Joint Special Operations University

7701 Tampa Point Boulevard

MacDill AFB, FL 33621

https://jsou.libguides.com/jsoupublications

JOINT SPECIAL OPERATIONS UNIVERSITY

After more than fifteen years of conflict, the fact that suicide persists 

as a command issue in the United States Special Operations Command 

(USSOCOM) is heartbreaking and serves as a clarion call to redouble 

efforts by individuals and institutions to invest in programs that demonstrate effectiveness in reducing suicide, eroding the stigma associated with seeking treatment, and increasing the use of behavioral 

health care (BHC). In this monograph, Dr. Craig Lefebvre offers a social 

marketing perspective that reveals insights and actions to enhance 

existing programs.

ISBN 978-1-941715-19-2

A Social Marketing Analysis 

for Suicide Prevention Initiatives 

in USSOCOM: A Framework for 

Future Research and Success

R. Craig Lefebvre, Ph.D.

JSOU Report 17-2

JSOU Report 17-2 Suicide Prevention Initiatives in USSOCOM Lefebvre

http://www.soc.mil/Stigma/BTSA.html

1-800-342-9647 is available 24/7. http://www.militaryonesource.mil. Military One Source 

provides up to 12 free counseling sessions per issue, per counselor. Counseling is treated 

confidentially regardless of rank with exceptions for the duty to report family maltreatment, 

threats of harm to self or others, substance abuse, and illegal activities. Source: United 

States Army Special Operations Command. 
Joint Special Operations University

and the Center for Special Operations Studies and Research

The Joint Special Operations University (JSOU) provides its publications 

to contribute toward expanding the body of knowledge about joint special 

operations. JSOU publications advance the insights and recommendations 

of national security professionals and the Special Operations Forces (SOF) 

students and leaders for consideration by the SOF community and defense 

leadership. 

JSOU is the educational component of the United States Special Operations Command (USSOCOM), MacDill Air Force Base, Florida. The JSOU 

mission is to educate SOF executive, senior, and intermediate leaders and 

selected other national and international security decision makers, both 

military and civilian, through teaching, outreach, and research in the 

science and art of joint special operations. JSOU provides education to the 

men and women of SOF and to those who enable the SOF mission in a joint 

and interagency environment. 

JSOU conducts research through its Center for Special Operations 

Studies and Research (CSOSR) where effort centers upon the USSOCOM 

mission: 

USSOCOM mission. USSOCOM synchronizes the planning of Special 

Operations and provides Special Operations Forces to support persistent, 

networked, and distributed Geographic Combatant Command operations 

in order to protect and advance our Nation’s interests.

Press publications are available for download from the JSOU Library 

web page located at https://jsou.libguides.com/jsoupublications.

Roby C. Barrett

Ph.D., Middle Eastern & South Asian History 

Public Policy Center Middle East Institute and 

JSOU Senior Fellow

James J.F. Forest 

Ph.D., Higher Education Administration

Associate Professor, School of Criminology and 

Justice Studies, University of Massachusetts 

Lowell and JSOU Senior Fellow

Mario Forestier

Chief Warrant Officer, U.S. Army, Ret.

Director, Joint Special Operations Command 

Center for Counterterrorism Studies

Thomas H. Henriksen

Ph.D., History, Hoover Institution 

Stanford University and JSOU Senior Fellow

Bernd Horn

Colonel, Canadian Dept. of National Defence, Ret.

Ph.D., War Studies

Director, CANSOFCOM Education and 

Research Centre

Russell D. Howard

Brigadier General, U.S. Army, Ret.

John D. Jogerst

Colonel, U.S. Air Force, Ret.

James Kiras

Ph.D., History, School of Advanced Air and Space 

Studies, Air University and JSOU Associate Fellow

William W. Mendel

Colonel, U.S. Army, Ret. 

JSOU Senior Fellow

Alvaro de Souza Pinheiro

Major General, Brazilian Army, Ret.

JSOU Associate Fellow

James F. Powers, Jr.

Colonel, U.S. Army, Ret.

JSOU Senior Fellow 

Bryan C. Price

Lieutenant Colonel, U.S. Army

Ph.D., Political Science

Director, Combating Terrorism Center at 

West Point

Richard H. Shultz, Jr.

Ph.D., Political Science

Director, International Security 

Studies Program, The Fletcher School, 

Tufts University and JSOU Senior Fellow

Robert G. Spulak, Jr.

Ph.D., Physics/Nuclear Engineering

Sandia National Laboratories 

and JSOU Associate Fellow 

Jessica Glicken Turnley

Ph.D., Cultural Anthropology

Galisteo Consulting Group 

and JSOU Senior Fellow 

Rich Yarger

Ph.D., History 

JSOU Senior Fellow

Joint Special Operations University

Brian A. Maher, Ed.D., SES, President

Francis X. Reidy, Interim Director, Center for Special Operations Studies and Research

Robert Nalepa, Lieutenant Colonel, U.S. Air Force, Ret., Editor in Chief

Lisa Sheldon, B.A., Advertising, JSOU Press Editor

Cindy Snyder, B.A., Mass Communications/Journalism, Assistant JSOU Press Editor

Resident Senior Fellows

Peter McCabe, Ph.D., Political Science, Colonel, U.S. Air Force, Ret.

Will Irwin, MMAS, Lieutenant Colonel, U.S. Army, Ret.

Paul Lieber, Ph.D., Mass Communication & Public Affairs

David Ellis, Ph.D., International Relations, Comparative Politics

Editorial Advisory Board
JSOU Report 17-2

The JSOU Press

MacDill Air Force Base, Florida

2017

A Social Marketing Analysis for 

Suicide Prevention Initiatives in 

USSOCOM: A Framework for 

Future Research and Success

R. Craig Lefebvre, Ph.D.
Comments about this publication are invited and should be forwarded to the 

Director of the Center for Special Operations Studies and Research, Joint Special Operations University, 7701 Tampa Point Blvd., MacDill AFB, FL 33621.

*******

The JSOU Center for Special Operations Studies and Research (CSOSR) is currently 

accepting written works relevant to special operations for potential publication. For 

more information, please contact the CSOSR Director at jsou_research@socom.mil. 

Thank you for your interest in the JSOU Press. 

*******

This work was cleared for public release; distribution is unlimited.

Printed in May 2017.

ISBN 978-1-941715-19-2
The views expressed in this publication are entirely those of the 

author and do not necessarily reflect the views, policy, or position 

of the United States Government, Department of Defense, United 

States Special Operations Command, or the Joint Special Operations 

University.

Authors are granted academic freedom provided their work does not 

disclose classified information, jeopardize operations security, or 

misrepresent official U.S. policy. Such academic freedom empowers 

authors to offer new and sometimes controversial perspectives in the 

interest of furthering debate on key issues.
Recent Publications of the JSOU Press

A Unified Theory for Special Operations, JSOU Report 17-1, Richard W. Rubright, Ph.D.

IS and Cultural Genocide: Antiquities Trafficking in the Terrorist State, JSOU 

Report 16-11, Russell D. Howard, Marc D. Elliott, and Jonathan R. Prohov

Cultural Intelligence for Special Forces Personnel, JSOU Report 16-10, 

Russell D. Howard, Greta Hanson, and Carly Laywell

Training Surrogate Forces in International Humanitarian Law: Lessons from Peru, 

Colombia, El Salvador, and Iraq, JSOU Report 16-9, Patrick Paterson

On the cover. A Special Tactics Special Operations weatherman from the 320th 

Special Tactics Squadron carries his parachute and gear after performing a HALO 

jump during exercise Talisman Sabre in Northern Territory, Australia, 10 July 2015. 

Photo by Senior Airman Stephen G. Eigel.

Back cover. Breaking the Stigma is the United States Army Special Operations Command’s (USASOC) comprehensive approach to help dispel the myths of seeking 

behavioral healthcare. The program employs a full range of training geared towards 

educating USASOC soldiers, leaders, and family members of primary stigma factors 

and barriers to care, as well as best practices for mitigating behavioral health stigmas. 

Source: United States Army Special Operations Command. 
v

Contents

Foreword .....................................................................................vii

About the Author ..........................................................................ix

Acknowledgements ......................................................................xi

Introduction................................................................................... 1

1. Social Marketing to Reduce Suicides, Mental Health 

Stigma and Increase Treatment-Seeking Behaviors......................... 5

2. Background and Overview of the Problem .............................. 19

3. What is Meant by “Stigma”...................................................... 27

4. Other Factors that Contribute to Avoidance of 

Treatment-Seeking Behaviors and Suicide.................................... 33

5. Programs that Address Suicide Prevention and 

Stigma Reduction ........................................................................ 43

6. Social Marketing Recommendations for USSOCOM Suicide 

Prevention, Stigma Reduction and Increasing BHC-Seeking 

Activities ..................................................................................... 57

Appendix: Acronym List .............................................................. 71

Endnotes...................................................................................... 73

vii

Foreword 

Every military leader is ingrained with the dual imperative: Mission 

First, People Always. After more than fifteen years of conflict, the fact 

that suicide persists as a command issue in the United States Special Operations Command (USSOCOM) is heartbreaking and serves as a clarion call 

to redouble efforts by individuals and institutions to invest in programs that 

demonstrate effectiveness in reducing suicide, eroding the stigma associated 

with seeking treatment, and increasing the use of behavioral health care 

(BHC). In this monograph, Dr. Craig Lefebvre offers a social marketing 

perspective that reveals insights and actions to enhance existing programs. 

Special Operations Forces (SOF) personnel have long recognized that 

people make the critical difference in special operations. That wisdom is 

shared by the individuals and families who live and work within the enterprise, or are life-long members of the SOF community. Their collective experience acknowledges the practical realities of this most important pillar of 

special operations. Chief among those realities are the frequently fragile 

qualities of human nature and the need to devote personal and professional 

attention, time, and resources, to ensure the sustaining fiber of human 

behavior. Every member of the SOF community plays a role in suicide prevention, but few are aware of how to play those roles.

In terms of BHC and suicide prevention, the operationalizing of this 

SOF Truth is carried out through various initiatives under the egis of Preservation of the Force and Family (POTFF). But it is in no way accurate to 

regard suicide prevention as the responsibility assigned to a small number 

of specialists. Dr. Lefebvre outlines in considerable detail the nature of the 

suicide problem in ways that inform leadership, colleagues, family members, 

and individuals and provides clear paths to the most relevant information 

for each of those roles. The monograph presents the structure and content 

of a social marketing plan for suicide prevention and its individual components are rich with information for all readers. He provides a comprehensive 

mosaic of available resources, case studies, and precedents.

Dr. Lefebvre relies on the principles and techniques of social marketing 

to precipitate behavioral changes. Such modifications strengthen the bonds 

of the SOF community, including family members that are regularly tested 
viii

by the tension, uncertainty, and rigor of operational environments and SOF 

career requirements. He devotes his first chapter to an overview of social 

marketing and how this approach draws on the multisource techniques of 

commercial marketing to focus persuasive messages on audiences of greatest 

interest or need. What results is a comprehensive program of engagement 

whose goal is preserving the lives, relationships, and cohesion of the SOF 

community. 

In the subsequent chapters, he provides a vast amount of important information, a navigable path for the way forward, and specific recommendations 

for steps along the way. Readers will learn early that considerable accessible 

research has been conducted in both military and civilian environments to 

identify and understand the psychological and behavioral dynamics involved 

with suicide. Dr. Lefebvre’s detailed survey of that literature performs an 

important service by identifying and discussing the implications of those 

sources of assistance. 

The fact is that suicide prevention is a responsibility that we all share. 

A central theme in Dr. Lefebvre’s monograph is that no one is powerless if 

sufficiently aware. But experience shows that the task at hand is more than 

encouraging individuals to pursue available resources. Assistance and treatment options exist and they have proven to be effective when pursued. The 

path that emerges in the pages that follow exposes the reader to the context, 

theory, content, and practical history of suicide and suicide prevention. More 

than a simple research survey, it provides specific ways forward to assist 

in sustaining the most compelling of all SOF Truths: “Humans are more 

important than hardware.” 

Francis X. Reidy

Interim Director, Center for Special Operations Studies and Research
ix

About the Author 

R. Craig Lefebvre, Ph.D. is an architect and designer of public health 

and social change programs. He is chief maven of socialShift, a 

social/design, marketing and media consultancy, Lead Change Designer at 

RTI International, and research professor at the College of Public Health, University of South Florida. An 

internationally recognized expert in social marketing and social and mobile technologies for behavior change, Craig has been involved in hundreds of 

projects in global, national, state and community 

contexts. He is the author of over a hundred articles 

and chapters, and his recent books include Social 

Marketing and Social Change: Strategies and Tools 

for Improving Health, Well-Being and the Environment and a six-volume series on social marketing for the Sage Library. He 

currently serves on the editorial boards of Journal of Social Marketing and 

Social Marketing Quarterly. Dr. Lefebvre received the 2014 Phillip Kotler 

Social Marketing Distinguished Service Award and the William D. Novelli 

Award for Innovations in Social Marketing. 

Craig is a founding board member of the International Social Marketing Association, a senior fellow in the Society for New Communications 

Research and an elected member of the American Academy of Health Behavior. His past positions include intervention director of the Pawtucket Heart 

Health Program, chief technical officer at Prospect Associates, chief scientist 

at the American Institutes for Research, and chief technical officer at PSI. Dr. 

Lefebvre received his Ph.D. in clinical psychology from North Texas State 

University; served in post-doctoral positions in behavioral medicine at the 

University of Virginia and the University of Pittsburgh; and has held faculty 

appointments at the University of Virginia, Brown University, Johns Hopkins 

University, the University of Maryland, Queensland University of Technology and George Washington University. He also produces the blog On Social 

Marketing and Social Change located at http://socialmarketing.blogs.com. 

xi

Acknowledgements 

There are two people at the Joint Special Operations University whose 

contributions to this project were invaluable. 

Doug Jordan initially conceived of the need for a social marketing perspective on the issue and approached me about researching and writing this 

monograph. His introduction of me to the SOF, and his continual guidance 

and support as I worked my way through the project, were essential.

Dr. Paul Lieber was my gentle yet ever-prodding mentor for this monograph. His comments and insights for the final drafts of this document were 

always on-target and greatly improved it. 

There are also many staff of the POTFF who met with me and shared 

information during the project’s development. I hope that the ideas in this 

monograph will be especially useful to them and their colleagues as they 

continue to identify and implement innovative, valuable solutions across 

the USSOCOM enterprise to improve the short- and long-term well-being 

of SOF warriors and their families. 

And most importantly, though I did not meet with any of them directly, 

it is the SOF warriors and their families I always kept in mind with the question: “What’s best for helping them meet needs, solve problems and achieve 

their dreams?” 

1

Lefebvre: Suicide Prevention Initiatives in USSOCOM

Introduction

USSOCOM Preservation of the Force and Family mission: To 

identify and implement innovative, valuable solutions across the 

USSOCOM enterprise aimed at improving the short- and longterm well-being of our Special Operations Forces (SOF) warriors 

and their families.1

This report is a detailed inquiry for augmenting the holistic approach of 

the U.S. Special Operations Command (USSOCOM) Preservation of 

the Force and Family (POTFF) task force with a social marketing perspective and approach. Social marketing provides paths to insights and actions 

to address the pressure on the force and families in order to maintain and 

improve readiness, operational effectiveness, and the immediate and longterm well-being of Special Operations Forces (SOF). This inquiry presents the 

findings and implications of a review of literature that is framed by the question: How can social marketing help reduce stigma and suicide and increase 

utilization of behavioral health care (BHC) among SOF and strengthen other 

programs under the purview of the POTFF? Six chapters present findings 

from research in USSOCOM, other military settings, and across diverse 

civilian populations that address issues of suicide including risk and protective factors, especially mental health stigma, and programs that have 

addressed one or more of these issues. This inquiry was not intended as a 

systematic review of the literature in each of these areas. Rather, selective 

reviews and programs are used to highlight some of the core questions that 

are addressed from a social marketing approach to understanding the determinants and consequences of these behaviors, the theories and evidence that 

have accrued on how to address them, and their implications for the future.

Chapter 1 serves as an introduction to the field of social marketing. It 

highlights how social marketing can be used by POTFF to provide: (1) a 

conceptual approach to link all of its efforts together that are grounded 

in the realities of the soldier and family, (2) a model to scale-up evidenceinformed and best practices, and (3) an approach that considers the criticality 

of pricing, opportunity, and access to support the achievement of objectives 

for behavioral health services and communication campaigns. The chapter 
2

JSOU Report 17-2

continues by describing key terms and concepts in social marketing and how 

a social marketing strategy and plan are developed. Social marketing strategy 

and planning processes focus on critical questions that program planners 

should consider for any initiative designed to address risk and protective 

factors for suicide and encourage BHC. This model guides to inquiry and 

recommendations in the next four chapters.

Chapter 2 provides historical and recent data on suicide in the military, and among SOF members in particular. This overview includes several 

external reviews of stigma reduction and suicide prevention activities in the 

U.S. military population. These reviews clearly show that stigma is just one 

of several pathways that lead to the avoidance of labeling and treatment. 

Another key issue identified across these reports is that theory, research, 

policy development, and program evaluations lack objective and observable 

behaviors of what constitutes stigma.

Chapter 3 looks more closely at how mental health stigma is conceptualized in literature. Recent formulations of stigma find that people may avoid 

being labeled with a behavioral health problem or avoid seeking treatment 

because of concerns about resulting discrimination due to existing laws or 

policies (structural stigma), social rejection and other negative reactions 

(public stigma), reflections that help-seeking may have on family and friends 

(courtesy stigma), and the undermining of self-esteem (self-stigma). While 

there is no empirical evidence for which types of stigma may be more prominent, it is generally acknowledged that each type of concern can influence 

the decision to seek help for one’s self or others. To better define objectives 

for stigma-reduction efforts, and to also separate what is stigma from other 

determinants of treatment-seeking behavior, it is suggested that a four-tiered 

approach may provide greater operational clarity.

Recent work has focused on a number of other critical determinants of 

treatment-seeking behavior and risk for suicide that are reviewed in chapter 4. Some of these determinants and risks include personal beliefs about 

mental illness, negative attitudes about mental health treatment and its effectiveness, legal and health problems, high combat stress exposure, financial 

problems, mental health diagnoses—particularly traumatic brain injury 

(TBI), post-traumatic stress disorder (PTSD), and depression—prescriptions 

of selective serotonin reuptake inhibitors (SSRIs) and sleep prescriptions.

A review of programs to reduce stigma and suicide, especially in military settings, is the focus of chapter 5. Several military suicide prevention 
3

Lefebvre: Suicide Prevention Initiatives in USSOCOM

programs have been shown to not only prevent suicide, but also reduce 

family violence and homicide, underlining that programs focused on risk 

and protective factors can have far-reaching positive impacts. Multiple component interventions have been found to be the most likely to reduce the 

risk of suicide, and the U.S. Air Force social marketing program is pointed 

to as an exemplar of such approaches. In contrast, the evidence for psychosocial interventions following a suicide attempt suggests that they are 

minimally effective, and there is even less evidence to recommend community-based suicide prevention programs among military populations. There 

is also little evidence to support the efficacy of mass media campaigns, use 

of gatekeepers, and general screening for suicidal ideation or depression to 

reduce suicides. However, efforts in military contexts to overcome barriers 

to care, make quality improvements in delivering mental health care, and 

organizational interventions to reduce workplace stress (duration and spacing of deployments, harassment prevention activities, employee assistance 

programs, dispute resolution services, and financial counseling services) 

were promising strategies to continue.

In chapter 6, the results and insights from the previous chapters are 

brought together to present recommendations for POTFF initiatives. Results 

of the POTFF Wave III Needs Assessment Survey-the 2014 iteration of a 

survey administered in “waves” since 2010 that assesses the short- and longterm well-being of SOF warriors and their families-provide a data-based 

context for eight recommendations for future actions. These include: 

1. Specify discriminatory behaviors that reflect USSOCOM priorities 

for reducing stigma.

2. Engage SOF members and civilian spouses more completely in the 

research and development process for programs aimed to mitigate 

suicide risk.

3. Utilize formative research in all POTFF messages, services and program development efforts.

4. Perform user preference studies in planning and refining programs 

and BHC service offerings.

5. Improve measurement of user satisfaction and perceived effectiveness 

of BHC offerings.
4

JSOU Report 17-2

6. Conduct research that is aimed at insights and understanding of the 

use of ‘outside’ BHC services.

7. Monitor, enhance, and sustain social connectedness and resilience 

through programs. This is a promising new approach to suicide prevention and increasing treatment-seeking behaviors.

8. Expand research and evaluation efforts that examine the role of selfstigma and perceptions of BHC effectiveness in mitigating treatmentseeking behaviors.
5

Lefebvre: Suicide Prevention Initiatives in USSOCOM

1. Social Marketing to Reduce Suicides, 

Mental Health Stigma and Increase 

Treatment-Seeking Behaviors

Social marketing developed as a response to tackling large-scale environmental, health, and social problems. In the mid-1960s India, the government viewed rampant population growth—more than 12 million births 

a year—as a signal for more concerted efforts to encourage its 500 million 

citizens to use family planning methods. Realizing that the scope of their 

ambitions swamped the expertise and resources available to the government, 

the Indian Institute of Management recommended a plan that developed and 

promoted family planning product brands (condoms, intrauterine devices, 

and birth control pills) supported by advertising and distribution of them 

through private sector channels rather than only government health clinics.2

 Several years later, two academic marketers in the U.S. looked at the 

social issues of the late 1960s (racial tensions, the first “Earth Day”), reviewed 

evidence for the effectiveness of some social advertising campaigns, and 

suggested the use of a marketing approach using the 4P marketing mix 

(products, price, place, and promotion) to plan social change efforts.3 Since 

those two seminal events, social marketing became a key methodology to 

address numerous social and health issues in both developed and developing countries.4,5

These two starting points focused on very different outcomes. In India, 

the purchase of family planning products was a key indicator for success. 

For Kotler & Zaltman,6 increasing the acceptability of social ideas was their 

intent, i.e. reducing pollution, improving race relations, preventing drug 

abuse and increasing use of mass transit. In the 1980s, Lefebvre and Flora7

presented their work in designing and implementing two of the world’s first 

community-based efforts to reduce a population’s risk behaviors for, and 

subsequent disability and death from, cardiovascular diseases. This marked a 

shift from social marketing being about changing ideas (knowledge and attitudes) and increasing the purchase of socially beneficial products to one that 

became more resolutely focused on the “bottom-line” of behavior change. 
6

JSOU Report 17-2

Within a few years, behavioral outcomes began to dominate the definitions 

of social marketing.8

The implications for USSOCOM behavioral health and suicide prevention 

actions are that social marketing can be applied to tackle three interrelated 

issues:

• Refining and scaling up of POTFF evidence-based products and services throughout USSOCOM;

• Addressing issues of stigma and other impediments to seeking treatment for behavioral health issues; and

• Focusing marketing and communication activities on specific behavioral objectives for a variety of priority groups.

There are several common features of a social marketing approach. The 

most consistently described characteristics of social marketing draw from 

managerial frameworks and approaches and include a consumer orientation, exchange and customer value, market analysis and segmentation (also 

referred to as selectivity and concentration), the use of the 4Ps marketing 

mix to develop and implement programs, various types of market or consumer research to test and refine offerings, and monitoring and effectiveness evaluations. Other features often found in programs in which product 

and service offerings, and not just behaviors, are important elements of the 

marketing mix include: a customer informed new product or service development process, brand development and management, positioning strategies, demand generation strategies, and management of the distribution or 

service delivery system.9,10,11

While there is much promise in such a comprehensive approach to behavioral health and suicide prevention in USSOCOM, social marketers also 

identify a number of organizational barriers that can prevent or undercut its 

full adoption, implementation, and effectiveness. Many of these barriers are 

characteristics of organizational structures, processes, and policies that can 

be quite resistant to the challenges and changes a social marketing approach 

brings to problem definitions and solutions. For example, there can often be 

an inadequate understanding of the needs and perspectives that people who 

are being served have of the problem and its possible solution. Often there 

are pressures in an organization to place professional, policy, and scientific 

priorities above people’s needs, wants, and aspirations. Aligned with these 

pressures are organizational and professional biases that favor expert- or 
7

Lefebvre: Suicide Prevention Initiatives in USSOCOM

evidence-driven efforts. In complex social systems, various stakeholders may 

impose their own agendas on solutions or modify and dilute customer-based 

ones. Some people may react to the term “marketing” as signaling attempts 

to manipulate people, rather than 

seeing that the cornerstone of the 

social marketing approach is listening to people and incorporating their 

views into program development and 

implementation. Even if accepted as 

a valid approach to reform current 

approaches or innovate new ones, 

organizational structures can impede 

the design of integrated marketing 

approaches; there may be a belief that 

social marketing is incompatible with 

other approaches, such as community-based efforts, policy development, and 

advocacy; and, there is a reluctance to tamper with existing programs.12-15

Throughout this discussion, these concerns will be addressed.

Social Marketing: The Starting Point

A comprehensive framework for using marketing to address behavioral 

health and suicide prevention objectives in POTFF will have two distinguishing elements: one that expresses the notion of a consumer orientation 

(listening and being responsive to SOF and family members, USSOCOM 

behavioral health staff and officers), and a second that embodies the idea 

that social marketing is designed for large-scale change efforts—not just 

individual or clinically focused education and behavior change activities.16

This is not to diminish the critical importance of educational and clinical 

interventions to assess and address intrapersonal and interpersonal factors, 

tailor the information to be conveyed to an individual or group, and provide the context to learn and practice the complex skills needed by people 

to encourage, support, engage in, and improve optimum behavioral health. 

Indeed, many of these types of services might become more attractive to a 

larger share of SOF and family members by integrating them into a larger, 

holistic framework through the use of the social marketing approach. 

Some people may react to the 

term “marketing” as signaling 

attempts to manipulate people, 

rather than seeing that the cornerstone of the social marketing 

approach is listening to people 

and incorporating their views 

into program development and 

implementation.
8

JSOU Report 17-2

The social marketing approach takes a systems-level, or social-ecological, 

perspective on addressing the problem in which individual-focused efforts 

occur in social, organizational, and policy environments. Social marketing strategy seeks to align these different levels of solutions so that all of 

them support the initiation, participation, and maintenance of behaviors 

that improve the short- and long-term well-being of SOF warriors and their 

families. These behaviors are not just those of the individual seeking assistance, but also the behaviors of people across the USSOCOM enterprise. 

What social marketing provides is: (1) a conceptual approach to link all these 

efforts together that is grounded in the realities of the soldier and family, (2) a 

model to scale-up evidence-informed and best practices, and (3) an approach 

that considers the criticality of pricing, opportunity, and access to support 

the achievement of objectives for POTFF initiatives—including behavioral 

health services and communication campaigns. 

An Integrated Model for Social Marketing Practice and 

Research

Building on these two core concepts, an integrated social marketing approach 

has four interrelated tasks that revolve around an identified benefit or value 

proposition for a priority segment of the population—whether it is an operator, a family member, civilian, other service members, behavioral health 

professional staff, or others (see fig. 1). The first task is to clearly identify and 

understand the priority group the resources are targeted to serve. However, 

this does not assume that each of these groups is homogeneous—there may 

be different groups of operators, family members and civilian workers who 

have characteristics in common and yet distinguish them from other peers 

(age or deployment status for example). This idea of segmentation is a critical 

step early on in the marketing process. It helps to avoid the ‘one-size-fits-all’ 

fallacy employed by too many communication, educational and policy interventions. This fallacy makes it difficult to evaluate the outcome of programs: 

answers to questions about what specific effects, among which sub-populations of soldiers and family members, in what contexts, were facilitated or 

inhibited by program components is lost in the quest for “an average effect.” 

The idea of discrete segments drives how measurement and monitoring systems are designed: the question shifts from “does this intervention work?” to 
9

Lefebvre: Suicide Prevention Initiatives in USSOCOM

“what intervention is most effective with this specific group of people who 

are experiencing a certain type of problem in a specific context?” 

The second task, shown in the center of figure 1, is to identify the essence 

of what each of these groups of people want or need, the specific problems 

they have, and the aspirations they have for themselves and others. The various needs, problems to be solved, and aspirations are the signals for what 

types of benefits and values are most important to this group. This terminology is important. Addressing people’s needs may be appropriate in a limited 

set of circumstances—such as when they cannot provide for themselves. But 

it is when marketers become partners in helping people solve their problems and enable them to reach their aspirations that more powerful results 

are possible. Many times marketers will do their initial segmentation of a 

priority group, such as operators or spouses, based on the benefits or values 

they have in common (to keep their family secure, solving problems such 

as purchasing a new car or finding new housing, educational goals for their 

children). Tapping into benefits and values also allows the marketer tap into 

existing motivations to change. 

Once these core benefits and values are understood from the perspective of the people served, attention is turned to understanding the determinants, consequences, and context for the current behaviors they engage in 

that may decrease or compromise behavioral health and/or lead to suicidal 

The Social Marketing Idea

Target Behavior

• Determinants

• Context

• Consequences

• Relevance

Products, 

Services, and 

Behaviors (PSB)

• Brand

• Personality

The Audience Benefit

The Marketing Mix

• PSB

– design and features

• Price

– incentives and costs

• Place

– access and 

 opportunities

• Promotion

– communications and 

 experiences

Figure 1. An Integrated Model for Social Marketing.
10

JSOU Report 17-2

behaviors. Many of these determinants may already be understood from 

previous research. However, it is also important to elicit the perceptions and 

ideas of the people being served by the programs. When program planners 

are considering options and designs for products, services, and behaviors 

they believe will reduce suicides or improve treatment-seeking behaviors, 

equal weight is given to peoples’ inputs as to what are the most desirable and 

relevant features for them, what behaviors fit their lives, how confident they 

are in actually engaging in the behaviors, and their expectations that the 

proposed solutions will meet their needs, help them solve their problems, 

or serve their aspirations. 

Equipped with this knowledge, the fourth task (the outer ring of the 

figure) is tailoring a marketing mix that is responsive to group members’ 

unique characteristics and concerns. Program designers consider at this step:

• How the product, whether it is a tangible item, a service offering (educational sessions, BHC), or a behavior is desirable, relevant, and tailored to fit the characteristics, concerns, and daily activities of each 

priority group.

• How price variables can facilitate or impede product or service use 

and adoption of new behaviors. Prices may be incentives or costs for 

change—financial, time/attention, effort, psychological, social, geographic/environmental, and policies among others (in the latter two 

cases, for example, that create barriers or facilitate access to care). 

Opportunity costs, or what the person forgoes to use a product or 

service or engage in a new behavior, are also considered part of the 

price element.

• The place component when products (tangible items, services, or 

behaviors) are accessible and available to members of the priority 

group, and opportunities for trying, practicing, and supporting new 

behaviors are designed. Place may be thought of as the physical location or proximity to offerings and opportunities; however, mobile and 

telehealth technologies can be employed to place and/or shift product and service distribution, and virtual reality technologies can be 

used to create opportunities to practice skills. New technologies have 

expanded the options for what constitutes a “place” for interventions.

• How these new products, services or/and behaviors, their associated prices, and the access points and opportunities to engage with 
11

Lefebvre: Suicide Prevention Initiatives in USSOCOM

them will be communicated to the priority group is the promotion 

component of the marketing mix. In social marketing, a message ‘to 

change’ in some way is not a promotional element. The purpose of 

the promotion “P” is to build awareness of the product, service and 

behavior; build demand for them; facilitate decisions to try them; and 

reinforce their continued use or sustained engagement in the behavior. This distinguishes social marketing from approaches that rely on 

various types of persuasive appeals and message design principles to 

encourage behavioral changes. In the best circumstance, these types 

of health communication campaigns are found to result in an average 

of five percentage points change in behavior from baseline.17 Social 

marketing may incorporate behavior change messages, but they are 

augmented and integrated with the other 3Ps. For example, a recent 

analysis of combining low-cost or free products with media campaigns 

demonstrated their superiority in achieving behavioral changes compared with mass media efforts alone.18

The importance of the initial stage of determining benefits and value for 

each priority group cannot be overstated. Rangan, Karin, and Sandberg19

found the lack of short-term, concrete benefits for an individual to be a 

major barrier to the success of social marketing efforts. They recommended 

that various types of benefits be considered in social marketing programs, 

with the choice depending on how people in the priority group perceive the 

costs for engaging in different behaviors and whether the expected benefits 

were directly to the individual or for a larger social good. This finding is 

useful when designing programs intended for SOF families in which each 

person might have different ideas about what value, benefit, or costs means 

to them. The notion of ‘courtesy stigma,’ for example, where a spouse might 

be more concerned about the stigma they experience than the help-seeker 

who has few concerns about “self-stigma,” is just one example where a larger 

good (protecting the family) may be inconsistent with individual beliefs. For 

example: “I don’t want to be labeled as the spouse of someone who is mentally 

ill.” Another important consideration is that these benefits or value cannot 

simply be ‘promised;’ people must be able to experience these benefits and 

value by observing or experiencing their ‘value-in-use.’ One example is that 

when marketing behavioral health services, users and their spouses need 

to experience the promoted ‘benefits’ for themselves, discover their own 
12

JSOU Report 17-2

unique value for participating, or learn from others what their experiences 

have been with the program (did the spouse feel treated in ways that suggested “courtesy stigma,” or were they relieved to find others like them in a 

peer support network?). 

Finally, social marketing recognizes that the context in which behaviors 

occur, or not, is an important lever for change efforts. Efforts to reduce stigma, 

increase help-seeking behaviors, or encourage use of behavioral health services occur in a social context of networks of people that are linked directly 

or indirectly with each other—a complex 

web of social determinants. How these 

networks encourage or discourage helpseeking behaviors, and more importantly 

can be leveraged to achieve better behavioral health outcomes, should be part of 

the social marketing plan. As was noted 

in the discussion of price, policies and 

procedures play an important role in 

facilitating or discouraging help-seeking 

behaviors. Initiating changes in policies 

and procedures that align with social marketing objectives are important 

steps in the longer-term support and sustainability of change efforts by the 

individual, their family, and USSOCOM.20, 21

Creating Social Marketing Strategy

Transforming social marketing ideas into strategies that serve USSOCOM 

and POTFF objectives involves taking the research findings and inputs 

from priority groups and stakeholders and deliberately working through a 

sequence of steps. Each step in the process of developing marketing strategy 

builds on what is learned at earlier stages and informs ideas for program 

development or refinement, but does not dictate them (see fig. 2). This iterative process of developing a marketing strategy involves:

1. understanding what the problem is from people’s points-of-view, 

2. informing those observations with relevant theoretical models and 

previous research,

Efforts to reduce stigma, 

increase help-seeking behaviors, or encourage use of 

behavioral health services 

occur in a social context of 

networks of people that are 

linked directly or indirectly 

with each other—a complex 

web of social determinants.
13

Lefebvre: Suicide Prevention Initiatives in USSOCOM

3. developing hypotheses about what behaviors may then be of the most 

value to each segment or priority group, 

4. testing these assumptions and prototypes with them—especially their 

feasibility, relevance and perceived superiority (positioning) to current 

behaviors or other options, and then

5. refining the concepts and offerings and articulating them in a marketing plan.

What distinguishes a marketing approach from other ways of developing 

interventions is its sole focus on a strategy that delivers a behavior, product, 

or service that people experience as a value or benefit in their everyday 

lives. The question the marketing strategist needs to answer is: What is the 

potential value (benefit) we are offering to people for this new way of meeting their needs, solving their problems, or achieving their goals? Results 

of literature reviews and surveys can be complemented with face-to-face 

interactions and conversations with members of the priority group to answer 

this question. This qualitative research may use anthropological methods, 

in-depth individual interviews, focus groups or any number of techniques. 

The outcome of this formative research should be one or more insights that 

answer the question of “what do they value that is relevant to our objective 

(of increasing treatment-seeking behavior, for example)” from the priority 

group’s point of view—not according to what the science, policy, or experts 

might dictate as the right thing to do.

Segments

Behavior

Value/

Benefits

Tailored

Marketing

Mix

Positioning Relevance

Develop Alternatives Test Assumptions Marketing Plan

Figure 2. The development process for social marketing strategy.
14

JSOU Report 17-2

What has been learned about the determinants, context, and consequences of the behavior guides how the value of new products, services, 

or behaviors is offered to people in ways that fit into their lives, the world 

around them, and within the resources that are available to them. The strategy needs to link the desired behavior: connecting behavioral health services 

with what the priority group finds valuable to them, what is feasible for them 

to do, what opportunities are available to them, and in ways that minimize 

their costs (financial, time, social and psychological among others). Then, 

and only then, are communication efforts developed that promote the adoption of the new behavior, product, or service.

The Marketing Plan

The outcome of marketing strategy development is the marketing plan. A 

social marketing plan is a translation document that considers: 

1. The understanding of the problem 

2. The context in which the intervention will take place

3. Organizational strengths and competencies

4. Implementers’ and partners’ capabilities 

5. Behavioral determinants of the problem and potential solution

6. Priority group insights

The marketing plan delivers program ideas and approaches to achieve 

changes among members of priority groups, or segments, and also details 

the tactics for using the resources available to capitalize on the most vital 

opportunities and insights from the priority group. To create a marketing 

plan, the following questions should have clear answers:

Who is (are) the priority group(s)—and what segments within each 

group are the focal point for the program? For example, are all SOF members the same, or are there different issues and problems that need to be 

addressed based on rank, gender, civilian or deployment status, length of 

service, whether they are in support roles, or members of the behavioral 

health team? The specificity of how priority groups are defined allows the 

program designer to then articulate the remaining questions and tailor how 

the program will be desirable, relevant and useful for each one. 
15

Lefebvre: Suicide Prevention Initiatives in USSOCOM

What do they do? Specificity of target behaviors is important as programs 

that set out to encourage self-reporting of behavioral health issues, seeking treatment, or eliminating discriminatory behaviors may have different behavioral targets depending on who is being asked to do something. 

For example, behaviors associated with encouraging treatment-seeking will 

be different for various priority groups noted above while those behaviors 

associated with supporting continued use of behavioral health services are 

likely different as well. If the formative research is done well, and the marketing strategy well thought through, then these behaviors should be selected 

because they are high leverage, relatively easy to do, and supported by the 

social and physical environment in which people live and work. Specifying 

the behaviors should also be used to guide monitoring and evaluation activities. If there are social and/or structural barriers to engaging in the behavior, 

then perhaps these issues should be addressed first or initiatives to address 

them be integrated into the marketing plan.

How will they do it? The process by which people in these different priority groups will incorporate new behaviors into their lives, or stop practicing 

others, needs to be understood from their point of view, not just in theory. 

Creating a journey map with representatives of each of these priority groups 

can help identify the decision points (where, when, and with what resources) 

that might influence their engagement in behaviors. A journey map can also 

identify some of the social or structural constraints that may need to be 

addressed by the program as well.

When are the best times for them to do it? The plan should specify particular times when people may be more open to engaging in new behaviors. 

Depending on the circumstances and behaviors, these times may present 

better access to opportunities, may be in a certain frame of mind when the 

behavior is more relevant, may be certain times in which these new behaviors become more salient to them, or particular moments in their daily lives 

when adopting the new behavior can become part of established patterns.

Where are the best places for them to do it? Even if people want to engage 

in new behaviors or discontinue other ones, or whether they have access 

to products and services to help them do it, the physical resources must 

be available to do so. Strategies to increase opportunities to practice new 

behaviors, or increase access and accessibility to services and resources, 
16

JSOU Report 17-2

can also include opportunities to remind them, facilitate engagement and 

provide support if it needs to be addressed. For behavioral healthcare, place 

strategies may start with convenient physical access, but may also expand 

to identify other critical places where, in an SOF member’s daily living and 

work routines, they may come in contact with POTFF staff or initiatives that 

can be used to connect them with behavioral healthcare (so-called “crossmarketing opportunities”). The admonition to “Just do it!” may make great 

advertising copy or campaign slogans, but it is not a marketing plan. The 

environment should be designed to make choices for behavioral healthcare 

the easy and ubiquitous one for those that may need it.

How much will they be rewarded by new behavior, or how much will it 

cost them? The marketing plan should address the most relevant incentives 

and costs that people in each priority group associate with the offering. Note 

that tangible rewards or incentives are not the same as the internal benefit 

or value people attach to the behavior, product, or service. In the absence of 

any internal motivation, using incentives or rewards can become a problem 

as they lead to short-term adoption and then rapid discontinuation of new 

behaviors, products, or service—a situation referred to as over-justification or 

crowding-out effect.22 This is why the earlier admonition to tap into existing 

motivations or values is important to successful change efforts.

Why would they do it? This question needs to be answered from the perspective of those in each priority group, and it should be addressed through 

the program’s positioning strategy. The positioning for the program answers 

the question for the priority group of how new behaviors are different and 

better from what they currently do or could do instead (are they as feasible 

as current behaviors, relevant to their daily life, and perceived as superior 

in some way to current behaviors). Therefore, the question of “why?” can 

be partly answered by positioning a behavior, product or service as a more 

satisfying resolution to a need, a better solution for a problem, or an advantage in achieving particular professional or family goals. Positioning can 

also answer the question by offering lower costs or a higher tangible value as 

well as being easier or more convenient than current ways of doing things. 

Finally, the “Promotion P” can be used to provide information to enable or 

support decision-making by directly addressing the question of “why” and 

the pros and cons for engaging in the behavior.
17

Lefebvre: Suicide Prevention Initiatives in USSOCOM

Who is going to implement the program elements? A clear outline of 

responsibilities needs to be detailed and agreed upon. One weakness of some 

plans is that they presume that people, organizational units, or partners 

will take on certain responsibilities, for example providing a service, using 

the materials in their own programs, distributing products to their clients, 

or constituencies or committing resources to the project. At other times, 

the program will impose additional burdens on staff that are not offset by 

reducing other ones or at least recognizing what these might be and how to 

mitigate them. The most successful marketing organizations are those in 

which the implementation staff is also a priority group (critical to success). 

For example, how POTFF encourages and supports many different types 

of service delivery agents—chaplains, social workers, psychologists, senior 

leadership, peer mentors, and teammates—who have different expectations 

for their role in improving the resiliency of SOF and their families, can be 

addressed through a social marketing approach. 

Social Marketing and Other Health Promoting Strategies

Some professionals are concerned that social marketing is a radical, and 

exclusive, way to think about, plan, and implement health promotion programs such as ones offered by the POTFF. However, the prescription for 

effective planning of social marketing programs bears a remarkable similarity to health promotion scholars’ conceptualization of effective practice. 

Consider the ten principles for health promotion programs put forth by 

Freudenberg et al.23 Effective programs, or interventions, should:

1. Be tailored to a specific population within a particular setting.

2. Involve the participants in planning, implementation, and evaluation.

3. Integrate efforts aimed at changing individuals, social and physical 

environments, communities, and policies.

4. Link participants’ concerns about health to broader life concerns and 

to a vision of a better society.

5. Use existing resources within the environment.

6. Build on the strength found among participants and their communities.
18

JSOU Report 17-2

7. Advocate for the resources and policy changes needed to achieve the 

desired objectives.

8. Prepare participants to become leaders.

9. Support the diffusion of innovation to a wider population.

10. Seek to institutionalize successful components and then replicate 

them in other settings.

Indeed, many of these principles for effective health promotion programs 

are equally relevant to POTFF’s initiatives. In particular, an emphasis on 

involving people from the priority group in planning and implementation, 

integrating efforts across different levels of the USSOCOM enterprise, utilizing assets and resources already available in the setting and among the 

priority group, and encouraging diffusion and sustainability are reminders that the successful program designer and manager will hold to closely. 

Social marketing is a strategic process for planning change programs at the 

individual, interpersonal, organizational, normative, and policy levels. It is 

through incorporating people’s perspectives, and applying behavioral and 

social theories of change, that POTFF can develop innovative, evidenceinformed, and people-tested programs. 

In the rest of this inquiry, a social marketing lens is applied to the many 

policy, research, and practice-based approaches that have been undertaken 

to address suicide prevention, stigma reduction and seeking BHC. 
19

Lefebvre: Suicide Prevention Initiatives in USSOCOM

2. Background and Overview of the 

Problem

Historically, the rate of suicides among active duty military personnel 

has been significantly lower than the rate for a comparable population of Americans. However, since 2001 these rates have risen to the point 

where members of the armed forces are at higher risk for suicide than the 

general U.S. population.24,25 Suicide rates began to increase in 2006, driven 

primarily by a steady upward 

trend in the number of suicides in 

the Army and Marine Corps. In 

2009, the Department of Defense 

(DOD) identified 309 total active 

duty suicides, for a rate of 18.3 per 

100,000. The number of suicides 

has climbed among service members in the Reserve Component, and by 2010 

there were 180, with the Army National Guard having the largest increase 

in the total number.26 Recent data from the Department of Veterans Affairs 

indicates that, on average, 20 veterans a day die from suicide. This rate of 

suicide is 21 percent greater than it is for a civilian population of comparable 

age and gender.27

One research review found that service members most frequently used 

firearms as the means for suicide.28 Drug overdose was the most frequent 

method for suicide attempts, and the misuse of prescription medication was 

more frequent than illegal drugs. Most service members were not known to 

have communicated their potential for self-harm with others prior to suicide 

or attempted suicide. The majority of service members who died by suicide 

did not have a known history of a mental or substance use disorder. Finally, 

the overwhelming majority of suicides occurred in a non-deployed setting, 

and more than half of those did not have a history of deployment. However, 

rates increased among two important groups: veterans who recently returned 

from service in Afghanistan and Iraq, and those who receive health care 

services from the Veterans Health Administration. 

In its own analyses of these trends, USSOCOM found that from 2012 

to 2013, Conventional Forces (CF) suicides decreased from 22.7/100,000 

Recent data from the Department 

of Veterans Affairs indicates that, on 

average, 20 veterans a day die from 

suicide.
20

JSOU Report 17-2

to 18.7/100,000. However, the CF rate showed a slight increase in 2014 to 

19.9/100,000. Among SOF there has been a 26 percent decrease in suicides 

over the same time period (per DOD policy, the number of suicides per 

year that are less than 25 do not use the per 100,000 comparison rate). SOF 

suicides have not been more than 25 per year since tracking began in 2007.29

Suicide prevention among SOF has the highest levels of attention and 

concern: the author considers preserving the force and families the SOF 

community's highest priority. The success of any mission depends on people. 

While the command has seen a steady decrease in suicides over the past four 

years, the authors’ focus on this problem will not waver. The author hopes 

to achieve a command climate that views behavioral healthcare as a normal 

and expected aspect of personal and professional development.30

USSOCOM POTFF is charged with building and implementing a holistic approach to address the pressure on the force and families in order to 

maintain and improve readiness, operational effectiveness, and the immediate and long-term well-being of SOF.31 POTFF initiatives were developed 

in response to clear demand signals from the SOF units and components 

that have been under unprecedented levels of stress during the past few 

years stemming from the high frequency of combat deployments, highstakes missions, and extraordinarily demanding environments. An integrated, embedded care model is used to maximize access and minimize 

stigma to: (1) improve the cognitive and behavioral performance of the force 

(psychological performance); (2) meet the unique physical needs of SOF 

operators and maintain their peak performance throughout their careers 

(human performance program); (3) incorporate family resilience programs 

to enhance service-provided programs and adapt them to meet the unique 

needs of the SOF family (social and family performance); and (4) enhance 

core spiritual beliefs, values, awareness, relationships and experiences (spiritual performance). 

POTFF initiatives build upon and complement service programs and are 

designed to supplement the capacity of service-provided programs by accelerating delivery and standardizing access across the SOF enterprise. All of 

the initiatives are designed to foster a culture of health and wellness where 

problems are addressed early and without fear of repercussion or embarrassment. This study supports USSOCOM and POTFF research interests in 

mitigating SOF suicides through better understanding of susceptibility and 

risk factors and also addressing the stigma associated with seeking medical 
21

Lefebvre: Suicide Prevention Initiatives in USSOCOM

and mental healthcare for SOF. This report reviews relevant research and 

examines how a social marketing approach—a model for developing largescale change initiatives in public health and other disciplines—can be applied 

to improving suicide prevention initiatives.

Current Efforts: DOD and United States Department of 

Veterans Affairs (VA)

A review by the United States Government Accountability Office (GAO) 

identified recent milestones in efforts by the DOD and VA to prevent suicide 

and reduce mental health stigma among military and veteran populations.32

These milestones are summarized in Table 1.

The Deputy Assistant Secretary of Defense for Readiness leads a collaborative effort across the DOD to address suicide. The Final Report of the 

Department of Defense Task Force on the Prevention of Suicide by Members of 

the Armed Forces has served as a catalyst for the DOD to review and assess all 

policies and programs that relate to suicide prevention. Based on the report 

and the action plans developed from it, a departmental implementation 

memorandum was signed by the Under Secretary of Defense for Personnel 

and Readiness in September 2011 to guide the DOD’s ongoing efforts.33

Established in November 2011, the Defense Suicide Prevention Office 

(DSPO) is part of the DOD’s Office of the Under Secretary of Defense for 

Personnel and Readiness. DSPO oversees all strategic development, implementation, centralization, standardization, communication, and evaluation 

of DOD suicide programs, policies, and surveillance activities. To reduce the 

impact of suicide on service members and their families, DSPO uses a range 

of approaches related to policy, research, communications, and behavioral 

health. DSPO works closely with the Army, Navy, Air Force, Marine Corps, 

Coast Guard, and National Guard Bureau, as well as other governmental and 

nongovernmental agencies, to support Service members and strengthen a 

resilient and ready force. DSPO strives to help foster a climate that encourages Service members to seek help for their behavioral health issues.34

A core emphasis of DOD suicide prevention and behavioral health programs is “reducing stigma.” The DOD Task Force on the Prevention of 

Suicide by Members of the Armed Forces noted: “The roots of stigma are 

anchored in stereotypes—generalizations perceived to be accepted by the 

population at large—such as ‘people with mental health problems are crazy’ 
22

JSOU Report 17-2

2007 DOD Task Force on Mental Health. This report states that maintaining psychological 

health, among other things, is essential to maintaining a ready and fully capable military force; 

however, stigma in the military remains pervasive and often prevents service members from seeking 

needed care. Available at: http://justiceforvets.org/sites/default/files/files/Dept of Defense, mental health 

report.pdf

2008 RAND Corporation Study: Invisible Wounds of War: Psychological and 

Cognitive Injuries, Their Consequences, and Services to Assist Recovery. This study 

addresses, among other things, gaps in knowledge about the mental health and cognitive needs of 

service members returning from Afghanistan and Iraq, the adequacy of the care systems available to 

meet those needs, and factors, such as stigma, related to whether and how injured service members 

and veterans seek care. Available at: http://www.rand.org/content/dam/rand/pubs/monographs/2008/

RAND_MG720.pdf

2010 DOD Task Force on the Prevention of Suicide by Members of the Armed Forces.

The final report of this congressionally mandated task force includes 76 recommendations, including 

developing a comprehensive stigma reduction campaign plan that attacks the issue of suicide 

prevention on multiple fronts to encourage help-seeking behavior and normalizes the care incurred by 

service members. The report stated that DOD’s challenge to preventing suicide and sustaining suicide 

prevention efforts involves addressing the large set of psychological, physical, spiritual, emotional, 

relational, environmental, occupational and social stressors that exist in a person’s life, as well as 

building resiliency and reducing stigma, which influence the impact of those stressors. Available at: 

http://www.sprc.org/sites/default/files/migrate/library/2010-08_Prevention-of-Suicide-Armed-Forces.pdf

2011 RAND Corporation Study: Promoting Psychological Resilience in the U.S. 

Military. This study found that without strong leadership, military resilience programs designed to 

help encourage and support service members in their capacity to adapt successful to risk and adversity cannot be successful. Leadership can play a pivotal role in creating a command climate in which 

it is okay to get help for psychological health concerns. However, current policy could promote cultural 

attitudes and beliefs that inhibit acknowledging problems and seeking mental health care. Available at 

http://www.rand.org/content/dam/rand/pubs/monographs/2011/RAND_MG996.pdf

2013 Institute of Medicine of the National Academies report: Returning Home from 

Iraq and Afghanistan: Assessment of Readjustment Needs of Veterans, Service 

Members, and Their Families. This report states, among other things, that stigma is a problem 

for military personnel receiving care or seeking care for mental health or substance abuse problems. 

According to this report, active duty service members fear that visiting a mental health care provider 

will jeopardize their careers because of the military’s long-standing policy of reporting these types 

of problems through the chain of command. Available at: http://nationalacademies.org/hmd/~/media/

Files/Report Files/2013/Returning-Home-Iraq-Afghanistan/Returning-Home-Iraq-Afghanistan-RB.pdf

2014 RAND Corporation report: Mental Health Stigma in the Military. This report contains 

six findings from a content analysis of DOD policies, including identifying policies that may expose 

service members to stigma or discrimination because they allow non–mental health professionals to 

determine mental health fitness. Available at: http://www.rand.org/pubs/research_reports/RR426.html

Table 1. Milestone Reports of Suicide Prevention and Reducing Stigma 

Associated with Mental Health in the Military
23

Lefebvre: Suicide Prevention Initiatives in USSOCOM

and ‘Service Members who seek behavioral healthcare are weak.’”35 However, 

the GAO found that while the term “stigma” is prevalent throughout DOD 

documents and policies, there is little specificity on what the term means or 

the behaviors that might be associated with it. Despite this lack of specificity, the GAO identified numerous stigma reduction efforts launched by the 

DOD including programs and awareness campaigns to change perceptions, 

develop skills to cultivate personal resilience, and increase mental health 

coping and awareness skills. Other DOD programs have encouraged helpseeking behavior through training and education on the benefits of mental 

health care and dispelling myths (for example, the Real Warriors campaign 

in 2009 that featured benefits of help-seeking through personal stories of 

successful outcomes from treatment).36 Based on the results of the Wave III 

Needs Assessment, POTFF recently concluded that increasing attention on 

social connectedness might also contribute to strengthening the resilience 

of SOF.37

The VA’s suicide prevention program is based on the principle of ready 

access to high-quality mental health services within the health care system, 

supplemented by (1) public education and awareness activities promoting 

engagement for those who need help, and (2) availability of specific services 

addressing the needs of those at high risk. Activities have included:

1. Creating a national office for suicide prevention

2. Partnering with the Substance Abuse and Mental Health Services 

Administration and its Lifeline program to add a veterans’ call center 

to its national 800-273-TALK/8255 crisis line

3. Funding suicide prevention coordinators with support staff in each 

VA medical center

4. Ensuring same-day access for veterans with urgent mental health needs 

at over 1,000 points of care by the end of calendar year 2016 

5. Improving case management and tracking38,39

External Evaluations of DOD Stigma-Reduction Activities

The suicide prevention activities of the DOD and VA have undergone several independent reviews over the past few years. These reviews are notable 
24

JSOU Report 17-2

for the attention they draw to key aspects of suicide prevention activities 

in the military that are applicable to POTFF initiatives. One major finding 

from these reviews is that while there is significant focus on reducing the 

stigma associated with help-seeking and mental illness, there are significant 

shortcomings. For example, GAO identified and reviewed 13 DOD, service, 

and joint staff policies that mention “stigma” with regard to mental health 

care. Although each of the policies reference stigma reduction as a goal or 

as something to be dispelled or countered, all but two policies used “stigma” 

as a standalone term with little specificity as to its causes, or how it could be 

manifested and observed in behaviors or in policies. Its review found that the 

DOD has not developed a clear and consistent definition for the concept of 

mental health care stigma, explanations of contributing causes or risk factors 

for stigma and mental health care, and how stigma is embedded through 

behaviors and policies. The GAO also noted that DOD did not have goals or 

performance measures to track progress in reducing barriers or stigma and 

that inconsistent methods are utilized to measure stigma across multiple 

DOD and service-sponsored surveys, making it difficult to examine trends 

over time and determine the effectiveness of stigma reduction efforts.40

Without clarity and consistency in the definition of those barriers to care 

that the DOD understands as mental health care stigma, including the causes 

or contributing risk factors and ways that stigma is evident through behaviors and policies, the GAO concluded that there may be stakeholders across 

the department who do not fully understand the concept of stigma to then 

recognize and take steps to reduce it. Further, the lack of operational definitions means that the department cannot develop specific goals and measures 

with which to evaluate its initiatives and progress toward reducing stigma. 

Together, the absence of a clear and consistent definition of those 

barriers to care that DOD generally understands as “mental health 

care stigma,” related goals and measures for reduction of stigmarelated barriers to care, and a coordinating authority with oversight 

prevent the department from positioning itself to evaluate progress 

and demonstrate efficacy and results from its initiatives.41

This lack of specificity of targets or outcomes for stigma-reduction efforts 

was also discovered in a report on five stigma-reduction programs, three 

of which were DOD-wide: Military Pathways, Afterdeployment.org, and 

the Real Warriors Campaign. The remaining two, Breaking the Stigma and 
25

Lefebvre: Suicide Prevention Initiatives in USSOCOM

Embedded Behavioral Health (EBH), were Army programs. Acosta et al 

found that the evaluations lacked the rigor, comprehensiveness, or specificity 

needed to determine whether these programs are effective.42 Although each 

of the five programs collects data, the metrics are largely process measures, 

such as website visits and satisfaction surveys. These process data are helpful in ensuring that the programs are being used, but they do not provide 

information on whether the programs are effective in reaching the intended 

priority groups, reducing stigma or increasing treatment-seeking among 

those in need of services. The next chapter looks at various definitions and 

approaches to conceptualizing stigma.

27

Lefebvre: Suicide Prevention Initiatives in USSOCOM

3. What is Meant by “Stigma”

The vast majority of efforts within the DOD and VA, as well as in many 

efforts directed towards civilian population groups, focus on reducing 

stigma around mental health problems and treatment-seeking behaviors. 

However, as noted by the GAO, what constitutes stigma in an operational sense—that is, the observable behaviors and barriers that exemplify 

‘stigma’—is often missing. Indeed, one GAO recommendation to the Secretary of Defense was to establish a clear, consistent definition of those barriers 

to care generally understood by DOD as “mental health care stigma.” The 

recommendation also encouraged an articulation of the presumed causes or 

contributing risk factors of stigma and ways that stigma is apparent in behaviors and policies. A corollary to this recommendation was also to establish 

goals for initiatives understood by DOD as “stigma reduction efforts,” and 

design performance measures that link to these goals.43

The GAO analysis of the most recently available data from a DOD-wide 

survey found that about 37 percent of active duty service members in 2011 

and 39 percent of reservists in the 2010/2011 timeframe responded that they 

thought seeking mental health care through the military would probably or 

definitely damage a person’s career. Among active duty service members, 

22 percent believed their career was affected somewhat negatively or very 

negatively because they sought counseling or mental health care treatment.44 

Service-sponsored surveys and comments from 26 focus groups conducted 

by the GAO with service members and with civilian employees of DOD 

who have deployed or were preparing to deploy reinforced perceptions of 

stigma about seeking mental health care. Some of their most prevalent specific concerns included: (1) being associated with “malingering,” (2) possibly 

losing job qualifications such as a security clearance or the ability to carry a 

weapon, and (3) having to live up to the competitive military image.45 GAO’s 

review of DOD-wide surveys also found that none of them measure deployed 

civilians’ perceptions of mental health care, including stigma. As a comparison, in the POTFF Wave III survey, 5.7 percent of active duty SOF reported 

beliefs such as “worried about effect on career/clearance,” “embarrassed,” 

“leadership will ruin career/poke fun,” and negative stigma as reasons for 
28

JSOU Report 17-2

not accessing BHC.46 How these specific beliefs are distinct from “negative 

stigma” was not addressed in the report.

The National Academies of Sciences, Engineering, and Medicine, in a 

report evaluating the evidence for stigma change, defined stigma as the 

relationship between an attribute and a stereotype that assigns undesirable 

labels, qualities, and behaviors to a person. These labeled individuals are 

socially devalued leading to inequality and discrimination.47 Further, stigma 

is a dynamic multi-dimensional, multi-level phenomenon that occurs at three 

levels of society—structural (laws, regulations, policies), public (attitudes, 

beliefs, and behaviors of individuals and groups), and self-stigma (internalization of negative stereotypes). Articulating stigma as being a structural 

concern; one of public attitudes, behaviors and norms; and being centered 

within the individual’s beliefs system leads to very different approaches to 

measuring and reducing it.

A review of mental health stigma in the military by the RAND Corporation referred to mental health stigma more narrowly as a dynamic process by 

which a service member perceives or internalizes this brand or marked identity about himself or herself or people with mental health disorders—what 

the National Academy of Sciences’ (NAS) report referred to as “self-stigma.” 

The researchers suggest that this process happens through an interaction 

between a service member and the key contexts in which the service member 

resides.48

Taking the next step, they proposed a conceptual model that operationalizes their definition of stigma by linking it to the key contexts that create 

stigma—the public context, the military context, a social context, and the 

individual context—and the empirically and theoretically derived impacts of 

stigma (see fig. 3). Four short-term impacts were empirically linked to stigma:

• interpersonal outcomes (e.g., self-esteem), 

• coping mechanisms (e.g., hide, withdraw), 

• negative attitudes toward treatment-seeking, and 

• lowered intentions to seek treatment.

A second set of five long-term outcomes are theoretically linked to stigma: 

(a) well-being, (b) readiness, (c) quality of life [e.g., productivity], (d) treatment-seeking, and (e) treatment success. However, the investigators were 

unable to find research evidence that directly links these long-term outcomes 

to stigma. One of their conclusions was that “despite popular opinion and a 
29

Lefebvre: Suicide Prevention Initiatives in USSOCOM

strong theoretical base that stigma deters treatment-seeking, we were unable 

to identify empirical literature to support this link.”50 They did note that 

a variety of other factors, including the availability of providers and time 

off of work to seek care, might affect whether intentions to seek treatment 

translate into actual behavior. Using the NAS model, these factors could be 

construed as evidence of structural stigma whose mitigation may, or may not, 

be reflected in one’s perception of “stigma.” Another review of the research 

literature attempting to relate mental health-related beliefs, including stigma, 

to treatment-seeking behaviors among military and veteran populations 

found that stigma may play a less substantive role in predicting treatmentseeking than personal beliefs about mental illness and its treatment.51

Corrigan has been a leading advocate for the idea that stigma is related 

to the avoidance of treatment-seeking for mental health concerns.52 He proposes that stigma is one of several reasons why people make such choices; 

Figure 3. A conceptual model for stigma reduction in the military49

Military

context

Military norms and culture

Public context

Military policies, programs,

and treatment system

Institutional context

Family, friends, and unit

Social context

Proximal Impacts

Distal Impacts

Interpersonal outcomes

(e.g., self-esteem)

Coping

mechanisms

Attitudes toward and intentions to seek treatment

Well-being Readiness Quality of life Treatment-seeking Treatment success

Service

member

Individual 

context

Perceived stigma
30

JSOU Report 17-2

people are motivated to avoid the label of mental illness that results when 

people are associated with mental health care. That is, it is the expectations of negative future consequences from being labeled as mentally ill 

that propels both treatment avoidance and the denial of symptoms. This 

process of stigmatization involves four processes: cues, stereotypes, prejudice, and discrimination. Corrigan cites literature showing that many people 

infer mental illness in others from four cues: psychiatric symptoms (inappropriate emotional responses, ‘bizarre’ 

behaviors), social-skills deficits (inability 

to carry on a conversation with others), 

physical appearance (being disheveled or 

unkempt), and labels (they must have a 

‘mental problem’). Such cues may not be 

accurate in distinguishing people with true mental illness from those who 

are not (for instance, some people may be very good at concealing their 

symptoms), but the heuristic of the first three cues often produces the label 

that leads to stigma. The label becomes reinforced when a health care provider applies a mental illness label to them, or that person is seen in close 

association with other evidence of ‘mental illness’—being with other known 

people with mental illness, or coming out of a psychologist’s office. Stigma 

elicits stereotypes that are socially learned by people about various categories of people and can be strengthened or mitigated by the social norms and 

organizational policies that reflect and support them. 

However, simply having a negative stereotype of a person with mental 

illness is not stigma.53 Stigma arises when the stereotype of a person with 

mental illness leads to prejudicial attitudes with a negative emotional, or 

judgmental, component. It is this negative stereotype plus the emotional 

response that leads to behavioral reactions that he refers to as discrimination—usually negative actions including avoidance of associations and interactions with the person. Stigma is the observable, behavioral response to the 

cues, stereotypes, and prejudices of people to those labeled as ‘other’ (mentally ill in this example). Thus stigma is manifested by the reactions of others, 

not by the perceptions or reactions of the person. Someone who believes that 

they will suffer negative consequences for their BHC seeking behaviors is 

not stigmatized in Corrigan’s view. It is the reactions of their peers, family 

members and others that create stigma. From this point-of-view, decreasing 

This process of stigmatization 

involves four processes: cues, 

stereotypes, prejudice, and 

discrimination.
31

Lefebvre: Suicide Prevention Initiatives in USSOCOM

barriers to BHC does not reduce stigma; reducing consequences of seeking 

BHC does.

This model for the development of stigma has been incorporated into 

many evaluations of stigma reduction programs. Corrigan et al54 report 

that these studies assume 

a linear model, depicted in 

figure 4, in which attitudes 

and stereotypes lead to emotional responses and prejudices that result in avoidance 

behaviors.

Yet, in their review of 

79 studies to reduce stigma, 

Corrigan et al55 found few 

that observed, measured, 

and reported changes in 

discriminatory actions or 

behaviors. The most typical 

outcomes of these studies 

are attitudinal or emotional 

changes and perhaps change 

in self-reported intentions to 

behave differently.

Corrigan also makes a distinction between “public stigma,” what a naive 

public does to the stigmatized group when they endorse the prejudice about 

that group, and “self-stigma”—what members of a stigmatized group may 

do to themselves if they internalize the public stigma.56 While public stigma 

will deprive people of social and career opportunities through the actions of 

others, self-stigma impacts the labeled person’s sense of self, or self-esteem. 

Avoiding self-stigma may be a critical driver for people to avoid seeking 

treatment and the consequences of labeling that then unfold, including the 

experience of shame. Indeed, much of Corrigan’s later work has focused 

on combatting the element of self-stigma through the Coming Out Proud 

approach57,58 that will be reviewed in greater detail in chapter 4.

Recent literature on stigma articulates three major interrelated types 

touched on in this section: structural (laws, regulations and policies), 

public (attitudes, beliefs, behaviors as described above), and self-stigma 

Figure 4. A model for the development of 

stigma used to guide many stigma reduction 

programs and their evaluation.

• Blame

• Dangerousness

• Incompetence

• Poor prognosis 

(condition not likely to improve)

• Anger

• Fear

• Pity

• Shame

• Deny Services

• Discriminatory actions

Attitudes

and 

Stereotypes

Emotional

Responses

and Prejudices

Avoidance
32

JSOU Report 17-2

(internalization of negative stereotypes). Another type of mental health 

stigma is referred to as “courtesy stigma” that is directed towards family 

and friends of those with a mental or substance use disorder (see fig. 5). People may 

avoid being labeled with a behavioral health 

problem or seeking treatment because of concerns about resulting discrimination due to 

existing laws or policies (structural stigma), 

social rejection and other negative reactions 

(public stigma), reflections that help-seeking 

may have on family and friends (courtesy 

stigma), and the undermining of self-esteem 

(self-stigma). While there is no empirical evidence for which types of stigma may be more 

prominent, it is generally acknowledged that each type of concern can influence the decision to seek help for one’s self or others.59

This review of how stigma is conceptualized is important in discovering 

ways forward to increase treatment-seeking behaviors and to reduce suicides 

in USSOCOM. There are two contrasting views of stigma: one approach 

views stigma as primarily residing in the person in response to interactions 

in his/her environment60 while the other sees stigma as primarily an attribute of one’s social environment.61 The former viewpoint might be better 

described as ‘self-stigma’—one of at least four types of stigma that may 

require different articulations of their associated determinants, behaviors, 

and solutions (see fig. 5). Yet, from a social marketing vantage point, there is 

little research evidence that stigma, however defined, leads to avoidance of 

treatment or that stigma reduction programs lead to changes in behavior. It 

is also clear that in theory, research, and program evaluations, objective and 

observable behaviors of what constitutes stigma are often lacking. This lack 

of explicit behavioral objectives and measurement constitutes a vital missing 

link in designing effective programs and policies. What is clear is that stigma 

is just one of several pathways that may lead to the avoidance of labeling 

and treatment. Other possible pathways are presented in the next chapter.

Figure 5. Four forms of 

stigma.

Courtesy

Public

Self

Structural
33

Lefebvre: Suicide Prevention Initiatives in USSOCOM

4. Other Factors that Contribute 

to Avoidance of Treatment-Seeking 

Behaviors and Suicide

As noted in the last chapter, several recent reviews of the relationship 

of mental health stigma to treatment-seeking behaviors find the evidence is insufficient to conclude that stigma is a singular determinant of 

treatment-seeking behavior for mental illness or suicide.62-64 Yet, stigma 

seems to remain the target for most DOD suicide prevention efforts. For 

example, the RAND report on developing a strategy for suicide prevention in 

the DOD made a number of recommendations to enhance and refine stigma 

reduction efforts. Although “stigma reduction” was referred to throughout 

this document, there was no attempt to define what was meant by the term. 

RAND recommendations include: 

1. Explore interventions that directly increase treatment-seeking. Focusing primarily on a single barrier to care, such as stigma, may neglect 

other potential interventions to increase treatment-seeking and reduce 

barriers to mental health care.

2. Consider evidence-based approaches to empowering service members 

who have mental health concerns to support their peers.

3. Design new or adapt existing intervention and delivery mechanisms 

to minimize operational barriers for service members seeking treatment. Especially noted here were programs that could appeal to service 

members with a preference for self-management.

4. Embed stigma-reduction interventions in clinical treatment.

5. Implement and evaluate stigma-reduction programs that target service 

members who have not yet developed symptoms of mental illness.

6. Provide better guidance for policies in which a mental health disorder 

(MHD) or treatment prohibits job opportunities or actions. A large 

number of the policies we reviewed prohibited specific job opportunities or actions if a service member had an MHD or sought mental 
34

JSOU Report 17-2

health treatment. For many of these policies, the language is unclear, 

stating only that a service member is prohibited if he or she has a mental 

health issue. It is imperative that DOD provide additional guidance 

that clarifies what is meant by having a mental health issue and that 

is more attentive to the continuum of mental health.

7. Continue to improve and evaluate the modifications made to existing 

programs that begin to address stigma and other barriers to care.65 

As suggested by the first recommendation, shifting from a singular focus 

on stigma may enhance suicide prevention efforts. These other facets of the 

problem are the focus of this section. Having a broad understanding of the 

factors that increase or reduce treatment-seeking behaviors and suicide are 

important to then explore how to enhance existing POTFF initiatives and 

design new ones using social marketing principles. 

If mental health stigma is to change among military forces, one question 

that arises is: Can perceptions of mental health stigma, however they are 

measured, change? Data concerning the stability of mental health stigma 

over time was tracked as part of the fourth cohort of the Marine Resiliency 

Study (n=892).66 In this cohort, perceptions of mental health stigma were 

assessed with the Barriers to Care scale at 1 month pre-deployment and at 1, 

5 and 8 months post-deployment. The 6-item stigma subscale included the 

following items to which respondents could respond on a 5 point scale with 

1=“Strongly Disagree” to 5=“Strongly Agree:”

• It would be too embarrassing. 

• It would harm my career. 

• Members of my unit might have less confidence in me. 

• My unit leadership might treat me differently. 

• My leaders would blame me for the problem. 

• I would be seen as weak.

The investigators found that perceptions of stigma were low and fairly 

stable, with a slight decrease noted over time. Among covariates of changes 

in perceptions of stigma, at least one mental health visit in theater did not 

predict the stability of perceptions of stigma over time, while lower PTSD 

symptoms and greater perceived vertical and horizontal cohesion predicted 

decreases in perceptions of stigma. This latter finding, they note, is consistent 

with other research that has demonstrated the importance of cohesion and 
35

Lefebvre: Suicide Prevention Initiatives in USSOCOM

leadership in mitigating stigma. It should also be noted that this research 

tracked perceptions of stigma (self-stigma) and not any of the external cues 

or behaviors that would be indicative of structural, social or courtesy stigma.

Acosta et al analyzed data from the Army’s Mental Health Advisory 

Team surveys and found indications that there may have been declines in 

stigma over time and differences across populations of Operation Iraqi 

Freedom (OIF) soldiers.67 Even though OIF soldiers seeking mental health 

treatment reported higher perceived levels of stigma, subsequent regression 

analysis showed that stigma did not predict initiation of treatment-seeking. 

The author noted that one of their expert panelists was not surprised that 

“changes in knowledge and attitudes [which are two of the key outcomes targeted by stigma-reduction programs] do not result in changes in behavior.” 

The expert proceeded to reference a large body of research on prevention 

programs that suggest that explicit behavioral changes need to be specified, 

modeled, and practiced before behavior can be expected to change.68 Indeed, 

when the researchers used microsimulation models to estimate the effect of 

decreasing or eliminating mental health stigma entirely they discovered that 

it would not significantly increase the number of service members seeking 

mental health treatment.

There has been remarkable progress in reducing stigma to seeking treatment for behavioral health problems in many branches of the military, to 

the point where stigma may no longer be the determinant to focus on with a 

social marketing program or POTFF initiatives. This is not to declare victory 

and move on. For example, Acosta et al found of the 444 DOD policies identified as being related to stigma (or structural stigma), 121 of those policies 

may contribute to stigma reduction, and 209 policies may contribute to its 

persistence.69 Concerns about certain DOD policies that may contribute to 

mental health care stigma have been long-standing issues identified in DODsponsored studies about mental health and suicide prevention. These studies 

have linked such policies with prevalent beliefs among service members that 

mental health care will end or limit their careers in the military, and they 

recommended clarifications and updates. For example, in 2007 the DOD 

Task Force on Mental Health reported that revisions to command notification policies were necessary to combat stigma caused by perceptions that 

mental health care services are costly to career progression. More recently, in 

2013 the Institute of Medicine of the National Academies recommended that 

DOD review its policies on mental health care with regard to confidentiality 
36

JSOU Report 17-2

and the relationship between treatment-seeking and career advancement 

due to service members’ fears that seeking mental health care will jeopardize their career. Changes in policies are 

vital to eliminating stigma at the institutional level. However, at the social and 

individual level of SOF, the data lead to 

the question of whether social marketing 

might be more usefully employed by POTFF to target other predictors of 

suicide prevention and treatment-seeking.

Changes in policies are vital 

to eliminating stigma at the 

institutional level.

 Personal Barriers

• Not ready to talk 

about traumatic 

events/problems

• Wanting to solve 

problems on their 

own

• Belief that the 

system is not 

trustworthy

• Thinking problems 

will go away without 

treatment

• Believing treatment 

is not helping

• Presence of mental 

health symptoms

• Fear of stigmatization (e.g. 

fear of negative 

consequences)

 Practical Barriers

• Unable to get time 

off

• Transportation 

problems

• Financial resource 

issues

• Frequent moves 

and changes in duty 

station)

 Social Barriers

• Not wanting to be 

viewed as weak or 

having a character 

flaw

• Concerns about 

command access 

to mental health 

records

• Concerns about 

command "rating" 

and being seen as 

unfit for duty

• Fitness for duty

• Security clearance 

policy

Figure 6. Personal, practical, and social barriers to

mental health care for service members
37

Lefebvre: Suicide Prevention Initiatives in USSOCOM

Addressing other Threats to Treatment-Seeking Behavior

Gibbons and colleagues, while still endorsing a view of treatment-seeking 

behavior largely driven by fear of stigma, presented a model of personal, 

practical and social barriers to BHC among service members.70 Figure 6 

shows the key issues subsumed under these three categories. What is important in these lists are that none of the barriers concern “stigma.” 

In another review of literature related to this issue, Vogt looked at 15 articles 

on beliefs about mental health in regard to service utilization among military 

and veteran populations.71 These studies demonstrated that personal beliefs 

about mental illness and mental health treatment may be the important predictors of service use, not perceptions of stigma. These personal beliefs were:

• Belief that one should be able to handle mental health problems him/

herself

• Pride in self-reliance

• Negative beliefs about the nature of mental health care

• Concerns about breaches of confidentiality and documentation of 

health problems in medical records

Vogt cites one study that found among those who recognized a need for 

mental health treatment, 45 percent reported perceived lack of effectiveness 

as a reason for not seeking treatment.72

Kim and colleagues examined the role of stigma and negative attitudes 

about treatment on the utilization of mental health services among soldiers.73 The investigators conducted a survey of 2,600 soldiers in 2008-2009, 

6 months post-deployment from Afghanistan or Iraq. In a factor analysis 

they identified three distinct clusters of barriers to care: stigma, negative 

attitudes towards treatment, and organizational barriers (see Table 2). When 

they looked at how these scales predicted subsequent use of health services, 

they discovered that stigma and organizational barriers were not predictive of treatment utilization of any type of care. Negative attitudes toward 

treatment were the only factor associated with treatment seeking. Soldiers 

endorsing negative beliefs were significantly less likely to report using any 

type of mental health service. Negative attitudes toward treatment were also 

associated with less use of military mental health providers. A perhaps not 

so surprising finding was that increased perceptions of organizational barriers were positively associated with the use of civilian mental health care.
38

JSOU Report 17-2

There is also the possibility that mental health related beliefs and their 

impact on service use may differ across different subgroups of military 

personnel and veterans (including, for example, women versus men and 

younger versus older service members). Vogt cites studies showing that: 

negative attitudes towards treatment seeking are more prevalent among 

males, public stigma (especially family reactions to seeking treatment) is a 

stronger predictor of service use among women, and concerns about public 

stigma and mistrust of the mental health care system is a particular issue 

among white males.75

In their review of interventions to address stigma, Dickstein et al concluded that future efforts aimed at reducing stigma in the military and the 

VA should focus on five targets: (a) perceptions that care utilization is a sign 

of weakness; (b) stereotypes about mental illness and mental health diagnoses (e.g., indicative of incompetence, dangerousness, or “craziness”—what 

might be considered “public stigma”); (c) self-blame (e.g., feeling responsible 

for having a mental illness); (d) uncertainty about the signs and symptoms of 

mental illness; and (e) uncertainty about the nature of treatment.76 Therefore, 

Stigma Negative Attitudes Organizational Barriers

It would be too 

embarrassing.

It would harm my career.

Members of my unit might 

have less confidence in me.

My unit leadership might 

treat me differently.

My leaders would blame me 

for the problem.

I would be seen as weak.

It might affect my security 

clearance.

I do not trust mental health 

professionals.

My leaders discourage 

the use of mental health 

services.

Psychological problems 

tend to work themselves out 

without help.

Getting mental health treatment should be a last resort.

A fellow soldier’s mental 

health problems are none of 

my business.

I would think less of a team 

member if I knew he or she 

was receiving mental health 

counseling.

Mental health services are 

not available.

I do not know where to get 

help.

It is difficult to get an 

appointment.

There would be difficulty 

getting time off work for 

treatment.

Table 2. Items loading on each of three factors affecting utilization of care74
39

Lefebvre: Suicide Prevention Initiatives in USSOCOM

while stigma is not meant to be cast aside as unimportant to solving the 

problem of increasing treatment-seeking behavior and reducing suicides 

(the behavioral outcomes of most interest), the evidence suggests that there 

are other important determinants of these behaviors that might be targets 

for social marketing efforts. 

Risk and Protective Factors for Suicide

The National Strategy for Suicide Prevention summarized the literature on 

known risk and protective factors to guide suicide prevention actions. As 

shown in figure 7, 9 protective and 10 risk factors are aligned along 4 levels of 

social ecology: the individual, his/her relationships, community and societal. 

This is not a comprehensive listing of all risk and protective factors, but these 

were highlighted in the report for their robustness across different groups 

of people and contexts. 

Availability of 

physical and 

mental health 

care

Restriction on 

lethal means of 

suicide

Safe and supportive 

school and community 

environments

Sources of continued 

care after psychiatric 

hospitalization

Connectedness to 

family, community, and 

social institutions

Supportive 

relationships with 

health care providers

Coping and problem 

solving skills

Reasons for living (e.g., 

children in the home)

Moral objections to 

suicide

Availability of 

lethal means of 

suicide

Unsafe media 

portrayals of 

suicide

Few available sources of 

supportive relationships

Barriers to health care (e.g., 

lack of access to providers 

or medications, prejudice)

High conflict 

or violent 

relationships

Family history of 

suicide

Mental illness

Substance abuse

Previous suicide attempt

Impulsivity/aggression

SOCIETAL COMMUNITY RELATIONSHIP INDIVIDUAL

PROTECTIVE

FACTORS

RISK

FACTORS

Figure 7. Protective and risk factors for suicide77
40

JSOU Report 17-2

The strategy also identified a number of population groups that are at an 

elevated risk for suicide where risk and protective factors may be less salient, 

or different from those in figure 7. Table 3 presents several of these groups, 

and their known risks, that should be priority groups for the POTFF.

York et al compiled a set of risk factors for suicide among military personnel and veterans. In addition to the ones above, legal and health problems, 

high combat stress exposure, long and multiple deployments, exposure to 

traumatic events, availability of weapons, skills using firearms, and relationship or financial problems were found to be risk factors for suicide among 

veterans.79 In another study of all active duty military personnel, mental 

health diagnoses (especially TBI, PTSD, and depression), suicidal ideation, 

suicide attempts, mental health visits, prescriptions of selective serotonin 

reuptake inhibitors, sleep prescriptions, deployed time in Operation Enduring Freedom or Operation Iraqi Freedom, reduction in rank, enlisted rank, 

and separation or divorce were associated with elevated suicide risk.80

Despite a large number of risk and protective factors identified by 

researchers, it is not yet possible to predict who will attempt or complete 

suicide.81 The inability to identify individuals most in need of interventions 

is one of the reasons a public health approach with a focus on force-level 

interventions is necessary for effective suicide prevention. However, as noted 

earlier, programs that focus on at-risk population groups, as well as clinical 

interventions for those identified at high risk, should integrate with and 

support population-wide approaches.
41

Lefebvre: Suicide Prevention Initiatives in USSOCOM

Group Surveillance Data

Members of 

the Armed 

Forces and 

Veterans

For calendar year 2010, service members who were white and under 

the age of 25, junior enlisted (E1–E4), or high school educated were at 

increased risk for suicide relative to comparison groups in the general population. Service members most frequently used firearms as the means for 

suicide, while prescription drug overdose was the most frequent method for 

suicide attempts. Most service members were not known to have communicated their potential for self-harm with others prior to suicide or attempted 

suicide. The majority of service members who died by suicide did not have 

a known history of a mental or substance use disorder. Finally, the overwhelming majority of suicides occurred in a non-deployed setting, and more 

than half of those who died by suicide did not have a history of deployment. 

Individuals 

Bereaved by 

Suicide (or 

survivors of 

suicide loss)

It has been estimated that a successful suicide affects at least five or six 

family members and up to 30 to 60 people in that person’s larger social 

network. These survivors may have an increased risk of suicide themselves. 

Research suggests that many of these individuals may not know where to 

find services and/or have difficulty in seeking help.

Traumatic 

Injuries of 

the Central 

Nervous 

System

Spinal Cord Injury (SCI): People with SCI attempt suicide more frequently 

than those in the general population. As many as 45 percent of people with 

SCI are diagnosed with depression following a traumatic spinal cord injury, 

and 10-13 percent of SCI patients suffer from anxiety and high levels of 

post-traumatic stress disorder.

TBI: People with TBI have an increased risk of death by suicide (three 

to four times greater for those with severe TBI), a higher frequency of 

attempts, and 21-22 percent have clinically significant suicidal ideation.

Individuals 

With Mental 

and/or 

Substance 

Use Disorders

Mental and substance use disorders are widely recognized as important risk 

factors for suicidal behaviors in all age groups. Alcohol and drug abuse are 

second only to depression and other mood disorders as the most frequent 

risk factors for suicide. People having both substance use and mood disorders may be at particularly increased suicide risk.

Men in Midlife Adult men in their early 20s through 50s, account for the bulk of suicides. 

However, there has been little research on protective and risk factors among 

this demographic group. Research points to mood and substance abuse 

disorders, as well as access to lethal means. Other factors that have been 

suggested include a reluctance to seek help, engaging in interpersonal 

violence, economic hardships, and the end of intimate relationships.

Lesbian, Gay, 

Bisexual, and 

Transgender 

Populations

(LGBT)

Research suggests that LGBT individuals may have an elevated risk for 

suicide ideation and attempts (2-4 times the risk of heterosexuals). Because 

of incomplete surveillance data about a decedents’ sexual orientation or 

gender identity, it is not known whether LGBT people die by suicide at 

higher rates than comparison groups from the general population.

Table 3. Groups with increased suicide risk78

43

Lefebvre: Suicide Prevention Initiatives in USSOCOM

5. Programs that Address Suicide 

Prevention and Stigma Reduction

The Congressional Research Service report on suicide prevention among 

veterans outlines how approaches to suicide prevention are not mutually exclusive. The “public health approach” intervenes with populations 

(e.g., distributing educational materials about mental illness and mental 

health services), whereas the “clinical approach” intervenes with individuals (e.g., prescribing antidepressant medication to a person diagnosed with 

depression).82 The individual focus of the clinical approach limits its reach to 

those who access the health care system and thus may be necessary but not 

sufficient to address broader issues of suicide prevention (for example, institutional and social stigma). In contrast, the population-based public health 

approach, to include social marketing, is considered essential to address the 

broader problem of suicide, including reaching people who may not currently 

be in contact with the health care system.83 This latter approach was developed as part of the U.S. Department of Health and Human Services’ National 

Strategy for Suicide Prevention,84 and consists of three interrelated pieces:

1. surveillance, 

2. risk and protective factors, and 

3. prevention interventions. 

Suicide surveillance involves collecting data on completed (i.e., fatal) 

suicides to define the scope of the problem. Data collected in surveillance 

can also be used to identify risk factors (i.e., characteristics associated with 

higher suicide risk) and protective factors (i.e., characteristics associated 

with lower suicide risk). The annual POTFF Needs Assessment Survey that 

is examined in more detail in chapter 6 is one example of this type of risk 

factor surveillance system. Prevention interventions may progress through 

a series of research and development actions that include the design of pilot 

studies; implementation of interventions assessed to be feasible, viable and 

effective in their pilot tests; and evaluation of these larger scale efforts. The 

objectives for specific programs might aim to reduce risk factors and/or 

enhance protective factors among the entire SOF population, focus on at-risk 
44

JSOU Report 17-2

subgroups (those with known risk factors, see below for more discussion of 

these) or concentrate on high-risk individuals—those diagnosed with TBI 

and PTSD or who have had recent suicide attempts.

Suicide surveillance data among active duty service members, veterans, 

and SOF were presented in the first chapter. Risks and protective factors 

were presented in chapter 3. In this chapter we focus of efforts to modify risk 

factors in primarily military settings and with social marketing approaches. 

Suicide Prevention and Stigma Reduction Programs in 

Military Settings

There are a number of published studies that examine the effects of interventions to prevent suicide and reduce the stigma of BHC among members 

of the military. The design of these interventions, and their results, when 

available, provide a context for answering the questions of what works, with 

whom, and when?

A comprehensive suicide prevention program implemented by the U.S. 

Air Force (USAF) beginning in 1996 was found to not only prevent suicide 

but also reduce family violence and homicide.85 This self-described social 

marketing program involved 11 initiatives that aimed to enhance understanding of mental health, decrease stigma, strengthen social networks, 

promote effective coping skills, and change policies and norms to encourage 

effective help seeking behaviors. Among these initiatives were suicide awareness, education, and training courses for squadron commanders; incorporation of suicide prevention into professional military education curriculums; 

guidelines for commanders on the use of mental health services; provision 

of one full time equivalent member of staff for community-based preventive 

services at every mental health work center; non-supervisory “buddy care” 

training for all personnel; elimination of duplicative, overlapping, and gaps 

in the delivery of prevention services; and establishment of psychotherapistpatient privilege for individuals at risk for suicide.

A quasi-experimental design used the 1990-1996 populations of personnel 

as the comparison group and the 1997-2002 populations (after implementation of the program) as the “exposed” group. Analysis of trends showed 

a 33 percent relative risk reduction of suicide in the exposed cohort; risk 

reductions for accidental death, homicide, and moderate and severe family 

violence ranged from 18-54 percent. There were also no differences in the 
45

Lefebvre: Suicide Prevention Initiatives in USSOCOM

proportion of the two groups that were assigned a mental health diagnosis 

that could have represented an unintentional consequence of the program.

Acosta et al identified five stigma reduction programs that were funded 

by the DOD.86 Breaking the Stigma is a U.S. Army Special Operations Command (USASOC) stigma-reduction program that aims to build resiliency and 

optimize performance by reinforcing the importance of maintaining psychological fitness and seeking mental health care when needed. The program is 

built around a 24-minute video in which senior-ranking and respected SOF 

personnel share their stories of dealing with combat- and deployment-related 

issues and the consequences to their units, careers, and families of seeking 

or not seeking help. The program consists of viewing the video, a presentation by two of the video participants, an overview of available resources, a 

briefing from unit providers, and a briefing from commanders (who share 

their own connections and experiences).

The Real Warriors Campaign is a multimedia communication campaign 

to increase awareness and encourage help-seeking behavior among service 

members, veterans, and military families. The campaign’s messages address 

the barriers and motivators to seeking care for psychological health:

• Reaching out for help is a sign of strength that benefits the individual, 

his or her family, and the entire military community.

• It is possible to seek care for psychological health concerns and maintain a successful military or civilian career.

• Warriors are not alone in coping with psychological health concerns, 

and every service member, veteran, and his or her family members 

should feel comfortable reaching out to his or her unit, chain of command, fellow warriors, and community resources for support.

• Experiencing psychological stress as a result of deployment is common, 

and successful care and positive outcomes are greatly assisted by early 

intervention.

The campaign includes video profiles of service members of varying 

ranks, services, and components sharing their stories of coping with and 

successfully seeking care for psychological health concerns. It also features 

perspectives from leaders, peers, and family members. The Real Warriors 

Campaign includes social and traditional media that are intended to reach a 

broad audience including leaders, families, providers, and the public at large.
46

JSOU Report 17-2

Other programs noted by Acosta et al include the Military Pathways program that operates through a web portal and includes outreach to military 

middle and high school students in the DOD Education Activities system 

(DODEA); Afterdeployment.com that is also a web-based effort targeting 

psychological health and TBI with videos and an interactive resource booklet; and The Embedded Behavioral Health (EBH) program that employs 

13 behavioral health and support personnel per brigade combat team to 

establish working relationships between behavioral health providers and 

key battalion personnel. However, Acosta et al noted that the evaluations of 

all five of these programs lacked the rigor, comprehensiveness, or specificity 

needed to determine whether or not they were effective, relying instead on 

process measures such as web metrics and satisfaction surveys. Whether any 

of these programs reduced stigma, increased treatment-seeking behaviors, 

or reduced suicides remains an open question.87

Hurtado et al reported on the usefulness and helpfulness of a 2-hour 

stigma-reduction program for 52 senior enlisted leaders and officers in the 

Marines.88 The goals of the training were to provide discussion tools highlighting the experiences of seven Marines seeking help for stress concerns, 

improve communication between leaders and their Marines around the issue 

of help seeking, and familiarize Marines with behavioral health treatment 

and resources. In a pre-post test assessment, four of 10 stigma-reduction 

awareness items improved. However, the authors point out that the lack of 

a comparison group renders any causal attribution of these changes to the 

program tenuous. There is also no indication of whether these immediate 

effects were sustained and/or carried over to real-life encounters.

A multiple component suicide prevention program was developed and 

implemented for Israeli Defense Forces (IDF) in which suicide is the leading 

cause of death.89 The program included a new directive to reduce weapon 

availability by requiring soldiers to keep their weapons locked in storage 

when on leave; new procedures for access and transfer of medical records; 

critical periods in a soldier’s life, especially basic and initial training and 

the year prior to discharge from service were identified and focused on with 

additional screening and coping skills education; use of Medical Health Officers (MHOs) who were trained and qualified to identify, treat, and prevent 

suicides; embedding these MHOs in each unit; and “psycho-educational” 

programs for commanders and soldiers to detect and identify symptoms of 
47

Lefebvre: Suicide Prevention Initiatives in USSOCOM

mental illness or overwhelming stress, as well as guidance on how to deal 

with them.

Using a similar quasi-experimental method to the USAF study cited 

earlier, soldiers were either not exposed (pre-implementation, 1992-2005) 

or exposed to the program (2006-2012). The authors reported a 57 percent 

decrease in the suicide rate between these two cohorts. Their analysis suggested that the intervention components that most contributed to this reduction effect were related to reduced access to weapons during leave and being 

able to benefit from improved help-seeking and de-stigmatization. However, 

the authors also noted the importance of using multiple strategies.

A review of interventions to prevent suicide among military personnel identified seven studies—including the USAF report cited earlier. The 

authors concluded from their review that multiple component interventions 

“probably” reduce the risk of suicide, and cite the USAF as the strongest 

evidence in support of their finding.90 They noted that programs similar to 

the USAF have been implemented in Yugoslavia, the U.S. Navy and Marine 

Corps. They call for more research in this area in order to strengthen the 

evidence for these effects. In contrast, they found the evidence for psychosocial interventions following a suicide attempt supported a conclusion that 

they are, at the very best, minimally effective. There was even less evidence 

to draw any conclusions as to the effectiveness of community-based suicide 

prevention programs among this population. Finally, they found no studies 

that assessed the specific effectiveness of hotlines, outreach programs as 

primary prevention interventions, peer counseling, treatment coordination 

programs, and counseling programs.

Zamorski also reviewed the literature for suicide prevention in the military.91 His key recommendations came from the Canadian Forces Expert 

Panel on Suicide Prevention, which he also authored, and included as 

priorities:

• Developing a protocol for mitigating suicide for personnel who are 

under investigation for legal or disciplinary problems.

• Exploring opportunities for means reduction for suicides with service 

firearms and medications.

• Invigorating efforts at media engagement to promote responsible 

reporting of military suicides. 
48

JSOU Report 17-2

He also noted that while the USAF program could be considered a benchmark for suicide prevention activities in the military, there was little evidence 

to support the efficacy of mass media campaigns, use of gatekeepers, and 

general screening for suicidal ideation or depression to reduce suicides in 

this population. He was more positive about potential contributions from 

clinician education components, systematic follow-up with people who have 

attempted suicide, more restrictive firearms access policies, media engagement to encourage more responsible reporting of suicides (to avoid any 

imitative or contagion effect), efforts to overcome barriers to care, quality 

improvements in delivering mental health care, and organizational interventions to reduce workplace stress (duration and spacing of deployments, 

harassment prevention activities, employee assistance programs, dispute 

resolution services, financial counseling services).

A relatively new approach to issues of destigmatization is a National Consortium on Stigma and Empowerment program called Coming Out Proud 

which focuses on the issue of self-stigma.92 Proponents of this approach and 

related ones suggest that people who internalize stigma about their illness 

(also known as self-labeling) experience significant losses in self-esteem 

and self-efficacy that, in turn, interfere with the course of their illness and 

participation in evidence-based services—what they refer to as the “why 

try?” effect. 

Coming Out Proud is based on research findings of several different 

stigmatized groups that individuals who identify with their stigmatized 

group may report less stress arising from prejudice and better self-esteem. 

However, this identification must also be accompanied by the rejection of the legitimacy of the 

stigma for positive benefits to occur. Identification 

then may be followed by telling no one about their 

mental illness, keeping it secret from most people 

but others who also have the illness (for example, 

in self-help or peer-led groups), selective self-disclosure to a few, indiscriminant disclosure where 

there is no active concealment from anyone, or 

“broadcasting” their experience through personal 

testimonials and advocacy. The Coming Out Proud program is facilitated 

in a community that disdains stigma and endorses affirming attitudes such 

as recovery and empowerment. Corrigan et al93 also note that in order to 

The Coming Out 

Proud program is 

facilitated in a community that disdains 

stigma and endorses 

affirming attitudes 

such as recovery and 

empowerment.
49

Lefebvre: Suicide Prevention Initiatives in USSOCOM

have programs maximize the use of face-to-face contacts to counter stigma 

in others, people with mental illness need to be supported in order to share 

their stories and experiences to others. However, there are no published 

studies documenting the feasibility or effectiveness of this approach with 

military populations. 

Suicide Prevention Programs in Other Settings

It is beyond the scope of this work to conduct a systematic review of suicide 

prevention and stigma reduction programs in other settings. However, several reviews of this literature are reviewed here for context. A review of 41 

interventions for suicide prevention in which suicides, suicide attempts, and/

or suicidal ideation were outcome variables identified 7 different strategies 

that were used:

1. limitation of access to lethal means (n=7);

2. preservation of contact (with individuals at risk for recurrence of 

suicide; n=5);

3. implementation of emergency call lines and centers (n=6); 

4. training of general practitioners (n=4);

5. school-based programs (n=7); 

6. reorganization of care (n=9); and

7. public information campaigns (n=3).

Their analyses found that limiting access to lethal means was an effective feature of reducing suicide in all seven studies, whether this occurred 

through national laws and regulations, securing at-risk environments such 

as prisons and psychiatric hospitals, or limiting access at the individual 

level. Three of the five programs that assessed the effects of preservation of 

contact with people who had been hospitalized for a suicide attempt reported 

reductions in either completed suicides or attempted suicide. Instituting call 

lines and emergency centers were found to reduce suicide rates and suicidal 

ideation in five of the six studies. Training of general practitioners and/or 

nurses in identifying depression and suicide risk was found to be effective in 

half of the studies. Interventions in schools reduced suicide attempts among 

children in one of three reports, and two of the four studies that concentrated 
50

JSOU Report 17-2

on at-risk youth reported reduced suicidal ideation. Interventions that were 

built around the reorganization of care for people at-risk for suicide achieved 

the best results when they focused on care during in-patient treatment (the 

use of cognitive behavioral therapy, brief family therapy, or referral to a 

specialist). Social assistance for people who have attempted suicide based 

on reports from others in their social networks (social workers, healthcare 

and educational professionals, and youth leaders) was shown to have only 

limited efficacy on suicide attempts and suicidal ideation. The only intervention that showed an impact on suicide attempts was based on individualized, proactive, intensive, and long-term (six weeks) follow-up provided by 

a personal counselor. Public information campaigns in Japan, in which the 

elderly were the priority group for a ten year project, and Germany, where 

the general population campaign was combined with professional training 

and patient/family support, both showed significant reductions in suicide 

rates and attempted suicides (the later in Germany only). An annual suicide 

prevention week general population campaign conducted in Canada showed 

no impact on suicide or suicide attempts.94

Corrigan et al conducted a meta-analysis of 79 studies that set out to 

change public stigma through public education and other efforts. Over threequarters of the studies targeted adolescents, adults, and college students, and 

while not conducted in the military context, have implications for POTFF 

activities to change the normative environment in SOF. The authors categorized the programs as following one of three strategies:

• Educational approaches that challenge stereotypes and myths about 

mental illness and seek to replace them with factual information 

through public service announcements, books, flyers, movies and 

videos, web pages, and other audio-visual materials.

• Interpersonal contact with people who have a mental illness to lessen 

fears and prejudices and counter existing stereotypes.

• Social activism and advocacy that highlight injustices of various forms 

of stigma and call to account people who hold stereotypic and/or 

discriminatory attitudes and exhibit behaviors consistent with those 

beliefs.

Summarizing the evidence for each of the three strategies, they concluded that both interpersonal contact and education strategies significantly 

improved attitudes and behavioral intentions toward people with mental 
51

Lefebvre: Suicide Prevention Initiatives in USSOCOM

illness (social activism and advocacy approaches were rarely evaluated). 

Yet, interpersonal contact seemed to yield significantly better change among 

adults while, among adolescents, the data indicated the relative superiority 

of education over interpersonal contact. What they describe as their most 

important finding is that face-to-face contact had a much greater impact 

on stigma reduction than videotaped presentations. They hypothesize that 

creating in-person contacts allows for greater local control and involvement 

in anti-stigma efforts than are feasible though more centrally planned and 

managed marketing campaigns.95 We will see some support for this assertion 

in the results of the English Time To Change (TTC) campaign presented in 

the next section.

A NAS review of interventions to reduce 

public stigma reached similar conclusions. 

They found that contact-based interventions 

alone and contact-based education programs 

have the strongest evidence base for reducing 

stigma. Educational programs alone were not 

found to be effective for adults, but were useful 

in changing younger people’s attitudes. Communication campaigns can be effective, they concluded, but often failed to 

identify goals and objectives for the campaign and did not reach the intended 

audience or audiences in a sustained or adequately frequent manner. They 

also cautioned about unintended consequences of anti-stigma campaigns 

that may include increased perceptions of differences between people with 

and without mental illness, fostering disbelief in the likelihood of recovery 

by concentrating on biological and genetic determinants of mental illnesses, 

and the potential negative effects of disclosing mental illness in a highly 

stigmatizing context (such as with contact-based interventions).96

Social Marketing Approaches to Reducing Stigma and 

Preventing Suicide

Only one program developed and implemented in a military setting, the 

USAF study,97 explicitly acknowledged social marketing in formulating their 

approach. In this section we review other social marketing efforts to reduce 

mental health stigma that have been implemented in other contexts and 

with different priority groups. It is important to point out that while these 

Educational programs 

alone were not found 

to be effective for 

adults, but were useful 

in changing younger 

people’s attitudes.
52

JSOU Report 17-2

programs self-label as social marketing efforts, and many of them follow the 

planning principles outlined in chapter 1, their execution is almost entirely 

based on communications activities alone. That is, few make full use of 

products and services, distribution channels (other than for messaging), 

and pricing elements of the marketing mix.

Kirkwood and Stamm described two social marketing programs to 

reduce stigma about mental illness and physical disabilities in Idaho.98 Both 

programs formed a campaign work group that included adult and teens with 

mental illness or a disability, providers, family members, and advocates 

who guided the design, implementation and evaluation of each campaign. 

It is important to note here that the social marketing plan came out of the 

experiences and discussions about stigma with people who have been stigmatized—not just the expert opinions of professionals. Part of these discussions centered on three critical questions: identifying (a) who are the priority 

groups and how have they been stigmatized; (b) what persuasive messages 

might counteract the stigma: and (c) what behavior and/or attitude changes 

are desired? The campaigns, despite using a social marketing approach to 

planning, only focused on communications or persuasive messages that 

were pretested in focus groups with members of the priority groups. Process 

and outcome measures for the mental health stigma campaign showed that 

trainings in interpersonal communications with gatekeepers, caregivers, and 

teenagers occurred in 66 percent of Idaho towns that together accounted 

for 90 percent of the state’s population. Levels of satisfaction, knowledge, 

and attitude gains were reportedly high, but there were no indications of 

outcomes among the general population or among people with mental illness and their caregivers (for example, were they aware of the campaign, had 

they noticed any differences in attitudes, media coverage, or conversations 

about mental health). 

The second campaign work group selected family physicians, housing 

providers, employers, and mental health providers as its priority groups 

as they were identified as people more likely to stigmatize against people 

with disabilities. A general audience campaign was also planned using four 

television and radio advertisements and distribution of 15,000 brochures. A 

pre-post survey of Idaho adults showed no changes in attitudes or a measure 

or social distance (being comfortable working or going to school with, living 

next door to, or living with someone with a physical disability). The authors 

reported that only 9 percent of respondents reported seeing or hearing about 
53

Lefebvre: Suicide Prevention Initiatives in USSOCOM

the campaign, signaling the limited reach and penetration of the advertising effort.

The TTC mental health stigma reduction program in England had a 

priority group of men and women in their mid-20s to mid-40s, from middleincome groups.99 Based on insights during the campaign-development phase, 

these individuals were segmented into groups termed active discriminators, 

subconscious stigmatisers, and those who are unaware of mental illness. 

The campaign design began with a survey of almost 400 people with direct 

experience with mental health problems. The survey was followed up by 

workshops with over 100 of the survey participants in which discussions 

were held about the types of situations people with mental health problems 

experienced stigma and discrimination, from whom they experienced it, and 

what should be done. Focus groups and interviews with the priority groups 

were conducted throughout the campaign period, and campaign messages 

were tailored according to what resonated best with each group.

Although described as a social marketing venture, TTC relied extensively 

on mass communication channels (television, print, radio, cinema, outdoor 

and online advertising) and social media (Facebook, Twitter, and YouTube). 

Advertising carried a call-to-action to visit or click on the TTC website, and 

social channels focused on behavior change targets such as starting a conversation about mental illness with a friend or help to organize a local event. 

Evaluation results included documentation of a modest level of self-reported 

campaign exposure (38-59 percent across survey waves), no changes in overall knowledge or intended behavior change over the three years of TTC, and 

a spurious finding (unplanned) that self-reported contact with someone who 

had a mental illness had a significant effect on attitude change and feeling 

more confident about challenging mental health stigma (intentions). 

Ten years of experience and a body of research evidence in changing 

stigma about mental illness is summarized in the Strategic Stigma Change 

(SSC) model and revolves around real-life contact between people in recovery 

and priority members of the public.100 Based on the SSC model, the author 

identifies five principles for social marketing campaigns to reduce stigma:

1. Contact. Contact with people with mental illness is fundamental to 

public stigma change

2. Targeted. Rather than focusing on the population as a whole, contact 

is more effective when it targets key groups
54

JSOU Report 17-2

3. Local. Programs tailored to local conditions and issues (assets, barriers) are more effective

4. Credible. Contacts should be similar to targets in demographics and 

role and should be in recovery

5. Continuous. Multiple contacts should occur, and the quality of the 

contact should vary over time (not be carbon copies of each other)

As demonstrated above, one of the prevailing strategies in many stigma 

reduction and suicide prevention efforts is the use of messaging (see the 

review of mass media campaigns to reduce stigma and increase referrals and 

treatment-seeking behaviors101). Langford and colleagues, in a commentary 

about “looking for a few good messages,” point out that the DOD and VA 

create only a small proportion of messages disseminated about military and 

veteran suicide.102 Each service, suicide prevention coordinators, and other 

veteran- and military-related organizations independently create the messages that are developed for military populations. Still other materials and 

messages are conveyed by civilian entities operating at multiple levels—the 

U.S. Department of Health and Human Services, state and local health agencies, nonprofits—as well as by various media outlets. They review literature to 

show that mass media campaigns that follow established principles of health 

communication and social marketing will yield small to moderate effects on 

the targeted behavior. These principles, which link to both anti-stigma and 

suicide prevention efforts, include:

1. Systematic planning that involves an analysis of the context, causes, 

and potential solutions to stigma, suicide prevention, and treatmentseeking behaviors. 

2. Setting behavioral objectives (not simply knowledge and attitudinal 

ones), supporting changes in policies and promoting existing programs 

and services. 

3. Defining priority groups and the actions that are feasible and relevant 

for them to take.

4. Conducting research with members of priority groups to understand 

and develop insight into their perceptions of the problem and desired 

behavioral or policy changes. 
55

Lefebvre: Suicide Prevention Initiatives in USSOCOM

5. Formulating a creative brief that identifies the priority group and the 

desired behavior, the audience’s perceived benefits and barriers for 

engaging in the new behavior, and supportive statements that make 

the benefits credible. 

6. Designing message content that is relevant, credible, and culturally 

appropriate for the priority group (not the clearance officers) and 

contains a call-to-action.

7. Pretesting the messages and materials with representatives of the 

priority group before final production and distribution.

In their report on the evidence for stigma change, they also called attention to the importance of the principles of science-based health communication strategies that are informed by behavioral theories.103

This brief overview of program effectiveness to reduce stigma and suicide, 

and increase treatment-seeking behaviors, highlights that there are many 

programs that are not well-evaluated, others that focus narrowly on one or 

two strategies that have varying levels of efficacy, and that multi-component 

programs appear to have positive impacts beyond the target of suicide reduction—for example, rates of suicide and domestic violence are also reduced.104

Research will continue to build our knowledge about the effectiveness 

of specific messages for particular audiences and goals, but the information 

needed to plan safer and more effective communications efforts is already 

available. We owe it to service members and veterans to apply it.105

In the final chapter, data from the POTFF Needs Assessment Wave III are 

highlighted, and based on the evidence reviewed in the previous chapters, 

recommendations are made for programs and initiatives to reduce stigma, 

increase behavioral healthcare-seeking, and reducing suicide.

57

Lefebvre: Suicide Prevention Initiatives in USSOCOM

6. Social Marketing Recommendations for 

USSOCOM Suicide Prevention, Stigma 

Reduction and Increasing BHC-Seeking 

Activities

The special operations community is unique in that it includes a more 

experienced, older population who are expected to meet exceptionally 

high standards of maturity, stability, and readiness. SOF and their families 

face consistently high Personnel Tempo and short notice deployments that 

are unique in both scope and mission requirements. Many of USSOCOM’s 

forces are geographically isolated and have sensitive mission sets that limit 

their ability to seek support outside of the unit. With the high demand for 

special operations, it is important that we have systems in place that keep 

our forces in the fight and return them to duty quickly when they experience 

illnesses and injuries.106

This chapter integrates the social marketing principles outlined in chapter 1 with what has been learned about the determinants of suicide and 

treatment–seeking behaviors among military personnel, and the research 

evidence from programs in the military and other settings to reduce suicide 

and stigma. It concludes with recommendations for enhancing or designing 

new POTFF initiatives in these areas.

Data Source: The POTFF Needs Assessment Survey Wave III

The key resource for this inquiry is the annual POTFF Needs Assessment 

Survey that is administered on an annual basis to assess the short-and longterm well-being of SOF warriors and their families and to evaluate the impact 

of POTFF activities on wellness levels, identify necessary improvements to 

maximize program success, and predict future needs.107 The Wave III data 

were collected from 5 January 2015 to 9 February 2015: 14,074 USSOCOM 

active duty (AD) SOF, civilian spouses, civilian employees, and contractors 

responded to the survey. Among those who responded to the survey, 11,615 

(87.7 percent) identified themselves as AD, which represents about 17 percent of USSOCOM’s authorized strength. Additionally, 1,631 (12.3 percent) 
58

JSOU Report 17-2

identified themselves as civilian spouses. This leaves 828 respondents who 

were either USSOCOM civilian employees or contractors. The analyses of the 

data in the report focused on AD operators and support personnel and civilian spouses. Discussion of these findings is limited to those that provide context for suicide prevention-related efforts; opportunities to link these efforts 

(or cross-market) with other POTFF initiatives should also be explored from 

the point-of-view of the operators, support personnel and spouses.

The survey results provide a view of SOF operators in which measured 

resilience is high (average score of 4.12/5), though there were reported significant differences between USASOC and other SOF, compared to Naval 

Special Warfare (NSW) and Marine Corps Forces Special Operations Command (MARSOC), and between USASOC and Air Force Special Operations 

Command (AFSOC). The primary drivers of resilience were increased social 

connectedness, reduced post-traumatic stress (PTS), and lower depression.

While 85 percent of AD SOF reported few symptoms of PTS, there was 

a significant increase in high PTS from Wave II to Wave III (to 8.6 percent). 

The report authors note that some of this increase may be attributable to 

the change in the PTS instrument. In addition to being less resilient, having 

more reported symptoms of depression and being less socially connected, 

this high PTS group was also at a higher risk of alcohol use/dependence and 

averaged fewer hours of sleep a night. Even if their PTS symptoms were not 

severe, 77 percent of AD respondents agreed that they could access services. 

What the other 23 percent thought or believed about access did not appear 

to be captured or was not reported.

Among AD SOF, 5.9 percent of operators and 6.3 percent of support 

personnel reported signs of depression at major or severe levels; however, 

treatment rates within these groups were only 2.26 percent and 4.07 percent, 

respectively. The majority (>93 percent) of AD SOF scored low in depression.

In Wave III, 9.4 percent of AD SOF (11 percent of operators and 7.9 percent 

of support personnel) and 5.1 percent of spouses had Alcohol Use Disorders 

Identification Test (AUDIT) alcohol screening scores that could indicate 

problematic or highly problematic drinking. Yet, just 3.80 percent of operators and 3.38 percent of support personnel reported treatment for alcohol 

abuse and dependence.

The average level of reported social connectedness (friendship scale) has 

remained high, or in the positive direction, over the past two years. However, 

enlisted and support personnel were reported to have scored significantly 
59

Lefebvre: Suicide Prevention Initiatives in USSOCOM

lower than operators—though this difference was less than 0.5 scale points 

(18.86, 18.90 and 19.29 respectively).

In assessing the Psychological Performance Program in particular, the 

survey documented a significant 4 percent increase in use of BHC services 

by AD SOF over the previous year. Data from the three waves of the survey 

for both AD SOF and civilian spouses are shown in figure 8. 

Among AD SOF, 5.7 percent reported “worried about effect on career/

clearance,” “embarrassed,” “leadership will ruin career/poke fun,” and negative stigma as reasons for not accessing BHC. “Access issues” were reported 

for not seeking BHC by another 4.2 percent of AD SOF (down from 5.1 

percent the year before). Further analysis of these findings suggested that 

they were more common among AD SOF who scored significantly higher in 

depression, potential alcohol abuse, and PTSD. Lower resilience and lower 

social connectedness were also more characteristic of AD SOF who cited 

access issues. Perhaps paradoxically, AD SOF who did access BHC scored 

significantly higher on resilience and lower on depression than those who did 

not. Figure 9 shows that levels of BHC care by AD SOF vary by component, 

Figure 8. Participation in past 12 months in behavioral 

health care by AD SOF and civilian spouses108

50%

40%

30%

20%

10%

0%

14%

18%

30%

11%

15%

19%

Baseline Wave II Wave III

AD SOF Civilian Spouse

Baseline: n= 9694 / 912 Wave II: n= 10675 / 1822 Wave III: n= 11302 / 1606

Civilian Spouses

 If no, reason for not seeking BHC:

 1) No need/interest (75.5%)

 2) Access issue (10.9%)

 3) Perception issues (4.1%)

Active Duty SOF

 If no, reason for not seeking BHC:

 1) No need/interest (88.6%)

 2) Access issue (5.7%)

 3) Perception issues (4.2%)

Behavioral Health Care:

Participation in the Last 12 Months
60

JSOU Report 17-2

with MARSOC clearly separating from other components in the past year 

with the highest utilization rate (27 percent) as compared with the lowest 

BHC rate of 13 percent among TSOC. For AFSOC and USASOC, BHC use 

significantly increased every year over the last three waves. Following no 

change in Wave II, MARSOC, NSW, and other SOF indicated significantly 

higher utilization rates in Wave III. However, whether these utilization patterns align with perceived needs, or reflect discontinuities between need and 

BHC use, are not known. Combined with the results noted above, these data 

suggest that there may be reasons for POTFF to specifically focus research 

and programs on discrete SOF segments, including AD, civilian spouses and 

by component, to understand and respond to these differences.

Figure 9. BHC use by AD SOF by component109

28

27

26

25

24

23

22

21

20

19

18

17

16

15

14

13

12

11

10

9

8

Baseline Wave II Wave III

Other SOF TSOC

Behavioral Health Care Use by Component (Active Duty SOF)

AFSOC USASOC

%

NSW HQ SOCOM MARSOC
61

Lefebvre: Suicide Prevention Initiatives in USSOCOM

Among those AD SOF who reported using BHC in the past year, off-base 

Counselors, MTF Psychiatrists, MTF Psychologist, on-base Counselor, and 

TRICARE were the top five services given. They rated the importance of BHC 

significantly higher than in the previous year, and reported the most useful 

resources as unit social workers, unit psychiatrists and unit psychologists. 

As the report authors noted: “These findings lend initial evidence to the 

effectiveness of the embedded approach to behavioral healthcare.”110

The Community Program and Peer Network Coordinators (CPPNC) 

pilot program was initiated in 2014. CPPNC was designed to embed peer 

mentors in SOF units to decrease suicidal behaviors and increase resilience 

by increasing social connectedness and enabling SOF members to ask for 

support when they are in distress. What was found is that 46 percent of 

AD SOF report having a mentor, and 80 percent find the mentor to be an 

important or extremely important element in their professional development—64 percent view it as important to extremely important for their personal development. When asked who they would be most likely to confide in 

when faced with difficult situations, overwhelming support was expressed for 

current teammates who are 

equal in rank to them (82.3 

percent) and family members/

relatives (77.6 percent). Peer 

mentors were the ones least 

likely to be confided in (see 

figure 10). Here again, social 

marketing research could be 

useful in better understanding this finding and uncovering insights that could be used 

to strengthen or redesign the 

CPPNC.

The active duty SOF who 

were least likely to confide in 

a mentor (regardless of who the mentor was) scored significantly lower in 

resilience and social connectedness and higher in PTS and depression compared to those who were more likely to choose a mentor.

The Unit Family Readiness Programs that are part of Social Performance 

Programs (SPP) were used by 43 percent of civilian spouses and 17 percent of 

Figure 10. Rated likelihood to confide 

in someone when faced with difficult 

situations111

Who will Active Duty SOF most likely confide 

in? (Wave III Only)

Most Likely Current Teammate (Equal Rank)

Family Member/Relative

Current Teammate 

(Senior in Rank)

Past Teammate (No Longer in 

Unit)

Friend (non-Military)

Senior Leadership

Least Likely Volunteer Peer Mentor
62

JSOU Report 17-2

AD SOF (fig. 11). It is unclear how this use rate compares with any program 

objectives. If this utilization rate is below POTFF expectations, this would be 

another set of programs that could benefit from a social marketing approach 

to revise the programs, build demand and improve satisfaction with them.

As noted in the call-out boxes in figure 11, access issues were cited by 

nearly 1/3 of spouses and 7.5 percent of AD SOF as reasons for not using 

the program, while finding no benefit in it was given by 7.6 percent and 6 

percent respectively. The questions these data surface include: (1) How are 

these programs not perceived (or experienced) as relevant or useful? Are they 

addressing spouses’ and AD SOF ‘real’ problems and aspirations? (2) How 

can access issues be addressed, especially among spouses? And, (3) how can 

unit family readiness programs be better positioned to each of the groups 

(and are their segments of spouses and AD SOF more or less likely to use 

60%

50%

40%

30%

20%

10%

0%

45%

39%

43%

23%

18% 17%

Baseline Wave II Wave III

AD SOF Civilian Spouse

Baseline: n= 9790 / 968 Wave II: n= 9816 / 1680 Wave III: n= 10124 / 1284

Civilian Spouses

 If no, reason for not using Unit FR:

 1) No need/interest (56.9%)

 2) Access issue (31.7%)

 3) Find no benefit (7.4%)

Active Duty SOF

 If no, reason for not using Unit FR:

 1) No need/interest (84.8%)

 2) Access issue (7.5%)

 3) Find no benefit (6.0%)

Unit Family Readiness:

Participation in the Last 12 Months

Figure 11. Participation by civilian spouses and AD SOF in unit family 

readiness in the past 12 months112
63

Lefebvre: Suicide Prevention Initiatives in USSOCOM

them)? The ‘branding’ and marketing implications noted in the conclusions 

of the report seem premature without addressing these questions first.

In light of the findings above, increasing attention on social connectedness may prove beneficial to the resilience of the force. According to the 

path models, the programs which have the greatest impact on resilience, and 

inherently are social or foster social connectedness, are Human Performance 

Programs (HPP) and SPP. Improving access and the availability to these 

programs, especially for support personnel who are less socially connected, 

may have an additional impact on resilience. 

Last, clear and consistent branding of POTFF programs, continuously 

marketing those programs, and accurately identifying those who participated in POTFF programs will be important for accurately assessing the 

impact of the POTFF initiatives.113

It is important to take into account when interpreting these data that 

they are all collected at the same point in time and are correlational, not 

causal, in the relationships they depict. This makes it difficult to ascertain 

whether certain factors ‘cause’ AD SOF and others to use or avoid BHC, and 

whether some determinants such as social disconnectedness lead to alcohol 

abuse and depression, or if the causal path may be in the opposite direction. 

The items that are selected for inclusion in the survey represent a broad mix 

of variables; but due to logistical and time constraints, not every question 

can be asked, answers have limited response options, and the selection of 

the items represents a judgment of what issues are deemed most important 

to track and analyze (for example, satisfaction with services items do not 

provide much latitude in response, expectations for BHC are not elicited). 

Also, it is unknown whether the 17 percent of the eligible AD SOF population 

that responded to the survey differ in important ways from the entire eligible 

population. What is reported is that the composition of survey respondents 

was fairly representative of the USSOCOM components. 

Provide a Ready and Resilient Force and Family

Future SOF capabilities are directly dependent upon our ability to 

maintain the unique and high-level capabilities of our most valuable 

resource: our people... We should engage and support research that 

contributes to our understanding of human behavior and performance, identify additional and emerging resources to assist our force 
64

JSOU Report 17-2

and families, and continue to work on reducing the stigma associated 

with seeking care when necessary. The Enterprise should seek out 

and establish a process to explore new authorities or modifications 

that will increase SOF’s ability to provide complete care across the 

medical spectrum while viewing the SOF family as a unique “force 

provider.” Wherever possible, we must mitigate suicide risk within 

the SOF community. This mitigation can be done through developed analysis and understanding of suicide risk factors as well as 

investigating how societal and generational differences may affect 

SOF subjected to high stress environments.114

Recommendations for Preventing Suicide, Reducing Stigma, 

and Increasing Access to BHC

This inquiry was limited to a data review only. How POTFF programs are 

developed, tested and implemented in actual practice was not part of this 

scope. Also, how SOF members and citizen spouses perceive, evaluate, and 

talk about these services—and the facilitators, barriers, and value of using 

them—were not elicited in any way (for example, through individual interviews, focus group discussion or other qualitative methods). Yet, based on the 

literature review and the data available, there are a number of insights and 

recommendations for improving access and availability of current POTFF 

programs, enhancing the marketing of them, and assessing their impact. The 

recommendations discussed below speak to future research and practices for 

preventing suicide, reducing stigma, and increasing access to BHC services. 

1. Specify discriminatory behaviors that reflect USSOCOM priorities for 

reducing stigma. It is apparent that USSOCOM has invested many resources 

in tackling the issue of mental illness stigma. The results of POTFF surveys 

demonstrate the program is having a positive impact on SOF members and 

spouses. Throughout the literature, and especially in the reviews of DOD 

stigma-reduction activities,115 it is noteworthy how often the lack of behavioral anchors, or reference points, as to what constitutes “stigmatic” behaviors is mentioned. Several reviews of the literature for the effectiveness of 

stigma reduction efforts also comment on the lack of behavioral outcomes 

or other clear markers of success. “Stigma” seems to have become a catchall phrase to signal institutional and/or social and/or individual attitudes, 
65

Lefebvre: Suicide Prevention Initiatives in USSOCOM

judgments, policies, perceptions and behaviors that separate a labeled group 

from mainstream society. This loose use of the term, or its specific subcomponents, hinders efforts to reduce stigma through policy change, institutional culture change, changes in social interactions and individual attitudes 

and judgments, and, most importantly, behaviors.116

It is recommended that identifying these stigmatic behaviors in the 

USSOCOM context would best be done through conversations with 

SOF members and their families and not through literature reviews. The 

USSOCOM community is unique, and it should not be overlooked that 

this uniqueness may transfer to how discriminatory behaviors (stigma) 

are expressed in policies, culture, relationships and individual actions. For 

example, some research suggests that female members of the military are 

sensitive to family sources of stigma and SOF civilian spouses cite ‘perceptions’ as a reason to not access BHC services. Unfortunately, surveys that 

are constructed from previous research to ensure their reliability may inadvertently not provide examples of discriminatory or judgmental behaviors 

that are experienced in the USSOCOM environment. The implication from 

this inquiry is whether the most relevant (to SOF members) behaviors are 

being addressed by anti-stigma efforts.

2. Engage SOF members and civilian spouses more completely in the 

research and development process for programs aimed to mitigate suicide risk. The idea of engaging potential users of products and services 

in their design has taken hold in many industries and within marketing. 

Co-creation, or co-production of BHC services should become a model for 

research and development. POTFF content experts should consider how 

they could bring SOF members and/or civilian spouses (depending on the 

user population they have in mind) to the planning table early and consistently throughout the process, and shift away from just testing nearly completed messages or prototypes in focus groups (assuming that they are tested 

prior to implementation). A co-creation paradigm for POTFF research and 

development can remove barriers among experts and users, gather insights 

as to the relevance and perceived effectiveness of the proposed activities 

throughout the development process, and also nurture ambassadors for 

new programs from those who have actively participated in their creation.

3. Utilize formative research in all POTFF messages, services and program development efforts. It was beyond the scope of this review to do an 
66

JSOU Report 17-2

in-depth examination of the development process for POTFF programs and 

services. This recommendation is based on the consistent finding from both 

health communication and social marketing research that formative research 

methods are found to be a critical effective ingredient in any program aimed 

at changing behaviors.117-119 Formative research is more than pretesting; in 

best practices of marketing the formative research phase also involves testing 

the concepts and assumptions underlying a campaign or program—what 

will (really) get people’s attention, engage them in the process (build on what 

motivations they have to consider the behavior or service being offered), offer 

user-relevant value or benefits, and the potential fit of the behavior or use 

of the service into existing work-life patterns. This ‘concept testing’ occurs 

before any decisions are made as to the content, structure, and branding 

of a new campaign or service. Indeed, the goal of formative research is to 

build as many touchpoints with potential users through the research and 

development process as possible to assure that resources have been directed 

towards crafting messages, products, and services that meet needs, help solve 

problems, and support achieving people’s aspirations.120

4. Conduct user preference studies. User preference studies are ubiquitous 

in certain industries, notably pharmaceuticals and medical devices. User 

preference studies are empirical attempts to understand how potential users 

weigh the potential features, benefits and risks of using a product or service 

before the product or service is designed.

Conjoint analysis is a quantitative method often used in these studies. It 

is useful when there is access to relatively large samples of the priority group: 

that is, more than just would be available for a few focus groups. Patient preference studies using conjoint analysis allow program planners and designers 

to assess how features and benefits, are valued when considered jointly, rather 

than one at a time. When faced with making trade-offs between program 

access, availability, costs (broadly construed), and features, these types of 

studies can be employed to make decisions with user input. The results can 

help designers make decisions about what are the most important elements 

to include in a program, how prices (or costs) are weighed in comparison 

to benefits, how best to design and package (or redesign and repackage) a 

product or service to meet the needs of intended users, how location and time 

commitments may affect anticipated demand for a product or service, and 

which features and benefits should be emphasized in promoting a behavior, 
67

Lefebvre: Suicide Prevention Initiatives in USSOCOM

product, or service to specific segments of a population. Preference studies 

have the advantage of being more generalizable to the larger population of 

SOF members and civilian spouses than a few focus groups might be. 

As one illustration of how this approach has been used, Spoth reviewed 

the smoking cessation literature, captured adult smokers’ preference ratings 

on potential program attributes, and conducted interviews with smoking 

cessation clinic facilitators and worksite benefit managers to develop a set 

of program components and attributes for a revision of a smoking cessation 

program (for example, various price points, program duration, inclusion of 

stress management or weight loss components, method of nicotine reduction, 

reward techniques, flexibility of the format, recommended behavioral alternatives to smoking, methods of support, and sources of program endorsements).121 A telephone survey of worksite benefit managers, the decision 

makers for purchasing the program, was used to get one reference point for 

attribute preferences. Telephone interviews were also conducted with smokers to gain their perspective on the relative importance and combination 

of activities. The results of these conjoint analyses were then used to guide 

revisions of the existing program and the introduction of new program 

components. Similar approaches with both users and implementers might 

be employed by POTFF when it initiates or revises program offerings.

5. Improve measurement of user satisfaction and perceived effectiveness 

of BHC offerings. Results from the POTFF Wave III survey found that 30 

percent of civilian spouses and 19 percent of AD SOF reported using BHC 

services in the past year. Of those who did not seek BHC services, about 76 

percent of spouses and 89 percent of AD SOF endorsed the item that they had 

no need or interest. The remainder of respondents attributed not using these 

services to reasons that were aggregated as perception and access issues. As 

was shown in the literature review, perceptions of effectiveness and attitudes 

towards BHC treatment may be as important, if not more so, than stigmarelated beliefs and attitudes in predicting which military personnel use these 

services. We recommend that more attention be given to these types of issues 

in future research and survey work.

Survey respondents rated BHC services on 4-point scales of satisfaction, 

importance and usefulness. Both groups of respondents, on average, rated 

each attribute at a “3” or higher (corresponding to very satisfied, extremely 

important and very useful). The literature on the measurement of service 
68

JSOU Report 17-2

quality and user satisfaction suggests that perceived quality leads to user 

satisfaction and that the level of satisfaction then influences intentions to use 

the service.122 We recommend that POTFF devote more resources to understanding perceived quality of its services (both its technical quality as well 

as how it is delivered, or its process quality), expand the range of responses 

from the current 4-point to a 7-point scale, and specifically ask questions of 

BHC service users about whether they would recommend that service to a 

friend or colleague (see Fan et al, 2005 in VA medical center settings). 

6. Conduct research that is aimed at insights and understanding of 

the use of ‘outside’ BHC services. One premise of the social marketing 

approach is that competition is inherent in all product and service offerings 

as well as in adopting new behaviors. In the context of BHC services, a better 

understanding of what the perceptions, attitudes and satisfaction levels are 

for SOF members and civilian spouses who utilize external resources could 

lead to insights into how to better structure and position POTFF services. 

In concert with the service satisfaction inquiries noted immediately above, 

this research could help to attenuate the negative perceptions and access 

issues documented in the POTFF Wave II survey. In seeking not only to 

reduce barriers, but actually attract those SOF members to BHC services, 

the POTFF should consider the investment in marketing research activities 

that can provide better articulation of barriers and drivers to BHC service 

use beyond the idea of ‘stigma-related concerns.’ As SOF continue to make 

significant headway in reducing these latter concerns at the policy, cultural, 

and social levels of the enterprise, we suggest that the incremental gains in 

converting the small numbers of SOF members who need help to actually 

seek it will take place in the way BHC services are structured and delivered 

to enhance perceived usefulness, satisfaction and continuity of use.

7. Monitor, enhance, and sustain social connectedness and resilience 

through programs. This is a promising new approach to suicide prevention 

and increasing treatment-seeking behaviors. The actions USSOCOM has 

taken to reduce stigma-related attitudes and behaviors have been found to 

be quite effective in lowering these concerns in AD SOF and their civilian 

spouses. Recent research suggests that the directions of enhancing social 

connectedness and resilience are important new steps to take and build 

upon the stigma-reduction activities. However, to avoid the opaqueness seen 

around the use of “stigma,” these resilience and social connectedness goals 
69

Lefebvre: Suicide Prevention Initiatives in USSOCOM

should be articulated into behavioral actions and options that can be more 

accurately assessed and tracked, much as physical performance is characterized by ‘what do you do?’ For example: “how much time do you spend 

participating in ... strength training, vigorous exercise, moderate or light 

exercise?” rather than, “how do you feel or think about exercising?” 

On a broader level, the positioning of BHC as a suite of services to solve 

problems or as a series of experiences that build behavioral and cognitive 

assets could be explored with POTFF staff and SOF members. Again, some 

perceptions of BHC that stop people from accessing them involve issues of 

self-stigma, perceived weakness or vulnerability, and low expectations for 

treatment success. One design challenge for POTFF could be: What if people 

viewed participation in Psychological Performance Programs (PPP) in the 

same way they view their participation in HPP? What changes in PPP would 

be necessary to align with perceptions and utilization of HPP? 

8. Expand research and evaluation efforts that examine the role of selfstigma and perceptions of BHC effectiveness in mitigating treatmentseeking behaviors. The theory and research on stigma and mental health 

has rallied around the ideas that stigma is composed of structural (laws, 

regulations and policies), public (attitudes, beliefs, behaviors as described 

above), and self-stigma (internalization of negative stereotypes). The research 

has also identified “courtesy stigma” that is directed towards family and 

friends of those with a mental or substance use disorder. People avoid being 

labeled with a behavioral health problem and possibly associating with them 

because of concerns about resulting discrimination or social rejection, and 

this can influence their decision to seek help for themselves or others. 

To enhance efforts to completely eliminate stigma-related behaviors and 

attitudes in USSOCOM, self-stigma and “courtesy stigma” appear to be two 

targets for more research and programmatic activity. Both of these stigmas 

could be addressed through the ‘contact’ types of interventions reviewed 

earlier in which in-person contacts, not just videos, might be tested. Program evaluations and surveys should assess the prevalence of self-stigma and 

courtesy stigma to understand their prevalence and nature in the USSOCOM 

enterprise and if and how they could be addressed by POTFF services.

Finally, the lessons of the comprehensiveness and effectiveness of the 

USAF123 and IDF programs124 should be considered benchmarks in assessing suicide-prevention activities across the USSOCOM enterprise. When 
70

JSOU Report 17-2

attempting to address multiple levels of stigma (structural, social, self and 

courtesy), multiple risk and protective factors for suicide, and improved BHC 

treatment-seeking, a management approach that considers the perspectives 

of priority groups and building ubiquity and synergy among initiatives for 

large-scale change—not a search for the “magic wand”—is important for success. In both auditing current efforts, and seeking innovative ways forward 

to improve upon them, a social marketing approach provides the POTFF 

with a large toolbox from which to draw inspiration and action.
71

Lefebvre: Suicide Prevention Initiatives in USSOCOM

Appendix: Acronym List

AD active duty

AFSOC Air Force Special Operations Command

BHC behavioral health care

CPPNC Community Program and Peer Network Coordinators

CF conventional forces

DOD Department of Defense

DSPO Defense Suicide Prevention Office

EBH Embedded Behavioral Health

GAO United States Government Accountability Office

HPP Human Performance Programs

IDF Israeli Defense Force

LGBT Lesbian, Gay, Bisexual, and Transgender

MARSOC Marine Corps Forces Special Operations Command

MHD Mental Health Disorder

MHO Medical Health Officer

NAS National Academies of Sciences

NSW Naval Special Warfare

OIF Operation Iraqi Freedom

POTFF Preservation of the Force and Family

PPP Psychological Performance Programs

PSB Products, Services, Behaviors

PTS Post-Traumatic Stress
72

JSOU Report 17-2

PTSD Post-Traumatic Stress Disorder

SCI Spinal Cord Injury

SOF Special Operations Forces

SPP Social Performance Programs

SSC Strategic Stigma Change

SSRI Selective Serotonin Reuptake Inhibitors

TBI traumatic brain injury

TTC Time To Change

USAF United States Air Force

USASOC United States Army Special Operations Command

USSOCOM United States Special Operations Command

VA United States Department of Veterans Affairs
73

Lefebvre: Suicide Prevention Initiatives in USSOCOM

Endnotes

1. “Mission Statement of U.S. Special Operations Command—Preservation of the 

Force and Families,” available at: https://www.socom.mil/ussocom-enterprise/hq.

2. K.T. Chandy et al, “Proposals for Family Planning Promotion: A Marketing 

Plan,” Studies in Family Planning, 1/6 (1965): 7. 

3. Philip Kotler and Gerald Zaltman,“Social Marketing: An Approach to Planned 

Social Change,” Journal of Marketing, 35/3 (1971): 3-12.

4. Craig Lefebvre, Social Marketing and Social Change: Strategies and Tools for 

Improving Health, Well-being, and the Environment (San Francisco: Jossey-Bass, 

2013). 

5. Craig Lefebvre, “An Integrative Model for Social Marketing,” Journal of Social 

Marketing, 1/1 (2011): 54-72. 

6. Kotler and Zaltman, “Social Marketing: An Approach to Planned Social Change.”

7. Craig Lefebvre and June Flora, “Social Marketing and Public Health Intervention,” Health Education & Behavior, 15/3 (1988): 299-315. 

8. Lefebvre, Social Marketing and Social Change, 37.

9. Kotler and Zaltman, “Social Marketing: An Approach to Planned Social Change.”

10. Lefebvre, Social Marketing and Social Change, 35.

11. Alan Andreasen. “Marketing Social Marketing in the Social Change Marketplace,” 

Journal of Public Policy & Marketing, 21/1 (2002): 3-13.

12. Ibid.

13. Lefebvre and Flora, “Social Marketing and Public Health Intervention.”

14. Robert Marshall, Carol Bryant, Heidi Keller, and Fred Fridinger, “Marketing 

Social Marketing: Getting Inside Those ‘Big Dogs' Heads’ and Other Challenges,” 

Health Promotion Practice, 7/2 (2006): 206-212. 

15. National Social Marketing Centre, “Review of social marketing within public 

health regional settings,” Snapshot: November 2008 to January 2009, London: 

National Social Marketing Centre.

16. Lefebvre, “An Integrative Model for Social Marketing.”

17. Leslie Snyder, “Health Communication Campaigns and Their Impact on Behavior,” Journal of Nutrition Education and Behavior, 39/Suppl (2007): S32-40.

18. Maren Robinson et al, “Mass Media Health Communication Campaigns Combined with Health-Related Product Distribution,” American Journal of Preventive 

Medicine, 47/3 (2014): 360-371. 

19. Vasturi Rangan, Sohel Karim, and Sheryl Sandberg, “Do better at doing good,” 

Harvard Business Review May–June (1996): 42–54.
74

JSOU Report 17-2

20. Jeff French and Clive Blair-Stevens, “Using social marketing to develop policy, 

strategy, and operational synergy,” in Social marketing and public health: Theory 

and practice, eds. J. French, C. Blair-Stevens, D. McVey and R. Merritt, (Oxford: 

Oxford University Press, 2010), 67–79.

21. Melanie Wakefield, Barbara Loken, and Robert Hornik, “Use of mass media 

campaigns to change health behavior,” The Lancet, 376/9748 (2010): 1261-1271.

22. Edward Deci, Richard Koestner, and Richard Ryan, “A Meta-analytic Review of 

Experiments Examining the Effects of Extrinsic Rewards on Intrinsic Motivation,” Psychological Bulletin, 125/6 (1999): 627-668.

23. Nicholas Freudenberg et al, “Strengthening Individual and Community Capacity to Prevent Disease and Promote Health: In Search of Relevant Theories and 

Principles,” Health Education & Behavior, 22/3 (1995): 290-306. 

24. United States Department of Health and Human Services, National Strategy 

for Suicide Prevention: Goals and Objectives for Action, Washington, D.C.: U.S. 

Department of Health and Human Services, Public Health Service, 2012, available 

at: https://www.ncbi.nlm.nih.gov/books/NBK109917/pdf/Bookshelf_NBK109917.

pdf. 

25. United States Department of Veterans Affairs, Suicide Among Veterans and Other 

Americans: 2001–2014, Washington, D.C.: U.S. Department of Veterans Affairs, 

Office of Suicide Prevention, 2016.

26. United States Department of Health and Human Services, National Strategy for 

Suicide Prevention: Goals and Objectives for Action.

27. United States Department of Veterans Affairs, Suicide Among Veterans and Other 

Americans: 2001–2014.

28. United States Department of Health and Human Services, National Strategy for 

Suicide Prevention: Goals and Objectives for Action.

29. Advance Policy Questions for Lieutenant General Raymond A. Thomas, USA, 

Nominee for Commander, United States Special Operations Command, 2016, 

p. 17.

30. Ibid. 

31. United States Special Operations Command, Mega Talker (3rd Edition), United 

Special Operations Command Communications Office (2016).

32. United States Government Accountability Office, HUMANCAPITAL: Additional 

Actions Needed to Enhance DOD's Efforts to Address Mental Health Care Stigma

(GAO-16-404), Washington, D.C.: U.S. Government Accountability Office, 2016, 

pp. 8-10.

33. United States Department of Health and Human Services, National Strategy for 

Suicide Prevention: Goals and Objectives for Action.

34. Ibid. 

35. United States Department of Defense, The Challenge and the Promise: Strengthening the Force, Preventing Suicide and Saving Lives. Final Report of the Department 
75

Lefebvre: Suicide Prevention Initiatives in USSOCOM

of Defense Task Force on the Prevention of Suicide by Members of the Armed Forces, 

2010, p. 63, accessed June/July 2016 at: http://www.sprc.org/sites/default/files/

migrate/library/2010-08_Prevention-of-Suicide-Armed-Forces.pdf.

36. United States Government Accountability Office, HUMANCAPITAL: Additional 

Actions Needed to Enhance DOD's Efforts to Address Mental Health Care Stigma.

37. Preservation of the Force and Family, Wave III Needs Assessment: USSOCOM 

Enterprise Report, United States Special Operations Command-Preservation of 

the Force and the Family, 2015, p. 63.

38. United States Department of Health and Human Services, National Strategy for 

Suicide Prevention: Goals and Objectives for Action.

39. United States Department of Veterans Affairs, Suicide Among Veterans and Other 

Americans: 2001–2014.

40. United States Government Accountability Office, HUMANCAPITAL: Additional 

Actions Needed to Enhance DOD's Efforts to Address Mental Health Care Stigma.

41. Ibid., p. 39. 

42. Joie Acosta et al, Mental Health Stigma in the Military, Santa Monica, CA: RAND 

Corporation, 2014. 

43. United States Government Accountability Office, HUMANCAPITAL: Additional 

Actions Needed to Enhance DOD's Efforts to Address Mental Health Care Stigma, 

p. 40.

44. Ibid., pp. 12-14. 

45. Ibid., p. 14.

46. Preservation of the Force and Family, Wave III Needs Assessment: USSOCOM 

Enterprise Report.

47. National Academies Press, Ending Discrimination against People with Mental 

and Substance Use Disorders: The Evidence for Stigma Change, Washington, D.C.: 

National Academies Press, 2016, pp. 1-5.

48. Acosta et al, Mental Health Stigma in the Military.

49. Ibid., p. xv.

50. Ibid., p. xiv. 

51. Dawne Vogt, “Mental Health-Related Beliefs as a Barrier to Service Use for 

Military Personnel and Veterans: A Review,” Psychiatric Services, 62/2 (2011): 

135-142. 

52. Patrick Corrigan, “How Stigma Interferes with Mental Health Care,” American 

Psychologist Vol. 99, No. 7 (2004), pp. 614-625.

53. Ibid.

54. Patrick Corrigan et al. “Challenging the Public Stigma of Mental Illness: A MetaAnalysis of Outcome Studies,” Psychiatric Services, 63/10 (2012): pp. 963-973. 

doi:10.1176/appi.ps.201100529.

55. Ibid.
76

JSOU Report 17-2

56. Corrigan, “How Stigma Interferes with Mental Health Care.”

57. Michelle Andra et al, “Honest, Open, Proud to Eliminate the Stigma of Mental 

Illness,” 2016, accessed June/July, 2016 at: http://comingoutproudprogram.org/

images/VHA_Honest_Open_Proud_ManualBooster_3.9.2016.compressed.pdf.

58. Patrick Corrigan, Kristin Kosyluk, and Nicolas Rüsch. “Reducing Self-Stigma by 

Coming Out Proud,” American Journal of Public Health, 103/5 (2013): 794-800.

59. National Academies Press, Ending Discrimination against People with Mental 

and Substance Use Disorders: The Evidence for Stigma Change, p. 1-6. 

60. Acosta et al, Mental Health Stigma in the Military.

61. Corrigan, “How Stigma Interferes with Mental Health Care.”

62. Acosta et al, Mental Health Stigma in the Military.

63. National Academies Press, Ending Discrimination against People with Mental 

and Substance Use Disorders: The Evidence for Stigma Change.

64. Vogt, “Mental Health-Related Beliefs.”

65. Acosta et al, Mental Health Stigma in the Military.

66. Maria Steenkamp, Alyssa Boasso, William Nash, and Brett Litz, “Does Mental 

Health Stigma Change Across the Deployment Cycle?” Military Medicine, 179/12 

(2014): pp. 1449-1452. 

67. Acosta et al, Mental Health Stigma in the Military.

68. Ibid., p. xvi. 

69. Ibid., p. 185. 

70. Suzanne Gibbons et.al, “Military Mental Health Stigma Challenges: Policy and 

Practice Considerations,” The Journal for Nurse Practitioners Vol. 10, No. 6 (2014), 

pp. 365-372.

71. Vogt, “Mental Health-Related Beliefs.”

72. Ibid.

73. Paul Kim et al, “Stigma, Negative Attitudes about Treatment, and Utilization 

of Mental Health Care Among Soldiers,” Military Psychology Vol. 23 (2011): pp. 

65-81. 

74. Ibid., p. 74. 

75. Vogt, “Mental Health-Related Beliefs.”

76. Benjamin Dickstein, Dawne Vogt, Sonia Handa, and Brett Litz. “Targeting Selfstigma in Returning Military Personnel and Veterans: A Review of Intervention 

Strategies,” Military Psychology, 22/2 (2010): pp. 224-236. 

77. United States Department of Health and Human Services, National Strategy for 

Suicide Prevention: Goals and Objectives for Action, p. 15.

78. Ibid., pp. 101-130. 

79. Janet York, Dorian Lamis, Charlene Pope, and Leonard Egede, “Veteran-Specific 

Suicide Prevention,” Psychiatric Quarterly, 84/2 (2012): pp. 219-238. 
77

Lefebvre: Suicide Prevention Initiatives in USSOCOM

80. Jeffery Hyman, Robert Ireland, Lucinda Frost, and Linda Cottrell, “Suicide Incidence and Risk Factors in an Active Duty US Military Population,” American 

Journal of Public Health, 102/S1 (2012): pp. S138-146.

81. Erin Bagalman, Health Care for Veterans: Suicide Prevention (CRS Report R42340). 

Washington, D.C.: Congressional Research Service. 

82. Ibid., pp. 1-2.

83. Ibid.

84. United States Department of Health and Human Services, National Strategy for 

Suicide Prevention: Goals and Objectives for Action.

85. Kerry Knox et al, “The US Air Force Suicide Prevention Program: Implications 

for Public Health Policy,” American Journal of Public Health, 100/12 (2010): 

2457-2463. 

86. Acosta et al, Mental Health Stigma in the Military. p. 72, 73.

87. Ibid., p. 74.

88. Suzanne Hurtado, Cynthia M. Simon-Arndt, Jennifer Mcanany, and Jenny Crain, 

“Acceptability of Mental Health Stigma-reduction Training and Initial Effects 

on Awareness among Military Personnel,” SpringerPlus, 4/1 (2015). 

89. Leah Shelef, Lucian Laur, Gil Raviv, and Eyal Fruchter, “A Military Suicide Prevention Program in the Israeli Defense Force: A Review of an Important Military 

Medical Procedure,” Disaster and Military Medicine, 1/16 (2015): DOI: 10.1186/

s40696-015-0007-y.

90. Paul Shekelle, Steven Bagley, and Brett Munjas, Strategies for suicide prevention in veterans, Washington, D.C.: Department of Veterans Affairs Health 

Services Research & Development Series, 2009. https://www.ncbi.nlm.nih.gov/

pubmed/21155206.

91. Mark Zamorski. “Suicide Prevention in Military Organizations,” International 

Review of Psychiatry, 23/2 (2011): pp. 173-180.

92. Corrigan, Kosyluk, and Nicolas Rüsch, “Reducing Self-Stigma by Coming Out 

Proud.”

93. Ibid.

94. E. Du Roscoät and F. Beck, “Efficient Interventions on Suicide Prevention: A 

Literature Review,” Revue D'Épidémiologie Et De Santé Publique, 61/4 (2013): 

pp. 363-374.

95. Corrigan et al, “Challenging the Public Stigma of Mental Illness: A Meta-Analysis 

of Outcome Studies.”

96. National Academies Press, Ending Discrimination against People with Mental 

and Substance Use Disorders: The Evidence for Stigma Change, Washington, D.C.: 

National Academies Press, 2016. 

97. Kerry Knox et al, “The US Air Force Suicide Prevention Program: Implications 

for Public Health Policy.”
78

JSOU Report 17-2

98. Ann Kirkwood and B. Hudnall Stamm, “A Social Marketing Approach to Challenging Stigma,” Professional Psychology: Research and Practice, Vol. 37 No. 5 

(2006): pp. 472-476.

99. Sarah Evans-Lacko et al, “Influence of Time to Change's Social Marketing Interventions on Stigma in England 2009-2011,” The British Journal of Psychiatry Vol. 

202 (2013): pp. S77-88. 

100. Patrick Corrigan, “Strategic Stigma Change (SCC): Five Principles for Social 

Marketing Campaigns to Reduce Stigma,” Psychiatric Services Vol. 62 No. 8 

(2011); pp. 824-826.

101. Thomas Niederkrotenthaler, Daniel Reidenberg, Benedikt Till, and Madelyn 

Gould, “Increasing Help-Seeking and Referrals for Individuals at Risk for Suicide 

by Decreasing Stigma,” American Journal of Preventive Medicine, 47/3 (2014): 

S235-243. 

102. Linda Langford, David Litts, and Jane Pearson, “Using Science to Improve Communications About Suicide Among Military and Veteran Populations: Looking 

for a Few Good Messages,” American Journal of Public Health, Vol. 103 No. 1 

(2013): pp. 31-38.

103. National Academies Press, Ending Discrimination against People with Mental 

and Substance Use Disorders: The Evidence for Stigma Change, p. 3-1.

104. Kerry Knox et al. “The US Air Force Suicide Prevention Program: Implications 

for Public Health Policy.”

105. Langford, Litts, and Pearson, “Using Science to Improve Communications About 

Suicide Among Military and Veteran Populations: Looking for a Few Good 

Messages.” 

106. Advance Policy Questions for Lieutenant General Raymond A. Thomas, USA, 

Nominee for Commander, United States Special Operations Command, 2016, 

p. 18.

107. Preservation of the Force and Family, Wave III Needs Assessment: USSOCOM 

Enterprise Report.

108. Ibid., p. 36

109. Ibid., p. 38. 

110. Ibid.

111. Ibid., p. 42.

112. Ibid., p. 45. 

113. Ibid., p. 63. 

114. SOCOM 2035: Commander’s Strategic Guidance, 7 March 2016, pp. 15-16. 

115. United States Government Accountability Office, HUMANCAPITAL: Additional 

Actions Needed to Enhance DOD's Efforts to Address Mental Health Care Stigma.

116. Richard Barrett. Building a Values-driven Organization: A Whole System Approach 

to Cultural Transformation, Amsterdam: Butterworth-Heinemann, 2006. 
79

Lefebvre: Suicide Prevention Initiatives in USSOCOM

117. Lefebvre, Social Marketing and Social Change.

118. National Academies Press, Ending Discrimination against People with Mental 

and Substance Use Disorders: The Evidence for Stigma Change.

119. Snyder, “Health Communication Campaigns and Their Impact on Behavior.”

120. Lefebvre, Social Marketing and Social Change, 185.

121. Richard Spoth, “Applying Conjoint Analysis of Consumer Preferences to the 

Development of Utility-Responsive Health Promotion Programs,” Health Education Research Vol. 4 No. 4 (1989): pp. 439-449.

122. Patrick Asubonteng, Karl McCleary, and John Swan, “SERVQUAL Revisited: A 

Critical Review of Service Quality,” Journal of Services Marketing, Vol. 1 No. 6 

(1996): 62-81. 

123. Kerry Knox et al, “The US Air Force Suicide Prevention Program: Implications 

for Public Health Policy.”

124. Leah Shelef et al, “An Effective Suicide Prevention Program in the Israeli Defense 

Forces: A Cohort Study,” European Psychiatry, Vol. 31 (2016): pp. 37-43.