IMPACT OF SELF-STIGMA ON SOLDIERS MENTAL HEALTH CARE ...

Running head: IMPACT OF SELF-STIGMA ON SOLDIERS MENTAL HEALTH CARE

DOES SELF-STIGMA INHIBIT MENTAL HEALTH HELP-SEEKING IN THE U.S. ARMY? THE ROLE OF RANK, GENDER AND YEARS OF SERVICE IN PREDICTING MENTAL HEALTH HELP-SEEKING INTENTIONS _______________________ A Doctoral Dissertation Presented to School of Psychology Touro University Worldwide Los Alamitos, CA 90720

______________________ In Partial Fulfillment of the Requirements for the Degree Doctor of Psychology in Human and Organizational Psychology _______________________ by Mohamadou Amar

IMPACT OF SELF-STIGMA ON SOLDIERS MENTAL HEALTH CARE

March 2016 © Mohamadou Amar 2016

Keywords: Veterans, Mental Health, Stigma, Self-Stigma, PTSD

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IMPACT OF SELF-STIGMA ON SOLDIERS MENTAL HEALTH CARE COMMITTEE MEMBERS Committee Chair: Timothy J. Legg, PhD Adjunct Faculty School of Health & Human services Touro University Worldwide Committee Member: Marie Gray, PhD Psychology programs Touro University Worldwide Committee Member: Christopher Ewing, PhD General Studies, Business and PsyD Programs Touro University Worldwide

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ABSTRACT Over 2.5 million US service members have served in the campaign in Afghanistan known as Operation Enduring Freedom (OEF) and the campaign in Iraq known as Operation Iraqi Freedom (OIF). Among those returning from OEF and OIF, 17% have developed significant psychological problems. It is reported that only a quarter of those affected can be reasonably be expected to seek mental health treatment. Stigma is often cited as the main reason for underutilization of mental health services by soldiers. This research examined the effect of self-stigma on military service members’ decision to seek mental health treatment and analyzed the relationship between the decision to seek treatment and a number of demographic variables. This quantitative study used a sample of 59 student US Army officers attending the Command and General Staff Officers’ Course (CGSOC). Hypotheses for research questions were evaluated using multiple regression analysis to test the statistical significance of the relationship between service members’ rank, gender, years of service, number of deployments and time deployed, self-stigma, and willingness to seek help for mental health concerns. Results showed no significant relationship between the demographic variables and service members’ self-stigma and their willingness to seek care for mental health issues.

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Dedication To the loving memory of my mother and father, who embedded in me the most precious of all treasures, the gift of Faith. To my wife and children who tirelessly supported me during this journey. To all who have suffered throughout history because of ignorance and to the victims of stigma. To my brothers in arms, past and present, members of the United States Armed Forces.

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IMPACT OF SELF-STIGMA ON SOLDIERS MENTAL HEALTH CARE ACKNOWLEDGMENTS First and Foremost I would like to thank God for guiding me on this journey. I would like to take this opportunity to acknowledge everyone who has contributed to the completion of my doctoral dissertation. To the best chair, one can hope for, Dr. Timothy Legg, for his unwavering support and guidance throughout this process. I also want to thank my committee members, Dr. Marie Gray and Dr. Christopher Ewing, for their unswerving support during the past two years, without them this work would not have been possible. I would like to thank all the military personnel who participated in this study. I express my gratitude to the US Army Combined Arms Center (CAC) for allowing me to conduct my data collection at CGSC. I gratefully acknowledge the generous assistance of Dr. David Bitters during my statistical analysis. I would like to thank Dr. Ed Edens (US Army Behavioral Science Researcher) for his mentorship, Mr. Rich McConnell (DTAC Instructor at US Army CAC) for his support and coaching, Mr. Wilcox and Mr. Porter for allowing me to complete this dissertation during “the best year of my life” at CGSOC. Lastly, I want to thank all my brothers in arms of the United States Armed Forces. I hope this research will contribute to improving the well-being of the service members.

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TABLE OF CONTENTS ABSTRACT ...................................................................................................................................iii DEDICATION ............................................................................................................................... iv ACKNOWLEDGMENTS ............................................................................................................... v LIST OF TABLES ......................................................................................................................... vi CHAPTER 1: INRODUCTION .................................................................................................... 11 Problem Statement............................................................................................................. 16 Purpose of the Study .......................................................................................................... 18 Research Questions and Hypotheses ................................................................................. 19 Theoretical Framework ..................................................................................................... 20 CHAPTER 2: BACKGROUND AND LITERATURE REVIEW ................................................ 22 The concept of stigma ....................................................................................................... 22 Process of mental health stigmatization ........................................................................... 24 Self-Stigma ........................................................................................................................ 30 History of mental health in the military ............................................................................ 32 Mental illness among OIF/OEF veterans .......................................................................... 34 Post-traumatic Stress Disorder .......................................................................................... 35 Traumatic Brain Injury ...................................................................................................... 37 Mental health issues related to non-combat exposure ....................................................... 40 Suicide in the military ....................................................................................................... 42 Military cultural values and beliefs ................................................................................... 43 Veteran healthcare utilization ............................................................................................ 45 Public perception of veterans with mental health issues ................................................... 46


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Consequence of Untreated Mental Illness ......................................................................... 48 CHAPTER 3: METHODOLOGY ................................................................................................. 51 Instrumentation .................................................................................................................. 52 Literature of the Instrumentation ....................................................................................... 52 Self-administered Online Survey ...................................................................................... 56 Participants and Selection Criteria .................................................................................... 56 Sample Size: Power Analysis ............................................................................................ 57 Data Collection .................................................................................................................. 58 Variables ............................................................................................................................ 59 Data Analysis..................................................................................................................... 60 Research Question and Hypotheses................................................................................... 61 Ethical Consideration ........................................................................................................ 63 CHAPTER 4: RESULTS .............................................................................................................. 66 Purpose .............................................................................................................................. 66 Research Questions and Hypotheses ................................................................................. 66 Data Collection .................................................................................................................. 68 Descriptive Statistics and Preliminary Analyses ............................................................... 68 Inferential Results .............................................................................................................. 68 Summary............................................................................................................................ 72 CHAPTER 5: INTERPRETATION OF FINDINGS, AND RECOMMENDATIONS ................ 79 Interpretation of the Findings ............................................................................................ 81 Theoretical Foundation ..................................................................................................... 85 Limitations ......................................................................................................................... 85


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Ethical Issues ..................................................................................................................... 88 Implications ....................................................................................................................... 89 Recommendations for Future Studies ............................................................................... 89 Conclusion ......................................................................................................................... 90 REFERENCES .............................................................................................................................. 92 APPENDIX A: CONSENT FORM............................................................................................. 115 APPENDIX B: SURVEY QUESTIONNAIRE .......................................................................... 117 APPENDIX C: FREQUENCIES ................................................................................................ 120 APPENDIX D: ANOVA POST-HOC ........................................................................................ 122 APPENDIX E: DEPARTMENT OF DEFENSE ADMINISTRATIVE REVIEW .................... 134


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LIST OF TABLES Table 1. Statistical Power in Relation to Effect and Sample Size ................................................. 58 Table 2. Definition and Description of Variables ......................................................................... 64 Table 3. Demographic Data ............................................................................................................. 69 Table 4. Means and Standard Deviations of ATSPPHS-SF for Gender ....................................... 70 Table 5. Means and Standard Deviations of ATSPPHS-SF for Rank ........................................... 70 Table 6. Means and Standard Deviations of ATSPPHS-SF for Years of Service ........................ 70 Table 7. Means and Standard Deviations of ATSPPHS-SF for Number of Deployments ........... 70 Table 8. Means and Standard Deviations of ATSPPHS-SF for Time Deployed .......................... 70 Table 9. Means and Standard Deviations of SSOSH for Gender .................................................. 71 Table 10. Means and Standard Deviations of SSOSH for Rank ................................................... 71 Table 11. Means and Standard Deviations of SSOSH for Years of Service ................................. 72 Table 12. Means and Standard Deviations of SSOSH for Number of Deployments .................... 72 Table 13. Means and Standard Deviations of SSOSH for Time Deployed................................... 72 Table 14. Kruskal-Wallis for Gender (Dependent variable: ATSPPH-SF)................................... 74 Table 15. Kruskal-Wallis for Rank (Dependent variable: ATSPPH-SF) ...................................... 74 Table 16. Kruskal-Wallis for Years of Service (Dependent variable: ATSPPH-SF).................... 74 Table 17. Kruskal-Wallis for Number of Deployment (Dependent variable: ATSPPH-SF) ........ 74 Table 18. Kruskal-Wallis for Time Deployed (Dependent variable: ATSPPH-SF) ..................... 75 Table 19. Regression Analysis Summary for Predictor (ATSPPH-SF) ........................................ 75 Table 20. Kruskal-Wallis for Gender (Dependent variable: SSOSH) ........................................... 76 Table 21. Kruskal-Wallis for Rank (Dependent variable: SSOSH) .............................................. 77


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Table 22. Kruskal-Wallis for Years of Service (Dependent variable: SSOSH) ............................ 77 Table 23. Kruskal-Wallis for Number of Depoyments (Dependent variable: SSOSH) ................ 77 Table 24. Kruskal-Wallis for Time Deployed (Dependent variable: SSOSH).............................. 77 Table 25. Regression Analysis Summary for Predictor (SSOSH) ................................................ 78 Table 26. Regression Analysis Summary for Predictor (ATSPPH-SF) ........................................ 79

IMPACT OF SELF-STIGMA ON SOLDIERS MENTAL HEALTH CARE CHAPTER 1: INTRODUCTION After more than ten years of continuous combat in Afghanistan and Iraq, over 2.5 million US service members have served in the campaign in Afghanistan known as Operation Enduring Freedom (OEF) and the campaign in Iraq known as Operation Iraqi Freedom (OIF) (Wood, 2012; Tan, 2010). Among those returning from OEF and OIF, 17% have developed significant psychological problems, including post-traumatic stress disorder (PTSD) (Hoge et al., 2008). Since 2001, service members returning from Afghanistan and Iraq accounted for 18.5% to 42.7% of the reported mental disorders according to multiple studies reviewed by Seal, Cohen, Metzler, Gima, Bertenthal, Maguen, and Marmar (2010). While the Army and other branches of the military make treatment available for both combat and non-combat related mental health problems, many military service members do not use the offered services to treat their mental health symptoms (RAND, 2014). Research also shows that the stigma of mental illness in the military remains high despite Department of Defense’s (DoD) anti-stigma efforts (Hodge, 2010; Miggantz, 2013). The DoD’s anti-stigma programs include, but are not limited to: the $2.7-million DoD-wide campaign focused on decreasing stigma by inviting ordinary service members to share their stories of seeking help; the anti-stigma initiative called the Real Warriors Campaign to highlight stories of successfully treated service members; the Marine Corps’ Operational Stress Control and Readiness (OSCAR) program that attempts to bridge the gap between mental health science and the art and science of military operations by embedding mental health professionals in infantry regiments, logistics groups and air wings to help in early detection and treatment of combat stress; and the integration of psychology into primary care settings across all services to improve

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IMPACT OF SELF-STIGMA ON SOLDIERS MENTAL HEALTH CARE patient access to skilled behavioral health services. The DoD has also mandated the PostDeployment Health Reassessment (PDHRA) Program for all service members returning from operational deployment in order to identify and address health concerns, with specific emphasis on mental health. The PDHRA program aims to better identify service members who are suffering from post-traumatic stress, depression and alcohol problems, and refer to specialty care (Miggantz, 2013). The PDHRA is a comprehensive health screening tool that measures service members’ answers on a standard questionnaire to identify military personnel in need of medical care and identifies the need for provision of immediate and future care (Bliese, Wright, Adler, Hoge, & Prayner, 2005).

A study conducted by Williamson and Mulhall (2009) reported that half of the veterans who have served in OIF and OEF are suffering from PTSD, but only a quarter of those affected can be reasonably expected to seek mental health treatment. This means that out of the 2.5 million US service members who served in OEF and OIF (Wood, 2012), an estimated 937,500 service members who likely have mental health problems will not seek treatment. Stigma associated with breaking the military’s cultural norms regarding seeking care for mental health conditions and the potential reprisals accompanying that action is often cited as the main reason for underutilization of mental health treatment by soldiers (DoD, 2008; Vogel, Wade, & Hackler, 2007). Stigmas associated with mental illness appear to be widely accepted by the general public (Corrigan, 2000). Although public stigma is not limited to mental illness, research suggests that stigma is more severe for persons with psychiatric conditions. One reason is that people with mental illness are often believed to be in control of their illness and responsible for causing their mental health conditions (Corrigan et al., 2000). Individuals with diagnosed mental illness are frequently considered as less competent (Corrigan &

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IMPACT OF SELF-STIGMA ON SOLDIERS MENTAL HEALTH CARE Kleinlein, 2005; Pescosolido et al., 1999); and such discriminatory views may have a negative impact on the individual’s self-perception. Corrigan (2004) identified two types of stigma associated with mental health: public stigma and self-stigma. Public stigma refers the general population’s perception that a person who seeks mental health services is undesirable or socially unacceptable (Vogel, Wade, & Haake, 2006; Corrigan & Waston, 2002). Such views about people with mental illness disorder may lead to discriminatory and stereotypical behaviors. For example, workers with mental illness are less likely to be hired and landlords are less likely to lease them apartments (Corrigan & Waston, 2002; Farina et al., 1974). These commonly held stereotypes about people with mental illness may have a negative impact on the individual’s self-perception (Link, 1987). A stigmatized individual may internalize their perceptions of discrimination, considering themselves as socially unacceptable, which can lead to self-stigma; a reduction in self-esteem or self-worth of the person seeking psychological help (Vogel et al., 2006). Research has hypothesized that stigma may be a barrier to mental health treatment-seeking among military service members (RAND, 2014). Studies show that patients have reported that a PTSD diagnosis is stigmatic in communities or occupations that promote strength and resilience, such as the military, as others saw them as weak or having failed (Hall et al., 2013). Service members diagnosed with PTSD worry about being viewed as weak, their leaders regarding them less positively, and that the diagnosis may undermine peer confidence if they seek help (Hoge et al., 2004; Kim et al., 2010). In an effort to reduce stigma associated with PTSD diagnoses and increase treatmentseeking, military leaders have recently advocated to the American Psychiatric Association (APA) to change the “D” for disorder in PTSD to “I” for injury (Army 2020,

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IMPACT OF SELF-STIGMA ON SOLDIERS MENTAL HEALTH CARE 2012). The APA board of trustees voted to retain the word “disorder” in the term “posttraumatic stress disorder” (PTSD).The fact that military leaders have tried to change the diagnostic label from PTSD to PTSI (“I” for injury) underscores the stigma associated with being diagnosed with PTSD (Hooyer, 2012). The military argues that changing PTSD to PTSI could “...reverse over 40 years (since Vietnam) of stigma associated with combat-related PTS “I” [PTSD] among America’s veteran population,” (Army 2020, 2012, pp. 25). Public and self-stigma can both prevent military personnel from seeking treatment for adverse mental health symptoms (Greene-Shortridge, Britt, & Castro, 2007). McFarling and colleagues (2011) argue that the U.S. military’s cultural norms include group cohesion and individual strength in coping with military related stressors. These two components are critical to maintain a unified fighting force. However, their enforcement may also foster divisions between service members perceived as fit for duty and others perceived as too weak to handle the stressors of military service. Therefore, seeking care for mental health conditions is stigmatized as a “weak” act and is seen as violating the military’s cultural norms (Gibbs et al. 2011; Kirke 2010; McFarling et al., 2011). Service members who have mental health problems struggle not only to cope with their symptoms, but also deal with the stigma associated with seeking treatment (Majette, 2013). For many of those service members this negative stigma is one of the reasons they do not seek treatment for mental health problems (Corrigan & O'Shaughnessy, 2007). This stigma is a barrier for military service members accessing mental health care (Rüsch, Angermeyer, & Corrigan, 2005; Kim et al., 2011). The fear of the negative stigma associated with being diagnosed with a mental health disorder can have a significant impact on whether military service members seek

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IMPACT OF SELF-STIGMA ON SOLDIERS MENTAL HEALTH CARE treatment (Pietrzak, Johnson, Goldstein, Malley, & Southwick, 2009). Self-stigma may lead some military service members with mental health symptoms to hide or otherwise attempt to minimize their psychological disorder to avoid seeking treatment and being labeled as weak (Seal et al., 2010; Vogel et al., 2007). Public data available at the Army’s Mental Health Advisory Team (MHAT) show that more than half of military service members returning from Iraq and Afghanistan believed they would be treated differently by their leadership if they sought mental health services (OSMF-I & OTSG, 2006; Hoge et al., 2004). Those who screened positive for mental health symptoms were found to be twice as likely as those without such symptoms to express concerns about stigma (Hoge et al., 2004). Additionally, the study's surveys show that more than half of military service members with psychological health issue believed they would be perceived as weak by their leaders and members of their unit if they sought treatment for their issues (Hoge et al., 2004; OSMF-I & OTSG, 2006). While some service members are seeking mental health care, research suggests a difference among military service members seeking treatment for mental health symptoms based on gender and rank (Majette, 2013). Cohen et al. (2010) suggested gender and military rank are factors associated with soldiers’ utilization of mental health care for a mental disorder and that lower ranking enlisted members are more likely to seek treatment for a mental health symptoms than military officers. There is a paucity of literature surrounding stigma associated with mental illness among US military service members. Moreover, military rank (Miggantz, 2013) and gender as factors have not been included in enough studies to adequately examine its relationship to self-stigma and mental health care seeking behaviors (Wright, Craig,

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IMPACT OF SELF-STIGMA ON SOLDIERS MENTAL HEALTH CARE Campbell, Schaefer, & Humble, 2006). Recent studies have assessed stigma-reduction strategies, identified programmatic strengths, and measured gaps in DoD efforts to reduce stigma and increase mental health care utilization among the military services and the effectiveness and the extent to which these efforts align with service members’ needs or evidence-based practices (RAND, 2014). These studies suggest there is a need for additional research and evaluation to more fully understand barriers to seeking mental health care among military service members and which barriers most affect treatment initiation and success. This study explored the relationship between military rank, gender, number of deployment, time deployed and the internalized stigma (or self-stigma) associated with seeking mental health services among military members to help address this gap. Problem Statement In the military, self-stigma may prevent many military service members from seeking treatment for mental health symptoms. Military personnel returning from deployment have experienced a high rate of psychological stressors that can lead to mental health problems, yet only 25% of them seek mental healthcare treatment (Kehle et al., 2010; Williamson and Mulhall, 2009). Despite the DoD’s efforts to reduce stigma and increase mental health care utilization, many service members are reluctant to seek treatment for fear of being labeled as mentally ill and the potential negative impact to their career of having a mental health diagnosis on record (Nash et al., 2009). Previous studies suggested that mental health care services for military service members differ by gender, but that variable alone cannot provide an adequate picture of mental health utilization (Chatterjee et al., 2009).

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IMPACT OF SELF-STIGMA ON SOLDIERS MENTAL HEALTH CARE As the largest medical healthcare provider for the military, the Department of Veteran Affairs (VA) has mainly focused its medical services on providing mental health care to male veterans. The reason for this is that men constitute the largest portion of the overall military population and have traditionally experienced the most exposure to combat. However, the decade-long conflict in Iraq and Afghanistan and changes in a battlefield environment that recognizes no ‘front lines’, have contributed to an increase in combat exposure among women (Patten & Parker, 2011). This trend may increase the rates of women who suffer from PTSD or other non-trauma-related mental health problems (e.g., depression, serious mental illness). These changes have raised concerns about lack of adequate healthcare in the VA health system for women (Chatterjee et al., 2009; Fontana & Rosenheck, 2006; Frayne et al., 2007), despite research findings that women are more likely to seek help for mental issues (Moller-Leimkuhler, 2002), and have better attitudes toward counseling than men (Fischer & Farina, 1995). One reason for this misconception is the traditional male-gender stereotype of being independent and in control along with a societal expectation of stoicism and self-sufficiency. Men, themselves, associate greater stigma with seeking mental help (Hammen & Peters, 1977; Angermeyer, Matschinger, & Riedel-Heller, 1999). Consequently, men with mental illness might experience a greater sense of failure if they seek counseling. This feeling would make seeking mental health therapy particularly difficult, as it may mean admitting to a lack of self-sufficiency which could in-turn degrade self-efficacy beliefs leading to a loss of self-esteem (Addis & Mahalik, 2003). This is consistent with a study conducted in college settings by Vogel and his colleagues (2006) with findings that men experience greater self-stigma than women.

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IMPACT OF SELF-STIGMA ON SOLDIERS MENTAL HEALTH CARE Purpose of Study The purpose of this study was to explore the relationship between rank, gender, years of service, number of deployments and time deployed of service members and the internalized stigma (or self-stigma) associated with the desire to seek mental health services. Leadership in the US Army is granted to individuals based on of assignment to positions of responsibility and is a function of rank and experience (Army Doctrine Reference Publications (ADRP) 22-6, 2012). The higher ranking the service member is, the more is expected of him or her in terms of elements of the military culture such as inner strength, self-confidence, and the ability to shake off injury (Burnam et Al., 2009). Despite the importance of rank and years of service, these factors have not been included in enough studies to examine their relationship to mental health care utilization in the military. The current study examined the relationship between service members’ rank, gender, years of service, number of deployment, time deployed and their self-stigma related to: (1) willingness to seek mental health services, (2) the moderating effects of self-stigma on care seeking behaviors, and (3) the predictive factors associated with service members’ rank, gender, year of service, number of deployments and time deployed and his or her willingness to seek mental health care. This study also determined if potential relationships exist

among variables such as self-stigma, rank, gender, and years of service, number of deployments and time deployed, and if so, which variables are most influential in

predicting military service members’ help-seeking attitudes toward mental health services. The results of this study can help US DoD policymakers and clinicians identify causes and develop specific treatment plans to help educate and counsel military personnel who experience self-stigma.

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IMPACT OF SELF-STIGMA ON SOLDIERS MENTAL HEALTH CARE Research Questions and Hypotheses The aim of this study was to assess for presence of self-stigma among service members and to determine the relationship between self-stigma and patterns of mental health seeking behaviors. Additionally, the study explored the relationship between service members’ self-stigma associated with seeking mental health services, and the five factors, rank, gender, years of military service, number of deployments and time deployed. Finally, the study explored those variables that will predict whether or not services for mental health issues will be sought by service members in need of such services and whether or not selfstigma serves as a barrier to seeking such services. The overarching research questions that

guided this study are as follows: Research Question 1: What is the relationship between rank, gender, years of military service, number of deployments, time deployed and service members' willingness to seek care for mental health issues? Research Question 2: What is the relationship between military rank, years of service, number of deployments, time deployed and measured levels of self-stigma? Research Question 3: What is the relationship between measured levels of selfstigma associated with mental illness and the decision to seek mental health care services? The hypotheses for these research questions are:

Hypothesis for Research Question 1: Ho: There is no relationship between military rank, gender, years of service, number of deployments and time deployed on service members willingness to seek care for

mental health issues.

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IMPACT OF SELF-STIGMA ON SOLDIERS MENTAL HEALTH CARE Ha: There is a relationship between military rank, gender, years of service, number of deployments and time deployed on service members willingness to seek care for mental

health issues. Hypothesis for Research Question 2: Ho: There is no relationship between rank, gender, years of service, number of deployments, time deployed and measures levels of self-stigma.

Ha: There is a relationship between rank, gender, years of service, number of deployments, time deployed and measures levels of self-stigma.

Hypothesis for Research Question 3: Ho: There is no relationship between the measured levels of self-stigma and the decision to seek mental health care. Ha: There is a relationship between the measured levels of self-stigma and the decision to seek mental health care. Theoretical Framework The theoretical foundation that underpinned this study is Link’s modified labeling theory, developed by Link and Colleagues (1989). According to the theory, negative consequences of labeling are induced by non-adaptive coping responses. Link et al. (1989) argued that an individual with a mental illness may develop negative beliefs from the public perception about what it means to be a person with a mental illness, in addition to beliefs about how the people with mental illness are viewed and treated by society. The mentally ills' self-efficacy is thus negatively impacted by a mental illness label. Individuals with mental illness start to fear uncontrollable negative reactions, and begin to act in a way that fosters rejection. This rejection impairs self-esteem. A person with

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IMPACT OF SELF-STIGMA ON SOLDIERS MENTAL HEALTH CARE mental illness can react by secrecy, withdrawal, or preventively educating others about his/her mental illness. This, in turn, can lead to either the persistence of an existing disorder or the development of a different one (Link et al., 1989). An individual who fears being stigmatized may not reveal his/her mental illness treatment to others because of the fear of being rejected by them. Therefore, if a person with a mental illness decides to enter treatment, he or she will likely focus on the stigma because of the negative societal beliefs about mental illness, which may become internalized (self-stigma), which, in turn, may impact access to services or to actual treatment (Link, 1987).

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IMPACT OF SELF-STIGMA ON SOLDIERS MENTAL HEALTH CARE CHAPTER 2: BACKGROUND AND LITERATURE REVIEW The Concept of Stigma Despite general agreement among researchers as to what stigma is, there is a lack of clarity on how the concept is defined (Smith, 2002; Papadopoulos, 2009). Perhaps it is due to the fact that stigma represents a complex interaction between social science, politics, history, psychology, medicine and anthropology (Smith, 2002). Many researchers do not explicitly define the concept of stigma and fail to differentiate it from related constructs such as stereotypes (Stafford & Scott, 1986; Link & Phelan, 2001). Depending on their discipline and research focus, scholars use different operational definitions for stigma. This renders the distinct components of stigma indistinguishable, creating discourse on specific aspects of stigma and their relation to one another ambiguous (Sayce, 1998). For instance, many social psychologists treat stigma as a social cognitive process that explains the process of stereotyping and discrimination (Crocker et al., 1998; Corrigan, 2004), while sociologists treat stigma as a stressor, studying its impact on stigmatized individuals (Link & Phelan, 1999). In his classic work examining of the concept of stigma, Goffman (1963) described stigma as those attributes that disqualify someone from full social acceptance by society. A person’s stigma “makes him different from others in the category of persons available for him to be, and of a less desirable kind” (Goffman 1963, p. 3). Stigma highlights the difference between a person’s “virtual social identity,” which refers to the general public’s assumptions about a particular individual, and their “actual social identity,” which refers to that individual’s innate attributes. Further, Goffman (1963) argued that stigma reflects any attribute which discredits a particular person and can lead to assumptions about the person’s character

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IMPACT OF SELF-STIGMA ON SOLDIERS MENTAL HEALTH CARE and abilities, often leading to discrimination. Many contemporary scholars have offered definitions that bear some degree of similarity to Goffman’s (1963) definition. For example, the idea that stigma dehumanizes and reduces the social value of an individual because he or she is seen as being “marked,” flawed, and less than average (Dovidio et al, 2000). Crocker, Major, and Steele (1998) argued that stigma is “the possession (or belief that one possesses) some attribute or characteristic that conveys a social identity that is devalued in a particular social context.” Similarly, Stafford and Scott (1986) define stigma as “a characteristic of persons that is contrary to a norm of a social unit.” Some scholars, like Goffman and later social psychological theorists such as Jones et. al (1984), Link et. al (1984; 2004), and Deaux et. al (1995), have developed frameworks for examining stigma. For example, Goffman (1963) noted three large classes, or categories of stigma: abominations of the body (e.g. physical deformities); blemishes of individual character (e.g. weaknesses or defects of individual character), and tribal stigma or tribal identities (e.g. race, religion, gender, etc.). Jones et. al (1984) defined six dimensions that predict the strength of stigma which included: 1. Concealability, which indicates how obvious or detectable the attribute/behavior is to others; 2. Course, which indicates the expected long term result associated with the attribute/behavior, and whether the stigmatizing condition is reversible over time; 3. Disruptiveness, which is an indication of the degree to which activities of everyday life is impeded. For example, the public’s interaction with the mentally ill may be disruptive because of a fear others have about the mentally ill's unexpected behavior (Link et. al, 2004);

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IMPACT OF SELF-STIGMA ON SOLDIERS MENTAL HEALTH CARE 4. Aesthetics, a reflection of the physical appearance of the person who has the stigmatizing attributes; 5. Origin, which is a reference to the perceived responsibility for the attribute/behavior, that is, how the condition came into being; and, 6. Peril, refers to the degree to which the attribute/behavior is dangerous to others (i.e. risk and threat of contagion). Deaux and colleagues (1995) built upon Jones et. al's (1984) research to demonstrate through empirical evidence that the dimensions central to the process of stigma are; 1. Peril, or the perceived danger of the stigma; 2. Concealability, or the visibility of the stigma; and 3. Origin of the mark, or the individual’s responsibility for the existence of the stigma. The concept of stigma have been applied to a wide range of attributes in minority groups in which a particular characteristic or a number of characteristics differ from the majority. One such group are those individuals diagnosed with mental illness. Mental illness stigma manifests itself in two ways that can be harmful to the wellbeing of people with mental illness: public stigma and self-stigma (Corrigan & Watson, 2002). Process of mental health stigmatization (public stigma) Many researchers have explained the process of stigmatization using terms that describe people’s attitudes and behaviors with respect to stereotypes, prejudice, and discrimination (Link et al., 1997; Link & Phelan, 2001; Sartorius, 2002; Corrigan & Watson, 2002; Corrigan, 2004; Corrigan, Powell & Rüsch, 2012). Social psychologists have explained the process of stigmatization as starting from the general public holding

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IMPACT OF SELF-STIGMA ON SOLDIERS MENTAL HEALTH CARE stereotypes that turn into prejudice and discrimination. Corrigan (2004) developed a model that attempts to explain the mental health stigma process into four social cognitive processes: cues, stereotypes, prejudice, and discrimination. This model seeks to conceptualize the evolution of the stigma process as a staged process from cues, to stereotypes and ultimately to prejudice. The process leads to discrimination which is the behavioral reaction against the stigmatized individual. The first component of the stigma process is cues. Cues signal symptoms of the mentally ill to the public. Corrigan (2004) identified four cues: psychiatric symptoms, social skills deficits, physical appearance, and labels. The first three cues are related to mentally ills’ psychiatric symptoms, their socialskills deficits, and their physical appearance. The psychiatric symptoms and social-skills deficits include detachment from reality (delusions), paranoia or hallucinations, trouble understanding or relating to situations and to people, and excessive anger, hostility, or violence. Physical appearance can also yield stigmatizing responses from the public. These cues may not always be readily apparent to the public. In fact, Goffman (1963) identified two types of stigmatized groups: the discredited and the discreditable. The discredited group has an apparent physical trait that cannot be concealed from others. For example, ethnic groups or physically impaired individuals with an apparent physical trait obvious to the public. By contrast, discreditable groups can conceal their condition; they have no readily manifest mark that differentiates them from the general public. The public cannot determine whether or not they are mentally ill just by looking at them. In fact, many mentally ill individuals are able to conceal their mental illness symptoms without others being aware. Conversely, potential misattribution by the public of someone as mentally ill based of these three cues, such a people with eccentric behavior

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IMPACT OF SELF-STIGMA ON SOLDIERS MENTAL HEALTH CARE unrelated to mental illness, is possible. Another misconception is that people with poor personal appearance and/or unintelligent people are more likely to be mentally ill, when well-kept or intelligence people can be afflicted as well. Therefore, if the absence of these three cues yield a false negative, their presence can yield a false positive as well, which leads us to the fourth cue: label (Corrigan, 2004, p. 615). Individuals with mental illness are commonly labeled as a result of their appearance, behavior, treatment, and/or socioeconomic status (Scheffer, 2003). Labeling subsequently leads to the stigmatized person being marginalized, isolated and discriminated against by non-stigmatized groups in society (Clinard and Meier, 1992). Once cues are present, they elicit stereotypes about the mentally ill. The second component of the social cognitive processes is stereotype (Corrigan, 2004). A stereotype is a mental image or an exaggerated belief generalized about a group of people which assumes that whatever is believed about a group is typical for the entire group, regardless of actual variation among group members (Farley, 2000, p. 19). Stereotypes play a key role in the devaluation of stigmatized individuals and pose an obvious threat to the psychological and social well-being of the stigmatized (Dovidio et al. 2000). Perhaps the most common stereotype about the mentally ill is that they are violent, dangerous, incompetent, and weak minded (Corrigan & Kleinlein, 2005; Cardwell, 1996; Link et al. 1997; Sartorius, 2002). When people believe and act on the basis of their held stereotypes they become prejudiced which is the third element of the social cognitive process. While stereotype is a belief, prejudice is a mental evaluation: a tendency to over-categorize certain individuals based on their affiliation with a particular group (Corrigan, 2004; Farley,

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IMPACT OF SELF-STIGMA ON SOLDIERS MENTAL HEALTH CARE 2012). Endorsement of bad stereotypes leads to prejudicial attitudes which in turn can lead to discriminatory behaviors. Discrimination is the fourth and final element of stigmatization process (Corrigan, 2004). Discrimination leads to the perception of in-groups and out-groups. In-group bias creates negative feelings and unfair treatment for others simply because the in-group members have categorized others as the out-group (Corrigan, 2004). An important distinction to note is that although stigma is linked to stereotypes, prejudice and discrimination. These social cognitive processes are not components of stigma; but the results of it. Research has shown an inverse relationship between perceived public stigma and care seeking (Rost et al., 1993; Hoyt et al., 1997; Cooper et al., 2003; Nadeem et al., 2007). This has raised concerns about the association between public stigma and the unwillingness of persons with mental illness to seek treatment from psychological distress (Leaf et al., 1987; Kessler et al., 2001; Meltzer et al., 2003). In addition to the public/social context of stigma discussed above an important point to consider for this study is the institutional context of stigma (structural stigma). Research has defined institutional stigma as the results of the policies of private and governmental institutions that either intentionally or unintentionally impede treatment opportunities or options for people with mental illness (Corrigan and O’Shaughnessy, 2007; RAND, 2008). Service members repeatedly report believing that their military careers will suffer if they seek psychological services. They believe that seeking care will lower the confidence of others in their ability, threaten career advancement and security clearances, and possibly cause them to be removed from their unit (U.S. DoD Task Force on Mental Health, 2007).

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IMPACT OF SELF-STIGMA ON SOLDIERS MENTAL HEALTH CARE Service members who seek a security clearance that allows them to serve in national security positions are required to fill out the National Security Positions Questionnaire (Standard Form 86 (SF-86)). Question 21 of the SF-86 form requires anyone seeking a security clearance to disclose any mental health counseling they have received in the past seven years and to allow security clearance investigators access to health records and permission to conduct personal interviews regarding the specific details related to mental health treatment. The DoD has taken positive steps in the continuing effort to reduce the stigma often associated with seeking professional mental health assistance and mental health treatment alone can no longer be the basis of denial of an interim security. The DoD has also approved a revision of Question 21 on the SF-86. The revision now excludes counseling related to marital, family, grief issues and sexual assault. This decision should lessen concerns that psychological or behavioral health counseling may jeopardize security clearance or adversely impact careers (DoD, 2012). Despite these efforts to address the issue related to Question 21 of SF-86, there are numerous other DoD policies that contain mixed messages. For example, the Deployment Limiting Psychiatric Conditions policy issued in November of 2006, is another policy that adversely affects service members with mental health illness. The policy requires that service members be stable for three months on their medication before deploying. Otherwise, they need a waiver submitted to the applicable Combatant Commander (the Four-Star General leading the Geographic Combatant Command) (DoD, 2006). This policy has the good intention of preventing service members with mental illness from being pulled from psychiatric hospitals and sent to the battlefield. However, it has numerous negative unintended consequences that may lead troops to avoid seeking

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IMPACT OF SELF-STIGMA ON SOLDIERS MENTAL HEALTH CARE mental health treatment. Deployment in the military increases chances of promotion and retention. For example, Army junior enlisted soldiers eligible for promotion will receive two promotion points per month in order to recognize the invaluable experiences gained while deployed in a combat zone. According to the Army, combat experiences shapes overall professional development of soldiers in a positive manner (HRC, 2014; Ritchie, 2007). While trying to prevent the mentally ill who seek treatment from being deployed, the military is also rewarding those who deploy, thus creating a mixed-message in its policy. There are also DoD policies that require disclosure, and command reporting, of mental health treatment of service members. This is another barrier that could be prevented if service members were afforded the same level of confidentiality that is extended to civilians by allowing them to voluntarily seek and receive mental health care. The DoD has mandated reporting of mental health service use by service members in order to determine the readiness of its fighting forces. However, this state of readiness could be determined using other means that protect the privacy of service members by relying more directly on functioning and performance assessment tool (Burman et al., 2009), rather than focusing on the identity of specific individuals seeking mental health care. Stigma is not always related to the public or institutions. Studies suggest that the internalization of public stigma by people with mental illness can lead to self-stigma which harms self-esteem, self-efficacy, and empowerment (Vogel et al., 2010; Corrigan et al., 2012). The process of internalizing public perception may prevent people with mental illness from seeking treatment to avoid being labeled (Corrigan, 2004, Vogel et al., 2010). This leads us to the phenomenon of self-sigma.

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IMPACT OF SELF-STIGMA ON SOLDIERS MENTAL HEALTH CARE Self-Stigma Self-stigma, also referred to as self-devaluation (Goffman, 1963) or as internalized stigma (Thoits, 2011) is the internalization of the negative attitudes such as feelings of guilt, shame, inferiority, and social responses that others people have toward marginalized groups (Corrigan & Watson, 2002; Corrigan & Calabrese, 2005). Selfstigma is believed to occur in mental health when mentally ill individuals or individuals seeking help are labeling themselves as socially unacceptable. In doing so, that person internalizes stereotypes, applies negative public attitudes to himself/herself, and suffers diminished self-esteem and self-efficacy (Corrigan & Shapiro, 2010). Research has shown that individuals who experience self-stigma suffer from reduction in self-esteem (Link et al., 2001; Vogel et al., 2006), self-worth (Vogel et al., 2006) increased depression (Manos, Rusch, Kanter, & Clifford, 2009), negative attitudes toward psychological treatment (Conner et al., 2010), and lower treatment compliance (Fung et al., 2007). Common demonstrations of self-stigma include feeling guilt, shame, inferiority, and limiting integration with others (Corrigan & Watson, 2002; Kranke, Floersch, Kranke, & Munson, 2011). Studies have also shown that individuals who self-stigmatize may avoid seeking psychological services to avoid being labeled as having a mental illness (Link et al., 2001). This is because people may see themselves as inferior, inadequate, or weak if they seek counseling services for mental illness (Fisher, Nadler, & Whitcher-Alagna, 1982; Nadler & Fisher, 1986). Moreover, those who associate seeking help with greater self-stigma are less willing to return for subsequent sessions (Wade et al., 2011). Therefore, self-stigma plays a powerful and unique role in the attitudes the

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IMPACT OF SELF-STIGMA ON SOLDIERS MENTAL HEALTH CARE mental ills have toward seeking psychological services (Vogel et al., 2013). Corrigan and colleagues (2002; 2006) proposed a regressive model of self-stigma that consists of four stages of successive, interrelated steps. According to Corrigan and colleagues (2002; 2006), self-stigma’s starting point is the mentally ill person’s awareness of the stigma associated with mental illness and the negative stereotypes other people espouse (stereotype awareness). The next step is the mentally ill’s personal agreement with the stigma and stereotypes associated with mental illness (stereotype agreement, agree) then self-application which is the mentally ill person’s application of these stereotypes to himself/herself (self-concurrence, apply) and finally the mentally ill person suffers from shame and low self-esteem due to application of these stereotypes (harm). Decreased self-esteem is therefore described above as a consequence of selfstigma (Link et al., 2001; Ritsher and Phelan, 2004) and is the final stage of the selfstigmatization process. Research has measured the four stage regressive model of selfstigma in patients with various mental disorders using the Self-Stigma of Mental Illness Scale (SSMI) and has shown good reliability and validity (Wahl, 1995; Corrigan et al., 2006; Rüsch et al., 2006). The SSMI is one of the few validated measures of mental health stigma (or self-stigma). The overwhelming majority of the existing measures of mental health stigma (or self-stigma) were developed but only tested in civilian populations (Corrigan et al., 2012) despite the long history of mental health issues in the military. Military mental health stigma may differ from mental health stigma in the civilian realm by virtue of the significant differences between civilian and military cultures. The main difference resides in the military’s long tradition of warrior ethos that emphasizes discipline, mental toughness, self-sufficiency and desirability of high levels

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IMPACT OF SELF-STIGMA ON SOLDIERS MENTAL HEALTH CARE of mental health to successful mission execution (Skopp et al., 2012). This brings up the importance of reviewing the history of mental health in the military. History of Mental Health in the Military Mankind's earliest literature that reported development of chronic psychological symptoms caused by witnessing death that occurred during wars or other combat related stress was recorded by the Greek historian Herodotus. Herodotus chronicled the presence of chronic mental symptoms caused by battlefield trauma in his account of the battle of Marathon written in 440 BC, (History, Book VI, transl. George Rawlinson). The phenomenon of combat stress has been well-documented as a consequence of war (RAND, 2008) with past names such as “vent du boulet” syndrome during the French Revolutionary wars, “battle hypnosis” or “shell shock” in 1914 (Milian, 1915), “soldier’s heart,” and “battle fatigue” represent a variety of terms used to describe the psychological wounds incurred during battle (Crocq & Crocq, 2000). The risk of mental health conditions among military service members clearly increases during wars and conflicts. Likewise, the demand for mental health services among military members is greater during times of conflict (Milliken, Auchterlonie, & Hoge, 2007; Rosenheck & Fontana, 1999; Marlowe, 2001). The U.S. military has monitored the incidence of psychological casualties since as early as World War II (RAND, 2008). Jones (1995) explained that in the beginning of the World War II, American planners opted for psychiatric screening of service members prior to their draft in order to avoid potential psychiatric casualties. There were no provisions for psychiatric treatment units to be embedded in combat divisions as they believed that those individuals who had mental health/illness issues were excluded from combat. The idea of having forward

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IMPACT OF SELF-STIGMA ON SOLDIERS MENTAL HEALTH CARE psychiatric treatment units did not materialize until the campaign of North Africa in 1943. When advised by the psychiatrist Frederick Hanson, Army General Omar N. Bradley issued a directive to establish a holding period of 7 days for psychiatric patients with the initial diagnosis of “exhaustion” at the 9th Evacuation Hospital (Glass, 1973). The term “exhaustion” was chosen to avoid patients being stigmatized. The term was thought to convey the least implication of neuropsychiatric disturbance. This innovative initiative turned out to be critical to retaining a fighting force resulting in 50% to 70% of psychiatric casualties able to return to combat. The admissions for neuropsychiatric causes was 43 per 1,000 per year for the total overseas forces in 1944 (Crocq & Crocq, 2000). Studies of the Korean War show an estimated incidence rate for psychological casualty of 37 per 1,000 for deployed troops (Dean, 1997; Jones & Palmer, 2000). During the Vietnam War, the military implemented treatment for psychiatric casualties in the area closer to the “frontline” of the battle with a correspondingly low level of acute psychiatric casualties, occurring at a rate of 11.5 per 1,000 men per year during the conflict (Crocq & Crocq, 2000). In spite of the careful prevention of psychiatric casualties in Vietnam, however, the late effects of combat exposure in the form of PostTraumatic Stress Disorder (PTSD) were a significant source of suffering and disability among returning Vietnam veterans (Belenky, 1987). Out of almost 2.6 million military personnel who served in Vietnam from 1964 to 1973, 700,000 required some form of psychological treatment. The post-Vietnam era witnessed an increase number of veterans diagnosed with the combat stress syndrome that ultimately led to the adoption of PostTraumatic Stress Disorder (PTSD) by the American Psychological Association (APA) in the Third Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III,

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IMPACT OF SELF-STIGMA ON SOLDIERS MENTAL HEALTH CARE 1980). PTSD was introduced to describe an individual’s reaction to a traumatic event (Friedman, Resick, & Keane, 2010). It seems puzzling that it took three decades for the DSM to include the term PTSD after a category of so-called “gross stress reaction” existed in DSM-I when it was first published in 1952, though later abandoned in the later DSM-II in 1968, the year of the Communist Tet Offensive in Vietnam (Crocq & Crocq, 2000; Friedman, Resick, & Keane, 2010). Mental illness among OIF/OEF veterans The campaign in Afghanistan (OEF) and Iraq (OIF) are the first major ground combat operations undertaken by the U.S. military since the war in Vietnam. Improvised Explosive Devices (IEDs) were the emblems of insurgencies in both conflicts and the number one cause of casualties, injuries, and emotional disorders; particularly PTSD and traumatic brain injury (TBI) for service members. The number of U.S. military members affected by PTSD and TBI has been higher than noted in other wars (Bender, 2009b). The insurgent nature of the Iraqi and Afghan conflicts combined with advances in medical technology and battlefield care has resulted in fewer deaths but more wounded warriors compared to Vietnam resulting in an increase in the number of veterans with both visible and invisible wounds. The intensity of these combat operations also raised many concerns about their effect on the mental health of deployed service members (Hoge et al., 2014). A study conducted before the Iraq and Afghanistan conflicts found that each year at least 6% of all active duty service members receive treatment for a mental health disorder (Hoge et al, 2002). A more recent study conducted by Hoge and Colleagues (2014) estimated the risk of major depression, PTSD, or alcohol misuse for service members with very high level of combat action to be higher post-deployment

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IMPACT OF SELF-STIGMA ON SOLDIERS MENTAL HEALTH CARE particularly with regard to PTSD. Additional studies suggest that frequency and intensity of service members’ involvement in combat operations increase the risk of developing chronic PTSD and associated mental health problems (Litz, 2005). Hoge and Colleagues (2014) have found a direct correlation between the prevalence of PTSD and the number of firefights in which a soldier had been engaged during the conflicts. These results were very similar among service members returning from Iraq and Afghanistan, suggesting that location did not play a factor in the prevalence of PTSD (Hoge et al., 2014). However, evidence suggests that combat operations in Iraq were more intense compared to those in Afghanistan (Litz, 2005; Hoge et al., 2014). Consequently, a study in early stage of the war found that the estimated risk for PTSD from service in the Iraq War (18%) was higher than the estimated risk for PTSD from the Afghanistan War (11%) (Hoge et al., 2004). Post-traumatic Stress Disorder According to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV), PTSD may begin within 6 months following exposure to an extremely traumatic event; events in which death was threatened or actually occurred. PTSD can be delayed and begin more than 6 months after the traumatic event but the symptoms usually appear shortly after exposure (North et al., 1999; American Psychiatric Association, 2000) and last more than a month (Rutherford et. al, 2013). Critical symptoms of PTSD include mentally re-experiencing the traumatic event, avoidance of situations associated with the trauma, numbing of general responsiveness, and ongoing increased arousal that did not exist before the traumatic event (American Psychiatric Association, 2000). The fifth edition of the APA’s Diagnostic and Statistical Manual of

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IMPACT OF SELF-STIGMA ON SOLDIERS MENTAL HEALTH CARE Mental Disorders (DSM-5) published in May, 2013, revised the PTSD diagnostic criteria to increase the specificity of the diagnosis, making it easier to meet the criteria for a diagnosis of PTSD. For example, Criterion A (prior exposure to traumatic events) is no longer limited to the requirement that people experience extreme fear, helplessness, and horror at the time of a traumatic incident. Criterion A is more specifically worded to include disaster, accident, fire, exposure to hazardous chemicals, combat or experience in a war zone, physical or sexual assault, witnessing physical or sexual assault, unexpectedly witnessing dead bodies or body parts, threat to life or serious injury to or violent death of a close friend or family member, or exposure to repeated accounts of traumatic events or images primarily because of occupational exposure. In Criterion C, the evaluation of a person’s emotional response at the time is deleted. Now Criterion C focuses solely on avoidance of behaviors or of physical or temporal reminders of the traumatic experiences. The new Criterion D puts emphasis on adverse alterations in cognition and mood associated with the traumatic events. It is important to note that the DSM-5’s changes should not adversely affect the case frequency of PTSD or the factors associated with the diagnosis substantially (APA, 2013; VA, 2014; Rutherford et. al, 2013). PTSD has been shown to be widespread among soldiers returning from combat (Tanielian & Jaycox, 2008). Soldiers who suffered from severe physical symptoms were most likely to have PTSD and depression at four and seven months post-injury (Grieger et al., 2006). Feelings of fear, helplessness, horror, distress, anger, and detachment make daily life an intense struggle for veterans with this disorder (Corrigan & Cole, 2008). PTSD is often accompanied by depression and anxiety disorders, substance-use disorders, sleep disturbances, and increased risk of suicide. Marital problems, parenting difficulties,

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IMPACT OF SELF-STIGMA ON SOLDIERS MENTAL HEALTH CARE and family-adjustment issues have also been associated with PTSD (Rutherford et. al, 2013). While the APA was deliberating on the content of its Fifth Edition of the DSM-5, senior U.S. Army leadership proposed changes to the labeling of PTSD (Sagalyn, 2011a; Sagalyn, 2011b; Jaffe, 2012). Some military leaders believe the word “disorder” is stigmatizing for soldiers diagnosed with PTSD symptoms. Those soldiers then become reluctant to seek help. The Army leaders urged the APA to replace “disorder,” the ‘D’ in PTSD, with “injury” and changing the name of the diagnosis to post-traumatic stress injury, a description that it is less stigmatizing and that, they believed, would encourage more U.S. military service members suffering from symptoms to access care. After arguments were made, the APA decided to retain the word “disorder”. Some attendees at the 2012 APA Annual Meeting believed that it was the military culture, not the name of the disorder, that needed to change in order to make mental health care more accessible to service members and encourage them to seek treatment in a timely fashion (RAND, 2013). PTSD increases comorbidity of other psychiatric disorders, conversely, other disorders increase the likelihood of PTSD. Information gathered from OIF and OEF injuries indicated that TBI, PTSD, and depression co-occur (Rutherford et. al, 2013). For those reasons it become important to review certain conditions associated with TBI. Traumatic Brain Injury Traumatic Brain Injury (TBI) is one of the “signature” injuries of the wars in Iraq and Afghanistan (Altmire, 2007) and has become a major focus of military medicine during the hostilities (Hoge et al., 2008). The Department of Defense (DoD) and the Department of Veterans Affairs (2009) define TBI as a traumatically induced structural

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IMPACT OF SELF-STIGMA ON SOLDIERS MENTAL HEALTH CARE injury and/or physiological disruption of brain function as a result of an external force that is indicated by new onset or worsening of at least one of the following clinical signs, immediately following the event, such as: •

Any period of loss of or a decreased level of consciousness;

•

Any loss of memory for events immediately before or after the injury;

•

Any alteration in mental state at the time of the injury (confusion, disorientation, slowed thinking, etc.);

• Neurological deficits (weakness, loss of balance, change in vision, praxis, paresis/plegia, sensory loss, aphasia, etc.) that may or may not be transient; • Intracranial lesion. The external forces include but are not limited to the following events: the head being struck by an object, the head striking an object, the brain undergoing an acceleration/deceleration movement without direct external trauma to the head, a foreign body penetrating the brain, forces generated from events such as a blast or explosion, or other force yet to be defined. Not all individuals exposed to an external force will sustain a TBI (DOD, 2009). The DoD and the Veterans Brain Injury Center associate 22% of all Iraq and Afghanistan combat casualties to brain injuries, while 12% of combat casualties were attributed to brain injuries in Vietnam (Summerall, 2012). Additionally, research found that 30% of troops actively engaged in combat in Iraq and Afghanistan have suffered at least a mild TBI (Glasser, 2007; Hoge et al., 2007; Hoge et al., 2008). The increased of reported TBI injuries are largely attributable to the unconventional nature of the conflicts in Iraq and Afghanistan with extensive use of improvised explosive devices (IEDs) by enemy combatants (RAND, 2008). Research estimates that nearly 40% of all

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IMPACT OF SELF-STIGMA ON SOLDIERS MENTAL HEALTH CARE casualties sustained by U.S. forces in Iraq and Afghanistan conflicts are attributable to IEDs (Brookings Institution, 2007). These TBI injuries are often classified according to severity: mild, moderate, or severe. A mild TBI, often referred as concussion, is the most commonly sustained injury among veterans, and can quickly be resolved within three months of sustaining the injury (Defense Veterans Brain Injury Center, 2009). The moderate to severe TBIs are more serious, and are associated with amnesia, skull fractures, intracranial lesions, and increased unconsciousness. In some cases moderate to severe TBI injuries can lead to death (Thurman, Sniezek, Johnson, Greenspan, & Smith, 1995; Colarusso, 2007). Additionally, moderate to severe TBI is often comorbid with mental health issues such as PTSD, depression, anxiety, substance use disorders (Altmire, 2007; Glazer, 2007; RAND, 2008; Colarusso, 2007; Tanielian and Jaycox, 2008, Corrigan & Cole, 2008), and decline in cognitive functioning (Raymont et al., 2008). A study found that 19.5% of veterans returning from Iraq and Afghanistan reported symptoms of TBI and 7.3% reported symptoms of both TBI and PTSD or depression (MHAT V, 2008). Additionally, the emergence of TBI and PTSD as the signature injuries of the conflicts in Iraq and Afghanistan (Altmire, 2007) and the possibility of comorbidity has required the military health system to apply interdisciplinary approaches to treatments and interventions for both injuries (Hoge et al., 2007; Hoge et al., 2008). In addition, research has shown that veterans have suffered from other mental health issues/problems not related to direct combat exposure such as depression, phobias, substance abuse, impaired social functioning, impaired ability to work, and the increased use of health care services (RAND, 2008; Rosenheck & Fontana, 1999; Prigerson, Maciejewski, & Rosenheck, 2002; Kang, Natelson, Mahan, Lee, & Murphy, 2003).

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IMPACT OF SELF-STIGMA ON SOLDIERS MENTAL HEALTH CARE Mental Health Issues Related to Non-Combat Exposure In addition to TBI, or multiple concussions from combat, many soldiers have experienced non-combat activities-related mental health issues. Many emotions related to being in a war zone, such as separation from loved ones, constant worry about personal safety, and the stressors inherent in multiple and extended deployments can also play a role in service members’ mental health issues (Litz, 2005). After the major combat operations ended in Iraq with the dismantlement of the Iraqi military much of the conflict has involved guerilla warfare defined by more insurgent attacks and terrorist actions from ambiguous unknown civilian threats and so-called green-on-blue attacks which occur when an Iraqi Afghan policeman or soldier fires on coalition forces. This state of chaos, where the enemy is not distinguishable from the civilian population, creates a great deal of concern and adds additional stressors to service members who must consequently remain in a constant state of alertness knowing that every location including military bases pose a potential threat to their life (LaBash et al., 2009). Service members were maintaining the high degree of vigilance necessary to respond cautiously to these threats. Additionally fighting frequently takes place in urban areas around civilians and service members needed to be careful about possibly causing collateral damage to innocent civilians. Service members often remained in a state of constant anxiety and experienced feelings of hyper vigilance (Bender, 2009b; Friedman, 2006; LaBash et al., 2009). These non-combat related stressors encountered by service members while deployed can also play a role in mental health issues, including anxiety, PTSD, and substance abuse. Additional factors like poor diet, lack of sleep, severe weather, and deficient accommodations as well as extensive time away from loved ones, and the disruption of

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IMPACT OF SELF-STIGMA ON SOLDIERS MENTAL HEALTH CARE occupational goals may become severe stressors particularly for national-guard and reserve troops (Litz, 2005; VA, 2010). Another non-combat related stressor worth mentioning is the Military Sexual Trauma (MST). During deployment military members live together in a confined space of the base creating more chances for sexual assault and greater trauma if a victim must live with his or her assailant (Frayne et al., 1999). There is some evidence that the stress of war is associated with an increase in the perpetration of sexual assault and sexual harassment also known as Military Sexual Trauma (MST) with both male and female soldiers at risk for this type a victimization. However, women service members represent the majority of victims. Perl (2009) cited a 2004 study that found the rates of female veterans who reported they have experienced sexual assault while seeking medical care through the VA to range from 23% to 29% (Perl, 2009), while 1.1% of male veterans reported having experienced MST (Kimerling, Gima, Smith, Street, and Frayne, 2007). Between 2003 and 2008, the prevalence of MST obtained from VA screening programs numbered 48,106 women and 43,693 men. These numbers may be similar in size despite the lower prevalence of MST among men because VA treats so many more men than women (Hyun et al., 2009). It is also important to note that these data speak only to the rate of MST among Veterans who have chosen to seek VA health care and do not represent an estimate of the actual rates of sexual assault and harassment experiences among all individuals serving in the U.S. Military. MST is strongly associated with PTSD (Davis & Wood, 1999; Kang, Dalager, Mahan & Ishii, 2004) and its effects are long-lasting (Sadler, Booth, Nielson & Doebbeling, 2000). MST increases victims’ risk of physical and mental health problems, including substance abuse, depression, and dissociative disorders including PTSD (Chang, Skinner & Boehmer,

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IMPACT OF SELF-STIGMA ON SOLDIERS MENTAL HEALTH CARE 2001; Davis & Wood, 1999; Frayne et al., 1999; Kimerling et al., 2007; Sadler et al., 2004; Suris et al., 2004). Military sexual trauma can also lead to poor self-image, feelings of loneliness and isolation, and ultimately suicide (Kimerling et al., 2007; Skinner et al., 2000; Zinzow et al., 2008). Suicide in the military Historically, the suicide rates in the military have been lower than those rates found in the general population. However with the wars in Iraq and Afghanistan the military suicide rates have been increasing and by 2008 exceeded the demographicallymatched civilian rate (20.2 suicide deaths per 100,000 vs. 19.2 in the civilian population) (Schoenbaum et al., 2014; Goode, 2009). There are important differences in suicide rates between the military and the civilian population. The military veterans account for only 10% of U.S. adults, but represented roughly 20% of suicides in 2008 (US Bureau of Census, 2008). In addition, suicide rates among VA patients are 43 per 100,000 for male and 10 per 100,000 for female, compared to 23 per100,000 for civilian men and 5 per 100,000 women (Kaplan, 2012). The VA Office of the Inspector General reported in 2007 that 6,000 veterans die by suicide every year. Studies have associated the rising rates of suicides to numerous factors such as frequent deployments, hostile living environment, extreme stress, death of a loved one, financial troubles, military sexual assault, previous suicide attempts, and combat exposures and injuries (National Suicide Prevention Lifeline, n.d.; Navy Personnel Command, 2008; Tanielian & Jaycox, 2008; Zinzow et al., 2008). According to the Army Study to Assess Risk and Resilience in Service members (Army STARRS), the increase in veterans’ deaths linked to suicide from 2004 to 2009 occurred not only in soldiers who experienced deployment, but also in

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IMPACT OF SELF-STIGMA ON SOLDIERS MENTAL HEALTH CARE soldiers who never deployed. Army STARRS also indicated that soldiers reported higher rates of mental disorders than civilians, including attention deficit hyperactivity disorder (ADHD), intermittent explosive disorder (recurrent episodes of extreme anger or violence), and substance abuse disorder. The study also found that being deployed for women increased suicide risk more than it did for men. Nevertheless suicide risk continued to be lower for deployed women than for deployed men (Schoenbaum et al., 2014). Research found that the Army and the Marine Corps, which are the two main ground forces involved in the fighting in OEF/OIF have higher suicide rates than in any of the other services (Jelinek, 2009). Despite being a concerning health problem, the root causes for the rise in Army suicides still remain unknown. The Department of Defense has taken steps to increase suicide prevention efforts. In 2009, while focusing on existing prevention programs the Army widened its suicide prevention efforts to help identify potential protective factors and foster the development of novel efforts to reduce suicide and suicidal thoughts. This included the October, 2009 introduction of its comprehensive Soldier Fitness Program in Basic Training that places the same emphasis on mental and emotional strength as the traditional military culture that puts emphasis on physical strength (McElroy & Oberst, 2014). Military cultural values and beliefs The negative stigma associated with seeking mental healthcare in the military may be related to issues unique to military culture. The U.S. military promotes a culture that values strength, resilience, courage, and personal sacrifice (Bryan & Morrow, 2011). “Army Strong,” “The Few, The Proud,” “Do Something Amazing,” and “A Global Force for Good,” are some of slogans used by the U.S. military to instill an identity of elitism

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IMPACT OF SELF-STIGMA ON SOLDIERS MENTAL HEALTH CARE and superiority that promotes both physical and mental toughness with an emphasis on inner strength and self-reliance in order to “shake off” injury and illness (Tanielian & Jaycox, 2008; Bryan & Morrow, 2011; Lorber & Garcia, 2010). Therefore, it is not surprising for service members who have been explicitly trained to “embrace the suck,” which translates to “the situation is bad, but deal with it,” to consider admitting mental health problems as sign of weakness, and to rule out the idea of seeking treatment for mental illness (Lunasco, et al., 2010; Bryan & Morrow, 2011). Service members fear being labeled as weak if they seek treatment for mental health (PCCWW, 2007a). Such beliefs are in-line with traditional societal conception of the male gender being selfsufficient. This culture of masculinity has largely influenced treatment of mental illness in the military (Hinjosa, 2010; Bryan & Morrow, 2011).It is commonly believed among service members that seeking care for mental health conditions is a sign of weakness (Kirke 2010; Gibbs et al. 2011; McFarling et al., 2011), creating a huge cultural barrier for service members to admit that they need help of any kind (Hoge et al., 2006; Hoge et al., 2007). Consequently seeking mental health therapy becomes particularly difficult for service members as it may mean admitting to the inability to handle one’s own issues and may contribute to a loss of self-esteem (Addis & Mahalik, 2003). The military cultural norms may have an important and unique impact on stigma. Miggantz (2013) cited many factors that can affect military service members’ level of stigma and their willingness to seek mental health treatment. These factors include the attitudes of ranked military personnel, potential reprisal of admitting to mental health issues, and gender. Considering the attitudes of these higher ranking military leaders, it is important to analyze their level of stigma and how they perceive mental health treatment. During past wars service

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IMPACT OF SELF-STIGMA ON SOLDIERS MENTAL HEALTH CARE members suffering from psychiatric symptoms were often treated poorly or even abusively and many times the military described individuals displaying their symptoms as lacking in moral fiber or denigrated them as cowardly as if they were making an attempt to escape military service (Mosse, 2000; Jones, 2006). Similar perceptions are reflected in our modern-day’s military, with service members expressing fears about being labeled as crazy, “gaming the system,” or accused of “malingering” and becoming non-deployable if they seek mental health treatment (Stecker, et al., 2007; Novier, 2007). Veteran healthcare utilization A VA study shows that women with PTSD symptoms or other mental health issues are more likely to seek treatment, compared to women without PTSD symptoms or men, respectively (Dobie, et al., 2006; Mojtabai et al., 2003). To address the growing demand and potential needs of women veterans, research priorities at the Department of Veterans Affairs have an increased emphasis on access, utilization, and quality of care for women veterans, with a focus on post-deployment health (Bean-Mayberry et al., 2010). In 1993, the VA created the Woman’s Stress Disorder Treatment Team (WSDTT) program with specialized services for female veterans. A study funded through the WSDTT program to measure the comfort level of female veterans diagnosed with PTSD in a male dominated environment indicated that women veterans’ level of comfort did not affect their satisfaction with treatment or quality of participation. However, one barrier that prevented service-women from seeking treatment was the unavailability of specialized programs (Fontana & Rosenheck, 2006). This may be due to a lack of knowledge of the VA health system among women veterans. Washington and colleagues (2007) conducted a qualitative study among women veteran users and non-users of the

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IMPACT OF SELF-STIGMA ON SOLDIERS MENTAL HEALTH CARE VA health system on patient preferences and found knowledge gaps about VA eligibility and services. The study shows a general lack of information about VA eligibility and available services among all female veterans and a sense from nonusers that the VA did not provide women veterans with adequate health care. Additionally, there were concerns among women veterans about the VA health system quality and environment. These concerns are believed to lead many women to limit their VA use to women’s clinics. Bean-Mayberry, et al. (2004) found that women veterans are more likely to report excellent satisfaction if they were seen in the women’s clinics as compared to those seen in traditional clinics. Additional research suggested that both women veterans with PTSD and female partners of Vietnam Veterans with PTSD preferred seeking treatment in women’s clinics (Fontana & Rosenheck, 2006; Sherman et al, 2005). The focus on mental health among women in the military remains high, with a continuing emphasis on PTSD and sexual-related trauma. Important studies has been done on women veterans’ mental health conditions in different settings (Bean-Mayberry et al., 2010) but gender alone cannot provide an adequate picture of the military’s mental health utilization (Majette, 2013) and the stigma associated with it. Adding variables such as self-stigma and its relationship with military rank, years of service and number of deployments can reduce the knowledge gap helping researchers and policymakers gain a better understanding of why most veterans are reluctant to utilize mental health services. Public perception of veterans with mental health issues There is an inaccurate public perception of veterans with mental health illness, namely: Post-Traumatic Stress Disorder (PTSD). This misconception is not only detrimental for service members trying to reintegrate back into the civilian work force,

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IMPACT OF SELF-STIGMA ON SOLDIERS MENTAL HEALTH CARE but has made some service members reluctant to seek help. Additionally, PTSD has been linked by some members of the public and the media to the commission of violent crimes by veterans and often used in the defense of convicted veterans even when there is little to no evidence of such a diagnosis (Ousley, 2012; Norman et al., 2014). This misinformation fuels a stigmatizing view from the public about veterans with mental illness, especially the desire for social avoidance and the assumption of dangerousness (Mittal et al., 2013). The high profile trial in February, 2015 of the killer of American Sniper author and veteran Chris Kyle has pushed the problem of PTSD among American troops to the forefront of the public debate. The former Navy SEAL, Chris Kyle, an advocate for veterans' mental health who volunteered to help veterans struggling with PTSD, was gunned down in February, 2013 by Eddie Ray Routh, a veteran who served in Iraq and Haiti, and who apparently suffered from PTSD. Law enforcement officials and the media immediately sought to connect Eddie Ray Routh actions to PTSD or some type of mental illness from his military service (Jervis, 2015). The same rush to judgment happened in the case of the shooting and killing of a Washington state park ranger in early January, 2012 by a veteran, and the Army soldier, Staff Sergeant Robert Bales, who murdered 16 Afghan civilians (Ousley, 2012). However in each of these cases the jury found the defendant guilty despite the PTSD claims presented by the defense during their legal argument (Jervis, 2015; Oulsey, 2012). Unfortunately each of these stories add to the public stigma associated with service members who are trying to reintegrate the public workforce despite strong national advocacy campaigns over the last two decades (Pescosolido et al., 2010). Many employers become reluctant to hire veterans with a combat background due to perceived mental health issues. It is estimated that 6 percent of

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IMPACT OF SELF-STIGMA ON SOLDIERS MENTAL HEALTH CARE employers considered PTSD a significant obstacle to hiring employees with military experience (Society for Human Resource Management, 2010). This is reflected in a recent report released by the VA showing an unemployment rate of 29.1 percent for male veterans ages 18 to 24, compared to 17.6 percent of civilians in the same age group (VA, 2014). Norman et al. (2014) argue that in spite of the public concerns about association of PTSD with an increased risk of violence, individuals with PTSD are not dangerous. In fact, research found no correlation between PTSD and commission of violent acts (O’Brien, 1998, Norman et al., 2014). However, when other factors like substance misuse and comorbid psychiatric disordered are considered, the risk of violence is increased (Management of Post-Traumatic Stress Working Group, 2004; McGuire and Clark, 2011). Therefore, it is important to consider a wide array of risk factors in addition to PTSD in order to understand the relationship between PTSD and violence (Norman et al., 2014). Consequence of Untreated Mental Illness There is a paucity of literature regarding the consequences of untreated mental illness in the military. For this reason, this section first highlights issues regarding untreated serious mental illness in the general public and discusses the particular case of the military mental health issue. Serious mental illnesses (SMI) are characterized by any mental disorder that leads to “substantial interference” with “one or more major life activities” (Kessler et al., 2001, p. 990). Research has shown a relationship between persons with untreated SMI such as schizophrenia and bipolar illness and violence (Lamb & Weinberger, 1998). A review of four surveys conducted on mass shootings that happened in the U.S. between 1999 and 2012 found that approximately half of the mass

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IMPACT OF SELF-STIGMA ON SOLDIERS MENTAL HEALTH CARE killings were perpetrated by individuals with SMI (Hemple et al., 1999; Fessenden et al., 2000; Duwe, 2007; Follman et al., 2012; Blair & Schweit, 2014). Violence committed by individuals with untreated SMI has become increasingly concerning among mental health professionals, policymakers, and the general public. Although uncommon these acts of violence are tragic events (Harrison & Beck, 2006; Jemelka et al., 1993). These episodes of violence are probably related to the increased number of incarcerated mentally ill individuals. A 2007 study by the U.S. Department of Justice (DoJ) found that 56% of state prisoners, 45% of federal prisoners, and 64% of local jail inmates suffer from mental illnesses (DoJ, 2007). Research also shown that 13% of those mentally ill individuals had been convicted of murder. With this percentage it is estimated that more than 26,000 individuals with a mental illness are incarcerated for murder in the United States (Matejkowski et al., 2008). In addition to violence and incarceration, individuals with mental illness are also often victims of homelessness. In the U.S., it is estimated that people with untreated psychiatric illnesses account for one-third, or 200,000 of roughly 600,000 homeless people (Treatment Advocacy Center, 2015). There is an abysmal quality of life associated with being a mentally ill and homeless. A 2014 literature review of 21 studies found that homeless people who have SMI have a 74% to 87% chance of being victimized and a 63% to 90% chance of being arrested during their lifetime (Roy et al., 2014). Research found that 28% of homeless people with previous psychiatric hospitalizations obtained some of their food from garbage cans and 8% used garbage cans as a primary food source (Gelberg & Linn, 1988). Untreated SMI also carries an enormous economic burden that is hard to quantify because it involves both direct and indirect cost. The indirect cost could be said to be incurred through reduced labor supply

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IMPACT OF SELF-STIGMA ON SOLDIERS MENTAL HEALTH CARE and reduced labor force In 2008, this indirect cost is estimated to be $193.2 billion of annual loss to the nation's earnings (Insel, 2008; Kessler et al., 2008). The direct costs of untreated SMI includes Social Security Disability Insurance (SSDI), supplemental cash assistance, food stamps, and federally funded public housing (Kessler et al., 2008; Wang et al., 2005). Research found that untreated mental illness in the military is linked to depression, anxiety, marital problems, sleeplessness, and substance abuse. Often unrecognized in returning veterans, depression manifests itself in incidents of domestic violence and/or other family problems (Sayers et al. 2009; Martinez, 2012; Toscano and Roberts, 2014). If left untreated, the mentally ill veteran is also prone to homelessness, inability to obtain or maintain employment, physical illness, school failure, and/or criminal acts (Sayers et al. 2009). An extreme negative consequence of depression and untreated mental illness can be suicide. Researchers among military veterans found evidence of the so-called contagion effect of suicides within military families which increases the risk of suicide among surviving family members, especially children who view parent as role model, and that’s no less true for a spouse. Therefore, there is a potential risk of suicide for the family members of thousands of service members who have committed suicide (American Foundation of Suicide Prevention, 2013).

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IMPACT OF SELF-STIGMA ON SOLDIERS MENTAL HEALTH CARE CHAPTER 3: METHODOLOGY The purpose of this study was to explore the relationship between rank, gender, years of service, number of deployments, time deployed and the self-stigma associated with the desire to seek mental health services among field grade officers of the U.S. Army. There is a paucity of literature surrounding the potential impact of self-stigma, rank, gender, years of service and number of deployments, time deployed on service members’ desire to seek mental health treatment. Despite the importance of rank, gender, years of service, number of deployments and time deployed these factors have not been included in enough studies to examine their relationship to mental health care utilization in the military. There is also a gap in the literature on self-stigma and its potential negative relationship to veterans seeking treatment (Majette, 2013). This study used a quantitative survey method to determine if potential relationships exist among the predictor variables of self-stigma, rank, gender, years of service, number of deployments and time deployed, and if so, which variables are most influential in predicting the criterion variable, mental health help-seeking attitudes. This section discusses the design of the survey research study including the participants and the methods for recruitment, instruments used to develop the demographic questionnaire, and the statistical techniques used to analyze the collected data. Participants were U.S. Army field grade officers invited using their email addresses to take a web-based survey. The questionnaire asked participants to provide information about their perceptions on receiving mental health counseling, their perceived levels of self-stigma as related to mental health help-seeking, and their attitudes toward seeking professional psychological help. Instruments used to develop the questionnaire are

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IMPACT OF SELF-STIGMA ON SOLDIERS MENTAL HEALTH CARE described in the following paragraphs. Instrumentation The questionnaire first asked a series of demographic questions to gather information about the participants such as rank, gender, years of service, number of deployments and time deployed. The next portion of the questionnaire utilizes the Attitudes Toward Seeking Professional Psychological Help Scale- short form revised (ATSPPH-SF) (Fischer & Farina, 1995) to measure attitudes toward seeking help and the final portion of the instrument is the Self-Stigma of Seeking Help (SSOSH) scale (Vogel et al., 2006), designed to measure self (internalized) stigma for seeking psychological help. The Self-Stigma of Seeking Psychology Help (SSOSH) scale is available in the public domain at https://selfstigma.psych.iastate.edu/SSOSH and is free for use for research purposes. The entire instrument takes about 10-15 minutes to complete. None of the instruments were altered in any way, but were included in the overall research instrument to be answered by each research participant. Literature of the Instrumentation The Attitudes Toward Seeking Professional Psychological Help Scale - short form The Attitudes Toward Seeking Professional Psychological Help Scale - short form (ATSPPH-SF) is a 10-item scale developed by Fischer & Farina (1995) from its longer version, the Attitudes Toward Seeking Psychological Help Scale (Fischer & Turner, 1970) to assess respondents’ attitudes toward seeking professional psychological help (e.g. positive or negative). Fischer and Farina (1995) found in the original development that the ATSPPH-SF correlated at a coefficient of 0.87 to the original 29-item long form,

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IMPACT OF SELF-STIGMA ON SOLDIERS MENTAL HEALTH CARE suggesting that the two are measuring the same construct. The revised scale also correlated with previous use of professional help for a problem (r =.39, p

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