Is it realistic to think that we can ever truly end the stigma against seeking professional behavioral health care? It’s a question that I’ve heard and asked myself for years as I’ve watched efforts to improve help-seeking behavior within the military. To their credit, I believe efforts by the Department of Defense since the early 2000s has made an incredible difference in Service members’ willingness to seek professional help when they are struggling.
But there is still a stigma - much less than previously but there at some level nonetheless. No amount of effort, insightful ideas, and proactive support seems to change that. It’s a common introductory script with patients – they would have come in sooner, knew there was a problem, etc., but didn’t because they didn’t want to look “broken”, “crazy”, or otherwise insufficient in the eyes of others or themselves. The more I talk with patients about stigma, the stronger my belief is that we will never truly do away with behavioral health treatment stigma because instead of treatment focusing on “what I am”, like in medicine, it focuses on “who I am”… a situation much more intimate, and threatening. “What I am” and “who I am” are related of course, but it is easier to separate the physical “what” from personality and self-identity. “What” can change, and while having an impact on how I see myself, I can more easily adjust aspects of my self-image a lot or a little to meet changes in physical realities. I could have my femur fractured and sticking out of my leg. While painful, it is easy to view it as an injury to my physical body, separate from my identity and how I define myself at the core. Even if part of my identity is as an athlete and those abilities are dramatically changed by the fracture, my personality, memories, and beliefs are still generally intact and for the most part unthreatened.
What is it we seem to fear when it comes to seeking help for who we are or have become? I think it is judgement – being judged and found wanting or deficient somehow in who we are as a person. This is especially true when problems, and subsequent judgements, are linked to choices we made. People are rarely negatively judged for being born without an arm. But they are judged if this is caused by driving while intoxicated. Even if the judgement swings in the direction of no-fault on the person, there is still the resulting pity to cope with. It is human nature to evaluate self, others and circumstances then draw conclusions. Because this is innate in humans, anxiety, fear, and stigma around judgements cannot be avoided.
No one likes to admit that change is needed, especially when change means admitting mistakes or less than optimal behavior. True, people seeking behavioral health treatment know that something in their life isn’t working well. But while they may be willing to admit and address this aspect, the uncertainty of what else may be uncovered, analyzed, and possibly found wanting can be too much to face. Pull a thread…. It may unravel more deeply into my concept of self than I want.
I have spent my entire professional life (outside of school practicums) working with the military or military-connected population. Not having worked outside of this, but knowing how different and group-based the military culture is, I wonder if stigma against mental health treatment is stronger for these individuals. There is a strong military cultural aversion to being seen as damaged or “not able to handle things.” One must be physically and mentally fit. The alternatives are to be ousted from the military, losing the cultural in-group status, employment, etc. or to be allowed to stay in as someone who isn’t able to fully meet expected standards (aka “broken” in military terms). Or, worse yet, being less-than-optimal and creating circumstances that lead to the death of others or another bad outcome.
For those of you reading this and thinking how existential this discussion could get, you aren’t wrong. The whole differentiation between “who” and “what” and how we define ourselves is probably a discussion that could occur on many levels around many topics. For this topic, though – behavioral healthcare stigma – I think it is an important to acknowledge that humans do make some type of separation between their physical being and internal experience/self-identity. I know that “what I am” physically is going to change. I even agree that “who I am” as evidenced by life experiences will also change. But the core of who I am, my personality, how I remember my past, and how I see the world is different. To change this means too much unknown. It is frightening, regardless of how much I may know it is needed.
So how do we handle this as providers? I’m don’t know what the larger answer is. For myself, I continue to normalize stigma and acknowledge with it is much more threatening and frightening, and takes much more courage, to have their “who” examined and challenged than their “what.”
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Debra Nofziger, Psy.D., is a Military Behavioral Health Psychologist and certified Cognitive Processing Therapy Trainer with the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. Located in San Antonio, TX, she develops, maintains, and conducts virtual and in-person training related to military deployments, culture, posttraumatic stress, and other psychological and medical conditions Service members and veterans experience.