Editor’s Note: As part of the Center for Deployment Psychology’s ongoing mission to provide high-quality education on military- and deployment-related psychology, we are proud to present our latest “Guest Perspective.” Intermittently, we will be presenting blogs by esteemed guests and subject matter experts from outside the CDP. This allows us to offer more insight and opinions on a variety of topics of interest to behavioral health providers.
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By Steven L. Sayers, Ph.D.
At least 60% of military Veterans who have served in Iraq and/or Afghanistan have enrolled in care in the Department of Veterans Affairs. However, many Veterans are reluctant to seek mental treatment. A recent study suggests that about one-third of Iraq and Afghanistan Veterans who have major depression or post-traumatic stress disorder (PTSD) and over half of those who acknowledge alcohol misuse, do not choose to get mental health treatment in the year following screening (Elbogen et al., 2013). Family members and other close supporters of Veterans often want to help, or are concerned enough about the Veteran in their lives that they want to say something. Studies have shown that Veterans will seek treatment when encouraged by people in their social network (Spoont et al., 2014).
Family members, or close friends, are often the ones to notice that the Veteran may be withdrawing from people, avoid going to public gatherings, drinking to excess, having difficulty sleeping, and being irritable. Unfortunately, the conversation the concerned family member or friend has with the Veteran may not go well. Their concern might be expressed in statements such as, “You should get some help” or “You have to recognize that you have a problem—you should see a therapist.” This type of conversation often prompts push-back from the person receiving the message. This may happen for several reasons.
There is still a stigma about mental health care that prevents many Veterans from seeking treatment (Hoge et al., 2004; Kim, Thomas, Wilk, Castro, & Hoge, 2010). Also, certain self-affirming beliefs of Veterans may keep them from reaching out or accepting help. Some interview studies have found that these beliefs include “[there is] pride in self-reliance,” or “I would be seen as weak” and this keeps Veterans from seeking care (Elbogen et al., 2013; Kim et al., 2010; Sayer et al., 2009; Vogt, Fox, & Di Leone, 2014). Beliefs that “treatment is not helpful” are also a barrier. In addition, a refusal to go for treatment may happen simply because each of us want to show that we are master of our own fate and refusing is a way of showing that. The feeling that a friend or family member is forcing the issue of getting treatment complicates the issue. However, there are several straightforward steps that a concerned family member or friend can take to help a Veteran who appears to be having trouble with these types of problems: anxiety, depression, problems with sleep, responses to wartime trauma, relationship conflict, or abuse of alcohol. In the paragraphs below I’ll refer to “the problem” or “this problem” which refers to any of the issues mentioned above.
First, take a step back, stop trying to force the issue and begin to listen. Take a pause from making the effort to convince the Veteran to decide enter treatment. This does not reduce your important role with the Veteran and it will help. Listening to what your Veteran-loved one is concerned about, without advice, judgment, or an attempt to solve the problem will show acceptance and care. In the long run, this is difficult, but crucial. In other words, start by practicing a “less is more” approach. Although, sometimes a loved one will do what you ask when you give an ultimatum (e.g., “Get help or else I am out of here!”), this type of demand rarely leads to a lasting attempt at changing or staying in treatment. It is hard for the person who is the target of the demand to “own” their decision to change—they are simply yielding to pressure.
Second, educate yourself about the things that many Veterans may be concerned about. Go to maketheconnection.net for a treasure trove of video-recorded interviews with Veterans who have experienced combat and reintegration after returning from deployment or after leaving military life. Interviews of family members are also included. The National Center for PTSD at the website www.ptsd.va.gov/public/ has many educational resources for family and friends about mental health issues. If you have become a better listener for your Veteran-loved one, you might be able to share one of these resources. For example, if your loved one states that other Veterans seem to be doing well without getting care, you might mention the Make The Connection website as a place that many Veterans have shared their stories about their struggles.
Third, look for opportunities to help the Veteran in your life focus on what solution he or she believes might address the current concerns. This is the step that requires the most patience with yourself and your Veteran-loved one. As you listen to whatever concern that he or she wishes to share, simply ask for a bit more detail (example: “Can you say more?”). Resist the urge to offer advice or to jump in with a solution. Say, “It sounds like things have been tough,” and continue to listen. Offering attention, and NOT offering a comment, can encourage your loved one to continue to talk about what is going on. This is difficult because listening without offering to help may lead us to feel that we are not doing anything to help. Nothing can be further from the truth—listening without judgment is the most important type of help to offer someone you care about.
When you are sure that the Veteran in your life is open to talking about a solution to his or her problem, you can ask a specific type of question that will help: “What do you think will help this problem?” Any similar question can work just as well—“What is the solution that you think will work the best?” “What do you think you should do?”, or “Who can you go to for help with this?” The key to these questions is to make it clear you are indicating the Veteran is the one to find the best solution, not anyone else. You can also be supportive by saying, “Let me know if you want help with this, I’ll be happy to do anything to support you in solving this problem.” This may be difficult when we are discussing some upsetting behavior, such as drinking to excess, but if this is the case look for times when your Veteran-loved one is not drinking to have this discussion.
Fourth, remind yourself and your loved one that it is up to him or her regarding what he or she decides to do to solve their issues. Communicate this clearly by saying, “I will be happy to help, but I realize that what you do to solve the problem is up to you; it is not for me to make that decision for you. I am willing to help you in whatever way I can, if you like.” This step is key—push-back to your insistence to go to treatment can be minimized by taking this stance and sticking with it. Remember, you can push someone to accept your solution by using an ultimatum, but it rarely leads to a sincere effort to change or to focus on self-improvement.
Separate efforts to improve an intimate relationship (marriage or dating relationship) from getting treatment. Relationship counseling is sometimes seen as a “back door” to individual treatment when one is in an intimate relationship with a Veteran who has been struggling: “If I can get him/her to go with me to a therapist, maybe after I few sessions I can drop out so he/she can continue with the therapist.” This rarely works. Suggest couple or relationship counseling only if you want this for yourself and want to ask for some changes within the relationship for your own sake. Efforts to smooth the way for your significant other into individual therapy by starting as a couple first may backfire. Individual therapy may be a positive side effect of couple therapy, but only if the effort to seek relationship treatment is sincere. The request of one’s partner for relationship counseling is clearest and most effective if it sounds like this message: “I would like us to get some help for our relationship. I will be happier and I think we will be happier. I do recognize that you have a choice in the matter, but it is very important to me. And whether you get individual treatment, of course, is entirely up to you.”
Recognize when there are risks to safety that require a different approach and/or crisis care. Personal safety of all involved is the most important health issue. If you feel that safety and the well-being of the Veteran you care about is at-risk, such as indication that your loved one is thinking about harming themselves or others, seek help. The Veterans Crisis Line (800-273-8255, press #1) can provide immediate help in determining whether there is a crisis and dealing with it. If you are feeling personally threatened, are physically harmed, or have been forced to behave the way your relationship partner wants you to behave, you can call the National Domestic Violence Hotline (800-799-7233).
You can get free help in working with the Veteran you are concerned about by calling a VA service called Coaching Into Care (888-823-7458). Coaching Into Care is a telephone-based service that helps family members or friends of Veterans learn to talk to a Veteran about seeking mental health care. The mission of Coaching Into Care is to educate, support and empower family members and others who are close to a Veteran to understand and support that Veteran in his or her desire to recover from challenges associated with military service. Callers will reach a Coaching Into Care staff member who gather background information about the callers concerns, provide some resources about those specific concerns, and help the caller determine the priority of their needs. If the caller is having difficulty discussing treatment needs with their Veteran-loved one, often the caller will receive telephone-based “coaching” from a social worker or psychologist to learn communication methods that might be more effective. There are no set limits on the number of coaching sessions provided the caller. If there are other family members or supporters of that Veteran who might have a better basis for discussing treatment with the Veteran, then coaching sessions can involve that person also. When needed, referrals are also to the friends and family member callers for their own treatment needs, but the work with Coaching Into Care primarily concerns the treatment needs of the Veteran. Supporters of Veterans from all service eras call the service, but the most frequent caller is reaching out about a Veteran of the wars in Iraq and Afghanistan. Call (888) 823-7458 or go to this website: www.va.gov/coachingintocare.
Close family members and friends of Veterans are often in good position to help a Veteran with the difficult decision to seek mental health care. Although it is important for these supporters to recognize that seeking care is a matter of personal choice, being a positive supporter for a Veteran who is struggling with this decision can make a remarkable difference.
email@example.comSteven L. Sayers, Ph.D., has been a clinical research psychologist at the CPL Michael J Crescenz Veterans Affairs Medical Center (Philadelphia) since 2000, where he directs the national VA service called Coaching Into Care (www.va.gov/coachingintocare). He is also Associate Professor of Psychology in the Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania. He has published over 70 articles, chapters, and books focused on the role of family members and other social supports in mental and physical health. In 2008 he presented testimony to the U.S. Senate Committee on Veterans Affairs regarding his research with Veterans and their family members.
Elbogen, E. B., Wagner, H. R., Johnson, S. C., Kinneer, P., Kang, H., Vasterling, J. J., . . . Beckham, J. C. (2013). Are Iraq and Afghanistan veterans using mental health services? New data from a national random-sample survey. Psychiatric Services, 64(2), 134-141. doi: 10.1176/appi.ps.004792011
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. doi: 10.1056/NEJMoa040603
Kim, P. Y., Thomas, J. L., Wilk, J. E., Castro, C. A., & Hoge, C. W. (2010). Stigma, barriers to care, and use of mental health services among active duty and National Guard soldiers after combat. Psychiatric Services, 61(6), 572-588. doi: 10.1176/appi.ps.61.6.582
Sayer, N. A., Friedemann-Sanchez, G., Spoont, M., Murdoch, M., Parker, L. E., Chiros, C., & Rosenheck, R. (2009). A qualitative study of determinants of PTSD treatment initiation in veterans. Psychiatry: Interpersonal and Biological Processes, 72(3), 238-255. doi: 10.1521/psyc.2009.72.3.238
Spoont, M. R., Nelson, D. B., Murdoch, M., Rector, T., Sayer, N. A., Nugent, S., & Westermeyer, J. (2014). Impact of treatment beliefs and social network encouragement on initiation of care by VA service users with PTSD. Psychiatric Services, 65(5), 654-662. doi: 10.1176/appi.ps.201200324
Vogt, D., Fox, A. B., & Di Leone, B. A. L. (2014). Mental health beliefs and their relationship with treatment seeking among U.S. OEF/OIF veterans. Journal of Traumatic Stress, 27(3), 307-313. doi: 10.1002/jts.21919