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
Executive Summary andRecommendations

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

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.

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

DEFENSE CENTERS
OF EXCELLENCEFor Psychological Health& Traumatic Brain Injury