In the wake of Kate Spade’s and Anthony Bourdain’s suicides last month and the news surrounding their deaths, I can’t help but wonder if stigma about getting mental health care may have deterred these talented individuals from seeking the help they deserved. These tragic events also led me to rethink stigma and its impact on Service members and Veterans.
To catch up on this topic, I read the article entitled, Stigma and Mental Health Utilization in Military Personnel: A Review of the Literature (2017) by Michalopoulou, Welsh, Perkins & Ormsby (https://doi.org/10.1080/21635781.2016.1200504). After initial searches and applying certain criteria, the researchers included 29 primary studies from June 2000 to June 2015 in their review on stigma and attitudes about mental health conditions, mental health treatment and seeking help in military samples. Importantly, the authors wanted to examine possible differences in military subgroups’ endorsement of stigma and help seeking, so they included studies on active duty personnel, Reserve and National Guard members, and Veterans. They also looked at demographic characteristics such as ethnicity and gender, as well as types of mental health problems, to see if these variables were related to stigma and help seeking.
The authors focused on two general categories of stigma found in the literature: 1) external or public stigma, which refers to the views of other people and 2) internal or self-stigma, which refers to self-perceptions, beliefs, and attitudes (Murphy & Busuttil, 2014; Murphy, Hunt, Luzon, & Greenberg, 2014). Only studies that used quantitative or qualitative methods and systematically assessed stigma ratings scales and/or semi-structured interviews with military samples were included in the review.
Below are some of the key findings that Michalopoulou et al. found. It’s worth reading the full article for their complete results.
- Overall, it was positive that the researchers found a reduction in public stigma about seeking mental health care and an improvement in its utilization over the period of the Iraq and Afghanistan wars. However, public stigma remains higher in military versus civilian samples.
- With respect to the active duty component and public stigma, the researchers found that military unit leaders sometimes perceived military members who seek mental health services as weak and malingering (Zinzow et al., 2013), which is something we’ve heard before. On the other hand, it was promising to learn that active duty members were more willing to seek mental health care when leadership was supportive (Adler et al, 2015), which makes sense. Also, it was interesting that reports of public stigma were unrelated to the use of mental health services (Adler et al., 2015; Momen et al., 2012).
- In terms of personal stigma, active duty members reported that being diagnosed with a mental illness was associated with negative feelings like feeling embarrassed, weak, or crazy (Zinzow et al., 2013). Also, characteristics such as self-reliance and the desire to problem solve independently were found to hinder help seeking (Adler et al., 2015; Momen et al., 2012). These findings are consistent with what we hear from military members and not surprising.
- The researchers found that members of the Reserve and Guard were concerned how their unit leaders and peers would perceive them and worried about appearing weak, similar to their active duty counterparts. They also were concerned that if they sought mental health services, this information would appear in their military records. Thus even though this subgroup of individuals sometimes receives mental health services from the civilian sector and may be less involved in military life than their active duty peers, they seemed to share similar attitudes about getting help.
- In the review, Veterans were also identified as reporting significant self-stigma about mental health disorders and mental health treatment (Conner et al., 2010). According to Vogt and colleagues (2014), Veterans’ personal mental health views impeded getting care more than their concerns about public stigma.
- The researchers found inconsistencies in the literature regarding self-stigma and ethnicity. For example, in some studies there were higher levels for Whites (Vogel, Wade, & Hackler, 2007), while in others there were higher rates in minority groups (Conner et al., 2010).
- The authors noted few differences in public stigma when comparing men and women (Adler et al., 2015). However, they found that men had stronger endorsements of self-stigma and perceived more barriers to care than women (Conner et al., 2010; Osorio, Jones, Fertout, & Greenberg, 2013; Skopp et al., 2012; Visco, 2009). These findings are consistent with gender differences found in civilian samples (MacKenzie, Gekoski, & Knox, 2006) and not unexpected.
- Similarly, the researchers did not identify age-related differences in stigma and help seeking. I thought that older (and perhaps wiser) Service members and/or Veterans would report less stigma – for example, they may be more able to recognize the benefits of getting care – as compared to less seasoned, younger military members, but this was not supported in the review.
- While research has shown that most people who screen positive for a mental health problem don’t pursue help (e.g., Quartana et al., 2014), Michalopoulou et al. wanted to see if the type of problem mattered. To address this question, they looked at the studies in their review and discovered that PTSD was the disorder most commonly measured. In fact, several of the studies examined the relationship between PTSD symptom severity and service utilization. They found that Service members who reported higher degrees of PTSD were more likely to endorse stigma (Osoria et al., 2013), which is not surprising. The reviewers also mentioned that reduced help-seeking efforts may be associated with PTSD because of factors including the negative association between PTSD and weak perceptions of social and unit support (Blais, Renshaw, & Jakupcak, 2014) and the severity of avoidance symptoms themselves (Ouimette et al., 2011).
- Depression was the second most examined disorder found in the studies. The researchers note an interesting finding in which depressive symptoms were positively associated with both public stigma and help-seeking intentions. They underscore that determining how or whether the type of mental health problem impacts stigma has been overlooked and needs to be studied further.
Among other things, Michalopoulou et al. recommend enhancing how we conceptualize and measure stigma; using clearer definitions and terminology and undertaking larger studies that would enable a closer look at potential subgroup differences within the military, particularly regarding leadership support and unit cohesion. Also, they stress that most published articles have examined public stigma (e.g., using the Stigma and Barriers to Care Scale) and logistical barriers, but not studied self-stigma, which is obviously different from public stigma.
After reading this article, I am left pondering how we can help make seeking mental health services more acceptable to military members across subgroups and branches. It’s clear we have a long way to go in reducing stigma, but here are some ideas:
- Efforts to integrate mental health care into primary care settings are one part of the solution and underway.
- Another piece of the equation is providing better education to military leadership, military-connected individuals, and their families that dispels myths about mental health problems.
- Additionally, given the incongruity between our traditional mental health culture and the warrior ethos/military culture, we may want to promote more strengths-based psychological interventions and military-consistent approaches that take into account the military context and mindset.
- Furthermore, we need to continue to be flexible in how we provide mental health services and use more online tools and apps including virtual reality technology that are associated with less stigma.
- It may help to more proactively expand who helps provide certain types of mental health support and involve more medical staff, chaplains/clergy, peers, and family members depending on the circumstances.
- Finally, we can clarify how mental health services are reported in the military record and correct misunderstandings that some military personnel have about this practice.
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.
Dr. Paula Domenici, Ph.D., is the Director of Civilian Training Programs at the Cetner for Deployment Psychology at Uniformed Services University of the Health Sciences in Bethesda, MD.