Best Paper Award for Methodology Employed (selected through peer review)
In Canada, Canadian Armed Forces (CAF) members are 32% more likely than civilians to have suicidal thoughts and 64% more likely to plan their suicide (Sareen et al, 2016). Depression is the most common mental health diagnosis for CAF members (Pearson et al., 2015) and regular force members report higher prevalence of depression and anxiety over the general Canadian population (Pearson et al., 2015). In spite of these findings, an estimated one-third of CAF members in 2002 did not access treatment-related services despite acknowledging the need for help (Fikretoglu, et al., 2008; Sharp, et al., 2015; Vogt, 2011). Members do access primary care providers first when suffering with symptoms of depression and stigma towards those with a mental illness still exists among health-care providers (Fikretoglu, et al., 2008; Greene-Shortridge et al., 2007; Langston, 2007; Lunasco, et al., 2010; Myerholtz, 2018; Sharp, et al., 2015; Vogt, 2011; Warner, 2008). The purpose of this Participatory Action Research (PAR) dissertation was an exploration of military members’ experiences with accessing mental health care, as encountered by service members and clinicians, with a specific focus on the facilitators to this care. Results indicate that culture and identity play a significant role for both military members and clinicians in terms of enabling or impeding the use of mental health care services. Facilitators to mental health care encompassed cultural change in the CAF, higher rank support for use of services, CAF wide education on mental health, time allotted for appointments and confidentiality. Normalizing the use of specialized resources, during cultural indoctrination into the military, and highlighting testimonials by credible CAF leaders may further the cultural shift in the CAF. Also, more than just addressing structural barriers is needed to facilitate mental health care seeking by military members.
Keywords: Canadian Armed Forces, mental health, warrior culture and mental health stigma, clinician culture and stigma, facilitators to accessing mental health care
Statement of Problem and Contextualization of the Research
Depression is the most common mental health issue for Canadian Armed Forces (CAF) members (Pearson, et al., 2015). According to Pearson, et al., (2015), depression is reported more often by regular force CAF members over symptoms of panic, post-traumatic stress, anxiety and alcohol abuse or dependence. There has been no change in the prevalence of depression among regular force members between 2002 and 2013, yet the frequency of panic and post-traumatic stress diagnoses has increased (Pearson, et al., 2015). It is also noted that regular force members report higher prevalence of depression and anxiety over the general Canadian population (Pearson, et al., 2015). According to Sareen et al. (2016), military members are 32% more likely than civilian Canadians to have suicidal thoughts and 64% more likely to plan their suicide.
In response to this dire public health concern, suicide prevention has become a top priority for the Canadian Armed Forces (CAF) (Government of Canada, 2017; Nock, et al., 2013). Yet, despite the availability of mental health services for soldiers that surpasses the services at the disposal of Canadian civilians (Sareen et al., 2016), a significant percentage of military members are not accessing the plethora of supports that are available to them (Fikretoglu, et al., 2016; Sareen et al., 2016). It is estimated that one-third of CAF members in 2002 did not access treatment-related services despite acknowledging the need for help (Fikretoglu, et al., 2008; Sharp, et al., 2015; Vogt, 2011).
According to Myerholtz (2018), patients access primary care providers first when suffering with symptoms of depression and despite the prevalence of depression in patients seeking treatment, stigma towards those with a mental illness exists among health-care providers (Myerholtz, 2018). Also impacting clinical settings is the privileging of specific disciplines like medical doctors and psychiatrists within a traditional health model which reinforces a silo effect in this model of care (Mueller, 2016). In practice, patient outcomes are negatively impacted by this silo effect of fragmented care (Mueller, 2016). Outcomes for both patients and providers are improved in an integrated and collaborative health care model where care is team driven, population focused, measurement guided and evidence based (Myerholtz, 2018). Best practices in transdisciplinary healthcare integrate participation of the patient, families and communities with a focus on patient informed care, a shared mission, clear vision, a mutual understanding of the goals and enhanced commitment of all involved (Myerholtz, 2018; Van Bewer, 2017). In light of the outcome research on the collaborative health care model as well as this researchers’ encounters over the years hearing members’ experiences with military health care, exploring the reasons CAF members access or do not access mental health services, via participatory action research (PAR), occurred. PAR’s collective intention includes creating a more reasonable, sustainable and inclusive practice, that increases understanding of our practice and the conditions under which we practice (Kemmis, et al., 2014) which aligns with transdisciplinary healthcare best practices.
The purpose of this research was an exploration of military members’ experiences with accessing mental health care, as encountered by service members and clinicians, with a specific focus on the facilitators to this care. In exploring these facilitators, the hope is that an increase in utilization of military mental health care can occur. In collaboration with PAR coresearchers, the research questions included: 1. “What’s one thing that needs change in order to make it easier to access mental health services for CAF members?” 2. In your mind, what role does culture play (warrior/clinician) in facilitating/creating barriers to accessing care? and 3. “What does the CAF as an organization do to foster active-duty military members’ engagement in military mental health services?” Using a pragmatic approach, participatory action research was used to explore medical stigma, warrior identity/hypermasculine ethos and facilitators related to active-duty CAF members’ use of military mental health services with the ultimate goal to facilitate change.
Participatory Action Research, like the philosophy of pragmatism, includes participants in the process of enhancing their practices and settings and aims at creating a shared language among the advisory team (Kemmis et al., 2014). Investigating facilitators to accessing military mental health care by engaging both providers of mental health care and those members accessing mental health services as coresearchers brings depth to the exploration by involving various stakeholders, perspectives and voices. PAR is considered more of an orientation to investigation that stems from two research approaches including action research (AR) and participatory research (PR) (Khanlou & Peter, 2005). Paulo Freire is considered one of the originators of PAR (Baum et al., 2006). Freire was concerned with marginalized members of society and he stressed the importance of critical reflection for personal and social change (Baum et al., 2006; Maguire, 1987; McIntyre, 2002; Selener, 1997). According to Freire, freeing oppressed individuals requires knowledge of the political, social and economic contradictions in order to act to change the oppressive elements of reality (Baum et al., 2006; Khanlou & Peter, 2005; Khan & Chovanec, 2010). PAR aims to help people recover from the constraints of unjust and unproductive social structures that limit their self-development and self-determination (Kemmis & McTaggart, 2000). It is suggested that prior to the start of any PAR research, it is important to be aware of the politics and the culture of the community with which one plans to collaborate (Khanlou & Peter, 2005; Khan & Chovanec, 2010). To ignore the politics puts the research and the validity of the analysis at risk (Herr & Anderson, 2015).
A variety of definitions of participatory action research, from several fields of inquiry, exist (MacDonald, 2012). According to Vollman, et al., (2004), the purpose of PAR includes fostering capacity, community development, empowerment, access, social justice, improving well-being and participation (Khanlou & Peter, 2005; Khan & Chovanec, 2010; MacDonald, 2012). It is “a philosophical approach to research that recognizes the need for persons being studied to participate in the design and conduct of all phases of any research that affects them” (Vollman et al., 2004, p. 129) as “multiple or shared realities exist” (Kelly, 2005, p. 66). It is also recognized as a more inclusive form of inquiry (Stringer & Genat, 2004).
In health literature, PAR is seen as transformative (Fals Borda, 2001; Green et al., 1995; Kemmis & Taggart, 2003; MacDonald, 2012). Researchers and participants co-create knowledge as a sense of community is built, meanings and language are negotiated and educating one another occurs (Fals Borda, 2001; Green et al., 1995; Kemmis & Taggart, 2003; MacDonald, 2012). First world countries currently use PAR as an approach to investigate the health programs of those whose health is being promoted (Baum et al., 2004). As a way of doing research, PAR aligns with my values of democracy, building capacity, encouraging self-determination and inclusiveness (Baum et al., 2004; Khanlou & Peter, 2005).
Members for the PAR advisory team were recruited via flyers placed in mental health waiting rooms in Esquimalt, BC, Edmonton, AB and Trenton, ON. The aim of the advisory team included collaborative discussion and agreement on the nature of the problem, as well as agreement on sources of change to this problem. The recruited advisory team included 3 active-duty CAF members (a social worker, a nurse and an officer) and 4 military mental health clinicians (3 social workers and 1 psychologist). This group initially met virtually and generated the questions to be asked during the focus group/individual interviews and convened quarterly over the year while the research was conducted. This researcher garnered feedback from the advisory team in terms of themes that emerged from the research. This group gave suggestions to this researcher related to the direction of the study, as well as the interventions to create change.
Focus group participants were recruited via flyers placed in the military base mental health waiting rooms in Esquimalt, BC, Edmonton, AB and Trenton, ON, as well as on the Military Minds Facebook page. Focus groups included 1-3 participants and the inquiry team agreed upon open-ended questions were asked. Confidentiality was addressed, participant agreements were signed and protocol for handling, storing and destroying the research was addressed with each group. The audiotaped sessions were transcribed by this researcher and shared with the reference group for collaboration over the emerging themes.
This researcher compiled the emerging themes and met for the last time with the advisory team regarding the findings, the dissertation format and the dissemination mediums. This researcher generated two research articles for publication, developed two infographics, created an online video presentation in the style of a TedTalk with the research findings, presented at a social science themed conference and the results were shared on the Military Minds Facebook page.
The focus group data were analyzed in collaboration with the inquiry team. Journal entries by the principal researcher contained observations and initial reactions to the focus group sessions and the focus group transcriptions were discussed with the inquiry team members. Emerging themes were identified in each transcription and consensus on the central themes were recorded. Seven very broad categories of health care in the CAF, barriers, beliefs, biases, gender, culture, and facilitators were further collapsed into four final agreed upon themes of “those people”/client identity, “old school CAF”/culture of stigma, loss of purpose/belongingness, and facilitators to care. This by hand process was done by printing out each transcription, cutting out all direct quotes from the focus group data and placing the quotes into piles of similar quotes. These broad piles were then further reorganized into specific themes using the words of the participants with the aim of the research in mind.
While analyzing the data from the focus groups, 12 categories were identified. These categories were then grouped into 7 themes, and further collapsed into 4 themes that include “those people”: client identity, “old school CAF”: culture of mental health stigma, loss of purpose/belongingness and facilitators to care.
“Those People”: Client Identity
Through investigating facilitators to care, participants addressed what prevented them from accessing mental health services. When asked what would make it easier to access services, the client identity emerged. Comments related to identity included, “…you are not ostracized, but you are kind of like “those people” and “I think services were available, but when I joined 20 years ago, it was really…you were ostracized for going to mental health” (Hanson et al., 2019, p. 2; Member, 2020, p. 1). Many mentioned taking months and years to come forward after trying to manage on their own (Hanson et al., 2019, p. 6). The indoctrination into unit cohesion and warrior culture is so pervasive, one member explained that he was “brainwashed” into believing that he was weak if he got help (Member, 2020). “I got so brainwashed that if you go to the MIR because you hurt yourself that you are weak and are whatever else, that I…it took me a while to change that for myself…for myself, I couldn’t, I don’t know, it’s weird to explain…because I don’t lead that way…I tell others to get help when you need it” (Member, 2020, p. 2). Another member with over 30 years’ experience stated that “self-stigmatization” still exists and commented that no professional wants to struggle (Cossar & Umbrico, 2019).19 “People are getting the message that it’s ok to get help…still self-stigmatization (still exists) in that there is no professional that doesn’t want to be able to do their job…there are still people that resist coming in” (Cossar & Umbrico, 2019, p. 3). Others also referenced special treatment centres for professionals and how clinicians access mental health care probably less than military people (Cossar & Umbrico, 2019; Ducros, 2019). “It’s kind of like how we have special treatment centres for doctors and pharmacists and professionals” (Cossar & Umbrico, 2019, p. 10).
“Old School CAF”: Culture of Mental Health Stigma
Many participants spoke of how culture plays a role in both facilitating and creating barriers to care. “There was a stigma attached to mental health and I think that even now we are still trying to change the culture of that stigma” (Hanson et al., 2019, p. 1). “Stigma from society and the old guard mentality is still very much alive (in the CAF)…unit level care would not be beneficial…things have to happen more at a higher level, not lip service forced down but implemented…the old guard needs to be weeded out and get the new thought process in” (Hanson et al., 2019, p. 3). The impact of language, the difference in the CAF elements and the past vs present military perspective was discussed, which highlights change over time, as well as the change that is still needed (Cossar & Umbrico, 2019; Hanson et al., 2019; Member, 2020).
One member with over 20 collective years in the CAF, 8 years combat arms service and 12 years in the air force referenced the difference between the army and the air force, as well as the forces from the past (Member, 2020). “I think we are better because, when I was a younger guy, I would have never told people that I don’t feel well, on a mental side because then you’re weak. Yeah, there is more empathy and less of that, I don’t like saying macho but like that toxic mentality that used to have before you know, there used to be that mentality like nothing can break us” (Member, 2020, p. 15). “…in the 90s, people would get kicked out of the CAF for mental health issues, unceremoniously kicked out…we’ve come a long way…not what we used to be by a long way…we are way better” (Member, 2020, p. 2).
Participants talked about the shift in the CAF culture and many referenced changes over the past 10 years (Cossar & Umbrico, 2019; Hanson et al., 2019; Member, 2020; Bell, 2020; MO, 2020). Participants talked about how, in the past, members would be kicked out of the military for mental health issues and said labels like “crazies” were used by the Chain of Command (Member, 2020). One participant said that he had a “…hard time pointing…like a specific point (to the shift) I would say at least 10 years ago, it starts to change at least 10 years ago…2000, we still had lots of the dinosaurs, you know, the dumb people from the late 70s early 80s that, for example, when we were doing a run one morning, it was the fast group, the slow group and the sick, lame and lazy…that was the three groups…if you were not capable of joining PT, you were sick, lame and lazy so you were labelled like that” (Member, 2020, p. 2). Another participant addressed the impact of a clinicians label on “finances, belongingness, identity, rank, my whole life” (Rochelle, 2019, p. 14). “…the main thing, the big points, the leadership culture change, that’s the most important, especially if you are a junior rank, if you see your leaders calling people crazies, you’re not going to want to be seeking help, so that’s changed” (Member, 2020, p. 14). A pivot in the beliefs, as shown in the language used, the leadership styles, and in the treatment of those accessing mental health services has occurred in the forces according to the expressed lived experience of members in these focus groups.
Loss of Purpose/Belongingness
Reinforcing the felt sense that accessing mental health impacts one’s purpose and belongingness within the unit, participants talked about their experiences after seeking support. “…it felt like things were against me…(Hanson et al., 2019, p. 19) “… you are already feeling terrible and now let’s make you feel insignificant” (Hanson et al., 2019, p. 20). Another participant talked about how, “…worse than getting kicked out or medically released is that you are still at the unit watching all of your friends do what you want to be doing but not able to do it…(Rochelle, 2019, p. 9) “I always use the phrase, the machine will keep moving… you don’t have to ostracize these people or us…this impacts postings, adoption, anything else that, outside of deployment…with things like that I really regret coming to mental health but I still would not direct people away from mental health if that makes sense” (Hanson et al., 2019, p. 20). Unit cohesion is the essence of military life from the beginning of one’s career starting in basic training. Mental health support is provided for members and the impact on one’s career and sense of belonging within the unit can occur.
Facilitators to Care
Overlapping responses, related to what participants thought helps CAF members’ access services, included leadership disclosing their own use of services, leadership’s knowledge and positive messages and promotion of mental health services, cultural attunement, allowing time for sessions, confidentiality and the availability of services (Ducros, 2019; Cossar & Umbrico, 2019; Hanson et al., 2019; Rochelle, 2019; Member, 2020; MO, 2020). “When a senior leader in the organization self-discloses their positive experience of mental health, it contributes to supporting the member in getting care when they need it” (Rochelle, 2019, p. 3). “A supportive CoC can definitely help let someone access care by telling them that they won’t lose their job and won’t be shunned or shamed or criticized or punished” (Ducros, 2019, p. 6).
Several participants talked about culture and reported, “I think there’s been an improvement in people being more open to go (to mental health) because their CoC is promoting it” (Member, 2020, p. 6). “The message coming from leadership that it’s ok to seek services, speaking about services…members are being given the language of the mental health continuum…a common language and we are having conversations about mental health…you are given permission that you can actually talk to your CoC or peers if having an orange moment” (Cossar & Umbrico, 2019, p. 4). “CAF promotes the use of mental health services via the R2MR training, unit training days, leadership not stigmatizing it” (Cossar & Umbrico, 2019, p. 10). “The primary thing is leadership knowing about the resources and referring their people to assistance” (Cossar & Umbrico, 2019, p. 11). “We do a great job of providing multidisciplinary services for our people” (MO, 2020, p. 10).
Focus group participants talked about feeling and being seen as “those people”, separate from the CAF warrior (Hanson et al., 2019; Member, 2020). These messages infer that warriors do not access support and we know that CAF members sometimes struggle with accessing services even when needed (Fikretoglu, et al., 2008; Sharp, et al., 2015; Vogt, 2011). Although structural stigma is addressed (Ting, 2011), as seen in the facilitators section, internal personal stigma (Ting, 2011) seems to continue to thrive.
The aim of military basic training includes immersing new members in the social norms and essential tasks of the armed forces including how to work as a team (Green et al., 2010). One’s civilian identity is stripped, and the warrior identity is donned (Herbert, 1998). Beliefs about warrior conduct, morals, unit cohesion, capabilities and expectations, as well as the ability to cope with high levels of stress exist and are taught (Weiss & Coll, 2011). Members align with their in-group membership beliefs, values and assumptions which, when help seeking, collides with the client/patient out-group (Turner & Haslam, 2001). It seems the client identity is a separate role that does not integrate with the CAF member role. Other research has addressed this insider and outsider or “us” and “them” that separate client/patient/”mad” and the warrior/”non-mad” along with the othering that goes along with it (Burnard, 2007; Kemble, 2014; Tay et al., 2018).
Unit cohesion, paramount to the CAF identity, may be seen as at odds with the individual focus of therapy (Atuel & Castro, 2018; Braswell & Kushner, 2012; King, 2006). Separating oneself from a unit, perceived as an out group member by others and oneself and expressed by the focus group participants (Hanson et al., 2019; Member, 2020; Rochelle, 2019), may be one element of the personal stigma ascribed to the client identity. To align with the client role, there are competing interests between unit cohesion (where the group is the focus not the individual) and therapy (where the focus is on individual processing and building tools). Other research found that with the start of mental illness struggle, a sense of loss of self is felt (Wisdom et al., 2008). In light of the importance of unit cohesion and the internalized qualities of the warrior, a sense of loss would be inevitable once help seeking actions are taken.
Members talked about the “old guard” and about what the CAF was like in the past (Cossar & Umbrico, 2019; Hanson et al., 2019; Member, 2020; MO, 2020). These past beliefs and ideas about mental health continue to linger, as seen in the members’ comments on the differences between units, despite the shift in perspective at the national level (Cossar & Umbrico, 2019; Hanson et al., 2019; Bell, 2020; Member, 2020; MO, 2020). The impact of the historical beliefs, language and actions by the CAF, specifically related to mental health, can be seen in the time it took members to access support; especially members with more time served. One member mentioned that he no longer fears career implications, and another said that although he supports his troops in accessing mental health, he did not do so for himself, despite the need (Cossar & Umbrico, 2019; Member, 2020). This emphasizes that more than just structural changes, like providing time to attend sessions and available resources, need to occur to support members in accessing mental health services.
Despite suffering, this researcher has heard members explain that they will ignore their physical and mental concerns for fear of the implications. Although structural changes have occurred over the recent past, the “old school CAF” belief system is apparent. Change over time has happened in the CAF and change is still needed as the disparity between the elements and with primary care and mental health care clinicians remains.
The impact of accessing mental health services was shared by focus group members who referenced various losses (Hanson et al., 2019; Rochelle, 2019; Bell, 2020). The theme, loss of purpose, includes change in identity; once members identified with the label of client, in their own perception and the perceived perception of others (CoC, family members, and friends) their role as a CAF member changed (Ducros, 2019; Hanson et al., 2019; Bell, 2020; Member, 2020; MO, 2020).
Unit cohesion is a foundational part of the CAF indoctrination. As part of a unit, members function as a group. Once members are ill or injured, their role within that unit changes. The loss of one’s role within a team is devastating for most and as Rochelle (2019) explained, to be on unit lines watching your friends do what you trained to do and are unable to, demolishes one’s sense of purpose. Clinicians struggle with juggling the role of caregiver with client which can be complicated by wearing a CAF uniform (Ducros, 2019; MO, 2020). Rank and role identity along with unit cohesion clash.
According to Peterson (2016), fundamental for health professionals with a mental illness is identity formation. Threats to identity, for those struggling with mental health concerns, include discrimination, stereotypes and prejudice (Peterson, 2016). Although the focus of Peterson’s (2016) research is health professionals, the findings ring true for CAF members. As CAF members, various roles are expected of them, depending on their rank, trade, element and commission. The role of client, if accepted by CAF members, requires a shift in identity (Leshem, 2020) in which members may experience “uncertainty about the identity of self and purpose” (Meyer & Land, 2006 p. 22 in Leshem, 2020).
Similar facilitators to care were identified in the focus groups. Participants referenced culture, time, confidentiality, rapport, the use of services by clinicians and peers, and disclosure of use by senior leaders, as well as that information regarding available services is shared (Cossar & Umbrico, 2019; Ducros, 2019; Hanson et al., 2019; Rochelle, 2019; Member, 2020, MO, 2020). According to Jones et al., (2018), “…senior UK military commanders may be able to influence stigma by encouraging the discussion of mental health among subordinates” and assert that “…combating stigmatising perceptions of weakness and fears of being treated differently should be the central focus of command activity” (Jones et al., 2018, p. 17). Senior leadership disclosing their own use of services seems to give permission to members to seek formal mental health support and reinforces that one can be warrior and client.
Through focus group data, it is apparent that structural barriers to military mental health care are being addressed (Cossar & Umbrico, 2019; Ducros, 2019; Hanson et al., 2019; Rochelle, 2019; Member, 2020, MO, 2020). The CAF provides time for members to attend appointments, resources exist, confidentiality is ensured and testimony by peers and senior leaders during briefings or informally addresses these barriers. Ting (2011) reports that personal reasons rather than structural barriers are more often the cause for not accessing mental health support. Although Ting’s (2011) research focused on students in caregiving professions of social work, nursing, psychology and medicine, there seems to be more similarities between the CAF warrior and the caregiver in terms of mental health seeking.
Every focus group participant in this research is Caucasian and all, but one, Anglophone. As well, the inquiry team consisted of CAF members from the army and navy and all, but one, is Caucasian which may limit the transferability of these findings. The number of focus group participants and the time allocated to complete the doctoral research are also limitations of this research.
Depression is prevalent and affects CAF members at higher prevalence than the general Canadian population (Pearson, Zamorski, & Janz, 2015). CAF members, however, do not always use the mental health services that exist (Fikretoglu, Liu, Zamorski, & Jetly, 2016; Sareen et al., 2016, although service use did increase between 2002 and 2013 (Fikretoglu et al., 2018). The aim of this research was an exploration of CAF members’ experience of military mental health services as well as the bias clinicians may have towards those diagnosed with a mental illness. During this investigation, the importance of identity and culture, for both military and clinicians, emerged. This research uncovered the strides made in the reduction of CAF structural barriers to mental health care and highlights the facets of personal stigma that continue to act as barriers. To further this cultural shift, normalizing the utilization of specialized resources during the indoctrination into military culture, as well as focusing on personal testimonials by credible CAF leaders, may be of benefit. The promotion of care seeking as part of unit cohesion and health, involving regular annual check-ins similar to dental checkups, may potentially help reduce the personal stigma of accessing mental health support when needed. Military members live with depression and suffer even when help exists. Addressing more than just the structural barriers is needed to continue to facilitate the accessing of services. Clearly, more research is needed to uncover ways of addressing warrior and clinician personal biases and stigma towards use of mental health care services.
This original applied research focused on acquiring new understanding of the experiences of mental health use by those engaged in these services. The experience of clients and those providing services pointed toward a practical aim for change. Participatory action research was the unique perspective used to explore, in a collaborative and participatory way, with the community and for the benefit of the community included in this study and a portfolio approach was used to support the implementation of the findings. PAR aligns with this researcher’s belief about knowledge, experience and expertise as well as with the Canadian Association of Social Workers code of ethics regarding the dignity and worth of people and pursuit of social justice (CASW Code of Ethics, 2005). Unit cohesion, a basic tenant in the CAF as well as the warrior mentality lend themselves to the use of a collaborative and action focused research perspective (Weiss et al., 2011). Inclusion of those providing service and those using services is needed to explore and understand the topic of military mental health care services use in order to discover what is working well and what needs change (Balakrishnan & Claiborne, 2017). The Surgeon General’s mental health strategic priorities include “optimizing health outcomes, investing in people, increasing partnerships with internal and external agencies, improve the efficiency of the mental health system and expand mental health education and training” (National Defence, 2016, p. 24-26) and this PAR research supports and informs these priorities. Transdisciplinary health care best practices include the users of care, families and the communities within the health care team (Van Bewer, 2017) and stress the importance of patient-informed care. Including various disciplines, sharing knowledge and decision making among participants and a focus on real-world issues, skills from various arenas are developed, improvement in services and innovation can occur and comprehensive services can be provided (Van Bewer, 2017). The focus was participation with various stakeholders to discover the facilitators to care, to ultimately help champion the well-being of members by enhancing those facilitators, by informing others of these aspects of care and highlighting the barriers to care as a way to expose areas in need of attention (change in various ways and more research for example). Improving service delivery and creating change, via collaborative partnership between the academy and National Defence, is one contribution of this dissertation, which speaks to achieving impactful change. Another contribution of this study is the display of the rich perspectives held by members of a specific community, in which multiple themes emerged. These themes enhanced a picture of the barriers and facilitators to mental health care seeking. It can be helpful for clinicians and researchers working and/or investigating mental health stigma and care seeking and CAF members at all levels to consider in terms of leading by example. Although clinician impartiality was considered as a facilitator to accessing care, this study uncovered the impact that clinician identity and culture can have on help seeking by clinicians, even when support is needed. Finally, this participatory action dissertation research contributes to and extends a small collection of applied research on military culture, warrior identity, mental health stigma and facilitators to mental health care. This research uncovered the importance of testimonials, by those who have accessed mental health services and about their experience of getting support, to other military members as well as the impact of leading by example. This area along with personal stigma as a barrier to care is in need of more exploration. The collaboration of various stakeholders, the academy and the organization facilitate the exploration and use of participatory action research through a pragmatic lens.
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