Spotlight on R&D

This edition of the newsletter highlights work conducted to understand the mental health treatment preferences of Navy submariners

By Krista Ratwani, PhD

Welcome to the Spotlight on R&D column! This column showcases research activities and projects underway in many of the R&D Laboratories within DoD, partnering organizations, and the academic and practitioner community in military psychology. Research featured in the column includes a wide variety of studies and programs, ranging from preliminary findings on single studies to more substantive summaries of programmatic efforts on targeted research topics. Research described in the column is inclusive of all disciplines relevant to military psychology — spanning the entire spectrum of psychology including clinical and experimental, as well as basic and applied. If you would like your work to be showcased in this column, please contact Krista Ratwani by email or (202) 552-6127.

This edition of the newsletter highlights work conducted to understand the mental health treatment preferences of Navy submariners. It provides needed insight into when sailors are likely to seek treatment and what resources they are most likely to use to obtain help.

Mental health treatment preferences of U.S. Navy submariners: The stigma, confidentiality, and risks

W. Anthony Smithson
Paul Larson
The Chicago School of Professional Psychology

Research overview

The intention of this study was to capture the subjective preferences of military members from a previously understudied population (i.e., submariners) for seeking help with coping with stress. Sailors’ perceptions were cataloged in order to enhance the understanding of current stigma, barriers to care, and preferences for care in order to establish baseline data on resource preferences within this unique population. These factors may then be used to update policy, general military training, deployment briefings, and supervisor attitudes toward promoting access to the most appropriate level of care.

Problem to solve

Military populations have advantages when it comes to psychological care, such as potential camaraderie in the workplace, proactive formal training on stress management and suicide, and systemic resources (e.g., financial, legal, and social support) for military members and their families. The military also has barriers that differ from the mental health processes within civilian populations, such as stigma based on a warrior ethos, varying confidentiality boundaries and the risk of temporary or permanent removal from duty. Even more distinct differences may exist between military specialty populations. Some of these specialties may have different or more rigorous requirements for personnel screening, fitness for duty, and security clearances. These differences are worthy of exploring, as prior research on these topics (e.g., Hoge et al., 2004) was limited to Army infantry and Marine populations. Access to care and attitudes toward seeking care seem essential to military personnel readiness, especially the personnel who serve in particularly arduous duties. Such military members may be at higher risk of mental health related problems due to the inherent nature of their duties, stress on their families and continual evaluation of their personnel performance readiness. Increased understanding of a military specialty population may result in enhanced access to care and overall increased operational and personnel readiness.

Stigma, help-seeking behavior, and barriers to care impact the military population as a whole, but may also present differently among certain military populations. Given that previous research (Bray et al., 2003; Hoge et al., 2004) has shown that formal treatment seeking behavior is low when the need is high and that use of military practitioners is low for those in need, the goal of this research was to examine the types of resources military members actually prefer to utilize. The focus was on identifying the preferences for care and help-seeking history among one military specialty group, active duty U.S. submariners. This group was selected as they likely have distinctive preferences due to unique systemic factors (e.g., additional security clearance, fitness for duty requirements, specialized duties); submariners also represent one group of many potential subgroups where access to care has not been studied.

Solution and approach

To investigate this issue, the idea that each resource available to these sailors may have its own unique degree of stigma, confidentiality, and risks that mediate help seeking behavior was evaluated. A list of 10 resources (see Table 1) was created based on a review of the literature and experienced submariner input. The resources were categorized into formal (e.g., military primary care or chain of command), informal (e.g., friends, family, and/or religion), and civilian-based (e.g., civilian mental health). Similar to works with different military populations by Bray et al. (2003) and Hoge et al. (2004), an additional area of inquiry was to observe the rate with which submariners wanted help versus actually sought help.

Table 1. List of resources available for seeking help rated by sailors




Friends, Family, Religion Internet or Social Media

Resources not directly related to a military chain of command (CoC) or do not report to a CoC


Chain of Command Military Primary Care Military Mental Health

Resources outside of one’s personal network, available immediately on base, and are accountable to military CoC


Military Chaplain
Fleet and Family Support



Civilian Mental Health

Resources potentially accountable to military CoC


Civilian Primary Care

due to local memoran dum of agreement, insurance regulations, local laws, or provider




A survey was created to assess sailors' 1) history of treatment seeking, 2) their preferences for each resource across varying degrees of stress (i.e., mild, moderate, and severe) by ranking them from 1 (most preferred) to 10 (least preferred), and 3) the degree to which stigma, confidentiality, and risks affected their preference to use each resource on respective Likert scales.

Approval for the study was granted by the IRBs of The Chicago School of Professional Psychology and the Office of Naval Research and the Trident Training Facility Kings Bay (TTFKB) commanding officer. All staff and students at TTFKB were eligible to participate and anonymously completed the online survey. Responses to the survey were analyzed for nominal and interval scale frequencies. We were interested in the frequency of resource preferences and used crosstab analysis to observe trends. In addition, the frequencies of risks, stigma, and confidentiality being perceived as factors of resource preferences were determined. Specifically, frequencies were computed for the following variables: demographics; health resource use history; perception of stigma, confidentiality, and risks toward resources; and ranked preference for each resource.


Twenty-four sailors at TTFKB completed the survey, ranging in age (M = 35.8, SD = 5.91), rank (E-5 through E-8; O-3 through O-6), and years of service (0-5, 0%; 5-10, 20.8%; 10-15, 29.2%; 15-20, 25.0%; 20-25+, 25%). Questions about their history of treatment seeking behavior revealed that out of those individuals (n = 4) who wanted help for distress at some point during their military career, 50% had not sought care due to perceived barriers to care. When sailors were forced to rank their preferences for each resource on the pre-determined list, internet and social media resources and the ombudsman were least preferred, while friends, family, and or religion were most preferred. Meanwhile, most formal military and civilian resources (e.g., chain of command, both military and civilian primary care and mental health, and the chaplain) were ranked neutrally, indicating that these professional resources were neither least or most preferred on average. In addition, these ranked preferences showed almost no change when the degree of distress (i.e., minimal, moderate, and severe distress) varied, suggesting that these sailors may not have seen the need to modify their care resource when the severity of stress becomes worse. Results are displayed in Table 2.

Table 2. Ranked stress-relieving resource preference based on degree of stress









Friends, family, religion




Internet or Social Media




Chain of Command




Military Primary Care

5.3 (1.7)



Military Mental Health




Military Chaplain




Fleet and Family Support

5.8 (2.6)







Civilian Mental Health




Civilian Primary Care




When asked to what degree stigma, confidentiality, and risks affected their preferences for care, stigma and risks were observed as the most perceived barriers to care, especially toward utilizing the ombudsman, chain of command, internet and social media resources. This trend was based on the frequency with which sailors reported these resources as having high to moderate risk, perception that their confidential information could or would be disclosed, and frequency of being moderately to very concerned about stigma if they used the resource.


Barriers to care are significant issues, mediate treatment engagement, and therefore may affect sailors’ wellness and operational readiness. Even though this research was based on a small sample, results demonstrate that submariners have preferences for care and strong perceptions about stigma, confidentiality, and risks toward seeking help. To address these heightened concerns, internet and social media resources and ombudsman programs should be modified. Internet resources, such as Military OneSource, may be least attractive to submariners, perhaps because of restricted use due to the personal reliability program (PRP; a program that has additional screening and reporting requirements for those who work with nuclear weapon related systems). While this program was not the focus of the study, it may have factors that mediate help seeking, such as increased risk of suspension from duty and reduced confidentiality when problems arise. Improved perception of the dynamic ombudsman program may include finding ways to improve confidentiality and reduce potential negative factors of the dual relationship, as ombudsmen report to the Commanding Officer but may be friends with many sailors and significant others. Future research directions include examining whether these barriers also vary among branch of service, warfare community, or those in other special duties.

To summarize, submariners have preferred resources for seeking help with distress. They also encounter psychological barriers for seeking help that resembles the non-treatment seeking features and rates of other military populations. Efforts to reduce distress, improve family and on the job relationships, prevent suicide, and improve overall mental health seem like a parallel mission to enhancing optimal operational readiness. Actions to reduce the barriers to treatment by increasing mental health primary care or routine treatment should continue to be taken, especially in the submarine community.


Bray, R.M., Hourani, L., Rae, K., Dever, J., Brown, J., Vincus, A., et al. (2003). Department of Defense survey of health related behaviors among military personnel. Report prepared for the Assistant Secretary of Defense (Health Affairs).

Britt, T.W., Greene-Shortridge, T.M., Brink, S., Nguyen, Q.B., Rath, J., Cox, A.L., et al. (2008). Perceived stigma and barriers to care for psychological treatment: Implications for reactions to stressors in different contexts. Journal of Social and Clinical Psychology, 27(4), 317-335.

Hoge, C.W., Castro, C.A., Messer, S.C., McGurk, D., Cotting, D.I., & Koffman, R.L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. The New England Journal of Medicine, 351(1), 13-22.

POC information

W. Anthony Smithson, MA, Lieutenant, MSC, USN
The Chicago School of Professional Psychology
325 N. Wells St
Chicago, IL 60654

Paul Larson, PhD, JD, ABPP Department Faculty and Professor
The Chicago School of Professional Psychology
325 N. Wells St
Chicago, IL 60654