MILITARY MEDICINE, 172, 2; 157, 2007

The Stigma of Mental Health Problems in the Military

Guarantor: Thomas W. Britt. PhDContributors: Tiffany M. Greene-Shortridge, MS, Thomas W. Britt, PhD; LTC Carl Andrew Castro, MSC USA

The present review addresses the perceived stigma associatedwith admitting a mental health problem and seeking help forthat problem in the military. Evidence regarding the publicstigma associated with mental disorders is reviewed, indicat-ing that the public generally holds negative stereotypes towardindividuals with psychological problems, leading to potentialdiscrimination toward these individuals. The intemalizationof these negative beliefs results in self-stigma, leading to re-duced self-esteem and motivation to seek help. Even if soldiersform an intention to seek help for their psychological diffi-culty, harriers to mental health care may prevent the soldierfrom receiving the help they need. An overall model is pro-posed to illustrate how the stigma associated with psycholog-ical problems can prevent soldiers getting needed help forpsychological difficulties and proposed interventions for re-ducing stigma in a civilian context are considered for militarypersonnel.

Introduction

A recent press statement has reported that 30% of troopsreturning home from the Iraq war have experienced some

type of mental health problem; difficulties have usually includedanxiety, depression, nightmares, anger, and inahility to concen-trate.' Additionally, 15 to 17% of troops returning from Iraq in2004 experienced acute stress or post-traumatic stress disorder(PTSD). The most common stressors reported by soldiers andMarines during the war included roadside bombs, length ofdeployment, handling human remains, killing an enemy, seeingdead or injured Americans, and being unable to stop a \1olentsituation.^ More than 90% of soldiers and Marines returningfrom Iraq reported encountering these stressors, with 12% ofthem reporting being wounded or injured. The rates of PTSDamong soldiers and Marines returning from war have been as-sociated with these stressors.^

Although many soldiers experience psychological problemsfrom the stressors encountered in combat, there is a lag ofsoldiers who actually seek help for their difficulties. Britt ex-amined the stigma attached to having a psychological versusmedical problem among service members returning from apeacekeeping mission. All soldiers underwent a mandatoiy psy-chological and medical screening before returning to their homestation. Soldiers who scored above a "cut-off" point on one ormore of the psychological questionnaires (assessing PTSD, de-pression, and alcohol abuse) were required to have a brief inter-view with a mental health professional (e.g., social worker orclinical psychologist), and soldiers who indicated medical symp-

Department of Psychology, Clemson Unlveral^. 418 Brackett Hall, Clemson, SC29634.

The views orpressed in this article are those of the authors and do not necessarilyrepresent the officiaJ policy or position of the Department of Defense or the U.S. ArrayMedical Command.

This manuscript was received for review in January 2006 and was accepted forpublication in June 2006.

Reprint & Copyright ® by Association of Militaiy Surgeons of U.S., 2007.

toms had such an interview with a medical professional (e.g.,nurse or medical doctor). Soldiers reported more discomfort Indiscussing potential psychological problems than medical prob-lems, especially when they were returning with their unit. Inaddition, soldiers reported a lesser likelihood of followingthrough with a psychological referral than a medical referral.^

Similarly, Hoge et al. found that of the soldiers and Martneswho met the crtterta for being diagnosed with a mental healthproblem, only 38 to 45% indicated an interest in receiving help:furthermore, within the previous year, only 23 to 40% reportedactually receiving professional help. The troops who scored pos-itively for a mental health problem were twice as likely thanother troops to report fear of stigmatization and concern aboutbarrters to obtaining psychological help.^

What leads soldiers expertencing psychological problems tonot seek help from a mental health professional? In the presentarticle, we argue that a major factor is the perceived stigmaassociated with admitting a problem and seeking help for thatproblem. Little research has been conducted on the stigma at-tached to admitting a psychological problem in a military con-text. The present article draws from civilian and militaiy re-search to present a model for how the stigma of admitting apsychological problem can prevent soldiers from seeking helpfor these problems. The model is presented in the context of asoldier experiencing symptoms of PTSD and having to decidewhether to admit this problem and seek help for the problem.We consider the public stigma attached to psychological prob-lems and how soldiers may internalize that stigma as a functionof attributions they make for the problem. We also consider theperceived barrters to accessing mental health care. Finally, weexamine potential interventions to reduee the negative conse-quences of stigmatization for help-seeking.

Defining Stigma

In considering the impact of stigma on seeking help for apsychological problem, it is first necessary to define stigma anddistinguish between public stigma and stigma as internalized bythe individual. Corrtgan and Penn'' have defined stigma as anegative and erroneous attitude about a person; it is a prejudiceor negative stereotype. Corrigan and Watson" note the differ-ences between public stigma and self-stigma. Public stigma isthe reaction of the general public toward people with mentalillness, whereas self-stigma is the intemalization of how thegeneral public portrays people with mental illness and the beliefin that portrayal. Although distinct in definition, both publicand self-stigma are composed of stereotypes, prejudice, anddiscrtmination.'' Stereotypes are defmed as knowledge struc-tures that are learned by members of society.^ Stereotypestypically lead to prejudice, where individuals engage in theseknowledge structures and generally hold a negative view of asubpopulation.^ Discrtmination is the behavioral reaction ofprejudice.^

157 Military Medicine, Vol, 172, February 2007

158 Stigma of Mental Health Problems

The Consequences of Societal Stigma

There are three themes reported in the stigma literature withrefiard to beliefs tbe public holds about individuals with severemental illness,"'' The first of the themes is "authoritarianism":individuals with a mental illness are seen as irresponsible andunable to tend for themselves. Tlie second belief is in referenceto "fear and exclusion"; individuals with a mental illness shouldbe feared and restricted from society. Lastly, the public tends tohold a theme of "benevolence" toward people with a psycholog-ical problem. Individuals with mental illnesses are seen as child-like, naive, and innocent.

Admitting a psychological problem such as PTSD can havedelrimenta! societal consequences for an individual. Link et al/used vignettes depicting individuals with psyehiatric conditionsto assess whether the public recognizes mental illness, theirbeliefs about the causes of mental illness, how dangerous peopleare with a mental illness, and the amount of social distancedesired from people with mental illness. The vignettes depictedpeople with schizophrenia, major depressive disorder, alcoholand dmg dependence, and an individual with subclinical prob-lems and worries. Respondents desired the most social distancefrom the cocaine-dependent person, followed by the individualwith alcohol dependence, schizophrenia, major depression, andlastly the troubled person. Nearly half of respondents indicatedthey would be very or somewhat likely to socially distance them-selves from an individual with major depressive disorder.

Corrigan" uses components of attribution theory to explainwhy society tends to stigmatize those with mental health prob-lems. Attribution theory is concerned with understanding howindividuals assign causality for different types of events (e.g., thedevelopment of a mental illness), aiid the consequences of suchattributions for emotional and motivational reactions to thesituation, Weiner et al, found that individuals with psycholog-ical problems were seen as more responsible for their difficultiesthan those with physical problems and that attributions of con-trollability were related to decreased pity and increased angertoward the individual possessing the problem. In examiningprevious research, Corrigan' also found tbat illnesses are usu-ally tinderstood in terms of controllability. Society tends to lookal whether people are responsible for their illnesses and if theyare coping with the illness,** Psychological disorders, as com-pared to physical disorders, are viewed as more controllable."'Furihemiorc. individuals who are seen as responsible for theirdisorder(s) are more likely to be reacted to angrily."-'

Within a military context, service members experiencingsymptoms of PTSD and considering admitting they have aproblem to someone else will likely be aware of public beliefsabout psychological problems, perhaps anticipating negativeconsequences from different individuals (e.g., fellow servicemembers, commanders). If soldiers fear social exclusion be-cause they have symptoms of PTSD, they may forgo seekinghelp due to apprehension about societal stigma. Further-more, soldiers' perceptions of society holding them account-able for their psychological problems may further inhibittreatment seeking. If the soldier comes to personally endorsethe negative beliefs and attributions held by the public, he orshe will experience a stronger sense of self-stigma, the con-sequences of which we now consider.

The Consequences of Self-Stigma

Past research has revealed specific factors that contribute todifferences in levels of treatment seeking and perceived stigma.Cooper et al.'' have reporied findings from two nationwide stud-ies suggesting that 50 to 60% of individuals who could seek helpfor a psychological problem do not. Additionally, Cooper et al,''found that individuals with a mental illness are less likely toseek treatment if they view themselves as being responsible fortheir disorder(s). Mechanic et al.'^ have hypothesized that anindividual with a mental illness may incorporate stigma intoone's sense of self, and, consequently, lower one's self-esteem.This inhibited sense of sell-esteem could lower one's motivationto seek psychological treatment.

Mechanic et al.'^ have also hypothesized that those individu-als with a psychological problem that attribute their condition toa physical, medical, or biological condition will be more satisfiedwith their social relationships and life in general than thoseindividuals who see themselves as being responsible for theirmental illness. Again, it is likely that those individuals whoperceive themselves as responsible for their disorder also per-ceive a greater degree of stigma than those individuals whoattribute their disorder to a cause not under personal control.Mechanic et al.'' conducted telephone surveys with familymembers of people with schizophrenia and also with the clini-cally diagnosed individual. Interview questions pertained to thequality of life, illness attribution, depressive symptoms, andsocial and clinical factors of those with schizophrenia. It wasfound that a higher quality of life was significantly correlatedwith rejecting mental illness as a cause for one's problems.Individuals reporting a higher quality of life also reporied little orno side effects from medication, fewer difficulties in everydayfunctioning, higher self-esteem, more personal control, andhigher family empowerment. Furthermore, quality of life wasfound to be negatively correlated with stigma and depressionsymptoms.

Other variables influencing psychological treatment seekinghave been examined in a military context, Britt et al. '•' examinedthe predictors and consequences of seeking treatment for apsychological problem in a military setting. More than 3,000soldiers completed measures assessing whether they were ex-periencing a psychological problem, the perceived stigma ofseeking help for psychological problems, psyehological distress,and whether they had sought help for a psychological problemand from what source (e,g., military,' mental health professional,civilian medical doctor). The authors also assessed quality ofleadership and the existence of a family friendly unit climate.The stigma of seeking help was negatively related to the reporiedquality of noncommissioned officer leadership and the existenceof a family friendly unit climate, Furthemiore, once psycholog-ical distress was controlled for, among those soldiers who indi-cated they had a psychological problem, those who sought helpfrom either a military or civilian mental health professionalrepori:ed lower perceived stigma than soldiers who did not seekhelp from this source. However, there were no difi erences foundin perceived stigma in seeking help from chaplains or medicaldoctors. Britt e{ al.''' hypothesized that this pattern of resultscould be a function of two factors: (1) perceiving less of a stigmawith seeking help may result in a greater likelihood of seekinghelp for mental health professionals and (2) once soldiers seek

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stigma of Mental Health Problems 159

help from mental health sources and have a positive experience.their perceptions of stigma may decrease.

Winerman" has also reported that men of all ages and eth-nicities arc less likely than women to seek help for depressionand stressful life events, even though men encounter thesestressors just as much or in greater occurrences than women.American Psychological Association President Ronald F. Levanthas also described the difficulties males have as a function ofthe fear of admitting mental health problems.'^ This finding hasimportant implications for the military in that the majority ofsoldiers exposed to combat are males. If men experience greateranxiety when seeking psychological treatment, and thus fail toseek help due to fear, then the numbers reported of individualswith a psychological problem in the military may be vastly un-derrepresented.

The Overall Model

The overall model detailing the process of potential stigmati-zation that a soldier could encounter during the period frominitially being exposed to a traumatic event during war to seek-ing mental health care for possible symptoms of PTSD is pre-sented in Figure 1. Exposure to traumatic events Is a require-ment for diagnosing a soldier as experiencing PTSD." Giventhat 90% of soldiers returning from war have encountered stres-sors such as roadside bombs and handling human remains, itbecomes clear that the great majority of soldiers are exposed totraumatic events while at war. Once exposed to a traumaticevent and symptoms of PTSD begin occurring, soldiers mayencounter a societal stigma within the military culture. Forinstance, some military personnel may begin socially distancingthemselves from soldiers they perceive as having mental healthproblems. These individuals may be uncomfortable around sol-diers with PTSD and perhaps even blame them for the develop-ment of the problem.

If soldiers internalize the stigmatizing behaviors of thosearound them, they will likely develop self-stigma. The develop-ment of self'Stigma has been hypothesized to lower one's self-esteem.'^ which in tum. could inhibit one's ambition to seekmental health care. Furthermore, given the finding of Cooperet al." that individuals are less likely to seek help if they viewthemselves as responsible for their disorder, soldiers may fur-

ther avoid seeking mental health care if they believe that theyshould have control over their condition and/or feel responsiblefor experiencing symptoms of PTSD.

Additionally, Hoge et al. found that the soldiers and Marinesin their study who met the screening criteria for a mental healthproblem were twice as likely to report concerns about stigmaand other barriers to care than those respondents who did notmeet the screening criteria. Perceived barriers to care includesuch items as "I don't trust mental health professionals" and "Idon't know where to get help."^ Thus, if soldiers decide to seekmental health care but perceive specific barriers (such as time,money, transportation) in this process, they may avoid seekingmental help altogether. Britt et al.'-' found an unconnected cor-relation of 0.37 (p < 0.001) between perceived stigma and psy-chological symptoms. We would argue that indi\iduals who areexperiencing mental health symptoms would be especially likelyto consider the potential stigmatizing consequences of seekingmental health care because of the immediate relevance of thedecision. Individuals who are not experiencing symptoms willlikely not actively consider these consequences, leading to re-duced reports of perceived stigma. This finding has importantimplications for interpreting the average perceived stigma ofseeking care for a mental health problem among respondents, liis likely that such a value is an underestimate of the actualstigma felt by individuals actually possessing extensive mentalhealth symptoms.

Given findings from past research on societal and self-stigma,barriers to care, and the current statistics on rates of soldiersencountering traumatic events and experiencing symptoms ofPTSD. it is not hard to see why soldiers would avoid seekingmental health care altogether. In the remainder of this article.we consider potential interventions for reducing the stigma ofseeking help for psychological difficulties among military servicemembers.

Interventions for Reducing Stigma in the Military

Interventions for reducing the stigma of mental health prob-lems should address both societal and self- stigma. Corriganand Penn^ have proposed three methods for reducing the stigmaattached to mental illness by society and these strategies mayprovide insights into interventions in a military context. The first

SocietalStigma of

Mental HealthDisorders

Exposure toTraumatic

Events

Developmentof Mental Health

Symptoms

OrganizationalBarriers to

Mental HealthCare

Need to SeekMental Health

Care

ReceivingMentalHealthCare

SelfStigma

Fig. 1. A path diagram reflecting how stigma and barriers to care can affect getting treatment for psychological problems.

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160 Stigma of Mental Health Problems

strategy involves protesting; in using this strategy, an attempt ismade to suppress stigmatizing attitudes and behaviors by in-forming society that they should not possess negative stereo-types about mental illness. It has been found that this methodgenerally does not have a significant effect in reducing stigmaand that protesting stigma may actually lead individuals torecall more negative information about persons with mentalillness when instnicted to suppress their stereo types. •* There-fore, it is not enough to simply demand that people eliminate thestereotypes they hold about mental illness.

The second technique involves educating and providing fac-tual information to society's members about mental disorders.'This technique has been met with some success, although thetype of information provided about mental health problems isimportant. This type of intervention should provide realisticdescriptions of problems, including accurate information on theunderlying causes of the problem, and emphasize that manyproblems can be addressed through different forms of treat-ment. The provision of accurate infonnation about the etiologyand treatment course of psychological problems can help de-crease the negative stereotypes surrounding the problem andalso change the public's view regarding the controllability of thedisorder. One popular program for reducing stigma among menseeking psychological help for depression is the media cam-paign. "Real Men. Real Depression."'^ This program has beendirected specifically for men who believe they are weak (e.g., not"real men") as a result of experiencing mental health problemssuch as depression and therefore not wanting to admit theyhave the problem or seek treatment for the problem. It has beenestimated that more than 345 million people are aware of thiscampaign that attempts to reduce stigma and educate men andtheir families about the symptoms and treatment of depression.

Within a military context, accurate information about thecauses and treatment of problems such as PTSD'** may influ-ence the way in which the broader military culture views suchdisorders. Clearly, soldiers are exposed to traumatic events thattax even the most resilient.^ '•' The presence of such a strongenvironmental determinant of problems such as PTSD shoulddo a lot to reduce the stigma associated with seeking help forsuch problems. Although many people exposed to the sametraumatic events do not develop mental health disorders, thecontrollability attributions for the development of PTSD shouldbe capable of being modified based on information showingthe importance of environmental factors in the etiology of thedisorder.

The third strategy, promoting contact with individuals whohave a mental illness, has been shown to be the most successfultechnique in reducing stigma.** This strategy involves reducingnegative beliefs about mental illness by placing the public indirect contact with the stigmatized group, Couture and Penn^cite past research suggesting that the contact method worksbest when the stigmatized individual has one-on-one contactwith members of society, when the environment is cooperative(rather than competitive), and when status is viewed as equalbetween the stigmatized individual and other members ofsociety.

The possibility of using this type of intervention in a militarycontext has not been adequately explored. Certainly, manyunits have experiences with members who have developed prob-

lems such as PTSD. although it is likely that contact with theseindividuals does not occur under the ideal circumstances de-scribed above. Unit-level interventions could involve having sol-diers who were successfully treated for FfSD discuss theirexperiences in a supportive unit environment akin to an after-action review. Fellow unit members could ask soldiers questionsabout various aspects of the problem, thereby increasing theirunderstanding of mental health difficulties and seeing thatmental health eare can successfully reduce maladaptive symp-toms. Such an approach may lead to an increase in soldiers whoseek help during the early stages of developing a mental healthproblem, leading to a greater likelihood that the soldier willsuccessfully deal with the problem and return to the unit as afully functioning member. Future research will be necessary toassess the effectiveness of these types of interventions in amilitary context.

In addition to the interventions suggested by previous ci-vilian research, we also recommend additional strategieslikely to be especially effective in a military context. The firstsuch strategy we label leader/supervisor support. Such aninten'ention would encourage leaders to take an active role inidentifying and assisting soldiers in receiving mental healthsupport. Senior leader treatment of service members needinghelp for mental health problems will likely have a major im-pact on the stigma perceived by service members. If leadersemphasize the importance of treatment early in the develop-ment of a mental health problem, service members will knowtheir leaders understand the importance of seeking help andtherefore the stigma associated with seeking help will mostlikely be reduced. Leaders at all levels are capable of creatinga climate where mental health problems such as PTSD arerecognized as potential responses to traumatic events andthat seeking help for these difficulties early in their develop-ment is an effective strategy for allowing the service memberto be a fully functioning part of his or her unit. In this sense,it becomes the responsibility of leaders to help service mem-bers receive help for a mental health problem.

In addition to leader/supervisor support, an additional wayof reducing stigma would be to implement organizational pol-icies and programs aimed at supporting soldiers in gettingmental health support. Examples of changes to existing pol-icies that would support soldiers receiving needed help in-clude soldiers not losing their job or security clearances forseeking mental health support, being able to seek mentalhealth support during the duty day. and having their visits tomental health professionals be anonymous. Future researchis needed to investigate whether these types of programsresult in service members getting treatment for mental healthproblems before these problems turn into more severe diffi-culties that compromise the unit's mission and the servicemember's own adaptive functioning.

Acknowledgments

The preparation of this manuscript was facilitated by contrarts fnimthe Medical Research and Material Command to Tifiany M. Greene-Shortridge (Contract W81XWH-05-P-0994) and Thomas W. Britt (Con-tract W81XWH-05-P-0497).

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stigma of Mental Health Problems 161

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