By Dorothy A. Kaplan, Ph.D.
July 8, 2019

U.S. Army photo

Stigma is associated with negative attitudes about psychological health care and poses a significant barrier to seeking help, engaging in care, and completing psychological health treatment.

Several types of stigma influence help seeking: perceived public stigma, self-stigma (also called internalized stigma), and attitudes toward help seeking. These attitudes include the perception of a need for help, stigma tolerance, openness regarding one's problems, and confidence that help will be beneficial. Those who are most reluctant to seek mental health care often perceive the lowest benefits from mental health treatment and have the most treatment-related doubts.

Mental health stigma in the military is strongly grounded in military culture and is linked to a desire to handle problems on one's own. Interestingly, service members who report psychological health concerns are most likely to perceive stigma and anticipate negative outcomes for seeking care, including career harm.

Individuals who experience or witness traumatic events and experience stress reactions that disrupt their psychological well-being may be particularly reluctant to seek mental health care. Concerns about re-experiencing traumatic events and the avoidance of traumatic reminders are a challenge to psychological health care engagement.

Consequently, clinicians need to be aware of how stigma affects service members seeking their help so these perceptions can be targeted for intervention. It's critical that clinicians address stigma and attitudes about psychological health and help-seeking during the initial session with a new patient as so many patients drop out of care after just a session or two. Premature termination hinders the effective delivery of care as a minimum of 11–13 sessions of evidence-based psychotherapeutic interventions are needed for symptom remission and recovery.

Other considerations for stigma reduction in military personnel seeking care

• Confidentiality: Military patients know that much of their medical life is not private. However, in increasing numbers of cases, some mental health treatment is confidential, including mild, transient problems and treatment related to sexual assault. Reassure patients that if they have sought psychological health care on their own, you will keep their confidence to the greatest extent allowable. Some information cannot be kept confidential, including symptoms which constitute a threat of harm to self, other, or mission as well as other situations (inpatient mental health or substance abuse program, Personnel Reliability Program, or an acute condition interfering with duty). DODI 6490.08 addresses command notification requirements. Informed consent with military patients is key.
• Career concerns: Service members' fears that seeking mental health care could negatively impact their careers are significant contributors to stigma in the military. Highlight these key points with your patients: seeking treatment early, soon after symptoms begin, is least likely to yield negative career repercussions; self-referring for treatment is associated with fewer duty restrictions and provider disclosures to command than command-referred treatment; and disclosing mental health treatment does not automatically adversely impact – and actually may favorably impact – the ability to gain or retain a security clearance. It's also important to educate yourself and your patient about the patient's military occupational specialty (MOS) and psychological health policies specific to that MOS. Order our career concerns infographic to share as patient handouts.
• Hope: The belief that treatment will not be effective is an important predictor of dropping out of treatment. Hope is among the most important messages a clinician can impart to a patient. Provide patients frequent feedback about their progress and educate them that psychological health disorders are highly treatable; for example, there is a 70–80 percent recovery rate from PTSD in individuals who complete evidence-based treatment.
• Patient-centered care: Many military service members feel uncomfortable seeking mental health care. Provide treatment options and incorporate the patient's preferences for treatment. Involve the patient in setting treatment goals and choosing treatment modalities and involve family members and others in the patient's social support system.
• Strength and self-reliance: Inquire about patients' perceptions about psychological health care and whether they think treatment will be effective. Address self-stigma and challenge the belief that handling problems on one's own is a sign of character strength and seeking care is a sign of personal weakness in a warfighter. Request free resources from the Real Warriors Campaign to help reinforce the message that seeking help is a sign of strength.
• Empathic and non-stigmatizing language: While it can be helpful to educate patients about their diagnosis, it's even more important to provide a psychological understanding of how their symptoms developed and convey concern for their well-being. Communicate your understanding of the service member as a whole person being mindful not to use pathological labels.

Dr. Kaplan is a clinical neuropsychologist at the Psychological Health Center of Excellence providing subject matter expert support to the Psychological Health Promotion branch. She has provided, developed, and directed interdisciplinary evidence-based treatment for individuals with traumatic brain injuries and associated psychological health conditions and has been involved with the review of military policies related to mental health stigma.