Abstract

Of the 1.8 million U.S. soldiers deployed to Operation Iraqi Freedom and Operation Enduring Freedom in Afghanistan, an estimated 10-18% are likely to have returned home with Post Traumatic Stress Related Disorder (PTSD). Veterans account for 14-16% of suicides in the U.S., yet are 8% of the population. Professionals advise that PTSD treatment should begin as soon as symptoms are observed, which can occur immediately after the event. Delays in treatment can worsen the individual’s symptoms.

A decrease in marital satisfaction and an increase in depression, anxiety, anger, and addiction following deployments have been observed. Yet when soldiers are deployed, often for six to twelve months at a time, access to mental health care options are limited and under-utilized.

This research explores how a system of designed interventions may address the unique mental health care needs of soldiers on deployment. This project acknowledges the barriers and resistance to care and explores the prevailing stigma surrounding therapeutic and healthy coping skills within the military. Solutions are proposed which leverage the unique camaraderie of the military community to encourage new practices which support mental health care, emotional intelligence, and emotional processing.

The first half of this study involved interviews with soldiers and behavioral health researchers, an analysis of the current mental health care options, and a taxonomy of therapy approaches. Next, rapid ideation produced an exploration of visual and systemic possibilities. These studies consider the user’s environmental factors, anonymity requests, and long-term objectives.

The results of this research show that there is a desire, need, and potential for a variety of new mental health care options for soldiers during deployment.
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The Challenge

Of the 1.8 million U.S. soldiers deployed to Operation Iraqi Freedom and Operation Enduring Freedom in Afghanistan, an estimated 10-18% are likely to have returned home with Post Traumatic Stress Related Disorder (PTSD). Veterans account for 14-16% of suicides in the U.S., yet are 8% of the population. Soldiers returning home with PTSD are three times as likely to show signs of spousal aggression when compared to civilian relationships and are twice as likely to end their marriages in divorce (Karney, 2016; McCarrol, 2010).

The mental and emotional health of U.S. soldiers is crucial to the physical capabilities, behavioral choices, and cognitive processing effectiveness of completing their job duties. Moreover, providing easily accessible, destigmatized, personalized, and effective mental health care is not only a matter of national safety, but a matter of ethics.

Stigma & Environmental Limitations

The U.S. Department of Veteran Affairs (VA) state that some soldiers do not seek mental health care for fear of being perceived as weak, privacy concerns, treatment side effects, accessibility (cost, location of treatment), and effective treatment options (“Mental Health Effects of Serving in Afghanistan and Iraq”, 2015).

Former Command Sergeant Major of the Army (SMA) Raymond F. Chandler III was forthright in sharing his experience with suicide, traumatic brain injury, and PTSD. He communicated with Army soldiers regarding mental health care concerns stating,“If I can do [therapy], you can. The stigma is really within ourselves. There may be some folks out there that think you may be less because of those injuries but that’s really not [true]” (Hames, 2014).

The current SMA, Daniel A. Dailey, has also expressed that “[PTSD] is not something we can change, but it is something we can treat…I urge everybody to break the silence and promote dialogue…seek help and take the first step in recovery in overall resiliency.” (The U.S. Army, 2017).

To further complicate this problem, the living conditions for soldiers in combat zones are often small and lack privacy. Depending on the base, higher ranking soldiers may have private bedrooms connected to common areas. Groups of soldiers may share large living quarters.

Timeliness is of the Essence

Professionals advise that PTSD treatment should begin as soon as symptoms are observed, which can occur immediately after the event. Waiting to receive treatment can worsen the individual’s symptoms over time (Mayo Clinic, 2018).

Yet when soldiers are deployed, often for six to twelve months at a time, access to mental health care options are limited and under-utilized. In the time it takes to get back home and speak to a professional, soldiers have likely learned how to suppress and ignore the warning signs of anxiety, depression, and anger.

Why a Product Development & User Experience Approach

Traditionally, Designers and User Experience Researchers are excluded from mental health interventions; especially those built by, and for, the military. The process of Product Development (incorporating Product Management, UX Design, and Research) bring a user-center approach to solution building.

UX Designers & Researchers are equipped with an array of user-centered product development methods and tools that would contribute to the advancement of addressing this nation-wide issue.

Along with an understanding of traditional design principles and elements (space, form, unity, hierarchy, balance, etc) which allows the creation of engaging and memorable visuals, research ensures the efficacy of the product being created.

Interviewing, user testing, rapid prototyping, and the application and merging of behavioral frameworks are just some practices of product management and UX Design that produce innovative, thought-provoking and meaningful experiences.

Product Design & Research Questions

How can the design of mobile applications and wearable technology function as a system to support the mental health care needs of U.S. Army soldiers while on deployment to combat zones?
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Supporting Questions:
How can a mobile application and wearable technology assist in identifying and managing symptoms of stress for soldiers on deployment?

How can this interface incorporate machine learning technology to anticipate and address concerning behaviors by intervening at the optimal time?

How can the design of an online community platform, gamification, and augmented reality connect colleagues to progress their mental health treatment as a group?

How can the use this system facilitates a shift in military culture to encourage new rituals around mental health and emotional wellbeing?

Conceptural Frameworks

David Rose’s Receptivity Gradient (Figure 2.1) is a measure for behavioral change over the course of six distinct positions; not ready to know, ready to know, knows the facts, accepts ideas, ready to act, and ready to advocate (Rose, 2015).

Most soldiers are aware that mental health care is important but are unsure or uncertain of how they can best address their concerns. Through first and second-hand interviews, I have learned that younger and lower ranking soldiers tend to fall to the left of the gradient. These soldiers have less exposure and knowledge regarding mental health care. They also feel more pressure to remain quiet if they experience anxiety, depression, or PTSD for fear of stigmatization or being passed up for promotions or deployments.

Higher ranking soldiers, soldiers who have had multiple deployments, and older soldiers tend to fall on the right side of the gradient. It is not uncommon to hear that these soldiers have already experienced mental health issues, spoken to therapists, have a spouse who has encouraged them to seek help, know someone who has attempted or committed suicide, and/or feel less uncertain of losing rank because they have “put in the time” with the military, and it would be much harder for them to be demoted.

behavioral objectives
In the process of reading, interviewing, observing, and speaking with experts and users I realized that all of the behaviors or actions users took as a response to stress, both positive and negative, fell into four categories: Expression          Education Encoding             Escapism I  have named these categories the “Behavioral Objectives”. Peer-reviewed studies support the notion that these four objectives can assist in the improvement of an individual’s mental health (See p. 40 - 43).

By combining the Receptivity Gradient and the Behavioral Objectives, the following conceptual framework was created:

Research Methods

Interviews: Spoke with with four mental health care, military family, and military culture experts were conducted. Precedent Studies Existing solutions were evaluated and critiqued for qualities and features that may benefit this specific user.

Rapid Ideation: A timed ideation exercise was practices. A wide variety of ideas were sketched and written. These ideas were the basis of the four concepts used in the visual studies.

Persona and Scenario: A hypothetical user and scenario were developed to assist in the storytelling and communication of how the design explorations and systems may be utilized.

Visual Studies: The strongest concepts from the Rapid Ideation exercise were further explored through visual studies.

Focus Group User Test: The visual studies were taken to Ft. Stewart, Georgia where 18 U.S. Army Infantry soldiers offered their first impressions and thoughts regarding these ideas.

Subject Matter Expert Interviews

Kellie Artis + Elizabeth Austin
One of my first steps in this research process was to sit down with Kellie Artis and Elizabeth Austin. Kellie is the Chief Operating Officer of Millie, a privately funded military relocation service. She is also a Board Member of the Military Family Advisory Network, consultant for private firms who wish to know more about the military lifestyle, and a military family researcher and advocate. Elizabeth is a veteran, former military chaplain, and a current researcher focusing on soldier resiliency and interdisciplinary approaches to performance optimization, PTSD, and moral injury. Elizabeth describes her specialty as a “preservation of force and family” and calls her line of work “spiritual fitness”. Both Kellie and Elizabeth are married to active duty and high-ranking soldiers. Below are the key findings from our conversation. (To read the entirety of our conversation, please refer to p. 137).

Key Findings: The stigma surrounding mental health in the military is very real and wide reaching. Gamification can hold a soldier’s interest. Have educational resources available when soldiers are ready – do not force it upon them too early. Chaplains are not trained to address mental health concerns.

Davon Goodwin
Davon Goodwin is a husband, father, farmer, and Army veteran with PTSD and a traumatic brain injury. He now works at the Sandhills Agriculture Innovation Center where he finds a sense of purpose and calm by farming. He speaks publicly about PTSD awareness and was a central role in a 10-part documentary series called “The War Within”.  Below are the key findings from our conversation. (To read the entirety of the interview, please refer to p. 140).

Key Findings: When soldiers are unable to decompress and process emotions, they learn how to bottle it up. But those emotions can come back in undesirable forms and actions. Soldiers do not want to be seen talking to a mental health professional while they are deployed. There is often a breaking point or an ultimatum presented by loved ones which becomes the catalyst for a solider to begin seeking help. Sharing your story and listening to others’ stories can be therapeutic, but it does not work for every soldier. Different forms of therapy work for different people, and some forms will be more effective at different times. Transitioning into non-combat or civilian living can be extremely challenging.

Anonymous
The final interview was conducted approximately one week before the rapid ideation stage of this research. The interviewee, who requested to remain anonymous, is a female in her 20s. For the purpose of this writing, I will call her Valerie. Valerie heard of my project and reached out to me asking if she may be of assistance. She has experience with PTSD, depression, and anxiety. Below are the key findings from my conversation with Valerie. (To read the entirety of our conversation, please refer to p. 143).

Key Findings: Behaviors can be directed for positive and negative outcomes to create forms of escape. A variety of methods can be used to compliment professional therapy. Peer support contributed to personal progress and feelings of worth. The individual is not always aware that they are engaging in destructive or unhealthy behaviors. This may require an outside force to bring their actions to their attention. Many family members held a negative perception of mental health. This contributed to the lack of mental health care received by other family members.

Rapid Ideation, Brainstorming

To assist with the generation of ideas, I compiled a list of technologies, people, and places available to soldiers while in a combat zone (farthest column to the left.) I then used an online randomization tool and requested classmates to select two to three of these options at a time (indicated by the green squares with X's). I considered all 25 combinations and selected seven which seemed most compelling (indicated with red squares and a dash.)

I asked myself, “What would happen if the only items or events available to a soldier to address their mental health were the things in this column?” These were combinations I would not have initially chosen for myself, but forcing connections would result in new and interesting ideas.

Taking small pieces of paper and a permanent marker, I challenged myself to sketch as many ideas as possible for each of the seven selected combinations. I allocated 10 minutes per combination, and the only rule was that I could not stop sketching new ideas until the timer was up. Ideas could be outlandish, wild, and future-thinking while neglecting realistic and logistical concerns. In 70 minutes I produced 60 ideas.

I then transcribed these ideas into a spreadsheet where I wrote short descriptions explaining the sketches, what I liked and disliked about each idea about each idea. Next, common ideas were compiled together to create eight solid concepts which could address my initial Research Question.

I selected four of the strongest concepts to further explore through visual studies.

Focus Group Discussion

The four visual studies in the next section were presented to 18 soldiers at Ft. Stewart, Georgia. (These studies were shown in their most preliminary forms). The soldiers in the group varied in age, rank, ethnicity, and deployment experience.

Working in large, medium, and small groups, I spent two hours at their unit. I did not disclose that I was addressing mental health care until the completion of the discussion. The proposed designs sparked an engaging conversation about mental health and the opportunities that technology has to address their concerns on deployment.

Using their feedback, the studies were refined. The responses to the preliminary designs will be included with each corresponding study below.

Persona

Ethan is a 25-year-old male in the Army. He enlisted when he was 20 years old and is an E6 (Staff Sergeant). Ethan is from Crystal City, Virginia, went to basic training in Ft Benning, Georgia, was stationed at Ft Stewart, Georgia, and finally transferred to Ft Bragg, North Carolina.

His Military Operational Speciality (MOS) is 11C, Indirect Fire Infantry. He is deployed to Ft Dwyer, Afghanistan for nine months with the 82nd Airborne Division. He is a platoon leader with four soldiers who report to him.

He is married to Margaret and they have a two-year-old daughter. Ethan has some college experience but did not complete his degree. His father and uncle both retired from the Army so Ethan grew up understanding military life. Like his father and uncle, Ethan enlisted because he has a desire to serve the military, would like a stable career, and enjoys the pay and healthcare.

Ethan has a few close friends from home but does not often communicate with them. He attends social outings with his coworkers on occasion but spends most of his free time with his wife and daughter. Because of his rank, Ethan finds it uncomfortable fraternizing with soldiers who are higher or lower enlisted than him.

One of Ethan’s former coworkers committed suicide recently. He is aware of the high suicide rates for soldiers and was encouraged by his wife, who pointed out his signs and symptoms of stress before he did, to see a civilian therapist under his wife’s name. He was afraid that if he sought help using his name, there would be a “paper trail” prohibiting him from career advancement. He saw personal growth from seeing the therapist but found it challenging to get time off of work to attend his appointments. While Ethan acknowledges the benefit of mental health care, he is afraid to speak openly to his peers about it.

Receptivity Positioning

Based on Ethan’s current beliefs and knowledge around mental health care, he likely falls somewhere between “Knowing the Facts” and “Accepting Ideas” on the Receptivity Gradient.