Young, A. (2015). What's Nosanchuk, T.A., & MacNeil, M.L. (1989). killing our medics? Ambulance service manager Examination of the effects of traditional and modern program, Conifer, CO: Reviving Responders. martial arts training on aggressiveness. Aggressive Retrieved from Reviving Responders: http:// Behavior, 15(2), 153–159. Retrieved from https:// www.revivingresponders.com/originalpaper/ doi.org/10.1002/1098-2337(1989)15:2<153::AID- wdlgreq94vhu8xrxpbvgetg2dv0167 AB2480150203>3.0.CO;2-V Brown, L.A., Zandberg, L.J., & Foa, E.B. (2019). Peña, J.J. (2019). The embodied intersubjective Mechanisms of change in prolonged exposure space: The role of clinical intuition in somatic therapy for PTSD: Implications for clinical practice. psychotherapy. Body, Movement & Dance in Journal of Psychotherapy Integration, 29(1), 6–14. Psychotherapy, 14(2), 95–111. doi: 10.1037/int0000109 Phillips, M.A. (2011). Classical martial arts Charmaz, K., & Belgrave, L.L. (2015). training: A zen approach to health, wellness and Grounded theory. In G. Ritzer (Ed.), The Blackwell empowerment for women. Canadian Woman Encyclopedia of Sociology (pp. 2148-2152). Retrieved Studies, 29(1/2), 67–71. from https://doi.org/10.1002/9781405165518. Pope, M. (2019). Flow with the go: Brazilian Jiu wbeosg070.pub2 Jitsu as embodied spirituality. Practical Theology, Collura, G.L. (2018). Brazilian Jiu Jitsu: A tool 12(3), 301–309. Retrieved from https://doi.org/10 for veteran reassimilation (Doctoral dissertation). Retrieved .1080/1756073X.2019.1595319 from https://scholarcommons.usf.edu/etd/7277 PTSD: National Center for PTSD. (2018, Csikszentmihalyi, M. (1990). FLOW: The October 2). How common is PTSD in adults? U.S. psychology of optimal experience (1st Harper Department of Veterans Affairs. https://www.ptsd. Perennial Modern Classics ed., Harper Perennial va.gov/understand/common/common_adults.asp modern classics). Harper Perennial. Tanielian, T., Jaycox, L.H., Schell, T.L., Department of Veteran Affairs/Department of Marshall, G.N., Burnam, M.A., Eibner, C.,… Defense. (2013). VA/DoD clinical practice guideline Vaiana, M.E. (2008). Invisible wounds: Mental for assessment and management of patients at risk health and cognitive care needs of America's for suicide (Version 1.0). Retrieved from https:// returning veterans. Santa Monica, CA: Rand www.healthquality.va.gov/guidelines/MH/srb/ Corporation. Retrieved from https://www.rand. VADODCP_SuicideRisk_Full.pdf org/pubs/research_briefs/RB9336.html Dursa, E.K., Reinhard, M.J., Barth, S.K., & Wang, F., Lee, E.K., Wu, T., Benson, H., Schneiderman, A.I. (2014). Prevalence of a positive Fricchione, G., Wang, W., & Yeung, A.S. (2014). screen for PTSD among OEF/OIF and OEF/OIF- The effects of tai chi on depression, anxiety, and era veterans in a large population-based cohort. J psychological well-being: A systematic review and Trauma Stress, 27, 542–549. meta-analysis. International Journal of Behavioral Even-tzur, E., & Hadar, U. (2019). Socially Medicine, 21, 605–617. doi:10.1007/s12529-013- accepted violence by “agents of law”: Sublimation 9351-9 of aggression as a model. Aggression and Violent Willing, A.E., Girling, S.A., Deichert, R., Behavior, 47, 21–28. Wood-Deichert, R., Gonzalez, J., Hernandez, Institute of Medicine. Returning Home From D.,…Kip, K. (2019, April 20). Brazilian Jiu Jitsu Iraq and Afghanistan: Assessment of Readjustment training for US service members and veterans with Needs of Veterans, Service Members, and symptoms of PTSD. Military Medicine, 184 (11– Their Families. (2014).Military Medicine, 12), E626-E631. 179(10), 1053–1055. https://doi.org/10.7205/ Wojdat, M., & Ossowski, R. (2019). Comparative MILMED-D-14-00263 analysis of the level’s aggression of women and Kohoutková, J., Masaryk, P., & Reguli, Z. men training Brazilian Jiu - Jitsu in the light of the (2018). The experience of the state of flow in possibilities for therapeutic purposes. Journal of Brazilian Jiu-Jitsu. Ido Movement for Culture. Education, Health and Sport, 9(5), 319–338. Journal of Martial Arts Anthropology, 18(3), 1–6. doi: 10.14589/ido.18.3.1

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 136 expensive traditional clinical approaches and Lancaster, C.L., Teeters, J.B., Gros, D.F., & About the Authors dependence on prescription medications. Back, S.E. (2016). Posttraumatic stress disorder: Kelly Weinberger served in the Military Overview of evidence-based assessment and Police in the United States Army and has a References treatment. Journal of Clinical Medicine, 5(11), 105. master’s degree in psychology, specialization in Abbot, C., Barber, E., Burke, B., Harvey, J., https://doi.org/10.3390/jcm5110105 military psychology from Adler University. Tracey Newland, C., Rose, M., & Young, A. (2015). What's Nosanchuk, T.A., & MacNeil, M.L. (1989). Burraston has a master’s degree in psychology, killing our medics? Ambulance service manager Examination of the effects of traditional and modern specialization in military psychology from Adler program, Conifer, CO: Reviving Responders. martial arts training on aggressiveness. Aggressive University and is pursuing a master’s in clinical Retrieved from Reviving Responders: http:// Behavior, 15(2), 153–159. Retrieved from https:// mental health with a specialization in trauma as www.revivingresponders.com/originalpaper/ doi.org/10.1002/1098-2337(1989)15:2<153::AID- well as a PhD in psychology at Grand Canyon wdlgreq94vhu8xrxpbvgetg2dv0167 AB2480150203>3.0.CO;2-V University. Brown, L.A., Zandberg, L.J., & Foa, E.B. (2019). Peña, J.J. (2019). The embodied intersubjective Mechanisms of change in prolonged exposure space: The role of clinical intuition in somatic therapy for PTSD: Implications for clinical practice. psychotherapy. Body, Movement & Dance in Journal of Psychotherapy Integration, 29(1), 6–14. Psychotherapy, 14(2), 95–111. doi: 10.1037/int0000109 Phillips, M.A. (2011). Classical martial arts Charmaz, K., & Belgrave, L.L. (2015). training: A zen approach to health, wellness and Grounded theory. In G. Ritzer (Ed.), The Blackwell empowerment for women. Canadian Woman Encyclopedia of Sociology (pp. 2148-2152). Retrieved Studies, 29(1/2), 67–71. from https://doi.org/10.1002/9781405165518. Pope, M. (2019). Flow with the go: Brazilian Jiu wbeosg070.pub2 Jitsu as embodied spirituality. Practical Theology, Collura, G.L. (2018). Brazilian Jiu Jitsu: A tool 12(3), 301–309. Retrieved from https://doi.org/10 for veteran reassimilation (Doctoral dissertation). Retrieved .1080/1756073X.2019.1595319 from https://scholarcommons.usf.edu/etd/7277 PTSD: National Center for PTSD. (2018, Csikszentmihalyi, M. (1990). FLOW: The October 2). How common is PTSD in adults? U.S. psychology of optimal experience (1st Harper Department of Veterans Affairs. https://www.ptsd. Perennial Modern Classics ed., Harper Perennial va.gov/understand/common/common_adults.asp modern classics). Harper Perennial. Tanielian, T., Jaycox, L.H., Schell, T.L., Department of Veteran Affairs/Department of Marshall, G.N., Burnam, M.A., Eibner, C.,… Defense. (2013). VA/DoD clinical practice guideline Vaiana, M.E. (2008). Invisible wounds: Mental for assessment and management of patients at risk health and cognitive care needs of America's for suicide (Version 1.0). Retrieved from https:// returning veterans. Santa Monica, CA: Rand www.healthquality.va.gov/guidelines/MH/srb/ Corporation. Retrieved from https://www.rand. VADODCP_SuicideRisk_Full.pdf org/pubs/research_briefs/RB9336.html Dursa, E.K., Reinhard, M.J., Barth, S.K., & Wang, F., Lee, E.K., Wu, T., Benson, H., Schneiderman, A.I. (2014). Prevalence of a positive Fricchione, G., Wang, W., & Yeung, A.S. (2014). screen for PTSD among OEF/OIF and OEF/OIF- The effects of tai chi on depression, anxiety, and era veterans in a large population-based cohort. J psychological well-being: A systematic review and Trauma Stress, 27, 542–549. meta-analysis. International Journal of Behavioral Even-tzur, E., & Hadar, U. (2019). Socially Medicine, 21, 605–617. doi:10.1007/s12529-013- accepted violence by “agents of law”: Sublimation 9351-9 of aggression as a model. Aggression and Violent Willing, A.E., Girling, S.A., Deichert, R., Behavior, 47, 21–28. Wood-Deichert, R., Gonzalez, J., Hernandez, Institute of Medicine. Returning Home From D.,…Kip, K. (2019, April 20). Brazilian Jiu Jitsu Iraq and Afghanistan: Assessment of Readjustment training for US service members and veterans with Needs of Veterans, Service Members, and symptoms of PTSD. Military Medicine, 184 (11– Their Families. (2014).Military Medicine, 12), E626-E631. 179(10), 1053–1055. https://doi.org/10.7205/ Wojdat, M., & Ossowski, R. (2019). Comparative MILMED-D-14-00263 analysis of the level’s aggression of women and Kohoutková, J., Masaryk, P., & Reguli, Z. men training Brazilian Jiu - Jitsu in the light of the (2018). The experience of the state of flow in possibilities for therapeutic purposes. Journal of Brazilian Jiu-Jitsu. Ido Movement for Culture. Education, Health and Sport, 9(5), 319–338. Journal of Martial Arts Anthropology, 18(3), 1–6. doi: 10.14589/ido.18.3.1

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 137 Teaching Military Cultural Competency to Clinicians and Clinical Students: Assessing Impact and Effectiveness Nancy Isserman and James Martin

Abstract Military members, veterans, and their families belong to a unique American subculture. Studies have identified the need for mental health professionals to attain military cultural competency to practice more effectively within this subculture. As an 88-year-old counseling and training agency with a record of service to the military/veteran communities, it was appropriate that Council for Relationships commit to providing training in military culture for its therapists and students. From 2017 to 2019, the course highlighted in this paper was part of an approved Institutional Review Board (IRB) study intended to assess the success of graduate-level instructional activities focused on promoting participants’ military and veteran-related cultural competency. This article includes an evaluation of the 2013–14 four-day training on military culture that preceded the course. In both, the unique cultural factors associated with military and veteran service were addressed within the context of evidence-based behavioral health treatment. A survey of the four-day participant training and qualitative interview follow-ups revealed that information about the military and its impact on veterans and families promoted changes in attitudes, knowledge, and clinical practice for both experienced and newly trained clinicians. These findings were replicated in the three-year evaluation results. This assessment provides valuable insight about military culture training for practicing and future mental health clinicians. Since there is very little information available in the literature on successful military culture competency training, sharing these results with the broader military and academic communities will give others information on the important components of effective training programs for clinicians, thus, potentially improving therapeutic services to these populations.

Introduction service components and various US military Culture Defined branches (i.e., the Air Force, Army, Navy, Marine The culture of an organization is defined Corps, Coast Guard, and newly created Space by its values, customs, rules, traditions, and Force) (Zimmerman et al., 2019). This diversity, unique language (Koenig et al., 2014). Military an amalgamation of overlapping, interrelated and culture, including service specific subcultures, is sometimes conflicting subcultures (Goodale et al., comprised of implicit values and beliefs shared 2012), is supported by the different recruitment and through specific rituals and customs and reflected selection criteria used by the various branches of in organizational traditions. Military culture is the military for meeting personnel levels and skill transmitted through training and experiences that requirements. For example, members of the Marine are integrated into the service members’ mind, Corps are more likely to be younger and serving in body, and spirit, often enduring into civilian life some type of direct combat specialty that requires after completing military service. significant physical capacities, while members of the Air Force are more likely to be older, many Why Military Culture Matters with college degrees, and mostly trained in some Military members, veterans, and their type of technical skill. The Army and Navy are the families belong to a distinct and multidimensional largest branches, and they reflect the widest array American subculture (Martin et al., 2016) defined of occupational specialties required to support by shared values, rules, observances, and routines their varied and numerous missions. (Koenig et al., 2014). Yet this culture is not While there is great diversity among the monolithic (Mackenzie et al., 2018). The diversity various sectors of our armed forces, there are within this military/veteran subculture is reflected implicit cultural values and beliefs shared within in the unique military missions and lifestyle and across all components and service branches. differences within as well as across the various For example, the concept of service before self,

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 138 represents a core military value that stresses assistance have a basic expectation of behavioral Teaching Military Cultural Competency integrity and requires service members to place health providers—that they recognize and to Clinicians and Clinical Students: their duty responsibilities before their own acknowledge their client’s military service and Assessing Impact and Effectiveness personal interests and desires. Many of these core that they appropriately use this knowledge values are ingrained early in military service and to inform treatment (Cogan, 2011; Lighthall, Nancy Isserman and James Martin remain with military members and their families 2010). Service members, veterans, and military/ even after transitioning from military service to veteran-connected family members expect that veteran status. While basic training focuses on providers will have a basic cultural appreciation, training recruits in military values and customs, understanding, and interest in their military/ Abstract no comparable training returns service members veteran-related experiences and how these Military members, veterans, and their families belong to a unique American subculture. Studies to the civilian world when they leave the military experiences may have influenced their lives have identified the need for mental health professionals to attain military cultural competency to practice (Koenig et al., 2014). These values and cultural (and the lives of those they love) both positively more effectively within this subculture. As an 88-year-old counseling and training agency with a record beliefs typically become a part of the veteran’s and negatively (Meyer et al., 2017). They expect of service to the military/veteran communities, it was appropriate that Council for Relationships commit identity. Aspects of this identity, the warrior behavioral health providers to be competent to providing training in military culture for its therapists and students. From 2017 to 2019, the course ethos, and training for success “outside the wire” and caring professionals who are able—when highlighted in this paper was part of an approved Institutional Review Board (IRB) study intended to (outside the base in a combat area or in operational invited—to listen to their experiences, even when assess the success of graduate-level instructional activities focused on promoting participants’ military environments) can lead to behavior that is these stories may be horrific and painful (Martin and veteran-related cultural competency. This article includes an evaluation of the 2013–14 four-day normal in a combat environment but abnormal et al., 2016). Everyone’s life experiences are training on military culture that preceded the course. In both, the unique cultural factors associated in the civilian world. Such behaviors sometimes unique, including the military member/veteran with military and veteran service were addressed within the context of evidence-based behavioral health precipitate a reverse culture shock when veterans experiences. It is critical that behavioral health treatment. A survey of the four-day participant training and qualitative interview follow-ups revealed that return to civilian status (Koenig et al., 2014). providers recognize this and not let their own information about the military and its impact on veterans and families promoted changes in attitudes, personal biases interfere with their understanding knowledge, and clinical practice for both experienced and newly trained clinicians. These findings were The Importance of Military Cultural Competence of a military/veteran-connected client and the replicated in the three-year evaluation results. This assessment provides valuable insight about military Numerous studies have identified the need client’s unique military duty and/or military culture training for practicing and future mental health clinicians. Since there is very little information for behavioral health professionals to acquire life experiences. From the discussions at the available in the literature on successful military culture competency training, sharing these results what is referred to as “military/veteran cultural beginning of the course each year it is clear that with the broader military and academic communities will give others information on the important competence” to effectively engage with this military culture evokes strong feelings in many components of effective training programs for clinicians, thus, potentially improving therapeutic services population (Nedegaard & Zwilling, 2017; of the students. Their lack of familiarity with to these populations. Kilpatrick et al., 2011; Petrovich, 2012; Meyer et people who have served and often their distaste al., 2016). Behavioral health providers who seek for war have frequently given them images of Introduction service components and various US military this cultural competence strive to recognize the veterans that could, if not addressed, impact the Culture Defined branches (i.e., the Air Force, Army, Navy, Marine diversity that exists within the US armed forces client-therapist relationship (Gross, 2019). The culture of an organization is defined Corps, Coast Guard, and newly created Space while at the same time become familiar with In support of these military/veteran by its values, customs, rules, traditions, and Force) (Zimmerman et al., 2019). This diversity, the core values that anchor military/veteran cultural competency goals, the Council for unique language (Koenig et al., 2014). Military an amalgamation of overlapping, interrelated and culture. Culturally-competent clinicians Relationships (CFR), a community-based culture, including service specific subcultures, is sometimes conflicting subcultures (Goodale et al., understand the importance of learning to mental health agency serving the greater comprised of implicit values and beliefs shared 2012), is supported by the different recruitment and recognize how a client’s life experiences and/or Philadelphia region, has taken on the specific through specific rituals and customs and reflected selection criteria used by the various branches of relationships have been impacted by military mission to promote awareness, knowledge, in organizational traditions. Military culture is the military for meeting personnel levels and skill service and/or veteran status (Meyer et al, and the practice of skills related to the mental transmitted through training and experiences that requirements. For example, members of the Marine 2017). This competency includes developing healthcare needs of the military/veteran are integrated into the service members’ mind, Corps are more likely to be younger and serving in an understanding of the basics of military population. CFR’s primary focus is directed body, and spirit, often enduring into civilian life some type of direct combat specialty that requires life and language (Hall 2011) and the impact at improving clients’ (individuals, couples, after completing military service. significant physical capacities, while members of of military lifestyles and military duties on family systems) interpersonal relationships the Air Force are more likely to be older, many behavioral and physical health, especially by providing exemplary “talk” therapy, as well Why Military Culture Matters with college degrees, and mostly trained in some combat-related exposures, family separations, as educating and training clinicians in family Military members, veterans, and their type of technical skill. The Army and Navy are the and various workplace challenges confronting systems approaches1 (B. Hollander-Goldfein families belong to a distinct and multidimensional largest branches, and they reflect the widest array the armed forces—issues like sexual violence, (personal communication, March 10, 2021; American subculture (Martin et al., 2016) defined of occupational specialties required to support addiction, and suicide. Competent behavioral Nichols & Davis, 2016; Gurman et al., 2015), by shared values, rules, observances, and routines their varied and numerous missions. health providers understand that military cultural and by advancing behavioral health practice (Koenig et al., 2014). Yet this culture is not While there is great diversity among the competence promotes improved mental health through research and evaluation. CFR has a monolithic (Mackenzie et al., 2018). The diversity various sectors of our armed forces, there are outcomes for military and veteran clients (Hoge long history as a training center in marriage and within this military/veteran subculture is reflected implicit cultural values and beliefs shared within 2011). family therapy, as well as a distinguished record in the unique military missions and lifestyle and across all components and service branches. Service members, veterans, and military/ of service since the end of World War II to the differences within as well as across the various For example, the concept of service before self, veteran-connected family members seeking military and veteran communities.

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 139 Recognizing the behavioral health needs of Mental Health Care to Veterans and Their Families” veterans and their families in the Philadelphia (Tanielian et al., 2014), reported that only 13% of region, CFR initiated a specific veteran-focused the community-based providers surveyed were initiative in 2007—Operation Home and Healing viewed as ready to deliver high quality, evidenced- (OHH)2—focused on assisting veterans and their based, culturally-competent behavioral health care families by promoting emotional healing and to veterans and their families (Tanielian et al., p. assisting veteran and veteran-connected clients to 18). Following this study, and the impact from the become better partners, parents, family members, OHH training program, CFR made a commitment and community members. In addition to private to provide clients with behavioral health therapists counseling, OHH focuses on promoting military/ who are both knowledgeable about military/ veteran culturally-competent clinical education veteran culture and who utilize CFR’s intake and clinician skill building. While the primary screening procedures to identify veterans and focus is on the veteran (and veteran-connected family members seeking CFR counseling services. family members), services are also available for These CFR program initiatives, coupled with CFR’s those currently serving in the military, and in counseling services that rely on evidenced-based particular, for members of the National Guard treatment modalities, continue to provide a high and other Reserve Component branches and their level of service to military and veteran clients in family members. this region. From the beginning of the OHH program, To accomplish the goal of educating therapists CFR offered a five-hour introductory workshop who are knowledgeable regarding military/veteran in military culture to CFR staff. The CFR culture, CFR made a commitment to require that commitment to clinical training in military/ all students in its Commission on Accreditation veteran cultural competency further evolved for Marriage and Family Therapy Education in 2013–14 because of a four-day mental health postgraduate certificate program receive training training course highlighting military/veteran in military/veteran cultural competency. The first culture. In 2012, CFR received a specific grant 15-hour course was conducted in June 2017. This from The Helen Bader Foundation3 to provide course was made available to all agency staff, as training for clinicians on the topic of military/ well as non-CFR behavioral health clinicians in veteran cultural competency. Over the past the Philadelphia region. Clinical students enrolled several years, and supported by OHH, CFR’s in CFR’s Master’s in Couples and Family Therapy continuing education programs have offered local program at Jefferson University4 were also invited area behavioral health providers educational to participate in this course. The course is based seminars focused on promoting military/veteran on a generic syllabus for introducing therapists cultural competency. to military culture. It is designed for clinicians Around the same time as the four-day who engage in couple and family therapy using behavioral health training program, a study by the a systems perspective and whose clients are not RAND corporation, “Community-Based Provider primarily composed of veterans. Capacity to Deliver Culturally Competent, Quality

1CFR therapists are grounded in the Systemic Model of Therapy. The foundation of Systemic Therapy is an understanding that the psychosocial development of individuals is based on the primary influence of relationships combined with genetic predisposition and innate potential. This approach assumes that the etiology of an individual's emotional problems stems from the quality of family attachment experiences that influence coping and adaptation in adulthood. Psychological difficulties that result from challenging adult experiences are influenced by the developmental history of key relationships that determine the emotional, cognitive, and behavioral functioning of the adult and are expressed within the relationships that are primary in the adult's life. Therefore, Systems Therapy focuses on significant relationships past and present to help individuals work through their difficulties and achieve change. This therapy model is relevant in working with veterans and their families who are best served by focusing on current relationships and family of origin influences to help work through the impact of their military experiences. 2The first author of this paper, CFR’s Director of OHH, created and teaches the Understanding Military Culture course. In addition, with an advisory team she planned the four-day training program. The second author serves on the OHH advisory committee for CFR and was involved in planning the four-day training. 3Subsequent grants to OHH were from this foundation’s successor, The Bader Philanthropies. 4The Couple and Family Therapy Master’s degree program is a unique collaboration between CFR and Thomas Jefferson University’s College of Health Professions. It is a full-time, two-year, 66-credit program, which is modeled on the core curriculum developed by the Commission on Accreditation for Marriage and Family Therapy Education (COAMFTE). CFR administers the program, teaches its courses, and supervises the students in their clinical internships.

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 140 This article discusses both the OHH military/ impact of trauma on veterans and their families; veteran cultural competency continuing education marital and partner relationship challenges; initiatives, as well as the CFR fifteen-hour infidelity; depression; reintegration; and the unique postgraduate course titled Understanding Military issues facing members of the National Guard and Culture and Behavioral Health Treatment for other reservists. Veterans and their Families. In both the continuing A total of 89 clinicians and advanced clinical education initiative, as well as the postgraduate students participated in this training. The majority course, the unique cultural factors associated with (63%) of the clinicians were staff members of the military service and veterans’ status are addressed CFR or students enrolled in CFR’s two postgraduate within the context of evidence-based behavioral programs. The remainder were clinicians in private health treatments. practice or with other local agencies. No other Insights learned from these two principal demographic information was collected on the OHH endeavors are discussed in the hope that they training participants. will add value for those looking to develop and/or Evaluation of the Training Experience enhance their own training efforts. Some of the A year and a half after completion of the limitations of these OHH initiatives are also noted. training program, a survey was sent to 77 of the Finally, there is a discussion of the Council’s plans original 89 participants (those with current/ for moving forward, addressing both the evolving known contact information). The evaluation was nature of military and veteran experiences, as well an initiative of a new OHH director who wanted to as advances in related behavioral health treatments understand the impact of the earlier training. and the impact of these advances on the services The survey was posted on Qualtrics in June offered by the Council. 2015 and included 26 content questions about the training material and sessions along with The Foundation of the CFR Training 10 demographic questions. Survey questions Program — The First Initiative included: whether training met the goals listed; how “Helping Vets Get Help”: A Four-Day Training respondents rated the quality of various training Program in Military Cultural Competency components; and whether the training had an The CFR commitment to offer yearly in-depth impact on their practice. Answers were placed on clinical training in military cultural competency a Likert scale. All answers were tabulated through evolved from a 2013–14 CFR four-day training Qualtrics. Thirty-nine of the participants (roughly course, Helping Vets Get Help: Training Therapists 50%) completed the voluntary self-assessment Who Work with Veterans and Their Families, which survey. In addition to the 39 survey responses, highlighted military culture. nine respondents were interviewed in-person or This intensive training program focused over the phone to gain additional insight into the on enhancing clinician knowledge and skills for training program’s strengths and weaknesses. The serving veterans and their families by educating nine individuals volunteered to be interviewed clinicians on important aspects of military culture from the 39 who participated in the survey. The and about basic behavioral health concerns for interviewees mirrored the original distribution veterans and their families. The training program of agency affiliation between CFR clinicians and presenters were CFR staff as well as national experts its students versus those from other agencies or in military culture, behavioral health problems and private practices. treatments, and aspects of trauma associated with The demographics of the survey participants military service. closely reflected the demographics of the CFR’s staff The goals of the program focused on imparting members who comprised the bulk of the training to participants an understanding of military program attendees. The majority (67%) were culture and structure. Specifically, these clinicians women, while just over half of the attendees (51%), learned about the challenges and the problems were over 55 years old. The rest of the participants facing active-duty service members including were fairly evenly distributed among three age issues associated with post-deployment challenges. categories: 25–35, 36–45, and 46–55 years old. The Since the participants were experienced therapists, racial demographic characteristics of the attendees seminar presenters concentrated on the distinct were: Hispanic (3%), African-American (5%), military aspects of these issues. Topics included and white (92%). Slightly more than half (55%) of challenges facing families and successful treatment survey respondents were employed full-time and approaches; suicide and suicide prevention; the 8% were unemployed.

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 141 The participants were mostly clinicians with for military/veteran status or connections. Thus, master’s or doctoral degrees. Three of the 39 a substantial number of clinicians, over half, respondents were students in the Post Graduate who replied to the survey noted that the training Certificate Program in Couple and Family Therapy changed their clinical behaviors and enhanced or the master’s degree in Couple and Family their interactions with veteran clients and family Therapy at Jefferson University. The majority of members. However, one quarter still were not the participants (59%) held either an MSW/MSS screening clients for military/veteran status or or an MA/MS degree, 2% held a BA degree, and connections. Since CFR, as an agency, screens for 39% either had obtained or were working toward military/veteran status, the respondents who are their doctorate. CFR affiliated may have benefited from this agency- The respondents primarily represent four wide procedure. Further research on the impact of professions: psychologists, social workers, training clinicians may yield additional methods of marriage and family therapists, and psychiatrists. changing clinician attitudes and behaviors. Not surprising given the CFR’s focus on training The survey highlighted specific content and marriage and family therapists, 59% of the techniques that are important to include when respondents were marriage and family therapists presenting new material to clinicians. Moreover, (MFTs). Over half of the MFT respondents the survey responses demonstrated that a well- were not yet licensed as therapists. Licensed designed program can benefit participants with psychologists (21%) and licensed social workers diverse years of experience and professional/ (25%) represented 46% of the total group. A small educational backgrounds. percentage of the survey participants (5%) were psychiatrists and 15% listed other professions Qualitative Interviews (e.g., professional counselor, lawyer, sex therapist, To learn more about the participants’ American Association of Marriage and Family post-training views and to expand on some of the Therapists supervisors). questions asked in the survey, nine respondents Most of the respondents had either been in were interviewed in brief in-person or phone clinical practice less than ten years (51%) or more interviews. These interviewees had indicated on than 20 years (33%). These demographics reflected the survey their willingness to be interviewed, the makeup of CFR: seasoned staff, trainees, and they had attended the full four days of and newly practicing professionals. Most of the training and spoke in very positive terms about respondents (61%) attended all four sessions and the training experience. Selection bias is always almost 80% attended at least three sessions. a factor to consider. However, in this case 90% of all the survey responses from the total agreed Results of the Survey or strongly agreed that the training achieved its Strong majorities, ranging from 87% to 100% educational goals. either agreed or strongly agreed that the training Summary of the Findings from had achieved important educational goals. Given the Qualitative Interviews the range of experience among the participants, The interviewees valued the following the overwhelming support for the effectiveness and characteristics of the training program: the appropriate level of training is remarkable. This clarity and quality of the military and academic finding may be the result of a lack of knowledge on presenters; the videos about military experiences this topic among all the participants regardless of especially on the effects of war and combat; and experience. It also may be a result of the training information that enhanced their understanding decision to assume that the participants were of the deployment experience and the effects of experienced clinicians and to focus the training these experiences on the family. Information about on the unique clinical challenges presented by basic military structures, the different branches military/veteran populations. and vocabulary, and the unique aspects of more The evaluation findings suggested that the recent wars was also seen as helpful. Specific training changed the professional behavior of implications for clinicians, such as how aspects of many of the attendees, with 61% indicating that Posttraumatic Stress Disorder (PTSD) may differ they had changed their own practice activities to for this particular population, and information on encourage military members, veterans, and their the impacts on families, specifically the impact of families to use their services. A slightly smaller multiple deployments, were all noted as important number (54%) said that they now regularly screen information for clinical practice.

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 142 The evaluation of CFR’s 2013–14 training as MFTs. Participant ages ranged from early helped CFR structure its new course on adulthood to middle age. The course was open understanding military culture. The survey to master’s students in the CFR training program highlighted content and techniques that were and students in Jefferson University’s Couple and important to include when presenting material Family Therapy course. Some CFR staff clinicians on this topic to clinicians. Moreover, the survey also participated in the annual course, as did several and interview responses demonstrated that a non-CFR therapists over the course of three years. well-designed program can benefit participants There were five main goals of the course. First, with varying years of experience and professional/ to identify and examine potential military-related educational backgrounds. prejudices and biases. Second, to understand the impact of military culture on service members, The Second Initiative, Understanding Military veterans, and/or military connected family Culture and Behavioral Health Treatment for members and their sense of self, others, and Active Military/Veterans and Family Members, worldview. Third, to identify how a military ethos Deepens the Training Experience may contribute to stress, stigma, help-seeking, and This training experience was a 15-hour behavioral health behaviors. Fourth, to analyze minicourse in the Post Graduate Certificate particular military duty and lifestyle stressors Program in Marriage and Family Therapy related to behavioral health issues. And fifth, accredited by the Commission on Accreditation to explore the research on problems related to for Marriage and Family Therapy Education military service and identify the unique behavioral (COAMFTE). The course offered 15 continuing health needs of military/veteran personnel and education credits to licensed behavioral health military connected family members. clinicians. The course focused on the unique cultural The course focused on the unique cultural factors associated with military service and factors associated with military service and veteran’s status with regard to establishing and veteran’s status in the context of behavioral health sustaining effective clinical relationships. The role treatment. The acute and chronic stressors that of both acute and chronic stressors that accompany often accompany military duties and lifestyle, military life and reintegration into civilian life and the challenges associated with veteran were examined. The tension between empathy and reintegration into civilian life were examined vulnerability within the therapeutic relationship, within a framework of clinical behavioral health as well as a culture in which vulnerability and help- practice. The tension between empathy and seeking are often perceived to be stigmatizing, vulnerability within the therapeutic relationship, was explored to identify the potential client and and a culture in which vulnerability and help- systemic barriers clinicians often face in providing seeking are often perceived to be stigmatizing, was mental health counseling to this population. explored during the course in order to identify Each year a small number of postgraduate potential client and systemic barriers clinicians students enrolled in the course for credit (nine face in treating this unique and diverse population. in 2017, six in 2018, and four in 2020). Over the Topics included stressors related to the military three years the total enrollment for all three classes, deployment cycle, reintegration, women in the including auditors, was 35.5 service, as well as post-deployment challenges, The course included an evaluation component grief and loss, suicide, moral injury, military sexual (part of an IRB-sanctioned study6) intended to trauma, PTSD, traumatic brain injury, intimate examine the success of graduate-level instructional partner violence, substance use disorder, and activities that focused on promoting participants’ intergenerational trauma through the lens of the military and veteran-connected cultural impact of military culture and experiences. competency in preparation for clinical practice. The evaluation study included a pre- and postmilitary The students were behavioral healthcultural competency checklist, a participant focus professionals, mostly at the master’s level, and from group, and a follow-up qualitative interview various disciplines seeking to become credentialed six months later. Students participated in class

5Specifically, in 2017 enrollment was 11; in 2018 it was 14; in 2019 it was 10. 6Both IRB projects in this article were approved by Bryn Mawr College, Bryn Mawr, PA.

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 143 discussions at the end of the course that centered The CDP self-assessment bias checklist was on their perceptions of how various components intended to reflect stereotypic images about the of the course influenced changes in their personal/ military and service members and their families. professional views regarding a range of military These items were meant to challenge current beliefs and veteran issues. In addition, the six-month and attitudes. In the second year of the course the follow-up interview explored the impact of the checklist was slightly modified to better relate to course experience on the clinician’s subsequent the material in the course. practice behaviors. Each year the findings from this multidimensional assessment have been used Findings: The Survey Instrument to modify the subsequent years’ course materials. Self-Assessment Test for Bias The CDP self-assessment checklist, originally Methodology intended as a quantitative measure of change in As previously noted, three evaluation attitudes toward the military, did not provide useful instruments were used in the class each year to information (even when tailored in the second year measure the impact of the course on participants’ of the course to better fit the course material). The knowledge about military culture and their original bias checklist items reflected stereotypic comfort with counseling veterans. images about the military, service members and The bias checklist was developed by the their families, beliefs about war and were meant Center for Deployment Psychology (CDP) and to challenge beliefs and attitudes about them. The used in their online course, Military Culture: Core items did not reflect the material covered in the Competencies for Health Professionals (Center for course and so did not illuminate potential bias that Deployment Psychology, n.d.) The CDP created clinicians could hold that could interfere with the this self-assessment checklist to enable healthcare client-clinician relationship. This lack of usefulness providers to identify the assumptions they bring to as a quantitative measure was also experienced by their work with the military or veteran community educators at the CDP and the measure has not been with the goal of shifting implicit bias about military further developed. However, in all three years the culture to explicit awareness.7 statements of bias on the checklist did stimulate As part of the CFR training, the first time useful class discussions around stereotypes— the course was taught each student completed the especially in the three focus group discussions. CDP self-assessment prior to the first day of class and then completed a reassessment on the last day The Focus Groups of class. A focus group held after the completion During the fourth and final class session each of the second assessment concentrated on general year, the last 30 minutes were devoted to a focus responses and changes to the assessment and on group discussion. Students had been presented the impact of the course experience on student earlier with the general questions that would be attitudes and practices. discussed. Each year the focus group was taped Six months after the class ended students were and a transcript was created of the discussion. The invited by email to participate in a short interview focus group questions were: on the impact of the class on their practice. The 1. Overall did your views on military personnel course instructor (and lead author) followed up and veterans change from those you held be- the email invitation with phone calls until four fore the class started? Why or why not? students in each class agreed to be interviewed. 2. Please give an example of a change in your Interview questions centered on routine screening viewpoint. and military history taking for veterans and 3. Which part of the class materials made the families; familiarity with military terms and biggest impact on changing your attitudes: the information; retention of military/veteran clients; readings, the videos, or the class discussions? and how and why the course information impacted 4. Why did the teaching strategy you just their clinical practice. Interviews were taped but identified have such an impact? not transcribed.

7Private email from Richard Westphal, Ph.D., RN, PMHCNS/NP-BC, department chair for Family, Community, & Mental Health Services, UVA School of Nursing, one of the creators of the checklist. Dated: 9-17-17.

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 144 5. How will the material you learned in this the same time, I’m aware that it’s important class help you with counseling the military/ to be aware of my own personal stuff. veteran community in the future? The focus group discussion revolved around Another student stated: three issues: confidence gained from the course information for working with veterans and their After taking the class, and throughout families; the change in their attitudes toward the the [course], I was able to take all these military and veterans resulting from taking the different perspectives in…It allowed me course; and the lack of clarity in the bias assessment to kind of open up and be okay about statements. The students commented that it was actually thinking about this and feeling difficult for them to rate their answers because comfortable about it and having empathy, the terms used in these statements were unclear. and also just accepting that war today is As noted earlier, after three years of trying to use part of our human condition, and that the self-assessment checklist as a measure of bias, vets and families are part of our society. including revising it after the first year to try to A third student noted the relevancy of the tailor it more to the course content, it became clear course to her current practice: from the student discussions that the instrument 8 itself did not provide a quantitative measure to You know the way that she said in the stimulate discussion and expand student thinking beginning people’s eye glaze over when around bias. Still, some individual items were useful you talk about the military? That is within the context of the focus group discussions. definitely me. Eyes glaze over; I really don’t Reflecting on the impact of the course, many want to know anything about this. This is students in each year felt that their personal about killing; this is about government; opinions on war and serving in the military had this is about coercion. So, to humanize become more nuanced as the class progressed and/ that and to break it down into…the or that they were now better aware of their own impact…on real men and women, who attitudes and personal biases. They attributed serve, why they serve, and the effects… these changes to their enhanced understanding on them, was a real eye-opener. And of the factors associated with military culture— then just coincidentally, getting a case factors that impact clinical work with veterans and yesterday with a military family suddenly associated family members. The examples given brought the whole thing home to me, in the class about the various military/veteran very relevant, and suddenly I’m like all and related family situations helped clarify and/or ears. So, it’s just quite a difference from expand their understanding. where I was at the beginning. The heterogeneity of the veteran population became clear through class material. Students The course gave the students information stated that their ideas were no longer simply “black about conditions and mental health issues that and white” about the military. Of note, a few of they did not normally receive in their postgraduate the students in each class were veteran-connected curriculum such as characteristics about traumatic family members as were the instructors. The brain injury, moral injury, and military sexual sharing of their personal experiences about what it trauma. Students remarked that covering this was like to be married to someone in the military material gave them a framework to know what to or to be a child or parent of a service member explore, to understand what questions to ask, and appeared to foster empathy and seemed to create to know how to better support the clients. They an openness toward future counseling with this noted that the myth that “everyone comes out of population. One student commented: the military with PTSD” was dispelled during the course. They gained a fuller understanding of why The whole point of this class is that no people join the military and gave them a different two situations are the same, you can never perspective on service members and veterans. know what that person experienced, and you must have unqualified empathy…At

8We used a five-item Likert scale for each statement on the checklist. This allowed us to use quantitative methods to analyze the students’ responses.

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 145 As one student declared: their understanding of terminology associated with military/veteran issues; about the impact I feel like I very much was walking around of the course material on their clinical practice; with that stereotype like there are no other and whether the class videos, materials, and class options for these folks, they’re just in such discussions were helpful. a deep situation that this is their only out. And for some people, yes, they have those Findings pre-traumas, but for a lot of folks they are Findings from these interviews support in a fine situation, they actually just want comments made during the focus group at the to go invest in their education. And then last class session of each course. No discernable the other part that was really shocking to differences were noted among the responses from me is that with PTSD we only actually see the members of the three classes. This is probably that in 20% of vets, and I thought that was because all the students were enrolled in CFR’s everybody that comes out of a combat postgraduate courses and interning at CFR. Thus, situation, which isn’t true. they had all experienced one or two years of classes and clinical supervision given by CFR staff Another student noted that: who follow a systemic model of therapy. Findings from these interviews can be aggregated into five Even just asking the question: Have you categories. served? Of course, developing rapport is 1. Routine checking of clients for military very important, but I wasn’t trained to or veteran status is important and affirms the ask “have you served” in my training… value of the systemic framework that is a key and then also learning… the unique element to the mission of the agency. Ten of the nuances of military life and military 12 interviewees stated that after taking the class culture. Certain things, like how military they routinely screened clients for military service. sexual trauma is different than incidences Some remarked that they paid more attention to of sexual harassment or trauma…in a the agency’s registration form on which there was civilian workplace, learning those kinds a box for the client to check veteran status. Two of differences, learning differences in interviewees reported that they did not look at the domestic violence situations, how a box on the registration form asking about veteran military family might be different, those connections. They also noted that none of their kinds of responses, was helpful just to clients mentioned having any military connection. apply…the knowledge that I’ve already One interviewee stated regarding the accumulated is more nuanced and more importance of asking about military experience, specific. “I am more aware of it [military experience] Follow-Up Six-Month Interviews as something that’s systemically important Over three years, a total of 12 students, four considering how much the military family is each year, volunteered to be interviewed roughly affected.” A second student noted that after taking six months after taking the course. The interviews the course she is more mindful of the experience focused on the impact of the course on subsequent of military culture as a process or way for clients practice. Volunteers were solicited by email until to express their feelings and that it has a role in a the number of four was reached each year. Since client’s development and relationships. class sizes were small, four interviews represented 2. Knowledge about military culture a reasonable percentage of the enrolled students promoted the clinician’s comfort with veterans (44%, 66%, and 100%). as clients. The students noted that knowing what The interviews lasted up to 30 minutes in questions to ask and what the military terms meant length. Interviews were conducted either in-person gave them a level of comfort in working with the or on the phone. Oral consent was given, and the military community clients. A student who had interviews were recorded on a digital tape recorder. decided prior to taking the course not to work Questions on the semi-structured interview guide with military or veteran clients due to his beliefs asked about the clinician’s routine screening and and values changed his perspective. He remarked military history taking in their clinical practice. in the interview, “You realize that there is more The interviewees were asked if the course increased than I have experienced; different perspectives

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 146 As one student declared: their understanding of terminology associated or interactions and I saw that my own hang-ups trauma that existed in this population that with military/veteran issues; about the impact shouldn’t hinder me from helping others.” I wouldn’t be qualified or helpful because I feel like I very much was walking around of the course material on their clinical practice; Another student stated that in gaining of my inexperience and lack of specialty with that stereotype like there are no other and whether the class videos, materials, and class familiarity with the military vocabulary she was in that area but watching the videos it was options for these folks, they’re just in such discussions were helpful. able to lessen “the barrier” between her and her impressive that even having therapists a deep situation that this is their only out. military clients. She continued, “It gave me the outside of…therapists without military And for some people, yes, they have those Findings insight that you don’t have to be military to help experience can be helpful to them and pre-traumas, but for a lot of folks they are Findings from these interviews support a military person. You have to be present and so many of the military and veterans on in a fine situation, they actually just want comments made during the focus group at the attuned, open and curious and have deep respect the videos had positive experiences with to go invest in their education. And then last class session of each course. No discernable for intergenerational issues of transmission of clients and not so specialized treatment the other part that was really shocking to differences were noted among the responses from trauma.” that I don’t have to shy away from it. me is that with PTSD we only actually see the members of the three classes. This is probably 3. The students noted that it was helpful to that in 20% of vets, and I thought that was because all the students were enrolled in CFR’s understand the cultural stigma that these clients Another student supported this view, claiming everybody that comes out of a combat postgraduate courses and interning at CFR. Thus, face in reaching out to therapists for counseling. that the material in the course from a civilian situation, which isn’t true. they had all experienced one or two years of In the interviews, the students remarked that professional’s “viewpoint revealed key insights, classes and clinical supervision given by CFR staff the course gave them an understanding and made the material easier to absorb, and encouraged Another student noted that: who follow a systemic model of therapy. Findings appreciation of the challenges faced by service empathy and a sense of the terrain and signposts from these interviews can be aggregated into five that therapists need to recognize.” Even just asking the question: Have you members, veterans, and family members. A categories. 5. Finally, several respondents mentioned a served? Of course, developing rapport is student noted that she realized that the “military 1. Routine checking of clients for military number of specific components of the course that very important, but I wasn’t trained to experience was a bigger piece of the puzzle” for a or veteran status is important and affirms the were the most helpful. They included pragmatic ask “have you served” in my training… family that she was currently counseling. She and value of the systemic framework that is a key discussions that contained structured questions and then also learning… the unique others stated that they would not have understood element to the mission of the agency. Ten of the to ask when working with military clients with nuances of military life and military the impact of military service on the family 12 interviewees stated that after taking the class specific problems around trauma including culture. Certain things, like how military dynamics and/or help-seeking prior to the course. they routinely screened clients for military service. military sexual trauma, intimate partner violence, sexual trauma is different than incidences 4. Understanding military culture Some remarked that they paid more attention to PTSD, and behavioral health issues as well as what of sexual harassment or trauma…in a addressed an intimidation factor that the the agency’s registration form on which there was signs and symptoms might be present. In addition, civilian workplace, learning those kinds students felt at the beginning of the course. a box for the client to check veteran status. Two each student received a folder containing articles of differences, learning differences in The course dispelled preconceptions that the interviewees reported that they did not look at the to read, information about additional resources, domestic violence situations, how a students held about the military. They gained box on the registration form asking about veteran handouts on military culture and language, and military family might be different, those an understanding of the values that informed connections. They also noted that none of their useful infographics on military culture versus kinds of responses, was helpful just to their clients’ identities and key factors that could clients mentioned having any military connection. civilian culture for different conditions such as apply…the knowledge that I’ve already impact their military clients’ behavioral and One interviewee stated regarding the moral injury to PTSD, challenges faced during accumulated is more nuanced and more relational difficulties. Several students noted importance of asking about military experience, deployment, military grief for children. specific. that the course broadened their perspective on “I am more aware of it [military experience] how they viewed military or veteran clients; Follow-Up Six-Month Interviews as something that’s systemically important specifically, why understanding military culture Insights from the Student Interviews Over three years, a total of 12 students, four considering how much the military family is is important for mental health professionals and During the follow-up interviews, students each year, volunteered to be interviewed roughly affected.” A second student noted that after taking how it may shape the behavior of the client. One offered recommendations to improve the quality six months after taking the course. The interviews the course she is more mindful of the experience student stated the course taught her, and impact of the course. One suggestion was to focused on the impact of the course on subsequent of military culture as a process or way for clients add more case studies of veterans facing behavioral practice. Volunteers were solicited by email until to express their feelings and that it has a role in a how to speak with veterans in the most health challenges. Case studies are a way to actively the number of four was reached each year. Since client’s development and relationships. respectful way. I had always heard people engage the students in learning and applying the class sizes were small, four interviews represented 2. Knowledge about military culture say there’s one question you never ask a material they have absorbed in class to realistic a reasonable percentage of the enrolled students promoted the clinician’s comfort with veterans veteran (e.g., “did you ever kill anyone?”) situations. Each class session now contains at least (44%, 66%, and 100%). as clients. The students noted that knowing what and I didn’t know what that question one case study. The interviews lasted up to 30 minutes in questions to ask and what the military terms meant was—it was really helpful to know what A second suggestion focused on the discomfort length. Interviews were conducted either in-person gave them a level of comfort in working with the not to ask. that students felt when starting the course. One or on the phone. Oral consent was given, and the military community clients. A student who had interviewee characterized this as feeling “resistant Students echoed similar thoughts in several interviews were recorded on a digital tape recorder. decided prior to taking the course not to work and intimidated” to learn about this particular interviews: Questions on the semi-structured interview guide with military or veteran clients due to his beliefs population. The student suggested starting the first asked about the clinician’s routine screening and and values changed his perspective. He remarked class session with an exercise in which each student in the interview, “You realize that there is more I had a lot of trepidation about working partners with another to discuss their fears, biases, military history taking in their clinical practice. with this population, my perceived The interviewees were asked if the course increased than I have experienced; different perspectives and personal issues about participating in this course. notions were that there was a lot of Following this brief exercise students are then asked

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 147 to share some part of the discussion of what they working with the military and veteran populations. learned about themselves with the entire class. Both programs, the four-day clinician training, and Another recommendation centered on the the three 15-hour postgraduate course had positive value of exposure in the course to someone who impacts on the participants. A survey of the four- had actively served in the military. In this course day training and subsequent qualitative interview over the three years, the participation of someone follow-ups revealed that information about the with an identified military-related background military and its impact on veterans and families included the co-instructor, who had served as promoted changes in attitudes, knowledge, and a chaplain in the National Guard for over two clinical practice for both experienced clinicians as decades, and students who had parents, spouses, well as clinicians just beginning their careers. The or siblings who had served. The “lived experiences” therapists expressed the view that the knowledge that they were able to contribute to the course the training provided informed their attitudes and added a richness to the class discussions. behavior in their work with military and veteran clients and family members. These findings were Future CFR Plans to Train Professionals replicated in the findings from the three-year The positive impact on students and training evaluation of the postgraduate course. participants of specialized training in military Students who enrolled in the Understanding culture has reinforced the commitment of CFR Military Culture course changed their attitudes to continue to provide military/veteran cultural and their practices in working with clients who competency training. Every year, a half day or had military experience. One benefit of the whole day training on specific relevant topics has course was that students who initially were not been provided by CFR to clinicians and other interested in serving military clients or who felt professionals in the region. Presentation topics insufficiently trained to work with this population to date have focused on PTSD, suicide, military gained confidence from the course and became sexual trauma, reintegration, and moral injury. In more interested in seeing clients with military the last three years, 130 individuals, including CFR experience. Without the course experience— staff and other professionals from the region have and given the small percentage of people now participated in these training sessions. serving in the military compared to the current In addition, OHH personnel have begun US population (Council on Foreign Relations, training clergy and students in seminaries in the 2020) and to previous eras prior to the volunteer Philadelphia region to understand military culture military and the diminishing number of veterans in the context of pastoral care. These courses are still living (Schaeffer, 2021)—it is unlikely that either a 42-hour intensive version of the 15-hour these therapists would have changed their attitudes CFR course for seminary students or a shortened on their own. three-hour workshop version presented to Furthermore, changes in practice resulted working clergy. The courses and workshops build from participating in the course. Students realized from the premise that clergy are “first responders” the value of asking about military experience with to the veteran population, administering to their all their clients as well as the impacts of serving in needs because veterans and their families are likely the military on the individual and on the family. to join and participate in religious institutions Moreover, the knowledge about the military, following service. about its impact on the family, and on a range of Finally, the authors are committed to behavioral health issues gave them insights into developing a bias questionnaire to use before better ways of addressing their clients’ problems. and after each course to uncover stereotypes and Drawing conclusions from the evaluation of misinformation about service members and/or CFR’s training efforts regarding military culture veterans. Wording will be reviewed to remove competency has limitations, including: the small response bias (acquiescence) from the process. numbers of students participating in the study Post-evaluation questions will also be reviewed through the different parts of the evaluation and modified to avoid response bias. process; the issues noted with the limitations of the CDP bias assessment checklist; and focus Conclusion group and the follow-up interviews with a limited Over the past seven years, CFR has conducted number of respondents. In addition, most of the two substantial training programs for clinicians participants were enrolled in an agency with

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 148 to share some part of the discussion of what they working with the military and veteran populations. a particular framework of practice (i.e., the Kudler, H., & Cornelison-Grant, V. (2011). Serving learned about themselves with the entire class. Both programs, the four-day clinician training, and systemic model), which focuses on the important those who have served: Educational needs of health Another recommendation centered on the the three 15-hour postgraduate course had positive relationships in clients’ lives. All the students in the care providers working with military members, value of exposure in the course to someone who impacts on the participants. A survey of the four- course base their practices around the belief that veterans, and their families. Medical University had actively served in the military. In this course day training and subsequent qualitative interview relationships are at the core and provide the basis of South Carolina Department of Psychiatry, over the three years, the participation of someone follow-ups revealed that information about the of mental health. The four-day training, however, National Crime Victims Research & Treatment with an identified military-related background military and its impact on veterans and families reached a wider group of clinicians, of which Center. https://www.mirecc.va.gov/docs/visn6/ included the co-instructor, who had served as promoted changes in attitudes, knowledge, and some had more experienced, and others were not serving_those_who_have_served.pdf a chaplain in the National Guard for over two clinical practice for both experienced clinicians as involved with CFR and the systemic model. Koenig, C.J., Maguen, S., Monroy, J.D., decades, and students who had parents, spouses, well as clinicians just beginning their careers. The It is clear from both the four-day training Mayott, L., & Seal, K.H. (2014). Facilitating or siblings who had served. The “lived experiences” therapists expressed the view that the knowledge and the postgraduate course that these are culture-centered communication between health that they were able to contribute to the course the training provided informed their attitudes and effective means of providing clinicians with care providers and veterans transitioning from added a richness to the class discussions. behavior in their work with military and veteran training in working with military and veteran military deployment to civilian life. Patient clients and family members. These findings were populations. While the 2014 RAND study pointed Education and Counseling, 95(3), 414–420. https:// Future CFR Plans to Train Professionals replicated in the findings from the three-year to inadequacies in the knowledge and practices of doi.org/10.1016/j.pec.2014.03.016 The positive impact on students and training evaluation of the postgraduate course. community health practitioners nationwide; this Lighthall, A. (2010). Rules of engagement: participants of specialized training in military Students who enrolled in the Understanding small evaluation study points to possible remedies. A civilian therapist’s guide to the military culture has reinforced the commitment of CFR Military Culture course changed their attitudes mindset. Psychotherapy Networker. https:// to continue to provide military/veteran cultural and their practices in working with clients who References psychotherapynetworker.org/magazine/ competency training. Every year, a half day or had military experience. One benefit of the Center for Deployment Psychology. (n.d) article/395/rules-of-engagement whole day training on specific relevant topics has course was that students who initially were not Faces of military culture: Core competencies for Mackenzie, L., Gaudin, E., & Tarzi, E. (2018). been provided by CFR to clinicians and other interested in serving military clients or who felt healthcare professionals. https://deploymentpsych. 2018 military cross-cultural competence annotated professionals in the region. Presentation topics insufficiently trained to work with this population org/test-face bibliography. Center for Advanced Operational to date have focused on PTSD, suicide, military gained confidence from the course and became Cogan, S. (2011) What Military Patients Want Culture Learning, Marine Corps University. https:// sexual trauma, reintegration, and moral injury. In more interested in seeing clients with military Civilian Providers to Know. SAMHSA News, 19(3), 4-6. apps.dtic.mil/dtic/tr/fulltext/u2/1059390.pdf the last three years, 130 individuals, including CFR experience. Without the course experience— Council on Foreign Relations (2020, July 13). Martin, J.A., Albright, D., & Borah, E. (2016). staff and other professionals from the region have and given the small percentage of people now Demographics of the U.S. Military. https://www.cfr. Expanding our understanding of military social participated in these training sessions. serving in the military compared to the current org/backgrounder/demographics-us-military work: The concept of military-and veteran- In addition, OHH personnel have begun US population (Council on Foreign Relations, Goodale, R., Abb, W.R., & Moyer, B.S. (2012, connected populations. Journal of Family Social training clergy and students in seminaries in the 2020) and to previous eras prior to the volunteer September 14). Military culture 101: Not one Work, 20(1), 5–8. Philadelphia region to understand military culture military and the diminishing number of veterans culture, but many cultures. WomenVets USA. Meyer, E.G., Writer, B.W., & Brim, W. (2016). in the context of pastoral care. These courses are still living (Schaeffer, 2021)—it is unlikely that https://www.womenvetsusa.org/library/library- The importance of military cultural competence. either a 42-hour intensive version of the 15-hour these therapists would have changed their attitudes info.php/num-210/ Current Psychiatry Reports, 18(3), 26. CFR course for seminary students or a shortened on their own. Gross, N. (2019, January 4). All veterans have Meyer, E.G., Wynn, G., West, J.W., & three-hour workshop version presented to Furthermore, changes in practice resulted PTSD’ and other myths — debunked. Military Times Morganstein, J.C. (2018). The importance of US working clergy. The courses and workshops build from participating in the course. Students realized Reboot Camp. https://rebootcamp.militarytimes. military cultural competence. In L. W. Roberts, & from the premise that clergy are “first responders” the value of asking about military experience with com/news/education/2019/01/04/all-veterans- C. H. Warner (Eds.), Military and Veteran Mental to the veteran population, administering to their all their clients as well as the impacts of serving in have-ptsd-and-other-myths-debunked/ Health, A Comprehensive Guide (pp. 15–33). needs because veterans and their families are likely the military on the individual and on the family. Gurman, A.S., LeBow, J.L., & Snyder, D.K., Springer Publishing. https://doi.org/10.1007/978- to join and participate in religious institutions Moreover, the knowledge about the military, (Eds.). (2015). Clinical Handbook of Couple 1-4939-7438-2 following service. about its impact on the family, and on a range of Therapy, 5th Edition. Guilford Press. Nedegaard, N. & Zwilling, J. (2017). Finally, the authors are committed to behavioral health issues gave them insights into Hall, L. (2011). The importance of Promoting military cultural competence among developing a bias questionnaire to use before better ways of addressing their clients’ problems. understanding military culture. Social Work in civilian care providers: Learning through program and after each course to uncover stereotypes and Drawing conclusions from the evaluation of Health Care, 50(1), 4–18. https://doi.org/10.1080/ development. Social Sciences, 6(13), 1–11. https:// misinformation about service members and/or CFR’s training efforts regarding military culture 00981389.2010.513914 doi.org/10.3390/socsci6010013 veterans. Wording will be reviewed to remove competency has limitations, including: the small Hoge, C.W. (2011). Interventions for war- Nichols, M.P., & Davis, S. (2016). Family response bias (acquiescence) from the process. numbers of students participating in the study related posttraumatic stress disorder. JAMA, Therapy: Concepts and Methods, 11th Edition. Post-evaluation questions will also be reviewed through the different parts of the evaluation 306(5), 549–551. https://doi.org/10.1001/ Allyn & Bacon. and modified to avoid response bias. process; the issues noted with the limitations of jama.2011.1096 Petrovich, J. (2012). Culturally competent the CDP bias assessment checklist; and focus social work practice with veterans: An overview of Conclusion group and the follow-up interviews with a limited the U.S. Military. Journal of Human Behavior in the Over the past seven years, CFR has conducted number of respondents. In addition, most of the Social Environment, 22(7), 863-874. two substantial training programs for clinicians participants were enrolled in an agency with Kilpatrick, D.G., Best, C.L., Smith, D.W., Schaerffer, K., (2021). The changing face

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 149 of America’s veteran population. Pew Research Center. https://www.pewresearch.org/fact- tank/2021/04/05/the-changing-face-of-americas- veteran-population/ Tanielian, T., Farris, C., Batka, C., Farmer, C.M., Robinson, E., Engel, C.C., Robbins, M., & Jaycox, L.H. (2014). Ready to serve: Community- Based provider capacity to deliver culturally competent, quality mental health care to veterans and their families. RAND Corporation. https:// www.rand.org/pubs/research_reports/RR806.html Zimmerman, S.R., Jackson, K., Lander, N., Roberts, C., Madden, D., & Orrie, R. (2019). Movement and Maneuver: Culture and the Competition for Influence Among the U.S. Military Services. RAND Corporation. https://www.rand. org/pubs/research_reports/RR2270.html

About the Authors Nancy Isserman, MSW, PhD, is the Director of Operation Home and Healing at the Council for Relationships, an organization that provides counseling and services for active service members, veterans, and their families. James Martin, PhD, is a Professor of Social Work and Social Research at Bryn Mawr College. Dr. Martin is a SMVDS and principal investigator of the research project.

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 150 of America’s veteran population. Pew Research Center. https://www.pewresearch.org/fact- U.S. Veterans Experience Moral Injury Differently tank/2021/04/05/the-changing-face-of-americas- Based on Moral Foundations Preferences veteran-population/ Tanielian, T., Farris, C., Batka, C., Farmer, C.M., Robinson, E., Engel, C.C., Robbins, M., & Daniel Perez, Paul Larson, and John Bair Jaycox, L.H. (2014). Ready to serve: Community- Based provider capacity to deliver culturally competent, quality mental health care to veterans and their families. RAND Corporation. https:// Abstract www.rand.org/pubs/research_reports/RR806.html This study is the first to examine the relationship between moral foundations preferences and the Zimmerman, S.R., Jackson, K., Lander, N., severity of moral injury symptoms reported by U.S. veterans. A total of 85 participants were recruited Roberts, C., Madden, D., & Orrie, R. (2019). through social media pages for veterans, and participants completed an online survey assessing their Movement and Maneuver: Culture and the severity and type of moral injury and their preferences for each of the five core moral foundations. Viewing Competition for Influence Among the U.S. Military moral injury through the lens of the moral foundations theory allows for an in-depth understanding of the Services. RAND Corporation. https://www.rand. cause and nature of moral injury. Overall, veterans’ preferences for different groups of moral foundations org/pubs/research_reports/RR2270.html had a significant relationship with the severity of the subtypes of moral injury they experienced. Veterans who have experienced a potentially morally injurious event (pMIE) and are suffering from moral injury About the Authors as a result are likely not receiving adequate treatment, as moral injury is often masked and presents Nancy Isserman, MSW, PhD, is the Director as alternative diagnoses (PTSD, depression, etc.). Assessing veterans’ moral foundations preferences in of Operation Home and Healing at the Council addition to determining the severity of their self- and other-directed moral injury will allow for more for Relationships, an organization that provides effective treatments to be developed and implemented. counseling and services for active service members, veterans, and their families. James Martin, PhD, is Moral injury is a fairly new concept that good vs. evil), and it often takes on a spiritual or a Professor of Social Work and Social Research at has arisen in recent years from research into religious quality (Haidt, 2012). Conceptualizing Bryn Mawr College. Dr. Martin is a SMVDS and post-traumatic stress disorder (PTSD) and individuals through this rudimentary lens of principal investigator of the research project. trauma among U.S. veterans. The particular morality not only hinders a clinician’s ability to manner in which moral injury affects individuals fully comprehend the subjective nature of moral differentiates it from previous understandings injury symptoms but also negates the aspects of of trauma and symptomatology associated with foundational moral systems that are crucial in traumatic experiences. Distinguishing indicators understanding morality as a whole. (Graham of moral injury from symptoms of PTSD in et al., 2013). Viewing morality as an adaptable, veterans is a difficult task, but it may ultimately pluralistic framework rather than as a rigid binary determine the effectiveness and outcome of allows for a more comprehensive and holistic therapeutic interventions. There are currently two understanding of adverse symptoms of moral “gold standard” evidence-based practices (EBPs) injury and creates space for the development of implemented at the U.S. Department of Veterans treatment interventions for these complex issues. Affairs (VA) to treat PTSD in veterans: cognitive processing therapy (CPT) and prolonged Moral Injury exposure (PE) therapy (Foa et al., 2013; Resick Developing an understanding of moral et al., 2012). While both treatments have been injury can be challenging, as many of its features proven to significantly reduce PTSD symptoms are abstract which makes it difficult for many in veterans who complete either program, both individuals to describe. The primary cause of moral also have high dropout rates (Hoge et al., 2014). injury is believed to be exposure to a transgressive Research also indicated that veterans do not act or acts or to pMIEs. Moral injury is not the perceive these EBPs as sufficient to address moral event itself, nor is it the negative emotions that injury (Borges et al., 2019). occur immediately after experiencing a pMIE. In order to develop more effective Moral injury is better explained as the result of interventions that focus on treating moral ineffective attempts to manage adverse emotions, injury specifically, it is important to first gain or moral pain, that have developed over time an understanding of how individuals' moral as a direct result of one’s experience of a pMIE. foundation may dictate how they interpret a Moral pain refers to the natural emotions that pMIE. Morality is a concept that is often thought an individual commonly experience after their of in dichotomous terms (right vs. wrong or values have been transgressed, and these emotions

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 151 alone are nonpathological. It is the intense, often subtypes, differentiating symptoms that are untreated, moral pain that continuously disrupts internalized or directed at the self (guilt, shame, and an individual’s life that ultimately creates moral depression) from symptoms that are externalized injury. There is currently no universal consensus or or directed at others (anger, distrust, and lack of explicit definition that captures moral injury, but connection with others; Currier et al., 2018). two main definitions are used in outlining what Acts that constitute a violation of one’s deeply constitutes an event that leads to moral injury. held moral beliefs, regardless of which definition is The first definition by Litz et al. (2009) outlines used, will undoubtedly have a profound impact on a morally injurious event as one that involves an individual’s moral foundation. These violations “perpetrating, failing to prevent, bearing witness often cause intense feelings of shame and guilt in to, or learning about acts that transgress deeply those who have been affected (Nash & Litz, 2013; held moral beliefs and expectations” (p. 700). This Shay, 1991). The damage caused by pMIEs has been definition serves as a general inclusion condition shown to contribute not only to the development of in that this standard must be met in order for PTSD symptoms in veterans but also to long-term there to be moral injury, much like the Diagnostic emotional, spiritual, psychological, behavioral, and Statistical Manual of Mental Disorders (DSM) and social difficulties (Yan, 2016). According to Criterion A for the diagnosis of PTSD. There is Jinkerson and Battles (2019), exposure to pMIEs currently no DSM diagnosis for moral injury. “statistically predicted guilt (five of six measures), Therefore, language such as Litz et al.’s definition meaning in life (negative relationship), depressive can be extremely helpful to clinicians as they symptoms, anxiety symptoms, reexperiencing, and clarify and rule out diagnoses for veteran patients avoidance” (p. 37). by differentiating nonoverlapping moral injury In addition to these symptoms, other symptoms from PTSD symptoms. symptoms have been associated with moral The second definition takes a more dynamic injury, including a loss of trust in oneself, others, approach to understanding pMIEs and asserts that or one’s chosen deity; feelings of betrayal; and the transgressive act or acts must involve “(a) a self-deprecation (Bryan et al., 2014; Bryan et al., betrayal of ‘what’s right’; (b) by someone who holds 2016; Currier, McCormick, et al., 2015; Jinkerson, legitimate authority; (c) in a high stakes situation” 2016; Shay, 1994, 2014). The extent and complexity (Shay, 2014, p. 183). This description differs from of the symptoms that may result from experiencing the definition proposed by Litz and colleagues as a pMIE demonstrate that a complex understanding it requires a violation of one’s moral beliefs by an of morality is needed to comprehend the nature individual who holds a position of authority and and dynamics of moral injury. hinges on a determination of “what’s right.” It is important to understand that the term “right” Moral Foundations Theory is inherently subjective, as what is right for one The moral foundations theory was initially person may be wrong for another. The differences developed to define differences in moral values in these two definitions are subtle but will help to systems across cultures and was later used to explain differences in subtypes of moral injury and assess such differences among U.S. individuals how moral injury can develop in some individuals with disparate political preferences (Graham et but not others. al., 2009). One of the theory’s major premises Building on these two core definitions of proposes that people make moral judgments moral injury, Jinkerson (2016) offered a more using a continuum of moral intuitions rather encompassing, conceptual definition of moral than one or two foundational values. The authors injury from a syndrome perspective. His work of the moral foundations theory proposed a built upon previous research into moral injury by nonexhaustive list of five core moral foundations: establishing more concrete criteria and symptoms Care/Harm, Fairness/Cheating, Loyalty/Betrayal, caused by moral injury and listed both “core” Authority/Subversion, and Sanctity/Degradation and “secondary symptomatic features” (p. 126). (Haidt, 2012, 2013; Haidt & Graham, 2007). Work of this nature will ultimately advance Researchers discovered a divergence within the understanding of moral injury and provide the core foundations while measuring the moral empirical evidence should moral injury become domain in terms of self-reported political ideology, an official diagnosis in the future. In addition to which they termed the individualizing–binding defining moral injury in a broad sense, recent distinction. Researchers hypothesized that the research has found evidence of moral injury “individualizing” foundations (Care and Fairness)

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 152 alone are nonpathological. It is the intense, often subtypes, differentiating symptoms that are place the individual as the locus of morality, and groups organized by Iraq and Afghanistan untreated, moral pain that continuously disrupts internalized or directed at the self (guilt, shame, and whereas the “binding foundations” (Loyalty, Veterans of America (IAVA) and Division 19 an individual’s life that ultimately creates moral depression) from symptoms that are externalized Authority, and Sanctity) place society, family, and of the American Psychological Association injury. There is currently no universal consensus or or directed at others (anger, distrust, and lack of one’s relationship with God as the locus of morality. (APA). Participants each completed an online explicit definition that captures moral injury, but connection with others; Currier et al., 2018). The Care foundation emphasizes protection survey and submitted a total of 116 responses. two main definitions are used in outlining what Acts that constitute a violation of one’s deeply of vulnerable individuals, particularly children, Of these 116 responses, 31 were discarded due constitutes an event that leads to moral injury. held moral beliefs, regardless of which definition is and underlies the virtues of gentleness and to incompleteness, resulting in a total sample The first definition by Litz et al. (2009) outlines used, will undoubtedly have a profound impact on nurturance. The Fairness foundation stresses size of 85 participants. For detailed demographic a morally injurious event as one that involves an individual’s moral foundation. These violations the importance of equality, rights, and justice, information on the participants, see Table 1. “perpetrating, failing to prevent, bearing witness often cause intense feelings of shame and guilt in and it also underlies the value of proportionality This study was exploratory in nature and was to, or learning about acts that transgress deeply those who have been affected (Nash & Litz, 2013; (Graham et al., 2011; Graham et al., 2009). designed to determine if the severity of moral held moral beliefs and expectations” (p. 700). This Shay, 1991). The damage caused by pMIEs has been The binding foundations place more injury reported by U.S. veterans is correlated definition serves as a general inclusion condition shown to contribute not only to the development of importance on duty, sacrifice for the good with a preference for any of the five core moral in that this standard must be met in order for PTSD symptoms in veterans but also to long-term of the community, and purity. The Loyalty foundations. The study procedures and documents there to be moral injury, much like the Diagnostic emotional, spiritual, psychological, behavioral, foundation emphasizes the virtues of patriotism were approved by the institutional review board and Statistical Manual of Mental Disorders (DSM) and social difficulties (Yan, 2016). According to and group responsibility and is related to of the Chicago School of Professional Psychology Criterion A for the diagnosis of PTSD. There is Jinkerson and Battles (2019), exposure to pMIEs humans’ historical inclination to form changing and complied with APA’s ethical standards for the currently no DSM diagnosis for moral injury. “statistically predicted guilt (five of six measures), coalitions. The Authority foundation underlies treatment of human subjects. Informed consent Therefore, language such as Litz et al.’s definition meaning in life (negative relationship), depressive ideals of leadership, followership, and respect for was obtained from each of the participants prior to can be extremely helpful to clinicians as they symptoms, anxiety symptoms, reexperiencing, and legitimate authority figures. The ethics of divinity initiation of the online survey. clarify and rule out diagnoses for veteran patients avoidance” (p. 37). are a major tenet of the Sanctity foundation, as by differentiating nonoverlapping moral injury In addition to these symptoms, other are principles related to religion, cleanliness, and Measures symptoms from PTSD symptoms. symptoms have been associated with moral suppressing humanity’s carnal desires of greed, Moral Foundations Questionnaire (MFQ) The second definition takes a more dynamic injury, including a loss of trust in oneself, others, hunger, and lust (Graham et al., 2013). When The MFQ was designed to quantify the approach to understanding pMIEs and asserts that or one’s chosen deity; feelings of betrayal; and making moral judgments, individuals give each degree to which respondents prefer each of the the transgressive act or acts must involve “(a) a self-deprecation (Bryan et al., 2014; Bryan et al., of these foundations more or less importance, five core moral foundations. It was initially used betrayal of ‘what’s right’; (b) by someone who holds 2016; Currier, McCormick, et al., 2015; Jinkerson, and their relative weights are influenced by to measure differences in moral foundations legitimate authority; (c) in a high stakes situation” 2016; Shay, 1994, 2014). The extent and complexity biological processes, childhood experiences, preferences along lines of self-reported political (Shay, 2014, p. 183). This description differs from of the symptoms that may result from experiencing parental and caregiver relationships, and cultural ideology. Results indicated that political liberals the definition proposed by Litz and colleagues as a pMIE demonstrate that a complex understanding and societal norms (Haidt, 2012). significantly preferred the two individualizing it requires a violation of one’s moral beliefs by an of morality is needed to comprehend the nature Examining moral injury through the lens foundations (Care and Fairness) over the three individual who holds a position of authority and and dynamics of moral injury. of the moral foundations theory will provide binding foundations (Loyalty, Authority, and hinges on a determination of “what’s right.” It is clinicians with a more advanced understanding Sanctity). Political conservatives, on the other important to understand that the term “right” Moral Foundations Theory of the cause and extent of moral injury and will hand, generally preferred each of the five is inherently subjective, as what is right for one The moral foundations theory was initially inform the most appropriate avenue of treatment foundations proportionately (Graham et al., person may be wrong for another. The differences developed to define differences in moral values for each affected individual. An individual’s 2009; Graham et al., 2012). The survey has since in these two definitions are subtle but will help to systems across cultures and was later used to preference for one moral foundation over become a universally reliable measure of moral explain differences in subtypes of moral injury and assess such differences among U.S. individuals another may serve as a protective factor in the foundations preferences across a wide variety of how moral injury can develop in some individuals with disparate political preferences (Graham et development of moral injury, while, conversely, variables beyond political ideology. but not others. al., 2009). One of the theory’s major premises holding on too tightly to one’s moral foundation The MFQ is a 32-question self-report Building on these two core definitions of proposes that people make moral judgments may serve as a risk factor. measure designed to determine respondents’ moral injury, Jinkerson (2016) offered a more using a continuum of moral intuitions rather levels of preference for each of the five core moral encompassing, conceptual definition of moral than one or two foundational values. The authors Method foundations (Graham et al., 2011). The first 16 injury from a syndrome perspective. His work of the moral foundations theory proposed a Participants and Procedures responses measure moral relevance by presenting built upon previous research into moral injury by nonexhaustive list of five core moral foundations: Participants for this study were a sample participants with scenarios and asking them to establishing more concrete criteria and symptoms Care/Harm, Fairness/Cheating, Loyalty/Betrayal, of veterans who had served in any military branch rate how relevant each scenario is to them when caused by moral injury and listed both “core” Authority/Subversion, and Sanctity/Degradation on active duty at some point during the years deciding right from wrong on a 0–5 Likert scale, and “secondary symptomatic features” (p. 126). (Haidt, 2012, 2013; Haidt & Graham, 2007). 2001–2014. Having never deployed to a combat where 0 = Not At All Relevant and 5 = Extremely Work of this nature will ultimately advance Researchers discovered a divergence within theater was not an exclusion criterion, as Relevant. The second part of the survey consists of the understanding of moral injury and provide the core foundations while measuring the moral transgressions to one’s moral belief system need 16 statements that measure moral judgments and empirical evidence should moral injury become domain in terms of self-reported political ideology, not occur solely in combat. Participants were asks participants to rate their level of agreement an official diagnosis in the future. In addition to which they termed the individualizing–binding recruited throughout the summer of 2018 using with each statement on a 0–5 Likert scale, with defining moral injury in a broad sense, recent distinction. Researchers hypothesized that the convenience sampling from online groups for 0 = Strongly Disagree and 5 = Strongly Agree. Each research has found evidence of moral injury “individualizing” foundations (Care and Fairness) veterans, including Facebook and LinkedIn groups of the five core moral foundations is measured by

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 153 six associated questions. To determine Table 1. Participant Demographic Characteristics how closely related these five moral foundations are as a group, Cronbach’s Variable Frequency % alpha was used as a measure of internal Total number 85 100 consistency. Cronbach’s alphas for the of participants six-item measures of each foundation are Age .68 (Care), .60 (Fairness), .75 (Loyalty), 40+ 39 45.9 .66 (Authority), and .76 (Sanctity). 35–39 23 27.1 30–34 17 20.0 Expressions of Moral Injury 25–29 6 7.1 Scale–Military Version (EMIS-M) The EMIS-M is a 17-statement Gender Male 58 68.2 self-report instrument that is designed Female 27 31.8 to measure the overall and subtype levels of moral injury symptoms endorsed by Ethnicity participants (Currier et al., 2018). For White 67 78.8 each of the 17 statements, respondents African American 4 4.7 are asked to rate their level of agreement Hispanic/Latinx 6 7.1 on a 1–5 Likert scale, with 1 = Strongly Prefer not to answer 2 2.4 Disagree and 5 = Strongly Agree. The Other 6 7.1 sum of the measure produces an overall score ranging from 17–85. In addition Political ideology Liberal 16 18.8 to producing this score, the instrument Moderate 23 27.1 further examines two subtypes of Conservative 31 36.5 moral injury: self-directed moral injury Prefer not to answer 13 15.3 (SDMI) and other-directed moral injury Other 2 2.4 (ODMI). Nine of the 17 statements inquire about SDMI and eight statements Branch of service address ODMI, and when totaled, they Army 54 63.5 produce scores ranging from 9–45 and Marines 7 8.2 8–40, respectively. For the purpose of this Navy 9 10.6 study, only the scores of the subset moral Air Force 13 15.3 Coast Guard 2 2.4 injury scales were calculated, and the overall score was not used. Cronbach’s Campaign deployed alphas for the items that measure SDMI OIF 25 29.4 and ODMI are .94 and .91, respectively. OEF 18 21.2 Both 27 31.8 Data Analysis Neither 15 17.6 From the MFQ results, sums of the sets of questions pertaining to each of Note. OIF = Operation Iraqi Freedom; the moral foundations were calculated OEF = Operation Enduring Freedom to produce scores between 0–30, with 0 signifying no preference for the The sums of the SDMI and ODMI scores foundation and 30 indicating extreme preference obtained from the EMIS-M were calculated for each for the foundation. These scores were rank ordered of the three groups, producing scores ranging from to display preference, with the highest number 9–45 (SDMI) and 8–40 (ODMI). These scores were being the most salient foundation. The sums for then placed into groups based on the participants’ each foundation were then categorized into one of level of preference for each foundation. From each three distinct groups illustrating the participant’s group, means were obtained and analyzed using level of preference, as follows: 0–10 = Low, Pearson’s correlation coefficient. This process was 11–20 = Moderate, and 21–30 = High. completed five times for each participant, once for each of the five foundations. See Table 2 for detailed results.

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 154 Results a marginally significant amount of the variance Table 2 illustrates the means, standard in the reported severity of SDMI (F(2, 82) = 2.71, 2 2 deviations, Pearson correlation matrix, and p = .07, R = .06, R Adjusted = .04). The results Cronbach’s alphas for each of the variables also indicate that individualizing and binding used in this study. The results indicate a strong foundations preferences were not statistically positive relationship between the outcome significant predictors of variance in the reported variables measuring SDMI and ODMI, r = .65, severity of ODMI (F(2, 82) = .86, p = .43). p < .001. There is also evidence of strong positive Figure 1 is a visual representation of how correlations within predictor variables measuring respondents reported severity of SDMI in terms individualizing foundations (Care and Fairness, of preference given to both the individualizing r = .66, p < .001) and variables measuring binding and binding moral foundations. This chart shows foundations (Loyalty and Authority, r = .66, that individuals who endorsed moderate to high p < .001; Loyalty and Sanctity, r = .61, p < .001; preference for the individualizing foundations and Authority and Sanctity, r = .58, p < .001). Only reported higher amounts of SDMI than those who one foundation was significantly correlated with a reported less preference for the individualizing outcome variable in the preliminary examination foundations. There is also evidence that as (Loyalty and SDMI, r = .22, p = .04 .05), while individuals report higher preferences for binding the relationship between Care and SDMI was foundations, they will also report more severe marginally significant (r = .21, p = .06). SDMI. Figure 2 shows that individuals who Given the strength of correlations within endorsed moderate to high preferences for both the individualizing foundations and binding the individualizing and binding foundations foundations, new variables were produced in will report more severe ODMI than individuals order to minimize the potential of error due who reported low preferences for both groups of to multicollinearity. Rather than examining foundations. each moral foundation individually, a multiple regression analysis was used to Discussion evaluate variance in both SDMI and ODMI The results of this study yielded several in terms of individualizing and binding notable findings. First, these findings show that foundation preferences. The results indicate that there is a meaningful relationship between the individualizing and binding foundations explain amount of preference an individual gives to specific

Table 2. Means, Standard Deviations, and Pearson Correlation Matrix for All Variables (N = 85)

SDMI ODMI Care Fairness Loyalty Authority Sanctity SDMI (.94) ODMI .65** (.91) Care .21 .14 (.68) Fairness .09 .12 .66** (.60) Loyalty .22* .02 .14 .03 (.75) Authority .15 .10 −.08 −.03 .66** (.66) Sanctity .12 −.02 .03 .01 .61** .58** (.74) Mean 19.48 22.39 19.85 20.66 18.47 18.84 15.5 Standard 9.72 8.50 4.81 4.14 5.37 4.93 6.04 Deviation

Note. SDMI = self-directed moral injury; ODMI = other-directed moral injury. **Correlation is significant at the .001 level (2-tailed) *Correlation is significant at the .05 level (2-tailed). Cronbach's alphas are shown in the diagonal.

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 155 moral foundations and the severity of moral Internalized moral injury is likely to arise injury symptoms that they endorse. Specifically, after an individual has witnessed, failed to distinguishing whether a veteran identifies more prevent, or even perpetrated acts that violate closely with either binding or individualizing their moral foundation, and it is often manifested moral foundations can explain how they interpret in symptoms such as shame, guilt, remorse, a pMIE. Veterans who demonstrate a high and depression.. These symptoms are closely preference for either individualizing or binding associated with individualizing foundations, foundations would likely benefit from treatment as they place more emphasis on the individual that differs from treatment given to individuals as the locus of morality. When someone else who endorse low preferences in either group of (whether it be peers, superiors, society, or deity) moral foundations. Examining preference given violates an individual’s binding foundations the to each moral foundation and comparing those transgression is externalized, which often results results with a veteran’s moral injury symptoms in anger. This violation can be perpetrated by can provide insight into the nature of the peers, superiors, society, or even one’s deity. When perceived transgression and can ultimately help an individual’s moral foundations are violated, to indicate the best course of treatment for the understanding which foundations were violated, specific individual. how they were violated, and how the patient has Although examining each individual’s manifested symptoms will allow clinicians to moral foundation preferences is a crucial step develop and implement more effective treatments. in the treatment of moral injury, this study also illustrates the importance of evaluating patients’ Clinical Implications symptoms in terms of moral injury subtypes. Recent studies have illustrated the need for Veterans who identify with individualizing new treatment interventions to specifically address foundations over binding foundations may be moral injury. They have also illuminated the ways prone to endorse higher SDMI than ODMI, in which current EBPs used to treat trauma-related while those who prefer binding foundations to symptoms in veterans are ineffective in treating individualizing foundations may endorse higher moral injury: Clinicians do not discuss moral ODMI than SDMI. From a practical perspective, injury during treatment, often have poor rapport it makes sense that an individual who is more with the veterans they serve, and implement concerned with aspects of equality, nurturance, therapeutic interventions too rigidly (Hoge et al., and caring for those unable to care for themselves 2014). Additional studies highlight the need to treat would interpret a pMIE much differently than moral injury using a more functional, adaptable would an individual who differentiates right from approach that allows for changes in agenda. wrong based on respect for authority, a sense of Farnsworth et al. (2017) demonstrated the positive group responsibility, and purity. aspects of treating moral injury with acceptance

Figure 1. Self-Directed Moral Injury Severity as a Function of Preference Given to Individualizing and Binding Moral Foundations

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 156 moral foundations and the severity of moral Internalized moral injury is likely to arise and commitment therapy (ACT) as an alternative to insufficiently address moral injury but injury symptoms that they endorse. Specifically, after an individual has witnessed, failed to to the “gold standard” EBPs for treating PTSD. also because veterans do not place as high of distinguishing whether a veteran identifies more prevent, or even perpetrated acts that violate Farnsworth et al. stated that while traditional a preference on religion/spirituality as was closely with either binding or individualizing their moral foundation, and it is often manifested EBPs designed to treat PTSD focus on trauma previously hypothesized. moral foundations can explain how they interpret in symptoms such as shame, guilt, remorse, symptom reduction, ACT invites the experiencing In this sample, veterans overwhelmingly a pMIE. Veterans who demonstrate a high and depression.. These symptoms are closely of guilt, shame, disgust, and so on, “allowing their exhibited the least preference for the Sanctity preference for either individualizing or binding associated with individualizing foundations, presence to inform those suffering from moral scale, which is highly influenced by religion. foundations would likely benefit from treatment as they place more emphasis on the individual injury, evaluating themselves as inhuman, that Furthermore, Question 16 on the MFQ asked that differs from treatment given to individuals as the locus of morality. When someone else they are human and the pain of their experience participants to what extent they believe “whether who endorse low preferences in either group of (whether it be peers, superiors, society, or deity) is a reminder of their intact, but unlived, values” or not someone acted in a way that God would moral foundations. Examining preference given violates an individual’s binding foundations the (p. 396). Treating moral injury with more holistic approve of” is relevant when determining right to each moral foundation and comparing those transgression is externalized, which often results and encompassing approaches, such as ACT, will from wrong. In this study’s sample of veterans, the results with a veteran’s moral injury symptoms in anger. This violation can be perpetrated by most likely decrease dropout rates and increase mean was 1.95 on a 1–5 Likert scale, indicating Not can provide insight into the nature of the peers, superiors, society, or even one’s deity. When veterans’ quality of life. Very Relevant–Slight Relevance, and was the least perceived transgression and can ultimately help an individual’s moral foundations are violated, In addition to creating more functional preferred statement overall when deciding moral to indicate the best course of treatment for the understanding which foundations were violated, and adaptive therapeutic interventions for the relevance. These findings suggest that emphasizing specific individual. how they were violated, and how the patient has treatment of moral injury, understanding how religion and spirituality may not be as important Although examining each individual’s manifested symptoms will allow clinicians to patients’ moral foundations can influence the as was previously believed, particularly among moral foundation preferences is a crucial step develop and implement more effective treatments. type and extent of their moral injury will help younger veterans, and that addressing the other in the treatment of moral injury, this study also dictate appropriate courses of treatment. As four core foundations will likely produce more illustrates the importance of evaluating patients’ Clinical Implications stated earlier, religion and spirituality are often active engagement in therapy. symptoms in terms of moral injury subtypes. Recent studies have illustrated the need for heavily emphasized in common conceptions of Veterans who identify with individualizing new treatment interventions to specifically address morality and moral injury; thus, some current Limitations foundations over binding foundations may be moral injury. They have also illuminated the ways treatment interventions stress spiritual- and There were several limitations in the present prone to endorse higher SDMI than ODMI, in which current EBPs used to treat trauma-related faith-based aspects of forgiveness, repentance, study. First, the study’s sample size (N = 85) may not while those who prefer binding foundations to symptoms in veterans are ineffective in treating and atonement. One such intervention, allow for the results to be generalized to the entire individualizing foundations may endorse higher moral injury: Clinicians do not discuss moral spiritually-integrated cognitive processing veteran population and may not fully encompass ODMI than SDMI. From a practical perspective, injury during treatment, often have poor rapport therapy, was created by adapting the current the experiences and attitudes of all veterans. Future it makes sense that an individual who is more with the veterans they serve, and implement CPT protocol to emphasize religious/spiritual studies would be wise to investigate the changes concerned with aspects of equality, nurturance, therapeutic interventions too rigidly (Hoge et al., aspects of the patient (Pearce et al., 2018). that occur to veterans’ moral foundations after and caring for those unable to care for themselves 2014). Additional studies highlight the need to treat While this approach may benefit a small sample exposure to pMIEs, provided a larger sample size is would interpret a pMIE much differently than moral injury using a more functional, adaptable of veterans, this form of therapy is likely to be obtained. The use of additional measures, including would an individual who differentiates right from approach that allows for changes in agenda. counterproductive in the treatment of moral those that assess for moral injury exposure, would wrong based on respect for authority, a sense of Farnsworth et al. (2017) demonstrated the positive injury not only because CPT has been shown provide detail that cannot be obtained using only group responsibility, and purity. aspects of treating moral injury with acceptance

Figure 1. Self-Directed Moral Injury Severity as a Function of Figure 2. Other-Directed Moral Injury Severity as a Function of Preference Given to Individualizing and Binding Moral Foundations Preference Given to Individualizing and Binding Moral Foundations

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 157 the EMIS-M. Measures such as the Moral Injury clinicians who work with veterans suffering from Questionnaire–Military Version (MIQ-M) and the moral injury. It provides empirical support for a Moral Injury Events Scale (MIES) are examples better understanding of why the current emphases of reliable and valid measures that may be used on EBPs and religious aspects of treatment are to evaluate moral injury in veterans and should often ineffectual, and it suggests that a more be incorporated into future studies (Bryan et al., holistic, functional view of morality may be 2016; Currier, Holland, et al., 2015). needed in order to fully encompass the complexity While examining the data for additional of moral injury. The study also offers insights results, another limitation was discovered. into the use of conceptual models informed by Question 28 on the MFQ, which asks respondents moral foundations theory; these models may to evaluate the statement “It can never be right to be helpful in creating treatment modalities for kill a human being,” is one of the most essential moral injury that address each of the five core items in determining moral judgment preference moral foundations. These treatments can be for the Care foundation. The original MFQ study adapted to meet the needs of individual patients found the mean score for this item among the based on their endorsements of particular moral general population to be 2.50, midway between foundations and the severity of their individual Slightly Disagree and Slightly Agree. The mean experiences of SDMI and/or ODMI. for Question 28 in this sample of veterans was significantly lower (M = 1.27), indicating that References participants universally disagreed with this Borges, L.M., Bahraini, N.H., Holliman, B.D., statement. Given the nature and purpose of Gissen, M.R., Lawson, W.C., & Barnes, S.M. (2019). the military, this is to be expected; however, it Veterans’ perspectives on discussing moral injury indicates that the MFQ may not be an entirely in the context of evidence‐based psychotherapies valid instrument for determining moral for PTSD and other VA treatment. Journal of foundations preferences among this population. Clinical Psychology, 76(3), 377–391. https://doi. The development of a military version of the org/10.1002/jclp.22887 assessment may be necessary. Bryan, A.O., Bryan, C.J., Morrow, C.E., Etienne, N., & Ray-Sannerud, B. (2014). Moral Directions for Future Research injury, suicidal ideation, and suicide attempts in Current research into moral injury has a military sample. Traumatology, 20(3), 154–160. allowed for the development of several measures https://doi.org/10.1037/h0099852 and treatment interventions that specifically Bryan, C.J., Bryan, A.O., Anestis, M.D., address symptoms of moral injury. This study is Anestis, J.C., Green, B.A., Etienne, N., Morrow, the first to incorporate the concept of moral injury C.E., & Ray-Sannerud, B. (2016). Measuring with the moral foundations theory in an attempt moral injury: Psychometric properties of the to discover previously unknown or misunderstood Moral Injury Events Scale in two military implications of how moral foundations preferences samples. Assessment, 23(5), 557–570. https://doi. can influence one’s development of moral injury. org/10.1177/1073191115590855 Future research should utilize these findings Currier, J.M., Farnsworth, J.K., Drescher, alongside other measures of moral injury and K.D., McDermott, R.C., Sims, B.M., & Albright, moral foundations to more specifically address D.L. (2018). Development and evaluation of concerns specific to the veteran population. The the Expressions of Moral Injury Scale–Military development of a military version of the MFQ to Version. Clinical Psychology and Psychotherapy, measure moral foundations preferences in active- 25(3), 474–488. https://doi.org/10.1002/cpp.2170 duty servicemen and women and veterans may Currier, J. M., Holland, J.M., Drescher, K.D., & allow for a more specific understanding of the Foy, D. (2015). Initial psychometric evaluation of effects one’s moral foundation development may the Moral Injury Questionnaire–Military Version. have on the development of moral injury. Clinical Psychology & Psychotherapy, 22(1), 54–63. https://doi.org/10.1002/cpp.1866 Conclusions Currier, J.M., McCormick, W., & Drescher, The findings of this study are meant to elicit K.D. (2015). How do morally injurious events discussion of new, alternative interventions for occur? A qualitative analysis of perspectives the treatment of moral injury in U.S. veterans. of veterans with PTSD. Traumatology, 21(2), 106– The study was also designed to provide insight to 116. https://doi.org/10.1037/trm0000027

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 158 the EMIS-M. Measures such as the Moral Injury clinicians who work with veterans suffering from Farnsworth, J.K., Drescher, K.D., Evans, W., Jinkerson, J.D., & Battles, A.R. (2019). Questionnaire–Military Version (MIQ-M) and the moral injury. It provides empirical support for a & Walser, R.D. (2017). A functional approach Relationships between moral injury syndrome Moral Injury Events Scale (MIES) are examples better understanding of why the current emphases to understanding and treating military-related model variables in combat veterans. Traumatology, of reliable and valid measures that may be used on EBPs and religious aspects of treatment are moral injury. Journal of Contextual Behavioral 25(1), 33–40. https://doi.org/10.1037/trm0000163 to evaluate moral injury in veterans and should often ineffectual, and it suggests that a more Science, 6(4), 391–397. https://doi.org/10.1016/j. Nash, W.P., & Litz, B.T. (2013). Moral injury: A be incorporated into future studies (Bryan et al., holistic, functional view of morality may be jcbs.2017.07.003 mechanism for war-related psychological trauma 2016; Currier, Holland, et al., 2015). needed in order to fully encompass the complexity Foa, E.B., Gillihan, S.J., & Bryant, R.A. (2013). in military family members. Clinical Child and While examining the data for additional of moral injury. The study also offers insights Challenges and successes in dissemination of Family Psychology Review, 16(4), 365–375. https:// results, another limitation was discovered. into the use of conceptual models informed by evidence-based treatments for posttraumatic doi.org/10.1007/s10567-013-0146-y Question 28 on the MFQ, which asks respondents moral foundations theory; these models may stress: Lessons learned from prolonged exposure Litz, B.T., Stein, N., Delaney, E., Lebowitz, to evaluate the statement “It can never be right to be helpful in creating treatment modalities for therapy for PTSD. Psychological Science in L., Nash, W.P., Silva, C., & Maguen, S. (2009). kill a human being,” is one of the most essential moral injury that address each of the five core the Public Interest, 14(2), 65–111. https://doi. Moral injury and moral repair in war veterans: items in determining moral judgment preference moral foundations. These treatments can be org/10.1177/1529100612468841 A preliminary model and intervention strategy. for the Care foundation. The original MFQ study adapted to meet the needs of individual patients Graham, J., Haidt, J., Koleva, S., Motyl, M., Clinical Psychology Review, 29(8), 695–706. https:// found the mean score for this item among the based on their endorsements of particular moral Iyer, R., Wojcik, S. P., & Ditto, P. H. (2013). Moral doi.org/10.1016/j.cpr.2009.07.003 general population to be 2.50, midway between foundations and the severity of their individual foundations theory: The pragmatic validity of Pearce, M., Haynes, K., Rivera, N.R., & Slightly Disagree and Slightly Agree. The mean experiences of SDMI and/or ODMI. moral pluralism. Advances in Experimental Social Koenig, H.G. (2018). Spiritually integrated for Question 28 in this sample of veterans was Psychology, 47, 55–130. https://doi.org/10.1016/ cognitive processing therapy: A new treatment significantly lower (M = 1.27), indicating that References B978-0-12-407236-7.00002-4 for post-traumatic stress disorder that targets participants universally disagreed with this Borges, L.M., Bahraini, N.H., Holliman, B.D., Graham, J., Haidt, J., & Nosek, B.A. (2009). moral injury. Global Advances in Health and statement. Given the nature and purpose of Gissen, M.R., Lawson, W.C., & Barnes, S.M. (2019). Liberals and conservatives rely on different sets Medicine, 7, Article 2164956118759939. https:// the military, this is to be expected; however, it Veterans’ perspectives on discussing moral injury of moral foundations. Journal of Personality and doi.org/10.1177/2164956118759939 indicates that the MFQ may not be an entirely in the context of evidence‐based psychotherapies Social Psychology, 96(5), 1029–1046. Resick, P.A., Suvak, M.K., Johnides, B.D., valid instrument for determining moral for PTSD and other VA treatment. Journal of Graham, J., Nosek, B.A., & Haidt, J. (2012). Mitchell, K.S., & Iverson, K.M. (2012). The impact foundations preferences among this population. Clinical Psychology, 76(3), 377–391. https://doi. The moral stereotypes of liberals and conservatives: of dissociation on PTSD treatment with cognitive The development of a military version of the org/10.1002/jclp.22887 Exaggeration of differences across the political processing therapy. Depression and Anxiety, 29(8), assessment may be necessary. Bryan, A.O., Bryan, C.J., Morrow, C.E., spectrum. PLoS ONE, 7(12), Article e50092. 718–730. https://doi.org/10.1002/da.21938 Etienne, N., & Ray-Sannerud, B. (2014). Moral https://doi.org/10.1371/journal.pone.0050092 Shay, J. (1991). 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The invisible wound: Moral can influence one’s development of moral injury. org/10.1177/1073191115590855 42(3), 281–297. https://doi.org/10.1080/03057240 injury and its impact on the health of Operation Future research should utilize these findings Currier, J.M., Farnsworth, J.K., Drescher, .2013.817327 Enduring Freedom/Operation Iraqi Freedom alongside other measures of moral injury and K.D., McDermott, R.C., Sims, B.M., & Albright, Haidt, J., & Graham, J. (2007). When veterans. Military Medicine, 181(5), 451–458. moral foundations to more specifically address D.L. (2018). Development and evaluation of morality opposes justice: Conservatives have https://doi.org/10.7205/MILMED-D-15-00103 concerns specific to the veteran population. The the Expressions of Moral Injury Scale–Military moral intuitions that liberals may not recognize. development of a military version of the MFQ to Version. Clinical Psychology and Psychotherapy, Social Justice Research, 20(1), 98–116. https://doi. About the Authors measure moral foundations preferences in active- 25(3), 474–488. https://doi.org/10.1002/cpp.2170 org/10.1007/s11211-007-0034-z Daniel Perez, Psy.D., obtained a doctorate in duty servicemen and women and veterans may Currier, J. M., Holland, J.M., Drescher, K.D., & Hoge, C.W., Grossman, S. H., Auchterlonie, clinical psychology from the Chicago School of allow for a more specific understanding of the Foy, D. (2015). Initial psychometric evaluation of J.L., Riviere, L.A., Milliken, C.S., & Wilk, J.E. Professional Psychology and is currently a clinical effects one’s moral foundation development may the Moral Injury Questionnaire–Military Version. (2014). PTSD treatment for soldiers after combat psychologist at the Loma Linda VA Medical have on the development of moral injury. Clinical Psychology & Psychotherapy, 22(1), 54–63. deployment: Low utilization of mental health care Center in Loma Linda, CA. He is also a veteran https://doi.org/10.1002/cpp.1866 and reasons for dropout. Psychiatric Services, 65(8), of the U.S. Army who served from 2001–2005 as Conclusions Currier, J.M., McCormick, W., & Drescher, 997–1004. https://doi.org/10.1176/appi.ps.201300307 an enlisted airborne infantryman. Dr. Perez is The findings of this study are meant to elicit K.D. (2015). How do morally injurious events Jinkerson, J.D. (2016). Defining andthe recipient of the Combat Infantryman Badge, discussion of new, alternative interventions for occur? A qualitative analysis of perspectives assessing moral injury: A syndrome perspective. Army Commendation Medal, Parachutist Badge, the treatment of moral injury in U.S. veterans. of veterans with PTSD. Traumatology, 21(2), 106– Traumatology, 22(2), 122–130. https://doi. Afghanistan Campaign Medal, Global War On The study was also designed to provide insight to 116. https://doi.org/10.1037/trm0000027 org/10.1037/trm0000069 Terrorism Expeditionary Medal, and National

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 159 Defense Service Ribbon. Paul Larson, Ph.D., J.D. obtained a Ph.D. in 1977 from the University of Utah and a J.D. from DePaul University in 1993. He served as a full professor in the clinical psychology program at the Chicago School of Professional Psychology from 2004-2019 and currently holds professor emeritus status. John Bair, Ph.D., obtained a Ph.D. from Northwestern University in 1990 and is currently a staff psychologist at the Lovell Federal Health Care Center in North Chicago. He instructs courses in group and social systems for psychiatry residents and psychology students. Bair also serves as a clinical associate professor at Rosalind Franklin University.

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 160 Defense Service Ribbon. Paul Larson, Ph.D., J.D. obtained a Ph.D. in 1977 from the University of Structural Examination of Moral Injury Utah and a J.D. from DePaul University in 1993. He and PTSD and Their Associations With served as a full professor in the clinical psychology Suicidal Behavior Among Combat Veterans program at the Chicago School of Professional Psychology from 2004-2019 and currently holds Allison R. Battles, Jeremy Jinkerson, professor emeritus status. John Bair, Ph.D., obtained a Ph.D. from Northwestern University Michelle L. Kelley, and Richard A. Mason in 1990 and is currently a staff psychologist at the Lovell Federal Health Care Center in North Chicago. He instructs courses in group and social Abstract systems for psychiatry residents and psychology Moral injury and post-traumatic stress disorder are argued to be distinct yet related constructs. students. Bair also serves as a clinical associate However, few studies have evaluated the factors distinguishing moral injury from PTSD. The present professor at Rosalind Franklin University. study sought to extend the work of Bryan et al. (2018) by differentiating the symptomology of moral injury and PTSD and their associations with suicidal behaviors among combat veterans. The study evaluated data from 129 combat veterans exposed to potentially morally injurious events. Exploratory structural equation modeling evaluated a measurement and structural model. Results revealed a four-factor solution, with the relevant factors being PTSD symptoms, guilt/shame, psychiatric comorbidities, and meaning in life. Guilt/shame and psychiatric comorbidities had significant positive effects on suicidal behaviors. The present findings suggest that combat veterans have a complex, dimensional response to combat trauma and pMIE exposure. These results diverged from previous research to suggest that moral injury symptoms may not constitute a single factor but rather a multifaceted constellation of symptoms. The present study also provided evidence that moral injury symptoms are both unique and overlapping with PTSD symptoms. Suicidal behaviors are a major area of concern among veterans, and the findings here implicate guilt/shame and psychiatric comorbidities as related to these suicidal behaviors.

Over the past decade, greater attention has Although moral injury has received been given to the psychological consequences considerable attention, a theoretically of wartime transgressions that may violate fundamental issue is how moral injury differs servicemembers’ moral beliefs and result in moral from post-traumatic stress disorder (PTSD). In a injury. Moral injury is believed to be the result of pioneering study, Bryan et al. (2018) examined the potentially morally injurious events (pMIEs), such similarities and differences between the symptoms as excessive violence, leadership failure, failure to of PTSD and those of moral injury and explored save a life or prevent injury, or the act of injuring how PTSD and moral injury were associated with or killing a noncombatant (Frankfurt & Frazier, suicidal thoughts and behaviors. They found that 2016). Although some combat veterans are able among Army National Guard members, moral to resolve the dissonance or internal conflict of injury was uniquely characterized by anhedonia, perpetrating or witnessing an act that transgresses anger, shame, guilt, and hostility toward oneself, one’s moral code, for others, these actions result in whereas PTSD was uniquely characterized by strong emotional reactions, such as guilt, shame, flashbacks, memory loss, nightmares, insomnia, loss of meaning, difficulties with forgiveness, and startle reflex. Although the Bryan et al. and spiritual/existential crisis. Collectively, these (2018) study was groundbreaking, only 58.2% of reactions and emotions have been termed moral the study’s sample had ever deployed. Combat injury (Jinkerson, 2016; Litz et al., 2009; Shay, veterans are arguably more likely than other 2002, 2014). Core symptoms of moral injury (e.g., military members to have been exposed to pMIEs guilt, shame) are believed to drive secondary due to the increased opportunities they have had outcomes (Jinkerson, 2016; Litz et al., 2009), for high-stakes moral decision-making (Shay, such as depression, anxiety, suicidal thoughts and 2014). Subsequently, they may be more likely to behavior, and hazardous substance use (Battles develop PTSD (Xue et al., 2015) or moral injury et al., 2018; Battles et al., 2019; Bryan et al., 2014; (Shay, 1991, 2002). Moreover, combat is associated Bryan et al., 2018; Jinkerson, 2016; Jinkerson & with PTSD (Maguen & Litz, 2012; Stein et al., Battles, 2019; Kelley et al., 2019). 2012) and moral injury symptoms (Drescher et

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 161 al., 2011; Nash & Litz, 2013). For this reason, we hypothesized that a measurement model of these examined moral injury and PTSD symptoms in a constructs would provide additional support for sample consisting solely of combat veterans. as well as extend the model delineating the unique In general, investigators have found that both and shared symptoms of moral injury and PTSD moral injury and PTSD are associated with suicidal as proposed by Bryan et al. (2018; see Figure 1). behaviors. For instance, Bryan et al. (2018) found We anticipated that a PTSD factor would emerge that the interaction of moral injury and PTSD separately from a moral injury factor but did not predicted both suicidal ideation and attempts. hold other specific hypotheses. Next, we examined Combat veterans, in particular, have been found whether moral injury symptoms and PTSD to be at a higher risk for suicidality compared to symptoms were associated with suicidal behaviors noncombat veterans (Fanning & Pietrzak, 2013). in combat veterans. Similar to the findings by This appears to be statistically explained, in part, by Bryan et al. (2018), we hypothesized an interaction combat experiences, as those exposed to killing and effect between moral injury symptoms and PTSD atrocities of war have a 43% greater risk of suicide- symptoms on suicidal behaviors. related outcomes than deployed servicemembers without combat experiences (Bryan et al., 2015). Method Additionally, combat experiences, particularly Participants killing and exposure to disproportionate violence The final sample consisted of data collected (e.g., pMIEs), tend to have a stronger association from 129 combat veterans (99 men). Criteria for with suicide than does deployment in and of itself participation were (a) a history of at least one (Bryan et al., 2014). deployment lasting for 90 days or more and (b) being a “combat veteran,” defined as anyone who Purpose of the Present Study “attacked enemy combatants, was attacked, or Similar to Bryan et al. (2018), in the present study who served in a military-designated dangerous we conducted factor analyses of moral injury and region during wartime.” Most participants were PTSD symptoms. We extended the work of Bryan male (77.3%), White (70.5%), and/or married et al. (2018), however, by examining additional (50.8%), with an average age of 36.72 years (SD factors that have previously been construed as = 10.52 years). Of the participants, 95 (73.6%) moral injury symptoms, such as impaired trust and were former military members, 17 (13.2%) were loss of meaning in life (Currier, Holland, & Malott, presently serving on active duty, and 17 (13.2%) 2015; Harris et al., 2015; Jinkerson, 2016). It was were currently National Guard/reserves members.

Figure 1. Expanded Model of the Theorized Overlap of PTSD and Moral Injury Components

PTSD Moral Injury

Anhedonia Sorrow Flashbacks Anger Guilt Memory loss Depression Shame Fear Anxiety Social alienation Hypervigilance Insomnia Loss of trust Startle Reflex Nightmares Loss of meaning in life* Difficulty with forgiveness

Note. Constructs in bold were measured in the present study. Original model created by Bryan et al. (2018). *New proposed symptom evaluated in current study.

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 162 al., 2011; Nash & Litz, 2013). For this reason, we hypothesized that a measurement model of these Branches of service (which were not mutually Exposure to pMIEs examined moral injury and PTSD symptoms in a constructs would provide additional support for exclusive) represented in the current study included The Moral Injury Questionnaire–Military sample consisting solely of combat veterans. as well as extend the model delineating the unique the U.S. Army (n = 77, 59.6%), U.S. Marine Corps Version (MIQ-M; Currier, Holland, Drescher, In general, investigators have found that both and shared symptoms of moral injury and PTSD (n = 20, 15.5%), U.S. Navy (n = 16, 12.4%), and et al., 2015) is a 20-item self-report measure that moral injury and PTSD are associated with suicidal as proposed by Bryan et al. (2018; see Figure 1). U.S. Air Force (n = 16, 2.4%). Participants were assesses the degree of exposure to pMIEs (e.g., “I behaviors. For instance, Bryan et al. (2018) found We anticipated that a PTSD factor would emerge involved in the following conflicts: Operation did things in the war that betrayed my personal that the interaction of moral injury and PTSD separately from a moral injury factor but did not Enduring Freedom (n = 54, 41.9%), Operation values.”). Participants rated each item on a 4-point predicted both suicidal ideation and attempts. hold other specific hypotheses. Next, we examined Iraqi Freedom (n = 81, 62.8%), Persian Gulf War Likert scale ranging from 1 (never) to 4 (often). Combat veterans, in particular, have been found whether moral injury symptoms and PTSD (n = 14, 10.9%), and Vietnam War (n = 10, 7.8%). Item scores were summed, with higher scores to be at a higher risk for suicidality compared to symptoms were associated with suicidal behaviors Most participants were enlisted (110, 85.3%). On reflecting higher levels of pMIE exposure. noncombat veterans (Fanning & Pietrzak, 2013). in combat veterans. Similar to the findings by average, they had deployed 2.92 times (SD = 0.83) This appears to be statistically explained, in part, by Bryan et al. (2018), we hypothesized an interaction and had served in the military for 9.14 years (SD PTSD Symptoms combat experiences, as those exposed to killing and effect between moral injury symptoms and PTSD = 6.58). All participants reported exposure to at The PTSD Checklist forDSM-5 (PCL-5; atrocities of war have a 43% greater risk of suicide- symptoms on suicidal behaviors. least one pMIE during deployment, per the Moral Blevins et al., 2015) is a 20-item self-report related outcomes than deployed servicemembers Injury Questionnaire–Military Version (MIQ-M). measure that evaluates PTSD symptoms per without combat experiences (Bryan et al., 2015). Method DSM-5 criteria (American Psychiatric Association Additionally, combat experiences, particularly Participants Procedure [APA], 2013). In the present study, two items were killing and exposure to disproportionate violence The final sample consisted of data collected Participants were recruited through Amazon’s used to measure hypervigilance, one item was used (e.g., pMIEs), tend to have a stronger association from 129 combat veterans (99 men). Criteria for Mechanical Turk (MTurk) service. Those who to measure memory loss, two items were used to with suicide than does deployment in and of itself participation were (a) a history of at least one provided informed consent were presented measure intrusive memories, and one item was (Bryan et al., 2014). deployment lasting for 90 days or more and (b) with demographic questions followed by survey used to measure nightmares. Items were rated on being a “combat veteran,” defined as anyone who questionnaires, which were administered in a a 5-point Likert scale ranging from 0 (not at all) Purpose of the Present Study “attacked enemy combatants, was attacked, or counterbalanced format. Two validity check items to 4 (extremely). Item scores were summed; higher Similar to Bryan et al. (2018), in the present study who served in a military-designated dangerous were administered: “What is the acronym for the scores reflected higher levels of PTSD symptoms. we conducted factor analyses of moral injury and region during wartime.” Most participants were location where physicals are taken prior to shipping PTSD symptoms. We extended the work of Bryan male (77.3%), White (70.5%), and/or married off for basic training?” and “What is the acronym Trauma-Related Guilt et al. (2018), however, by examining additional (50.8%), with an average age of 36.72 years (SD for the generic term the military uses for various The Trauma-Related Guilt Inventory (TRGI; factors that have previously been construed as = 10.52 years). Of the participants, 95 (73.6%) job fields?” (Lynn & Morgan, 2016). Of the 496 Kubany et al., 1996) is a 32-item self-report measure moral injury symptoms, such as impaired trust and were former military members, 17 (13.2%) were individuals who responded affirmatively to having that assesses guilt after a traumatic event. Items were loss of meaning in life (Currier, Holland, & Malott, presently serving on active duty, and 17 (13.2%) served in the U.S. military, only 132 answered rated on a 5-point Likert scale ranging from 0 (not 2015; Harris et al., 2015; Jinkerson, 2016). It was were currently National Guard/reserves members. the two validity checks accurately; of those 132 at all true) to 5 (extremely true). Two items were individuals, only 129 endorsed exposure to at least analyzed as representative of trauma-related guilt. Figure 1. Expanded Model of the Theorized Overlap of PTSD and Moral Injury Components one pMIE. Data from these 129 participants was Item scores were summed; higher scores reflected used in all analyses. Participants were compensated higher levels of trauma-related guilt. $2 through MTurk. Following survey completion, participants were provided with service branch– Trauma-Related Shame PTSD Moral Injury specific and veteran-specific national mental The Trauma-Related Shame Inventory (TRSI; health resources. The study received institutional Øktedalen et al., 2014) is a 24-item self-report review board approval. measure of feelings of shame following a traumatic Anhedonia event. Participants rated their responses on a Sorrow Flashbacks Anger Measures 4-point Likert scale ranging from 1 (not true of me) Guilt Memory loss Depression Mirroring the approach of Bryan et al. (2018) to 4 (completely true of me). Two items were used to Shame Fear Anxiety and to reduce the burden on respondents, select represent trauma-related shame. Summed responses Social alienation Hypervigilance Insomnia items were used to represent corresponding yielded continuous scores, with higher scores Loss of trust constructs. For example, the PTSD symptom reflecting higher levels of trauma-related shame. Startle Reflex Nightmares Loss of meaning in life* flashbacks was represented with the PTSD Difficulty with forgiveness Checklist-5 item “Suddenly feeling or acting as if Trust the stressful experience were actually happening The World Assessment Questionnaire (WAQ; again.” Items or sample items for each construct Kaler, 2009) is a 25-item self-report inventory that are shown in Table 1. See Table 2 for descriptive assesses an individual’s fundamental assumptions statistics and reliability indices for all measures. about the world. Given the study’s focus on trust in For all constructs, item scores were summed to others, only the Trustworthiness and Goodness of Note. Constructs in bold were measured in the present study. create a total score; higher scores reflected higher People subscale was administered. Items were rated Original model created by Bryan et al. (2018). levels of a construct. on a 6-point Likert scale ranging from 1 (strongly *New proposed symptom evaluated in current study.

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 163 Table 1. Indicator Variables Selected to Measure Each Symptom of PTSD and/or Moral Injury

Proposed Symptom Indicators Sample Item Construct TRGI items 18, Overall, how guilty do you feel MI Guilt 25 about the event(s)? I am ashamed of myself because MI Shame TRSI items 3, 8 of what happened to me. WAQ-T items MI Loss of trust Most people can be trusted. 2, 4 Loss of meaning MLQ-P items My life has a clear sense of MI in life 2, 3 purpose. I feel lonely and isolated from MI Social alienation SFQ item 7 other people. Little interest or pleasure in doing MI Anhedonia PHQ-2 item 1 things Feeling down, depressed, or MI & PTSD Depression PHQ-2 item 2 hopeless I often find myself getting angry MI & PTSD Anger DAR item 1 at people or situations. Feeling nervous, anxious, or on MI & PTSD Anxiety GAD-2 edge Repeated, disturbing dreams of MI & PTSD Nightmares PCL-5 item 2 the stressful experience Suddenly feeling or acting as if PTSD Flashbacks PCL-5 items 3 the stressful experience were actually happening again Trouble remembering important PTSD Memory loss PCL-5 item 8 parts of the stressful experience Being “superalert” or watchful or PTSD Hypervigilance PCL-5 item 17 on guard PTSD Startle reflex PCL-5 item 18 Feeling jumpy or easily startled

Note. MI = moral injury; PTSD = post-traumatic stress disorder; TRGI = Trauma-Related Guilt Inventory; TRSI = Trauma-Related Shame Inventory; WAQ-T = World Assumption Questionnaire–Trustworthiness and Goodness of People subscale; MLQ-P = Meaning in Life Questionnaire–Presence subscale; SFQ = Social Functioning Questionnaire; PHQ-2 = Patient Health Questionnaire–2; DAR = Dimensions of Anger Reactions; GAD-2 = Generalized Anxiety Disorder–2; PCL-5 = PTSD Checklist for DSM-5. agree) to 6 (strongly disagree). Two items were used our focus on subjective meaning in life, only items to represent levels of trust in others. Responses from the Presence subscale were administered. were summed to yield continuous scores, with Items were rated on a 7-point Likert scale ranging higher scores reflecting greater levels of trust. from 1 (absolutely untrue) to 7 (absolutely true). Two items were analyzed as representative of Meaning in Life subjective meaning in life. Responses were The Meaning in Life Questionnaire (MLQ; summed to yield continuous total scores, with Steger et al., 2006) is a 10-item self-report higher scores reflecting higher levels of subjective instrument with subscales measuring the meaning in life. presence of and search for meaning in life. Given

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 164 Table 1. Indicator Variables Selected to Measure Each Symptom of PTSD and/or Moral Injury Table 2. Descriptive Statistics for Study Measures

Proposed Symptom Indicators Sample Item Measure M (SD) Range* Reliability Construct MIQ-M 39.20 (9.74) 41 [21, 62] .89 TRGI items 18, Overall, how guilty do you feel MI Guilt 25 about the event(s)? PCL-5 47.52 (18.14) 69 [20, 89] .96 I am ashamed of myself because MI Shame TRSI items 3, 8 TRGI 78.02 (23.21) 98 [38, 136] .94 of what happened to me. WAQ-T items TRSI 42.22 (18.18) 65 [24, 89] .98 MI Loss of trust Most people can be trusted. 2, 4 WAQ-T 15.10 (3.89) 20 [6, 26] .77 Loss of meaning MLQ-P items My life has a clear sense of MI in life 2, 3 purpose. MLQ-P 23.11 (7.48) 28 [7, 35] .92 I feel lonely and isolated from MI Social alienation SFQ item 7 PHQ-2 5.22 (2.01) 9 [3, 12] .83 other people. Little interest or pleasure in doing GAD-2 4.07 (1.71) 6 [2, 8] .84 MI Anhedonia PHQ-2 item 1 things DAR 11.30 (4.31) 17 [5, 22] .85 Feeling down, depressed, or MI & PTSD Depression PHQ-2 item 2 hopeless SFQ 13.54 (2.53) 13 [6, 19] .78 I often find myself getting angry MI & PTSD Anger DAR item 1 SBQ-R 5.24 (2.78) 12 [3, 15] .82 at people or situations. Feeling nervous, anxious, or on MI & PTSD Anxiety GAD-2 Note. N = 129; MIQ-M = Moral Injury Questionnaire–Military version (modified); PCL-5 = PTSD Checklist edge for DSM-5; TRGI = Trauma-Related Guilt Inventory; TRSI = Trauma-Related Shame Inventory; WAQ-T Repeated, disturbing dreams of = World Assumption Questionnaire–Trustworthiness and Goodness of People subscale; MLQ-P = Meaning MI & PTSD Nightmares PCL-5 item 2 in Life Questionnaire–Presence subscale; PHQ-2 = Patient Health Questionnaire–2; GAD-2 = Generalized the stressful experience Anxiety Disorder–2; DAR = Dimensions of Anger Reactions; SFQ = Social Functioning Questionnaire; Suddenly feeling or acting as if SBQ-R = Suicide Behaviors Questionnaire–Revised. PTSD Flashbacks PCL-5 items 3 the stressful experience were *Range represents the range of scores for study participants and includes the [Min, Max]; actually happening again Trouble remembering important PTSD Memory loss PCL-5 item 8 parts of the stressful experience Being “superalert” or watchful or Depression Anger PTSD Hypervigilance PCL-5 item 17 on guard The Patient Health Questionnaire–2 (PHQ-2; The Dimensions of Anger Reactions (DAR; Kroenke et al., 2003) is a two-item screening Forbes et al., 2004) is a seven-item self-report PTSD Startle reflex PCL-5 item 18 Feeling jumpy or easily startled measure of anhedonia and depressed mood (“Little measure of anger directed toward others. interest or pleasure in doing things” and “Feeling Participants rated their degree of anger on a 9-point Note. MI = moral injury; PTSD = post-traumatic stress disorder; TRGI = Trauma-Related Guilt Inventory; TRSI = Trauma-Related Shame Inventory; WAQ-T = World Assumption down, depressed, or hopeless”). Responses were Likert scale ranging from 0 (not at all) to 8 (exactly so). Questionnaire–Trustworthiness and Goodness of People subscale; MLQ-P = Meaning in recorded on a 4-point Likert scale ranging from 0 One item was analyzed as representative of anger. Life Questionnaire–Presence subscale; SFQ = Social Functioning Questionnaire; (not at all) to 3 (nearly every day). Responses were PHQ-2 = Patient Health Questionnaire–2; DAR = Dimensions of Anger Reactions; summed to yield continuous total scores, with Social Functioning GAD-2 = Generalized Anxiety Disorder–2; PCL-5 = PTSD Checklist for DSM-5. higher scores reflecting higher levels of anhedonia The Social Functioning Questionnaire (SFQ; and depressed mood. Tyrer et al., 2005) is an eight-item self-report agree) to 6 (strongly disagree). Two items were used our focus on subjective meaning in life, only items measure of perceived social functioning. Items to represent levels of trust in others. Responses from the Presence subscale were administered. Anxiety were rated on a 4-point Likert scale ranging from were summed to yield continuous scores, with Items were rated on a 7-point Likert scale ranging The Generalized Anxiety Disorder–2 (GAD-2; 0 to 3, with response options corresponding to the higher scores reflecting greater levels of trust. from 1 (absolutely untrue) to 7 (absolutely true). Kroenke et al., 2007) is a two-item screener for nature of each question. Two items were analyzed as representative of generalized anxiety symptoms. Items were rated on Meaning in Life subjective meaning in life. Responses were a 4-point Likert scale ranging from 0 (not at all sure) Suicidal Behaviors The Meaning in Life Questionnaire (MLQ; summed to yield continuous total scores, with to 3 (nearly every day). Responses were summed The Suicidal Behaviors Questionnaire–Revised Steger et al., 2006) is a 10-item self-report higher scores reflecting higher levels of subjective to yield continuous total scores, with higher scores (SBQ-R; Osman et al., 2001) is a four-item instrument with subscales measuring the meaning in life. reflecting higher levels of anxiety symptoms. self-report questionnaire that assesses history presence of and search for meaning in life. Given of suicidal ideation and attempts, frequency of

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 165 ideation, suicidal verbal expressions, and likelihood branches of service) were significantly correlated of future suicide. At the request of the institutional with suicidal behaviors and were controlled for as review board, the item regarding likelihood of covariates across structural model analyses. future suicide was excluded. Response options vary by question. Responses were summed to yield Results continuous total scores, with higher scores reflecting Exploratory Structural Equation Modeling (ESEM) more suicidal behaviors. Over half (57.4%) of participants endorsed suicidal behaviors. Correlations among Data Analyses study-developed item constructs are presented in After removing data from participants who Table 3. Results of the ESEM model found that a did not accurately respond to validity checks, no four-factor model produced the best fit: χ2(101) missing data were found. Analyses were conducted = 165.25, p = .001, comparative fit index (CFI) = using Mplus 8.3 (Muthén & Muthén, 2017). Prior 0.947, Tucker–Lewis index (TLI) = 0.901, root- to testing the proposed hypotheses, common mean-square error of approximation (RMSEA) method variance was examined by conducting = 0.068 (90% confidence interval [CI; 0.050, a factor analyses of all items to determine the 0.087]), standardized root-mean-square residual presence of a single latent variable (Kline et al., (SRMR) = 0.042. Utilizing Hu and Bentler’s 2000; Lindell & Whitney, 2001). No single latent (1999) recommendations for evaluating overall variable was found, suggesting the presence of model fit (i.e., CFI > .95, TLI > .95, RMSEA < .06, multiple variables. Individual items rather than and SRMR < .08), the four-factor model was full-scale sum scores were used in identifying determined to have acceptable fit (Byrne, 2012). latent variables, as is the preferred methodology When considering only statistically significant for assessing latent factors. factor loadings exceeding a minimum value of To test the hypothesized model of overlapping .30, the first factor was uniquely characterized constructs, a measurement model was examined by flashbacks, memory loss, startle reflex, and using exploratory structural equation modeling nightmares, which largely correspond with the (ESEM). ESEM allows for less restrictive proposed composition of PTSD (see Table 4). The measurement models by permitting correlated second factor was composed of guilt/shame, which residuals among observed variables and potential corresponded with proposed core symptoms of cross-loading of observed variables onto multiple moral injury. The third factor was characterized variables (Asparouhov & Muthén, 2009; Marsh et by anhedonia, depression, anxiety, anger, loss of al., 2014). Select items were used from each measure trust, and social alienation, which appeared to as representative of their corresponding construct, correspond with psychiatric comorbidities often mirroring the approach of Bryan et al. (2018), to associated with trauma exposure. The fourth factor ensure that each construct had a similar number was solely characterized by loss of meaning in life. of items and to reduce subject burden (see Table Given that the hypervigilance item significantly 2). Model fit criteria suggested by Hu and Bentler cross-loaded with the PTSD and psychiatric (1999) were used to evaluate overall model fit. All comorbidities factors, this item was dropped from parameters were specified using robust maximum the structural model analyses. likelihood estimation. Indicator variables utilized different scoring systems, therefore standardized Results of Structural Model values are reported. As shown in Figure 2, results of the ESEM A structural model was then specified to structural model demonstrated that the factors determine how the latent variables of moral injury guilt/shame (β = 0.34, SE = 0.15, 95% CI [0.02, symptoms, PTSD symptoms, and their interactions 0.64]) and psychiatric comorbidities (β = 0.77, SE = were associated with suicidal behaviors. Given 0.17, 95% CI [0.44, 1.07]) had a significant positive that the structural model involved the interaction effect on suicidal behaviors such that Guilt/Shame of multiple continuous latent variables, Monte and Psychiatric Comorbidities were associated Carlo numerical integration with 500 randomly with increased risk of suicidal behaviors (see generated integration points was required Figure 2). Neither the PTSD factor nor Meaning to conduct maximum likelihood estimation in Life were associated with suicidal behaviors. No procedures (Muthén & Muthén, 2017). Gender significant interaction effects were found. (dummy coded 1 = men, 0 = women) and branch of service (dummy coded 1 = Army, 0 = all other

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 166 Table 3. Correlations Between Study-Developed Item Constructs and Covariates — 16 — 15 .03 * — 14 .16 − .22 * ** — 13 .18 − .13 .49 ** ** — 12 .16 − .13 .48 .33 ** ** ** — 11 .12 − .17 .47 .73 .35 ** ** ** ** — 10 .16 − .08 .59 .42 .77 .39 ** ** ** ** ** ** 9 — .10 .53 .60 .41 .60 .55 − .26 ** ** ** ** ** ** 8 — .15 − .17 .56 .34 .51 .33 .52 .33 * ** ** ** ** ** ** ** ** 7 — .24 .43 .74 .54 .47 .31 .56 .66 − .18 * ** ** ** ** ** ** ** ** 6 — .12 .71 .53 .74 .50 .56 .38 .62 .59 − .19 ** ** ** ** ** ** ** ** ** 5 — .15 − .03 − .53 − .62 − .43 − .54 − .35 − .45 − .35 − .44 − .49 4 — .04 .03 .04 .01 .04 − .01 − .11 − .09 − .10 − .08 − .03 − .04 * ** ** ** ** ** 3 — .01 − .04 − .17 − .08 − .15 − .12 − .04 .25 − .21 − .28 − .22 − .30 − .22 ** ** ** ** ** ** ** ** ** ** ** 2 — .13 .10 − .06 .39 .51 .33 .55 .50 .51 .33 .53 .50 − .36 − .27 * ** ** ** ** ** ** ** ** ** ** ** 1 — .14 .05 − .10 .46 .37 .38 .50 .68 .50 .62 .44 .37 .48 − .21 − .37 < .01. < p N = 129; Guilt = Trauma-Related Guilt Inventory items 13 and 25; Shame = Trauma-Related Shame Trauma-Related = Shame 25; and 13 items Inventory Guilt Trauma-Related = Guilt 129; = N 11. Hyperarousal 11. 12. Memory loss 15. Gender 15. BoS 16. 6. Anhedonia 6. 5. Alienation 5. 4. MiL 4. 3. Trust 3. 10. Nightmare 10. Construct Guilt 1. 2. Shame 2. 9. Anxiety 9. Flashback 13. 7. Depression 7. Anger 8. Suicide 14. Note. of Goodness and Questionnaire–Trustworthiness Assumption World = Trust 8; and 3 items Inventory 5; and 4 items subscale Questionnaire–Presence Life in Meaning = MiL 4; and 2 items subscale People 1; item Questionnaire–2 Health Patient = Anhedonia 7; item Questionnaire Functioning Social = Alienation 1; item Reactions Anger of Dimensions = Anger 2; item Questionnaire–2 Health Patient = Depression 2; item DSM-5 for Checklist PTSD = Nightmares screener–2; Disorder Anxiety Generalized = Anxiety item DSM-5 for Checklist PTSD = loss Memory 18; and 17 items DSM-5 for Checklist PTSD = Hyperarousal Questionnaire– Behaviors Suicide = Suicide 3; and 1 items DSM-5 for Checklist PTSD = Flashback 8; coded dummy was Service of Branch = BoS 0); = women 1; = (men coded dummy was Gender Revised associations for conducted were correlations product-moment Pearson 0). = branches Other 1; = (Army associations for conducted were correlations point-biserial and variables continuous two between variable. dichotomous one and variable continuous one of consisting ** .05 < * p

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 167 Table 4. Factor Loadings of the Four-Factor Measurement Model of Moral Injury and PTSD

Item 1 2 3 4 PCL-5 item 2 .60 .12 .14 −.02 PCL-5 item 3 .95 −.13 −.03 −.09 PCL-5 item 8 .36 .03 .18 −.08 PCL-5 item 17 .42 .02 .36 .16 PCL-5 item 18 .64 .16 .22 .11 TRGI item 18 .11 .36 −.06 −.09 TRGI item 25 .02 .75 −.04 .08 TRSI item 3 .08 .72 .07 −.05 TRSI item 8 −.03 .75 .06 −.10 PHQ-2 item 1 .14 −.15 .78 −.15 PHQ-2 item 2 .01 .13 .67 −.14 GAD-2 item 1 −.02 .07 .77 −.17 GAD-2 item 2 .05 .20 .64 −.04 DAR item 1 .15 .04 .57 .14 WAQ-T item 2 .21 .01 −.59 −.11 WAQ-T item 4 .15 .14 −.51 −.18 SFQ item 7 .07 .01 .51 −.26 MLQ-P item 2 .03 −.04 −.16 .78 MLQ-P item 3 −.06 −.02 −.02 .93

Note. Significant factor loadings are bolded and are based on a minimum eigenvalue of .30; PCL-5 = PTSD Checklist for DSM-5; TRGI = Trauma-Related Guilt Inventory; TRSI = Trauma-Related Shame Inventory; PHQ-2 = Patient Health Questionnaire–2; GAD-2 = Generalized Anxiety Disorder–2; DAR = Dimensions of Anger Reactions; WAQ-T = World Assumption Questionnaire–Trustworthiness and Goodness of People subscale; SFQ = Social Functioning Questionnaire; MLQ-P = Meaning in Life Questionnaire–Presence subscale.

Discussion in the Diagnostic and Statistical Manual of Mental To extend the work of Bryan et al. (2018), Disorders, Fourth Edition, Text Revision (APA, we examined their model of the similarities and 2000). In the shift from the DSM-IV-TR to the differences between moral injury and PTSD DSM-5 (APA, 2013) diagnostic system, negative among combat veterans, included additional changes in mood and thoughts were incorporated constructs key to moral injury and PTSD, and into the PTSD framework (p. 271). This alteration conducted factor analyses to test their model (see in diagnostic criteria from DSM-IV-TR to DSM- Figure 1). We then examined how these factors 5 could be indicative of various PTSD diagnostic were associated with suicidal behaviors in combat subtypes, an issue that Bryan et al. (2018) veterans. considered along with Griffin et al. (2019). It may also be viewed as an inclusion of proposed Delineation of Expressed Factors “moral injury” symptoms into the broader PTSD The first factor was uniquely characterized framework. by flashbacks, memory loss, startle reflex, and As to moral injury, our outcomes diverge nightmares and was nearly identical to a factor from Bryan et al. (2018), as their “Moral Injury” identified by Bryan et al. (2018). This factor factor contained items/symptoms that, for us, were corresponds closely to the PTSD criteria described distributed across three factors. Our second factor

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 168 Figure 2. Structural Equation Model of Effects on Suicide Behaviors Standardized path coefficients are shown. Significant effects in bold. Standardized Note.

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 169 was characterized by guilt and shame symptoms, in life (e.g., Jinkerson, 2016; Litz et al., 2009). The which have been referred to as the linchpin inclusion of meaning in life was distinct to the components of moral injury (Jinkerson, 2016; Litz current study and marks meaning in life as an et al., 2009). Consistent with previous research important outcome variable for consideration in (Bryan et al., 2013; Currier, Holland, & Malott, future studies. 2015; Marx et al., 2010; Stein et al., 2012), our Differences between our findings and those results underscore the primacy of guilt and shame of Bryan et al. (2018) may reflect the nature of symptoms for moral injury. the two studies’ populations. Bryan et al. (2018) The third factor, however, posed greater examined Army National Guard members, difficulty with respect to nomenclature, as it of which 58.2% had deployed. In contrast, included items indicating depression, anhedonia, participants in the present study all reported anxiety, anger, loss of trust, and social alienation. combat experience and exposure to at least one As shown in Bryan’s et al.’s model (2018; see Figure pMIE. It is possible that Bryan et al.’s (2018) 1), this third factor appears to be best categorized findings may be most generalizable to a National as psychiatric comorbidities involving negative Guard sample (and especially one of a western/ alterations in thought and mood that frequently southwestern demographic), whereas our findings co-occur with both PTSD and moral injury (Griffin may be more generalizable to a broader sample et al., 2019; Jinkerson, 2016; Litz et al., 2009). of pMIE-exposed combat veterans. Additionally, Thus, the third factor appears consistent with both the current study included members of all service the symptoms of moral injury (other than guilt branches, which may have partially accounted for and shame) as well as the negative alterations in the differences. Service branches are known to thought and mood that characterize PTSD. have cultures specific to themselves in addition In accordance with Jinkerson’s (2016) to the general military culture and warrior ethos. formulation, the second factor (Guilt/Shame) It is possible that these distinct service-branch could be viewed as encompassing the core moral cultures and additional subcultures may influence injury symptoms, whereas the third factor, the development and cause of combat-related Psychiatric Comorbidities, might represent reactions. Although the current study cannot secondary, potentially co-occurring, mental health speak more to the influence of military culture on conditions that may be indicative of either PTSD PTSD and moral injury, it is imperative that future or moral injury. Further, recent research has research adopt a multicultural lens to examine the distinguished between self-directed moral injury role of military culture in moderating veterans’ and other-directed moral injury (e.g., Bravo et responses to service-related traumatic events. al., 2020). Acts of commission (i.e., perpetrating Our findings highlight the complexities of an action) and acts of omission (i.e., not limiting combat trauma reactions and emphasize that the others’ wrongdoing) may be more likely to result moral injury construct may not be as clear cut in self-directed moral injury. That is, when as previously found. Although there are unique servicemembers feel personally responsible for differences between our findings and those of perpetrating a transgressive act or not limiting Bryan et al. (2018), both studies suggest clear others’ wrongdoing, they may be more likely differences between PTSD and moral injury factors. to experience guilt and shame. In contrast, acts Both studies also demonstrate, however, that some of betrayal or leadership failure may result in constructs, such as depression and anhedonia, may experiences of other-directed moral injury and overlap between PTSD and moral injury. Overall, may be more likely to result in anger, disgust, our factorial findings paint a cloudier picture of the and mistrust (Currier et al., 2019). Although our symptomatology of PTSD and moral injury. The measure of pMIEs and moral injury symptoms diversity of symptom clusters found here suggests does not allow us to test this premise directly, that conceptualizations of moral injury may need this would be an important direction for future revision, possibly to include loss of trust as a research. comorbidity rather than a core symptom, though The fourth factor, Meaning in Life, was that is speculative at this point. comprised of items from the Presence subscale of the Meaning in Life Questionnaire, with higher Structural Model Outcomes scores denoting greater awareness of meaning in Suicide Behaviors one’s life. In the context of moral injury research, Our results suggest that Guilt/Shame we are most concerned with the loss of meaning and Psychiatric Cormorbidities may be key to

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 170 suicidal behaviors in combat veterans. It was not symptoms. This dimensional argument is not surprising that the Psychiatric Comorbidities intended to defeat existing theories/constructs but factor was associated with suicidal behaviors, as its rather to spur moral injury research to embrace components of depression, anhedonia, and social construct flexibility. The differences found alienation are included in many models of suicide between the current study and Bryan et al. (2018) (e.g., Jobes, 2012; Stanley et al., 2010; Van Orden leave us wanting to understand the divergence in et al., 2010). Surprisingly, the PTSD and Meaning addition to the convergence. One promising area in Life factors were not associated with suicidal for further exploration may be to consider how behaviors. This finding was unexpected given that military and unit culture affect servicemembers’ previous research has shown that PTSD is robustly moral expressions and responses to their military associated with suicide attempts and deaths experiences. Ultimately, a deeper understanding (Hendin & Haas, 1991; Koven, 2016) and that loss of the symptomology and implications of moral of meaning in life tends to be a primary predictor injury and PTSD may help us understand and fight of suicide (Kleiman & Beaver, 2013). Our findings against the persistent rise of suicidal behaviors suggest that core symptoms of moral injury (i.e., among combat veterans. guilt and shame) and other comorbid mental health concerns (e.g., depression, anhedonia) References may have a greater association with suicidal American Psychiatric Association. (2000). behavior in combat veterans than do symptoms Diagnostic and statistical manual of mental disorders unique to PTSD, such as intrusive memories and (4th ed., text revision). American Psychiatric Association. hyperarousal. This emphasizes the salience of American Psychiatric Association. (2013). negative changes in mood and cognition when Diagnostic and statistical manual of mental disorders considering risk for suicidal behaviors among (5th ed.). American Psychiatric Association. combat veterans. Asparouhov, T., & Muthén, B. (2009). Exploratory structural equation modeling. Limitations Structural Equation Modeling: A Multidisciplinary Several limitations of the current study Journal, 16(3), 397–438. https://doi. warrant discussion. First, our findings are based org/10.1080/10705510903008204 on cross-sectional data and therefore limit Battles, A.R., Bravo, A.J., Kelley, M.L., White, the current investigation’s ability to determine T.D., Braitman, A.L., & Hamrick, H.C. (2018). Moral temporal associations. The current study also injury and PTSD as mediators of the associations utilized retrospective self-report measures subject between morally injurious experiences and mental to response bias. Additionally, akin to Bryan et al. health and substance use. Traumatology, 24(4), 246 (2018) and to reduce subject burden, in some cases, –254. https://doi.org/10.1037/trm0000153 we analyzed one or two items to measure each Battles, A.R., Kelley, M.L., Jinkerson, J.D., construct. Our findings deviated from those found Hamrick, H.C., & Hollis, B.F. (2019). Associations by C. Bryan and colleagues (2018), and sample among exposure to potentially morally injurious size may have played in a role in the differential experiences, spiritual injury, and alcohol use outcomes. Alternatively, within-factor shared among combat veterans. Journal of Traumatic Stress, method variance may provide some explanation 32(3), 405–413. https://doi.org/10.1002/jts.22404 for the current findings. As such, future research Blevins, C.A., Weathers, F.W., Davis, will benefit from replication of and expansion of M.T., Witte, T.K., & Domino, J.L. (2015). The the current research, utilizing alternate means of posttraumatic stress disorder checklist for DSM‐5 assessing the variables in question. (PCL‐5): Development and initial psychometric evaluation. Journal of Traumatic Stress, 28(6), 489– Future Directions and Conclusion 498. https://doi.org/10.1002/jts.22059 The present study reevaluated the Bravo, A.J., Kelley, M.L., Mason, R., Ehlke, S.J., symptomatic profiles of moral injury and PTSD Vinci, C., & Redman, J.C. (2020). Rumination as a found in Bryan et al.’s (2018) seminal research mediator of the associations between moral injury among a group of pMIE-exposed combat veterans. and mental health problems in combat-wounded Consistent with Bryan et al., a clear PTSD factor veterans. Traumatology, 26(1), 52–60. https://doi. was identified; however, our results suggest that org/10.1037/trm0000198 moral injury may not represent a single factor but rather a multidimensional constellation of

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 171 Bryan, A.O., Bryan, C.J., Morrow, C.E., Forbes, D., Hawthorne, G., Elliott, P., McHugh, Etienne, N., & Ray-Sannerud, B. (2014). Moral T., Biddle, D., Creamer, M., & Novaco, R.W. (2004). injury, suicidal ideation, and suicide attempts in A concise measure of anger in combat‐related a military sample. Traumatology, 20(3), 154–160. posttraumatic stress disorder. Journal of Traumatic https://doi.org/10.1037/h0099852 Stress, 17(3), 249–256. https://doi.org/10.1023/ Bryan, C.J., Bryan, A.O., Roberge, E., B:JOTS.0000029268.22161.bd Leifker, F.R., & Rozek, D.C. (2018). Moral injury, Frankfurt, S., & Frazier, P. (2016). A review posttraumatic stress disorder, and suicidal behavior of research on moral injury in combat veterans. among National Guard personnel. Psychological Military Psychology, 28(5), 318–330. https://doi. Trauma: Theory, Research, Practice, and Policy, org/10.1037/mil0000132 10(1), 36–45. https://doi.org/10.1037/tra0000290 Griffin, B.J., Purcell, N., Burkman, K., Litz, Bryan, C.J., Griffith, J.E., Pace, B.T., Hinkson, B.T., Bryan, C.J., Schmitz, M., Villierme, C., Walsh, K., Bryan, A.O., Clemans, T.A., & Imel, Z.E. (2015). J., & Maguen, S. (2019). Moral injury: A integrative Combat exposure and risk for suicidal thoughts review. Journal of Traumatic Stress, 32(3), 350–362. and behaviors among military personnel and https://doi.org/10.1002/jts.22362 veterans: A systematic review and meta‐analysis. Harris, J.I., Park, C.L., Currier, J.M., Usset, Suicide and Life‐Threatening Behavior, 45(5), 633– T.J., & Voecks, C.D. (2015). Moral injury and 649. https://doi.org/10.1111/sltb.12163 psycho-spiritual development: Considering the Bryan, C.J., Morrow, C.E., Etienne, N., & Ray- developmental context. Spirituality in Clinical Sannerud, B. (2013). Guilt, shame, and suicidal Practice, 2(4), 256–266. https://doi.org/10.1037/ ideation in a military outpatient clinical sample. scp0000045 Depression and Anxiety, 30(1), 55–60. https://doi. Hendin, H., & Haas, A.P. (1991). Suicide and org/10.1002/da.22002 guilt as manifestations of PTSD in Vietnam combat Byrne, B.M. (2012). Choosing structural veterans. The American Journal of Psychiatry, equation modeling computer software: Snapshots 148(5), 586–591. https://doi.org/10.1176/ of LISREL, EQS, AMOS, and Mplus. In R.H. Hoyle ajp.148.5.586 (Ed.), Handbook of structural equation modeling Hu, L.-T., & Bentler, P.M. (1999). Cutoff (pp. 307–324). The Guilford Press. criteria for fit indexes in covariance structure Currier, J. M., Holland, J.M., Drescher, K., & analysis: Conventional criteria versus new Foy, D. (2015). Initial psychometric evaluation of alternatives. Structural Equation Modeling: A the Moral Injury Questionnaire –Military Version. Multidisciplinary Journal, 6(1), 1–55. https://doi. Clinical Psychology & Psychotherapy, 22(1), 54–63. org/10.1080/10705519909540118 https://doi.org/10.1002/cpp.1866 Jinkerson, J.D. (2016). Defining and Currier, J.M., Holland, J.M., & Malott, J. (2015). assessing moral injury: A syndrome perspective. Moral injury, meaning making, and mental health Traumatology, 22(2), 122–130. https://doi. in returning veterans. Journal of Clinical Psychology, org/10.1037/trm0000069 71(3), 229–240. https://doi.org/10.1002/jclp.22134 Jinkerson, J.D., & Battles, A. R. (2019). Currier, J.M., McDermott, R.C., Farnsworth, Relationships between moral injury syndrome J.K., & Borges, L.M. (2019). Temporal associations model variables in combat veterans. Traumatology, between moral injury and posttraumatic stress 25(1), 33–40. https://doi.org/10.1037/trm0000163 disorder symptom clusters in military veterans. Jobes, D.A. (2012). The Collaborative Journal of Traumatic Stress, 32(3), 382–392. https:// Assessment and Management of Suicidality doi.org/10.1002/jts.22367 (CAMS): An evolving evidence-based clinical Drescher, K.D., Foy, D.W., Kelly, C., Leshner, approach to suicide risk. Suicide and Life- A., Schutz, K., & Litz, B. (2011). An exploration Threatening Behavior, 42(6), 640–653. https://doi. of the viability and usefulness of the construct of org/10.1111/j.1943-278X.2012.00119.x moral injury in war veterans. Traumatology, 17(1), Kaler, M.E. (2009). The World Assumptions 8–13. https://doi.org/10.1177/1534765610395615 Questionnaire: Development of a measure of Fanning, J.R., & Pietrzak, R.H. (2013). the assumptive world [Doctoral dissertation, Suicidality among older male veterans in the University of Minnesota]. University of Minnesota United States: Results from the National Health Digital Conservancy. https://conservancy.umn. and Resilience in Veterans Study. Journal of edu/handle/11299/55049 Psychiatric Research, 47(11), 1766–1775. https:// doi.org/10.1016/j.jpsychires.2013.07.015

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 172 Kelley, M.L., Bravo, A.J., Hamrick, H.C., Maguen, S., & Litz, B. (2012). Moral injury in Braitman, A.L., & Judah, M.R. (2019). Killing veterans of war. PTSD Research Quarterly, 23(1),1–3. during combat and negative mental health Marsh, H.W., Morin, A.J.S., Parker, P.D., and substance use outcomes among recent-era & Kaur, G. (2014). Exploratory structural veterans: The mediating effects of rumination. equation modeling: An integration of the best Psychological Trauma: Theory, Research, Practice, features of exploratory and confirmatory factor and Policy, 11(4), 379–382. https://doi.org/10.1037/ analysis. Annual Review of Clinical Psychology, tra0000385 10, 85–110. https://doi.org/10.1146/annurev- Kleiman, E.M., & Beaver, J.K. (2013). A clinpsy-032813-153700 meaningful life is worth living: Meaning in life Marx, B.P., Foley, K.M., Feinstein, B.A., as a suicide resiliency factor. Psychiatry Research, Wolf, E.J., Kaloupek, D.G., & Keane, T.M. (2010). 210(3), 934–939. https://doi.org/10.1016/j. Combat-related guilt mediates the relations psychres.2013.08.002 between exposure to combat-related abusive Kline, T.J.B., Sulsky, L.M., & Rever-Moriyama, violence and psychiatric diagnoses. Depression and S. D. (2000). Common method variance and Anxiety, 27(3), 287–293. https://doi.org/10.1002/ specification errors: A practical approach to da.20659 detection. The Journal of Psychology, 134(4), 401– Muthén, L.K., & Muthén, B.O. (2017). Mplus 421. https://doi.org/10.1080/00223980009598225 statistical analysis with latent variables: User’s guide Koven, S. G. (2016). PTSD and suicides among (8th ed.). Muthén & Muthén. veterans—Recent findings. Public Integrity, 19(5), Nash, W.P., & Litz, B.T. (2013). Moral injury: A 500–512. https://doi.org/10.1080/10999922.2016.1 mechanism for war-related psychological trauma 248881 in military family members. Clinical Child and Kroenke, K., Spitzer, R.L., & Williams, J.B. Family Psychology Review, 16, 365–375. https://doi. W. (2003). The Patient Health Questionnaire–2: org/10.1007/s10567-013-0146-y Validity of a two-item depression screener. Øktedalen, T., Hagtvet, K.A., Hoffart, A., Medical Care, 41(11), 1284–1292. https://doi. Langkaas, T.F., & Smucker, M. (2014). The Trauma org/10.1097/01.MLR.0000093487.78664.3C Related Shame Inventory: Measuring trauma- Kroenke, K., Spitzer, R.L., Williams, related shame among patients with PTSD. Journal J.B.W., Monahan, P.O., & Löwe, B. (2007). of Psychopathology and Behavioral Assessment, Anxiety disorders in primary care: Prevalence, 36(4), 600–615. https://doi.org/10.1007/s10862- impairment, comorbidity, and detection. Annals 014-9422-5 of Internal Medicine, 146(5), 317–325. https://doi. Osman, A., Bagge, C.L., Gutierrez, P.M., org/10.7326/0003-4819-146-5-200703060-00004 Konick, L.C., Kopper, B.A., & Barrios, F.X. (2001). Kubany, E.S., Haynes, S.N., Abueg, F.R., The Suicidal Behaviors Questionnaire–Revised Manke, F.P., Brennan, J. M., & Stahura, C. (1996). (SBQ-R): Validation with clinical and nonclinical Development and validation of the Trauma-Related samples. Assessment, 8(4), 443–454. https://doi. Guilt Inventory (TRGI). Psychological Assessment, org/10.1177/107319110100800409 8(4), 428–444. https://doi.org/10.1037/1040- Stanley, B., Brown, G., Brent, D.A., Wells, 3590.8.4.428 K., Poling, K., Curry, J., Kennard, B.D., Wagner, Lindell, M.K., & Whitney, D.J. (2001). A., Cwik, M.F., Klomek, A.B., Goldstein, T., Accounting for common method variance in Vitiello, B., Barnett, S., Daniel, S., & Hughes, J. cross-sectional research designs. Journal of (2010). Cognitive-Behavioral Therapy for Suicide Applied Psychology, 86(1), 114–121. https://doi. Prevention (CBT-SP): Treatment model, feasibility, org/10.1037/0021-9010.86.1.114 and acceptability. Journal of the American Litz, B.T., Stein, N., Delaney, E., Lebowitz, Academy of Child and Adolescent Psychiatry, L., Nash, W.P., Silva, C., & Maguen, S. (2009). 48(10), 1005–1013. https://doi.org/10.1097/ Moral injury and moral repair in war veterans: CHI.0b013e3181b5dbfe A preliminary model and intervention strategy. Shay, J. (1991). Learning about combat Clinical Psychology Review, 29(8), 695–706. https:// stress from Homer’s Iliad. Journal of Traumatic doi.org/10.1016/j.cpr.2009.07.003 Stress, 4(4), 561–579. https://doi.org/10.1002/ Lynn, B.M.-D., & Morgan, J.K. (2016). Using jts.2490040409 Amazon’s Mechanical Turk (MTurk) to recruit Shay, J. (2002). Odysseus in America: Combat military veterans: Issues and suggestions. The trauma and the trials of homecoming. Scribner. Military Psychologist, 31(3), 10–14.

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 173 Shay, J. (2014). Moral injury. Psychoanalytic Psychology, 31(2), 182–191. https://doi. org/10.1037/a0036090 Steger, M.F., Frazier, P., Oishi, S., & Kaler, M. (2006). The Meaning in Life Questionnaire: Assessing the presence of and search for meaning in life. Journal of Counseling Psychology, 53(1), 80– 93. https://doi.org/10.1037/0022-0167.53.1.80 Stein, N.R., Mills, M.A., Arditte, K., Mendoza, C., Borah, A.M., Resick, P.A., Litz, B.T., & STRONG STAR Consortium. (2012). A scheme for categorizing traumatic military events. Behavior Modification, 36(6), 787–807. https://doi. org/10.1177/0145445512446945 Tyrer, P., Nur, U., Crawford, M., Karlsen, S., MacLean, C., Rao, B., & Johnson, T. (2005). The Social Functioning Questionnaire: A rapid and robust measure of perceived functioning. International Journal of Social Psychiatry, 51(3), 265– 275. https://doi.org/10.1177/0020764005057391 Van Orden, K.A., Witte, T.K., Cukrowicz, K.C., Braithwaite, S.R., Selby, E.A., & Joiner, T.E., Jr. (2010). The interpersonal theory of suicide. Psychology Review, 117(2), 575–600. https://doi. org/10.1037/a0018697 Xue, C., Ge, Y., Tang, B., Liu, Y., Kang, P., Wang, M., & Zhang, L. (2015). A meta-analysis of risk factors for combat-related PTSD among military personnel and veterans. PLoS ONE, 10(3), Article e0120270. https://doi.org/10.1371/journal. pone.0120270

About the Authors Allison Battles is currently a psychology postdoctoral fellow at the Minneapolis VA Health Care System. Jeremy Jinkerson, ABPP, is a clinical psychologist in the U.S. Air Force and will soon enter the Brooke Army Medical Center Neuropsychology Fellowship program. Michelle L. Kelley is professor in the Department of Psychology and an Eminent Scholar at Old Dominion University. Richard Mason is a psychology student at Towson University.

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 174 Shay, J. (2014). Moral injury. Psychoanalytic Psychology, 31(2), 182–191. https://doi. org/10.1037/a0036090 Steger, M.F., Frazier, P., Oishi, S., & Kaler, M. (2006). The Meaning in Life Questionnaire: Assessing the presence of and search for meaning in life. Journal of Counseling Psychology, 53(1), 80– 93. https://doi.org/10.1037/0022-0167.53.1.80 Stein, N.R., Mills, M.A., Arditte, K., Mendoza, C., Borah, A.M., Resick, P.A., Litz, B.T., & STRONG STAR Consortium. (2012). A scheme for categorizing traumatic military events. Behavior Modification, 36(6), 787–807. https://doi. org/10.1177/0145445512446945 Mission and Description Tyrer, P., Nur, U., Crawford, M., Karlsen, S., MacLean, C., Rao, B., & Johnson, T. (2005). The Social Functioning Questionnaire: A rapid The mission of JCES is to provide a mechanism through which faculty, staff, and and robust measure of perceived functioning. students of academic institutions and their community partners may disseminate International Journal of Social Psychiatry, 51(3), 265– scholarly works from all academic disciplines. JCES accepts all forms of writing, 275. https://doi.org/10.1177/0020764005057391 Van Orden, K.A., Witte, T.K., Cukrowicz, analysis, creative approaches, and methodologies. JCES is a peer-reviewed K.C., Braithwaite, S.R., Selby, E.A., & Joiner, T.E., journal open to all disciplines. Its purpose is to integrate teaching, research, and Jr. (2010). The interpersonal theory of suicide. community engagement in ways that address critical societal problems through Psychology Review, 117(2), 575–600. https://doi. a community-participatory process. org/10.1037/a0018697 Xue, C., Ge, Y., Tang, B., Liu, Y., Kang, P., Wang, M., & Zhang, L. (2015). A meta-analysis of risk factors for combat-related PTSD among military personnel and veterans. PLoS ONE, 10(3), Article e0120270. https://doi.org/10.1371/journal. pone.0120270

About the Authors Allison Battles is currently a psychology postdoctoral fellow at the Minneapolis VA Health Care System. Jeremy Jinkerson, ABPP, is a clinical psychologist in the U.S. Air Force and will soon enter the Brooke Army Medical Center Neuropsychology Fellowship program. Michelle L. Kelley is professor in the Department of Psychology and an Eminent Scholar at Old Dominion University. Richard Mason is a psychology student at Towson University.

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 175 Guidelines for Submission of Manuscripts

The editorial board of theJournal of Community Engagement and Scholarship (JCES) invites the submission of manuscripts that relate to its mission: To provide a mechanism through which faculty, staff, and students of academic institutions and their community partners may disseminate scholarly works from all academic disciplines. A goal of the publication is to integrate teaching, research, and community engagement. All forms of writing, analysis, creative approaches, and methodologies are acceptable for the journal.

Traditional submissions are quantitative, engaged scholarship. Given the interdisciplinary qualitative, and mixed-methods empirical studies. nature of the field, scholarly contributions of We also welcome submissions that utilize new and many kinds related to the field of engagement emerging methodological techniques. Traditional scholarship are encouraged and will be considered manuscript submissions should be based on a solid for publication in JCES. Community Perspective theoretical or conceptual framework and the manuscripts should be between 750–2,000 words in discussion of the research findings should include length. Examples may be found on the JCES website. practical, theoretical, and/or policy implications. These submissions should demonstrate central Students from all disciplines are invited to submit involvement of students and/or community original work to the Student Voices section. All partners and advance the field of community forms of writing, analysis, creative approaches, and engagement scholarship, and should not exceed methodologies are acceptable for this section. 8,000 words. Specific types of submissions appropriate for the Student Voices section include commentaries, From the Field articles have a practice or case critical reflections, and opinion pieces related study orientation and share best practices, practical to community engagement and/or engaged wisdom, and applied knowledge. Context is an scholarship. Given that engagement scholarship essential part of community engagement work; is such an interdisciplinary field in which there are therefore, it is critical to situate From the Field many appropriate ways to best “tell the story,” submissions philosophically, historically, scholarly contributions of many kinds related to and theoretically in order to systematically extend the field of engagement scholarship are welcome our knowledge and understanding. Innovative and will be considered for publication. Student partnerships that demonstrate central involvement Voice manuscripts should be between 750–2,000 of students and/or community partners have the words. Examples may be found on the JCES website. potential to make highly interesting pieces for this section. From the Field submissions should go Book Reviews submitted to JCES should give the beyond a simple project description to include reader a well-developed sense/description of the innovative lessons learned or best practice book, but should also go beyond description to principles with strong application and practice discuss central issues raised by the text. Reviewers implications. From the Field manuscripts should are encouraged to address how the reviewed book not exceed 6,000 words. addresses theory, current scholarship, and/or current issues germane to the subject of the book Community members working with academic and engagement scholarship. Reviewers may partners from all disciplines are invited to submit reference other material that has bearing on the original work to the Community Perspectives book being reviewed, particularly when these section. All forms of writing, analysis, creative sources have the ability to position the book within approaches, and methodologies are acceptable for larger discourses regarding the topic. Ideally, Book this section. Specific types of submissions Reviews should not exceed 1,500 words. appropriate for Community Perspectives include commentaries, critical reflections, and opinion pieces related to community engagement and/or

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 176 JCES Manuscript Review Process*

Manuscript Receipt Resubmitted Manuscript and Second Review • Editor scans for style and documentation • Editor scans for compliance with reviewer standards, requests revisions if necessary evaluation; if necessary, author is sent request • Editorial staff assigns manuscript number, sends for further revisions acknowledgment email to corresponding author • Editorial staff sends to the original reviewers (usually, but not always, the first author) the revised manuscript, a copy of the original • Editor selects appropriate reviewers manuscript with editors’ and reviewers’ com- ments and tracked changes, the review form, and First Review a copy of the letter to the corresponding author • Editorial staff sends manuscript to reviewers, • Editorial staff requests return of second review with review form and return due date within two weeks • Editor reassigns manuscript if reviewer unable to complete review Editor Options Following Second Review • Editorial staff sends reminder email one week • Editor accepts manuscripts in advance of due date (proceed to Edit for Publication) • Editorial staff sends reminder email one week • Editor accepts manuscript with minor revisions after due date if review not yet received • Editor receives reviewers’ evaluation and Accept with Minor Revisions rating forms • Editor sends corresponding author notification of decision to accept with minor revisions and Editor Options requests a final revision within two weeks • Editor accepts manuscript • Editor ensures minor revisions have been made (proceed to Edit for Publication) (proceed to Edit for Publication) • Editor sends corresponding author the recommended revisions and requests resubmission Edit for Publication • Editor rejects manuscript (end of process) • Final editing and proofreading by editor and editorial staff Revise and Resubmit Instructions • Editorial staff sends proof to corresponding author • Editorial staff notifies author of publication • Editorial staff negotiates editorial changes decision with corresponding author • Editorial staff sends to corresponding • Editorial staff sends official copyright forms author a letter regarding the decision, for corresponding author’s signature reviewer comments, and manuscript with edits and tracked changes Publication • Editorial staff requests resubmission within four weeks

*Authors’ names on all documents viewed by reviewers, including manuscripts, letters, emails, and other identifying information, are masked throughout the process.

Visit jces.ua.edu to submit an article.

SPECIAL ISSUE NO. 3, 2021—JOURNAL OF COMMUNITY ENGAGEMENT AND SCHOLARSHIP—Page 177 JOURNAL of COMMUNITY ENGAGEMENT and SCHOLARSHIP www.jces.ua.edu | [email protected]

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For subscription information, contact Diane Kennedy-Jackson Publications Coordinator Division of Community Affairs The University of Alabama Box 870372 Tuscaloosa, AL 35487

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Published and Distributed by the Division of Community Affairs at The University of Alabama with generous support from the Engagement Scholarship Consortium (ESC) ISSN 1944-1207 Regular issues published twice a year with occasional special issues

JCES is a peer-reviewed international journal through which faculty, staff, students, and community partners disseminate scholarly works. JCES integrates teaching, research, and community engagement in all disciplines, addressing critical problems identified through a community-participatory process. The University of Alabama Office of Community Affairs Center for Community-Based Partnerships Box 870372 Tuscaloosa, AL 35487-0372

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The Journal of Community Engagement and Scholarship is published at The University of Alabama by the Division of Community Affairs, with the generous support of the Engagement Scholarship Consortium, for the advancement of engaged scholarship worldwide.