F O RU M O N H E A LTH A N D N ATIO N A L SE CURITY

Stigma and Barriers to Care
Caring for Those Exposed to War,
Disaster and Terrorism
Conference Report

Center for the Study of Traumatic Stress
Department of Psychiatry
Uniformed Services University of the Health Sciences
and Defense Centers of Excellence

DEFENSE CENTERS
OF EXCELLENCEFor Psychological Health& Traumatic Brain Injury

FO RU M O N H E A LTH A N D N ATIO N A L SE CURITY

Stigma and Barriers to Care
Caring for Those Exposed to War,
Disaster and Terrorism
Edited byRobert J. Ursano, M.D.
Carol S. Fullerton, Ph.D.
Mark C. Brown, M.D.

A Conference Sponsored by:Center for the Study of Traumatic Stress
Department of Psychiatry
Uniformed Services University of the Health Sciences andDefense Centers of ExcellenceFrom the Conference Series:
FORUM ON HEALTH AND NATIONAL SECURITY

Stigma and Barriers to Care
Caring for Those Exposed to War, Disaster and Terrorism
Editor’s Note: This transcript has been edited, however, as in most transcripts some errors may
have been missed. The editors are responsible for any errors of content or editing that remain.

IPD 2011 by Center for the Study of Traumatic Stress
Department of Psychiatry
Uniformed Services University of the Health Sciences
4301 Jones Bridge Road
Bethesda, MD 20814-4799
First Edition

Contents
List of Speakers........................................................................................................................... i
List of Attendees....................................................................................................................... iii
Preface......................................................................................................................................vii
Executive Summary........................................................................................................... 1
1

Introduction..................................................................................................................... 9Mark C. Brown, M.D., M.P.H.
Robert J. Ursano, M.D.

2

Mental Health, Stigma and Barriers to Care ............................................................ 11
Ronald C. Kessler, Ph.D.

3

Stigma And Barriers to Care in Military & Veteran Populations ........................... 19
Charles W. Hoge, M.D.
Paul S. Hammer, M.D.
Matthew J. Friedman, M.D., Ph.D.

4

Stigma and Barriers to Care in Disaster .................................................................... 29
Dean G. Kilpatrick, Ph.D.
Sandro Galea, M.D., M.P.H.
Moderator: Stevan E. Hobfoll, Ph.D.

5

Stigma and Barriers to Care in Terrorism & Public Health Emergencies ............. 41
Simon Wessely, M.D.
Brian W. Flynn, Ed.D.
Moderator: Dori B. Reissman, M.D., M.P.H.

6

Conceptualizing Stigma and Barriers to Care........................................................... 51
Bruce G. Link, Ph.D.
Bernice A. Pescosolido, Ph.D.
Arieh Y. Shalev, M.D.

7

Mitigating Stigma and Barriers to Care .................................................................... 65
Patrick Corrigan, Psy.D.
Sue E. Estroff, Ph.D.
Moderator: Thomas Bornemann, Ed.D.

8

Optimizing Access to Care ............................................................................................ 77
C. Hendricks Brown, Ph.D.
Wendi F. Cross, Ph.D.
Moderator: Doug Zatzick, M.D.

9

Day 1 Discussion ............................................................................................................. 89
Robert J. Ursano, M.D.

10 Conference Reccomendations ..................................................................................... 97
Robert J. Ursano, M.D.

i

Speakers
Mark C. Brown, M.D., M.P.H.
LTC, MC, USA
Senior Fellow, Disaster and Preventive
Psychiatry
Uniformed Services University

Matthew J. Friedman, M.D., Ph.D.
Professor, Psychiatry and Pharmacology &Toxicology
Executive Director, National Center for PTSD
U.S. Dept. of Veterans Affairs

Thomas Bornemann, Ed.D.
Director, Mental Health Program
The Carter Center

Sandro Galea, M.D., Dr.P.H., M.P.H.
Gelman Professor and Chair, Dept. of
Epidemiology
Columbia University

C. Hendricks Brown, Ph.D.
Professor and Director, Prevention Science andMethodology Group
Dept. of Epidemiology and Public Health
University of Miami Miller School of Medicine

Paul S. Hammer, M.D.
CAPT, MC, USN
Director, Naval Center for Combat andOperational Stress Control

Patrick Corrigan, Psy.D.
Distinguished Professor, Dept. of Psychology
Associate Dean, Psychology Research
Illinois Institute of Technology

Stevan E. Hobfoll, Ph.D.
Presidential Professor and Chair
Dept. of Behavioral Sciences
Rush University Medical Center

Wendi F. Cross, Ph.D.
Associate Professor of Psychiatry (Psychology)
and Pediatrics
Co-Director, Resilience Project
Director, Observational Research andBehavioral Information Technology
University of Rochester Medical Center

Charles W. Hoge, M.D.
COL, MC, USA
Director, Division of Psychiatry and 		
Neurosciences
Walter Reed Army Institute of Research

Sue E. Estroff, Ph.D.
Professor, Dept. of Social Medicine
Adjunct Professor, Depts. of Anthropology andPsychiatry
University of North Carolina at Chapel Hill
School of Medicine
Brian W. Flynn, Ed.D.
RADM/Asst. Surgeon General, USPHS (Ret.)
Associate Director
Center for the Study of Traumatic Stress
Uniformed Services University

Ronald C. Kessler, Ph.D.
Professor, Dept. of Health Care Policy
Harvard Medical School
Dean G. Kilpatrick, Ph.D.
Distinguished University Professor, ClinicalPsychology
Director, National Crime Victims Research &Treatment Center
Vice-Chair for Education, Dept. of Psychiatry& Behavioral Sciences
Medical University of South Carolina

ii

Bruce G. Link, Ph.D.
Professor, Epidemiology and Sociomedical
Sciences
Columbia University
Research Scientist
New York State Psychiatric InstituteBernice A. Pescosolido, Ph.D.
Distinguished Professor of Sociology
Director, Indiana Consortium for Mental
Health Services Research
Indiana University / Schuessler Institute forSocial Research
Dori B. Reissman, M.D., M.P.H.
CAPT, USPHS
Senior Medical Advisor, Office of the 		
Director, National Institute for 		Occupational Safety and HealthRobert J. Ursano, M.D.
Professor and Chair, Dept. of Psychiatry
Uniformed Services University
Director, Center for the Study of TraumaticStressSimon Wessely, M.D.
Professor, Epidemiology and Liaison Psychiatry
Director, King’s Centre for Military HealthResearch
Vice Dean, Academic Psychiatry, Teaching andTraining: Institute of Psychiatry
Douglas Zatzick, M.D.
Professor, Dept. of Psychiatry and Behavioral
Sciences
Research Faculty Harborview Injury 		Prevention and Research Center
University of Washington School of Medicine

Arieh Y. Shalev, M.D.
Professor and Head, Dept. of Psychiatry
Hadassah University Hospital

Conference Planning Committee

Editing Committee

Mark C. Brown, M.D.
Robert J. Ursano, M.D.
Mary Lee Dichtel, R.N.
James A. Naifeh, Ph.D.
Alisha H. Creel, Ph.D.
Carol S. Fullerton, Ph.D.
Julie Grieco, M.A.

Robert J. Ursano, M.D.
Carol S. Fullerton, Ph.D.
Mark C. Brown, M.D.
Francis Gabay, Ph.D.
Christine Gray, M.P.H.
K. Nikki Benevides, M.A.
Julie Grieco, M.A.
Alisha Creel, Ph.D.

iii

Attendees
Robert R. Arnold, MSN, PsyCNS, RN
MAJ, USA
Assistant Professor and Deputy Director
Psychiatric Mental Health Nurse Practitioner
Program
Uniformed Services University
Mark J. Bates, Ph.D.
Interim Director, Resilience and Prevention
DCoE for Psychological Health and Traumatic
Brain Injury
Sonja V. Batten, Ph.D.
Deputy Director
DCoE for Psychological Health and Traumatic
Brain Injury
Carl C. Bell, M.D.
President/CEO, Community Mental HealthCouncilActing Director, Institute for Juvenile Research
Professor, Dept. of Psychiatry and School of
Public HealthDavid M. Benedek, M.D.
COL, MC, USA
Professor, Deputy Chair, Associate Director,
Senior Scientist
Center for the Study of Traumatic Stress
Uniformed Services University
William T. Bester
BG, USA (Ret.)
Acting President
Uniformed Services University
Quinn M. Biggs, Ph.D., M.P.H.
Research Assistant Professor, Dept. of
Psychiatry
Center for the Study of Traumatic Stress
Uniformed Services University

Jennifer Bornemann, M.S.S.W.
LT, USPHS
Dept. of Psychiatry, Center for the Study ofTraumatic Stress
Uniformed Services University
Thomas Bornemann, Ed.D.
Director, Mental Health Program
The Carter Center
Thomas W. Britt, Ph.D.
Professor, Dept. of Psychology
Clemson University
C. Hendricks Brown, Ph.D.
Professor and Director, Prevention Science andMethodology Group
Dept. of Epidemiology and Public Health
University of Miami Miller School of Medicine
Patrick Corrigan, Psy.D.
Distinguished Professor, Dept. of Psychology
Associate Dean, Psychology Research
Illinois Institute of Technology
Mark C. Brown, M.D., M.P.H.
LTC, MC, USA
Senior Fellow, Disaster and Preventive
Psychiatry
Uniformed Services University
Stephen J. Cozza, M.D.
COL, MC, USA (Ret)Professor, Dept. of Psychiatry
Associate Director, Center for the Study ofTraumatic Stress
Uniformed Services University

iv

Alisha H. Creel, Ph.D.
Assistant Professor, Division of Social and
Behavioral Sciences
Dept. of Preventive Medicine & Biometrics
Uniformed Services University

Matthew J. Friedman, M.D., Ph.D.
Professor, Psychiatry and Pharmacology &Toxicology
Executive Director, National Center for PTSD
U.S. Dept. of Veterans Affairs

Wendi F. Cross, Ph.D.
Associate Professor of Psychiatry (Psychology)
and Pediatrics
Co-Director, Resilience Project
Director, Observational Research and Behavioral Information Technology
University of Rochester Medical Center

Carol S. Fullerton, Ph.D.
Science Director, Professor
Center for the Study of Traumatic Stress
Uniformed Services University

Bruce E. Crow, Psy.D.
COL, MS, USA
Clinical Psychology Consultant to the U.S.
Army Surgeon General
Director, Warrior Resiliency Program
Mary Lee Dichtel, R.N.
Program Coordinator and Associate
Disaster and Homeland Security Group
Center for the Study of Traumatic Stress
Uniformed Services University
C.J. Diebold, M.D.
COL, MC, USA
Tripler Army Medical Center
Psychiatry Consultant to the Army Surgeon
GeneralCharles C. Engel, M.D., M.P.H.
COL, MC, USA
Associate Professor, Dept. of Psychiatry
Uniformed Services University
Sue E. Estroff, Ph.D.
Professor, Dept. of Social Medicine
Adjunct Professor, Depts. of Anthropology andPsychiatry
University of North Carolina at Chapel Hill
School of Medicine
Brian W. Flynn, Ed.D.
RADM/Asst. Surgeon General, USPHS (Ret.)
Associate Director
Center for the Study of Traumatic Stress
Uniformed Services University

Sandro Galea, M.D., Dr.P.H., M.P.H.
Gelman Professor and Chair, Dept. of
Epidemiology
Columbia University
Robert K. Gifford, Ph.D.
Executive Officer, Dept. of Psychiatry
Center for the Study of Traumatic Stress
Uniformed Services University
Matthew Goldenberg, M.D.
Assistant Professor, Dept. of Psychiatry
Center for the Study of Traumatic Stress
Uniformed Services University
Jennifer Guimond, Ph.D.
Research Assistant Professor, Dept. of
Psychiatry
Research Psychologist, Child and Family
ProgramCenter for the Study of Traumatic Stress
Uniformed Services University
Paul S. Hammer, M.D.
CAPT, MC, USN
Director, Naval Center for Combat andOperational Stress Control
Stevan E. Hobfoll, Ph.D.
Presidential Professor and Chair
Dept. of Behavioral Sciences
Rush University Medical Center
Charles W. Hoge, M.D.
COL, MC, USA
Director, Division of Psychiatry and 		
Neurosciences
Walter Reed Army Institute of Research

v

Harry C. Holloway, M.D.
Professor, Psychiatry and Neuroscience, Dept.
of Psychiatry
Uniformed Services University
Edmund (Randy) G. Howe, M.D., J.D.
Professor of Psychiatry
Director, Programs in Ethics
Senior Scientist
Center for the Study of Traumatic Stress
Uniformed Services University
Ronald C. Kessler, Ph.D.
Professor, Dept. of Health Care Policy
Harvard Medical School
Dean G. Kilpatrick, Ph.D.
Distinguished University Professor, ClinicalPsychology
Director, National Crime Victims Research &Treatment Center
Vice-Chair for Education, Dept. of Psychiatry& Behavioral Sciences
David S. Krantz, Ph.D.
Professor and Chairman
Dept. of Medical & Clinical Psychology
Uniformed Services University
Larry W. Laughlin, M.D., Ph.D.
Dean, F. Edward Hebert School of Medicine
Uniformed Services University
Bruce G. Link, Ph.D.
Professor, Epidemiology and Sociomedical
Sciences
Columbia University
Research Scientist
New York State Psychiatric InstituteJames E. McCarroll, Ph.D., M.P.H.
COL, USA (Ret.)
Research Professor, Dept. of Psychiatry
Center for the Study of Traumatic Stress
Uniformed Services University

Jodi B.A. McKibben, Ph.D.
Research Assistant Professor, Dept. of
Psychiatry
Center for the Study of Traumatic Stress
Uniformed Services University
James A. Naifeh, Ph.D.
Research Assistant Professor, Dept. of
Psychiatry
Center for the Study of Traumatic Stress
Uniformed Services University
John H. Newby, Ph.D., M.S.W.
Research Assistant Professor, Dept. of
Psychiatry
Center for the Study of Traumatic Stress
Uniformed Services University
Bernice A. Pescosolido, Ph.D.
Distinguished Professor of Sociology
Director, Indiana Consortium for Mental
Health Services Research
Indiana University / Schuessler Institute forSocial Research
Alan Q. Radke, M.D., M.P.H.
DHS Medical Director & SOS Chief Medical
Officer
Minnesota Dept. of Human Services
Dori B. Reissman, M.D., M.P.H.
CAPT, USPHS
Senior Medical Advisor, Office of the Director
National Institute for Occupational Safety and
HealthCharles L. Rice, M.D.
President
Uniformed Services University
Josef I. Ruzek, Ph.D.
Director, Dissemination and Training Division
National Center for PTSD
U.S. Dept. of Veterans Affairs
Patcho Santiago, M.D., M.P.H.
LCDR, MC, USN
Assistant Professor, Dept. of Psychiatry
Uniformed Services University

vi

Kenneth W. Schor, D.O., M.P.H.
CAPT, MC, USN (Ret)Acting Director, National Center for 		
Disaster & Public HealthAsst. Professor, Preventive Medicine &Biometrics
Uniformed Services University
Arieh Y. Shalev, M.D.
Professor and Head, Dept. of Psychiatry
Hadassah University Hospital
Edward Simmer, M.D., M.P.H.
CAPT, MC, USN
Senior Executive Director for Psychological
HealthNavy Intern Specialty Leader
General and Forensic Psychiatrist
DCoE for Psychological Health and 		Traumatic Brain Injury
Laurie B. Slone, Ph.D.
Associate Director for Information andCommunications
National Center for PTSD
U.S. Dept. of Veteran Affairs
Dale C. Smith, Ph.D.
Senior Vice President
Uniformed Services University
Loree K. Sutton, M.D.
BG, USA
Director
DCoE for Psychological Health and 		Traumatic Brain Injury

Kenneth S. Thompson, M.D.
Associate Professor of Psychiatry and Public
HealthUniversity of Pittsburgh and Western Psychiatric Institute and Clinic
Medical Director, Center for Mental HealthServices (CMHS)
SAMHSA
Farris Tuma, Sc.D.
National Institute of Mental Health
Division of Adult Translational Research andTreatment Development
Traumatic Stress Disorders Research Program
Mary P. Tyler, Ph.D.
Senior Scientist, Dept. of Psychiatry
Center for the Study of Traumatic Stress
Robert J. Ursano, M.D.
Professor and Chair, Dept. of Psychiatry
Uniformed Services University
Director, Center for the Study of TraumaticStressSimon Wessely, M.D.
Professor, Epidemiology and Liaison Psychiatry
Director, King’s Centre for Military HealthResearch
Vice Dean, Academic Psychiatry, Teaching andTraining: Institute of Psychiatry
Douglas Zatzick, M.D.
Professor, Dept. of Psychiatry and Behavioral
Sciences
Research Faculty Harborview Injury 		Prevention and Research Center
University of Washington School of Medicine

vii

PrefaceThis Forum on Health and National Security, directed to addressing stigma andbarriers to care, brought together a diverse group of leaders in order to expand ourhorizons on these issues of important national need in times of war, disaster and terrorism. The individuals represented national leaders, educators, researchers and healthcare planners across mental health, health care systems, military and disaster care andthe specific issues of stigma and barriers to care. Our goal was for individuals who
did not usually talk with each other or even know of each other’s work, to hear new
perspectives and create a new vantage point on this difficult topic. We operated underthe belief that if one only talks to people that you already know we cannot maximize
our joint knowledge and opportunities. We hoped that those in attendance would
leave with at least two new names of people who would be helpful and of interest in
pursuing our needs to address stigma and barriers to care.
Our primary goal was to better understand the issues of stigma and barriers tocare as they relate to the trajectory from illness, distress and health risk behaviors
after war, disaster or terrorism to care and needed help. At that point the group could
translate their understanding into action through recommendations. The work of theForum was a series of presentations followed by thinking together. Our final discussions were to formulate a set of recommendations to capture the ideas generated. The
recommendations were organized into the areas of research, education and training,leadership and intervention. We hope this volume communicates the important ideas
and recommended actions from this distinguished group.

Our primary goal was
to better understandthe issues of stigma andbarriers to care as they
relate to the trajectoryfrom illness, distress andhealth risk behaviors
after war, disaster or
terrorism to care andneeded help.

Executive Summary

1

Executive Summary andRecommendations
What is stigma? What is it that prevents people from getting help for psychological and behavioral problems after war, disasters or terrorism when they need
it? What are the predictors of not coming for care and assistance? Is it because
one would feel embarrassed? Is it because of inadequate transportation? Or that aperson cannot get an appointment? Or are there other factors such as lack of trust
in mental health professionals or people thinking treatment is not going to work,or believing “I can handle it myself”?
The Forum on Health and National Security is a conference series addressing theintersection of health and national security needs. The goal of this first conference
was to better understand stigma and barriers to care in those exposed to war, disasterand terrorism and to translate that understanding into action. Stigma is associatedwith behavioral health in general and emergency behavioral health in particular. To
address stigma and barriers to care it is important to address the marginalizationand misunderstanding about what we can and cannot do in mental health and themyths about our field. Mental health stigma is not just about getting treatment. It
is an attribute of many aspects of behaviors, including health and illness, and it isa part of our social interactions. It disqualifies individuals from a particular group
citizenship. It can negate acceptance in the family sphere and the work place.
There are other reasons which also play a part in why people do not come forward for treatment. Perhaps most importantly if they believe that we are offering
them treatment for something they do not see as a problem. Similarly, as care providers we like diagnoses — they orient our treatments and give us guideposts — butpeople who have illnesses do not always like them. People do not like to be placed
into the ‘abnormal’ category. For mental health diagnoses, both in the military orcivilian worlds, how to modify societal beliefs that psychiatric and psychologicalproblems mean weakness is a major challenge.
Looked at from the other side of stigma— what are its consequences? What are
the behavioral implications of stigma? Over the years there have been a number ofefforts by community mental health to educate neighborhoods about mental healthand illness. Often these messages have been that mental illness is not really an illness
and not really dangerous. What researchers have discovered is that when we provide
education to the community it may only help the neighborhood mobilize against
those with behavioral and health problems more quickly. People who have behav-

What is stigma? What is
it that prevents people
from getting help for
psychological andbehavioral problems
after war, disasters or
terrorism when theyneed it? What are thepredictors of not coming
for care and assistance?

2

Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism

There is good

ioral and health problems “know” that other people feel awkward around them.
Therefore people often are reluctant to go for treatment. This is particularly true inthe armed forces where the ethos is, “I don’t need help. I can handle things myself.”
There is good reason to think that embarrassment is an important cause of
failure to get treatment and an important cause of dropping out of treatment
prematurely. This embarrassment is based in part on the perception of the stigma
associated with emotional disorders, the idea that it is shameful to have a mental
illness and that it is a character flaw. The General Social Survey (GSS) conducted by
the National Opinion Research Center, University of Chicago, has been monitoring attitudes about mental illness since 1972 and has documented an increase in
the perception that mental illness is attributable to biological causes rather than acharacter flaw. There has been an increase in the perception that biological treatment
is likely to be the most effective kind of treatment. Part of the reason for this is that
there has been a massive increase in public information about mental illness since
the early 1990’s. However, it is not always true that giving people more information
creates the behavioral changes desired. Now the perception that one’s family may
carry dangerous genes has become part of the stigma burden.
Mental health includes resilience as well as disorders, distress responses,
and health risk behaviors. How do barriers to care affect each of these? Distressresponses can also be thought of as subthreshold mild to moderate symptoms andoften are early signs indicating the need for treatment or psychological rest. They
also impair performance. We need to particularly better understand how barriers tocare can impact the performance and health of individual service members, publichealth responders and other safety and security personnel as well as their organizations. It is important to address the individual’s impairment of function and how
barriers to care also lead to increased disability. Complicating the issues is the factthat disability may increase with the award of compensation.
Health risk behaviors, e.g., use of cigarettes, changes in use of alcohol, accidents
in particular road traffic accidents, and substance abuse, are a part of the healthburden after war and disasters. They are too often overlooked in the broader publichealth issues after traumatic events. These are important targets for prevention andintervention in which stigma and barriers to care also impact health trajectories. For
example, altering cigarette use substantially alters morbidity and mortality related
to disease. In addition it is a part of the health environment of our families andour service members. We know cigarette use changes after exposures to combat,
disasters, and terrorism. Our 18–25 year-olds are those who have the highest ratesof cigarette use.
The individual’s perception of the need for care is an important part of the
trajectory from illness, distress or health risk behaviors to care. About 17% of DoD
reported a need for counseling. Approximately 4.8% of DoD has received a medication for depression, anxiety, or sleep; 14.6% have received some type of mental
health counseling. Half of the counseling is from a military mental health professional. Importantly, approximately 44% describe probable or definite perceived
damage to their career for seeking mental health counseling. Sorry to say but true isthat this is similar for the nation as a whole. In 2004 Hoge et al. found that considerably more than half of the soldiers and marines who were surveyed and seemed to
be in need of treatment, indicated that they had not received any treatment. Stigma
and barriers to care were an important component in their path to care.
Families also have particular problems during war and disasters and concern

reason to think thatembarrassment is an
important cause of
failure to get treatment
and an important causeof dropping out oftreatment prematurely.

Executive Summary

about stigma in families can prevent care to children and family members. For
example, there are barriers to care related to intervention for family conflict andchild neglect. We need to consider outreach to these populations. How to alter thesystem to better reach them and they reach us? Somatic symptom reporting is particularly important to the health care system. Unexplained and idiopathic somatic
complaints increase in times of war and disasters also as shown following Katrina
or in New York City after 2001. Somatic symptoms complaints raise issues of stigma
and barriers to reaching the correct care, and the overtreatment of people who may
not need physical health care.
In considering recommendations to address stigma and barriers to care as an
impediment in the illness to treatment path, there are several models to consider. One
approach is the traditional primary, secondary, and tertiary prevention. This involves
response and prevention of disability. Another approach follows the IOM suggestions from 1994 which address whether an intervention is for the entire populationor high risk groups. In addition, for war, disaster, and terrorism — similar to the
Haddon Matrix — there are stages to consider: pre-stage, an event stage in which
we operate, and a post-event stage.
How do we place disaster response, war and terrorism in these frames of reference to better address barriers and stigma? These are the issues addressed by the distinguished group of speakers and participants in this Forum on Health and National
Security. Our recommendations inform and direct thoughts for research, training
and education, leadership and intervention to best address stigma and barriers tocare of our service members, their families and our nation as a whole in times of war,disaster and terrorism. The following summarizes the recommendations of the group.

Research Directions
1. The stigma associated with psychological health has changed little since the startof the war despite massive education and screening campaigns. It is conceivablethat the stigmatization process as a means of differentiating “in” and “out”
groups plays such a central role in maintaining performance that changing theculture will continue to be a long-term goal. In order to mitigate the healthand national security implications of such a phenomenon research is needed todevelop alternative approaches to care. Areas for exploration include the studyof the effects of relationships on altering barriers to care, coaching models ofcare, processes of effective care, case definition and identification, and referral
and access to health care. The role of buddy care and mechanisms for fostering
connection with others and support require further study.
••

Develop alternatives to diagnosis and disability-based models of care.

••

Examine the effects of buddy, leadership, and family relationships on barriers to care.

••

Examine the effectiveness of coaching models of care in decreasing barriers
to care.

••Examine the process of reaching care from case identification to referral toaccess.

••Examine the role of buddy care and psychological first aid in altering barriers to care.

3

The stigma associatedwith psychologicalhealth has changed
little since the start of
the war despite massive
education and screening
campaigns.

4

Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism

Many factors,••

Identify the role of self-help groups in promoting care seeking and adherence.

including stigma,••

Examine the mechanisms of fostering connections with others as a factor inaltering stigma and interpersonal barriers to care.

inhibit symptomatic
individuals fromseeking care following
exposure to disaster,war, and terrorism.

2. Many factors, including stigma, inhibit symptomatic individuals from seeking care following exposure to disaster, war, and terrorism. Of those who arebrought to clinical attention many drop out or receive inadequate care. Researchis needed to better understand vocational trajectories after care seeking, thepositive effects of treatment, the process of reaching effective care, and theeffectiveness of contact at various stages from symptom onset to impairment
across outcomes. These outcomes include distress, disorder, health risk behaviors,
and injury. There is a paucity of qualitative study of the narratives of injured
soldiers who successfully negotiated barriers to care including stigma, received
treatment, remained in treatment, and shared their experience of effective care.
There is a need for case control or cohort studies of “declining care” with outcome variables including job function, home function, health and resilience.
••

Identify vocational trajectories after care seeking including the positiveeffects of treatment.

••

Examine the impact of contact across stages of psychological and behavioral
responses to traumatic events on the trajectory of care seeking.

••Use qualitative techniques to examine the narratives of trauma survivors.

••

Conduct studies of the effects of declining care across various outcomes.

3. Research is needed to understand, develop, and make accessible high-quality,
practical, evidence-based care for symptomatic individuals exposed to disaster,war, and terrorism. We need to better understand how to get rapid relief for
those who enter primary or specialty care. Research is needed to examine whatis effective in therapy and how to optimize primary care settings to identify andtreat mental health disorders in less stigmatized settings in a manner which does
not burden the primary care practitioner. We need to better understand what
happens in psychotherapy in order to encourage participation in specialty care.
Studies are needed to examine technologies used to get patients to treatment, gettreatment to patients and to provide information and treatment in less stigmatizing settings.
••

Further develop high-quality, practical, evidence-based care for symptomatic
individuals exposed to trauma.

••

Identify treatments that provide rapid and sustained relief and methods ofdelivery that decrease stigma and barriers.

••

Identify ways to optimize collaborative care in the primary care setting.

••

Develop qualitative methods to examine the narratives of successful treatment across the trajectories of accessing care.

••

Examine technologies to get patients into treatment that present informationand treatment in less stigmatizing settings.

4. Screening programs such as Post-Deployment Health Assessment (PDHA) andReassessment (PDHRA) should be examined for positive and negative predictive

Executive Summary

value, cost-effectiveness, and unintended consequences. For example, universal
face-to-face mental health screening of all redeploying soldiers is difficult toimplement and can deplete already overwhelmed treatment resources. In addition
it may exacerbate patient concerns about confidentiality and decision-making
autonomy. Selective Primary Care Screening for Depression and PTSD, as implemented in the Re-Engineering Systems of Primary Care Treatment in the Military(RESPECT-MIL) program sets the standard for optimizing access to primary
health care while minimizing the potential for stigmatization associated withhealth care utilization. Internet-based interventions designed to get people into
treatment need further development, broader implementation, and an evaluation
strategy. Research is needed to evaluate the collaboration between the primarycare and mental health communities in order to optimize collaboration.

5

Initial and refresher
training and educationof primary and specialty
care providers’ forencouraging service
members and disaster
exposed families
and public healthworkers to enter care(e.g. motivational••

Study positive and negative predictive value, cost-effectiveness, and potential
unintended consequences of PDHA, PDHRA.

••

Study the unintended consequences of mandatory face-to-face mental healthscreening for all redeploying soldiers, irrespective of risk stratification.

important for optimal••Continue implementation and evaluation of RESPECT-MIL program.

programs and goals.

••

Develop, implement and evaluate the effectiveness of internet-based interventions.

••

Evaluate the collaboration between the primary care and mental health care
communities’ considerations in order to optimize collaboration.

••

Examine the trajectory of post-traumatic reactions, including recovery, disability, and impairment.

••

Examine the effects of co-morbid medical illness on barriers to care andstigma.

••Identify factors that initiate and perpetuate the illness role.

Training and Education
Initial and refresher training and education of primary and specialty care providers for encouraging service members and disaster exposed families and public healthworkers to enter care (e.g. motivational interviewing) are important for optimaltreatment strategies, programs and goals. Individuals seeking assistance need to be
directed to high quality easily accessible information. A clearinghouse to establish
and maintain sources of information is needed. Military leadership education andtraining at all ranks should include education on barriers to care (including stigma),and help seeking as an element of the service’s core values and on various cultural“languages” acceptable to care seeking. In keeping with a “safety culture/safety climate” emphasis, help seeking as a means of performance optimization and training
on recognizing evidence of distress should be included as an element of such curricula. It is important to maximize the extent to which this training can be provided
by unit leaders to forward unit mental health providers. Leadership mastery of skills
should be tested and rewarded, offering badges or special skill identifiers analogous to the Combat Lifesaver designation as potential reinforcements for soldiersdeveloping expertise in this area. Vocational rehabilitation should be included as anelement of performance enhancement. It is important to optimize, disseminate, andinterviewing) aretreatment strategies,

6

Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism

Public mental healthevaluate web-based treatments for PTSD and to identify ways to inform the use of
testimonials as evidence of effective care. Training in non-health care settings suchas communities, work places, and jails should be provided.

and military mental
health leadership needto integrate the message••

Provide initial and refresher training and education of primary care andspecialty care providers in optimally motivating patients to seek care as wellas treatment strategies, programs and goals.

••

Direct individuals seeking assistance to high quality, easily accessible
information. Establish and maintain a clearinghouse of sources of accurate
information.

••

Establish military leadership education and training at all ranks to include
education on barriers to care (including stigma), and promoting help seeking
as an element of each service’s core values. This should include training on
recognition of signs of distress in self and others, normalization of work-rest
cycles. The DCoE Real Warriors program is an excellent example.

••

Reframe help seeking as a means of performance optimization and include
training on recognizing signs of distress in oneself and others.

••

Promote vocational rehabilitation as an aspect of performance enhancement.

••

Optimize, disseminate, and evaluate web-based treatments for PTSD.

••

Use individual testimonials to highlight the availability of effective care.

••

Include non-health care personnel and settings in training and education.

••

Study the science and processes of training in order to optimize effectiveness.

of help seeking as an
aspect of performanceenhancement andorganizational
development.

Leadership
Public mental health and military mental health leadership need to integrate themessage of help seeking as an aspect of performance enhancement and organizational
development. Leaders should incorporate a blend of behavioral health prevention
and improving capacity for evidence based service delivery in their organizations.
Military leaders should integrate evidence based interventions into training andimplement this at the level of operational units. Leaders need to reinforce the valueof recognizing signs of distress, along with endorsing and underwriting a culturalshift toward rest and “taking a knee” when indicated. Structural efforts should bedirected at improving confidentiality associated with care seeking. When highly
effective treatments are available and accessible leaders need to articulate their support for care seeking and aid in dispelling myths about what happens in treatment.
••

Consider a conference to expand the focus of this discussion to the broader
national public mental health agenda to provide strategies and vision on
behavioral public health of the nation.

••

Integrate the message of help seeking as performance enhancement into alllevels of leadership education and training, and policy making.

••Train leaders to incorporate a balanced blend of behavioral health prevention
and improving capacity for evidence based service delivery.

••

Ensure that evidence based interventions are integrated into training andimplemented at the level of operational units.

Executive Summary••

Reinforce the importance of recognizing signs of distress, along with endorsing and underwriting a cultural shift toward rest and “taking a knee” whenindicated.

••

Continue structural efforts toward improving confidentiality associated withcare seeking.

••

Leaders must be able and willing to articulate their support for care seeking, and aid in dispelling myths about what happens in treatment and after
treatment is sought.

••

As a preventive measure, policy makers and leaders should continue toimprove deployment to dwell time ratios for military personnel.

Intervention
Many excellent programs for stigma mitigation designed to reduce barriers
to care exist in the Department of Defense, Department of Veterans Affairs andcivilian public health and academic centers. Leaders should foster and support
ongoing evaluation of these program interventions using measurable and operational outcomes. We must consider how non-health care systems can be leveraged
to reduce stigma and other barriers to care spanning the contexts of war, terrorism
and disaster. Appealing to altruism, enlisting others to provide support has been
an important guiding principle in the British TRIM program. Evidence informed
frameworks such as Psychological First Aid should guide targeted interventions.
Effective public health planning tools, such as the Haddon Matrix, can be helpful
in designing phased programs. It is important to optimize the use of self-help groups
to promote treatment adherence. Programs such as the DCoE Real Warriors, Bryan
Doerries Theatre of War, and social media such as Twitter or Facebook are examplesof creative interventions to promote “contact”, widely regarded as the most criticalelement of successful stigma mitigation effort. Mental health should collaborate
with marketing and media experts to establish long-term public behavioral healtheducational campaigns and to promote collaboration between civilian and militarycommunities.
••

Leaders should foster and support ongoing evaluation of programmed
interventions using measurable and operational outcomes.

••

Non-health care systems can be leveraged to reduce stigma and other barriers
to care in the context of war, terrorism and disaster.

••

Evidence informed frameworks such as Psychological First Aid should guidetargeted interventions.

••

Effective public health planning tools, such as the Haddon Matrix, can beused to design public health programs.

••

Self-help groups, which are known to promote treatment adherence shouldbe optimized.

••

Programs such as the DCoE Real Warriors, Bryan Doerries’s Theatre ofWar, and social media such as Twitter or Facebook are examples of creativeinterventions to promote “contact”, widely regarded as the most criticalelement of successful stigma mitigation efforts.

7

Many excellent
programs for stigma
mitigation designed toreduce barriers to careexist in the Departmentof Defense, Department
of Veterans Affairs andcivilian public healthand academic centers.

8

Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism••

Collaborate with marketing and media experts in establishing long-term
public behavioral health educational campaigns.

••

Promote collaboration between civilian and military communities.

Introduction

1

Introduction
Mark C. Brown, M.D., M.P.H.
Robert J. Ursano, M.D.
DR. BROWN: Good morning and welcome to the Forum on Health and National
Security meeting on “Stigma and Barriers to Care: Caring For Those Exposed toWar, Disaster and Terrorism” working meeting. I stand before you today feelingas I do prior to many big events — excited, anxious if not afraid, and somewhat
uncertain about what we are getting into. I am a fellow in the Disaster and Preventive
Psychiatry Program at USUHS (Uniformed Services University of the Health Sci‑
ences) and a mid‑career Army psychiatrist. I first became interested in this program
when I met COL Chuck Engel, the architect of the RESPECT‑MIL (Re-Engineering
Systems of Primary Care for PTSD and Depression in the Military) program. COL
Engel encouraged me to see mental health problems through a population-healthlens and inspired me to sign up for the disaster psychiatry fellowship, which has
been a great experience.
Sadly, I am near the end of that journey and want to take a couple of minutes
to thank some important people. First I should comment on the origins of this con‑ference. The idea was born during a meeting about a year ago when I was waxing
philosophical about my research findings and the secondary analysis of COL Hoge’s
land combat study data. A smile came across Dr. Ursano’s face and he said, “Mark,
you’re going to lead a conference on this topic next year.”
So here we are. Thankfully, when he made that statement, he had also hired awonderful woman named Mary Lee Dichtel. Without her, I could not have done
this. Mary Lee is a former ICU and pediatric oncology nurse who is exceptionallycaring and who has a very gentle touch. She was extremely well qualified to help me
orchestrate this meeting. Along with Mary Lee, Julie Grieco did much of the hard
work. Dr. Jamie Naifeh is responsible for the conference website, which some ofyou have joined and contributed to. All of the talks will be posted on the website,which will remain available after the conference.
I want to thank COL Chuck Engel for his mentorship and friendship over thelast couple of years. In addition, I want to personally thank Dr. Alisha Creel, who
has a Ph.D. in Public Health, Social and Behavioral Science, and is a great studentof stigma. As my key mentor during the MPH year, she guided me through directed
readings on stigma, most written by people who are in the room today.
Indeed, we have convened the world’s experts on stigma and we will soon hear9

10

Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism

Our first goal is betterfrom them. We also have experts from a variety of other areas. Together we are goingto think across disciplines to try to better understand this topic.
COL Hoge graciously allowed me to analyze his dataset to develop some newskills under the expert supervision of Dr. Creel. Dr. Bob Ursano has been an abso‑
lutely great mentor and a real gentleman, leading me through a mid‑career learning
experience. I would like to take this opportunity to thank him for all that he has
done.

understanding andthen to translate that
understanding into
action in the areas ofdealing with stigma andbarriers to care for our
three populations: those
exposed to war, disaster,and terrorism. We haverepresentatives from allof those areas of study.

DR. URSANO: Thank you, Mark. I would like to thank all of you for being here.
We brought together a diverse group of leaders in their fields who may or may notknow each other’s work and that is why you are each here. If you are only talking topeople that you already know we are not accomplishing one of our goals. We want
you to leave here with at least two new names of people who will be helpful and ofinterest to you in pursuing these topics. To help with this, in your packets we haveprovided a list of the e-mail addresses and affiliations of all attendees.
Our primary work today is a series of presentations and thinking together. Our
work tomorrow is to formulate today’s discussion into a set of recommendations,so you should capture ideas generated today that you want to bring up tomorrow.
Specifically, the goal tomorrow will be to take what we have learned and translate it
into a series of recommendations in the areas of education, training, leadership, andresearch. Our first goal is better understanding and then to translate that understand‑ing into action in the areas of dealing with stigma and barriers to care for our three
populations: those exposed to war, disaster, and terrorism. We have representatives
from all of those areas of study.
It is a great pleasure to have as our first speaker Ron Kessler. Ron is not only oneof the brightest people I have ever met, he is also one of the most gracious. As you allknow Dr. Kessler is a professor at Harvard. He has done most of the epidemiologic
studies that we all cite in our papers, including the National Comorbidity Study, theNational Comorbidity Study-Replication, and the related Adolescent Study. He is
the head of the ongoing World Health Organization (WHO) studies. He is also thedriving force in the Army STARRS (Study to Assess Risk and Resilience in Service‑members) study, which is our ongoing study of suicide within the Army looking at
risk factors and resilience. He is gracious and brilliant, and he is here to talk with
us today as well as to join the discussion. Welcome, Ron.

Mental Health, Stigma and Barriers to Care

2

Mental Health, Stigma andBarriers to Care
Ronald C. Kessler, Ph.D.

DR. KESSLER: There are a couple of reasons, at least, for studying stigma. One
is, of course, that we are interested in discrimination, the behavioral implications of
stigma, for example, discrimination in housing and jobs and in research. I do notknow how many of you have seen Ben Druss’ interesting paper in Health Affairs
which had a rank ordering of the societal burdens of different classes of illness anda rank ordering of how much money is given to research on those illnesses. The
biggest discrepancy is mental disorders.
Quite a bit of interesting work has been done in diverse ways concerning
behavioral implications and discrimination. Rich Hogan, who is one of my former
students, has done this fascinating work on the question of, “How do the community
mental health centers decide where to put a group home?” Essentially, what happens is that it is done in the middle of the night by stealth. When they discover thata group home is going to be put at the end of the block, communities mobilize, go
and get their local councilmen and lobby against it.
Over the years there have been a number of efforts by community mental healthpeople to meet with the neighborhood and tell them how mental illness is not reallyan illness and not really dangerous. What researchers have discovered through considerable practical research on this topic is that when they provide education to thecommunity in advance it only helps the neighborhood mobilize against them more
quickly. They discovered the best thing to do is rent the place, get in before anybody
knows, and then fight people off after it is too late. That is the practical implicationof the perceptions of mental illness in the community.
The aspect that I have been most interested in has to do with the other side ofit. That is, people who have mental illnesses know that other people feel this way
about people living with mental illnesses. One of the implications is that people havea great deal of reluctance to go for treatment. This is nowhere more true than in
the armed forces where the ethos is, “I don’t need help. I can handle things myself.”
There is good reason to think that embarrassment is an important cause of failure
to get treatment and an important cause of dropping out of treatment prematurely.
Premature dropout is a massive problem and I will discuss some data on that in a

11

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Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism

little while. This embarrassment is based, at least in part, on the perception of thestigma associated with emotional disorders, the idea that it is shameful to have amental illness, and that it is a character flaw.
There is reason to think that some of these attitudes might be changing. For anumber of years now the General Social Survey has been monitoring attitudes about
mental illness and has documented an increase in the perception that mental illness
is attributable to biological causes, rather than a character flaw. There has been an
increase in the perception that biological treatment is likely to be the most effective
kind of treatment. Part of the reason for this, presumably, is that there has been a
massive increase in public information about mental illness since the early 1990s
when Prozac became the first prescription drug to be advertised on TV.
I do not know how many of you are familiar with this but it is really not coincidence that in the last 15 or 20 years there has been this boom in understanding of
mental illness. I was, as it so happens, working as a graduate student at the National
Broadcasting Company in New York at the time that it became illegal to advertise
cigarettes on television. The television networks in their eagerness to improve publichealth and also, as an aside, to get a little bit more money, decided that it was a terrible thing that prescription drugs could not be advertised on television and started
something called the Prescription Drug Advertisement Coalition. They came together
with a bunch of pharmaceutical companies to lobby to make it legal to advertiseprescription drugs on television.
As it turns out there is some interesting economic evidence about this. Advertising on TV for eyeglasses, which also require a prescription, is illegal in some states.
It turns out that when you look at the states where you can advertise prescription
eyeglasses on TV, the cost of eyeglasses is only about 60% as high as in the states
where you cannot advertise. The result is that all of these eyewear shops only go
into the states where they can advertise because they make their money on volume.
In fact, being able to get this information out has a positive impact on getting
people access. That is not always the case, though. If you look at over-the-counter
medications, like Bayer aspirin versus aspirin, the companies that spend most on
advertisement raise the prices of their products more.
It is not always true that giving people more information is a good thing. For one
reason or another, the networks and the pharmaceutical industry combined to convince the FDA that there should be direct-to-consumer advertisement for prescription
medications. It just so happened that ruling occurred at exactly the time that Eli
Lilly developed Prozac, the very first drug that was advertised direct-to-consumer.
As you know, Prozac had this unbelievable uptake. The idea that depression is an
illness and that treatment was available was compelling. We now know that theeffectiveness of SSRIs and SNRIs is not that much greater than TCAs. There is a side
effect profile advantage. But the dramatic change in the number of people who were
getting treatment for depression was really unprecedented. It is hard to know which
was the horse and which the cart. It is true that direct-to-consumer advertising ofProzac coincided with front page feature stories about Prozac on the covers of Timeand Newsweek, and all of a sudden we became inundated with Prozac.
Subsequently, we have had many front covers of Time and Newsweek that havetalked about PTSD, stress, trauma, and suicide in the Army. Various famous people
have gone on the Tonight Show to talk about their depression and their drugs andhow they overcame it. There are lots of tell-all books, etc. If you look at the mass
media archives, the number of stories about mental illness in the past 15 years has

Mental Health, Stigma and Barriers to Care

increased dramatically. Based on that dramatic increase it is probably no surprisethat the treatment of mental illness has skyrocketed since the early 1990s.
I want to discuss aspects of the National Comorbidity Survey (NCS) and the
National Comorbidity Survey Replication (NCS-R). In 1992 and 2002, we didnational surveys and looked at rates of mental illness and treatment for mental illness. There was no increase at all in the prevalence of mental illness over the decade.
When you see changes in treatment it is not because there are more people who need
it. It is the same people who are changing their probability of getting help.
In 1992 we looked at specialty treatment, general medical treatment, and humanservices treatment for mental illnesses among people who have a severe mental illness
and those who have a less severe mental illness. The treatment went from about 4%
to 6% in a decade, up 50%. It is actually about a 60% increase overall in specialty
treatment from a psychiatrist, psychologist, psychiatric social worker or psychiatricnurse. General medical treatment increased from 3% to 9%, about a three-foldincrease in treatment in 10 years. The human services treatment, which is treatment
by a minister, priest, rabbi, social worker, or counselor increased by about 50%.
What is striking about this is when you look at the people who have a serious
mental illness such as schizophrenia, other nonaffective psychoses, bipolar disorder,
atypical psychosis, severe depression, and severe OCD, the changes are quite different
from people who have more garden variety disorders. Those who watch televisiona great deal are influenced by this advertising. If you look at specialty treatment,
the percent of people with a severe mental illness who received treatment froma psychiatrist did not change much. However, treatment for the people with lesssevere illnesses doubled. What may be happening due to the advertising boom isthat people who may not need treatment are going to see their psychiatrist. When
you look at the general medical sector, people with a severe mental illness are twice
as likely to get treatment with their family doctor. The percent of people with lesssevere disorders who sought treatment almost tripled.
One big difference is that in the early 1990s, of the people with severe illness,more were being treated by a mental health professional than by a general medical doctor. It flipped and it stayed flipped. If you look at more recent data, people
who have a serious mental illness are much more likely to be treated in the general
medical sector than in the specialty sector. As a result, the proportion of people intreatment has gone up over time. Conversely, the quality of treatment has gone downover time. There has been a decrease in the quality of care for mental disorders since
the early 1990s.
As people with severe disorders have gone to see their family doctor there has
been a dramatic increase in the proportion of those in treatment who are being
treated with pills and not with talk. As we know, combined therapy works better
than either alone but there has been a big shift toward treatment with psychopharmacology, particularly for men. It is clear that men do not want to talk about it:“Just give me the pill. Thank you.” That is probably better than nothing, but it has
implications. Now, we need to ask, “How much of this dramatic increase in treatment was due to a decrease in perceived stigma?” Were people less embarrassed
about going to care? “Everybody has this illness. After all it is on the front page ofTime magazine and I read this article that says that zillions of Americans have it.
Treatment is available. Why am I letting myself suffer?”
We were also interested in the possibility that people recognized that they had
an illness more so than in the past. In our early work with the NCS one of the most

13

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Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism

If you pull the NCS andstriking things we found was that when we asked people with disorders, “How comeyou didn’t get treatment for this problem?” They said, “What problem?” This is moretrue for some illnesses than others, such as excretion disorders. The real poster childfor this is social phobia. People who are painfully shy tend to say, “I’m shy. I’m not
sick.” That is not coded as an illness. Many people who have depression before it
gets severe feel that it is not an illness. Rather, it is simply, “I have an awful life.”
People who have panic disorder, on the other hand, go for treatment. They might
think they are having a heart attack so they get evaluated because it is clear that
there is something wrong. For many mental disorders it is not so clear.
Now, we looked at three things in our data that might have influenced thischange. First, to determine increases in recognition of a problem we asked people,“Was there ever a time in the last year when you thought that you might needtreatment for some kind of emotional problem?” Second, to assess perception that
effective treatment was available we asked people, “How much do you think thesetreatments for mental disorders help? Out of every hundred people who have an
emotional problem and go for treatment, what number out of a hundred is helped?”
Third, to assess perceptions about stigma we asked people, “How embarrassed
would you be if your friends or neighbors knew you had a mental illness? Howmuch do you worry that you would be discriminated against by your coworkers or
you wouldn’t get a promotion?”
We found that after a massive amount of money was spent on direct-to-consumer
advertising in the 1990s the perceived helpfulness of treatment had not changed
much a decade later. Forty percent of people versus 38% said it was very effective.
Thirty-five percent versus 37% said it was moderately effective. “It doesn’t reallyhelp many people at all” changed from 5% to 7%. The perception that you have aproblem did go up even though the percent of people in the population who had amental disorder did not change. What we are calling stigma, i.e., these perceptionsof concerns about somebody knowing about you having a problem, showed only amodest reduction but it was not statistically significant.
If you pull the NCS and NCS-R data and put in a variable for time you see an
80% increase in the odds of getting treatment in the decade, controlling for thedisorder. The more serious your disorder, the more likely you are to get treatment.
Getting treatment from a psychiatrist, other mental health professionals, and general
medical providers all moderately or robustly increased. Treatment from humanservices and self-help groups remained flat over the decade.
The question is, if we introduce measures of perceived need, stigma, and perceived effectiveness, does this change? The answer is no, which is not surprising giventhat these things have not changed much over time. To review, the more severe yourdisorder, the more likely you are to get treatment. If you are not worried about what
people think, you are more likely to get treatment. Perceived need for treatment isan enormous factor. Perceived helpfulness of treatment is not very salient in getting
people the treatment. It is noteworthy that whether you have a serious disorder or
not the perception is obviously more important than the reality.
Turning to the second of our two surveys, we found that many people are intreatment. Among those with a disorder in the last year, 41% were in treatment. Of
the people with a serious disorder, nearly two thirds were in treatment. Treatment
rates were actually quite high.
We asked the people who did not get treatment, “How come you didn’t get
treatment?” You see that a very high percent of them said, “I didn’t need it. It wasn’t

NCS-R data and put ina variable for time you
see an 80% increasein the odds of getting
treatment in the decade,controlling for thedisorder.

Mental Health, Stigma and Barriers to Carereally bad enough. What problem are you talking about?” This is less likely to be a
response among the people with a severe disorder than those with a mild disorder.
To the people who say they have a snake phobia, we ask, “Why didn’t you gettreatment for that?” They answer, “I live in an apartment in Manhattan. What do I
need treatment for my snake phobia for?” People who had suicide plans, who wereactively ruminating about killing themselves and were having a hard time functioning on a day-to-day basis, but who did not get treatment were asked, “So how comeyou didn’t get treatment for this problem?” They said, “What problem?” One outof every four of them responded this way.
Structural things such as not having insurance, not knowing where to go, longwaiting lists and so forth were not really all that important. Structural barriers
become more important for people who have severe disorders, because if it is severe
enough your inclination is to go and get help. The only reason you are not goingto get help is if there is something that really gets in the way. Thus, it turns out that
attitudinal barriers are not as important among people who have severe disorders.
“I want to handle it on my own,” is something that people frequently say. They do
not say as much, “I’m embarrassed,” but they say, “I want to handle it on my own.”
If we try this with a person with a broken arm it does not happen so much.
These comments do not really come up among people who say, “I don’t have aproblem.” Really, what we should be doing is looking at the people who recognizethat they have a problem. When you survey the people who do recognize they havea problem, structural barriers become a little more important and attitudinal issues
are overwhelming. These people have all kinds of good reasons why they cannot go
into treatment. If you figure out a way of refuting one, they have another one handy.
Elderly people, men, and those with more education are less likely to say they havea problem. It is middle class people who say, “Oh, this is not a problem.”
Structural barriers are more prominent for young people who do not have insurance, do not know where to go, or are married with obligations, and for people
who have more severe disorders. As I said, as the disorder gets more severe people
do not say, “I don’t need it.” They recognize they need it and practical stuff gets inthe way. These attitudinal barriers are there across the board.
Getting people to treatment is not the only place where stigma issues play apart. For the typical person who goes to a family doctor for treatment of a mental
disorder, the average number of visits is 1.7. There are not many evidence-based
therapies that work in 1.7 visits. We reviewed our data about whether respondents
were getting medication alone, psychotherapy alone, or both in combination, as wellas who provided the treatment. We then went to the literature to define appropriate
treatment.
There are quite a few people who have a major depressive disorder who are getting benzodiazepines alone, or people who have a bipolar disorder who are getting
Prozac without a mood stabilizer. That is not appropriate treatment. We discovered
even in these newer data that the quality of care for mental disorders in America
is absolutely abysmal. A big part of the problem is treatment dropout with people
quitting treatment before they get an adequate course of care.
For example, the median number of visits to a general medical doctor amongpeople who got treatment is one. They went once and they never went back. Theinter-quartile range is one to two, so one standard deviation above the mean is twovisits to the family doctor. We looked to say, “So where are you now? Are you stillin treatment? Did you complete the treatment? You’re cured or did you drop out?”

15

Structural things such as
not having insurance, notknowing where to go,long waiting lists and soforth were not really allthat important.

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Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism

We discovered that for most sectors the percent that dropped out is pretty close to
the percent who completed treatment and said they were cured. We found a dropoutto-cure ratio of 15% to 23% for psychiatrists, and 19% to 27% for other mental
health specialists. In the general medical category, 30% dropped out compared to
22% that continued what they thought was an effective course of treatment. Dropout is an enormous problem.
When we asked, “How come you quit?” sometimes people said it was not effective but very often they said, “It was not as painful anymore as it was before. I canfunction at least minimally. As soon as I can function at least minimally I can handle
it myself.” There is this embarrassment about getting treatment and people get out
very quickly. Dropout tends to occur early in the treatment course, particularly ingeneral medical. The more providers you have the less likely you are to drop out.
If you have a self-help group you are very unlikely to drop out. When you look at
the average number of visits to a self-help group in America it approaches 17 times
a year. Close to 50% of all visits for a mental health problem each year are visits
to a self-help group. It is a small number of people going a large number of times.
We originally thought self-help groups were competing with professional
treatment but that is not the case. It is worth noting that most people who are in aself-help group are in for reasons other than substance problems. The people whoare in self-help groups for emotional problems are often also seeing a mental healthprofessional of some sort. If you do both of those things your probability of dropping out of professional treatment is substantially lower than if all you are doing isseeing a professional.
It is interesting that in the mental health world we have not done much with
self-help. There is not a great deal of coordination between self-help and professional treatment. That is quite different in other areas of medicine. If you go to
Sloan Kettering in New York for example, people who are getting treatment forcancer are deeply invested in self-help groups. Nurses often run them for patientsand their families.
People who fly in from California for treatment are in treatment eight hours
a week. Five of those hours are with a facilitator in a self-help group, one hour iswith social workers, a half hour is with a resident, and two and one half minutes
are spent with a doctor. The idea is a pyramid of care where self-help is integrated
into the system and people feel that they are connected. The dropout problem isconsiderably lower in some areas than it is in psychiatry. It could well be that weshould focus our energy on some combination of these concepts.
What do we take away from this? The NCS-R and NCS comparisons demonstrate a dramatic increase in treatment with no real reduction in mental illness
stigma. Why did that occur? We originally thought recognition that help was available caused it. Clearly that is not going on. Then we thought there was an increasein the recognition of a problem. That does not seem to be it either. At this point
we honestly do not know the answer. Clearly some dramatic increase in treatment
occurred without changes in stigma and perceptions of treatment effectiveness. One
possibility is that there actually was a change in perception of stigma that we did
not pick up.
Sociologists in the audience may remember the work of Richard LaPierre. In the
1950s, LaPierre studied discrimination by calling hotels and asking if they would be
willing to have a black person stay at the hotel. The vast majority said no. Then he,a black person, showed up and registered. The vast majority of the hotels let him

Mental Health, Stigma and Barriers to Carein. What people tell you and what they actually do are not always the same thing,
and the disparity is not always in a bad direction. It could be that our simpleminded
questions just did not work very well.
You might be familiar with Charles Turner’s work published in Science a numberof years ago which used ACASI interviews to get information about stigmatizing
behaviors. These interviews are administered with a laptop at a person’s house.
You plug in a little headset on it, turn around the computer and let people answer
the questions privately. Essentially the computer will digitally ask a question suchas, “How often do you have sex with small animals - often, sometimes, rarely, or
never?” You just punch in the answer and then the computer will follow up with aseries of questions.
Turner did a series of experiments in which a random half of the respondents
were asked, “How often do you have sex with small animals?” Then the otherrandom half of the people had the question asked privately on the computer. They
found that when you ask the questions in a private, less embarrassing way, more
people admit to stigmatizing behavior. They found that people were more willingto admit drug problems, sexual things, illegal things, but not mental illness. There
was no change. Does that mean that mental illness was less stigmatizing, or does itmean that it was so much more stigmatizing than having sex with a small animal
that people would not admit to it? There is good reason to believe that it was theformer— that actually mental illness is becoming less stigmatizing than it was in
the past.
These techniques represent an interesting paradigm that we have not tried instudies of stigma. To the best of our knowledge it looks like people are willing totell you that they have these problems if they are asked in the appropriate way. We
know from the work of Greg Simon and colleagues that when you pose mental
health screening questions in a primary care waiting room, patients will check off
the boxes in very high proportions, even though most of them are likely not there
for treatment of the emotional problem.
We also know from those same studies that when you do thoughtful outreachwith stages of change interviewing, you can get a substantial proportion of thosepeople into treatment. If you use thoughtful case management, such as that being
implemented in RESPECT-MIL, you can keep them in treatment. The problem wehave is that case management does not often happen, and when they get typicaltreatment it is so lousy that it is not worth the effort to get them into treatment.
What I conclude from this is that stigma is not that big of a deal, at least for thethings I am interested in. Stigma, as a practical matter, is probably doing quite a bit
to get people not to reach out for help.
I did not show you the data about reasons for dropping out of treatment but
it is clear that we can implement structural processes to reach out to people, getthem into treatment, and keep them in treatment. The question is, “Do we want to
get a worldview change in the way the world sees mental illness, or do we want tomake practical changes to get them to enter and stay in the treatment?” My guessis that the latter is going to be more effective in the short run. To the extent that
we can work on the former, that is great—but I would not hold my breath. I think
the action is in trying to do outreach, recognize that there are embarrassment issues
and that they do not go away when the person gets into treatment. They are still
there—sometimes bigger—so you have got to keep holding their hand. We could

17

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Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism

do much better, at least on the treatment side, if we address those things in a moreproactive way rather than a societal way. Thank you very much.
DR. BELL: Do you have any idea about how people are welcoming prevention?
DR. KESSLER: Yes, we have done rigorous research and discovered beyond a
shadow of a doubt that people want to quit smoking after they have cancer. It ismuch more difficult before they have cancer. Prevention is a very tough sell. Further,early intervention is something that is in a woefully neglected state of affairs in themental health arena. Hendricks Brown can tell you from his work at Hopkins withbehavioral researchers that at the age of four, children already have mental illness.
So we could try prevention and early intervention, but you have got to start at about
six months of age if you want to do that.
What is more important is that the vast majority of people with a mental
disorder do not get into treatment. In our data if you look at age of onset of yourfirst mental illness and age of first contact with a treatment system, the differenceis 12 years. Most people who have serious disorders in adulthood have onset inchildhood and get treatment when they go to college, join the military, or get intoa relationship that falls apart at the age of 22. I wish we could do a better job ofearly intervention with mild disorders when people are in pain and are interested ingetting treatment. There are lots of kids out there, usually sitting in the back of theroom, the quiet kids who are scared to death, who would love to have somebody
reach out to them. They are not going to seek care of their own volition. That isthe biggest bang for the buck. Early intervention, primary prevention of secondary
disorders to try to influence the course of illness, is really where the action is. Of
course, we know exactly where these kids are five days a week, nine months a year,
from 9:00 to 3:00. It is a crime that we are not doing more in the schools.
DR. HENDRICKS BROWN: Ron, do you have any information on changes instigma associated with mental disorders after September 11th?
DR. KESSLER: We do, however I have never looked at that. It turns out that
we were in the field then and half of our survey was done. We could see a clear blipin 30-day prevalence of disorder. We did not see any blip at all in lifetime disorderwhich is comforting. It likely means that most of the people who had the extreme
distress reactions were people who had a history of disorder in the past, but wenever looked at the stigma issue.

Stigma and Barriers to Care in Military & Veteran Populations

19

3

Stigma and Barriers to Care in
Military & Veteran Populations
Charles W. Hoge, M.D.
Paul S. Hammer, M.D.
Matthew J. Friedman, M.D., Ph.D.

DR. URSANO: I am pleased to introduce our first panel, Charles Hoge, Paul
Hammer, and Matt Friedman. Charles Hoge has led much of the effort in military
psychiatric epidemiology throughout this war. He is an epidemiologist and psychiatrist by training. Matt Friedman is the Director of the National Center for PTSD.
Paul Hammer is the Director of the Naval Center for Combat and OperationalStress Control in San Diego.
DR. HOGE: In 2004 we put the stigma discussion on the map by observing thatconsiderably more than half of the soldiers and marines who we surveyed, and who
seemed to be in need of treatment, indicated that they had not received any treatment. Based on the responses to the survey, it appeared that stigma and barriers tocare were important components to that. We did not have a causal relationship, butthere has since been other work on that question.
I will present some of the data from the Land Combat Study. One of the earlier
observations was that those soldiers who met screening criteria for PTSD, depression, or generalized anxiety had a much higher rate of endorsing stigma items thansoldiers who did not have a mental health problem. We surveyed attitudes that might
represent barriers to care using questions such as, “I’d be seen as weak by membersof my unit.” Or, “leadership might treat me differently.” “Members of my unit might
have less confidence in me.” We also explored barriers of an organizational sort,such as can you get an appointment, can you get to the appointment, and so forth.
Tom Britt did factor analysis and confirmed that those two categories of questions
related to stigma and barriers differentiated into two nice groups.
Some of the work conducted since then indicates that there is actually a third
component, and Ron Kessler alluded to this in his work. It begs the question, “Whatis stigma?” What is it that prevents people from coming in to get help when theyneed it? What are the predictors of not coming in to get help? Is it because I would
feel embarrassed? Is it because I don’t have adequate transportation? Or that I can’t
get an appointment? Other factors may also play a role, such as I don’t trust mental

In 2004 we put thestigma discussion on
the map by observing
that considerably morethan half of the soldiersand marines who wesurveyed, and who
seemed to be in need oftreatment, indicated thatthey had not received any
treatment.

20

Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism“Has stigma changed

health professionals or I don’t think it’s going to work. Or, I think I can handle iton my own, which is the construct that Ron was talking about.
We have looked at several questions. One is whether stigma has decreased since
the start of the war. We have had massive education campaigns. We have a post
deployment health assessment process and post deployment health reassessment
which came into effect a couple of years after the start of the war. Has it made adent in stigma? Are there differences between the Reserve and Guard with respect
to stigma and changes in stigma since the start of the war? Finally, what otherconstructs should be considered?
So in the first question — “Has stigma changed since the start of the war?”—the answer appears to be “no,” at least based on in-theater Mental Health Advisory
Team (MHAT) data collected since the start of the war. I think this is very consistent
with what Ron showed in the civilian population between 1992 and 2002. We havedone three samplings in Afghanistan and every year since the start of the war in Iraq.
There are some Reserve and National Guard differences. We are finding that theactive component seems to have higher rates of stigma than in the National Guard.
I think that may have to do with organizational differences in terms of the higher
OPTEMPO deployment cycle, short dwell time, and the fact that there probably aresome cultural differences to seeking care in the active component compared to the
National Guard. Once the National Guard members come back and demobilize,
they are particularly interested in getting care after they have been home for several
months.
There are other relevant constructs around receiving help that are in need ofinvestigation. Mark Brown and Alisha Creel have done analyses of these constructs
in their work recently, as has Tom Britt. There are some other interesting things
including perception of how I would be viewed versus how I would view others whoseek help from a mental health provider. This is work that Sebastian Schnellbacher
did during his residency at Tripler Army Medical Center. It is very interesting thatthe perception that I would be seen as weak does not correlate with the perceptionthat I would see another soldier as weak if they sought mental health care. Again,
the perceptions of stigma are very individual and personal.
There are three factors to consider when we talk about the concept of stigma:
stigma, barriers, and then attitudinal perceptions. Then there is the difference
between perceptions of how I would be treated versus how I would treat others ifthey seek treatment. We have not seen much of a dent in stigma over time. How
is stigma going to change, in society at large or in the military culture, if we havenot made much progress since 1992, despite a large change in the way in which weperceive mental illness?
One of the questions I am grappling with now in my clinical practice is, “Justwhat is mental illness, exactly?” For instance, if you believe Ron Kessler’s data fromthe National Comorbidity Study, half of everyone in this room will in their lifetime
have a mental illness.
How many people in this room have a close relative who has a mental healthproblem?
This means that mental illness is part of the fabric of what it means to be human.
Then the question arises: Is there anything that we can do as mental health professionals to change the way in which society views mental illness, and in what way
are we as mental health professionals contributing to the problem?
It is possible that we are contributing to stigma at times in subtle ways which

since the start of thewar?”— the answer
appears to be “no,” atleast based on in-theater
Mental Health Advisory
Team (MHAT) datacollected since the startof the war.

Stigma and Barriers to Care in Military & Veteran Populations

we do not even realize. For instance, consider the soldier in Iraq who experiencesa devastating loss of his buddy from an IED explosion. When he cannot get out of
bed the next day, his commander thinks he should be able to get out of bed and his
unit peers think he should be able to get out of bed.
Eventually, he gets air evacuated back to Walter Reed for “PTSD” and is put in
the WTU where there is some sergeant whose job is to make this guy get out of bed
and come in and get care.
Then he meets the mental health professional who says, “You’ve got 17 out of
17 PTSD symptoms and you need treatment. There are two treatments of choicethat are approved and certified in our treatment facility. These are prolonged exposure therapy where you can talk about your worst traumatic event in present tense
repeatedly until you feel better. Or you can reframe your thinking, your ‘distorted’
way of viewing the world that has resulted from this experience.”
The soldier is incredulous. He does not want to get out of bed because of thedevastating impact the loss and grief has had on him and the awareness of the pointlessness and senselessness of the situation he has been through. He does not want to
get out of bed to come see a mental health professional who says he is “crazy.” Who
is “crazy” here? Is he the one who is “crazy” or are we “crazy?” I submit that he isactually the one who has the more accurate perception of reality. Every message,
implicit and explicit, that he receives from the medical professionals who treat him
reinforces societal perceptions. That is not necessarily going to lead him or encourage
him to continue with treatment, and this may be contributing to our high dropout
rates from therapy.
The overall effectiveness of most of the treatment that we have for PTSD isrelatively poor. The recovery rate is around 40%, maybe 50%. You may get some
symptom resolution in a higher percent of people, but not full recovery.
The data show that one principle reason we do not see higher recovery rates isbecause people drop out of treatment. Then I think the question for our patients is,“Who is crazy?” Is it them or is it the folks who are around them? Until we start tolook at mental illness as part of what it means to be human, there is not going to
be any change in stigma.
If you want further information on any of my comments, please see my new
book, “Once a Warrior, Always a Warrior.” Thank you very much.
DR. HAMMER: The title of this particular segment is, Stigma in Military and
Veteran Populations. I would like to propose that we change the word “populations”
to “culture.” I think the context of culture is critical when we start talking about
stigma and barriers to care.
I think about stigma in three ways. First we have the institutional factors that
we talk about with stigma, such as policies, rules and regulations. Rules tend topromote things that may not make sense from a scientific or rational point of view
but we follow them because they are rules.
For example, you cannot take an SSRI and be on a submarine. Why does thatrule exist? Or you cannot carry a weapon if you are on an SSRI. There is actually norational basis for that other than we do not want “crazy people” carrying weapons.
Those institutional things are relatively easy to fix. You simply change the rules.
The other two parts to consider are the external and the internal factors impacting on military context and culture. An example of an external influence is seen in
the misperceptions of people, the images in the media, and the terms that are incommon use. Last night, while watching Law and Order SVU, I was amazed to hear

21

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Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism

The problem comesthe portrayal of a serial killer described as having schizophrenia brought on by his
PTSD. Who wrote that! In this day and age, when we understand so much more
about mental disorders, a writer carries on this wild old Vietnam veteran stigma of
the crazy Rambo who is going to go out and kill everybody.
I think that what happens internally is most important. Charles Hoge and others have alluded to the relationship of the individual and how she perceives herself
within the culture. What is her identity as a member of a larger group and does her
perception of having something that we define as mental illness make her separate
from her larger perceived group? As a former Marine, I like to use the example ofMarines because they are so clear and distinct in many ways. What makes a Marine
a Marine? If you take a kid who is 18 years old, shave his head and put him in theright uniform is he a Marine? No. It is not until he has gone through boot campand had that collection of shared experiences, taken on values, taken on particular
attitudes, and taken on a certain level of training that he becomes a Marine. It is notjust Marines. It is the same with soldiers, sailors, airmen, Coast Guardsmen, police
officers, fire fighters and disaster workers. You become that person. You incorporatethat training as part of your identity. You take on the warrior code and you incorporate that external set of cultural norms and external experiences into your identity.
When a warrior is wounded, we have warrior transition units, wounded warrior
barracks, wounded warrior regiments in the Marine Corps, and Safe Harbor in the
Navy. These are places where wounded warriors go to recover and they wear theirstigma of physical injury with pride. Their amputated limbs or the scars that they
have from the numerous surgeries are worn proudly as badges of honor.
The problem comes when we have to deal with the invisible wounds of war,
the wounds from psychological trauma, from fatigue, from loss and grief, and evenfrom moral injury of having to deal with the ambiguous, difficult, and untenablesituations into which we place our young men and women when we send them towar. The treatment of these unseen, invisible wounds is difficult. While it may not
require great physical pain, numerous surgeries, or refitting prostheses on amputatedlimbs, it demands dealing with the questions, “Who am I now? Where do I belong?
What have I become? Has this turned me into somebody who is no longer a warrior? Am I now a member of some other group?” In the mind of the warrior, that
other group may include that guy who is living in the park homeless. “Am I going
to become that burned out guy who is hopelessly cynical and going to numerous
self-help groups? Am I no longer a warrior? Am I no longer a proud, fit, active,
engaged, fired up, strong young man or woman? Am I now a wounded, damaged
person? What have I become?”
Regarding PTSD, there are many tasks in treatment and most require integrating
the experience of what happened to the Marine in war into her current identity. The
treatment often requires a certain level of “mature intimacy,” a term I have borrowed
from Bessel van der Kolk’s book about traumatic stress. Successful treatment requires
the capacity to bear pain in the presence of another human being. Together, patientsand therapists must confront the conflicts, ambiguities, inconsistencies, and difficult
issues, and tolerate them while going through this process of recovery—to look atthem openly, honestly, and drop that “image armor” of a warrior long enough toaddress those deeper issues requires that you become vulnerable.
As I have implied, vulnerability is the antithesis of the warrior ethos. As a warrior you rarely want to talk about vulnerability. You only talk about that in termsof infantry tactics and addressing vulnerabilities to the security and protection ofwhen we have to deal
with the invisible
wounds of war,
the wounds frompsychological trauma,
from fatigue, from loss
and grief, and evenfrom moral injury
of having to deal
with the ambiguous,difficult, and untenablesituations into which
we place our young
men and women when
we send them to war.
The treatment ofthese unseen, invisible
wounds is difficult.

Stigma and Barriers to Care in Military & Veteran Populations

the unit. As a warrior you never want to be vulnerable because we have asked ourpeople to do incredibly difficult, insane things in the name of serving their country.
Nobody enlists saying, “I think I’m going to get a job requiring that I go out and get
killed.” They say, “I’m going to serve my country, and I’m going to be proud.” They
are going to do this wonderful thing and we collude in disguising the true nature of
their job with its inherent risks.
The question is, “Can we make this process of dropping the image armor andallowing for vulnerability part of what happens within the culture?” My vision isthat two Marines are walking along on base and one says to the other, “I’m goingover to the hospital for my therapy.” His battle buddy asks, “Is it physical therapy
for your knee?” He replies, “No, no. My psychotherapy.” His boddy replies, “Okay.
See you at 1500 when you get back.”That is the conversation I want to hear, but I do not think it is going to happen
anytime soon. When we reach that point, we will have incorporated psychotherapy
into the larger culture. We need to discover how we can make vulnerability and careseeking an acceptable part of the culture, part of their identity, in a way that does
not make people feel weak, excluded or part of the “other” group. The individual
Marine, soldier, sailor, airman, and veteran will not be reassured that his status
within the group is secure until we really make it part of the culture.
DR. FRIEDMAN: My job is to talk about VA (Veterans Affairs) work on stigma.
I have identified two good studies that I think will expand the context of the discussion that we have started.
First is a study by Tom Britt which raises the issue of social support and social
context. This was done in the setting of a post-deployment screening for mental andphysical problems. One finding was that people expressed more discomfort disclosing mental problems than physical problems. In this survey sample, some of thepeople were there with their units and others were by themselves. Those that were bythemselves felt more comfortable disclosing psychiatric or psychological problems.
I think that social context, as others have begun to suggest, is very important.
Tom Britt’s work shows some of the predictors of people not coming in fortreatment: younger age, being male, nonwhite, active duty, with no social support,
and a strong need for personal control, “I can do it myself. I don’t need help fromanybody else.”
The second study I want to talk about was done by Nina Sayer and her colleagues at the Minneapolis VA. This was a structured interview given to 44 veterans,some from Vietnam, some more recent, some male, some female. All of them had
filed a disability claim for PTSD. They all had recognized that they were somehow
disabled and wanted to be compensated, yet only about half of them were actuallyin treatment. The other half were not in treatment but their opinions were fairly
comparable.
There are several barriers to care that were identified from these structured
interviews. The first one has not been mentioned yet, but is important to note,
although perhaps limited to PTSD. Part of the PTSD construct is the avoidance
symptoms, which extends to treatment-seeking. People do not want to talk about
what happened to them. They do not want to have to relive it. That is why rape
victims do not press charges. Well, the same thing is true for servicemen and servicewomen regarding their military experiences. This tendency has been addressed bysome of the previous speakers. That is, the individual’s values and priorities stand in

23

Part of the PTSD
construct is the
avoidance symptoms,
which extends totreatment-seeking.
People do not wantto talk about what
happened to them.
They do not want tohave to relive it.

24

Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism

The findings showed

opposition to treatment-seeking. A pride in self reliance exists, and the mental healthproblems are much less important than maintaining a job or a family.
Treatment-discouraging beliefs get into the perception that those who have notshared in the combat experience simply cannot understand it. “If they haven’t been
there, they just aren’t going to be able to understand and help me.” Some otherbeliefs include, “Treatment doesn’t work,” “I’m relinquishing control,” and “Theycould lock me up if they knew how crazy I feel sometimes.” This view was prominent
among the older veterans, the Vietnam vets that need treatment.
Some of the other stigma issues you have heard about include, “Treatment isfor those who are weak, incompetent,” or “It’s only for the really disturbed and I
certainly don’t fit in that category.”
There are system concerns, including limited resources. However, perhaps forthe first and only time in history, the different veterans groups have agreed thatthey do not want their mental health treatment outsourced. They do not think thata community-based civilian provider could possibly provide the kind of treatmentthat a VA practitioner could provide.
Knowledge barriers also pose a significant problem. Veterans do not understandwhat treatments and resources are actually available. Many OIF and OEF vets do
not know that they have five years of eligibility at the VA, no questions asked. The
area of military sexual trauma is an important issue that has not been mentioned
yet, and it is very stigmatized. Access barriers have also been highlighted. The onerous paperwork one must complete, taking time off from a job, and, particularly for
women, childcare issues are all cited as access barriers.
Finally, the authors described the “invalidating post-trauma social environment”
affecting people who have had bad experiences becoming unwilling to take anotherchance that they may not receive support. Vietnam vets in particular who had avery negative homecoming are not going to risk outing themselves and going fortreatment. This may represent PTSD withdrawal, but it is partly related to sufferingwith a stigmatized health condition.		
The third study I am going to talk about was done at the National Center for
PTSD by Rob Pietrzak and Steve Southwick. This study involved a questionnairethat was mailed to a thousand military returnees in Connecticut. They had a 27%
response rate to questions on a wide variety of issues including barriers to care andbeliefs in mental health treatments. The majority of the population were aged 20
to 30, white, with some college, married, serving in the Army, mostly Guard andReserves, and in theater during 2004 and 2006, having completed one or two deployments. Most of them were working, so it was a fairly functional group of people.
The findings showed that on both the perceived stigma scale and the perceived
barrier scale, the people with PTSD were much more likely to endorse these items.
Interestingly, those people who were positive for depression or substance misuse
were not more likely to endorse items on these scales. At least in this cohort, PTSD
seemed to be uniquely predictive of endorsement of stigma and barriers to care.
Another element that was done very nicely by these investigators was asking
specific questions about psychotherapy and psychotropic medications. Again, thepeople with PTSD, in contrast to people with the other mental health problems, weremuch more likely to express negative beliefs about psychotherapy and psychotropic
medications.
Despite these stigma issues, people are coming in for treatment. The VA’s market
penetration has traditionally been about 20% of veterans. It is now over 40% andthat on both theperceived stigma scale
and the perceived
barrier scale, the people
with PTSD were much
more likely to endorsethese items.

Stigma and Barriers to Care in Military & Veteran Populations

heading toward 50% among the OIF and OEF cohort. Whatever their belief system
is about stigma, mental health, or psychotherapy, people are coming in for treatment. That may have some very interesting effects in terms of how they feel about
themselves for doing this.
I found it interesting that if you thought that medication did not help, you weremore likely to seek counseling. If you thought that therapy did not work, you weremore likely to go for medication. Again, beliefs are clearly affecting behavior. It isalso interesting that the beliefs about medication and psychotherapy, and beliefs
about treatment were completely independent of perceptions of stigma or barriers
to care.
When they did a multivariate analysis, they found that the people who hadreported greater unit support in theater and good unit cohesion were less likely toendorse those barriers to care or stigma items. People who had negative beliefs about
mental health care were more likely to endorse them. This group is now looking at
some data about social support among families, and it seems important in treatmentseeking, so this social support factor is something we ought to talk about as well.
To summarize, we need to understand the unique contribution of PTSD to suppressing treatment-seeking in terms of the avoidance, the alienation, and the lack ofsocial support. Erroneous beliefs about treatment further exacerbate this.
I am going to finish with results from Nina Sayer’s structured-interview study of
44 veterans. In addition to asking why they did not seek treatment, researchers also
asked, “What would make things better? What would make it easier for you to comein for treatment?” Remember not everyone in this group was treatment-seeking eventhough they all perceived themselves as having a PTSD related disability. One of the
key items was a recognition and acceptance that PTSD is a treatable problem andthat help is available. Secondly, recognition that getting help is socially acceptable,
and that the system of care is trustworthy, delivering confidential care, would encourage help seeking. Finally, social networking with other vets, peer-to-peer programs,
as well as incorporating family and employers, are very important areas of emphasis.
Hopefully I have added a few things on the table for our discussion. Thank youvery much.
DR. ESTROFF: Part of what I have been thinking about for the first two sessions
is this emphasis on getting people into care, that this is what we need to do. We
have already agreed that the system needs to be improved, the care is not optimal,
and we do not have capacity. Despite this, we have emphasized, “This is what theyneed to do. They need to come to us.” If we want to do something concrete, I would
argue that we need to improve the quality of care and have greater capacity. To me
there is an obvious disconnect. If they come to a place that is not so good they are
not going to come back. It is a question of what you are fore grounding and what
you are back grounding. Coming to care in a system that you perceive as toxic or
ineffective is sometimes worse than not coming. At least in our research, people talkmore about symptoms of treatment rather than symptoms of illness.
DR. BELL: One other serious problem I have seen is this notion of media epidemiology. I think the public gets its ideas about prevalence not from science, butfrom distorted media reports. This drives people in the wrong direction which isa serious problem in terms of help seeking behavior. My sense is that we scientists
do not market our knowledge well, so people are walking around with the wrong
ideas about what is going on.
DR. HOBFOLL: I want to follow up on Dr. Estroff’s comment. At an important25

When they did a
multivariate analysis,
they found that thepeople who hadreported greater unit
support in theater andgood unit cohesion
were less likely toendorse those barriers
to care or stigma
items.

26

Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism

level it is as simple as this: if people who walk into a room get poked in the eye witha sharp stick, they do not walk into the room anymore and they tell their friends,“Don’t go to that room.” That is especially true in military or other predominantly
male and performance-directed contexts.
To expand it a step further, psychology and psychiatry are both professions basedon what is comfortable for the provider, which is to be in a room and to write scripts.
That is really easy to do compared to say, going into a coal mine. Or, even worse, you
conduct psychotherapy on a comfortable couch because you get to sit with coffee
and talk to people as opposed to working with the media on the consultant level.
We need to consider being much more multi-faceted in the kinds of things we train
mental health professionals to do. If we moved more toward education and skillbuilding in our continuum of care we could become de-stigmatized as a profession.
As we help people become more resilient, then everyone goes for that at some level,
and we are easily moved to the next step.
I would also say that we have known all this throughout my whole career. I wastrained as a community psychologist so it was pushed on me a little more. The question is, “Why don’t we do those things?” Why are we stuck doing the same things
wrong and looking at societal stigma and other things that we already know fromthe past how to change?
DR. HAMMER: Part of the problem is that there is a perception that we should
just give a pill and it will be alright. Treating PTSD is hard work both for the patientand for the therapist. If you are going to do it you had better get down in the mudwith the patient and be willing to get dirty. It is not going to be comfortable. It is
not going to be easy. Our responsibility is to acknowledge that and to dig in andget better at it.
DR. FRIEDMAN: I do not agree with some of the comments that have beenmade. I think that many people in this room do know about getting down in the
mud and going where the patient is. I do not think we need to be preached to aboutsome of that. I also do not agree that we have nothing to offer. If we get people tocome in, I think we have a great deal to offer. However, there are two different levels
on which we have to have this discussion. One is on the traditional patient/doctor
clinical discussion.
However, the other discussion that is in some ways more important is at the
public health level, where the mental health team is not a psychologist, a psychiatrist,a social worker or nurse.
It is someone who understands how to use the media, someone who is a sociologist or an anthropologist. We are starting to learn that. It is not what we weretrained to do but many of us realize that it is what we have to do.
I do think there have been efforts to increase capacity. The treatment that isavailable is better, so I cannot agree with some of these negative characterizationsof what we have to offer and what we are trying to do.
DR. ESTROFF: I do not want to be misunderstood. Most of us who work, andhave done research in the public mental health system in the US know that the quality of care is not great. I have to say in the several weeks that I have been trying tolearn about what goes on in the armed services, I am pretty impressed. I have been
to all the websites including Wounded Warriors and Battlemind. These are amazing
so I am not saying that the armed services do not have things to offer people. It
is part of the general situation when you are out of theater and back home. Sure,
there are people who can do it but it is not widespread. We know the quality varies

Stigma and Barriers to Care in Military & Veteran Populations

tremendously so it is about making sure that when we are working so hard to bringthem in they are going to have a good experience.
DR. HOGE: I think it is both. The reality is that there is a huge benefit in seeking treatment. What we do in mental health and the incredible programs that havebeen stood up in DoD and VA in particular, is extraordinary. The reality, though, formany individuals who seek treatment within our system is that they have negative
experiences. There are some fundamental assumptions we make about the nature oftreatment, treatment effectiveness, and the application of evidence-based practices.
For many individuals evidence-based treatments are inflexible and end up being
detrimental because every individual has an extremely personal experience requiring a tailored approach. There is no way we can tell that individual what they needin order to get over that experience, to integrate it into who they are now, to once
again have meaning, joy, and purpose in their life. I sometimes try to get my residents
and cofacilitators in PTSD groups to do a moratorium on the terms, “You need to.
It’s important to consider. You need to consider.” They almost become completely
incapable of speaking when you do that.
DR. RUZEK: I work in the VA system at the National Center for PTSD. There
are people who actually do engage in treatment. In many different treatment programs within the VA the normative experience is an attitudinal change. It would bevery interesting to see studies of people moving through the treatment process andhow that affects their views of mental health participation. In fact, what we usuallyfind in VA PTSD treatments are a range of experiences, including negative ones.
People who pass the threshold of five or six visits end treatment with tremendously
positive views of the treatment experience, the treatment providers, the caring of
the providers, their views about the importance of disclosure, and their willingness
to disclose.
One of the untapped tools for us to change attitudes towards treatment is tobetter capture those success experiences, to magnify the perceptions of benefit, andchange the perceptions of what happens in treatment. We ought to be videotaping
testimonials about treatment. It is possible that the stigma of treatment inhibits thosesuccessfully treated individuals from having conversations with the body of veterans
who are not seeking treatment. We want to get veterans and active duty treatment
participants talking about their treatment experiences.
DR. LINK: I am speaking as a stigma researcher and coming back to theexchange that Sue Estroff and Matthew Friedman had. Perhaps the facts about
treatment capacity are disputed, but the extent to which capacity has not developed
through history could be due to stigma. Also, regarding the concern that if everybody
came to treatment we would not be able to take care of everyone, we might consider
a shift in our frame of reference. I was interested in thoughts about the culture andwhether you can imagine helpful interventions that have to do with the culture of
the soldiers and how they deal with each other. We could explore not just whatclinicians can do, but what the context can do to help with these kinds of problems.
DR. RADKE: I am the State Medical Director for the Minnesota Department of
Human Services and Chief Medical Officer for State Operated Services. We run all
the disability programs in the state. My perspective is from the public mental healthsector. Obviously, we know we are running a fragmented, discontinuous, gap-filled
system, or lack of a system. In spite of that people come to treatment or they arebrought to treatment. The point I want to make is that a person with schizophrenia
does not come to treatment or get brought to treatment because of their psychosis.

27

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Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism

We have a threshold,

They never end up in the hospital because they are psychotic. They end up at thehospital because of their behaviors. Those behaviors have either become overwhelming for the individual or overwhelming for the society. Those behaviors have gotten
so painful and have produced so much suffering for the family or the individual thatstigma is overcome by the fear of loss of control.
That is a powerful point because it is not what we should be doing in our society,but that is what we do. We have a threshold, a barrier, stigma, a fear of the systemthat has to be overcome by tremendously difficult and painful behaviors. You would
not say that about somebody who needs surgery or an internal medicine clinic, but
you can say that about somebody coming to the mental health system. That worries
me a great deal because no matter what we do—fill all the gaps, become continuous, comprehensive, resolve the fragmentation—if we do not resolve the barrier ofstigma and the fear of the system, we will only bring people in when their pain andsuffering is such that they cannot resist coming.
DR. URSANO: Alan Radke’s comments also touch on the differences between
internalizing and externalizing disorders, and how they may be affected. I know Ron
Kessler has data on some of those issues.

a barrier, stigma, afear of the system thathas to be overcome bytremendously difficultand painful behaviors.

Stigma and Barriers to Care in Disaster

29

4

Stigma and Barriers
to Care in Disaster
Dean G. Kilpatrick, Ph.D.
Sandro Galea, M.D.
Stevan E. Hobfoll, Ph.D.

DR. URSANO: I am pleased to introduce our next panel. We are shifting frommilitary to disaster with the leading epidemiologists and social scientists in the worldon this topic. Dean Kilpatrick and Sandro Galea have led the way on the issue of
psychological first aid (PFA) and understanding resource loss and its contribution
to recovery, illness, and disease.
DR. KILPATRICK: As we have heard this morning, the notion that there isstigma and that many people who could benefit from treatment do not seek treatment, is not limited to disaster victims. I am going to address several questions about
disaster victims per se. One of them is, “What do we know about help seeking formental health problems among disaster victims who have PTSD?” What special
characteristics of disasters create unique barriers to care that are not present in someof these other situations? What do disaster victims tell us about stigma and otherbarriers to care? Why do disaster victims have concerns about getting mental healthtreatment and whether it works? Most importantly, what are some of the new ways
to address stigma and overcome barriers?
Sandro Galea and I have conducted several studies with support from NIMH
about various types of disasters. All the studies got information about PTSD andseveral of them also gathered information about help seeking from mental healthprofessionals after disasters. I want to briefly run through some of the disasters andpresent some of the data about help seeking among PTSD sufferers after these events.
First, I am going to talk about some relevant older studies including Hurricane Hugo,
which first peaked my interest in disasters and mental health. Later, I will touchon the Oakland Hills fire, the Sierra Madre earthquake, and the Los Angeles civil
disturbances, so an array of different types of disasters will be discussed.
Hurricane Hugo was a category 4 storm with very strong winds which produced
a fair amount of physical damage over a very broad area, including where I live. The
Oakland Hills fire storm happened in 1991 and destroyed a great deal of acreage
and many homes. Again, this was an expensive storm in terms of the amount of“What do we know
about help seeking
for mental healthproblems among
disaster victims who
have PTSD?” What
special characteristics
of disasters create
unique barriers to carethat are not present
in some of these othersituations?

30

Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism

The leading response

damage. Many people narrowly escaped with their lives and little else. There weresome people who were killed. We located people who had been affected by the firestorm and interviewed them three to eight months after the fire.
An earthquake occurred in 1991 in the San Gabriel Valley of California. Even
though it was a moderate earthquake in terms of deaths, injuries, and economic
damage, it was particularly difficult psychologically because there had been four
earthquakes in that same general area within a short period of time. We wereinterested in the cumulative trauma that might magnify the effect of a moderate
earthquake. Again, involved adults were screened and interviews were conducted
between four and seven months after the earthquake.
The final disaster I will discuss is the L.A. Riots project. It was the largest civil
disturbance in quite some time in the United States. There were a number of people
killed, many injuries, and much damage. Due to widespread media coverage, theeffects were not limited to South Central L.A. but incorporated the whole of L.A.
County. We over-sampled from South Central L.A., the main area of civil disturbance. Then we conducted these interviews in both English and Spanish. There
were 1,200 people interviewed overall, with a high participation rate in this study.
What I want to illustrate here is that among these people with PTSD across a rangeof different disasters, fewer than 50% in each of those four studies sought mental
health care.
I am poaching on terrorism territory here, but we were involved in a study of
the Pan Am 103 bombing and it was a disaster initiated by terrorists. I want tospend a little time going over the predicate for this. Before 9/11 there were moredeaths associated with this act than any terrorist attack in U.S. history. The Officefor Victims of Crime, which is part of the Justice Department, developed somespecial services for family members in this case. They approached us at the National
Crime Victims Research and Treatment Center to do an assessment study of theservice utilization and how satisfied people were with services to make recommendations for changes in policy. The salient point is that to get into this study,
every single one of these people had had at least one relative killed in that planecrash. For me, this is as bad as it gets in terms of suffering a loss, because there is
no way anybody can ever bring that person back. Secondly, if you are looking fora blameless victim situation, this would probably be it. Nobody is going to blamea parent for their child’s death in this context. Further, the circumstances are so
tragic that you could argue that maybe mental health stigma would not be suchan issue. Who is going to blame somebody for coming forward to get treatment
under these conditions?
Notwithstanding, only 6% of these family members said they had utilized
unlimited, conveniently located, free counseling, covered by the Office for Victimsof Crime, despite 48% of the sample reporting emotional or behavioral problems
severe enough that they considered mental health counseling. Most people who got
unspecified treatment thought it was helpful.
We asked, “People don’t always seek mental health counseling even after losing
a family member in this type of terrorist crime. What do you think are the mostimportant reasons family members do not seek mental health counseling in a caselike this one?” The leading response was they do not think mental health counselingwould help. They have negative attitudes about mental health counseling. Secondly,
they have good support from family, friends, religion, etc. Thirdly, denial, inability toadmit they need help. Stigma is not far from the top, followed by, “they don’t want

was they do notthink mental healthcounseling would
help.

Stigma and Barriers to Care in Disaster

help,” and “prefer to handle it on their own.” “Insurance or cost concerns” was an
issue for some. I think these are instructive and they fit in nicely with some of theother data that have been presented earlier about other contexts.
It seems that stigma is less of an important issue than just having negative expectations about counseling. Why might that be? Why would it be that some people
feel negatively about counseling? Sam Goldwyn, the film producer, said, “Anyone
who would go to a psychiatrist ought to have his head examined.” That is an oldquote but I suspect that many people would extend that to psychologists and othermental health professionals, too. It is probably still operative.
Then there are some highly marketed treatments that make fairly radical claims.
This is the kind of material that might help us understand why people have somemisgivings about treatment.
Many of you may have seen a recent Newsweek front cover reporting thedepressing news about antidepressant studies suggesting that the popular drugs are
no more effective than placebo. In fact, they may be worse. I am not getting into
debating whether antidepressants work or not. I am presenting this because many
people probably read this and when their doctor says, “You should undergo a courseof antidepressants,” they might have some questions about it. The way these things
are presented in the media does have an effect.
There are some things about disasters that may be different in terms of barriers
to care. One is the disruption in services. Secondly, basic needs are probably more
important than mental health needs and so if you are attending to those you cannot attend to the other. Then, as I have said before, there may be less blaming ofdisaster victims.
I would like to leave you with some ideas about ways that we might address this.
Stigma issues associated with web-based things might be less prominent. Web-based
interventions may provide a way of tapping into some of our self-help oriented,
rugged individualist tendencies, such as, “I can do it on my own. I don’t have to go
forward. I don’t have to label myself as being a psychiatric or psychological patient.”
Long story short, these things represent self-help opportunities and mechanisms.
They have videos with them, and good information about utilization suggests thatpeople seem to like these things. Some preliminary data suggest that people who go
through this compared to controls actually get better on some measures.
In conclusion, ways of addressing stigma and barriers include crafting a way tospread the word about effective treatments in ways that people can understand them.
We also need to be more careful in how we discuss resilience. Without question,
most people after disasters are resilient. However, when we stress that, which may
be a good thing to do, suppose I am not resilient? What does that say about me? Is
that stigmatizing me? Is that going to make it more likely for me to come in and gettreatment? I think we need to figure out a way to hit the sweet spot as opposed to
the way we do it now. I do think that the web-based psychosocial self-help interventions may have a great deal to offer because they get around some of the barriers.
DR. GALEA: Good morning. It is an honor to be here. As Dean said, we havedone a great deal of work together and we agreed that I would present some newdata from one of our recent studies. Before I do that I want to talk a little bit about
disasters because there are some of us who have done a fair amount of work on
disasters and some of you who understandably do not think as much about disasters.
I want to make a point as to why we should think about disasters.
This is the bad news from the best database that exists about disasters worldwide

31

In conclusion,
ways of addressing
stigma and barriers
include crafting a
way to spread theword about effective
treatments in waysthat people canunderstand them.

32

Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism

In the context ofin the past 100 years: the frequency of disasters is increasing. Everybody asks, “Whyis the frequency of disasters increasing?” Meteorological and hydrological disasters
are probably linked to changing global and environmental conditions. Anotherreason is probably due to urbanization, concentrating more people in smaller areas.
The same natural events that were happening 200 years ago perhaps resulted in trees
falling into forests with no human injury toll. Now, when trees fall in the forest there
are a thousand people underneath it so disasters are increasing. We are packing more
people into areas where these large scale traumatic events are happening. The goodnews is that more people are surviving disasters. One more piece of bad news is thatmany more people are being affected.
An interesting phenomenon from an epidemiologic point of view is that every
time a disaster passes we have an unerring ability to forget all about the disaster andthink another one will not happen. We see this time and time again including recently
with Haiti. Of course, these events attract a great deal of attention and breathless
reporting in the news like, “Wow, this is shocking and surprising and we don’t know
anything about it.” Then two months later you forget all about it. In fact, Haiti was
not predictable but it is entirely predictable that some other big event was going tohappen and something else will happen again.
Having said that, it is well worth the effort to make epidemiologic inquiry into
disasters. In the context of stigma, there are things we can learn from disasters that
can assist us in thinking about the military context and culture. When thinking aboutbarriers and stigma to mental health care after disaster, three central domains are
pertinent: predisposing characteristics, enabling factors, and need. I am going tofocus my comments around the health behavior model. I am going to show you somedata related to predisposing characteristics, enabling factors, and need as associatedwith barriers to care and stigma after one particular event.
I want to talk about Hurricane Ike in the Galveston Bay recovery study. Hurricane Ike is one of those neglected events. On September 13, 2008, it essentiallywiped out Galveston on the Texas gulf coast. The interesting thing about Hurricane
Ike is that much of the impact on the population was a combination of the winds
as well as the flood. This was an event that we studied as part of a consortium. It isa National Center grant funded by NIMH that is co-directed by Dean Kilpatrick,myself, and Fran Norris at Dartmouth who works as part of the National Center
for PTSD. We were able to launch a study soon after Hurricane Ike to look at theconsequences. The study is called the Galveston Bay Recovery Study.
It was a fairly large event with substantial impact. Then it faded from publicawareness soon afterwards because it occurred just before the national election andour attention span is short.
We made a big effort to recruit a population representative sample of people
who were living in the area before the disaster. This is no easy task when you think
about the population displacement. We reconstructed sampling frames and foundpeople all over the country. We ended up talking to 658 people, 80% by phone,
20% in person. Of particular interest is that we asked about mental health service
need, utilization, and reasons for not using services. We used a fairly structured
instrument, the primary care needs questionnaire, which allowed us to study someof the barriers that were discussed in the previous discussions. We looked at concerns
around stigma, preferences for care, expectations, and resource barriers. About 40%
reported mental health service need, which is fairly consistent with the previous
presentations. It is astonishingly consistent in these samples that we have a little

stigma, there arethings we can learn
from disasters that
can assist us inthinking about the
military context andculture.

Stigma and Barriers to Care in Disastermore than a third of the people reporting need yet only about a third of those whoreport need actually obtain service.
Let me start with predisposing factors including gender, race, ethnicity, social
support, stigma concerns and preference for mental health services. The only thing
associated with perceived need was social support, with a very dramatic increase
in reporting need among people with low social support. Looking at those who
actually sought services, men were more likely to seek services than women, whichis unusual in large, population-based samples. In the group seeking services, age andsocial support do not seem to matter much. Different factors are associated with
reporting need and getting services. One reason people did not obtain services isembarrassment or shame and not wanting friends or family to know. Note that thisis only about 17% of the individuals who did not seek services. Expectations andpreferences actually explain 70% of the reluctance to seek services in this group.
I am struck how this resonates with Ron Kessler’s talk from this morning. He
pointed out that stigma in many ways is not our biggest concern. It actually pales
when you look at other barriers to care, and we see it again here. People want tosolve problems on their own, prefer to rely on family or friends, and want to pray.
Again, applying the useful metaphor of a broken limb, I do not know many people
who pray as a primary means of addressing a broken limb. However, it does seemto be a preferred approach to coping with mental illness.
I want to pause on this point because it is emerging as a common theme in many
presentations. I thought it was very smart of Mark Brown and Bob Ursano to label
this meeting Stigma and Barriers to Care. Stigma has gotten a great deal of play
as a label but it is instructive to think of it as part of a bucket of barriers to care.
There could potentially be different interventions that are required for people withdifferent barriers to care, stigma or otherwise.
Looking at gender, race, and social support, we see that men are much more
likely than women, by about 60%, to report stigma as the reason they did not seek
care. Dramatic racial differences, bigger than anything I have shown so far, areevident. Black and Latino subjects were actually four-and-a-half times more likely
than whites to report stigma as a barrier. Similarly, low social support was related
to concerns about stigma. Looking at expectations of treatment, most factors do
not seem to matter, but race does matter. Minority races are much more likely toreport negative expectations about treatment. Age and social support also seem tomatter. Older individuals with high social support are more likely to prefer to deal
with it themselves.
The summary from the predisposing factors is that men were more likely toobtain services than women, and low social support is associated with a perceived
need for services, but does not predict whether people actually get services in thecontext of a disaster. Men, minorities, and those with low social support are likely
to report stigma, while those who are older with high social support prefer to takecare of the problem on their own. That concludes the discussion of the predisposing
factors.
Let me show you two enabling factors in the interest of time. I want to talkabout income and health insurance. I have to discuss health insurance given thecontentiousness of the debate on this issue of late. Regarding need, there is absolutely
no association with employment and health insurance in the sample. In the groupof people who actually did get services, you see once again no association between
employment, health insurance, and getting service. When we study the people who

33

Looking at gender,
race, and social
support, we see that
men are much more
likely than women,
by about 60%, toreport stigma as thereason they did notseek care.

34

Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism

need and did not obtain services, we find that employment does not matter but insurance does. Insurance does not matter for perceiving need, but it does differentiate
between those who get service and those who do not. What you find is that those
who have public insurance or no insurance are much less likely to get services thanthose with private insurance.
Moving now to perceived need for mental health services I am going discuss factors that are much more objective than people reporting perceived need. I am goingto look at event exposure, stressors, PTSD, depression, and generalized anxiety. The
good news is that the people who we might think objectively would need services
are the people who do actually report needing services. We found about a threefold
greater likelihood of reporting need in those who have PTSD, depression, anxiety,a number of stressors, and a number of traumas. There is a dose-response relationship between being exposed to traumatic events and actually getting services among
those who report need. This is likely due to the availability of services arranged bygovernment and not-for-profits for the people who are most severely exposed.
What emerges from this event is that men, minority groups, and persons withlow social support are the people who are expressing concerns about stigma overall,while minority racial groups report low outcome expectations. Health insurance andpsychopathology matter in this context, while predicting need is actually not predicting access to services, and this is quite concerning. Across these varied contexts ofdisaster, trauma and war, if we are to make a difference in this area we need to get
more sophisticated in parsing out the barriers to care among different vulnerability
groups in order to identify just what we need to overcome. Thank you.
DR. HOBFOLL: First, I would like to thank Drs. Brown and Ursano and MaryLee Dichtel. I want to begin by stating that I think the first point of this meeting
may be some meaning that is beyond what we could get by reading the importantpresentations of Dean Kilpatrick and Sandro Galea. If someone as smart and experienced as Matthew Friedman and myself and a few others disagree, that is really aninteresting point to get at, to advance. I want to get us to argue a bit more, therefore
I am going to try to say a few things that will cause argument.
Uncle Sam is getting older, and America is facing some large problems in dealing with disasters, terrorism, and trauma on the world stage. The FALLS model
expands the principles and parameters of the adaptation process in the Conservationof Resources model and stands for Fitting, Adaptation, Limitations, Leniency, andSelection. First is fitting. Resources do not just fit demands. Humans are active andour institutions and culture are active in fitting. Fit is a verb. Resources often need
to be molded or altered to fit. How do we mold and alter our institutions and our
culture itself in order to fit demands? The distance of resources of any group to new
demands makes this fitting more or less difficult. If you are in the group that haslots of resources, you make the transition rather quickly and easily. If you are in
the group that does not, there will be many more impediments. A great example ofunexpected fitting of resources is when the Mohawk Indians moved from Canada
in the early 1900s to build skyscrapers. Someone realized that although they had
never been up in a skyscraper or even seen one, hardly anyone had at that time, they
were not scared of heights and they needed jobs. They had a little bit of a resource,
but a great deal of adaptation was required to go find them, bring them in, andtrain them.
Second is adaptation. Adaptation is a process of successive approximations, notStigma and Barriers to Care in Disasteran outcome. It is hard to get publications on process but that is what adaptation
is about.
Adaptation is bound by expectations on the part of any special group or classof people to the host culture. If you are wealthy in this society and white, you can
do just about anything and get along. That is equated with adaptation but that is
not adaptation. When an inner city woman who is black or Hispanic with somelanguage difficulties and lack of education feeds her family, that is adaptation.
Adaptation follows the allocation of resources and can be rapid. If you moveresources around, rapid adaptation will follow those resources. When adaptationis blocked, when people are blocked from services, conflict will arise. There isconflict in the military right now, between most senior commanders who are notvery interested in mental health, and Congress and parents and the press who are
bugging them about it, because a lack of adaptation leads to conflict. Of coursecommanders care about every suicide, but it is not their main care because it is nottheir primary mission. The mission is protecting the United States against its enemies.
It is the same situation I have when I meet with my dean. He says, “I really think
your ideas are important here.” I say, “Yes, but how are my concerns ranked compared to the other chairs of departments? If you only have three rooms to give out
and I’m number five, it doesn’t matter if you like me among 20. You’re only giving
out three rooms.” Another example of a movement of adaptation with conflict was
the civil rights movement. Blacks were well adapted to very difficult situations, butcorridors leading to success and a less stressful life were to a much larger degree
blocked to them.
Third is limitations. We know about limitations from sociology. The resourcesof those who are disenfranchised have reduced currency. A dollar is not a dollar.
It takes about a $1.30 for an African American person to get the same credit as
it does a white person in the United States. Certain neighborhoods are redlined. I
was looking for a house in the Cleveland suburbs and I am Jewish. That has notbeen a big obstacle for me in the period of my growing up in the United States, but
I was told by the realtor as we went to several neighborhoods, “This street has ahousing association. They vote and you will not get a house on this street.” Whatthat means is any dollar I have is not exchangeable. The housing association did notsay, “It will cost you more for the house.” They said, “You will not be voted to beallowed to enter this house.”
Some pathways are blocked or bottlenecked. A great deal of mental health pathways are not entirely blocked, but we see some people getting through while there
are huge bottlenecks and obstacles for others. Some resources that people have arerejected outright in this limitations process. For example, many areas of government
and medical assistance say, “You cannot pay for psychological care.” That policy
was put in place by psychiatrists who wanted to block psychologists from giving
care, even though those psychiatrists know the literature and know that both kindsof care are important. There are turf battles that play a role.
Fourth is leniency. Positive status confers extra value on resources. For example,
you can be not terribly bright and get into Harvard or Yale as a legacy. That is
the opposite of limitation. That is a leniency that occurs. One of the major leniencies of our society, in economic terms, is the intra alia distribution of funds. As an
upper/middle class child you receive about a million more dollars from your parents,
without paying any taxes on that turnover of money, than a child in the inner city in
the United States. That is a million dollar grant per upper/middle class child for allo-

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Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism

I would end with thiscation to all kinds of resources such as better schools, mental healthcare, medicalcare, and so on. Courts, jobs, and universities treat those of higher status with greater
leniency. We know, for example, the greater distance you are from a judge in social
status the more likely you will be incarcerated and receive a stiffer sentence, and also
the more likely you will be found incompetent and put into mental health care. Said
another way, public defenders lose all their cases in the mental health court, almost
100% of their cases. I got a call from a friend of mine’s son the other day who won
his first mental health case in Los Angeles after a year as a public defender.
If you are of certain classes or groups in society, you go up on a glass escalator towhatever you want, including mental health care. All of my friends that need mental
health care get it. I do not know if they feel there is a stigma. Those in need may not
be blocked by prejudice but may not qualify, as others are treated and fill the rooms.
All psychologists and psychiatrists are very busy. But those who are treating thepoor see a patient every two minutes in community mental health centers, and those
who are seeing wealthy patients spend an hour to an hour-and-a-half with each one.
The Institute of Psychoanalysis in Chicago is still very active with people coming totreatment for five days a week seeing psychiatrists.
Finally, there is selection. People select into certain roles, and the host culture
will select individuals for certain roles. Certain roles will be prohibited. The role ofdoctor and patient is relevant here. I actually think what Matt Friedman’s centerhas done is create a full continuum of care including prevention, education, andearly intervention, and it has gotten away from the role of doctor, expert, and sickpatient in terms of how they are approaching the problem. Diagnosis is a big devil
in all of this. We are still pushing a diagnosis as something that is meaningful.
Recent data, for example, a study by Kubzansky and her colleagues (2009) showedthat women, who were rather resistant to heart disease, with minor PTSD symptoms have about a threefold increase in coronary heart disease. There was nothing
about reaching diagnostic levels. The sorting of selection occurs differently if welook at the continuum beginning when someone starts getting symptoms and focus
on preventing symptoms from occurring and skill building, rather than on treating
disorders. The role of a mental health patient is used for selection by those in power,
creating stigma and barriers.
I would end with this point: The reason the military has problems is that it isstill using a mental health diagnosis to categorize and get certain people out. The
seeds for change are already in the military culture, in which the focus is shifting
to training soldiers to become more resilient and not breakdown with PTSD. When
you talk about resilience you are talking about performing better at all levels, andthen going back home to be a spouse and a more effective parent. That will make asoldier who continues service for an entire career as opposed to being pulled out. I
think we are spending upwards of $30,000 per recruitment right now for the military. If you are highly trained there are some categories of training for which thereenlistment bonus is over $100,000. Those are good things, by the way. You haveto incentivize, but you will also have to change the barriers, take the data, and placethem into the context of theory in order to know where to go.
DR. ZATZICK: I wear a number of hats. I am a clinical investigator in trauma
center settings. My academic pedigree derives from Greg Simon and Wayne Katon incollaborative care and primary care. We have been trying to adapt those models
working with Chuck Engel here on a large military trial for acute care in posttrauma populations. I am also Chair of the Services in Non-Specialty Settings, NIMH

point: The reason the
military has problems
is that it is stillusing a mental
health diagnosis tocategorize and get
certain people out.

Stigma and Barriers to Care in Disaster

Study Section. In that capacity, I am often in a room like this reviewing grants withfolks from multiple disciplines, and we have the potential to get into argumentsthat we are trying to resolve to come to some sort of agreement. I think we needto fastidiously think through the different disciplines that are around the tables
and come up with higher order constructs that may help us have dialogues over thecourse of the next day-and-a-half.
Sandro, I just came back from nine days in Haiti earlier this month. You havetalked about, from an epidemiologic perspective, how population impact and safe
population impact is related to the effect, the quality and the reach of an intervention.
Say I am the frontline provider delivering care after a hurricane in my trauma centerin Haiti. I am like Charles Hoge, screening a veteran after a buddy has been blown
away the day before. I realize that there is treatment effect heterogeneity. The issueof tailoring that intervention is key. How would you take the goal of wanting tohave a large population impact and meld it with my desire to tailor and deliver carein a very unusual context very far from where the interventions were developed?
DR. GALEA: Doug Zatzick and I have had this argument for about a decadeand I think we are never going to resolve it. We did a paper together trying toresolve it but it seems to somehow not have stopped the argument. There is atension between improving population mental health and improving individual
mental health. We have to be very careful about conflating the two. The evidence
around the drivers of population mental health suggest certain approaches thatwould improve the mental health of everybody, both those who are at the high endof disability versus the low end of disability. For example, given the data I showed
here, one would think that improving social support across the board would
improve people’s access to care. Other data from many other areas including HIV
in marginalized populations shows that people who are networked and have social
support actually get care. If you improve networks and supports in populations,
I would expect us to see increase in the utilization of mental health services. Thisis population-based information.
You are asking about the individual level. At the individual level, the fact that I
have low social support has relatively poor predictive value for the outcome of having barriers to care, because the population of observation is not necessarily telling us
about a given individual. Epidemiologists and population health scientists have beenpoor at providing guidance to clinicians who need algorithms for tailoring interventions. You cannot state from my data the characteristics of the individual that should
be targeted for care. We need specific studies that identify the features that are most
likely to predict poor access to care among individuals. Nothing that I showed cantell you that.
DR. ZATZICK: The VA is refining and honing and delivering evidence-based
treatments. To increase population access, would you think about generating on thefly, in-setting kinds of treatments that focus on engagement? How would you think
about this notion of reach?
DR. GALEA: It depends on what you mean by the word treatment. If you havea “population-wide treatment” that improves networking, linkage, and support
among everybody then my data would support that. If by treatment you mean you
are targeting a particular subset of the population, nothing from my data can tell
you that a treatment is going to work and you actually need separate trials to tell
you that it is going to work for a particular subset of individuals.
DR. FRIEDMAN: Putting these issues in a public health preventive context

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Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism

challenges the title of this conference. In a preventive context, the outcome is notnecessarily clinical utilization. The goal is to abort situations where one exceeds aclinical threshold at which mental health treatment becomes necessary. We can use
social media, Twitter, Facebook, and websites to provide education that may help
people recognize that they are starting to take on water. They are not necessarily
exceeding a clinical threshold but they are not functioning as well at work and with
their families. It is not a clinical issue, it is a public health issue unless left unattended.
If you can provide sufficient education, monitoring, and corrective steps early on ina preventive way, that will reduce stigma issues that we have been talking about ina more clinical context.
DR. KILPATRICK: Populations are made up of individual people and some willneed more help than others. A website may not help those at the top of the pyramidof care who have major mental health problems. But for many people education
may desensitize them to getting treatment if they need it. It gives you the opportunity
to provide information to many more people than if you are talking about mental
health professionals meeting with people individually or even in groups. Web-based
self help tools may help get around some of the stigma of having to label yourself as
being so bad off that you need the services of a mental health professional. It may
also be a tool for self assessment to help people see they need something more andmaybe there is some education that can be included about that.
DR. WESSELY: Dean Kilpatrick mentioned Pan Am 103 and Lockerbie andthe research on the families. A professor of psychiatry at Dundee wrote a very
good account of what happened in the village of Lockerbie itself. He organized amental health response based on the local town hall. There were policemen who
were upset by having to stand by body parts all night right after the event. There
were also 13 killed in the town and others injured, and many people were very
shaken by Pan Am 103 disintegrating above them. Without exception, none of themcame to the mental health center. They all came to the primary care center, which
was run by three general practitioners who they knew and were people they could
talk to. I thought Ron Kessler was a bit mean to primary care, because in mosthealth care systems, primary care will be where the vast majority of mental healthcare is going to be delivered. It is an existing structure. It is much freer from stigma
because they are the same people you also talk to about childbirth and other things.
In the U.K., general practitioners will deliver 90 to 95% of the mental healthtreatment for common mental disorders, not schizophrenia or bipolar disorder. Given
that they actually will deliver the bulk and they are acceptable to the population,
we should think more about supporting the primary care practitioners who actually
are trusted and will deliver much less stigmatized service than I am afraid the folks
around this table will, including me.
DR. KILPATRICK: First of all, the families who lost somebody on the groundin Lockerbie were included in the sample because they were included in the services
that the Office for Victims of Crime provided. Secondly, it is true that most people
go to primary care. The question is whether, aside from giving medications, primarycare doctors really are equipped to handle serious PTSD and other disorders. The
advantage is people will go to them. The disadvantage is that if you have got two,
three, or maybe 10 minutes for a complicated case, primary care doctors do noteven have the time to handle the issues for which people go to primary care in thefirst place.
DR. URSANO: We have introduced the question of primary care. We have intro-

Stigma and Barriers to Care in Disaster

duced the question of access. We have introduced the question of whether primarycare is prepared to use the latest treatments and whether they have the time. If not,what do they need?
DR. LINK: We have discussed the different reasons people do not seek care, andcomments have been made that reasons related to stigma are less common than ones
like, “I can handle it on my own.” If you imagine a respondent reacting to a questionsuggesting “Why aren’t you doing something that would be good for you?” they
are less likely to say, “I would be embarrassed” than “I can handle it on my own.”
There could be demand characteristics in the questions that shape the responses.
The second point is that if you ask the respondent why do they want to handle
it on their own, you might see that there are identity issues about what that would
mean about them. You would see stigma issues rolled in with respect to beliefs about
what kind of person needs treatment. Put another way, imagine us saying that wewould go out and change people’s beliefs about that one narrow thing, “I can handle
it on my own,” to say, “No, I can’t handle it on my own.” Do we really think that
we would make them come into treatment?
DR. KESSLER: One important aspect of disasters is that stigma can get flipped.
If you look at national data among people who have a mental illness and predictwhether they got into treatment in the last year, having trauma is a very strong
predictor of them getting into treatment, and the reason is that there is a goodreason to get into treatment. “This terrible thing happened to me that is beyond
the range of normal human experience.” Anybody would be upset by that. It gives
you a license to talk about it in a way that you would not otherwise. Very often
the people who get into treatment after being in a car crash or a natural disasterare talking about their mother not loving them 30 years ago. The trauma is anoccasion for getting into treatment, so many of the people you see have chronic,
ongoing problems.
We did a study looking at the impact of the Virginia Tech shootings on students,
and there were 32 students killed in a population of 30,000. There was a massive
increase in the number of kids who got into treatment for mental health problems.
The main reason reported was that a close friend of theirs died. However, each of
the kids who died had to have had 370 close friends for that to be true, which ispretty unlikely. Twitter studies of close friendships show that people tend to havearound eight.
Trauma is an occasion for going into treatment. One problem with trauma
treatment setups, particularly in natural disasters, is that they are set up on anacute disease model. A team swoops in for two weeks with Cipro and these chronic
schizophrenics are wandering in with this little bag of pills that are sort of purple.
“I don’t have my pills.” “What’s it called?” “I don’t know.” They do not have any
antipsychotic medications or antidepressant medications in the strategic drug file.
We have to figure out some way of giving longer term treatment and mass treatment after a disaster because this is the opportunity to reach an enormous numberof people. They feel it is okay to come in a way they normally do not. They do notwant to come in for two weeks. They want to come in long term, so we have to figureout some way of doing something. One possibility is to work more on telemedicine.
There have been some movements in that direction in the last few years. For a coupleof natural disasters recently, the American Psychiatric Association and the American
Psychological Association had people who were volunteering to see two patientsa week for free forever on the telephone. The problem was that if the patient was in

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Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism

New Orleans and the physician lived in Cleveland, malpractice insurance did notcover the treatment because insurance is defined under state laws. There are federal
ways of overriding that.
Once the crisis is over, people stop thinking about mental health. We need more
people thinking about how to get long term treatment in place in a mass way. Thereis no way that the people in the local area can handle it all. The primary care people
would be swamped. You have to figure out how to have a decentralized method oftreating these people. That means innovative approaches with group treatment orcommunity treatment or more likely some kind of triage system on the telephone
so the treating provider does not have to be in the same physical place as the patient.
DR. URSANO: That model is also talked about in terms of clinicians in San
Francisco talking to soldiers in Afghanistan, so it works across other domains.
DR. SHALEV: One thing that should be raised is the threshold issue. What is
the actual threshold above which you need treatment and below which you do not?
People are identified as needing help because of exposure or from endorsing symptoms. Questionnaires often do not include the disability impairment component, justa list of symptoms. We had a study showing that under the threat of terror only onefifth of those who endorse the full set of symptoms for PTSD also have impairment
and disability. So do they need treatment? In discussing whether diagnosis is usefulor not, are we diluting our own message about when people should seek treatment?
We can become very confused and very ambiguous in terms of recommending what
to do in a specific setting. I wanted to put on the table the notion of a threshold thatshould be used for inferring need for treatment and eventually inferring that without
treatment there will be no recovery.
DR. GALEA: I do not disagree with the need for a threshold, but let me
add another view. In this country in the 1950s there was an epidemic of a particular disease that was largely driven by a particular kind of person. One option was tointervene with those people, meaning to figure out the threshold and to try to makethe disease go away by focusing on them. The option that was instead taken was tochange the context for everybody and, in fact, levels of the disease dropped dramatically. What I am talking about, of course, is motor vehicle accidents. The decreasein motor vehicle fatalities is one of the largest public health successes of the 20th
century, and we did not do that by targeting bad drivers and giving them driver
training. We did it by improving roads and cars.
There are two separate issues here. Issue A is identifying a threshold and identifying people who we want to treat. Issue B is, how do you change population levelfactors to improve population mental health separate and apart from the thresholds?
I think these are two equally important issues. Going back to Ron Kessler’s point, thecurrent model for disasters certainly is an individual-based parachuting in intervention. The model of improving population-based context to shift mental health sub or
supra threshold does not really exist right now. In a group like this with a nice mixof clinicians and population health scholars, we need to push on both approaches.

Stigma and Barriers to Care in Terrorism & Public Health Emergencies

5

Stigma and Barriers to Carein Terrorism & Public Health
Emergencies
Simon Wessely, M.D.
Brian Flynn, Ed.D.
Dori Reissman, M.D.

DR. URSANO: Our next panel is on stigma and barriers to care and is particularly
focused on terrorism and public health emergencies. Simon Wessely is the provost andvice dean from the Institute of Psychiatry at King’s College and directs the Center for
Military Health. Brian Flynn is a retired Rear Admiral, Public Health Service, and amember of our Center, and has probably spent more time on disasters from the publichealth side than anybody else I know. Dori Reissman is from CDC and NIOSH, andis now detailed to the Center for the Study of Traumatic Stress with us.
DR. WESSELY: I am going to divide the talk into two parts. I will talk about people
who have been exposed to disaster, terrorism, etc., who actually do not need help or
do not want help and then I will talk about those who do and the differences between
them. I will use two examples from London, the city in which I live and work. The
first example is when Alexander Litvinenko was poisoned with polonium in a London
sushi bar, or possibly a London hotel, and subsequently died, triggering a radiation
alert. Our Home Office, equivalent to your Department of Homeland Security, wasvery interested in this incident for obvious reasons. They wondered if this was a goodmodel for all of the various exercises that we had been doing about population reactions to dirty bombs. We were asked to carry out a very rapid study in the first few
days of the crisis of reactions of ordinary Londoners, and also to interview most of thepeople who had been in direct connection with Litvinenko and the other Russians in
the bar and hotel. For everyone living in London, this was a completely normal timeof the year and the incident made no difference to anything. The further away you got
from London the more people seemed to think this was some form of crisis. A generalobservation I have is that the further away people are from the epicenter where very
many things happen, the more they assume that things are going wrong and there is asense of panic. Russian television viewers, who are not disinterested observers in this

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Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism

particular episode, were talking about panic on the streets of London and the evidence
was that there were police on the streets.
A telephone random sampling study found that only 11% of London residents perceived any threat to their health and only 2% thought they actually had been affected.
The vast majority of people were unconcerned by what had been going on. We foundthat concern depended on the motives the respondent attributed to the perpetrators.
Ninety percent of Londoners thought this was just Russians killing each other; they did
not think it was of any relevance to them. The small minority of people who thought
this was an act of terrorism directed at the population found it much more distressing
and were the only ones who felt it was likely to affect their health. Keep in mind thatthe actual medical risks of polonium are completely independent of the motivationof the perpetrator. We concluded that this was actually a rather bad model for a dirty
bomb and a terrorist incident because people did not think that was what it was.
We interviewed people who had been either in Itsu, the sushi bar, or the Millennium
Hotel, where it actually turned out he had been poisoned. Of the 130 people who had
been identified by the police and had their names passed on to the Health Protection
Agency, only two were upset; the vast majority were remarkably unconcerned by thewhole thing. At the same time this was occurring, there was a launch of the new James
Bond movie, Casino Royale. Nearly everyone described the incident at the Millennium
hotel as like an episode of James Bond. As they did not work for the KGB, they did
not think it was at all relevant to them. We looked at the possible stigmatization of thepeople who had been exposed to the radiation source. One person said, “Yes, before
Christmas we went to some parties. One or two people asked us to stand outside.
They wanted us to illuminate the parking lot so people could see where they parked
their cars.”
I will move on to an event that had a broader impact on London, the London
bombings of 2005. These bombings had a death toll of 68 and paralyzed London
for some time. Again, we spoke to ordinary Londoners, not the people who wereinvolved in the incident. This was a random sample of people in the city. We used thesame questions that had been used in the New England Journal of Medicine Shuster
papers about September 11th. Despite the considerable difference and the impact of
the two episodes, people’s emotional reactions were rather similar. Negative responses
were higher in New York, but not as dramatically as you might think. We are talking
about normal emotional reactions in the few days following, not PTSD or psychiatricdisorder.
Those most dramatically upset by the London bombs were Muslims. Twelve percent of the population of London is Muslim, as were 10% of the victims killed in thebombs, excluding the suicide bombers. The second most distressed group were people
who were uncertain of the safety of others and who could not reach their family or
friends or loved ones by telephone. The mobile system was partially switched off toreduce the risk of secondary devices being used and partially due to call volume. Studies
in Israel have shown that those who can immediately make contact with their family
and friends are less distressed than those who cannot. The surprise was that the effectpersisted six months later. Those who had not been assured of the safety of their family
and friends were still significantly more upset by what had happened. We are still nottalking about PTSD, but about a normal range of emotional reactions. So what did
people do about their distress? Many did want to talk about the event. It was a major
attack on our city. It was repeated three weeks later, albeit unsuccessfully. It was atime of great uncertainty, with concern and anxiety on the streets of London. The vast

Stigma and Barriers to Care in Terrorism & Public Health Emergencies

majority dealt with the event within their own social networks. Only 1% had actuallygone for professional help.
Neal Greenberg, a Royal Marine, studied peacekeepers coming back from Bosnia
in the days of the UN intervention and the results were very similar. Many people
wanted to talk first to their peers and to their family. Psychiatrists are down at thebottom of the list. For every person who wanted to see a psychiatrist, five or six
wanted to see the chaplain. In general most people prefer to seek other sources of help,
predominately in their own social networks. As Sandro Galea said, encouraging social
support is very important and people are mobilizing their own sets of social support.
The home office asked us to assess how much penetration there had been of thevarious systems and services that had been set up in the aftermath of the London
bombs. They asked us to see how many people knew about the different responses
that had been organized by the NHS and by the government. There were actually three
government responses and one we made up. Anyone guess which one we made up?
Yes, it is the one that was the most popular: the London Rescue Programme. The onethat did not exist got a higher rating and was better known than the three that did.
This leads me to be quite skeptical about many of these studies. We should be very
careful when we assess the impact of services. The Home Office was not pleased that
we asked the fake question because they wanted to publish data saying how successful
they had been with reach for the first three services. But that is not the way that weshould be assessing success.
We believe that what is important is that people are talking to each other;
we should pay much more attention and try to assist with that. The advice we aregoing to give in the next terrorist incident in London is not to tell people not to use
their phone but instead to keep it short. In those first few weeks we should simply
help people mobilize their own social support. That is what people want to do, it iswhat comes naturally, and for the majority of people, that is sufficient. But of course
it is not sufficient for everyone.
Let us have a look at the people who do need and want help. What happens
to them? Chris Brewin and his group did a screen-and-treat program of the 540 or so
people who were in the three tube trains or the buses. These are the people who wereactually there, many of them injured. Dr. Brewin and colleagues set up a program andwaited eight to ten weeks, following our standard policy. The vast majority got better,but around 20%, as predicted, did not and then they got treated very successfully.
The first problem was bureaucracy. They did not contact all who were affected,
namely those who went to St. Mary’s hospital. The authorities there refused to release
the names of those who had been involved, citing the Data Protection Act. That meantthat immediately one quarter of those who had been affected could not benefit from theresearch because the hospital erroneously felt patient confidentiality meant that they
could not tell Ehlers and Brewin who they had treated for physical injuries. Later thedecision was challenged and the hospital officials admitted that they got it wrong but
it was far too late by then.
We will move on to examine data from our health surveillance studies on the armed
forces during the wars in Iraq and Afghanistan. For the last seven or eight years, wehave followed a large random sample of all three of our armed forces, including those
who have left the services as well. We just completed a follow-up of over 10,000 ofthem. We also conducted follow-up interviews by phone, adding information aboutchanges over time that is not typically available. For these interviews, we over-sampledthose whom we knew from the study had mental health problems. We managed to

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interview 75% of these individuals directly. I often talk about the differences between
Britain and the USA, but with respect to stigma and barriers to care there was absolutely no difference at all. You could not put a cigarette paper between our responses
and Charles Hoge’s when we repeated exactly the same questions as Charles had in
the Land Combat Study.
We looked at these 800 veterans to see what had happened to them. Many of them
have left the services, and many have mental health problems. But very few of themactually come to see us. Only one-third of them get any care at all. For those who seea health professional, they are four times more likely to see a non‑mental health person.
Health professionals themselves are not that popular; however mental health professionals are even less popular. Of those who are seeking help, very few get adequate
treatment. Only 1% receive the best standard of treatment, CBT. I do not suppose thatis an entire surprise to you but the scale of it may be somewhat surprising. It could
also be that the military is a very macho organization, in the UK as in the US, and thatparticular culture is what prevents help seeking. But is this unique to military culture?
We compared data from the military with those in the rest of the population using
data from our psychiatric census, which takes place every ten years. We managed to
ask who had served in the armed forces, something they had never done before. Comparing veterans and non‑veterans, we confidently predicted that veterans would haveworse mental health, be worse in treatment seeking, and have more problems the longer
they served. In fact, that is not what we found. When you compare veterans with therest of the population, there were no differences in their treatment seeking, except foralcohol problems. They did not have more mental health problems compared tothe population. The longer they had served, the less likely they were to have problems.
Veterans’ rates of help seeking behaviors are actually comparable to the rest of the
population. It is not true to say, certainly for the UK, that they are worse help seekers
than others. Actually, everyone is bad at help seeking. Having a mental disorder is bad
news wherever you are, but it probably is not any worse if you are in the armed forces.
Concentrating on stigma only within the military misses the point. It is a broader social
issue.
My final point is that part of our job is to reduce the number of people whocome to see us and who need to see us by providing less stigmatizing alternatives. I
have already mentioned primary care, but we also need to put a great deal of effort
into building up peer support. Neal Greenberg and I train one in two of all the Royal
Marines with a very simple two-day course on mental health measures. That has been
repeated across the whole of the British Army. The idea is to put us out of business. I
think it is highly unlikely to happen, but the idea is that the fewer people who cometo see us, the more pleased we will be. Thank you very much.
DR. FLYNN: Let me provide some context before making my comments. My
background is primarily in disaster and emergency, mental health and behavioral healthissues. The organizational home for most of my career was the U.S. Public HealthService. I am not a researcher, but I have had a great deal of experience in government
and in the field. I made a career out of going to the nicest places at the worst possible
times. I think I have learned something in the process.
I want to use a different lens and talk about systems issues because that is really
where most of my work and my familiarity lie. Stigma involves a number of factors.
There are individual and cultural factors. Stigma and barriers differ depending on thedisorder or the context, such as whether the disorder derives from a war experience ora disaster or a rape. Then there is stigma about the field of behavioral health in generalStigma and Barriers to Care in Terrorism & Public Health Emergencies

and disaster and emergency behavioral health in particular. I want us to think about
the issues of stigma as it pertains to our field and about what we do, but we should
not equate that with the stigma that individuals feel. They are not comparable. Thoseof us who choose to be in this field choose to be in this field. People do not choose
to have a mental illness. The magnitude of problems for individuals should not be
trivialized in any way.
I want to talk particularly about disaster and emergency behavioral health asa subset of our field, particularly about how it interacts and intersects with healthand medical and emergency management issues. If I were to redo my slides based on
my thinking today, I would probably add a couple of more pieces about the need toconsider stigma and barrier issues with primary victims and survivors and also withworkers and helpers, because while I think there is overlap, there are also some separate
issues. As we move away from the more traditional areas of health and into behavioral
health and then into disaster and emergency behavioral health, there is increased marginalization, misunderstanding about what we can and cannot do, and myths about
our profession along with stigma. The irony is that if you get into a major public healthdisaster, some of this may shift. When we talk about emergency management, we again
have the same problems of marginalization and stigma.
I worked with the Federal Emergency Management Agency (FEMA) over the years.
The health component is not really central to their operation and they sometimes
do not know how to handle it. Once you get into the health and medical emergency
support function, they do not know what to do with the mental health component.
There are increasing issues of stigma and marginalization that happen as you moveaway from the core. In a public health emergency, emergency management may not beat the center; rather, public health and medicine will be central. When the shoe is on
the other foot, we need to be careful that we do not trivialize the emergency management function. It may be just as important to get vaccines in place and out to people,
or whatever kind of medical interventions are appropriate.
We also want to make sure that we have people who understand human behavior
and who understand the importance of social functions and community continuity.
We need to make sure that the food supply is maintained if there are blockages ofborders and that the guy who fills the ATM machine gets there. These functions may
be just as important as getting people inoculated or immunized. For those of us whochoose to be in this field, if we are going to escape with our egos intact we need toshare some delusions. One of those delusions is that emergency management always
values what we do in this field. That has not always been my experience when I getout in the field in disasters.
The other delusion is that I am always a full-blown part of the team. Manytimes when I have been out working on disasters, I felt like a lonely cat in the presenceof a row of dogs, the emergency managers. In 2004 I was invited to be part of a CDC
process to develop an operations manual for what to do in the first 48 hours of anevent that had public health consequences. The process used computer-based decision
making. Everyone in the room had a computer, you were asked a question, you typed inyour response, and it appeared on a big screen in front of the room. It was anonymous
so people were more candid. There were only two of us in this group of about 60
people who had a behavioral health background. Because of my bias I kept injecting
comments about behavioral health because I feel it has a role in everything.
Apparently that view was not shared. A public health official said, “I understandand empathize with your concerns about mental health and public health emergencies.

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Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism

However, the issues I have to deal with and the decisions I have to make in the first
24 hours are life and death issues. Mental health concerns, while important, do not riseto that level of importance.” Well, excuse me. When I got over the narcissistic injury of
this, I realized that this was a problem. My colleagues and I have not been doing the
job that we should do in defining where we can contribute and what our behavioral
health concerns are. In fact, the behavioral choices that people make in these kindsof situations are very much life and death decisions. I realized then how important it
was to make sure that we correct some assumptions about what our jobs are and canbe in these situations.
I have been in this field for many decades and my view is that things are improving.
One of the ongoing frustrations I have is that much of the improvement in the field
does not seem to be systemic. It seems to be personality dependent: who is sitting inwhat chair at what time and who is sitting in the chair across from him or her at thatsame time. When that constellation changes, a great deal of good work gets undone
or forgotten. I am not sure what to do about that. It has gotten better but we have along way to go.
I want to end with some suggestions. One is that we need to more broadly define
our contribution. Getting in and doing individual interventions with people is important work, and I do not want to trivialize it. We also need to do more consultation andleadership training. One of the areas that I have been involved with more intensely inthe last couple of years is trying to integrate behavioral health principles with messaging and communication. I think that is where there is a whole lot of bang for the buckand where I want to put some of my energies. It is an exciting area. Systems design
and preparedness is another area where we have something to contribute.
We need to continue to increase the evidence base. When you look at where theevidence basis comes from and how it has advanced, probably 90% of it comes fromthe people in this room; we need to keep doing that. The more our consultationand systems design is based on evidence rather than on marketing or belief, the better
off we will be. We need to get to and stay at the table somehow. We need to have apresence in discussions about systems issues, whether it is in emergency management
or public health. If you are not invited, go anyway. If you do not make a fool out ofyourself, you might get invited back. Get there and stay there somehow.
I also think that part of what we need to keep in mind when we are dealing
with these other systems is how to make other people’s jobs easier. That will get us
incorporated and invited back. The FEMA-funded program that I administered formany years is now almost 40 years old, and once you work with people long enough,they begin to tell you the truth. This program was not generated by a humanitarianconcern. It was generated because at that point there were one-stop shops for people
to come in and apply for FEMA assistance. People were getting upset and crying in
those situations, and FEMA personnel did not know how to handle them. People were
so distraught that they could not fill out the forms. They wanted us to solve that stressbased administrative problem for them and it was the birth of something that has goneon for many decades.
There are many fantasies about what we do, including a belief that our job is goingto make other people’s jobs more difficult or complicated. We always need to go into
these systems discussions with an eye toward how we are going to solve a problem
for the people who we are doing business with. And then we need to push for parity.
We need to continue to advocate within these other systems to ensure that behavioral

Stigma and Barriers to Care in Terrorism & Public Health Emergencies

health consequences get their due in terms of money, respect, recognition, and inclusionin plans and strategies.
With respect to stigma, I think of the State Department after the bombings in
Nairobi and Dar es Salaam. Many people needed care very desperately. They were very
traumatized, but they would not go anywhere for care due to the fear of jeopardizing
their security clearances. We have situations in which the stigma may not be just in
the individual. We need to consider that it may be in our processes. We need to beaware that there are stereotypes about this field and we have to go the extra mile to
make sure that our help is practical, legitimate, and evidence based, and that it helps
other people do their jobs. We must take care not to reinforce negative stereotypes of
behavioral health.
DR. REISMAN: I would like to thank Drs. Ursano and Brown for having me
here. It is quite daunting to be here talking to you because I view you as the experts
and see my job as carrying your flag. According to Erving Goffman, who did someof the earliest work on this, stigma is “an attribute that is deeply discrediting,” andthe attribute of the person in some way reduces the bearer “from a whole and usual
person to a tainted discounted one.” If we think about stigma, whether it is barriers
to care, stigma, or negative attitudes toward the care that is available, you can see thateverything answers to culture and power. Power of labeling others and making themfeel bad about their labeling. People’s beliefs may be within culture but also may bebased on life experience as separate from culture.
Social conditions are often captured in our epidemiology studies by using socioeconomic status as a proxy. You are potentially more exposed in lower SES environments to crime, infections, poor diet, pollution, and other lifestyle factors that are
not very health-promoting. Access to quality of care and capacity for that care may
be compromised. Transportation to get out of your environment to access that care
may also be problematic. Thinking about this in terms of public health emergencies,of which disasters is a subset, you are thinking about a sudden discontinuation or
disruption of service and the underlying unevenness of the distribution of resources.
Stigma in the center is a social cause of disease.
With respect to the distribution of life chances, for conditions such as mental illness, leprosy, HIV, or a disability that the world can see, money may not be spent as
quickly as it might be on problems that are more hidden, not so disfiguring or not so
obviously labeling. The science may lag behind in providing treatment. This reduces
life chances of people with these conditions by affecting the education, jobs, housing
and health care environment that they experience. Stigma affects all of these things at
once. We tend to focus our research on one issue such as mental illness or HIV. Most
people have a compilation of characteristics; they may already be stigmatized andanother condition might discriminate them further.
This brings up an issue of terminology. Stigma makes you think about the individual who has the problem, the “other.” The word “discrimination” makes you think
more about the person who is labeling. The self view has a great deal to do with thecultural milieu in which you live, your life experiences, and how you view your own
characteristics, whether it is the color of your skin, an obvious disfigurement, or adisease that people just do not want to get near within the psychiatric realm. These
conditions can lead towards a sense of broken self and lower self-esteem. It questions
the whole notion of trying to push resilience because it sets up the capability for people
to blame themselves for not being resilient or for organizations to blame their members
for not being resilient. It also sets up the idea that if our communities are not resilient,

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Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism

Stress and fear

there is something wrong with the community because they need outside help. I raise
this as an example of creating an intervention for a problem that can also create new
barriers and new problems.
Stress and fear contribute to reluctance to seek care because of fears of reprisal,and fears of being labeled because care may lead you to be “outed’ with a problem
that people would stigmatize. There are many disincentives in the system for people
to access care. If mental health services are not co-located with other services, people
can tell what problem you have just by what room you go into. We have also had totry to do collaborative care in which we empower professionals of other disciplines to
do some of the basic mental health work. The organizational implications of mental
health have to do with job evaluations, someone’s position, and how people withmental illness are viewed.
Since this is also about terrorism it would not be fair to ignore it since it was thesource of so much money for so long. We can think of terrorism as a subset of disaster.
There is the attacker and what they look like or what group they represent. There is
the situation that the attacker caused and the inadvertent fallout from that, both ofwhich interact to form a profiling event. A very simple way of looking at that would be
the anthrax and World Trade Center disaster and the Pentagon disaster of 9/11, 2001.
Crime statistics, especially near places like convenience stores and gas stations, showedthat more people of Middle Eastern descent were being beaten up after these events
happened because they were now the face of the enemy, even though these people werepart of the communities. When anthrax killed workers at the postal service, people
were afraid of their children being exposed to postal workers’ children because they
were concerned they would get anthrax, as if it were transmittable person-to-person.
Labeling occurs not only for groups associated with the attacker, but also the victim.
There is fear of contagion associated with the victim and concern you might be the next
target.
DR. HOBFOLL: The different talks bring up a number of issues for comparison.
The military is a closed system. It is all-controlling. Your records are available as partof your performance. Society is an open system, and I think that makes a big difference
for stigma because within the military context, it is possible to change policy rather
immediately. For example, you could set up a system to reward going for behavioral
treatments that enhance your skills, and society cannot do that in general.
I also want to point out that there is almost nothing in our society that is opposite
of stigma, especially American culture. The use of the honorific was made absent by
the founding fathers in the United States. Part of our problem should be creating an
opposite notion to stigma when there is not even a lexicon for it and it has fallen outof the culture.
DR. RADKE: The National Medical Director Council and the American Association for Psychiatrists have tried to use the public health model, but there are significant
barriers in doing that. There are clinical barriers where the clinicians are focusedon active treatment and rehabilitation. They are not interested in early intervention
because they have no time and there is no money for that. There are administrative
barriers where there are silos created by policy that do not allow for the applicationof a model. And there is a political barrier where disenfranchised populations such as
people with serious mental illness, or children and adolescents, have no say in the political will for using the public health model. Those are additional concerns beyond thestigma that have come to mind as I was listening to the talk.
DR. HOLLOWAY: The military is not a closed system. It is an open system that iscontribute toreluctance to seek
care because of fears
of reprisal, and fears
of being labeledbecause care maylead you to be“outed’ with aproblem that people
would stigmatize.

Stigma and Barriers to Care in Terrorism & Public Health Emergencies

different than the civilian system, and both are very complex. The overall assumptionthat you can equate the overall reduction of burden of disability in a society with areduction in caseness is based on two ideas being confused. You can prevent casenessand not change disability at all. The example was offered earlier about fixing cars.
That is a good example of a situation where you do not change caseness but you lower
disability by making better cars. Another classic example would be that you can treat
diarrhea, but it would be better to fix the water by putting chlorine in it. That is theway to lower disability. We ought to distinguish in these response systems between
ways of lowering the prevalence and incidence of disability as opposed to lowering
the incidence and prevalence of caseness. This is important because they are very different systems and they require very different kinds of interventions, which may or
may not be related.
DR. BRITT: Something worth highlighting is the difference between the stigma andbarriers to care of getting treatment following disasters versus military combat duty interms of the context of traumatic exposure. A soldier who is exposed to high levels of
combat is accruing these experiences as part of his or her job. In terms of encouraging
treatment-seeking versus focusing on resiliency and not needing treatment, when you
have soldiers who are exposed to the highest levels of combat reporting elevated
symptoms, there is really a majority who are reporting symptoms. I wonder whether
an emphasis on resiliency might be detrimental to that segment of the population
getting treatment.
DR. URSANO: I noticed the progression of ideas is appropriate to the collegial
sense that we are all in this together to do some tussling. That is the usual progress ofsuch a conference that is headed in the right trajectory. It was said somewhere that
this is a military meeting. This is not a military meeting. It has to be funded by DoD
funds, but remember our topic is war, disaster, and terrorism.
As many others have pointed out, we are attending to the public health model, notjust the treatment model. Think about the different tools and the different targets
that are present in those two models. All of that is to say there is a reason why thisconference is called stigma and barriers to care—because we really do think stigma
is just one of the buckets under barriers to care. We chose care and not health carebecause the questions of dealing with distressed populations involve issues such asincreased motor vehicle accidents or people deciding to not shop, which can impair the
economy and become a national security issue. That is why this is the forum on healthand national security because it is important to address the entire range of populations
from distressed, mild disorder, moderate disorder, to severe disorder. There are people
with problems caused by the trauma itself, along with those who have emergent mental
health problems and who take the opportunity of the trauma event to come in forcare. We need a public health model and a treatment model to address the questionsof stigma and barriers to care across the whole population.
We have now begun to reveal the complexity of this problem. We want to informand keep track of this complexity. If you are still in your bucket of being a disasterperson or a military person or a terrorism person, it is time to jump out. This is where
it begins to be important to think across those frames, because if we do not, there will
be national security, continuity of operations, and continuity of government problems
for us in the future. Whether the issue is 9/11, suicides in the military, or Katrina, there
are substantial issues of getting people to care. Health care is one aspect of care, not
all aspects of care, or of sustained national security.

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As many others havepointed out, we areattending to the publichealth model, not justthe treatment model.

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Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism

Conceptualizing Stigma and Barriers to Care

6

Conceptualizing Stigma
and Barriers to Care
Bruce Link, Ph.D.
Bernice Pescosolido, Ph.D.
Arieh Shalev, M.D.

DR. URSANO: The challenge before all of us is how to think together so that
we can be creative in our endeavor and not only see what we have always seen
before and say what we have always said before. I am pleased to have our next
panel on conceptualizing stigma and barriers to care. Bruce Link is a professor
at Columbia. Bernice Pescosolido is a professor at Indiana University, and Arieh
Shalev is professor and chair at Hadassah University School of Medicine.
DR. LINK: It is a great pleasure to be here. I have spent a good part of my career
thinking about stigma. I think about its effects being very broad, affecting many different circumstances, not just mental health. The effects of stigma penetrate deeply
and influence people’s lives in deep ways. Stigma is often very hard to see and if
you do not have the concepts for it, you will not build the measures for it, you will
not capture the phenomenon, and you will not see how it flows out and affects
people.
I want to start with some classic definitions of stigma and then talk about adefinition that I developed with my wife, Jo Phelan. The dictionary defines it as amark of disgrace or infamy. You have already heard Goffman’s definitions. Jonesand his colleagues defined stigma as a mark that sets a person apart and links themarked person to undesirable characteristics. There are two criticisms leveled atthose particular definitions. The first is that the attribute or the mark is somethingthat the stigmatized person has; it is their stigma. It emanates from them rather thanbeing conferred on them. The second criticism is that too much attention has been
paid to marks and associated stereotypes and too little to the broad disadvantages
that many people experience because of stigma. Those two criticisms came fromconsumer groups in mental health. I wanted to see if we could use those to leveragea new look at stigma and generate a new definition of it.
Goffman had one insight that I wanted to draw upon in constructing this definition, which was his view of stigma as a relationship between concepts, such as therelationship between a mark and a stereotype. Stigma exists when interrelated con-

51

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Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism

cepts converge. First, people distinguish and label human differences. Second, labeledpersons are linked to undesirable characteristics, creating unwanted negative stereotypes. For example, the stereotype of someone who has been in a mental hospitalis that the person is more likely to be dangerous. Third, labeled persons are viewed
as an out-group, as “them” and not “us.” There is some degree of separation between
us and them. Fourth, people experience emotional reactions to labeled people, suchas fear, repulsion, disgust, or pity. Labeled persons may feel shame, embarrassment,
and humiliation or, as Pat Corrigan might point out to us, righteous anger. Fifth,
as a result of these emotional reactions, labeled persons experience status loss anddiscrimination. When all of these things unfold, stigma is present, and this definition
gives the stigma concept a flow across these interrelated dimensions.
The last thing to point out is that stigma is dependent on power. For example,
you can have negative stereotypes about lawyers. But we do not use the term stigma
for lawyers because they do not face huge societal discrimination. We are not fighting
to keep them out of our neighborhood. I do not mind if my daughter marries one.
Stigma is dependent on power and who has the power to exercise the discriminationthat follows from their beliefs about a stigmatized person.
Now I want to talk about the kinds of discrimination that can follow in this paradigm of stigma. First is direct discriminatory behavior towards other people. You
know about the labeled person and you do something unpleasant towards them. The
second one is structural discrimination. Here stigmas exist around some problem
or circumstance. For example, in a military context there might be a strong andeffective response to wounded soldiers but much less effort put into wounds of a
psychic nature. If less has been developed, they face a kind of discrimination bygetting less when they have a psychic injury than when they have a physical injury.
The third type is discrimination that operates through the stigmatized person. This
brings up modified labeling theory. Growing up in our society we learn what it
might be like to develop any set of statuses. We also learn what it would mean todevelop a mental illness.
Imagine two people, one who never develops a mental illness, never goes
into a psychiatric hospital. Beliefs about how other people might treat him if
he were to develop a mental illness have no relevance to him. He might thinkthat people would look down on someone with mental illness, might not wantto date them, marry them, or hire them, but it does not matter to him personallybecause he has not developed a mental illness and gone into a psychiatric hospital.
In contrast, another person does develop a mental illness, and as a consequence
everything learned suddenly becomes potentially personally relevant. That canaffect a person in multiple ways. One way is that they feel badly for having
entered a status that others view negatively. They might cope by trying to protect
themselves from rejection, and, therefore, might withdraw to a smaller group offriends and not venture out. He or she might not look for a date or ask for a job,might eschew going to treatment, or might disengage from treatment to avoid
these possibilities feared associated with being mentally ill. Studies have shownthat social performance can be harmed if participants think another person knows
they have been in a psychiatric hospital.
I developed a measure for this theory that asks what the respondent thinks mostpeople think about someone with mental illness. Items include, “Most women
would not marry men who have been in a mental hospital” and “Most people
think less of a person who has been hospitalized for a mental illness.” All of us canConceptualizing Stigma and Barriers to Careanswer those questions and then form a scale that works pretty well in measuring
the perceived devaluation and discrimination against people with mental illness.
The main idea is that for people who never develop a mental illness, their function is not related to their score on the perceived devaluation-discrimination scale.
But for people who develop a mental illness, the stronger their belief that people
reject others with mental illness, the worse they are likely to feel, to perform, towithdraw and to have a constricted social network. This theory has been tested
with longitudinal data, and we have looked at effects on unemployment, income
loss, constricted social networks, quality of life, depressive symptoms, delayed help
seeking and self esteem.
As far as implications for help-seeking in military situations, it is possible to ask
these questions framed in terms of what soldiers or most military personnel think
about someone with mental illness. From the theory, we would expect that thestronger the belief that others would look down or discriminate on someone withmental illness, the less likely someone with a psychiatric problem would be to seek
help. What would we do if that theory were true? Do you really want to tell people
that other people will not reject them? One response is that the extreme fear is probably excessive, and we could bring that down some. People do not have to fear at
the far end of this scale that everyone is going to vilify them. That is probably notin accord with reality. We could change that belief some to good effect. The second
response is to change the ambient culture of beliefs, and if we can find ways to dothat, then we would be able to move forward and do some good.
The last major topic I want to talk about is motivations for stigma. We often
think about stigma as stemming from ignorance. There is a great deal of truth tothat perhaps, but people can get things they want from stigmatizing. One motivation is exploitation. For example, racism was a way of justifying slavery. That is
an example of stigma in the service of exploitation. Another motivation is norm
enforcement, or keeping people in. Stigma can be useful for telling ourselves when we
step out of bounds, and we stigmatize people who step out of bounds to bring themback in. The final motivation is disease avoidance, or keeping people away.
I think norm enforcement is particularly important for this forum. In military
settings, we need people to be strong. We need them to be brave. We need them to self
deny. To reinforce such norms, perceived weakness is stigmatized as a way of keeping
people in. From the vantage point that stigma serves a purpose, the question becomes
how do we serve that purpose without stigmatizing mental health help-seeking? Can
we exempt psychiatric and psychological problems from being perceived as weakness in these cultures? A solution may be to convince people who need these norms
to be reinforced to keep those norms strong but to exempt psychiatric problems
from them.
To summarize, stigma is a multi‑faceted concept. Many concepts have to be integrated to understand all the ways in which stigma expresses itself. Stigma-based barriers involve multiple mechanisms of discrimination, not just person‑to‑person discrimination, but also structural discrimination that operates through the individual.
Modified labeling theory suggests mechanisms that could produce barriers to treatment seeking in military and other situations. Norm enforcement—keeping people
in—may be a motivation for stigma that is particularly strong in the military context.
DR. PESCOSOLIDO: I start with a confession. I am not a psychiatric epidemiologist. In fact, I am not an epidemiologist of any sort. I belong to that group which
is much less revered, the group of health services researchers. I entered this area of53

To summarize, stigma
is a multi‑faceted
concept. Many
concepts have to
be integrated tounderstand all theways in which stigma
expresses itself.

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Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism

research because I had gained knowledge on two of the dominant theories of helpseeking that existed when I started my research agenda: the health belief model andthe socio-behavorial model. Unfortunately, after looking at those models for a while,
I could not figure out how they matched reality. They were cleaner, more elegant, andhad a nicer match with research methods than what I knew from looking around me.
Therefore, I embarked on an agenda to develop a different way of thinking about
the ways people enter into services. It is a messier and more complex way of thinking,but it is based in the notion of social networks. Social networks may or may not getpeople into care, depending upon culture. I started looking at networks and saw,
for example, that on the upper west side of Manhattan, having social networks got
people into care, while in Puerto Rico social networks were keeping people out ofcare. That points to a large cultural difference.
I looked at the literature on what people think, believe, and feel about the useof health services. Due to the lack of research on the topic I realized that it was not
a popular area to study. When I came upon a line of research pertaining to stigma,
I called one of the premiere stigma researchers in the country, Bruce Link, and said,“I think this is something we need to think about.” At that time I was sitting on theoverseers’ board of the General Social Survey, which has existed since 1972 andis the longest running monitor of American public opinion, beliefs, attitudes, andbehaviors. I thought this would be the place to replicate the three national studies
on stigma existing in the United States.
The first national study was done in 1950 by Shirley Starr under the auspices of
the National Opinion Resource Center (NORC). The study was never published, but
NORC saved every one out of three of the original surveys. The second and third
studies were the Americans View Their Mental Health studies done at the Universityof Michigan in 1956, 1957 and 1976. We drove up to Michigan and found all of theoriginal surveys. In looking at these studies, not only could we get a sense of what
stigma looked like in the United States now (1996), but in a rigorous way we could
get a sense of how it had changed.
At that point Bruce Link and I went begging for money. Neither the National
Institutes of Health (NIH) nor the National Science Foundation (NSF) were interested so we turned to the private foundations. Under the imprimatur of Dr. Ron
Kessler, we were able to secure money to do the first national study of stigma in 40
years. And that started a 15 year process.
I would like to give you the eight most important findings we have from thatline of research, but first I would like to present the four key points that guided our
research. First, stigma disqualifies individuals from citizenship, so stigma is not justcentered solely on treatment. It is about acceptance in the family sphere and in thework place. Second, stigma is an attribute known to others, only occurring in social
interaction. Thus, as a basis for understanding, we wanted to either observe social
interactions or ask people about their social interactions. Third, stigma has different
forms. Fourth, stigma is dynamic, not static, and it creates careers. Whether we aretalking about careers in the workplace, in the military, or in domestic life, we get areal sense of dynamics from looking at this aspect of stigma.
There are different types of stigma. Today I will mainly focus on public stigma.
I think this is important because it sets the cultural context in which people experience the onset of mental health problems, in which others respond to them, and inwhich they either go on to live a full life, what we now call recovery, or they live alife that is damaged by others’ responses to that illness. A second type of stigma, self

Conceptualizing Stigma and Barriers to Carestigma, occurs when people internalize the negative beliefs and responses of others.
Another type is courtesy stigma. Ron Kessler discussed how much money goes into
mental health research. Institutional stigma is enacted in organizations, including
treatment sites. We have conducted studies of both long-term care facilities andacute psychiatric hospitals and find dramatically different attitudes toward people
with mental illness in those two sectors of the mental health system. Finally, there isprovider-based stigma. Here we are talking about whether or not people who comein for care are given a sense of hope or a sense of discouragement.
Here are some of the findings from the national stigma studies we conducted.
The first important finding is that the public has become more sophisticated overtime. When we asked individuals, “What is mental illness?” they were able to give
us a much broader spectrum of problems that might be considered mental healthproblems than they could in 1950. The second finding is that there have beenchanges in formal and informal treatment responses to the onset of mental healthproblems. There were no dramatic changes in the use of the formal treatment sector;
the people who were using avoidance as a strategy continue to use avoidance. In
contrast, there has been a dramatic change in how proactive people are in response
to mental health problems, and further, the American public has opened up to talkabout mental health problems with their informal supports.
Psychiatrists do not use the term nervous breakdown, but the question waswhether or not the American public did. We set up a two-stage question. To havecomparability with the earlier studies, the first part asked about the term ‘nervous
breakdown.’ The second part asked about mental health problems, and we foundthat most people did respond to nervous breakdown. I would argue that if you
watch one episode of Judge Judy you will see that it is still in the common parlance.
The third finding from the national stigma studies shows that stigma is alive
and well, that there are clear gradients, and that both the behavior and the label
matter. What does this mean? Approximately 50% of the American population
indicates some form of prejudice towards people with a variety of mental healthproblems. I should mention that we did not ask, “Do you want to sit on the bus
next to somebody with a mental illness?” We did not even ask the second generationquestion, “Would you like to sit next to someone on the bus who has depression?”
We provided a vignette which is exactly what people confront in the community.
We wanted to know one of the most important questions that other approaches did
not provide: Do people recognize problems that would meet DSM (Diagnostic andStatistical Manual of Mental Disorders) criteria for mental health? That turned out
to be very important in understanding whether or not people want to respond tomental health problems.
There are two clear gradients. First, the type of mental health problem matters.
It turns out that schizophrenia is not at the end of the negative spectrum; drug
dependence is, followed by alcohol abuse, schizophrenia, and then depression. The
second gradient is the venue in which we are asking people to have contact matters.
The more intimate the contact, the greater the levels of rejection. In America, andthis turns out to be a particularly American phenomenon, the highest levels are inwork and marriage. We see the marriage phenomenon everywhere, but the work
phenomenon appears to be specific to the United States.
In the 1970s there was a debate in the social science literature about whether
it was the behaviors that people were rejecting or the label of mental illness. Thisdebate went on for a number of years, and what we find in our studies is that both

55

The first important
finding is that the
public has become
more sophisticatedover time.

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Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism

The fourth finding

matter. People respond differently to the behaviors, but those people who went on tolabel the scenario as involving mental illness also had an elevation in their responses
regarding stigma.
The fourth finding from the national stigma studies shows that in some ways
stigma has increased, and this is a uniquely American message. There are two
findings that support this idea. The first is the work that Jo Phelan did, in which
she showed that there has been a doubling of the spontaneous mention of violenceand dangerousness in response to the question, “What is a mental illness?” This isa direction that we had neither hoped for nor expected. The second finding comesfrom recent work by a young scholar who did an analysis of the major newspapers
in the United States, Germany, and Iceland. She analyzed the content tone of allarticles on mental illness in one year in those countries. She found that the dominantthemes regarding mental illness vary across society, so culture matters both in the
micro and the macro sense. In the United States, 46% of the articles had a dominanttheme of fear and danger. That was not the case in Iceland where the dominantthemes were inclusion and integration. In Germany the major theme centered onfear of repeating the past in terms of dealing with difference, particularly people
with mental illness.
We are currently analyzing data from samples of individuals in 15 countries
looking at stigma and we find there is tremendous global variation. But unlike theWorld Health Organization (WHO) international study of schizophrenia, these findings do not have to do with societies that are more simple and open. There had beena notion from the Insurance Services Office’s studies that individuals in developing
societies recovered faster and better from schizophrenia than individuals in developed societies. They suggested that perhaps this was due to differences in stigma.
We find just the opposite. In our sample the three most stigmatizing countries are
Bangladesh, Bulgaria and Cyprus. The United States does not anchor the bottom,
Iceland does again. However, we do find that competence and public health spending
matter for lower levels of tolerance at the societal level.
The fifth finding from the national stigma studies is that sociodemographics are
unrealistic, inconsistent, or impotent predictors of public health literacy, treatment
predispositions, and stigma. However, we do find occasional correlates. For example,
women experience more prejudice, yet they are more tolerant. But that does not exist
in all societies or for all kinds of stigma that we might measure. Although there has
been a great deal of assumption about how African Americans feel in this country,
our research indicates that African Americans are actually more positive about thepotential of the treatment system than are Caucasians. This is not the case for all
kinds of services, but it does indicate that we need to understand culture rather thanmake assumptions about culture based on sociodemographic characteristics.
Can we change stigma? We did an evaluation of the Public Service Announcement (PSA) campaign that the Substance Abuse and Mental Health Services Administration (SAMHSA) put out called What a Difference a Friend Makes. This campaign
was a result of the 1999 Surgeon General’s report, which itself is an indication of
stigma. There were Surgeon General Reports on cancer in the 1960s, but it was not
until 1999 that there was a Surgeon General report on mental health.
Following the Surgeon General’s report was the 2003 President’s New Freedom
Commission whose first recommendation was a national anti-stigma campaign.
SAMSHA took that recommendation and ran with it, developing three PSAs with the
Ad Council. The first PSA was, The Door, in which the person approaches a door,

from the national
stigma studies showsthat in some ways
stigma has increased,
and this is a uniquely
American message.

Conceptualizing Stigma and Barriers to Careknocks, and when no one answers, they go through the house. The second, which I
call the Friendster video, is a short PSA that shows all the people you are friends withon Facebook. Then it shows all the people you go clubbing with, a smaller group.
That is followed by all the people you see on Friday nights and watch DVDs with,an even smaller group. Finally, it asks, “Are you going to be the one who stands by aperson with mental health problems?” The third PSA involves two guys on a couchplaying video games. One discloses to the other that they have a mental illness, andthe question is, “Are you going to be the one who stays, or are you going to be theone who runs?”
The sixth finding involves our laboratory study using a physiological marker
and a national survey. The two methods produced the same finding, which is that
overall PSA campaigns showed a reduction in stigma. But each PSA worked very
differently. The Friendster video is the clear winner. This one showed the greatest
and most consistent reduction in stigmatizing attitudes among the target audience,
18 to 25 year olds. Older respondents found the video game PSA insulting, but
the younger ones liked it. The Door PSA had either no effect or actually increased
stigma. It does have some semblance of a horror movie trailer so I can see why that
one did not work. I think we have to consider the plus and minus of focus groups
in this kind of evaluation research. People who come to focus groups want to help
us make things better so they do not tell us if something is bad. They just try to help
us make it better.
The seventh finding from the national stigma studies was that there have beenmodest changes over the last decade with regard to the adoption of neuroscientificbeliefs underlying mental illness. We found that significantly more Americans attribute depression and schizophrenia to chemical imbalance, as well as to genetics,
than was the case in the past. There are also fewer people associating mental illness
with God’s will. However, there has been some negative change. More Americans
are associating alcohol dependence with bad character. Finally, the disappointing
finding from this study is that if we look across the different venues in which people
can interact with or reject individuals with mental illness, there has been absolutely
no change in the United States along these lines.
In terms of general take-away points from this research agenda, the science baseis much stronger now than it was a decade ago. The fact that we have been working
in trained disciplinary groups, like this meeting, is very important. Treatment-based
stigma has decreased but community-based rejection has not. We need to rethink
our models. Since World War II, the National Alliance on Mental Illness and othergroups have taken the disease model to try to reduce stigma. I do not know if thatmodel has failed because there are no good data on which to make that claim but I
think the model has taken us as far as it can go. In fact, Jo Phelan’s research suggeststhat there is some backlash to the genetic attribution of mental illness.
Even if PSA campaigns are effective, and this is one of the first studies of theireffectiveness, the traditional logistics with regard to younger age cohorts and thedevelopment of new media suggest that this may not be the way to go in terms ofstigma reduction. While beliefs and attitudes are powerful markers, because of the
LaPierre study that Ron Kessler mentioned earlier, in terms of changing the hearts
and minds of Americans that may not be the way to go. We need to think morestrongly about institutional regulations that prohibit people from acting upon
whatever prejudicial beliefs and attitudes they might have. We have conducted ananalysis of 1,640 hours of television showing that at least one time during each unit

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Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorismof children’s programming a slang term for mental illness is mentioned. Therefore,
we also need to think about different kinds of vehicles for anti-stigma campaigns.
We need a new strapline in terms of how we think about stigma reduction inorder to get past the inoculation model one panel at a time, one group at a time,
one meeting at a time. When reconsidering stigma reduction efforts, awareness andknowledge are important. I think education is important, but it is not going to havea direct result in lowering stigma. One of the things we found in both our laboratory
studies and our survey studies is that the ability to attend to television programs
that have a character with mental illness depends on whether or not a person has
individuals in their social network that have mental health problems. Contact is very
potent. Americans respond more kindly to children and children are more kind in
responding to people with mental health problems. We need to think about attitudes
as a litmus test rather than as the marker that we want to change.
One of my favorite advertisements, which indicates the continued stigma of
people with mental health problems, shows world class Olympic athletes, including
Jackie Joyner-Kersee, Bob Bearman, Greg Louganis, Bruce Jenner, Peggy Fleming,and Mark Spitz. They all have a range of problems, some of which we think about
as stigmatized, such as HIV, but what is missing? There is no person with mental
illness in this advertisement. There is no one with depression. There is no one withbipolar disorder. There are two potential explanations for this. First, it could be thatmental illness is more stigmatized than any of those other conditions and has not
moved as far along on the change dimension. Second, it is possible that the particulardrug company that did this advertisement does not have a drug for mental healthproblems to advertise.
The focus of what we should be looking at from our local, regional, national,
and international studies is the idea of similar competence. When individuals see
people with mental illness as competent, they are less likely to reject them.
DR. SHALEV: I would like to thank the organizers for having me here. I havechanged my attitude and my position, but I could not change my presentation so it
will remain empirically based. I am going to present barriers to care and I wanted
to start with a definition. The Goldberg and Huxley definition uses the term ‘filters’
to access to mental health care. First, the individual must identify his own issues
as being problematic. Second, the provider must identify the presence of an illness.
Third is the process of referral to mental health care. These are the three filters to
obtaining mental health care. In the Goldberg and Huxley study in 1980 there was a
50% detection error by the primary providers and an 80% referral error. The filters,in 1980, were within the referral identification system.
What we were challenged to do in the Jerusalem Trauma Outreach and Prevention Study (J‑TOPS) was to bypass these filters by providing detection regardlessof illness behavior. We contacted every trauma survivor admitted to our emergency
room over a four-year period to alleviate the need for them to seek help. Once wefound that an individual had qualifying symptoms we invited them to clinical assessment. If they met criteria in the clinical assessment they were invited for treatment.
We referred every symptomatic survivor to readily available treatment. There wasno service delivery constraint. It was almost the ideal setting to observe individual
attitudes towards treatment because it reflected their own treatment decisions, notsome external constraint.
We offered people to enter a randomized control trial in one of the following
treatment groups: prolonged exposure (PE), cognitive therapy (CT), selective sero-

Conceptualizing Stigma and Barriers to Caretonin reuptake inhibitors (SSRI) and placebo, or a wait list control. The members of
the wait list control received late PE treatment provided five months later. The equipoise stratified randomization allowed our subjects to choose among four treatment
options and they could refuse up to two of them. Participants were still randomized
to the other two treatment options so we kept almost everyone in the study. There
were two layers of longitudinal survey, both blinded and nested. The two layers
were telephone interviews and clinical interviews. The telephone interviewers did
not know whether the person came for a clinical assessment or not, and the clinical interviewers were blinded as to whether the person went to the recommended
treatment, avoided it, or dropped out.
The ecologic sensitive approach, which gives me the opportunity to speak about
the threshold issue, is that we were all inclusive. If a person told us, “I need to see
someone,” he went to clinical evaluation regardless of meeting the threshold of
symptoms. If the assessor found that the particular person deserved a treatment for
Posttraumatic Stress Disorder (PTSD) symptoms, the individual went into treatment
regardless of meeting a DSM‑IV structured clinical interview derived diagnosis of
PTSD.
Here is the basic structure of the study. Telephone interviews occurred withinnine days of trauma, seven months later, and 14 months later. There was a layer ofclinical assessment before treatment, between treatment, and after treatment. Only
6% of those approached by telephone within nine days of the trauma declined to
speak with the telephone interviewers. These interviews could be up to 40 minutes
long, detailing the exposure and what the reactions were. This is a very low refusal
rate.
We invited 1,470 people to treatment, clinical assessment, and a face-to-faceinterview, and about half declined. This is the barrier. People do not accept faceto-face contact with a clinician at that early stage of traumatic event. The bias hereis that those who accept treatment have more symptoms than those who decline
treatment. If there is any bias, those who need care are more likely to opt for care.
In terms of declining treatment, after participating in the telephone interview anda clinical assessment, 27% still said, “I am not going to start treatment.” All in all,the majority of those who may require treatment declined treatment at the earlystages in this almost ideal condition. There was no difference in symptom intensity
or severity between those who declined treatment and those who did not.
Within those who accepted treatment there was an equipoise stratified randomization and the patient could refuse a condition. The single condition that was
declined by almost a third was pharmacological treatment, SSRIs. Those who did
accept the pharmacological treatment had more severe illness. Those who are lessdistressed are pickier about what treatment to accept. In terms of treatment adherence, prolonged exposure had a lower rate than all the others. The results indicatethat five months after trauma, PE and CT appear the most effective in preventing
PTSD. Even those who had to wait four months for PE treatment had low rates of
PTSD. This shows that it does not matter if treatment is delayed.
We all think about stigma in terms of preventing care, but we ventured intomeasuring what happens with those who decline care. At the end of seven months thedecline in symptoms in those who accepted treatment was significantly higher thanin those who declined treatment or declined clinical interview. Declining a clinicalinterview within 19 days of a traumatic event affects your symptom trajectory. You
are less likely to recover. I think this is one of the first studies to look at the long-term

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affect of just avoiding treatment. Only 3% of those who the clinician decided did
not need treatment had PTSD at eight months. The false/negative error is negligent.
Now we turn to the threshold issue, unnecessary treatment. I told you that we
also took into treatment survivors whom the interviewer believed could benefit
from cognitive behavioral therapy, or any therapy, regardless of meeting the threshold criteria for PTSD. Of the 55 individuals with partial PTSD, 17 received active
treatment, PE or CT, and 23 were on the wait list receiving no treatment. What
happens when we compare them? They get to exactly the same place. Partial PTSD
patients, in our study, do not need treatment. For me, that is the illustration of thethreshold. Now I will discuss the burden of services. We all think that we will havethe resources to accomplish our dream. We had 7.4 new treatment episodes eachmonth for four years. This is feasible if you have a good CBT clinic in a receiving
hospital that receives hundreds of injured patients. Even if these numbers doubled
to 14 per month it can still be handled in a CBT clinic. It is not beyond our capacity
to provide the necessary treatment so why are we not doing that?
One reason is the cost of screening. It took almost seven hours of telephoneinterviews and five hours of clinical interviews to bring just one patient to treatment. The cost of screening and evaluation is enormous. There is almost moretime spent on screening and evaluation than on treatment itself. A prevention
program has a difficult choice between allocating resources to earlier assessment
or providing expensive treatment to survivors who may not need it. The sourceof this is that early-on after trauma you evaluate a large number of patients who
are going to recover spontaneously. This is the barrier built into the situation of
acute trauma.
Despite outreach, most eligible survivors avoid early care. In our study people
were not going to be on record. They were not going to be ostracized by their friends.
They were almost in an ideal condition, yet even if they did not decline a telephoneinterview, half declined treatment. Even when you provide almost ideal conditions
this barrier is there, and the numbers are quite similar to the ones that you eventuallyfind in military populations. The avoidance of care affects the recovery. This study
was the first time we could show that.
The cost of screening and evaluation is significant, and the main source of thatcost is the unavoidable inclusion of a survivor who subsequently recovered on theirown. My recommendation is that the systematic outreach should be reserved for
extreme events where the high probability of developing a disorder justifies the
allocation of significant resources to treatment.
DR. KILPATRICK: Those are very interesting data, Dr. Shalev. You mentionedthat the cost of screening was one of the large barriers to feasibility. What would you
think about some type of online screening which could be done in a cost-effective
fashion? I still think that if somebody says, “Hey, congratulations. You have a problem that could benefit from treatment,” not all of those people will come forward.
But, at least if we considered other ways to screen, there might be a way of reachingout to more people.
DR. SHALEV: In terms of treatment, we recently started a telephone-based CBTstudy on the assumption that people more readily accept telephone contact thanclinical contact. The jury is still out, but we are getting quite a number of people
who decline even a telephone based intervention.
DR. KESSLER: Dean Kilpatrick’s question reminds me of an interesting study
Rick Price at the University of Michigan did a number of years ago. He had a job

Conceptualizing Stigma and Barriers to Careskills club during plant closings in the Detroit area. The program was for people atrisk of family violence, alcohol abuse, and depression after losing their job. Priceevaluated their skills and did some behavioral workshops to help them get jobs. As
part of this program he did a recruitment experiment. First, he pinned three by fiveinch cards to the union wall that said, “The program is available. Call this number.”
Second, he gave a speech at the union to talk about the program. Third, he went tounemployment lines and twisted arms to get people to attend the program. Priceconducted three separate experiments with the three groups of recruits.
The first experiment was a complete failure because anybody who responded
to the three by five cards was going to do really great whether or not he had his
program. They were the aggressive people. The people who he had to drag in failed
because they were going to fail no matter what. It was the people in the middle who
he had the effect on. It is the idea that there is some gradient across which screening
and intervention is going to work and you can maximize that program.
DR. ESTROFF: I have a question for Bruce Link and Bernice Pescosolido about
the overall state of discrimination, or stigma. How do we parse in the monumental
shift to guilty and mentally ill from guilty but mentally ill, and the increased deployment of both outpatient treatment and forced treatment in terms of public attitudes
and stigma?
DR. PESCOSOLIDO: There has not been a dramatic change. There may havebeen a small decline in terms of Americans’ willingness to support coerced medication, but not other forms of coerced treatment. Even in 1996 when we asked aboutfour different forms of coercion and we had people who did not meet criteria, 10%of Americans were still willing to use legal means to coerce those individuals into
treatment. The fear/danger coercion issue is a particularly American thing. I think it
is dangerous, and I worry about some of the messages that are put out by the Treatment Advocacy Center. One of the things they argue is that if we show Americans
that some of these people are dangerous the public will be willing to put more money
into services. Well, we were able to do some analysis in 1996 that shows that there
is absolutely no relationship between associating danger and increased funds ortreatment resources for people.
DR. ESTROFF: My question was more about if the effects of stigma are effecting
the institutional change in how we view the deservedness, or lack thereof, of people
who have psychiatric disorders in terms of the switch to guilty and mentally ill.
DR. LINK: This may not directly answer the question, but the thing about theincrease in spontaneous mentions of dangerousness from 1950 to 1996 was that it
was all written down and we could see exactly what people said. I thought maybe
Sue Estroff’s idea was that the coercion of treatment would stimulate the stigma.
The most common phrasing in 1996 was ‘dangerous to self or others.’ When we put
forward the idea about coercion people understand it and they parrot it back when
they talk about what they think mental illness is.
DR. PESCOSOLIDO: I think Sue Estroff’s question is too sophisticated for theAmerican public. The American public is smart, I do not want to be misinterpreted.
But the notion is that anybody who does anything really bad is sick and people do
not make the distinction with legal issues. I ask people all the time about Jeffrey Dahmer and the woman who drowned her kids and people see no distinction whatsoever.
DR. ESTROFF: But these statutes do not say that. They say you are bad andsick but your sickness does not mitigate your badness the way it did under guilty
but mentally ill.

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DR. PESCOSOLIDO: I do not think Americans have moved along with thatlegislation. I do not think they watch these issues at that level of detail.
DR. BATTEN: Dr. Pescosolido, I am so glad you are not a psychiatric epidemiologist because your perspective was really important. The data that you presented
have a feature that I hope can be discussed tomorrow, this issue of targeting public
education campaigns. I also find it interesting that helping people understand thetrue neuroscience that underlies different forms of mental illness has no effect on
stigma and, in fact, may have a negative effect. These potentially well intended waysof trying to de‑stigmatize mental illness by saying, “it is a brain disease just like anyother disease” could have negative consequences, so what should the next wave of
public education be focused on?
DR. PESCOSOLIDO: This notion of moving from bad to mad, which is what
Sue Estroff is saying, may have had an effect earlier in the history of the U.S., but I
think now we have got to find another way. Jo Phelan has been doing extraordinary
work on genetic backlash because now people are saying, “This is in their genes and,
therefore, it would be in my grandson.” I think the human genome project has had
really interesting unexpected latent consequences for science and society.
DR. URSANO: The bad news is that the population is beginning to believe ingenes.
DR. THOMPSON: I am from the Center for Mental Health Services (CMHS)
in SAMHSA. I have two questions that I want to ask Bernice Pescosolido. First,
did you get any sense, or is anybody at all talking about, this idea that people canrecover? That there is a process by which it is possible for people to take advantage
of opportunities and become participants in society in some way that they previously
were not able to do because of the lack of opportunities?
My second question is related to the research on which a PSA story may havesalience with the people. You indicated that there were some differences in age
groups. I am wondering if there are any differences by urbanicity, rurality, ethnicity, and gender both by the people receiving the message and the people who aredescribed as being psychiatrically ill. I often wonder whether or not much of what
actually ends up being about mental illness is a condensation of a number of otherstigmas that get focused in a particular population and projected onto them. Do
you have any sense about corresponding prejudices that may also affect how people
understand mental illness.
DR. PESCOSOLIDO: In our study we varied the gender, the education, and therace of the people in the vignette. We found that the results were not consistent. That
is why I said the sociodemographic factors, of either the potential stigmatizer or
the person who would potentially be stigmatized, were not very effective. I thought
it was genius to target 18 to 25 year olds, and I think the Friendster video really
hit a nerve of something that we should be following. You would not be surprised
to hear that the video game had a gendered effect with women not responding to
it at all. I think we should have different messages for people who have different
experiences with mental illness because what we are finding is this very strong social
network effect. Telecom has a theory called The Limited Capacity Processing Theoryof media effects, or something to that effect. They argue that people filter throughtheir own experiences, and what we are finding is a very dramatic difference between
individuals who have people with mental illness in their social networks and those
who do not.
When I saw the Friendster video I brought it up to our state government andConceptualizing Stigma and Barriers to Carethey asked me, “What should we do?” I said, “You know what? To me the answer
is clear. Put your money on the Friendster video. It is very powerful.” I think we cando these evaluations now pretty simply. Yes, they are not free but they are pretty
cost effective compared to the $250,000 it costs to make a PSA campaign. To show
the PSA enough to make it effective would cost about $10 million, and that is where
we do not have the societal support. I am not even sure if we had the support thattelevision is the right median. I am not saying PSA campaigns should not be used.
I just think the traditional PSA campaign evaluated through focus groups and put
on television has to be rethought.
DR. BELL: I am told that the frontal lobes of the brain do not develop until age
26, so in my world children are all gasoline and no brakes. We might want to think
about how to influence stigma in young children as opposed to older individuals.
Another issue is that when Dr. Satcher was doing his mental health report andasked people about stigma, most people said, “You know I really do not care whether
it is biologic or whatever it is. I am concerned about the unpredictability of people.”
We need to figure out how to deal with that because that is what scares people.
DR. PESCOSOLIDO: First, I agree that we should target the kids, and target
a general idea of ‘difference’ rather than just mental health problems. I take fromthat a relatively old piece of sociology, which showed that during the Vietnam War
it was not that the hawks changed their mind in Congress. We voted them out andwe voted the doves in. I think the analogy, although not very kind to American
society, is focused on the kids. We need to focus on the children regarding both theirown mental health issues, because they are more open at that point, and on stigma
towards anyone with mental health problems. I agree that unpredictability is the
big issue, but I do not have an answer for that.
DR. LINK: That coheres with the most powerful anti-stigma tool: contact.
Contact can help with the unpredictability part.

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Mitigating Stigma and Barriers to Care

7

Mitigating Stigma
and Barriers to Care
Patrick Corrigan, Psy.D.
Sue Estroff, Ph.D.
Thomas Bornemann, Ed.D.
DR. URSANO: Patrick Corrigan is a professor from the Illinois Institute of Technology. Sue Estroff is a professor from the University of North Carolina, Chapel Hill,
and Tom Bornemann is the Director of Mental Health for the Carter Center, and aretired Rear Admiral in the Public Health System.
DR. CORRIGAN: I want to talk more specifically about several issues that people
have discussed already today. The issue here is not what the problem is, but more
how to fix it. I am not a population person, an epidemiologist, or sociologist. I am a
psychologist and the models I propose are mostly focused on psychological constructs.
Much of our work comes from the National Consortium on Stigma and Empowerment. We were recently funded by NIMH as a collaboration of Yale, the University ofPennsylvania, Rutgers, and the Illinois Institute of Technology.
There are three goals I want to discuss. First is getting a sense of what it means tochange stigma and what stigma is, because defining the phenomena has a big influenceon the way we decide to change it. Second is understanding stigma change. Third isdiscussing implications for evaluation and some of the interesting challenges in trying
to study these topics.
I think it is easy to feel like you have been hit in the face with this idea of stigma.
The headline “Freed Mental Patient Kills Mom” is from the New York Post. That
headline is about 30 years old so we hope that things have gotten better. In July of
2002 Trenton State Hospital had a bad fire. The next day headline in the local Trentonian was “Roasted Nuts.” Many people say it was just a media issue and if the media
behaves the stigma will go away. I think the impact of stigma far exceeds anything
the media is doing.
I wanted to get some sense of what it means to try to change stigma. First we had
to get a better handle on what the constructs and types of stigma are. The first construct
is stereotypes, which are unavoidable attitudes about groups of people. Everybody inthe room today knows stereotypes about people with serious mental illness. Growing
up in our society, as Bruce Link suggested, stereotypes are just inevitable. The second
construct, prejudice, is agreeing with stereotypes, for example, “Yes, all people with

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mental illness are weak or dangerous.” Prejudice brings in an affective component. The
third construct, discrimination, is a behavioral result.
The other part of our model is types of stigma, which Bernice Pescosolido discussed earlier. Public stigma is what the public does to people with mental illness
when we endorse stigma about them. Self stigma is what people with mental illness
do to themselves if they internalize the stigma they receive. Structural stigma involves
socioeconomic forces that result in laws, statutes, and unclear structures that keep agroup down. The group we are interested in and the kind of stigma we are interested
in at our center is what we have come to call label avoidance because it does not seemto fit under any other type.
Label avoidance does not necessarily involve a person with mental illness. It isalso not the concern of the public. It is the concern of a person who fears there might
be mental illness and in order to avoid that fear they avoid the label. The best way to
avoid the label is to avoid all mental health professionals because the easiest way to
get labeled is to be seen coming out of a psychiatrist’s office or have people learn thatyou are taking psychiatric drugs. We realize the reason people do not get treatment is
to avoid the shame of serious mental illness, therefore avoiding discrimination.
What is of particular concern is adherence. We have come to understand adherencein two separate ways. Both might be a function of label avoidance. One is to not seek
care. We looked at NCS and ECA (Epidemiologic Catchment Area) to get a sense of
the huge number of people who never seek care when they are in need. The other way
we understand adherence is by looking at people who do seek out care, but who do
not stay in treatment.
In thinking about developing an anti-stigma program we have to be clear about
what we are focusing on, which is people who are trying to avoid the label. We arelooking at one small part of stigma. One of the important behaviors we are interested
in is getting people to participate in treatment. One way to assess that is website use
because all PSAs include websites with the hope that people will use them for significant
information and to get direct help for their problems.
Our research group distinguishes between the processes and the vehicles of stigmachange, what an individual might do to change mental illness and the vehicles theymight employ to do so. There are three different processes for stigma change. Educationis the one that readily comes to mind for most people: If we provide more information
about mental illness, people are more likely to give up the myth. The second process,protest, is probably the way a Baptist minister would approach stigma change, “Shameon us for thinking that way. We should not pursue this kind of viewpoint anymore.”
The third process is something that is still used, especially in school settings, and thatis contact. I agree with what was said earlier—if you had to throw all your money atsomething, contact is the thing to look at.
Education tends to be a comparison between the myths of mental illness and thefacts. For example, one of the myths of mental illness is that serious mental illness israre. This is known as the “leprosy myth,” the idea that leprosy was this evil rare thing
for which people were thrown out of the world. In reality we know that, dependingon whose numbers and what epidemiologic study you are looking at, schizophrenia
is about 0.8% of the population. That is difficult to get a handle on until you realizethat Chicago has about 64,000 people with schizophrenia. That is the same numberof people who live in Joliet, Illinois. That is just people with schizophrenia. If you
throw in bipolar disorder and significant psychotic depression, serious mental illness
is common and frequent.

Mitigating Stigma and Barriers to Care

Protest involves reviewing the stigmatizing images of people with mental illness
and saying shame on us for that. There are many tabloid examples of this, such as “Getthe violent crazies off our streets.” The problem with protest is that it tends to lead toa rebound effect. Many of you may remember this from Introduction to Psychology:“For the next two minutes I do not want you to think about white bears. Keep themout of your head.” Like most people in the audience you probably have the Klondike bear bouncing around in your head right now. The problem with trying not tothink about something is that it actually raises its prominence in a group. There is aninteresting study in which people were divided into two groups. One group looked atskin-head pictures with a caption that said, “Don’t think bad things about skinheads.”
That group had a much worse attitude toward skinheads than the group that were
provided no caption.
Contact, as I said before, is a very important way of looking at changing stigma.
Bob Lundin is a friend and colleague of mine and a person with schizoaffective disorder, so the contact situations I will talk about today involve Bob. The way contact
works is, Bob will get up and tell his story. He will say, “My name is Bob and I havea serious mental illness. I have schizoaffective disorder. We are not talking about test
anxiety. This is a major thing that affects my life. It did not happen as a kid.” There
are still frequent attitudes that serious mental illness started in childhood. If it comes
later in life it is just because you are weak. One interesting thing that comes out of
this is the ‘for real’ effect. “For real? You look too good. There is no way somebody
like you could have a mental illness.” Bob has to qualify, and the way he qualifies ingroups is to ask what it means to be seriously mentally ill. “I have been hospitalized
and I have taken drugs for years.”
Now I want to give you a sense of what some of our research looks like. We dida randomized control trial with a sample of 152 people. The participants took apretest on mental and physical illness stigma. Then they were randomized into four
conditions: education, protest, contact, or a control group. The significant finding
here is that education and contact improved in terms of their ability to respond totreatment. Social psychiatrists call this stability, the idea that you are not stuck inyour mental illness but you can get out of it. The control condition produced aninteresting finding pertaining to social desirability. If I come around and ask youwhat you think of enkephalins—an actual study was conducted on this made-up
word—your attitude is going to get better when I ask you twice because you arethinking, “Well, he’s trying to show if I am a bigot.”
Another study we did involved randomizing people into four groups; two wereeducation groups and two were contact groups, each containing a responsibility
group and a dangerousness group. The results are clear: contact has a huge effectover education. What is interesting about this data is not just that contact shows a
big effect but that follow up to any education diminished over time while changes
due to contact were sustained. Perhaps one of the best ways to challenge stigma is
to have people with mental illness come and tell their stories.
I also want to look at the vehicles of changing stigma, the way we get protest,
education, or contact out there. We divided the vehicles into media-based, with PSAs
being the best example of that, and in vivo, which involves inviting an outside expert
to educate people about mental illness.
The media is a population-based vehicle and its strength is that it is likely tohit huge numbers. In vivo is a face-to-face approach and, therefore, localized toindividual groups.

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A media-based example of a vehicle to changing stigma comes from a Glenn
Close public service announcement that came out in October of 2009. Her sister, Jessie, has bipolar disorder. It is a very moving and compelling 30-second PSA. You see
pairs of people coming up wearing different shirts. One shirt says “schizophrenia”
and the other says “mother.” One shirt says “bipolar disorder” and the other one
says “spouse.” This program is called Change A Mind. When I am sitting aroundwith friends I ask how many people ever saw that video. When you ask this at the
population level no one has ever seen the video. Why not? Well, as you may know,
broadcasting networks are required to show public service announcements as part oftheir national mandate. But when they do this, the PSAs are frequently relegated totimeslots very early in the morning so that the audience seeing it is greatly reduced.
Then there is the issue of the Screen Actors Guild. When they produce these public
service announcements, they are only good for a limited amount of time, usually
one year. If you go beyond that amount of time you have to pay the actors again sothese PSAs disappear quickly.
Bernice Pescosolido talked about the issue of impact, that is, do these PSAs
change anything? First, I want to look at the issue of penetration. Do people in
the world see the PSAs? In response to the video game PSA with two guys on the
couch, which was aired nationally, 31% of the population reported seeing it. The
good news is that about a year later that sample was still pretty high, about 28%.
A quarter of the population seeing something surely shows its wealth and value interms of affecting a public agenda.
Our other question was whether websites have any value in terms of tracking
actual changes in behaviors. There is a set of PSAs that was done several years ago
showing different people. Betty is black, Frank is European and Harry is Chinese.
There are different ethnic groups and they are all able to work. What do they havein common? They are all mentally ill. This is important because it challenges theunderlying stigma, which is the idea that people with mental illness are different
than me. Researchers went out and counted how many people went to the website
as a result of seeing the PSA. Between time one and time two, when the PSA hit themarket and about three months later, they found a pretty significant increase of hitson the website, almost threefold.
That PSA was shown in eight states in the union, to 127 million people. Of those
127 million people, you have a few thousand at the bottom that saw it. The firstquestion is whether that is a cost-effective way to continue to use that PSA. What iseven more compelling to me is that, of everybody who went to the websites, 88%
left in less than one minute. That phenomenon is probably typical for any type of
PSA. Nevertheless, we need to realize that only about 10% of people going to thesewebsites are actually using them.
One of the things discussed today was direct-to-consumer advertising, andpeople opined that perhaps it has improved attitudes about people with serious
mental illness. We did a study about three years ago randomizing people into twogroups. One group was a direct-to-consumer advertising for Cymbalta and the othergroup was a direct-to-consumer advertising for a heart ailment. In both cases, thePSAs were embedded in the clutter of four other commercials. The only thing thatdiffered between the groups was that the PSA pertained to physical versus mental
illness. People in the mental illness group showed no change in their attitudes about
mental illness or their endorsement of stigma.
I want to address an issue that came up earlier concerning self-help. It seems like

Mitigating Stigma and Barriers to Careself-help is a great way to go in terms of trying to decrease stigma. I mostly agreewith that but I am struck by some perplexing data we found. We were part of aneight state multisite study that SAMHSA-CMHS just put out on consumer operated services. People in the study were randomized to a consumer operated service,self-help, or control group. The mean number of people going to a session was one.
People would not go. What is really germane to stigma change in self-help groups
is the decision to go in there and make an attempt to change.
The last thing I want to discuss is that I think the best kind of stigma change istargeted locally. PSAs tend to target the overall population. What I think we needto do is narrow the focus down into landlords and teachers. Local might break
down to the same branch of service, people of the same ethnicity or same disorder,
or we may get more localized by looking at the base in which somebody lives or the
regiment to which they are assigned. We also need to look at the issue of distressedpeople: the depressed employee, the suicidal adolescent, the panicked drug user, andthe soldier with PTSD. These are all populations that NIMH and other organizations
recognize as important groups.
I have presented a nice balance of the different research we have been doing interms of analyzing stigma change. I hope today and tomorrow we have an opportunity to talk more about all of these things.
DR. ESTROFF: I would like to acknowledge my research assistant for this talk,my brother who was an Army doctor. He retired as a Colonel last year and is now
a civilian doctor at Grafenwoehr. There are two things I would like to do today.
First, I want to set some common ground in terms of how we understand and deal
with stigma and discrimination in general. Second, I want to take some time to talkabout several unique challenges.
I want to start with this idea that mental illness is something that we are and not
something that we have. I have a quote from Mark Vonnegut’s wonderful book, The
Eden Express: “Most diseases can be separated from one’s self and seen as foreign,
intruding bodies. Schizophrenia is very poorly behaved in this respect. Colds, ulcers,
flu, and cancer are things we get. Schizophrenic is something we are. It affects thethings we most identify with making us what we are.” We did a longitudinal study
on self-labeling as part of a much larger project. We found that it was remarkably
unstable and amenable to change. The participants were early in their careers withserious mental illness. We thought that when they started receiving disability payments they would label themselves. Most of them changed their labels from mentally
ill to disabled. The process of labeling is dynamic.
A broad review of the anti-stigma strategies out there include human rights andcivil rights, the “We’re just like everybody else” education that Pat Corrigan justdiscussed, proximity, or contact, and legislation. The Americans with Disabilities
Act (ADA) and the right to treatment are examples of legislation we have tried.
One of the questions I always ask my students is “Why did we even need an ADA?”
That should tell us a great deal. We need to shift the focus to something like yourinability to see my ability is your disability. We also need to challenge what is alreadyestablished. Only 5% of people who are disabled are in wheelchairs but there is one
universal symbol. Why did we adopt that?
The next set of anti-stigma strategies are medicalization, brain disease, empowerment, recognition, self advocacy, and chemical imbalance, which I am delighted tosee has a growing consensus that it was a failed strategy. One of the anthems is thatstigma is the real disease, not schizophrenia or any other disorder. “I don’t want pity,
I want rights.” This is politicizing rather than pathologizing.

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Then we have the issue of the dangerous individual whose rights could be
abridged in the safety of the collective, an idea put forth by Foucault. There is adrawing from a Charlotte, NC newspaper displaying a man whose head is a bombwith ‘mental illness’ written on it. The man is holding a gun with the words ‘easy
gun access’ written on it. The caption reads “American Suicide Bomber.” What isinteresting about this is that it implicates everybody. In addition to the dangerous
individual we have this pervasive sense of anxiety out there. So we have these twothings, risk and anxiety and the quick cure is a pill, this idea of medicalizing.
Part of the problem has to do with this nonsystem that we have and the idea thatyou get lost in it, that it is some kind of a maze. Part of the reason I want to raise thisnotion is that we have to recognize that even though there is a maze, people havesome well-founded concerns about seeking services. I do not think this is confined
just to the people who might use our services. I have listened to enough of you andI know enough of my clinical colleagues who have serious reservations about theposition they get put into in the middle of formularies, regulations and rules.
We are just completing a study in Pittsburgh of people who went to outpatienttherapy at a public mental health clinic, and we asked them to tell us what thebarriers to engagement were. I think you will see they look pretty familiar: “I’mgoing crazy. I’m afraid. I do not need it. I am concerned about having to talk about
intensely personal topics. I have social anxiety. I do not want meds. Stigma.” We also
asked about their apprehensions toward therapy. Responses included: “Nothing has
ever helped, I am scared to open up to a therapist, I have loss of privacy worries, I
was forced to have an assessment.”
Now I want to talk about the challenges that are somewhat unique. Context isreally important. Ron Kessler brought up the idea earlier that maybe after a disasteryou could be more normal and you can go get services without being stigmatized. I
am reminded of a wonderful book by Lucy Grealy called, Autobiography of a Face inwhich she talks about being facially disfigured. She has a wonderful chapter on how
Halloween was her favorite day because she could wear a mask like everybody else.
What is the context? I took the cultural competence test for military culture on a
website, which lists the core values of each branch of the military, including loyalty,
duty, respect, selfless service, honor, integrity, courage, and commitment. There arethree things in particular I want to highlight. The first one is the word “always.”
That means no hitches, no down time; you always have to be this way. If you havea setback or things are not going well, that is a problem. The emphasis is on being
courageous and faithful and ready at all times. Second, we talked before about thissense of selflessness, of putting others first, something we do not learn about verymuch in the civilian world except with our immediate families. Third is a question
I want to raise. Are mental illness, military service, and treatment autonomy andprivacy compatible? Talkot Parsons states that the American Sick Role is that if you
want to be legitimately sick, you have an obligation to try to get well and cooperate with others, and you have an obligation to prevent threatened illness whenpossible. This moral calculus is one of the potholes on the road to prevention. In
the service, given those core values and the limited autonomy and privacy, you getcaught between those expectations and the symptoms and distress you feel. How
do you get out of it?
One of my concerns was the different kind of citizenship you have when you
are in the service and the different sense of self you are supposed to have. There isa bill of rights for behavioral health care in the military. It outlines such items asMitigating Stigma and Barriers to Care“individuals should seek and receive behavioral health support to maintain fitness forduty without fear of stigma and discrimination, be taken seriously to receive dignity
and respect from leaders, and receive screening and treatment without automaticallyaffecting security clearance solely on the basis of seeking care.” How many people
do you think believe that? I think Captain Hammer said earlier that people have to
see that this really works for it to be real. Just because it is in the bill of rights does
not mean people will believe it.
The commander of Grafenwoehr released a statement after there were about fivesuicides last year. The statement read, “We need to say it is OK to discuss mental
health, and that OK will not disadvantage one’s career.” However, in an article in
the Military Times the recommendation was to, “Protect your confidentiality giventhat there are limits. Read your rights before you seek care. Use hypotheticals or
seek help from a civilian mental health care person.” So where is the safe place?
Chaplains. That is the only place that confidentiality can be taken seriously, or is
inviolate. In that sense I think we have a great deal to overcome.
I want to return to stigma and discrimination. I want to raise other reasonspeople might avoid seeking care. If I am in the middle of a divorce and a custody
battle, the last thing I want to do is see a shrink or get help. There may be rational
reasons people do not seek care that we do not think of if we are not in thosepeople’s shoes.
In an attempt to wrap up, I want to point out that we need to stop this processof disablement and enhance recovery. I am currently working on one of the teams
that is doing a huge randomized control trial of early intervention, first-episode treatment for schizophrenia. One of our big concerns is avoiding labeling for these young
people. However, labels are not all bad. There is a thing called label attachmentthat we have seen recently with people who have Asperger’s saying, “Don’t take itaway. Don’t put us in there with the autism people.” Sometimes people are attached,sometimes not, but we need to watch that process and try to find alternatives.
In the end I have two questions for people to consider. Maybe we are asking thewrong question. Not “Why don’t you get treatment?” but “Why would you?” We
know a great deal about people who drop out of treatment, but what about the ones
who stay? Maybe we need some information from them beyond demographics. The
last question I want to leave you with is one that is of interest to me. I am wondering
if there are any changes in stigma about mental health and mental illness related towarriors and soldiers that would generalize to civilians. The thinking is that people
in the military are courageous individuals. This is an opportunity for the public tohave exposure to people who they honor and see as courageous. Can some of thatgeneralize to people who have not served?
DR. BORNEMANN: I am pleased to be on this panel and in the interest of full
disclosure I am working with Sue Estroff, Pat Corrigan, Bernice Pescosolido, andothers on some anti-stigma work through our venue at the Carter Center. We havebeen looking at effectiveness of anti-stigma campaigns and the things that workand those that do not.
We have a major anti-stigma effort of our own as well. There is a journalism
fellowship program in which we award a one-year fellowship to mainstream journalists and make very few requirements of them. It is not a residential fellowship.
It is modestly paid and is awarded competitively. They have to stay in their own
venue, their own media form, and then propose a piece of work. They come in at
the beginning of their fellowship year and talk to us about what they want to do,71

In the end I have
two questions forpeople to consider.
Maybe we are asking
the wrong question.
Not “Why don’t you
get treatment?” but“Why would you?”

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conduct their work during the year, and then come back at the end and show what
they have done. We provide a great deal of assistance along the way, a little bit oftraining in the beginning and a listserv with access to experts and data that can help
them work more effectively. We currently have an external review of that program
to look at its effectiveness, but so far we have been pleased with and are proud of it.
Bob Ursano asked us to acknowledge the lenses through which we are making
our remarks. I will give you several of mine. One is public policy. The recommendations around mitigation that I will talk about will likely have much more of a policy
flavor than a clinical flavor because that is what we do at the Carter Center and thatis what I have done for the last portion of my career. The second lens through which
I am looking involves disaster work that I did for 12 to 14 years of a very different
type. That is through the lens of refugee mental health.
We underwent some major migration events during the 1980s, several of whichwere unplanned and chaotic and caused a tremendous amount of social disruption
in certain parts of the country. Some of those who migrated had preexisting mental
disorders. Those people taught me a great deal about the kinds of needs that peopleof other cultures have. Culture was mentioned earlier. I think Paul Hammer was thefirst one to bring it up. I think culture is vitally important.
The third lens I am looking through is cultures within cultures. I thought about
my remarks more from the military standpoint since I am a veteran. As a memberof the military, not only do you have thoughts and ideas from the greater culturethat we are all part of, but you have a military culture that is very steeped in norms
and values. The military culture, unlike other subcultures in our society, talks a great
deal about norms and values and reminds the members of that culture that they are
expected to live by those norms and values. That sets an expectation that is fairly
high. Those of us who are not involved in those types of organizations are not asked
on a routine basis to reexamine our values and our adherence to those values. In
some ways there is a higher standard.
I want to return to the larger culture for a moment. In working with refugee
populations, I realized that my formal education prepared me in no way for thatwork. All of a sudden we were faced with people from vastly different countries
who think about the world very differently than we do, populations that may nothave labels for things like depression. Some cultures do not have a word for depression in their language. We initially thought we could take western principles thatare very much couched in our own cultures and our own ways of seeing the world
and apply them to people of vastly different backgrounds. It was a learning curve
for me and my colleagues. It was a very sharp learning curve because as we went tolook for knowledge and information to inform our work, there was none. This work
generally involves a new migrating group, applying treatment to 15 or 20 people,
and reporting on that treatment, and it gets no further than that.
It is difficult to get mainstream refugee research funded. But it taught me theimportance of things like community, tribe, and family. Family was vital. When I wastrained, family was the potential perpetrator so you had to hold them suspect. In
the refugee world, if you do not legitimize yourself with the family and community
they will not come. It was important to understand that the role of family is very
different than we think about it in most cultures in the world.
What I came to understand, and this is not a criticism, is that we are much moreindividually focused than most people in the world. America is the outlier in manyof the ways we conceptualize care, and the way in which we provide, organize, andMitigating Stigma and Barriers to Caredeliver that care is very foreign to most people. We had to learn how to have respect
for spirituality, which was trained out of me 40 years ago. “Do not talk about religion or politics.” Well, religion and politics are an important part of people’s lives.
We just have to figure out how to do that and do it in a respectful way. Those aresome of the lenses through which I make my remarks today.
I saw the Glenn Close PSA that Pat Corrigan talked about. It was sent to us
by the group that produced it. When they sent it to us they also sent some trailers.
They were not shown publicly, but they were interviews with the participants. They
were the most powerful images that you could ever imagine, showing the compassion and the manner in which these families worked things out in such a naturalway. If you want to really go after stigma you have got to make it real for people.
Most people know somebody with a mental illness, are living with someone with amental illness, or have a mental illness. If we could get those natural moments out
to people, it would have a substantial effect.
Somebody who entered their professional career as an Army medic at the endof the Vietnam War when we were receiving veterans home can tell you it is vastlydifferent now than it was then, and in a good way. We did not do a good job ofreceiving those people home and we are still experiencing some of the effects ofthat. I cannot imagine that this type of meeting would have been held in 1971. I
applaud the efforts of those who have tried to make a difference by moving theseissues out into the sunlight so that we can understand them better and serve thesepeople better on their arrival home.
People are empowered as a group, not just as individuals, in the military environment, which once again speaks to culture. One of the overarching themes in any formof real, legitimate social change is the vital role of leadership. We have learned someother things in terms of mitigating stigma in the military. Soldiers who rate theirleaders more highly and report higher unit cohesion are also reported to have lower
scores on both stigma and perceived barriers to care. Positive leadership and unit
cohesion can reduce perceptions of stigma and barriers to care even after accounting
for the relationship between mental health symptoms and outcomes.
One of the areas that I think has unique challenges to the military, and maybe
you could add police and firefighters to that, is the career repercussions of seeking
care, which Sue Estroff brought up earlier. Everybody recognizes it but I am notsure we operationalize it. What does it mean? There is this career kiss of death for
those who seek help. Is it a one-time opportunity and you can either never get ridof it or you can go on to serve? When I was still working in the government we had
a big fight with the Central Intelligence Agency (CIA) over security clearances andpeople who had sought mental health care, even people who had been successfully
treated. We did not win that fight back then.
An area of consideration when addressing stigma in military populations andfirst responders is the public policy angle. Both of the previous speakers talked
about this as well. Recently, after decades of struggle, we have ended one of themost obvious structural forms of stigma, which was the lack of insurance parity
for the treatment of mental illnesses. Why did that fight go on for so long when theinformation showed that not only was it the right thing to do but it was the smart
thing to do? It was a cost-effective thing to do.
Another sensitive area is illustrated by the example of a veteran, a former
Marine, who had suffered tremendous physical injuries but who had a hard timereconciling the fact that he also had PTSD. That raises a very troubling question. We

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I also like the notion

certainly have to respect this man’s service and sacrifice, but by not acknowledging
a mental illness for what it is, are we allowing for structural stigma to continue?
We just launched a new project on scaling up services in a post-conflict environment in Liberia. We took a look at how they deal with stigmatizing conditions otherthan mental illness. They have reasonably successfully dealt with HIV/AIDS. We
went to a village way out in the bush. The form they were using, and this is used ina number of other African countries that I am familiar with, was dramas to resolve
social problems that are common in the villages. This is a village with thatched roofs,
no floors, no potable water. They did three dramas when I was there. One of them
involved a man and a woman, husband and wife, and it was about a rape trauma
where the woman was raped multiple times, her husband forced to watch, and they
were having ongoing marital problems. They played out this scene in front of theentire village from small children to older adults. At the end they had a conversation
about how it went for the husband and the wife. I thought, “Wow. That is powerful stuff.” I would love to see somebody take a look at that and evaluate it for its
overall effectiveness.
I will close with this. I took a look at the Department of Defense (DoD) Task
Force on Mental Health Final Report and Recommendations. There is a recommendation about the operationalizing of career effect. They recommended suchthings as integrating mental health providers in primary care settings, embedding
psychological health workers throughout the outfits and units, including deployedunits. This is a great idea and I think it is already happening.
The task force recommends developing DoD-wide curricula for psychologicalhealth as an integral part of all levels of leadership training for family members andall medical staff and mental health personnel. This too is a great idea. Thank you
all and I look forward to the discussion.
DR. HOGE: I liked Dr. Estroff’s comments using the term ‘fault.’ For combat
veterans there exists sensitivity to judgment, guilt about things that happened overwhich they had absolutely no control. There is in fact, the illusion of choice projectedbackwards in time. Our brilliant cortex has the capacity to project back in time tosee other alternatives that appear to have been there at the time but really were not.
This idea gets into fundamental concepts of how our society perceives blame,
fault, accountability, and responsibility. We are a society that is quick to blameand find fault with individuals. I am not talking from a legal perspective but froma societal perspective. “It is your fault” implies that there is something personallywrong with you, and that is the way a soldier who has come back from combat
interprets it: “There is something wrong with me, or people are saying there issomething wrong with me.” I hope at some point in evolution there will be a shift
toward the concept of responsibility and accountability and away from fault andblame, recognition that in virtually every situation people find themselves, they do
not have the choices that they project back in time. That does not mean they are
not accountable and responsible for what happens because they were there. But
they do not necessarily have a choice in the way that we project onto them with theconcepts of blame and fault.
DR. BELL: A while ago I decided that I would be responsible for my mistakes. I
would not be condemned by them. I struggle with the internet because I think having
mental health information there is a good thing, but there is so much misinformation
there too. I do not know quite how we send people to the right sources.
I also like the notion that mental illness is something that has happened to me

that mental illness
is something thathas happened to me
versus who I am.

Mitigating Stigma and Barriers to Careversus who I am. I remember what a woman who had been raped said to me as I
was apologizing to her for manhood. She said, “That which happened to me does
not define who I am.” If people can make that subtle distinction it is much easier
to do some things.
But I guess I also struggle with people’s level of understanding and how able
they are to differentiate these subtle differences. Someone said they were impressedwith the American public’s intelligence. I am not one of those people.
DR. PESCOSOLIDO: No, I think that sometimes researchers go into researchthinking, “These people will not do this because they are stupid” or “These people
will not understand what I am saying.” I do not think that is true. People believe
what they believe and we may think what they believe is stupid, but I do not thinkthat they are unable to answer the questions that we ask or the things we want toknow about.
DR. HOBFOLL: I have several thoughts. One, it has been discussed a numberof times that, if you had the data, you would do it differently. I think that is in parttrue. For example, our surgeons ignore psychological stuff entirely except for thetransplant surgeons because they get certified. If you fall below a certain level you
lose certification so all transplant teams have psychologists on them who they listen
to carefully.
DR. ZATZICK: Dr. Hobfoll, I have to take issue with that. The American Collegeof Surgeons, for the first time in any general medical setting, has mandated brief
motivational interviewing as part of trauma center accreditation. Just like there
has to be a trauma surgeon in house 24 hours, you have to have somebody who isavailable to deliver motivational interviews.
DR. HOBFOLL: But every transplant team already has a psychologist involved
with them. The second part is that men are generally more resistant to this than are
women. I would say that for military commanders, if 20% of people are coming
up with PTSD, it is deeply affecting those combatants’ ability to behave in the field.
If you look at the data it would have to be obvious and devastating. So, there issomething about the resistance to facts that is underlying much of this.
DR. HAMMER: I wanted to comment on Dr. Corrigan’s point regarding theeffectiveness of contact. There is a program in San Diego called Kids Included
Together, which encourages kids with disabilities to be included in after school andsummer recreation programs. They implemented this in order to help benefit the
kids that have the disabilities, but what they found was a concurrent benefit withthe kids without disabilities who became much more tolerant, more effective, andmore engaged with the kids with disabilities. The benefit was on both sides.
Kids Included Together counselors come to the YMCA and summer camp programs, and their mission is to provide the training to the counselors in order to help
them know what to do with kids in wheelchairs and children with autism. It is aninteresting model that might be useful. They may be further ahead in the anti-stigma
campaign for children with disabilities than we are for mental health.
DR. BATTEN: Theater of War is a project that several of us jointly in the Department of Defense have been spearheading over the past couple of years. Chuck Engelpiloted it, but now we have a large contract across the DoD. In Theater of War weare presenting two of the works of Sophocles, an ancient Greek general who wrote
several of his plays about the experience of warriors and their families. There is atranslator from New York, Brian Doerries, who translated the ancient Greek text
of two plays, Ajax and Philoctetes, looking at different aspects of the effect of war

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on warriors and their families. One deals with suicide. One deals with a warrior
who is left behind by his unit and how that affects not just him but also his fellow
service members. We have been taking this around the country and we are hoping
to take it around the world. We have amazing actors who perform the readings ofthe plays. They are not staged. There is nothing fancy about it. It is just the words
and the performance. It is like the approach of using drama as a method of getting
communities to talk and to be able to talk openly about these issues.
Following the play there is typically a panel of individuals up on the stage to
get the conversation going. Then we open it up so that the audience, and these areusually service members, family members, sometimes doctors, chaplains, and otherprofessionals, can share how this relates to their experience. It is an innovative andpowerful technique. You can learn more about it at Theaterofwar.com or Google
Philoctetes project.
DR. ENGEL: One fundamental view I have that makes Theater of War importantis that, although there is a large proportion of people in the military who are notseeking care, many of those people do believe that they have a problem. It leads
me to think that we must not be offering the right thing for them to engage. What
we currently have to offer is either a pill that affects your brain in some fashion ortalking to a stranger about intimate things. That does not appeal to a large portionof people. I like Charles Hoge’s view that you wonder who is crazy sometimes.
Perhaps we should reformulate the way we are thinking and try to offer things
that work that are outside the box. Sometimes we do not know if these things will
work. Certainly Theater of War is among those. But, anecdotally, as we go aroundthe United States with Theater of War we see communities engaged, we see people
respond. It creates a teachable moment where you can provide literature about
where they can go for care. Often it is not the people who have issues that are theones most affected by this. It is the ones who have a loved one at home or in theirneighborhood who they know needs some assistance. They are able to learn waysthat they can help them. I also think that these are ways that we can reach a larger
proportion of people who have needs. When we do not know what the therapeutic
effects of these things are, I think we are obligated to study them further. We haveto expand our notion of what is therapeutic.
DR. HOLLOWAY: Charles Hoge commented on the blame culture. I want toraise the issue that such cognitive activity, along with its overall accompanying
emotional consequences, is frequently supported by society as a delusion that wereally do have control in these circumstances. One of the large delusions is that when
you enter into these deadly quarrels, in which people are actively killing each otherin a chaotic and violent environment, certain things can be done and that they will
come out in a fixed way. We have seen people plan wars with those assumptions
with some disastrous results. The consequence for the individual is to carry theblame and guilt in the psychotherapeutic range. My point is that social structure andcultural assumptions sometimes operate to produce what is in fact undistinguishable
from delusional thinking. Nonetheless, it is very hard to get people to give that up
because it allows them to avoid the thing that people said made them so anxious:
uncertainty about the future.
DR. URSANO: This addresses some of the comments Bruce Link and BernicePescosolido were making about what motivates stigmatizing and, in this case, what
motivates is for the larger society to have a sense of control over a series of events.

Optimizing Access to Care

8

Optimizing Access to Care
C. Hendricks Brown, Ph.D.
Wendi Cross, Ph.D.
Doug Zatzick, M.D.

DR. URSANO: Our next panel includes the premiere health services and implementation people, Hendricks Brown from the University of Miami, Wendi Cross, theUniversity of Rochester, and Doug Zatzick, University of Washington.
DR. BROWN: I really appreciate being invited to join this group. I am going totalk about some of the work that I am doing with my colleague Peter Wyman andother people in the Prevention Science and Methodology Group (PSMG). The PSMG
group has been funded by NIMH and NIDA for 22 years to look at the integrationof scientific work around prevention science and the methodology that goes withthat. Wendi Cross, presenting right after me, is one of the other members of the
PSMG group. I do not work with the military or disasters. But I think that some of
the work that has been going on in suicide prevention may be relevant here so thatis what I would like to share with you.
The first thing I would like to do is ask two questions and have you raise yourhand if you agree. How many people have heard the statement that, “The path to
Heaven is paved by good intentions?” About a third or so. How many people haveheard the statement, “The path to Hell is paved by good intentions?” Which is right?
It is definitely a cultural thing.
DR. ENGEL: I find “no good deed goes unpunished” is probably more accurate
than either of those.
DR. BROWN: Right. I think 100% of the people would agree with that. The
reason why I raise that question here is because I think the field that we are in—thatof delivering effective programs to people in need at the appropriate time—requires
more than just good intentions. Most of what we have done so far in this fieldhas been coming up with good ideas, but we do not have a system yet to carefully
evaluate whether programs will work and what kinds of policies and programs need
to be put together as we move forward. Suicide is an interesting project and test
case because a great deal of the research in suicide is behind the times in terms ofunderstanding outcomes, particularly for youth, compared to other outcomes that
we deal with such as drug abuse, depression, etc.
As I start to talk about this, I will talk about what kinds of scientific paradigms

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might make sense and how we are going to learn anything about this field in very
complex settings such as the Army, and in disasters; settings in which we normally
would not think of bringing to bear the strongest scientific methods. My suggestionis that we should pause to consider using some of the traditional experimental andnon-experimental methods in our adaptation so that we can provide the most useful
information on care in wars and disasters.
The goal here is to provide generalized knowledge. I recall going to the World
Federation for Mental Health meeting a number of years ago; people were there
from Bosnia at the time that the war was going on. We have talked about the samekind of theme. Unfortunately, these disasters are going to be continuing and we need
generalizable knowledge about what works and under what conditions. Particularlyin the field of suicide prevention, we are facing very important struggles. I think thata number of the programs have at least the potential for doing harm. It is importantto recognize that these programs might have negative impact on some individuals,
and we should be very, very careful when looking at that.
The most powerful scientific design we have is the randomized trial, so I will
discuss ways that we have been able to do this in the suicide field as we move
forward with a broader based understanding of what these programs are actually
doing. Do studies have the right mechanisms and effective mediators as we expect
them to? There are two suicide prevention trials, one called the Georgia Gatekeeper
Trial and the other one, the Sources of Strength Trial, both of which Peter Wyman
and I have been working on for a number of years.
I am going to talk about issues of optimal care. The first thing that came up
earlier today is, “What if there is no optimal care, what if it does not exist?” What doyou do? When is any formal care virtually unavailable? I will describe the Sources ofStrength Trial. There is data that talk about levels of youth suicide between ages 15
to 19. I do not know if people really are aware of this, but there is certainly a strong
relationship between the levels of urban/rural suicide rates for youth, particularly inthe west. These are frontier areas, and if you actually go out west, you will see thatthe environments there are dramatically different from many of the other environments that we ordinarily study in urban settings and other places.
Just as one indication of that, when a principal in some of the plains states getsa notification that a kid is suicidal, they cannot use their own cell phone to talk to
the mental health counselors. The reason is because in some rural areas people go
to Radio Shack and buy a little device that allows them to listen in on other people’scell phone calls as entertainment. So what we take for granted here in a different
environment may not be the same in other places. Issues of rural and underserved
areas are a critically important piece where the mental health systems are virtuallyunavailable. The question is what we should be able to do under those settings.
There are three general kinds of approaches to handling those exposed to war
and natural disasters or terrorism when expert care is not currently available. One
strategy is to increase system preparedness. Wendi Cross has been working on an
evaluation of a rollout trial for testing the suicide hotline to see whether the new
assist program being used in a multilevel training model is going to be effective in
identifying those who are suicidal and getting them help. The other two approaches
are built on a public health model. To build positive supports of resilience, we need to
be close to the time of risk when people might need it most, as opposed to jumping
to put people into a care system which might not exist.
The second approach is to intervene early on by looking at targeted antecedentOptimizing Access to Carerisk factors for suicide. One name used is developmental epidemiology. Another, usedin cardiovascular disease, is called primordial prevention. It is a simple idea: if you
want to prevent heart disease, diet and exercise is really good. But you might want
to do that early on, when kids are young enough to develop those habits rather than
wait until they are 55 years old and settled in their ways.
For multiple levels of intervention, I am going to discuss Sources of Strength,
which is one of the interventions that we found in North Dakota that Mark
LoMurray has done. We have been in the process of testing through a number ofrandomized trials. It really has a comprehensive resilience model. Access to mental
health and medical systems is one of several components. It also includes spirituality, generosity, etc.—the things that appeal to the broadest number of kids. We havea model and 20 years of research looking at preventive interventions that target
issues for kids: depression, drug abuse, family conflict, child abuse, and conductdisorder. We have many interventions that are effective on those kinds of things.
So the question is, if we could affect those things in the beginning, can we affectthe long-term outcomes of suicide as well? The possibility is there, although being
able to evaluate them in a very careful manner is difficult because of the relatively
low rates of suicide.
To give you an example of the developmental epidemiology approach to target
early risk factors, there are data from an intervention done on first graders. A study
did a randomized intervention on first graders called the Good Behavior Game. It
looked developmentally at how long effects lasted to age 25. Lifetime rates in thestandard setting were over 20%; in the Good Behavior Game, it was down to lessthan 10%. These can be very powerful approaches, and we have not even scratched
the surface of examining what their long-term effects will be.
I will switch now to an intervention that is targeted more directly at the time of
the needs that are available, and looking at those who are at risk for suicide. What
we are calling a “rollout trial” has a more technical name, Dynamic Wait-Listed
Design. There are ways of doing this systematically in community settings withappropriate partnerships. This is an efficient way to provide training, and is what
the military does. They efficiently train a large number of communities and get avery high fidelity of that training. Another asset is that it has many nice statisticalproperties, including an improved statistical power over traditional wait list designs.
The Dynamic Wait-Listed Design also improves the modeling and models for causality as well. We have been promoting this as a design strategy that might fit in somekinds of research questions.
The first trial was a gatekeeper training trial that focused on training all adults
in schools. The goal of this was to identify and refer those at risk of suicide fortreatment. The trial took place in a county that had an active mental health coalition and organization that could be marshaled. The question is, if the schools could
identify those at risk for life threatening behavior, could they actually refer those kids
more effectively through a training program for gatekeepers? Gatekeeper training isprobably the single leading model for youth suicide prevention, as well as the mostcommon one. The target is the intervention. Training is only at the level of the adultgatekeepers.
I will emphasize three things here. One is suicidal youth. We know from otherdata that almost all suicidal youth tell somebody in their networks that they aresuicidal, that they are ready to end their life. They give many suicide warning signs
that are just not picked up very often. This model trains gatekeepers to read warn-

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ing signs more effectively. It also trains them to directly ask kids whether they aresuicidal, and then gives them a way to provide those kids direct links to existing
mental health services. That is the model. Does anybody think it is workable? Thisis the model we are trying to use.
DR. ZATZICK: There is a provider level denominator and it might take a very
sophisticated provider. I would be interested in what the aptitudes were of the
population of providers in training, the providers being the gatekeepers.
DR. BROWN: There are some differences at the gatekeeper level. There is anidea that we have been calling a “surveillance model” and it does have the potentialof having an effect. In this school district about 8% of kids who reported that they
had a suicide attempt this last year were known to the school. If you were able toimprove the ability to recognize suicide warning signs and to marshal each person’s
ability by a very small amount, you might have a better effect, particularly with alarge number of staff in the school. Instead of 8% you could potentially identify 40% prior to attempt.
We conducted a randomized trial called QPR in a large school district that had
already decided they were going to implement the training and we simply steppedin with the support of NIMH and then later with SAMSHA funding to do thisrandomized trial in all 32 middle and high schools that were available. The school
district was extremely well organized. The Mental Health Coalition was also very
organized. This is not a disaster model at all. The only two schools that had a suicide
occur during the previous year were already trained prior to the trial because theschool felt that something needed to be done. If there was a suicide that actuallyoccurred in this school, instead of stopping the study, we were allowed to continue.
That was because this school district had an average of four suicides per year. It had
50,000 individuals, not very much above the national average.
When we initially were funded we did not have this technical paper regarding
what kind of evaluation opportunities that the dynamic waitlist or rollout designoffered, so we came in with a standard waitlist randomized design. Sixteen schools
were trained early on; sixteen schools were trained later on. Everybody in the school
district was required to get training. What we found was that asking 32 schools to
get trained is like herding cats. It took a long time to do. We realized that what wereally need to do from a logistics point of view is to focus on smaller numbers ofgroups at the same time.
We locked on four schools at one time and said, “We want to get you trained
this month and then we will evaluate you,” and then we would go to the next setof schools, and then the next set of schools, and so on. We switched to this rollout
design so that eventually everybody got trained on the schedule we had intended but
in a much more systematic way. That is what the idea of rollout design is. Logistically, the design actually increased the proportion trained in schools. It took muchless time to do and it increased the statistical power as well.
We did two-year evaluations from the perspective of those who were trained.
We had strong increases over a two-year period of knowledge of warning signs. We
also had some very strong effects in shifting attitudes. People were definitely willingto take on gatekeeper roles. Self reported intervention behaviors were examined.
When asked, “Did you ask a student about suicide?” they replied, “Yes, a little bit,
but not very much.” The training effects and benefits of getting to those students
who were suicidal only occurred in about 14% of the staff who were alreadyengaged with students. Wendi Cross has done a great deal of work on identifying

Optimizing Access to Carethose characteristics of who might benefit and who might not benefit from anintervention like this.
Another thing we did was ask the students, “Did you have a suicide attempt thispast year?” and inquired what their likelihood was that if they were overwhelmedby life they would talk to an adult, either counselor or a friend. There were huge
differences found. Referrals for life threatening behavior had overall a very small
effect, and were significantly positive in middle schools in the direction we wanted,
though the effect was nowhere near as large as we had anticipated or thought it
might be. Eventually what was happening in the high schools was that the referrals
actually decreased.
The referrals also went down immediately upon training, so this is an unworkable model. Particularly in high schools the referrals do not work as an effective
method. Effects only increased when most of the adults in the school had completed
training. A conclusion from this study is that youth who are at the highest risk forsuicide are the least likely to talk to adults. This is an intervention for adults to try
to reach out to kids who are not going to reach out on their own, and it just does
not seem like a very sensible model. So we did a second trial. We are in the processof doing this with 18 schools. There is a focus now on giving the peer leaders inschools a major role in shifting the norms about suicide and getting kids connectedwith trusted adults. We also note that the mental health services themselves are notalways going to be available in some areas, such as in the plains states.
We also looked at a social network model that involved many adults who areconnected to highly connected youth—the peer leaders. The peer leaders are connected to others. We have a systematic way to collect peer leaders from almost every
kind of clique we could possibly find, to break down these codes of silence with a
training program for the peer leaders. We would then use the peer leaders to givemessages of hope and support to those kids who are suicidal. The key pieces areto connect up those peers and use them to connect up the other kids with trusted
adults. There are a great deal of other media and new kinds of messages that arealso out there.
I will go back to the Sources of Strength. Mark LoMurray, who developed thisintervention, has a message that he gives to both the adults and kids. He asks, “Supposing you are a parent and you have a suicidal kid, do you believe if you pray to
God that this kid is going to get better?” Spirituality can be extraordinarily important, but it is dangerous if you are only turning to that and leaving other resources
out. The same applies to using only mental health services. Activating other methods
is important, particularly in areas where we do not have very many formal healthsystems available.
Our focus is looking at creating youth/adult partnerships to break down thecode of silence. These things are measurable. This is looking at the complementsthat could happen within this social network. Both in Sources of Strength andgatekeeper training, interventions are aimed at making these social links occur. We
did this in 18 schools with a randomized design. We identified the peer leaders thesame way for all the different schools. Some schools were randomly selected afterthat point to receive the intervention that first semester. We have baseline and sixmonth data, and this will be coming out in the American Journal of Public Health.
The help-seeking norms of the peer leaders dramatically changed. We found effects
at the student population level, which is what we really needed to achieve increased
help for suicidal peers and help seeking from adults.

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It is important to start obtaining generalized knowledge during these unusualexperiences where we are not typically using carefully designed randomized trials.
What that is going to require is institutional partnerships with advanced directives.
Otherwise, we are going to be doing passive studies and making the same mistakes
each time. I think there is a good opportunity to design randomized trials in disastersettings. I understand with suicide that a standard control group is next to impossible
to do; thus, the rollout design is a useful design. The last point I want to make isthat these broad-based interventions have differential impact as a function of social
networking. If we do not take that into account when designing and measuring
interventions, we probably will not be successful.
DR. CROSS: I am going to focus on this pragmatic topic of train­ing and thetransfer of training. I hope it has some relevance for what you are all thinking about
tonight and tomorrow. Why should we focus on training? This was brought upearlier today. The issue of stigma and disparities in care is a workforce educationand development issue. It is an issue in a couple of ways. One is to develop competencies among the providers. Another, which a couple of us were talking about
earlier today, is the issue of stigma within our own behavioral network, even in ourown workforce.
But what I will focus on today is the first issue, the well documented gap between
programs that are shown to be efficacious and how they function in usual care.
People are talking a great deal today about evidence-based practices. Those practices,
those programs, those procedures, big or small, were developed in one setting andproven to be effective in that setting. Then, when we take them to communities wefind them to be not as effective. One of the reasons for that gap is due in part to
failures in training practices.
My main point today is that a program cannot be more effective than the persondelivering it. Once you choose your program, you need to plan the implementation.
The implementation can be measured on at least two levels. One is at the macro
program/intervention level and the other is at the implementer/provider level. Thisis the level that I am most interested in talking about today. It is as if there is a blackbox. The black box exists between the intervention that you are going to roll out,
and the outcomes that you are expecting. There are a number of efforts and activities
going on between the choice of the intervention and the outcomes, including training
interventionists. They occur in this “black box” of implementation.
Once you have chosen your intervention, you are going to “let your training
begin.” Here is a cartoon that shows someone who has just come back from training.
He says, “I have this really big binder. The training has already been forgotten, but
the binder will last forever. It is a living monument to temporary knowledge.” Not
exactly what we want to hear, right? Now, this person who attended the training
was probably very satisfied with the training. One thing we know, however, is thatsatisfaction is not related to learning outcomes. Satisfaction is the one variable thateverybody measures though. Whether you are in business or education or mental
health, we want to know if people liked the training. Their responses will likely
inform our training design. But, satisfaction does not tell us if participants learned
from the training or if they will carry that new learning into practice.
I am going to build a model of training and transfer of training that occurs in theblack box previously mentioned. One way to think about the model is in terms ofphases starting with pre-training characteristics or variables, the training event itself

Optimizing Access to Carewith its learning outcomes, the transfer of that training — meaning, to the setting it
is supposed to be implemented, and then finally the clinical outcomes.
Variables at the pre-training level phase include things like the program components, the curriculum, and manuals. What about the training modality? That isa pre-training variable. Is it conducted face to face? What about the move toward
online training? Wouldn’t it be interesting to put these modalities head to head instudies of training? Other pre-training variables are the trainer and trainee characteristics. Hendricks Brown mentioned something about this. There are studies thathave looked at individual training char­acteristics, and we have examined some ofthese characteristics in our studies as well. It turns out that if somebody already had
similar training, they show better learning outcomes than those who are new to thetraining. The question of trainee selection challenges our typical “one-size-fits-all”
approach to many of our training programs.
We have conducted studies that have examined training modalities. One study
examined a program that Hendricks discussed, the QPR program, which is primarilya “passive learning” approach in the form of lecture. We wanted to do a training
study and thought that if we are looking for behavior change as a learning outcome,why do we not put behavior into the training? We randomly assigned people to two
conditions, either training as usual — which is a knowledge transfer type of training
using a lecture like I am doing right now — or training with a low-tech, behavioral
rehearsal condition within small groups. We used standardized patients, actors actually, to test trainee gatekeeper skills. I will present our findings in just a minute. The
other training modality that we have examined in two studies is the train-the-trainer
model. It is very popular and considered to be very efficient. Here is an example of
how a train-the-trainer program can be efficient. First, you have master trainers who
deliver the training to people who come to be trained, and here are all those new
instructors delivering the training to many other people, who then go on to deliver
the intervention in practice to many, many target individuals. Exponential growth!
I said that I would mention two train-the-trainer studies. One was a naturalistic
study of a disaster mental health training program. We followed the dissemination
process for a year to assess “spread”: Does the train-the-trainer model actually
spread the way it is intended? That is, do new instructors go on to train others as
intended? The other study is a suicide hotline prevention study. In this case, we areconducting observational coding of the newly trained trainers to look at “quality”
to answer the question: If you could get 100% of the people to conduct the training
with the next generation in the train-the-trainer model, how well do they deliver it?
These are the types of questions you might pose about pre-training characteristics
and variables.
Moving on in the model to the training event, we can measure learning outcomes such as knowledge, attitude, and skills. Often, people assess confidence orself-efficacy as a measure of attitudes. In terms of popularity, after satisfaction, themost frequently measured learning outcome is pre-post knowledge change. Change
in knowledge is considered to be necessary for change in behav­ior, but the literatureshows that improved knowledge is not sufficient for changes in most behaviors.
There is a relationship between enhanced attitudes and skill development, therefore
it would be good to measure attitude change — it might predict behavior change.
We demonstrated the same learning outcomes with the QPR program as Hendricks
Brown did in a different school setting. We found that both parents and teachers had
the same change in knowledge about suicide and suicide prevention and the change

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was maintained at follow-up. As an aside, we were happy to see, and the school
district was too, that the mental health profes­sionals demonstrated high levels ofknowledge about suicide prior to training.
In terms of confidence, our attitude measure, there was also a positive change
from pre-training to post-training for parents and teachers. They maintained theirenhanced attitudes about intervening with distressed kids at follow-up, which was
nice to see. As I noted, we had a condition where we provided the opportunity forbrief behavioral rehearsal to compare to the training as usual. We found that thissmall group practice resulted in better gatekeeper skills demonstrated during aninteraction with “standardized patient” actors. We measured skills using objective,
observational coding of the videotaped interaction.
The difference between that group and the group that received the “passive
learning” training-as-usual was maintained at follow-up, but both groups showed
decay in skills over time. At three months they were both losing their gatekeeper
skills. The question becomes, how might you keep those skills at a high level? These
parents and teachers were probably not using gatekeeper skills very often, and decay
would be expected. But is it possible that there are ways to keep the skills “at theready?” We think that using technology may a good way to maintain establishedskills over time.
Another way to keep skills at a high level is through feedback. We did not give
any feedback to participants while they were doing the behavioral rehearsal inthis study, but studies show that feedback can be important if you want to achieve
a complex skill. Some studies look at how much feedback supervisors should be
giving on specific skills. If you want to see results in terms of behavior change andskill development, you likely need to monitor and give feedback for maintenance.
Sometimes people think that our providers, or parents, first line workers or outreachpeople are not going to want feedback. Yet it turned out in our study, with teachersand parents, that 100% did want the feedback that we offered them after the final
assessment with the “standardized patient” actor. We were surprised. Then, at the
one-year or two-year mark, we did a follow-up survey and asked, “Remember that
feedback we gave you about your skills with the actor? How did you feel about
that?” Eighty-eight percent of participants thought it was important to receive feedback, and many wished we had provided it earlier. They also seemed to feel that it
had some influence on how they behaved later.
One way we measure skill as a “learning outcome,” at least in our field, is interms of adher­ence to the program and competence in delivery. If you are measuring
a program’s outcomes, you want to know that the program being tested is actuallywhat was delivered, and how well it was delivered. We do a great deal of observational measurement work to answer these questions. Some people use self reports,
which are very common and pretty easy to do, but have questionable reliability andvalidity from our perspective. There have been some observational rating scales thathave been developed for the treatment literature and we have developed measuresfor our school-based prevention program, Rochester Resilience Project, as well.
The PI on this random­ized control trial is Peter Wyman. Here is another example
where we are looking at provider skills in program delivery. The providers in the
Resilience Project are school aides trained to deliver a manualized intervention to
at-risk elementary children in schools. We trained the providers and videotaped theirprogram delivery with the kids. Then, we objectively scored their behavior with thechildren in two ways. First, we coded adherence: Did they deliver the content theyOptimizing Access to Carewere supposed to in accordance with the manual or did they do something else?
Second, we coded their competence, which included items about timing, empathy,
and use of active learning techniques, which are very important in our program.
Let me show you why we look at both of these aspects of implementer behavior.
Here we have two interventionists; we call our implementers “Resilience Mentors.”
In this example, we have coded two Mentors delivering the same session to two
different children. They had the same amount of experience delivering the program,by the way. So, as you can see, they each score the same in terms of adherence tothe manual —- they are each delivering a little over 80% of that session as written.
But, as you can see, they do not have an equal level of competence. They scored very
differently on this measure: One scored very high and the other quite low in terms ofobjectively measured competencies such as empathy, pacing, and actively engaging
children in learning. We think this discrepancy — between adherence and competence — will likely have some implications for outcomes. This is an important way
to start thinking about how people are actually deliver­ing the manualized program,because our conclusions might not be valid if the program is not being delivered in
the way that we think it should be. It would not be a true test of the intervention.
The transfer of training phase of the model is often where implementation breaks
down for many of the reasons that have already been brought up today. Recall our
train-the-trainer model in the disaster mental health program. The question was, didthese newly trained instructors go out and conduct trainings for others as expectedby the model? How many newly trained instructors went on to train others? In
the 12 month timeline that we followed dissemination, 60% trained at least one
other person. That means, though, that 40% did not. We are not sure how to think
about this finding because not many people have done this kind of work. Is thiscost-effective? Perhaps. But, let us assume that we could get 100% of the people tocarry out the training with others. Wouldn’t we want to know about the quality ofthe training they conducted? We are looking at this quality question with Madelyn
Gould at Columbia University in a randomized control trial using the dynamic
waitlist design model that Hendricks described earlier. As I mentioned, the targets
for this training are crisis hotline counselors. Centers chose individuals to be trainedin the program who, in turn, trained hotline counselors. We videotaped the newly
trained instructors delivering the training to their counselors, and we are now coding
their delivery to assess how closely they follow the manual — adherence. We arealso measuring how competent they are at delivering the training. This is a groupbased training program which requires certain group facilitation skills, for example.
So, we are coding those competencies. The final outcome is how the counselors
interact with suicidal callers and if the training program influenced them. The teamis measuring this by moni­toring calls. We do not have data on this study. We think
the findings will be very helpful to our understanding of the cost-effectiveness of
train-the-trainer models.
The model shows two other variables that can contribute to breakdown of aprogram’s effectiveness in communities. One is the popula­tion. If a program wasdeveloped with middle class, white children in a certain community, the evidencebase that is cited for that program is based on this population. When you take theprogram to an inner-city community, such as downtown Rochester for example,
where there might be up to 70% African American and 30% Hispanic children
living in very different circumstances, program adaptation by providers may occur.
Then finally, we have been talking a great deal about this today, the context for the

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transfer of the training is also important. When you come back from your training,are you able to apply what was learned? It may depend on support in the workplace,resources, technology, time or other organizational factors.
I would now like to summarize some highlights of this training model thatexists in that black box of implementation: Satisfaction is not related to learning
outcomes but is a good thing to measure to inform your training design. A lecture
is not likely to help with behavior change and individual characteristics but may
matter in some programs. Practice is important for skill development. Skills can be
operationalized and studied. Expert guidance and feedback must be ongoing forcomplex skills to be maintained. Train-the-trainer models may spread a program
but we need to learn much more about the quality and the quantity of the dissemination process. Consideration of these factors, this model, is all in the service of
training interventionists to do a better job with people who need access to effective
interventions in the real world.
DR. ZATZICK: I would like to start inductively from a case study and look at it
historically or developmentally. I will start in the fall of 2001 when Chuck Engel gave
me a call. The Pentagon attack had happened and Chuck was setting up Operation
Solace, which was placing care managers in the primary care medical clinics thatsurrounded the Pentagon, one in each of 10 clinics. From Seattle I was providing
telephone care management in our acute care setting, in our trauma center. It wasa similar sort of acute trauma intervention with care managers that would go into
orthopedic clinics or meet people in primary care and check in with them and try
and get them into evidence-based PTSD care ultimately after meeting them, accessing
them in their primary point of care and engaging them.
We had an individual who had worked his way up the Pentagon and had been
deployed multiple times as part of the Special Forces. He had tremendous exposures prior to the Pentagon attack. He suffered a smoke inhalation injury and had
pneumonia but had also witnessed a number of colleagues being wounded and acouple actually dying. He was coming into this primary care clinic ostensibly to get
antibiotics for his pneumonia.
His primary care doctor quickly noted that this guy was having problems.
He could not sleep due to his lung problem, so he was assigned to one of the caremanagers in the clinic, who did a fantastic job of engaging him around his primaryconcern. As the weeks went on it turned out that not only could he not sleep, butduring the day he was consumed by memories. He was having nightmares and wasashamed of this. He had been a tough guy, Special Forces, and there was stigma
around the revelation of his difficulties with the trauma.
So what are the principles in this case? One is access. This individual is being
met at the primary point of care. Hendricks and Wendi talked about delivering theseinterventions in non-specialty settings. Schools, primary care, forward field stations,disaster mental health tents. That is often where these early post-trauma interventions occur. This is about access and being in the field. The first issue that comesup then as we move out of the mental health specialty sector is the development ofevidence-based PTSD interventions from special mental health. There is going to
be a fundamental question, an extensive complicated CBT protocol that takes 12
sessions in an outpatient clinic. What is that going to look like in a primary caresetting or post-disaster field setting?
The modification, the initial kind of issue we have around the table, is that wehave services researchers in these funky settings and we have interventions that wereOptimizing Access to Caredeveloped in specialty mental health. We need to know how that is going to cometogether because we want to hold on to our evidence base. We do not want to throwout those years and important efficacy trials.
The second principle, as we are building on access and meeting people where
they are coming to care, is engagement. For engagement I am going to try and bring
together two intellectual persons. We have had some wonderful talks by Sue Estroff
and other sociologists. Once upon a time I aspired to be an anthropologist, but was
not smart enough, so I went into medicine. I followed Arthur Kleinman’s work.
Much of the collaborative care model is founded in the illness perspective and meeting the patient where they are at. Arthur has some fascinating studies of Taiwanese
shamans. The shamans have incredible retention rates because you come with any
problem and you can lay it out for the shaman and the shaman will deal with it;
marital conflict, death of a relative, a trauma. Those are some of the fundamental
aspects, actually, of care management. At a population level, if you are going to do
population-based medical phenomenology, you are concerned with the needs andconcerns of the population.
I will not get too much into Haiti, but I ended up in this mode with a populationthat has profound religious and spiritual beliefs. I may not be a priest, but someone
may come to me and say, “My church is in rubble. My congregation is scattered
and I am having trouble praying, which is my primary coping mechanism.” I do notknow how to deal with that but I certainly can problem solve around, “Can you
find your congregation?” I can deal with the general issue; I cannot help with theactual prayer. What we are trying to do is to engage people with whatever needs
and concerns they have.
The third principle gets to what Chuck Engel now is doing 10 years later, which
is a stepped-care protocol. There is a very strong evidence base for this sort of intervention, in which a care manager engages the patient in primary care and then steps
up the care to evidence-based CBT and medication for depression. There is muchless of an evidence base in PTSD. It is very hard to field the kind of trial that Art
Kleinman did in the Jerusalem trauma study, even in a day-to-day routine trauma
center context let alone in the chaos post disaster.
Going back to Kleinman, we have access, we have engagement, and we have
stepped care, all basic principles that can be applied across post-disaster settings.
Not much of this has been tested and we have STEPS-UP that is leading up to test
these principles in a military context. What about stigma? As a frontline hardheaded
clinician, the cases we saw post 9/11 made a great deal of sense to me in terms of thestigma of having nightmares, memories, and wanting to be seen in a primary careclinic rather than a mental health specialty clinic. That makes intuitive sense to me.
Arthur and Joan Kleinman have written about how suffering can be biomedicalized.
If social scientists do not address frontline patient and provider concerns, we cantake what is happening in the clinic and make it too much of an abstraction so it is
not really relevant and does not get into clinical encounter.
What I think is important is that in these post-disaster contexts, stigma may be
important but there may be other concerns or competing demands that come first.
Again, we do not have the luxury of doing population-based clinical phenomenological studies with every population. But as front line providers we need to learn
to taste what the different issues are and then engage around the key concerns. We
are moving inductively from clinical work and case studies, and we are trying tothink about theory. I agree with Sue Estroff, who said that theory is really important

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within all these domains. We have social epidemiology, we have clinical interventions,and we have sociology and stigma. Where is the meta-theory that helps out in theseincredibly challenging contexts? People around the table have talked about context
again and again today. Working in a trauma center I can tell you, whichever training
mode you have, something is going to come at you that you have not anticipated.
To me, no matter how much I understand stigma as a provider, as an actor, as
part of the exposure, I am going to need to be able to think on my feet. This is what
I think Charles Hoge is getting at, especially in the military, with regard to training
better officers. I am responsible for a group of people at my trauma center. I cannot
always anticipate what is going to come up, but I know I am going to have to havea level head. I know also that there will be these intense moral conflicts raised bywhat I am experiencing and what is in front of me. I think the meta-idea is that,
especially in the acute setting, you are going to be faced with these scenarios thatyou have not anticipated. That is one of the key things to think through and think
about. As the provider and in that work unit you have to ensure access.
We debated screening in October 2001, and when Haiti finally turned itself on
its head I realized that the whole population was exposed. We ended up with the old
Buddhist question, “Who in this room has not suffered loss?” The true answer is noone. We threw the training out after two hours because everybody had lost a closefriend or relative. We took the provider self-care portion and put it up front. Simon
Wessely and I have debated screening for years, but the reason you would screen inthis context is because you are looking for the 5 to 10% of the population that isgoing to be able to be resilient and carry the organization and the society throughreally challenging times. It was not screening for disorder, but screening for resilience.
DR. WESSELY: That is a completely noble argument that has been never used
before and it admittedly defeats all the other ones.
DR. ZATZICK: We were doing an organizational training. Many people left,
there were aftershocks during the course of the training. But the idea is that the content is so personalized. Everybody there has experienced traumatic grief, everybody
is having PTSD symptoms. We are looking for the people who can get through thetraining and then work within the healthcare organization long-term. That is what
we are screening for.

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Robert J. Ursano, M.D.
DR. HOBFOLL: I will discuss Conservation of Resources (COR) theory. In
my own theory across all kinds of trauma, a loss of resources, both economic andpsychosocial, is the best predictor of outcomes virtually in every test. I know that
this is not the only useable theory, but I do think there is a problem going on inacademia when we have to reference someone else’s theory. There is a great sayingthat theories are like toothbrushes, no one wants to use someone else’s. I would say
for stigma, COR theory is not the essential theory by any means. There are othergood theories out there.
DR. ZATZICK: At ISTSS (International Society for Traumatic Stress Studies)
last November Stevan Hobfoll and Sandro Galea and George Bonanno presented
some of these theories on resistance and resilience and I raised the question that isstill a question to me. Each of these theories has the exposure, and then there aretrajectories of resilience or resistance. It seemed like, and George Bonanno evenadmitted this, when you try to account for recurrent stressful and traumatic life
exposures, randomization or cohort definition, the models do not converge. You
cannot account for the patterns of psychological resistance and resilience you havenot identified. Sandro Galea presented the West Africa study in which people had
had on average 11 serious traumatic life events. It could be that the recurrent eventsare driving the patterns.
DR. HOBFOLL: Absolutely. For example, in studies by Moose and Holihan they
showed that a resource loss was the full and total mediator of change in depression
over a 10-year period in patient populations. Also, even though there are other things
going on, it is one of the areas in which you can pick interventions and points tointervene.
DR. ZATZICK: We are both interested in malleable factors for intervention
but what I am saying is, rather than attribute it to resource loss without addressing
recurrent stressors, you can also target interventions towards recurrent stressors.
DR. RADKE: There is a critical point here in this discussion. Many of us do notwander too far from our comfort zones. We have agendas and biases that we bring
into this room. That is not why I come to these kinds of meetings. I come to thesemeetings to learn and to be challenged. We get into these battles which do us nogood because it does not get us to the gestalt of trying to deal with the stigma andbarriers that interfere with whatever theories we have, whatever practice we have.

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DR. URSANO: You will now have about 30 seconds to think about this. We aregoing to go around the room and you will be given 10 seconds to say one bullet:
something you liked, something you took away, and something you want people toremember for tonight because you are going to talk about it more tomorrow. This is
a way to be sure that even those who are silent have an opportunity to educate us.
DR. DIEBOLD: I am the psychiatry consultant and I want to complement all thepresenters today. What I would encourage the group to do is think about continuityof care with our service members. One of the reasons I bring that up is that I am
stationed in Hawaii, where we have a big Guard and Reserve component. Certainly
they are faced with many barriers and stigma going from their civilian jobs backinto active duty.
We need to keep in mind the family members as well. Again, this was brought
up a great deal today but I would hope tomorrow that we talk about, really, what
I view as the big picture here, both the continuity of care for service members andnot losing contact with the family’s needs.
DR. THOMPSON: I will say these bullets: recovery, social inclusion, and thehealth opportunity ladder.
DR. SANTIAGO: I am a Navy psychiatrist in the Department of Psychiatryat the Uniformed Services University. In my 10 seconds I would like to throw out
there that perhaps society chooses stigma because stigma is cheap, or inexpensive,
relative to our other choices.
DR. BATTEN: First of all, culture change is hard, and if we are talking aboutchanging stigma, we are talking about changing cultures. I like the idea of focusing
resources where we are likely to get more bang for the buck and have longer-term
impact with younger generations.
DR. BORNEMANN: I would like to do some more thinking about Bernice Pescosolido’s data. We are doing a great deal of anti-stigma stuff, and I am not confident
that much of it is that effective, so I would like to drill down a little deeper on that.
DR. BELL: Something we learned from the Institute of Medicine suicide report
and Dr. Satcher’s youth violence report is that risk factors are not automatically
predictive due to protective factors. Also, there is apparently a split in the states
about using marijuana to treat PTSD and I think we need to discuss that tomorrow.
DR. CORRIGAN: The question I would like to ask is where are the consumers
today?
DR. SHALEV: I have the perspective of a person responsible for delivery ofclinical service. I live in Jerusalem, where for a third of the population, the ultraOrthodox, just seeing a psychiatrist is a stigma that may affect your family and yourreputation. We humbly try to alleviate part of that by making our clinical services
effective and known to be effective to that particular community. This is as muchas I think that we can do for them.
DR. RADKE: Stigma and barriers to care exist because society allows it to exist
as an excuse not to do the right thing.
DR. FLYNN: I would like us to take what we have heard today and think about
making some very specific application recommendations in four domains: clinical,
training and education, program design and management, and policy.
DR. URSANO: And research.
DR. HOLLOWAY: I want to hear one or more definitively named variables, andI want to know what independent variables are likely to influence them.
DR. BATES: I am a clinical psychologist with the Resilience and Prevention

Day 1 Discussion

Directorate at DCoE. Since I did not speak today, I would like to make two quick
points. One is peer-to-peer programs. It seems to me that social support literature
is associated with one of the most robust findings for resilience and promise formeaningful effect sizes. Do we know enough about how to leverage them, are we
fully leveraging them? The other point comes after hearing Dr. Hoge’s remarks. Is
there potential in the value of training our younger recruits in dialectical thinking,similar to the serenity prayer, to deal with some of the ambiguities they face laterin their development?
DR. HOWE: I teach ethics at USUHS. I was struck by the many comments ofwhat does not work in stigma. The challenge is discovering what will work. We have
had many suggestions there. There are some that have intrigued me that I would liketo pursue. The first one is structural. There were two speakers, one who spoke ofthe problem of confidentiality being a block, the other one the problem of security
clearances. A question, then, is could those be crunched at all and, if so, how?
The second suggestion I would like to pursue is the picture that we saw of Uncle
Sam saying, “Your duty is to get mental health care.” I would love to see if that
picture could be taken further. And finally, Charles Hoge’s and Chuck Engel’s comments on when the soldier comes in asking what crazy is, which I thought was very
profound, provocative, and courageous. It struck to me the importance of validation
being a first step toward engaging, and that might be worth pursuing as well.
DR. BRITT: I would be interested in further discussing how mental healthproblems among combat veterans are really seen as occupational hazards that
result directly from the work in which they have chosen to participate. Also, what
are the implications of this for addressing stigma and reducing stigma through,maybe, novel interventions that take an occupational health approach as opposed
to a victim-based approach?
DR. HOGE: We are all touched in some way. Mental illness is part of what itmeans to be human. How we communicate as mental health professionals, implicitly
and explicitly, contributes to stigma.
DR. REISSMAN: I want to mention a couple things that have not come up yet,and that is the interface between stigma and ethics in public health. There is anarea here that has yet to be explored in terms of health protection strategies. In ourcurrent national scene the term ‘community resiliency’ is being used a great deal.
Maybe there are ways to look at that in the different work forces you are addressing,whether military or civilian.
DR. FRIEDMAN: I just want to remind people that we are having two conversations. We fluctuate back and forth, and they are overlapping. One is at the clinicallevel where we talk about access to treatment. Then there is the public health discussion, where we are not necessarily talking about symptoms but maybe talking about
distress. The outcomes are really very hard to measure for things like prevention
or resilience or self-knowledge. To both of those ends, I think we will have to be
thinking outside of the box tomorrow because we need to move this forward.
We have technologies available to us; and we have not had much discussion
about that. There is the Internet. There is social networking. There is the scienceof messaging that we do not use very much in mental health. How can we avail
ourselves? I know General Sutton has been doing some of that in DCoE and manyof the rest of us have been doing that. It seems like the things that really need to beenhanced are social support, whether it is at the unit cohesion level or at the moregeneral public level, and education. So many of the barriers involve lack of knowl-

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edge or misunderstandings or stereotypical thinking that is just wrong. There is also
leadership and how it manifests itself in the different clinical and public contexts.
DR. PESCOSOLIDO: I have two quick points from the micro to the macro. The
micro goes to Tom Bornemann: A number of researchers around the room have data;
and we would like to know what you would like to see from it that might help youin what you are doing. For the macro, I would like to go to Doug Zatzick’s point,
what is the model and what is the study that is really going to push our understanding and our ability to change it forward?
DR. KILPATRICK: I would like to talk about erectile dysfunction. In a serious
way, I think it might be a good metaphor for us because it used to be pretty stigmatizing, but now you cannot watch TV without having people telling you that they haveit and are coming forward for treatment. If we can do it for erectile dysfunction, we
can do it for mental health problems.
DR. RUZEK: One of the things that struck me is the importance of getting to
the places and people that individuals do go for help. We know that they do not go
to mental health providers. They are seeing and talking with chaplains. They arein primary care. And, for example, in acute trauma they are going through ERs, so
there are places where conversations are happening.
Wendi Cross’ presentation is a warning sign for that because that means there arehuge training needs, and that training is labor intensive. Quite apart from time constraints, there are training and competency factors that are important. The answer tothat may be something that Matt Friedman raised, which is technology. I think thatweb programs and soon to be iPhone apps—those kinds of things—can be put in thehands of those providers. Those technologies will shape what they deliver, perhaps
making it easier to accomplish the goal without complex skills-training regimens.
DR. ARNOLD: I am from the Graduate School of Nursing at USUHS, Psych/
Mental Health Nurse Practitioner Program. I like the contact concept. One of themost impressive things that I saw recently was a one- or two-star general who cameto our campus and spoke about the personal impact that mental health had had on
him in regards to having a son who committed suicide and having another son who
had a traumatic brain injury.
Being able to hear that from somebody at that level is impressive for change. I
know the DoD made an announcement two years ago that they want people coming in to get treatment for mental health. It is their duty. But when you think of
the number of years prior to then when that was not the case, we are not going tochange that overnight. Unless it comes from the top down, we are not going to seethat kind of change.
DR. CREEL: I am in the Department of Preventive Medicine at USUHS. I wantto think tomorrow about identity and social roles and how those play a role, andhow we can use them for intervention. Also, efficacy beliefs, both in terms of whether
we believe that there is something that can be done for us or for others, and howthat plays a role in terms of stigma.
DR. SCHOR: I am the Acting Director of the presidentially mandated National
Center for Disaster Medicine and Public Health, the purpose of which is to addresseducation and training and competencies in disaster medicine and public health atthe domestic level.
I am disliking the word stigma more and liking stigmatizing or stigmatization
better because I am thinking that in a couple of interesting ways they are very
disparate. There was mention of social networks. We have talked about them asDay 1 Discussion

tools to address this in a good way. I would suggest that social networks are also
increasing tools for the bad guys to use stigma against us. I think we have seen some
Congressional use of this recently with the stigmatization of voting on National
Health Care. I think that was a stigmatization in action. I am sure that folks wholive in other countries or are sitting amongst us definitely know that. I see that as ahuge national security threat.
Let me take it on a different level. How do you de-medicalize stigma? My experience brings in musculoskeletal injuries and working with the Marine Corps. We
do not medicalize injuries. It is for the generals to figure out what the pain needs
to be. We were able to de-medicalize injuries in the Marine Corps by using athletic
trainers. Those of you that know what athletic trainers do, they do not take people
out of the game. They get them back into the game.
From a military, a continuity of operations, a national security or health security
standpoint, I wonder, how can we use the athletic trainer model to keep us in the
game? Whether it is Haiti or wherever the next disaster or terrorist event might happen, there are two very different bookends that are sort of vibrating around with me.
DR. HOBFOLL: To quote Pogo, from whom I learned everything I know, “We
have met the enemy and he is us.” We have to look at how as leaders we have notchanged training to make a difference. Really the things that we have talked about
have been well known for 30, 40 years. The real question is why are we stuck shortof implementation and change on these things?
DR. LINK: I come here with this interest in stigma and I get to look at it throughdifferent lenses and from different angles. One way is thinking about the militaryculture and also about what is done after disasters or terrorist attacks. One of thethings I like about studying this area is that every time you take a different lens, youlearn something new. I will say a few of the things that I have learned in listening
to the rest of you.
A specific thing I would like somebody to talk about tomorrow, which would
have theoretical significance to me, is how stigma lines up with ranks in the military?
I have a specific prediction about that from where I sit and I would like to see what
others think.
DR. WESSELY: What is your prediction?
DR. LINK: My prediction in the military would be that the stigma would bestrongest higher up.
DR. ENGEL: Plus we have more money to go out and buy it ourselves somewhere else.
DR. WESSELY: I am the Brit. If I had my time again I would be a historianbecause historians know that most people have coped with adversity for long before
us and without us. There are only a few who do not. Even then I think we have torecognize that at the moment either our products, or perhaps ourselves, still are notthat attractive to a large number of people. If only they would come and see us, we
can help them, though that really does not seem to be enough.
DR. ESTROFF: I am going to fall back on a couple of my favorite old sayings.
One is,“not everything that counts can be counted and not everything that we count
counts.” That is from Einstein. The other one is, I think, from Will Rogers. I am
paraphrasing here that, “It is not what we do not know that is the problem. It iswhat we think we know that is not so that is the problem.”Given that, I would like to return to this broader concern of what, if any, collateral repair or damage the entry and openness about stigmatized conditions in

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America’s heroes will have across the board or not—which way it is going to flowin the broader social sphere.
DR. ENGEL: I think this whole notion of stigma is very important. I will establish that right up front. We have to think a great deal about unintended effects.
The military, where I lived most of my life, is fundamentally a culture built aroundcollectivism, if you will. It is about small group function to accomplish dangerous
tasks. Bruce Link said something about the functions of stigma in some fashion, theidea that stigma reinforces norms, that stigma extrudes, if you will, disease. There
are potential ramifications of the idea that we could completely de-stigmatize someof these things. You could have these problems and continue on and make them
irrelevant to your ability to stay on in the military.
While we could become more open-minded about our policies, it is going to beawfully tough to completely take that out of the mix. If we do, we may find ourselvesin a place that we did not want to be as far as the military goes. By the same token,
I think we should be looking for ways to better deliver care. Along the lines of what
Simon Wessely said a moment ago, we have to rethink how we consider therapy.
We have to think along the lines of what is acceptable to our population. We haveto think about choices and we have to think about preferences which, again, we are
not accustomed to in the military. We do what we are told.
If we are ever going to reach out to the large fraction of people who do not seek
mental health care, I think we have to address the nature of the problem, which isthat right now we are pretty limited on what we can offer in terms of acceptability
to many of the people we are seeing.
DR. SLONE: I work with Matt Friedman at the National Center for PTSD. My
role here is a bit different. I am the Associate Director for Information and Communication so I do a great deal of work trying to actually take what we learn fromresearch and get it out to the general public so that it does do some good on the
education level.
I want to remind everyone to think outside the box and to remember that thisis not just a public health model or a clinical model; there might even be anotherlevel in between because the problems are very different. Our thinking about treatment really needs to cover a wide range of areas, not only the public health policy
issues or clinical issues, but different things that we do not normally think aboutsuch as social media and contacts, and advertising. We cannot just think that one
solution is going to fit everything. We need the variety because there are a variety ofproblems. With policy you need to look at what good you can do for the average
person, for the greater sum of people. But interventions for the smaller groups are
just as important, and we need to continue to test on those levels as well.
DR. CROW: I am the clinical psychology consultant to the Army Surgeon
General. I am also Director of the Warrior Resiliency Program which is an Army
Medical Command program. Today I heard several references to mental illness inthe course of presentations. Sometimes it concerns me when I hear that, particularly
if the parameters of the term are not real clear.
I do have a real interest in how we might be able to use concepts and perspectivesof resilience and life skills as a way to address problems of living. I get concerned
when we talk about de-stigmatizing mental illness or imply that is what we are talking about. It almost seems to require that our beneficiaries by definition have to be
sick in order to access our services. I would rather see that we look at ways to makewhat we have to offer available in a less illness-based kind of a model.

Day 1 Discussion

DR. SUTTON: It means so much to me and members of my team that each ofyou would spend this kind of time and this kind of energy to figure this out. Because,as the Secretary of Defense has said, we are truly in uncharted territory going into
year number nine of this conflict. What has been said here about needing to lookfor novel ways to look for paradigms, ways of communicating with this generation,is critical. Some wag once said, “Culture eats strategy for lunch any day.” I would
welcome anybody’s thoughts on how we can accelerate relevant cultural change thatfits this generation. Keep in mind, our troops today knew our country was at war
when they raised their hands and said, “Here I am. Send me.”That was well before the economic downturn happened. They are a group who
do not think of themselves as sick. They prefer to think of themselves as injured.
They have been raised and trained to be part of a team. Perhaps that is why the Armyslogan “Army of One” was relatively short lived and has now been replaced with
“Army Strong.” They develop bonds of trust with their coaches. When that trust is
fractured, no good comes out of that. It is a wound that has to be dressed. We havea bit of that going on right now in the three years following the wound that was
exposed and endures at Walter Reed.
So I need help from each of you here. How can we help dress that wound of
mistrust that still exists, not just between our providers and our public, our leaders and our providers, but within each of us as citizens of this great nation and as
global citizens of this very small planet? Someone once said that a wound inflicted
is a wound endured. We as a nation have sent our sons and daughters into harm’s
way. We have inflicted this wound and together, to heal, we must endure it together.
That is going to take time. That is going to take thinking. It is going to take bringing
together novel thoughts and novel ideas. It is going to take humility because, I canassure you, not only do we not have all the right answers at this point, I am not sure
we have even asked all of the right questions. I would just ask us all to keep asking
the right questions, and above all, let us measure whatever success we achieve on
this journey through the eyes of our warriors and their loved ones, whom we areso privileged to serve.
DR. BROWN: I returned with Wendi Cross and Doug Zatzick and perhaps
some others from a conference last week on dissemination and implementation.
The thing I would be interested in looking at is how we move from an information
production system, which includes things like clinical knowledge as well as someresearch studies, to a knowledge implementation system where we can actually movepractice and policy.
DR. CROSS: I would be interested in having people talk a little bit about thedifference between the confluences of factors around help-seeking. We talk a great
deal about getting people to seek help but I guess I am wondering about the flip side.
If you ask somebody if you could help them, would they accept the help? What isthe difference between being on each side of that relationship? I am also interested
in credible messaging and how that might be helpful.
DR. ZATZICK: Disaster and terrorism, clear, simple, eloquent models, ideasthat will help me out because I do not know what to do. I have been working with
Chuck Engel on his STEPS-UP trial, trying to help him think about returning Central
Asian veterans. We need clear, simple, and eloquent ideas to lend these hardheaded
clinicians and to help other people implement trials.
DR. URSANO: The good news is that we have created a marvelous list. The badnews is that we now all own it, and not just within this meeting. We will clearly only

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take a small piece of that which we will ever be able to touch. We have created a listthat we all own and that we all have said we wish to address and go after.
I look forward to our discussions tomorrow which will be targeted around theconcept of recommendations. It is most helpful for you to let your memory processes
think around a clear recommendation, to make two or three sentences of justificationthat fall into the categories of education, training, research, leadership (policy), andthen interventions — clinical and population. I look forward to moving to that levelof discussion so that we take our ideas, digest them and come forward with what wewould like to see changed and formulate that into recommendations in the proper
category. Thank you all for an excellent day.

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Conference Recommendations
Robert J. Ursano, M.D.

DR. URSANO: We have much work to do thinking about and making recommendations that we want to capture. Our goal is to limit the discussion to recommendations, and we will try to put them into a bullet form. I want us to think about
the question, “What constitutes the level of the burden of disease?” The top twoitems in the burden of disease within the military, number one is injury, and number
two is mental disorders. So what are our targets?
Please remember that psychiatric responses to disaster, war, and terrorism occur
in different places. We have the question of mental disorders and also the questionof resilience. We have the question of distress responses, and we have health risk
behaviors, which include things like changes in use of cigarettes, changes in use ofalcohol, and issues of driving and road traffic accidents. These are all targets for prevention and intervention in which stigma and barriers to care can impact outcomes.
The issue of distress responses is particularly important; it falls into the categoryof mild to moderate disorders in some of the studies Ron Kessler has done, which,number one, indicate that they need treatment because of their trajectory of course.
Number two, they also impair performance, and in DoD we are in a performance
activity. In the nation, if one addresses the question of safety workers, such as policeand firefighters, the question of performance in terms of national security is much
more important than disease, because people get sacrificed as individuals in orderto protect the continuity of the nation.
Please remember there are disorders, there are distress responses, and there is
how we intervene for them. How do barriers to care interfere with these factors andwith health risk behaviors? Think about driving accidents, motor vehicle accidents,
as one example of that. Across the spectrum, of course, there are also all types ofpsychosocial responses that have an impact, from sleep problems, to demoralization,to scapegoating and blaming, all of which are outcomes in an organization and a
population we are concerned about because they affect performance activities.
There was a study that Chris Warner did, in which he asked people, “If wechange this, will it matter to you?” And he found differences among those who were
deployed and those who were not. In addition, he found that if we tell you thatyour family is concerned about you, it has the highest impact. The issue of trying
to identify what may be most effective for overcoming barriers to care is one target

The issue of
distress responses isparticularly important;it falls into thecategory of mild tomoderate disorders
in some of the studies
Ron Kessler has done,
which, number one,indicate that they needtreatment becauseof their trajectoryof course. Number
two, they also impair
performance, andin DoD we are in a
performance activity.

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for us to think about. But effective for what, with which population, and for whichtarget? One conclusion of this conference could be that barriers to care in the military are pretty much like barriers to care outside of the military. We are leading thenation in trying to address this issue, and we are trying to solve our own problems
at the same time.
Similarly, there exists the question of stigma. One of our targets when we think
about continuity of care, and the trajectory of illness, which C.J. Diebold brought
up yesterday, is the question of whether we can alter the length of time to get into
treatment. That is just one target, never mind onset of disease, never mind the disability level. Can you alter length of time to treatment? The average length of time
for a PTSD case is about 12 years, as I recall.
One of the topics we did not spend much time talking about is the topic offamilies and children. Some of you may know that Ed McCarroll was the first to
identify increasing rates of child neglect occurring within the Army since the onsetof the war. What about barriers to care that have to do with intervention for family
conflict, and, in particular, child neglect? How does one reach out to that population?
How does one alter the system? What research do we need to do? What training do
we need to do that would allow us to better address that particular target?
Similarly, we did not say much about substance use. Substance abuse is always aproblem within DoD. Too often we overlook the question of cigarette use. Altering
cigarette use alters, in fact, a huge morbidity and mortality of disease. It is unrelated
to psychiatric issues but tremendously related to the health of our families and ourservice members. We know cigarette use changes after exposures to combat, disasters,
and terrorism. Our 18-25 year-olds are those who, in fact, have the highest rates ofcigarette use.
If you look at perceived need of mental health counseling, 17% of DoD reported
a perceived need of counseling, broken down by service. If you ask if they received aprescribed medication, about 4.8% of DoD has received a medication for depression,anxiety, or sleep; 14.6% have received some type of mental health counseling; 7.8%
was from a military mental health professional. So, half of the counseling going on
is from a military mental health professional. Somewhere around 44% describe
probable or definite perceived damage to their career for seeking mental healthcounseling. This is not so different from the rest of the nation. What we have is theopportunity to address the ways that may lead us forward around this problem.
We have hardly said anything about somatic symptoms and how they present
in times of disaster—whether it is somatic symptoms in family members, somatic
symptoms in service members, or somatic symptoms from Katrina or in New York
City after 2001. When referring to barriers to care, barrier may be the wrong word,
but in addition, people come in who may not need care. There is also, of course,
post-concussive syndrome, otherwise known as mild TBI, which we have not spoken
too much about.
It is important to our discussions to recall that the number one target within
DoD is injuries — often a behavioral event related to distress or risk behaviors. Carefor injuries, trying to prevent how stigma and barriers to care increase the injury
rate, how they decrease access to treatment after an injury has occurred. Each ofthese issues would require substantive hours; we are talking weeks of work to think
through all of the elements. We can think about each of these targets, and how barriers to care may be impacting performance and health of an individual member, as
well as the organization.

Conference Recommendations

Several models we have implicitly been using as we move toward making
recommendations. We approach problems from certain angles. One approach is
our traditional primary, secondary, and tertiary prevention. How do we respond,
and how do we prevent disability? Another approach is the IOM suggestions from1994, which asks things such as, “Is this for the entire population? Is it for those atrisk, or is it for those at significantly high risk?” Where does what we are doing fit
in that frame?
If we think about war, disaster, and terrorism — as in the Haddon Matrix —there are also a pre-stage that we have to work in; an event stage in which we operate, and a post-event stage. Therefore, thinking from the perspective of preventive
interventions, primary, secondary, tertiary, universal, selective, and indicated are allvery helpful. If we were really good, we would take everything we say today andput them into those categories.
The Haddon matrix had much of its original importance with the question of
motor vehicle accidents. It is essentially a three by three table in which you have theagent, the vector, and the population. You could think of the agent as malaria, thevector as mosquito, and then choose your population: children, workers, et cetera.
So, what would be the pre-event intervention to address the agent? One might takeanti-malarial drugs as a pre-event, to decrease the malaria load. Each of those boxes
should be filled in to disrupt the disease process.
Is there a similar way to apply the three by three models to barriers to care andstigma? This was accomplished in the IOM report that I and others worked on
for a number of psychological issues, so it can be done, but it needs to be thought
through. How would it work if we said that the agent was stigma, the vector was
the sergeant, and we are worried about the squad members? How would we address
stigma or barriers to care across those nine squares?
Disease occurs across multiple domains, and stigma and barriers to care aregoing to be different across different domains. We have the disorder, say PTSD, but
we also have symptoms, and symptom presentations, and perhaps partial disorders.
We have nightmares separate from PTSD. We also have to address the questionof impairment of function, and how will barriers to care address impairment offunction, which is not the same as disability. Disability tends to be an attribute thatusually accompanies the award of funds. There is also the question of comorbid
conditions. If we are thinking of one condition, what else goes with it, and how dothe barriers to care interact with those comorbidities? If we are dealing with PTSD
and barriers to care, are we really dealing with the issues of depression and the barriers to care? Are we working toward answering the questions of substance abuse
and the barriers to care?
There is a system of care, so where in the system are we focused? A particular
example addresses PTSD, and we go from the question of screening and surveillance
to education around battle mind, to buddy care, to RESPECT-MIL, Chuck Engel’s
program, to DESTRESS, down to the issues of complicated disorder, and the question of care for care givers.
Whenever clinicians use the word “manipulating,” it is usually a sign that theclinician is overworked, and has begun to feel the burden of care as more, in fact,
than they can do. During that time, there is a new barrier to care that has been created by the clinician within the clinician, and the management of that barrier also
needs to be addressed.
Now lets return to our goal, to come up with recommendations. I want us to

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address research first. Why? Because, as Harry Holloway commented yesterday,
research recommendations will require us to be more specific about what ouroperational variables are. We cannot talk about any of the others unless we becomea bit clearer on our operational variables. What are the operational variables that
we need to learn more about? What might need to be reorganized in our system;
which are system comments to think about, address, consider? What are trainingor education needs for providers, for leadership, for soldiers that might further
address these issues? What might we advise leadership to assist in their awareness,knowledge, and interventions in these settings? The spot that we might gravitate themost to, but in truth, we know the least about, is to actually propose interventions,either at the clinical patient level, or at the population level. That is the dichotomy
to think through with the question of clinical and population interventions.
With those introductory comments, we are going to open the floor for discussion,and begin to capture some of our thoughts and recommendations.
DR. ESTROFF: I have a question about the issue you just raised, the careerconsequences of seeking help, which we have all identified as a barrier. Do you
have any empirical data on career trajectories of people who have sought care? Not
accounting for the fact that it is a preselected group, but it would seem to me to bereally important to be able to address that in some way.
DR. URSANO: First of all, I know studies have been done in the Air Force, inparticular, to look at fliers who seek and receive psychiatric care, because there istremendous worry in that community around that topic. The data say that 80% offliers go back to work, and complete their tour. That means 20% do not. That may
or not may not deal with the fear attached.
Second, there is great interest in this issue of career trajectories. There has beensome marvelous work on that many years ago by Card and others. We need toreplicate that around the questions of health behaviors, and health risks, and theirimpacts on trajectory. Harry Holloway, you have been around long enough to know
if there are some other data specific to that.
DR. HOLLOWAY: There are some. One is the SAMHSA study of fliers who enter
into alcoholic treatment, a study of matching them career-wise. Those who finishedalcohol treatment then had careers that were better than their matched colleagues,
they move forward more rapidly, achieved more in terms of rank, etc. A set of operational items were examined. The Navy is very good about this in terms of instituting
alcohol treatment, when alcohol went from being a crime, to being a treatment issue.
They did a great deal of highlighting of flag rank officers who entered and successfully completed alcohol treatment at some stage during their career.
I think here it is very important to make sure that we speak generally. The paradox is that any injury or any disease must threaten your career. There is frequently
an issue of why confidentiality is so breached in this setting. Obviously one thing
they would like to improve is privacy. But the truth is, any time I get hepatitis, or
any time I sprain my ankle, I threaten my career. And if I seek care, I may solidify
my capacity to continue my career, or I may end my career. These are the paradoxesof serving.
DR. URSANO: Sue Estroff, did you want to formulate something around that
into an area about which we need to learn more?
DR. ESTROFF: Yes. It is in the area of similarities and differences between thecivilian and the military population, which would be interesting to look at in termsof vocational consequences. Because there, I think, we are going to see a huge differ-

Conference Recommendations

ence. Many of the people with the more serious problems do not have a vocational
career to begin with.
This would be interesting for two reasons; one is to be able to provide somedata for people who may be reluctant. Two, to actually look at how, and why, andwhere those changes were made. Given that every injury, including an injury to yourpsyche, is going to have some effect, if I am a reluctant soldier I want to know theins and outs. I think right now we have a very gross understanding of it, in general,
but not a real sensitive specific understanding.
DR. URSANO: So to capture it: understand the trajectory of vocational consequences.
DR. KESSLER: One thing that was said in passing yesterday was about resilience
training, and if it could be packaged. People get badges for these things they gothrough. If there were a way in which having resilience training was something tocheck off as you went through it, as if it was a skill that you now have. I can imagine
packaging mental disorder training so that there is not a distinction of the people
who are trying to maximize the upside, and get back to a baseline. Another thing isthat in the civilian world there are many people who do not want to go to mental
health care through their employer-sponsored health plan so they pay out-of-pocket.
The military has now put in place this new program where you can get telephonicpsychotherapy without the therapist knowing who you are. I think both sides arebeing worked in that regard.
The thing I wanted to say before, which occurred to me in regard to Sue Estroff’scomment. There were an enormous number of interesting ideas here yesterday, but
the one that I went away with, and I kept mulling over, was the critical comment by
Dean Kilpatrick about Viagra. Here we have another thing that is a very embarrassing male-oriented kind of thing. It is feeling as though you are not strong any more.
Yet there is a flood of people going in for that kind of treatment, despite it being
embarrassing. How come? What is the difference? One difference is this: everybody
believes Viagra works. I think this is not true for mental disorders.
There is another kind of stigma that we have not talked about. We talked about
the stigma of being mentally ill and the stigma of people knowing you are in treatment. There is also the stigma of the processes of care. There exists this image ofwhat it is to be in treatment. There is some work that needs to be done to market
a more positive image of being in treatment. It actually can help you. If people had
the sense that psychotherapy works as well as Viagra, we would have a long line ofpeople waiting for psychotherapy. In terms of practical research, there are several
things that we need to do.
I think the very first thing that has to be done is research on treatment dropout.
Once you get somebody into treatment, why is it that such a high proportion ofthem say, “You know, on second thought, I would rather be depressed than go backto see this guy.” We have to figure out what it is that makes people drop out. Is it
something about the kind of patient? Is it something about the kind of processes ofcare? Is there something we can do to improve the way we are doing things? Why
is it that more people are more willing to go to chaplains than go to psychiatrists?
Years ago, NIMH had an Indian Mental Health Service Program to train chaplains.
It was collaborative care between people who were in the non-medical system andthe medical system to make it more palatable. How can we package treatment in a
way that people would find more palatable?
The second thing we have to do is figure out how to sell mental health treatment.

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I think this should be relatively easy once we have a product that has the kind ofvalue that we could sell. If America is good at anything, it is good at marketing, so
once we have a product that has real value and that is recognized by the consumer,
it should not be a difficult thing to figure out the things that Madison Avenue would
do to sell it. We do not have to talk about it, because there are people who are really
good at that. Our job is to figure out how to make the product good enough so thepeople who know how to sell it, can sell it.
DR. ESTROFF: I would argue that we know more about why people drop out
than why they stay. Perhaps we are asking the wrong question.
DR. HOLLOWAY: At the time of the beginning of the large drug epidemic,
we were approached by a number of advertisers, in particular, the advertisers for
Budweiser, Anheuser-Busch. They presented the way you sell beer to psychiatrically
disturbed people. They showed us the ads they developed that showed pictures ofpsychiatrically disturbed people. The standard one was for anxiety, and you may
remember a chap by the name of Knox, who used to shake. The minute he would
touch a Budweiser, the shaking would stop. They marketed loneliness. You may
remember Yooper, a guy who is isolated. Nobody will associate with him, but theminute he touches a Budweiser he suddenly has friends, and people are talking tohim.
There is a systematic approach already existent within the overall advertisingcommunity that specifically addresses the selling of cures to the psychiatrically ill.
When I asked to whom those ads were directed the answer was, the mentally ill. The
advertiser’s goal was to create a 1 to 2% shift in the market. Notice that a 1 to 2%
shift in the market in terms of numbers of referrals is a trivial item, and probably
would not improve care. The idea that there is a marketing system that systematically can move large populations is an image that advertisers sell for hundreds ofmillions of dollars. They will admit, however, that they only want to move a verysmall segment of the market.
DR. KESSLER: In the early 1990s Prozac, along with some other drugs, began
direct-to-consumer advertising. Subsequently there was a 60% increase in the percent
of people getting treatment for mental disorders in the United States—not a 2% but
a 60% increase over the decade.
One of the unique things about the military is that the military is not just a job.
The military is a world, with the possibility of having a multi-pronged approach,where you can control what happens at breakfast, you can control eating, and othervariables. Several years ago, the Annals of Internal Medicine published a paper thatanalyzed the cost effectiveness of screening for depression in primary care. Theyevaluated the effectiveness of getting people to admit they were depressed when they
were coming in for a cold or for a broken finger, etc. They analyzed the dollars andhours cost to get a patient into treatment and found that, in terms of cost-effectiveness of improving the mental health of the population, it was completely infeasible.
The reason was that the first nine out of the ten steps were incredibly cost-effective,
and the tenth step was a disaster. The tenth step was the effectiveness of treatment.
In other words, you can inexpensively get many people into care, but when weput in the numbers about how successful treatment is, it turns out it is $70,000 per
QALY (Quality Adjusted Life Year). But the reason was that only 10% of people
were getting treatment effectively. Then they said until we improve the quality ofcare, it makes no sense to screen for depression in primary care. First we have to get
the processes of care right and make that clear to the people who are getting treat-Conference Recommendations

ment. We have to find out what is successful. Then it makes sense to do a marketing
campaign.
DR. URSANO: Ron is recommending issues that have to do with education ortraining. The capability to provide evidence-based, effective care is critical. If we are
not providing effective care, it does not matter how many people we bring in thedoor. We are spending a great deal of money without any outcome.
DR. KILPATRICK: I think we need research on how treatment can be mademore palatable to people. We need to understand what people’s expectations are,and what their understanding is of the treatments that we provide. The pharmaceutical industry has done a great job of convincing people that our problems are
not personal or societal. They are problems in our synapses that particular agentscan address. I wonder what people think about psychological treatments that havegood efficacy. We need to find out what causes people to come to treatment. We
are not explaining what treatment is, so it is mystifying to people. Secondly, do wereally know why people come in? What would make it more attractive for people
to come in?
DR. URSANO: Dean has illuminated a multi-step process beginning when someone first thinks they have a problem. Then they must believe that there is effective
help, and then they must be able to physically get there. How do they make that lastleap to actually going to care?
DR. KILPATRICK: I am worried about confidentiality, worried about ruining
my career, people will think I am nuts, so what about coming into therapy is pretty
attractive to me? In other words, what are my expectations? Do I expect to get any
change out of this? Do I expect to get better?
Back to the Viagra thing, I think it is pretty clear why people are willing to comein and take Viagra, because they anticipate a pretty specific positive effect. What kindof effects do people expect to get out of treatment? We focused on the negatives, butwhat are the positive things about it?
DR. HOBFOLL: We have lost Goffman’s original idea of stigma, which was
the purpose of stigma. It is that a person assigning stigma gains status. That is why
stigma occurs. No one looks to be stigmatized. So this is the enemy, and he is us. The
mental health establishment gains tremendous status by the ability to diagnose. In
fact, they can even override the orders of a Commanding General by their diagnosis.
That is an incredible amount of power, and that power rests in the Surgeon General’s
office, and they do not want to give it up easily.
So, the fight in the military is to move it out of the realm of diagnosis, andinto the realm of functioning. Of course, psychiatrists and psychologists still havea tremendous amount to contribute there, but they will lose a great deal of power
because functioning puts the power back in the Commander’s hands.
The one area of policy that must be changed for this to occur is the well-known
picket fence, though not in military parlance. Soldiers get evaluations which ultimately determine their rank. If quality evaluations are not perfect, you do not makerank, so any negative evaluation means really the end of your being on the fast
track. That has to end. In great armies in the world, including the American Army
during World War II, the picket fence did not exist, because you promoted based on
performance. Promotion based on the standard of 12 perfect evaluations from yoursenior officers produces “yes men and women” and people who are scared to speak
up. Obviously, someone in uniform cannot say that, but I can.
I will discuss recommendations. Moving to a coach’s model does not mean that

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you end diagnosis. Diagnosis has an importance, and those with severe disorders
should be treated as having severe disorders. Separating and looking at the functioning is important. If 20% of those coming back from Iraq have PTSD, most of thosepeople actually have walking PTSD, meaning that they are still functioning with their
PTSD. In the first relevant study on this, we found that PTSD is almost unrelated
and that depression is only slightly related to functioning, so you can still function
very well, even though you are suffering. Coach’s model could be done immediately.
That is already going on, by the way. Pushing resiliency and functioning is really
the way to go.
As mental health professionals, we have to be ready to let go of some of thestatus of being the person who stigmatizes. No one has more to contribute to thisinteraction of distress, stress, and functioning than mental health professionals
working now in a team with Commanders who are really interested in performance.
DR. LINK: So the story for me would invoke the military cultural componentsof courage, bravery, strength, and camaraderie. People are trained in the culture, andthen they live in the culture. In the course of their career, they have the opportunity,or the misfortune of encountering different types of injuries. I very much like theidea of talking about this as injury, rather than illness, because I think it works wellin this narrative. One injury would be like physical maiming or injury. Another is
psychic injury. The culture prescribes what happens when physical injuries andpsychic injuries occur. If you have a psychic injury you have the possibility of feeling
failure, feeling depressed and worrying about your future job prospects. You mightalso avoid treatment.
There are analogs for studying this kind of process, and research could reveal
them. It also could be deepened by qualitative work if we put this story together in
a compelling way. This could be a basis for how we portray at least one part of thisproblem to the people who have the problems. It would also give them a language
for talking about what is happening to them. I think we could do that, and I think
it could be helpful.
DR. URSANO: We might frame that as a need to examine and further explore
the relationship of how the narratives of the military encounter the experience of
injury. Highlighting a couple of points, Bruce Link, you are actually saying given
the success of Theater of War, which is a narrative about the experience of soldiers
meeting injury and damage related to war, we should explore that. We should
understand it more in the present context. And, also, to go to Steve’s comment, thecoaching model is a hot model right now within DoD, both in terms of resilienceand in terms of networks. There are working efforts to build virtual coaches thatwould follow someone around during their entire career. These are right in line withefforts that we need to know more about, that are frequently moved forward fasterthan we have the opportunity to understand their effective elements.
DR. BELL: When we were at the Carter Center right after 9/11, the Medical
Director of the Fire Department got up and spoke. She talked about how there was
not as much PTSD in her fire folk because she had thoughtfully built the social fabricof that group. In their training, she built-in social emotional tools, affect regulation,
self-esteem, connectedness—all of the things we described in that paper we did about
the five essential elements of responding. This might be the way to go in terms of auniversal approach.
We understand that when some people are exposed to trauma they develop posttraumatic growth. Some people take that helplessness and they transform it intoConference Recommendations

helpfulness, and that is a protective factor. We sort of understand from this 2009
IOM Prevention Report that we just did, that there are things that you can do toprevent these problems. The difficulty is in the implementation, so some researchon implementation and effective ways of doing this would be helpful. There is theInternet-based Depression Prevention intervention we have been doing. It seems tobe very helpful in terms of coaching people, building resiliency, and helping people
learn how to flourish.
Richard Bryant talked about catastrophizing as a risk factor for developing
PTSD and how the notion of self-efficacy was a protective factor. The more of those
things that can be cultivated, the better off we could be.
The thing that I struggle with in terms of information is all the garbage thatis on the Internet. Apparently people who frequent the internet have much moredifficulty understanding truisms that are actually real, authentic, and genuine. Partof the challenge is directing people to the right internet sources. Maybe some sortof Good Housekeeping Seal of Approval might be helpful; because I think theDepression Prevention studies we have been doing show that is a very efficacious
way to reach large populations. You do not have to worry about fidelity and you
do not have to worry about dissemination. You push a button and you are there.
The problem is all the garbage.
DR. CORRIGAN: Every English-speaking country in the world has an antistigma program. In the United States it is run by SAMHSA. It is called the Center
to Address Discrimination Stigma. Ken Thompson would be a wonderful resourceon that. The person running it is a gentleman named Chris Marshall. I have thewebsite here. They talk about all sorts of important groups of people. They talkabout employers, landlords, politicians and the like. Under employers and under
employment is the military. They have had webinars on military issues and stigma.
One webinar was done by a series of veterans groups, including a veterans groupthat represents OEF, OIF, Iraq and Afghanistan Veterans of America. Also, we talked
about marketing as having some work based on the research here on marketing toemployers.
One of the first priorities is to help them further develop their research agenda
and their focus on the military. The Ad Center is one excellent start, keeping in mind
whatever sort of stuff you use, the unique culture of the military is going to spinthat in a way that is very important to them. For example, we talked about contact.
Contact with whom in the military? With the General, the NCO, the soldier? Probably with all three groups. We can look for existing research. One is the Ad Center,the other one is NIMH. There are several people in the room that have received
NIMH grants on stigma.
One of the concerns I have is that NIMH may be losing its sense of priority
in that regard. It had its own portfolio defined as stigma. I am not sure if it is an
explicit or implicit agenda, but Director Insel may be decreasing the concern andinterest in stigma research. I think we want to really promote this group, promoteand encourage more work in that area, especially with a military flair. I am also
aware that the VA is starting to pick up on this concern. I am aware of small projects
around the country. Rediscovering research agendas at SAMHSA Ad Center, the
NIMH portfolio, and the local VA work coming out of some of the minor places
into bigger places are all important.
DR. SHALEV: I endorse the idea that we need effective therapy. The productthat we package must be effective. There is quite a bit of work to do in that regard.

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Treatment can be stigmatizing. Early in my career I studied antipsychotics. The maindifference between the newer and the older agents is that with the older ones, youand everyone else knew your patient was on an antipsychotic because they were
Parkinsonian. They could not smile or interact socially. It was a stigmatizing typeof treatment.
I think that when you take a gun from a soldier or marine who takes SSRIs,
treatment in itself becomes stigmatizing. So, we should really think about making
treatment itself less stigmatizing. The other point is about treatment decliners.
There might be situations in which declining care is effective, and we should notjust assume that it is always bad. For some of those who do not want to come, they
may have good reason to decline. Research into the efficacy of declining care under
different circumstances might be helpful.
DR. URSANO: So you are saying that clinicians may have false positives, andthat we ought to understand our false positive rate as well as our true rate.
DR. SHALEV: Those with partial PTSD who declined care did not waste fourmonths of treatment resources that they really did not need. We are not yet at thelevel of defining the specific phenotype and circumstances that might benefit mostfrom treatment. The point I am driving is that there is a variety of outcomes. If I justmeasure their PTSD symptoms, for some it may appear that the treatment did not
help. However, some patients with persistent symptoms are very grateful for having
had that treatment, which helped them to be able to play with their kids without
being so sensitive to the noise. This is a multiple outcome question, and we should
think about it as a multiple outcome question.
DR. ZATZICK: Recommendation one: We optimize survey methods in randomized trials by looking at entry, retention and dropout from treatment. Recommendation two: We take qualitative methods and we move them very much into aclinical paradox.
We are working with The Disparity Center and Spero Manson. We want torecruit Native American patients from trauma wards, and we want to randomize
them. People are saying there is no way you are going to get injured Native American patients to be randomized. Native American patients do not enter randomized
trials. What did we do? We learned that the Native American spirituality is a core
concept and construct. We have to engage these folks immediately after the trauma
in this concept of spirituality. What did we do? We got a Tlingit Shaman. We asked
her if she would be a care manager. She says okay, I will do this, but you have to letme do my thing. What is your thing? I have all these different rituals I want to doin the Trauma Center, and I want to intervene with patients. For example, if I wakeup in the middle of the night having a dream about a patient, I want to intervene.
Then you become a boundary spanner. You say, “We want this match component.
We want to go to the bedside. We want a Tlingit Shaman to engage this patient andrecruit them into the study and randomize them.” Thirty patients consented to thisprotocol. It is the application of ethnographic methods. It is clinical ethnography.
We know a great deal so let us apply it. Let us measure outcomes and let us span
the boundaries that allow us to use the “out of the box” thinking.
DR. RADKE: I have two points to make. Being an action thinker, the first thing I
think about is Asics which is a shortcut in Latin for, “Sound mind and sound body.”
Health promotion needs to be integrated into this discussion because we need tofocus on physical and emotional strength and endurance. Unless we do that, everything else becomes after-the-fact, after the injury, after the event. And I do not thinkConference Recommendations

you want to go there, especially when we are dealing with soldiers, and airmen, andsailors. We want to and do have emotion.
The other point I want to make is why stigma? It could be the individual, but it
could be the system. We need to be able to discriminate between individual stigma
and system stigma. If it is an individual, then maybe it is a lack of knowledge. Why
are they feeling stigmatized, or why do they represent a stigmatic situation? If it isa lack of knowledge, then we have the education issues. If it is a belief, we have awhole different world, because beliefs are not going to be argued. Beliefs are going
to be discussed. We need to develop relationships like Doug was talking about toget over the beliefs.
Second point, if it is systemic stigma, then we have to look at what we havecreated. What are the policy and funding silos that have created a system of stigma?
Have we politicized the stigma so that we are now fighting in a political arena
because it is cost-effective not to treat and not to promote mental health care?
DR. BATES: My recommendations utilize a broad comprehensive integrated
resource-type model, shifting the culture towards a strength-based focus. What typesof skills could we develop in our service members that would counter stigma? How
can we identify standardized outcomes that cover the range of stigma and accessto care issues, so that we can look at them more broadly across the services? How
can we leverage the tremendous resources available across the services components,
including the VA?
We recently put together a model of psychological fitness for the Chairman and
the Joint Chiefs of Staff. We also advocated a model based on the conservation of
resources model, where it is important to identify all the resources we have andleverage them appropriately. The military has a tremendous range of resources wecan bring to bear on this problem. We have potential to integrate across our DoD
Health and Service Agencies, like Force Health Protection and Readiness, DCoE,
and Military Community and Family Policy. I think synchronizing efforts in DoD
alone could go a long way.
DR. KESSLER: We need to do treatment retention experiments. There is a bookby Don Meichenbaum, called Facilitating Treatment Adherence. It was written in
the late 1980s, and it was directed at behaviors like getting black men to take their
hypertension medication. Meichenbaum saw dramatic effects in keeping people intreatment.
We need to understand why people come into treatment. The reason people
come to treatment is not the same reason they stay in treatment. Many people comewith one presenting complaint and the next thing you know they are talking aboutsomething completely different. We have got to figure out how to get people to stayin treatment to successfully market treatment.
In the U.S., only about 20% of the people who have a serious mental illness in ayear get effective treatment. That is because 40% never get any treatment at all. Of
the six out of ten who get treatment, four drop out. That means that we lose 40%
because we never get them in the door, but we lose another 40% after they are in
the door, which is a crime. Which 40% is the easiest one to hold on to? We could
triple the effect of the system if we could keep people in treatment. We have got todo systematic studies to define best practices to keep people in treatment.
DR. PESCOSOLIDO: Recommendation one: I think we need to rethink some ofour research questions and, at minimum, supplement the way that we think aboutsome of these processes. First of all, it is not help-seeking. In our studies, 25% of the

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people who get into mental health treatment are coerced by the police and by theirbosses. A third does not really understand how they got there, so I think we needto move away from the image of help-seeking. We need to understand the process
and the key turning points. What are the identity shifts that it takes for people tocontinue to take their medication or stay in treatment?
All of us can think of 100 reasons why we do not want to take a pill every day.
What identity shift and acceptance does it take to become somebody who is dealing
with a chronic problem? Let us study patterns and pathways, rather than study afictional decision to use care or not use care.
Recommendation two: We need to normalize the whole idea of mental health in
the fabric of an individual reward system that has a high level of altruism.
DR. ZATZICK: I would strongly urge that we follow people at different stagesof their careers. Look at some of whom have had treatment, some of whom haveexhibited symptomatology, and look at how well they functioned. I think that many
officers believe that the stigma is from officers. If you screen positive for a psychiatricillness you are considered not fit for duty, or not trustworthy. We can go beyond thebelief systems, because the data is there. We just need to look at it.
Secondly, one of the greatest barriers to care is the concern about confidentiality. Except for military chaplains and Vet Center counselors in the VA, we cannot
guarantee confidentiality. How can we find out how often the Command is actually
requesting confidential information? If people felt that this was a very, very low
probability event, I think that would reduce this kind of a barrier. Internet-based
treatments, where one can have privacy, are a good resource. Web-based treatments
are getting more sophisticated and more effective.
My final suggestion is to frame PTSD as they do in Canada, where it is considered an operational stress injury. It is not considered a psychiatric disorder. How
does the re-framing play out in terms of function, in terms of follow-up, and interms of future prospects?
DR. FRIEDMAN: Military populations do not want to think of themselves
as being mentally ill. They are horrified by that thought. We need to find a way tocircumvent that.
What people are doing today is talking about function. Many of our leaders use
the term PTS, and actually abhor adding the D to it. They are trying to encourage theterm PTS without the D in the common parlance of the language. I like what Stevenhad to say about function, because I think that is the key thing. Can they function?
We need to highly encourage and improve the whole concept of embedding mental
health providers in the operational forces. It is incredibly effective when you haveyour doc walking around. You can walk up, hey, doc, let me run this one by you. I
am not sleeping very well. When you have access to that you do not have to make ahuge leap to drive all the way to the hospital. You do not have to leave the culturethat you live in, and enter the medical culture. Once you cross the threshold of thehospital or the clinic, you get into the medical world. You enter another vulnerable
place. By embedding providers, like the flight surgeon model, or the division psychiatrist model, or the OSCAR model they are using now, you become more effective.
What they are doing in the Marine Corps now is OSCAR Extender Training.
The OSCAR program stands for Operational Stress Control and Readiness. Mental
health professionals are the OSCAR professionals, but they also have Extenders
modeled on what the TRiM program does with the Royal Marines. Extenders aretrained to be peer counselors. Part of that training involves leaders talking aboutConference Recommendations

their own experiences with traumatic stress type symptoms. It is an incredibly powerful experience to have the Major who is the CO of your battalion talking about
his own symptoms, and his own struggles with dealing with his symptoms post
deployment. To have a Major, a Sergeant Major, a Gunnery Sergeant, and a MasterSergeant talk about their symptoms is incredibly powerful. Encouraging leaders totalk about their experiences is very important.
DR. SCHOR: I think that there should be a strategy for identifying the researchneeds. If you do not influence the decision makers in DoD, and in Health and Human
Services to apply resources, and if you cannot sell it, then why should they want tobuy it? There should be some sort of a needs assessment approach, perhaps stratified
across different areas. Education, training, policy, and clinical versus population
health all have different needs assessments.
DR. ARNOLD: You must have the leadership buy-in. I am speaking from theperspective of a Combat Stress Control Fitness Team Leader. When we got to Iraq,
we made contact with the leadership of the units we were supporting. Soldiers fromthe units that did not buy into what we did usually came to us fearing that theirleadership did not understand, and did not care. Unfortunately, that often panned out
to be true. From the leadership perspective, we need public service announcementsfrom all levels of leadership. Leaders need to be able to tell their service members thatcoming to seek help, whether it is for mental or physical health, is compatible withthe core values of the service to which they belong. If they can convey that message
by speaking openly of personal experience, it is very moving, because the person
seeing that realizes that they can step forward. They also see it has not adversely
affected their career. They have been able to go on.
When I was in Iraq, many soldiers came to see me with their battle buddy. They
would not come on their own, but they would come with their battle buddy. Sometimes they came in clusters. It was amazing to see how once one person got help,
and the other one saw what was going on, then they would come back individuallyand seek more help. I think we need to take the battle buddy model and incorporate
it in basic training in all branches of the military.
DR. URSANO: Robert, you are suggesting two battle buddy models. One could
actually study the effect. One could study the match in attitudes between battle buddies and see if one’s perception of stigma and barriers to care is the same as theirbuddy’s. One could look to see how altering one alters the other. It is an education
and an intervention strategy.
DR. RUZEK: One priority for research would be to show the impact of psychological programming on war-fighting performance, and other kinds of performance.
The strategy that I would like to champion is a series of RCTs comparing basic training with psychologically enhanced basic training. Let us look at the outcomes, basedon people’s ability to perform in the field. I am quite sure that techniques like anxiety
management and buddy systems, disclosure training, and self-taught procedures
would enhance ability to perform in stressful situations. If we could implement anddemonstrate that, then we could begin to de-stigmatize psychological programming.
The second area of research I think is important is comparative research thatlooks at different ways of presenting treatment and making referrals. We do notknow as much about why people are coming to treatment and what they hope to get
out of it. We need to learn more. We also need more research on what role significant
others, spouses, partners, and family members play in getting people to treatment.
There is a very important group of potential patients who are going to be recal-

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citrant to coming to care. They are the ones who are having problems in tyrannizing
the family and withdrawing from the world. Probably these people eventually arrive
for care through the intervention of family members. In the field of alcohol, there isan evidence-based protocol working with the significant other of an alcoholic who
is refusing care. I think we can develop similar protocols based on this model.
This is a technology transfer issue more than a research issue. We know thatgetting videos of patients talking about treatment and sharing their reluctance toenter treatment are good teaching models. They are more effective than masteringmodels in reducing anxiety about entering treatment. There are also different waysof making referrals that are more effective, too.
DR. URSANO: Recall that our plan is to create a transcript from which we willdevelop the most important part of the document that will become the Executive
Summary. This process will take somewhere between three and six months. Afterwards you will all receive a copy of the document.
Consider the question of other system issues, or reorganization that you wish tobring up. Consider the questions of leadership, direction to leadership, the questionof intervention, clinical or population-based. The truth of the matter is, we do nothave much data on what will work, but we may have some thoughts of things that
may be worth considering. And perhaps the most important one is to foster required
program evaluation, which is very difficult to accomplish. Those of you who workin states know that. It is the same issue within DoD. General Chiarelli says, “I havea thousand programs planted, but which of those are really bearing fruit?”
I want to make sure that we also touch on and talk about the issues of disasterand terrorism, not just DoD. Many of your comments apply in all those areas.
We have not said anything about emergent mental health needs that occur after adisaster. We have not said anything about the tireless work Ron has done related
to Katrina, which clearly documents the doubling of mental health disorders after
Katrina, and what that implies for particular barriers to care. We have not raised
anything about the distribution of people after a disaster. I am sure many of you haveseen the map that shows how people dispersed post Katrina. It would have done
little good to concentrate resources in New Orleans at that time. The distribution of
resources and barriers to care that have to be addressed become widely dispersed.
DR. COZZA: I think we need to have a better sense of the primary concerns of
the population as they describe them. We tend to focus our research on disorders
and diagnoses, instead of how to best understand the target population’s concerns.
We are dogmatic in thinking that mental disorders are the population’s principal
concerns, but they are not. Understanding their concerns serves as a portal of entry
for intervention. I think we can better access our target audience when we better
understand their concerns, making our interventions more effective. Second, we needto change our language. We may like naming our disorders, but people do not likethe complicated words that we use. As we were discussing, I think people accept
Viagra because ED is a more like a yes/no diagnosis — you know whether you
have it or not and it disturbs you if you do. You may not like accepting it, but you
have to accept it if you want to solve the problem. How does a person distinguishbetween what is normal and abnormal? This stigmatizes people. People do not liketo think of themselves as abnormal. Third, I think we need to be targeting interventions to where individuals are most likely to feel the pain, and most likely to engage
and want help. Bill Beardsley has done great work with parental depression. You
can engage families around parental depression when they realize that they can beConference Recommendations

good parents, if they take responsibility for their disorder. It helps parents be able
to frame any problem in away that reflects the importance of their parenting, which
may allow for more engagement.
Finally, we should look at functioning as an important intervention strategy.
Although we get concerned about the treatment and the pain of PTSD, what we getmost concerned about are the dysfunctional changes that occur as part of the development of the diagnosis of PTSD. I think if we focus on certain targeted symptoms
or behaviors that are far more likely to be self-identified as problematic, we may be
more successful.
DR. CROW: My recommendation would be to utilize a task force, a Blue Ribbon
Panel, that would include stakeholders, perhaps a subset of the group that is here
from Uniformed Services University, DCoE, U.S. Army Public Health Command,and civilian experts to provide a strategic vision of how the DoD can develop andimplement a Behavioral Public Health capability in the form of a brief White Paper
Task Force Report oriented toward senior leadership.
A public health approach would provide a vehicle for addressing issues ofresilience, life skills, and performance enhancement. Looking for a vehicle thatallows us to provide a behavioral public health orientation to the service is what I
am recommending.
DR. ESTROFF: Consider the process of how, or if, non-civilians would connect
with civilian processes dealing with stigma and discrimination. There is not a whole
lot of overlap, and there is a great deal going on. The big elephant in the room is
how or if people want to collaborate.
I think it is a mistake to assume that research is equal to listening or knowing
people’s experiences. I want to harken back to Pat Corrigan’s comment yesterday
about the absence of consumers. We have to question our own expertise. I am
reminded of two anthems from the consumer and mental health groups that I know.
The first one is, “Recovery begins with non-compliance.” The other one is, “Do not
let your treatment interfere with your recovery.” I take these as very serious statements. Research is not necessarily listening. I do not think research is the only thingthat is going to help. One thing that can be helpful is diarizing and journalizing ina freeform kind of way, which is both therapeutic and also informative.
There is a tremendous amount of literature accumulating on what is called
narrative medicine. We have had some good effects with this approach. It preserves
privacy, and deals with the third issue. I think that trying to talk with people, andwork with people is really the key.
DR. WESSELY: I have four points. On research, I think you have an adequate
knowledge of precisely what is going on in the figures that have been presented. I
just think it is increasingly implausible, that one-third of the Reserves have PTSD,
even though they score high on the PCL. You need to look and see what actually iswrong. One of the reasons they may not be coming forward for treatment is because
you may be treating them for something that they have not got. I do not think wehave a grasp of what is going on. There is a concern that we may not adequately
understand what the question or studies are saying. There is a remarkable lack,despite all the research money, of interview studies.
Switching to policy, Ron Kessler has said that marketing is not the answer if
people do not like the product, and that is absolutely correct. But there is a second
possibility. Perhaps they do not like the people delivering the product. In the film
Hurt Locker, the stereotype of the psychiatrist was very cringing and embarrassing,

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but it was telling us something that we should not ignore. How do you improve theproduct? That is quite difficult, and many people smarter than I have been working
on that for a long time. To echo what is being said across the room, it is time tomobilize the non-mental health sector that has higher credibility.
Point number three: It is pretty clear that targeting people, telling them they havea problem, let alone a mental health problem, or they need to change, or they need
to be more resilient, or less vulnerable, is not working. No matter how you phrase
it, people feel that you are targeting them. And, in a way, you are. Be clear as towhat these Peer Support and TRiM Programs are doing. They are not treating PTSD.
What they are doing is enlisting people to identify, support, and help others. It is anappeal to altruism. You are here to support others, but we hope, it actually supports
the individual directly to help themselves. It is free of stigma and the intervention
has been done without people actually being aware that they might be the target of
the intervention. It might help them. It certainly does not do any harm.
All of you will feel much better when you finally admit that screening programs
are incredibly expensive, and they do not work. It is flooding your system withpeople who immediately drop out of treatment, if they go into treatment at all. We
know from Charles’ papers that the ones you want to target are missing the system.
They are missing the system because they are the ones who are most severely ill,
who most severely feel the stigma, and, therefore, make the best efforts they can
to avoid your system. Resources are being wasted on an ineffective intervention. It
is clearly not working, because your rates are still going up and up. All of you will
feel so much more relieved when you finally admit that screening is not working.
DR. BATTEN: I just realized that we have not mentioned our Real Warriors
Campaign. My Bottom Line Up Front (BLUF) is that the Defense Centers of Excellence would welcome anyone’s partnership in this room with either the implementation or evaluation of our Real Warriors Campaign. Our Real Warriors Campaign
is a national and international public awareness campaign primarily targeted in
the Department of Defense to promote help-seeking for those who are having
functional concerns that are not resolving on their own. We did focus groups before
we launched, in which we talked to service members and their families, and asked
them, “What would encourage you to seek treatment?” They said, “We want to see
examples. We do not want to have a shrink telling us what to do. We want to see
examples of real people who have had struggles like ours, and who have sought
treatment. We want to see proof that it has not harmed their careers.” That is thefoundation on which our campaign has been developed. We find individuals froma variety of ranks, from Sergeant up to Two-Star Major General, who have talked
about their experiences after returning from combat. We also have some medical
professionals who talk about compassion fatigue from treating trauma patients intheater. They talk about what it was like to come home. What struggles did they
have? What was their resistance and hesitancy to enter treatment? How did they
finally come to treatment? Usually it is either a family member or a leader whointervenes.
We use video-based clips that you can view in 30-second or five-minute versions,which we have been pushing out around the country in both PSA format as well as
a longer format. We have a Facebook page and a Twitter page. We have forums inwhich people can type to each other. We have a chat function, which they can use
to talk to trained health resource consultants 24 hours a day. We are very proud of
the program. It has only been up and running for about 10 months. Our primaryConference Recommendations

mode of evaluation has been market saturation, not effectiveness and outcome. We
were recently notified by Nielsen that we have made one billion—with a b—media
impressions. I do not really know exactly what that means, but it is a big number.
We feel like we are getting the program out there. We would love to tap into theexpertise of those of you who can help us with some of the more outcomes-based
evaluation. We want see if the program is actually doing what we hope it is doing.
We are also evaluating the Theater of War project.
DR. BROWN: My recommendation is that it is important to put effort where
you are going to make big differences. I suggest that the evaluation component iswhere you can make a big difference; that is, there needs to be large-scale emphasis
on a large group-based randomized trial. The level of the group is something verylarge like a base. There is a history of this in the military. It should accomplish threegoals. Developing and testing implementation. Developing and testing effectivenessand inputting a quality-improvement control system so that you actually are improving over time. What we have been lacking is a knowledge-base to tell us whether
big-scale programs are improving.
It seems like there are many brilliant ideas in programs already. Perhaps they are
not integrated as well as they should be. That is the component we can test. One of
the best examples is the Thai military experiment that David Celentano ran years
ago, which demonstrated that you can reduce HIV infections in the Thai military.
The study was a randomized trial of probably about 50 to 100 thousand recruits in
the Thai military. The technology is there for us to use.
The last comment I want to make is about psychic fitness and resilience issues.
We can learn from other cultures outside the military. One example is the culture
in Disney World. The Disney Institute is very good about service. That is what theytrain people to do. They train people to be very effective in a very difficult job in
a service setting. They have a concept called “On Stage and Off Stage.” When you
are on stage, you have a set of standards to which you are expected to adhere. They
also provide a set of standards for off stage. That is not the analogy for the military.
However, the culture in Disney is just as strong as it is in the military. I think weneed to figure out where these key pieces are, and repeat them systematically over
and over again in the interventions.
DR. SHALEV: I will raise another construct, which is the anti-stigma. In mycountry of Israel, we are struggling with some people who seem to be stuck witha deteriorating course of PTSD for years. The more help they get, the more they
deteriorate. We should remain aware that some disorders in certain contexts becomeso rewarding that people maintain them. I would recommend looking at the maintaining factors. Maintaining factors of disorders, symptoms, impairment, disability,
reported disability, or perceived disability, are all important because at the end of
the day, these individuals perceive themselves as having severe disabilities. We should
remember that once you get into the PTSD club, you can get out of it. PTSD andseveral other disorders are transient. They are not one-way tickets.
DR. URSANO: That is an interesting challenge to think about exit strategies.
How does one exit the illness role and how does one exit the picture. How does one
get in it, and how does one get out of it?
DR. FLYNN: I would like to suggest four recommendations based on the ideathat these recommendations are how to move the field forward, not necessarily
things we ought to be doing. We might want to consider changing the sequenceof the title that we are using. I have gone through a transformation preparing for

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this group, thinking about stigma being first, and then other barriers being second.
Most of what we are talking about is other kinds of barriers, of which stigma is one
important one. Maybe we want to shift the sequencing.
The second is that we broaden the perspective domains that we are discussing.
This is not a criticism, it is an observation. I think there is a bias of our discussionthat is a product of the constellation of people here. There has been a great deal of
discussion about research, primarily, because many of the people here live in theworld of research. There has also been a bias about medical systems and health caresystems, because that is where most of the people here live. However, many of theconcerns that we are talking about do not play out in these systems or in research.
They play out in the workplace, in schools, in jails, in decisions and choices thatleadership make, whether that is politic leadership or organization leadership. A
future recommendation is to broaden our scope.
The third recommendation is to expand our discussion of issues of history
and culture in the discussion. We have not had much discussion about the roleof otherness, shame, blame, power dynamics, and those kinds of things as part ofthis dynamic. The final recommendation is that we make sure that we include awide array of expertise as we begin to make recommendations to the field. Manyof these issues include our areas of expertise. We should also include faith issues,
anthropology, linguistics, social marketing, and communications. There are many
very professional fields that have a great deal to contribute.
DR. HOLLOWAY: I recommend that we investigate ways of integrating ourservice delivery toward primary care. It may not be obvious how to do it so we may
want to try several different models. My overall statement is that the system that
we have now, to go back to Simon Wessely’s point, is not working. We will all feelbetter if we admit that.
The other thing I would like to focus on is that we take care as we develop our
expansion into new areas—examine what the real potential is rather than what we
believe about the potential. The chaplaincy does not have, by the way, confidentiality.
Number two, the chaplaincy right now is badly split between the Fundamentalist
Churches and the traditional churches. The Fundamentalist churches are refusing
to provide religious care to soldiers who are not of their particular domain. Those
battles are part of what it means to contact the chaplain. It is not just a chaplain. It
is which kind of chaplain, which place, and it becomes a large bureaucratic struggle.
In each of these cases we need to examine what the real facts are on the ground.
For instance, the overall misstating of facts here was striking. The Surgeon Generalcannot use a diagnosis to overrule anybody. He is a Staff Officer; he is not a Command Officer. Number two, it was stated that people follow orders within the service.
Commanders would love it if people commanded and followed orders. But let metell you, Commanders know that they are giving orders to people, and that people
act like people.
DR. REISSMAN: Suppose you have a physical injury instead of a psychologicalillness? There is a whole literature on safety climate, and changing the climate, which
is how people talk to each other about what is going on in an organization. How
culture gets into climate is not always so straightforward. That relates to what somepeople were talking about earlier with injury.
I think we also need to think one step beyond those who are in the active component. We need to think about those who are in the reserves, including the Guard
who come in and out of this kind of activation. How do we work psychologicalConference Recommendations

fitness into this component? How do we think about reintegration more broadly, sothat reintegration is not only to civilian life but also back to military life? All thosetransitions play a big part in where some of these wounds are coming from.
Finally, vocational rehabilitation is part of the shaft of support. Vocational rehab
should be a component of performance enhancement. It does not mean you haveto change your job. You need some help getting back to your job. You might needhelp feeling like you fit the core values of your job.
DR. TUMA: My recommendations will be framed as questions. I would like toknow how we can help an important point of contact through primary care. Rather
than blame, bash, and burden, how can we assist and extend through primary care?
I would like to know how the ideas of psychological maintenance and fitness
can become embedded and tested in the military and civilian cultures. This is not
something that is going to change in a generation, but I think keeping up the battle
is a good idea. We might get to a point where early symptoms and signs of distress,
and perhaps functional problems, would be viewed as injuries that have an unknown
prognosis. With a physical injury one might wonder for a few days whether they canmanage. If they cannot manage it then they would seek some assistance. Framing
things in terms of psychological fitness or maintenance is one strategy that has notbeen studied. There is certainly a great deal of activity now and exciting programs
being put in place. I would be very interested to know if we have the ability tomonitor what programs actually change beliefs and behaviors.
Third, I would like to know how to get rapid relief for people who do make itinto care because I think it helps people continue care. Related to that, I would liketo learn how to better mitigate the other reasons people discontinue care. I would
like to know what actually happens in therapy. You know, several comments havebeen made about marketing, and the way people flock or do not flock to certain
approaches. I would like to know what happens in psychotherapy to know whether
we can tell a better story about why people should participate.
Finally, I would like to know something about the use of technology to scale-up.
I would like to know how successful technology is to extend care. If it is successful
in the context of a crisis, what are the lessons learned for people in non-crisis situations to access care?
DR. CROSS: My BLUF is going to address the research area and also training
and education. As programs roll out there is an opportunity to add to the scienceof training, and maybe bring the science of training to some of the evaluations. We
are talking a great deal about mental health and stigma, but there are all kinds oftraining efforts that could benefit from some of this work. We could learn about
training and education, and transfer of these programs, regardless of who the interventionist is. We have heard about the use of coaches, peers, extenders and mental
health professionals. We have heard about many program models. Whatever thesetting is, we could study implementation at all levels. We could even do hypothesis
testing. We could do trials within trials. Some of these training and transfer studies
could be rolled into other evaluation and research efforts. That is why it is research,and training, and education, with the effort to improve these processes over time.
Secondly, I really like the idea of building skills. I have never seen the Haddon
matrix before. I would like to focus on the left-hand of that matrix which is thelife-skill building part.
DR. RUZEK: I was struck yesterday about the importance of self-help organizations. That is where many people are actually embedded in mental health

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care. Participation in self-help organizations can also help maintain participationin professional care. I think something is being overlooked in research, and it has
been relatively overlooked in terms of partnerships, engaging people in services, andchanging stigmatization.
One of the benefits of working with self-help organizations is that you then havea cadre of people who model outreach, as well as internal mutual helping. I felt forsome years that I ought to be trying to build a self-organization of PTSD sufferers
inside the VA, but I think it is far more general than that. We ought to work withexisting organizations, as well as create new ones. Many self-help organizations werepartnerships between professionals, mental health professionals and the lay public
who were suffering. There is a potential for real synergy between them. It makes
sense to follow the inherent preferences of our people who are talking to chaplains,
talking to primary care docs, and who are going to ERs at the early stage of recovery.
But it brings up many issues.
Number one, we have not developed and tested interventions for post trauma
and psychological problems in those environments, so there is a research issue.
There is a research issue in terms of whether those kinds of ordinary referrals, orordinary contacts, are helping people, or not. Should we be bringing the evidencebased protocols into those settings or modifying them for use by other folks? I think
there is a big hole there.
I wonder if it would be feasible to mount a health education campaign with
Hollywood and media moguls directed at how treatment is represented in televisionshows, films, and other media places. It is fairly clear to me that showing people
wrestling with issues about coming to treatment and showing the benefits of treatment opens up the black box of what happens in treatment. My bias is that treatment
is the most practical thing in the world. It is sitting down and setting a few goals.
It is prioritizing what to do. It is problem-solving issues and learning a few verypractical skills. It is not all this crazy stuff that people think it is.
DR. BROWN: Many in our group have resonated with the resilience theme of“taking a knee” and being “on stage or off stage.” Sue Estroff noted that “always” isan element of so many military core values and associated expectations. An important target of universal prevention may involve teaching people to recognize when
they need a break, how to take a break, and how to shift the cultural expectation toallow rest. Additionally, all of us must continue the struggle toward understanding
what works in therapy.
DR. KILPATRICK: My colleagues have developed two online training courses
about evidence-based treatments for PTSD. Trauma Focus CBTWeb is for childtrauma, and the other is CPT, or Cognitive Processing Therapy Web, which has only
been online for about a month. Trauma Focus CBTWeb is a nine-hour course andhas had more than 60,000 users. There has not been evaluation of these kinds ofmethods in terms of what is the best way to use them. Could they be used independently? Should they be used before going into more in-depth training? Should theybe used as a reinforcer? I would recommend that there be some evaluation of thesekinds of approaches. We like them very much. We can give some great testimonials,
but I am not sure we have information about how online courses work.
The second thing is if we are talking from a policy point of view, many of us
around the table are pointy-headed intellectual researchers; therefore, data andstudies are very important to us. I have observed that many policy makers do notConference Recommendations

like data. I think there is power in the personal story. How can we appeal to both
the researchers and the policy makers?
DR. GOLDENBERG: What do primary care physicians think about psychiatricillness? And is it stigmatized there? Is the psychiatry clerkship a place where stigma
reduction can happen, or does it happen just by exposure? We talked a great deal
about exposing people to patients with psychiatric illness. Is that a place where
stigma reduction or promotion happens?
DR. TYLER: During the Cold War and first Gulf War, I studied fatal training
accidents involving armored track vehicles in deployed organizations in Germany.
What struck me the most was the wonderful way that soldiers of all ranks took careof each other in these perfectly horrible situations. I think there needs to be moreexamination of how that happens, and what makes it work.
DR. BENEDEK: I was very much impressed by Dr. Pescosolido. What I learned
from her was that we have made some progress regarding stigma in some pieces ofmental illness, and we have gone backwards in others, particularly with substanceabuse.
I also would echo the importance of figuring out what causes people to drop outof treatment. What is the tipping point that makes people enter treatment? It may bevery different for different people. It is supposed to be different for different people.
DR. NAIFEH: Are we trying to make it so that every single person who could
potentially benefit from treatment is both willing and able to seek treatment, andstay in it for the full course? Is that realistic? Is it even desirable? And if not, what
are we willing to tolerate? What is a realistic and desirable goal in terms of getting
people to seek services and to stay in services? At what point does the cost outweighthe benefits?
DR. GUIMMOND: As a child-focused person, I have been thinking about how
children are integrating messages about mental health. There are so many concerns
about over-treating or over-labeling kids.
DR. BIGGS: What can we do to change the perception of threat that someone
with mental illness might have or impose? Ultimately, we are talking about helping
the individual man or woman. The perspective I have is that there are three things
that need to be kept in mind. How does he or she see the world? How does the world
see him or her? And how does that person see himself? That is the ultimate focus.
MS. DICHTEL: From a nursing perspective, I think stories are important, andI think buddies are important.
DR. SCHOR: I am not sure that we have emphasized a total workforce development approach. What skills do people need to have at different work force levels?
I have not heard risk communication mentioned. That may be primary prevention,
but the way in which you discuss this risk may actually mitigate the impact of the
injury and how it is perceived. I am not sure that we have emphasized that enough.
DR. HOWE: Sonja Batten pointed out that from the focus groups, a reason fora person not getting treatment has to do with security concerns. What we have notaddressed at all is the possibility of changing that structure. I may be optimistic
but it can be changed. What I am talking about is the military’s structural policy of
how it handles confidentiality. In the early days of HIV infection, there was a newpolicy that came out when it was essential for the military to identify the source ofHIV. They made some new rules regarding confidentiality for people who would
acknowledge, for example, that they were gay. Similarly, there used to be a concern
about commanders going on fishing expeditions. That has been changed as a matter

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Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorismof policy very profoundly, so that it could be that inroads in those areas could makeit easier for active duty persons to go for treatment.
DR. SHALEV: Stigma is a bit of a heavy word. We are dealing with belief
systems, so maybe we should more closely examine what people believe about
themselves and others. It might be better if we use other words.
DR. BATTEN: We need to work with people on developing more flexible waysof looking at the world, understanding there are lots of possible alternatives andinterpretations.
DR. HOLLOWAY: I recommend one further conference, primarily focused on
barriers to care and forget stigma. Half the attendees of the conference should beofficers who have commanding responsibility, NCOs, and at least a quarter of theprofessionals should be primary care doctors to consider these same issues.
DR. URSANO: Great comment, both as an intervention and as an education
activity for all at that conference.
DR. ARNOLD: I would like to include in that conference people who haveactually had these injuries, the consumer.
DR. ESTROFF: Two concerns. One is that this is not a randomized controlled
drug trial, and it is going to take a long time. Tom has heard me say this over andover at the Carter Center, and this sort of anxiety about measuring and doing isgoing to take a long, long time. I see the change from when I started teaching medical students 30 years ago to what I see now, and many of the things that we findproblematic are no big deal to them. Gender issues, ethnicity, they are in a different
place, and who knows why they changed, but it is going to take a long time. We
should not expect that we will be able to see an effect like that in the time span ofour studies, which are totally arbitrary in duration. Research is not the same thingas knowing and listening. It is not clear to me that there has been enough of that.
It is just not a substitute. A survey and symptom scale is not going to tell you what
you need to know, with all due respect, at the level that we need to know.
DR. BROWN: In closing, we have achieved one of the primary goals of thisconference, bringing people from different disciplines and fields together to build
relationships and bridges between one another. Thank you so much for coming.
DR. URSANO: I would like to thank everyone for your outstanding contributions.

Center for the Study of Traumatic Stress
Department of Psychiatry
Uniformed Services University of the Health Sciences
4301 Jones Bridge Rd
Building B, Rm. 3068
Bethesda, MD 20814
Phone 301-295-3293
www.cstsonline.org

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