FORUM ON HEALTH AND NATIONAL SECURITY

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 EXCELLENCE

For Psychological Health

& Traumatic Brain Injury 
FORUM ON HEALTH AND NATIONAL SECURITY

Stigma and Barriers to Care

Caring for Those Exposed to War, 

Disaster and Terrorism

Edited by 

Robert 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 and 

Defense 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.................................................................................................................... 9

Mark 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.
Mark C. Brown, M.D., M.P.H.

LTC, MC, USA

Senior Fellow, Disaster and Preventive 

Psychiatry

Uniformed Services University

Thomas Bornemann, Ed.D.

Director, Mental Health Program

The Carter Center 

C. Hendricks Brown, Ph.D.

Professor and Director, Prevention Science and 

Methodology 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

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

Sue E. Estroff, Ph.D.

Professor, Dept. of Social Medicine

Adjunct Professor, Depts. of Anthropology and 

Psychiatry

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

Matthew J. Friedman, M.D., Ph.D.

Professor, Psychiatry and Pharmacology & 

Toxicology

Executive Director, National Center for PTSD

U.S. Dept. of Veterans Affairs

Sandro Galea, M.D., Dr.P.H., M.P.H.

Gelman Professor and Chair, Dept. of 

Epidemiology

Columbia University

Paul S. Hammer, M.D.

CAPT, MC, USN

Director, Naval Center for Combat and 

Operational 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

Ronald C. Kessler, Ph.D.

Professor, Dept. of Health Care Policy

Harvard Medical School

Dean G. Kilpatrick, Ph.D.

Distinguished University Professor, Clinical 

Psychology

Director, National Crime Victims Research & 

Treatment Center

Vice-Chair for Education, Dept. of Psychiatry 

& Behavioral Sciences

Medical University of South Carolina

Speakers

i
Bruce G. Link, Ph.D.

Professor, Epidemiology and Sociomedical 

Sciences

Columbia University

Research Scientist

New York State Psychiatric Institute

Bernice A. Pescosolido, Ph.D.

Distinguished Professor of Sociology

Director, Indiana Consortium for Mental 

Health Services Research 

Indiana University / Schuessler Institute for 

Social Research

Dori B. Reissman, M.D., M.P.H.

CAPT, USPHS

Senior Medical Advisor, Office of the 

Director, National Institute for 

Occupational Safety and Health

Arieh Y. Shalev, M.D.

Professor and Head, Dept. of Psychiatry

Hadassah University Hospital

Robert J. Ursano, M.D.

Professor and Chair, Dept. of Psychiatry

Uniformed Services University 

Director, Center for the Study of Traumatic 

Stress

Simon Wessely, M.D.

Professor, Epidemiology and Liaison Psychiatry

Director, King’s Centre for Military Health 

Research

Vice Dean, Academic Psychiatry, Teaching and 

Training: 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

Conference Planning 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.

ii

Editing Committee

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.
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 Health 

Council

Acting Director, Institute for Juvenile Research

Professor, Dept. of Psychiatry and School of 

Public Health

David 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 

Attendees

Jennifer Bornemann, M.S.S.W.

LT, USPHS

Dept. of Psychiatry, Center for the Study of 

Traumatic 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 and 

Methodology 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 of 

Traumatic Stress

Uniformed Services University

iii
Alisha H. Creel, Ph.D.

Assistant Professor, Division of Social and 

Behavioral Sciences

Dept. of Preventive Medicine & Biometrics

Uniformed Services University 

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

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 

General

Charles 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 and 

Psychiatry

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

Matthew J. Friedman, M.D., Ph.D.

Professor, Psychiatry and Pharmacology & 

Toxicology

Executive Director, National Center for PTSD

U.S. Dept. of Veterans Affairs

Carol S. Fullerton, Ph.D.

Science Director, Professor

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 

Program

Center for the Study of Traumatic Stress

Uniformed Services University

Paul S. Hammer, M.D.

CAPT, MC, USN

Director, Naval Center for Combat and 

Operational 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

iv
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, Clinical 

Psychology

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 Institute

James 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 for 

Social 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 

Health

Charles 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

v
Kenneth W. Schor, D.O., M.P.H.

CAPT, MC, USN (Ret)

Acting Director, National Center for 

Disaster & Public Health

Asst. 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 

Health

Navy Intern Specialty Leader

General and Forensic Psychiatrist

DCoE for Psychological Health and 

Traumatic Brain Injury

Laurie B. Slone, Ph.D.

Associate Director for Information and 

Communications

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 

Health

University of Pittsburgh and Western Psychiatric Institute and Clinic

Medical Director, Center for Mental Health 

Services (CMHS)

SAMHSA

Farris Tuma, Sc.D.

National Institute of Mental Health

Division of Adult Translational Research and 

Treatment 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 Traumatic 

Stress

Simon Wessely, M.D.

Professor, Epidemiology and Liaison Psychiatry

Director, King’s Centre for Military Health 

Research

Vice Dean, Academic Psychiatry, Teaching and 

Training: 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

vi
Preface

This Forum on Health and National Security, directed to addressing stigma and 

barriers to care, brought together a diverse group of leaders in order to expand our 

horizons on these issues of important national need in times of war, disaster and terrorism. The individuals represented national leaders, educators, researchers and health 

care planners across mental health, health care systems, military and disaster care and 

the 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 under 

the 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 to 

care 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 the 

Forum 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.

vii

Our primary goal was 

to better understand 

the issues of stigma and 

barriers to care as they 

relate to the trajectory 

from illness, distress and 

health risk behaviors 

after war, disaster or 

terrorism to care and 

needed help.

Executive Summary 1

Executive Summary and 

Recommendations

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 a 

person 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 the 

intersection 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, disaster 

and terrorism and to translate that understanding into action. Stigma is associated 

with behavioral health in general and emergency behavioral health in particular. To 

address stigma and barriers to care it is important to address the marginalization 

and misunderstanding about what we can and cannot do in mental health and the 

myths 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 is 

a 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 — but 

people 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 or 

civilian worlds, how to modify societal beliefs that psychiatric and psychological 

problems 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 of 

efforts by community mental health to educate neighborhoods about mental health 

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

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 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. 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 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 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? Distress 

responses can also be thought of as subthreshold mild to moderate symptoms and 

often are early signs indicating the need for treatment or psychological rest. They 

also impair performance. We need to particularly better understand how barriers to 

care can impact the performance and health of individual service members, public 

health 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 fact 

that 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 health 

burden after war and disasters. They are too often overlooked in the broader public 

health issues after traumatic events. These are important targets for prevention and 

intervention 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 and 

our 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 rates 

of 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 is 

that 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 

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. 
Executive Summary 3

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 and 

child neglect. We need to consider outreach to these populations. How to alter the 

system 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 population 

or 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 to 

care 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 start 

of the war despite massive education and screening campaigns. It is conceivable 

that the stigmatization process as a means of differentiating “in” and “out” 

groups plays such a central role in maintaining performance that changing the 

culture will continue to be a long-term goal. In order to mitigate the health 

and national security implications of such a phenomenon research is needed to 

develop alternative approaches to care. Areas for exploration include the study 

of the effects of relationships on altering barriers to care, coaching models of 

care, 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 to 

access.

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

The stigma associated 

with psychological 

health 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

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

• Examine the mechanisms of fostering connections with others as a factor in 

altering stigma and interpersonal barriers to care.

2. Many factors, including stigma, inhibit symptomatic individuals from seeking care following exposure to disaster, war, and terrorism. Of those who are 

brought to clinical attention many drop out or receive inadequate care. Research 

is needed to better understand vocational trajectories after care seeking, the 

positive effects of treatment, the process of reaching effective care, and the 

effectiveness 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 positive 

effects 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 what 

is effective in therapy and how to optimize primary care settings to identify and 

treat 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, get 

treatment 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 of 

delivery 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 information 

and treatment in less stigmatizing settings.

4. Screening programs such as Post-Deployment Health Assessment (PDHA) and 

Reassessment (PDHRA) should be examined for positive and negative predictive 

Many factors, 

including stigma, 

inhibit symptomatic 

individuals from 

seeking care following 

exposure to disaster, 

war, and terrorism. 
Executive Summary 5

value, cost-effectiveness, and unintended consequences. For example, universal 

face-to-face mental health screening of all redeploying soldiers is difficult to 

implement 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 with 

health 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 primary 

care and mental health communities in order to optimize collaboration.

• 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 health 

screening for all redeploying soldiers, irrespective of risk stratification. 

• Continue implementation and evaluation of RESPECT-MIL program.

• 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 and 

stigma.

• 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 health 

workers to enter care (e.g. motivational interviewing) are important for optimal 

treatment 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 and 

training 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 soldiers 

developing expertise in this area. Vocational rehabilitation should be included as an 

element of performance enhancement. It is important to optimize, disseminate, and 

Initial and refresher 

training and education 

of primary and specialty 

care providers’ for 

encouraging service 

members and disaster 

exposed families 

and public health 

workers to enter care 

(e.g. motivational 

interviewing) are 

important for optimal 

treatment strategies, 

programs and goals.
6 Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism

evaluate 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 such 

as communities, work places, and jails should be provided.

• Provide initial and refresher training and education of primary care and 

specialty care providers in optimally motivating patients to seek care as well 

as 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.

Leadership

Public mental health and military mental health leadership need to integrate the 

message 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 and 

implement this at the level of operational units. Leaders need to reinforce the value 

of recognizing signs of distress, along with endorsing and underwriting a cultural 

shift toward rest and “taking a knee” when indicated. Structural efforts should be 

directed 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 all 

levels 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 and 

implemented at the level of operational units.

Public mental health 

and military mental 

health leadership need 

to integrate the message 

of help seeking as an 

aspect of performance 

enhancement and 

organizational 

development. 
Executive Summary 7

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

indicated.

• Continue structural efforts toward improving confidentiality associated with 

care 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 to 

improve 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 and 

civilian 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 examples 

of creative interventions to promote “contact”, widely regarded as the most critical 

element of successful stigma mitigation effort. Mental health should collaborate 

with marketing and media experts to establish long-term public behavioral health 

educational campaigns and to promote collaboration between civilian and military 

communities.

• 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 guide 

targeted interventions.

• Effective public health planning tools, such as the Haddon Matrix, can be 

used to design public health programs.

• Self-help groups, which are known to promote treatment adherence should 

be optimized. 

• Programs such as the DCoE Real Warriors, Bryan Doerries’s Theatre of 

War, and social media such as Twitter or Facebook are examples of creative 

interventions to promote “contact”, widely regarded as the most critical 

element of successful stigma mitigation efforts.

Many excellent 

programs for stigma 

mitigation designed to 

reduce barriers to care 

exist in the Department 

of Defense, Department 

of Veterans Affairs and 

civilian public health 

and 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 9

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 to 

War, Disaster and Terrorism” working meeting. I stand before you today feeling 

as 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-health 

lens 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 a 

wonderful 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 exceptionally 

caring 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 of 

you 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 the 

last 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 student 

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

from them. We also have experts from a variety of other areas. Together we are going 

to think across disciplines to try to better understand this topic. 

COL Hoge graciously allowed me to analyze his dataset to develop some new 

skills 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. 

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 not 

know each other’s work and that is why you are each here. If you are only talking to 

people 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 of 

interest to you in pursuing these topics. To help with this, in your packets we have 

provided 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, and 

research. 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 one 

of the brightest people I have ever met, he is also one of the most gracious. As you all 

know 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, the 

National Comorbidity Study-Replication, and the related Adolescent Study. He is 

the head of the ongoing World Health Organization (WHO) studies. He is also the 

driving 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.

Our first goal is better 

understanding and 

then to translate that 

understanding 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.
Mental Health, Stigma and Barriers to Care 11

2

Mental Health, Stigma and 

Barriers 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 not 

know 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 and 

a 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 that 

a 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 health 

people to meet with the neighborhood and tell them how mental illness is not really 

an illness and not really dangerous. What researchers have discovered through considerable practical research on this topic is that when they provide education to the 

community 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 implication 

of the perceptions of mental illness in the community. 

The aspect that I have been most interested in has to do with the other side of 

it. 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 have 

a 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 
12 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 the 

stigma associated with emotional disorders, the idea that it is shameful to have a 

mental illness, and that it is a character flaw.

There is reason to think that some of these attitudes might be changing. For a 

number 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 coin-

cidence 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 public 

health and also, as an aside, to get a little bit more money, decided that it was a ter-

rible 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 advertise 

prescription drugs on television. 

As it turns out there is some interesting economic evidence about this. Advertis-

ing 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 con-

vince 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 the 

effectiveness 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 of 

Prozac coincided with front page feature stories about Prozac on the covers of Time

and Newsweek, and all of a sudden we became inundated with Prozac.

Subsequently, we have had many front covers of Time and Newsweek that have 

talked 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 and 

how 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 13

increased dramatically. Based on that dramatic increase it is probably no surprise 

that 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 did 

national surveys and looked at rates of mental illness and treatment for mental ill-

ness. 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 human 

services 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 psychiatric 

nurse. General medical treatment increased from 3% to 9%, about a three-fold 

increase 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 television 

a 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 from 

a psychiatrist did not change much. However, treatment for the people with less 

severe illnesses doubled. What may be happening due to the advertising boom is 

that 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 less 

severe 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 medi-

cal 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 in 

treatment has gone up over time. Conversely, the quality of treatment has gone down 

over 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 psychophar-

macology, 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 treat-

ment 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 of 

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

striking things we found was that when we asked people with disorders, “How come 

you didn’t get treatment for this problem?” They said, “What problem?” This is more 

true for some illnesses than others, such as excretion disorders. The real poster child 

for 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 this 

change. 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 need 

treatment for some kind of emotional problem?” Second, to assess perception that 

effective treatment was available we asked people, “How much do you think these 

treatments 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? How 

much 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 really 

help many people at all” changed from 5% to 7%. The perception that you have a 

problem did go up even though the percent of people in the population who had a 

mental disorder did not change. What we are calling stigma, i.e., these perceptions 

of concerns about somebody knowing about you having a problem, showed only a 

modest 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 the 

disorder. 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 human 

services 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 given 

that these things have not changed much over time. To review, the more severe your 

disorder, 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 is 

an 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 in 

treatment. 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 

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 the 

disorder. 
Mental Health, Stigma and Barriers to Care 15

really 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 get 

treatment 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 were 

actively 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 come 

you didn’t get treatment for this problem?” They said, “What problem?” One out 

of every four of them responded this way.

Structural things such as not having insurance, not knowing where to go, long 

waiting 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 going 

to 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 a 

problem.” Really, what we should be doing is looking at the people who recognize 

that they have a problem. When you survey the people who do recognize they have 

a 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 have 

a 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 in 

the way. These attitudinal barriers are there across the board.

Getting people to treatment is not the only place where stigma issues play a 

part. 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 well 

as 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 among 

people who got treatment is one. They went once and they never went back. The 

inter-quartile range is one to two, so one standard deviation above the mean is two 

visits to the family doctor. We looked to say, “So where are you now? Are you still 

in treatment? Did you complete the treatment? You’re cured or did you drop out?” 

Structural things such as 

not having insurance, not 

knowing where to go, 

long waiting lists and so 

forth were not really all 

that important. 
16 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 can 

function 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 in 

general 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 a 

self-help group are in for reasons other than substance problems. The people who 

are in self-help groups for emotional problems are often also seeing a mental health 

professional 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 is 

seeing 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 for 

cancer are deeply invested in self-help groups. Nurses often run them for patients 

and 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 is 

with 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 is 

considerably lower in some areas than it is in psychiatry. It could well be that we 

should 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 increase 

in 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 Care 17

in. 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 number 

of 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 such 

as, “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 a 

series 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 other 

random 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 willing 

to 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 it 

mean 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 the 

former— 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 in 

studies of stigma. To the best of our knowledge it looks like people are willing to 

tell 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 outreach 

with stages of change interviewing, you can get a substantial proportion of those 

people into treatment. If you use thoughtful case management, such as that being 

implemented in RESPECT-MIL, you can keep them in treatment. The problem we 

have is that case management does not often happen, and when they get typical 

treatment 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 the 

things 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, get 

them 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 to 

make practical changes to get them to enter and stay in the treatment?” My guess 

is 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 
18 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 more 

proactive 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 is 

much 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 the 

mental health arena. Hendricks Brown can tell you from his work at Hopkins with 

behavioral 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 your 

first mental illness and age of first contact with a treatment system, the difference 

is 12 years. Most people who have serious disorders in adulthood have onset in 

childhood and get treatment when they go to college, join the military, or get into 

a relationship that falls apart at the age of 22. I wish we could do a better job of 

early intervention with mild disorders when people are in pain and are interested in 

getting treatment. There are lots of kids out there, usually sitting in the back of the 

room, 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 is 

the 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 in 

stigma 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 blip 

in 30-day prevalence of disorder. We did not see any blip at all in lifetime disorder 

which 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 we 

never 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 Operational 

Stress Control in San Diego. 

DR. HOGE: In 2004 we put the stigma discussion on the map by observing that 

considerably 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 to 

care were important components to that. We did not have a causal relationship, but 

there 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 than 

soldiers 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 members 

of 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, “What 

is stigma?” What is it that prevents people from coming in to get help when they 

need 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 the 

stigma discussion on 

the map by observing 

that considerably 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. 
20 Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism

health professionals or I don’t think it’s going to work. Or, I think I can handle it 

on 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 a 

dent 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 other 

constructs 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 have 

done 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 the 

active 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 are 

some 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 of 

investigation. 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 who 

seek 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 that 

the perception that I would be seen as weak does not correlate with the perception 

that 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 if 

they 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 have 

not made much progress since 1992, despite a large change in the way in which we 

perceive mental illness?

One of the questions I am grappling with now in my clinical practice is, “Just 

what is mental illness, exactly?” For instance, if you believe Ron Kessler’s data from 

the 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 health 

problem? 

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 

“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.
Stigma and Barriers to Care in Military & Veteran Populations 21

we do not even realize. For instance, consider the soldier in Iraq who experiences 

a 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 choice 

that are approved and certified in our treatment facility. These are prolonged expo-

sure 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 the 

devastating impact the loss and grief has had on him and the awareness of the point-

lessness 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 is 

actually 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 is 

relatively 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 is 

because 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 to 

look 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 to 

promote 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 that 

rule exist? Or you cannot carry a weapon if you are on an SSRI. There is actually no 

rational 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 impact-

ing 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 in 

common use. Last night, while watching Law and Order SVU, I was amazed to hear 
22 Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism

the 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 of 

Marines 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 the 

right uniform is he a Marine? No. It is not until he has gone through boot camp 

and 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 not 

just Marines. It is the same with soldiers, sailors, airmen, Coast Guardsmen, police 

officers, fire fighters and disaster workers. You become that person. You incorporate 

that 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 their 

stigma 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 even 

from moral injury of having to deal with the ambiguous, difficult, and untenable 

situations into which we place our young men and women when we send them to 

war. The treatment of these unseen, invisible wounds is difficult. While it may not 

require great physical pain, numerous surgeries, or refitting prostheses on amputated 

limbs, 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, patients 

and therapists must confront the conflicts, ambiguities, inconsistencies, and difficult 

issues, and tolerate them while going through this process of recovery—to look at 

them openly, honestly, and drop that “image armor” of a warrior long enough to 

address 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 terms 

of infantry tactics and addressing vulnerabilities to the security and protection of 

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 even 

from moral injury 

of having to deal 

with the ambiguous, 

difficult, and untenable 

situations into which 

we place our young 

men and women when 

we send them to war. 

The treatment of 

these unseen, invisible 

wounds is difficult. 
Stigma and Barriers to Care in Military & Veteran Populations 23

the unit. As a warrior you never want to be vulnerable because we have asked our 

people 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 and 

allowing for vulnerability part of what happens within the culture?” My vision is 

that two Marines are walking along on base and one says to the other, “I’m going 

over 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 and 

physical problems. One finding was that people expressed more discomfort disclosing mental problems than physical problems. In this survey sample, some of the 

people were there with their units and others were by themselves. Those that were by 

themselves 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 for 

treatment: 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 from 

anybody 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 actually 

in 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 by 

some of the previous speakers. That is, the individual’s values and priorities stand in 

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

opposition to treatment-seeking. A pride in self reliance exists, and the mental health 

problems are much less important than maintaining a job or a family.

Treatment-discouraging beliefs get into the perception that those who have not 

shared 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 other 

beliefs include, “Treatment doesn’t work,” “I’m relinquishing control,” and “They 

could 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 is 

for 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 for 

the first and only time in history, the different veterans groups have agreed that 

they do not want their mental health treatment outsourced. They do not think that 

a community-based civilian provider could possibly provide the kind of treatment 

that a VA practitioner could provide.

Knowledge barriers also pose a significant problem. Veterans do not understand 

what 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 another 

chance that they may not receive support. Vietnam vets in particular who had a 

very negative homecoming are not going to risk outing themselves and going for 

treatment. This may represent PTSD withdrawal, but it is partly related to suffering 

with 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 questionnaire 

that 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 and 

beliefs 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 and 

Reserves, 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, the 

people with PTSD, in contrast to people with the other mental health problems, were 

much 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% and 

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. 
Stigma and Barriers to Care in Military & Veteran Populations 25

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 were 

more likely to seek counseling. If you thought that therapy did not work, you were 

more likely to go for medication. Again, beliefs are clearly affecting behavior. It is 

also 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 had 

reported greater unit support in theater and good unit cohesion were less likely to 

endorse 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 of 

social 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 come 

in for treatment?” Remember not everyone in this group was treatment-seeking even 

though 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 and 

that 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 you 

very 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 they 

need 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 talk 

more 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, but 

from distorted media reports. This drives people in the wrong direction which is 

a 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 important 

When they did a 

multivariate analysis, 

they found that the 

people who had 

reported greater unit 

support in theater and 

good unit cohesion 

were less likely to 

endorse 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 with 

a 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 based 

on 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 was 

trained 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 from 

the 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 patient 

and for the therapist. If you are going to do it you had better get down in the mud 

with 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 and 

get better at it.

DR. FRIEDMAN: I do not agree with some of the comments that have been 

made. 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 about 

some of that. I also do not agree that we have nothing to offer. If we get people to 

come 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 were 

trained 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 is 

available is better, so I cannot agree with some of these negative characterizations 

of 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, and 

have 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 to 

learn 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 27

tremendously so it is about making sure that when we are working so hard to bring 

them 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 have 

been stood up in DoD and VA in particular, is extraordinary. The reality, though, for 

many individuals who seek treatment within our system is that they have negative 

experiences. There are some fundamental assumptions we make about the nature of 

treatment, 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 need 

in 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 be 

very interesting to see studies of people moving through the treatment process and 

how that affects their views of mental health participation. In fact, what we usually 

find 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 to 

better capture those success experiences, to magnify the perceptions of benefit, and 

change the perceptions of what happens in treatment. We ought to be videotaping 

testimonials about treatment. It is possible that the stigma of treatment inhibits those 

successfully 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 the 

exchange 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 and 

whether 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 what 

clinicians 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 health 

sector. 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 are 

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

They never end up in the hospital because they are psychotic. They end up at the 

hospital 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 that 

stigma 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 system 

that 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 of 

stigma and the fear of the system, we will only bring people in when their pain and 

suffering 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. 

We have a threshold, 

a barrier, stigma, a 

fear of the system that 

has to be overcome by 

tremendously difficult 

and 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 from 

military to disaster with the leading epidemiologists and social scientists in the world 

on 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 is 

stigma 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 for 

mental health problems among disaster victims who have PTSD?” What special 

characteristics of disasters create unique barriers to care that are not present in some 

of these other situations? What do disaster victims tell us about stigma and other 

barriers to care? Why do disaster victims have concerns about getting mental health 

treatment 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 and 

several of them also gathered information about help seeking from mental health 

professionals after disasters. I want to briefly run through some of the disasters and 

present 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 touch 

on 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 health 

problems among 

disaster victims who 

have PTSD?” What 

special characteristics 

of disasters create 

unique barriers to care 

that are not present 

in some of these other 

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

damage. Many people narrowly escaped with their lives and little else. There were 

some people who were killed. We located people who had been affected by the fire 

storm 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 were 

interested 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, the 

effects 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 range 

of 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 to 

spend a little time going over the predicate for this. Before 9/11 there were more 

deaths associated with this act than any terrorist attack in U.S. history. The Office 

for Victims of Crime, which is part of the Justice Department, developed some 

special 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 the 

service 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 plane 

crash. 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 for 

a blameless victim situation, this would probably be it. Nobody is going to blame 

a 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 such 

an 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 Victims 

of 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 most 

important reasons family members do not seek mental health counseling in a case 

like this one?” The leading response was they do not think mental health counseling 

would help. They have negative attitudes about mental health counseling. Secondly, 

they have good support from family, friends, religion, etc. Thirdly, denial, inability to 

admit they need help. Stigma is not far from the top, followed by, “they don’t want 

The leading response 

was they do not 

think mental health 

counseling would 

help. 
Stigma and Barriers to Care in Disaster 31

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 the 

other 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 old 

quote but I suspect that many people would extend that to psychologists and other 

mental 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 some 

misgivings about treatment.

Many of you may have seen a recent Newsweek front cover reporting the 

depressing 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 course 

of 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 of 

disaster 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 that 

people 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 to 

spread 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 get 

treatment? 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 have 

done a great deal of work together and we agreed that I would present some new 

data 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 

In conclusion, 

ways of addressing 

stigma and barriers 

include crafting a 

way to spread the 

word about effective 

treatments in ways 

that people can 

understand them. 
32 Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism

in the past 100 years: the frequency of disasters is increasing. Everybody asks, “Why 

is the frequency of disasters increasing?” Meteorological and hydrological disasters 

are probably linked to changing global and environmental conditions. Another 

reason 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 good 

news is that more people are surviving disasters. One more piece of bad news is that 

many 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 and 

think 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 to 

happen 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 about 

barriers and stigma to mental health care after disaster, three central domains are 

pertinent: predisposing characteristics, enabling factors, and need. I am going to 

focus my comments around the health behavior model. I am going to show you some 

data related to predisposing characteristics, enabling factors, and need as associated 

with 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 essentially 

wiped 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 is 

a 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 the 

consequences. The study is called the Galveston Bay Recovery Study. 

It was a fairly large event with substantial impact. Then it faded from public 

awareness soon afterwards because it occurred just before the national election and 

our 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 found 

people 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 some 

of 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 

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. 
Stigma and Barriers to Care in Disaster 33

more than a third of the people reporting need yet only about a third of those who 

report 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, which 

is unusual in large, population-based samples. In the group seeking services, age and 

social support do not seem to matter much. Different factors are associated with 

reporting need and getting services. One reason people did not obtain services is 

embarrassment or shame and not wanting friends or family to know. Note that this 

is only about 17% of the individuals who did not seek services. Expectations and 

preferences 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 to 

solve 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 seem 

to 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 with 

different 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, are 

evident. 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 to 

report negative expectations about treatment. Age and social support also seem to 

matter. 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 to 

obtain 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 the 

context 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 take 

care 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 talk 

about income and health insurance. I have to discuss health insurance given the 

contentiousness 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 group 

of 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 

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. 
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 than 

those 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 going 

to 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 by 

government and not-for-profits for the people who are most severely exposed.

What emerges from this event is that men, minority groups, and persons with 

low social support are the people who are expressing concerns about stigma overall, 

while minority racial groups report low outcome expectations. Health insurance and 

psychopathology matter in this context, while predicting need is actually not predicting access to services, and this is quite concerning. Across these varied contexts of 

disaster, 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 Mary 

Lee 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 important 

presentations 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 an 

interesting 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 Conservation 

of Resources model and stands for Fitting, Adaptation, Limitations, Leniency, and 

Selection. First is fitting. Resources do not just fit demands. Humans are active and 

our 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 has 

lots 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 of 

unexpected 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, and 

train them.

Second is adaptation. Adaptation is a process of successive approximations, not 
Stigma and Barriers to Care in Disaster 35

an 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 class 

of 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 some 

language difficulties and lack of education feeds her family, that is adaptation. 

Adaptation follows the allocation of resources and can be rapid. If you move 

resources around, rapid adaptation will follow those resources. When adaptation 

is blocked, when people are blocked from services, conflict will arise. There is 

conflict in the military right now, between most senior commanders who are not 

very 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 course 

commanders care about every suicide, but it is not their main care because it is not 

their 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 com-

pared 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, but 

corridors 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 resources 

of 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 not 

been 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 a 

housing association. They vote and you will not get a house on this street.” What 

that means is any dollar I have is not exchangeable. The housing association did not 

say, “It will cost you more for the house.” They said, “You will not be voted to be 

allowed to enter this house.”

Some pathways are blocked or bottlenecked. A great deal of mental health path-

ways 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 are 

rejected 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 kinds 

of 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 lenien-

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

cation to all kinds of resources such as better schools, mental healthcare, medical 

care, 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 to 

whatever 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 the 

poor 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 to 

treatment 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 of 

doctor and patient is relevant here. I actually think what Matt Friedman’s center 

has done is create a full continuum of care including prevention, education, and 

early intervention, and it has gotten away from the role of doctor, expert, and sick 

patient 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) showed 

that 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 we 

look 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 is 

still 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, and 

then going back home to be a spouse and a more effective parent. That will make a 

soldier 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 the 

reenlistment bonus is over $100,000. Those are good things, by the way. You have 

to incentivize, but you will also have to change the barriers, take the data, and place 

them 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 in 

collaborative 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 

I would end with this 

point: The reason the 

military has problems 

is that it is still 

using a mental 

health diagnosis to 

categorize and get 

certain people out. 
Stigma and Barriers to Care in Disaster 37

Study Section. In that capacity, I am often in a room like this reviewing grants with 

folks from multiple disciplines, and we have the potential to get into arguments 

that we are trying to resolve to come to some sort of agreement. I think we need 

to 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 the 

course of the next day-and-a-half.

Sandro, I just came back from nine days in Haiti earlier this month. You have 

talked 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 center 

in 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 issue 

of tailoring that intervention is key. How would you take the goal of wanting to 

have a large population impact and meld it with my desire to tailor and deliver care 

in 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 decade 

and I think we are never going to resolve it. We did a paper together trying to 

resolve it but it seems to somehow not have stopped the argument. There is a 

tension 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 that 

would improve the mental health of everybody, both those who are at the high end 

of 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. This 

is 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 been 

poor 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 can 

tell 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 the 

fly, 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 have 

a “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 
38 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 not 

necessarily clinical utilization. The goal is to abort situations where one exceeds a 

clinical 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 in 

a preventive way, that will reduce stigma issues that we have been talking about in 

a more clinical context.

DR. KILPATRICK: Populations are made up of individual people and some will 

need more help than others. A website may not help those at the top of the pyramid 

of 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 and 

maybe there is some education that can be included about that.

DR. WESSELY: Dean Kilpatrick mentioned Pan Am 103 and Lockerbie and 

the 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 a 

mental 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 them 

came 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 most 

health care systems, primary care will be where the vast majority of mental health 

care 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 health 

treatment 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 ground 

in 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, primary 

care 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 not 

even have the time to handle the issues for which people go to primary care in the 

first place.

DR. URSANO: We have introduced the question of primary care. We have intro-
Stigma and Barriers to Care in Disaster 39

duced the question of access. We have introduced the question of whether primary 

care 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, and 

comments 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 question 

suggesting “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 we 

would 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 predict 

whether 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 good 

reason 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 disaster 

are talking about their mother not loving them 30 years ago. The trauma is an 

occasion 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 is 

pretty unlikely. Twitter studies of close friendships show that people tend to have 

around 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 an 

acute 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 treat-

ment after a disaster because this is the opportunity to reach an enormous number 

of people. They feel it is okay to come in a way they normally do not. They do not 

want to come in for two weeks. They want to come in long term, so we have to figure 

out 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 couple 

of natural disasters recently, the American Psychiatric Association and the American 

Psychological Association had people who were volunteering to see two patients 

a week for free forever on the telephone. The problem was that if the patient was in 
40 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 not 

cover 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. There 

is 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 of 

treating these people. That means innovative approaches with group treatment or 

community 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 symp-

toms. Questionnaires often do not include the disability impairment component, just 

a 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 useful 

or 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 that 

should 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 particu-

lar disease that was largely driven by a particular kind of person. One option was to 

intervene with those people, meaning to figure out the threshold and to try to make 

the disease go away by focusing on them. The option that was instead taken was to 

change the context for everybody and, in fact, levels of the disease dropped dramati-

cally. What I am talking about, of course, is motor vehicle accidents. The decrease 

in 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 identi-

fying people who we want to treat. Issue B is, how do you change population level 

factors 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, the 

current model for disasters certainly is an individual-based parachuting in interven-

tion. 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 mix 

of clinicians and population health scholars, we need to push on both approaches.
Stigma and Barriers to Care in Terrorism & Public Health Emergencies 41

5

Stigma and Barriers to Care 

in 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 and 

vice 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 a 

member of our Center, and has probably spent more time on disasters from the public 

health side than anybody else I know. Dori Reissman is from CDC and NIOSH, and 

is 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, was 

very interested in this incident for obvious reasons. They wondered if this was a good 

model 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 the 

people 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 time 

of 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 general 

observation 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 a 

sense of panic. Russian television viewers, who are not disinterested observers in this 
42 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 found 

that 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 that 

the actual medical risks of polonium are completely independent of the motivation 

of 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 the 

whole 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 the 

people 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 were 

involved in the incident. This was a random sample of people in the city. We used the 

same 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 psychiatric 

disorder. 

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 the 

bombs, 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 to 

reduce 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 effect 

persisted 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 not 

talking 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 a 

time of great uncertainty, with concern and anxiety on the streets of London. The vast 
Stigma and Barriers to Care in Terrorism & Public Health Emergencies 43

majority dealt with the event within their own social networks. Only 1% had actually 

gone 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 the 

bottom 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 the 

various 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 one 

that 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 we 

should 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 are 

going 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 is 

what 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 were 

actually there, many of them injured. Dr. Brewin and colleagues set up a program and 

waited 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 meant 

that immediately one quarter of those who had been affected could not benefit from the 

research because the hospital erroneously felt patient confidentiality meant that they 

could not tell Ehlers and Brewin who they had treated for physical injuries. Later the 

decision 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, we 

have 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 of 

them. We also conducted follow-up interviews by phone, adding information about 

changes over time that is not typically available. For these interviews, we over-sampled 

those whom we knew from the study had mental health problems. We managed to 
44 Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism

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 abso-

lutely 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 them 

actually come to see us. Only one-third of them get any care at all. For those who see 

a 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 profes-

sionals 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 that 

is 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 that 

particular 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. Com-

paring veterans and non-veterans, we confidently predicted that veterans would have 

worse 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 the 

rest of the population, there were no differences in their treatment seeking, except for 

alcohol problems. They did not have more mental health problems compared to 

the 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 who 

come 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 come 

to 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 health 

issues. The organizational home for most of my career was the U.S. Public Health 

Service. 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 the 

disorder or the context, such as whether the disorder derives from a war experience or 

a 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 45

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. Those 

of 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 as 

a subset of our field, particularly about how it interacts and intersects with health 

and 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 to 

consider stigma and barrier issues with primary victims and survivors and also with 

workers 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 mar-

ginalization, 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 health 

disaster, 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 move 

away from the core. In a public health emergency, emergency management may not be 

at 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 manage-

ment 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 of 

borders 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 who 

choose to be in this field, if we are going to escape with our egos intact we need to 

share 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 get 

out in the field in disasters.

The other delusion is that I am always a full-blown part of the team. Many 

times when I have been out working on disasters, I felt like a lonely cat in the presence 

of 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 an 

event 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 in 

your 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 understand 

and empathize with your concerns about mental health and public health emergencies. 
46 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 rise 

to 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 kinds 

of 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 can 

be 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 in 

what chair at what time and who is sitting in the chair across from him or her at that 

same 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 a 

long 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 and 

leadership training. One of the areas that I have been involved with more intensely in 

the last couple of years is trying to integrate behavioral health principles with messag-

ing and communication. I think that is where there is a whole lot of bang for the buck 

and 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 the 

evidence basis comes from and how it has advanced, probably 90% of it comes from 

the people in this room; we need to keep doing that. The more our consultation 

and 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 a 

presence 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 of 

yourself, 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 for 

many 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 humanitarian 

concern. 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 stress 

based administrative problem for them and it was the birth of something that has gone 

on for many decades.

There are many fantasies about what we do, including a belief that our job is going 

to 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 47

health consequences get their due in terms of money, respect, recognition, and inclusion 

in 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 be 

aware 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 some 

of the earliest work on this, stigma is “an attribute that is deeply discrediting,” and 

the 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 that 

everything answers to culture and power. Power of labeling others and making them 

feel bad about their labeling. People’s beliefs may be within culture but also may be 

based on life experience as separate from culture.

Social conditions are often captured in our epidemiology studies by using socio-

economic status as a proxy. You are potentially more exposed in lower SES environ-

ments 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 ill-

ness, 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 and 

another condition might discriminate them further.

This brings up an issue of terminology. Stigma makes you think about the indi-

vidual 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 the 

cultural 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 a 

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

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 to 

try 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 with 

mental illness are viewed.

Since this is also about terrorism it would not be fair to ignore it since it was the 

source 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 of 

which 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, showed 

that 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 were 

part 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 part 

of 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 out 

of 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 focused 

on 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 application 

of 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 the 

stigma 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 is 

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. 
Stigma and Barriers to Care in Terrorism & Public Health Emergencies 49

different than the civilian system, and both are very complex. The overall assumption 

that you can equate the overall reduction of burden of disability in a society with a 

reduction in caseness is based on two ideas being confused. You can prevent caseness 

and 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 the 

way 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 and 

barriers to care of getting treatment following disasters versus military combat duty in 

terms 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 of 

such 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, not 

just 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 this 

conference 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 care 

because the questions of dealing with distressed populations involve issues such as 

increased 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 health 

and 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 for 

care. We need a public health model and a treatment model to address the questions 

of stigma and barriers to care across the whole population.

We have now begun to reveal the complexity of this problem. We want to inform 

and keep track of this complexity. If you are still in your bucket of being a disaster 

person 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.

As many others have 

pointed out, we are 

attending to the public 

health model, not just 

the treatment model. 
50 Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism
Conceptualizing Stigma and Barriers to Care 51

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 a 

definition that I developed with my wife, Jo Phelan. The dictionary defines it as a 

mark of disgrace or infamy. You have already heard Goffman’s definitions. Jones 

and his colleagues defined stigma as a mark that sets a person apart and links the 

marked person to undesirable characteristics. There are two criticisms leveled at 

those particular definitions. The first is that the attribute or the mark is something 

that the stigmatized person has; it is their stigma. It emanates from them rather than 

being 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 from 

consumer groups in mental health. I wanted to see if we could use those to leverage 

a 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 the 

relationship between a mark and a stereotype. Stigma exists when interrelated con-
52 Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism

cepts converge. First, people distinguish and label human differences. Second, labeled 

persons are linked to undesirable characteristics, creating unwanted negative stereo-

types. For example, the stereotype of someone who has been in a mental hospital 

is 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, such 

as 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 and 

discrimination. 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 discrimination 

that follows from their beliefs about a stigmatized person.

Now I want to talk about the kinds of discrimination that can follow in this par-

adigm 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 and 

effective 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 by 

getting 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 to 

develop 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 think 

that people would look down on someone with mental illness, might not want 

to date them, marry them, or hire them, but it does not matter to him personally 

because 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 can 

affect 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 of 

friends 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 shown 

that 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 most 

people 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 Care 53

answer 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, to 

withdraw 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 the 

stronger the belief that others would look down or discriminate on someone with 

mental 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 not 

in 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 do 

that, 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 to 

that 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 them 

back 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 of 

To summarize, stigma 

is a multi‐faceted 

concept. Many 

concepts have to 

be integrated to 

understand all the 

ways in which stigma 

expresses itself. 
54 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 and 

the 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, and 

had 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 get 

people 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 of 

care. That points to a large cultural difference. 

I looked at the literature on what people think, believe, and feel about the use 

of 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 the 

overseers’ board of the General Social Survey, which has existed since 1972 and 

is the longest running monitor of American public opinion, beliefs, attitudes, and 

behaviors. 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 University 

of Michigan in 1956, 1957 and 1976. We drove up to Michigan and found all of the 

original 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 inter-

ested 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 that 

line 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 just 

centered solely on treatment. It is about acceptance in the family sphere and in the 

work 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 are 

talking about careers in the workplace, in the military, or in domestic life, we get a 

real 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 experi-

ence the onset of mental health problems, in which others respond to them, and in 

which they either go on to live a full life, what we now call recovery, or they live a 

life that is damaged by others’ responses to that illness. A second type of stigma, self 
Conceptualizing Stigma and Barriers to Care 55

stigma, 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 and 

acute psychiatric hospitals and find dramatically different attitudes toward people 

with mental illness in those two sectors of the mental health system. Finally, there is 

provider-based stigma. Here we are talking about whether or not people who come 

in 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 over 

time. 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 health 

problems than they could in 1950. The second finding is that there have been 

changes in formal and informal treatment responses to the onset of mental health 

problems. 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 talk 

about mental health problems with their informal supports. 

Psychiatrists do not use the term nervous breakdown, but the question was 

whether or not the American public did. We set up a two-stage question. To have 

comparability with the earlier studies, the first part asked about the term ‘nervous 

breakdown.’ The second part asked about mental health problems, and we found 

that 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 health 

problems. 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 generation 

question, “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 and 

Statistical Manual of Mental Disorders) criteria for mental health? That turned out 

to be very important in understanding whether or not people want to respond to 

mental 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, and 

this turns out to be a particularly American phenomenon, the highest levels are in 

work 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. This 

debate went on for a number of years, and what we find in our studies is that both 

The first important 

finding is that the 

public has become 

more sophisticated 

over time. 
56 Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism

matter. People respond differently to the behaviors, but those people who went on to 

label 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 violence 

and dangerousness in response to the question, “What is a mental illness?” This is 

a direction that we had neither hoped for nor expected. The second finding comes 

from 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 all 

articles on mental illness in one year in those countries. She found that the dominant 

themes 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 dominant 

theme of fear and danger. That was not the case in Iceland where the dominant 

themes were inclusion and integration. In Germany the major theme centered on 

fear 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 the 

World Health Organization (WHO) international study of schizophrenia, these findings do not have to do with societies that are more simple and open. There had been 

a 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 the 

potential 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 than 

make 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, 

The fourth finding 

from the national 

stigma studies shows 

that in some ways 

stigma has increased, 

and this is a uniquely 

American message.
Conceptualizing Stigma and Barriers to Care 57

knocks, 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 with 

on 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 a 

person with mental health problems?” The third PSA involves two guys on a couch 

playing video games. One discloses to the other that they have a mental illness, and 

the question is, “Are you going to be the one who stays, or are you going to be the 

one 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 been 

modest changes over the last decade with regard to the adoption of neuroscientific 

beliefs underlying mental illness. We found that significantly more Americans attri-

bute 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 base 

is 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 other 

groups have taken the disease model to try to reduce stigma. I do not know if that 

model 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 suggests 

that 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 their 

effectiveness, the traditional logistics with regard to younger age cohorts and the 

development of new media suggest that this may not be the way to go in terms of 

stigma 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 more 

strongly about institutional regulations that prohibit people from acting upon 

whatever prejudicial beliefs and attitudes they might have. We have conducted an 

analysis of 1,640 hours of television showing that at least one time during each unit 
58 Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism

of 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 in 

order 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 and 

knowledge are important. I think education is important, but it is not going to have 

a 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 with 

bipolar disorder. There are two potential explanations for this. First, it could be that 

mental 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 particular 

drug company that did this advertisement does not have a drug for mental health 

problems 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 have 

changed 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 regardless 

of 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 we 

found 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 was 

no service delivery constraint. It was almost the ideal setting to observe individual 

attitudes towards treatment because it reflected their own treatment decisions, not 

some 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 Care 59

tonin 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 within 

nine days of trauma, seven months later, and 14 months later. There was a layer of 

clinical 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-face 

interview, 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 here 

is 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 and 

a 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 early 

stages 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 less 

distressed are pickier about what treatment to accept. In terms of treatment adherence, prolonged exposure had a lower rate than all the others. The results indicate 

that 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 into 

measuring what happens with those who decline care. At the end of seven months the 

decline in symptoms in those who accepted treatment was significantly higher than 

in those who declined treatment or declined clinical interview. Declining a clinical 

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

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 the 

threshold. Now I will discuss the burden of services. We all think that we will have 

the resources to accomplish our dream. We had 7.4 new treatment episodes each 

month 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 telephone 

interviews and five hours of clinical interviews to bring just one patient to treatment. The cost of screening and evaluation is enormous. There is almost more 

time 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 source 

of 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 telephone 

interview, 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 eventually 

find 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 that 

cost is the unavoidable inclusion of a survivor who subsequently recovered on their 

own. 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 mentioned 

that 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 reaching 

out to more people.

DR. SHALEV: In terms of treatment, we recently started a telephone-based CBT 

study on the assumption that people more readily accept telephone contact than 

clinical 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 Care 61

skills club during plant closings in the Detroit area. The program was for people at 

risk of family violence, alcohol abuse, and depression after losing their job. Price 

evaluated 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 five 

inch 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 to 

unemployment lines and twisted arms to get people to attend the program. Price 

conducted 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 deploy-

ment 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 have 

been a small decline in terms of Americans’ willingness to support coerced medica-

tion, but not other forms of coerced treatment. Even in 1996 when we asked about 

four 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 Treat-

ment 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 or 

treatment 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 the 

increase 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 the 

American 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 Dah-

mer 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 and 

sick but your sickness does not mitigate your badness the way it did under guilty 

but mentally ill.
62 Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism

DR. PESCOSOLIDO: I do not think Americans have moved along with that 

legislation. 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 the 

true 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 ways 

of trying to de-stigmatize mental illness by saying, “it is a brain disease just like any 

other 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 in 

genes.

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 can 

recover? 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 have 

salience 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 are 

described 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 other 

stigmas 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 the 

race 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 Theory 

of media effects, or something to that effect. They argue that people filter through 

their 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 Care 63

they 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 can 

do 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 that 

television 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 and 

asked 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 from 

that 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 and 

we 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 their 

own 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.
64 Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism
Mitigating Stigma and Barriers to Care 65

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 a 

retired 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 of 

Pennsylvania, Rutgers, and the Illinois Institute of Technology. 

There are three goals I want to discuss. First is getting a sense of what it means to 

change stigma and what stigma is, because defining the phenomena has a big influence 

on the way we decide to change it. Second is understanding stigma change. Third is 

discussing 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 in 

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

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 dis-

cussed 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 a 

group 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 seem 

to fit under any other type. 

Label avoidance does not necessarily involve a person with mental illness. It is 

also 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 that 

you 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 adherence 

in 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 are 

looking 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 stigma 

change, what an individual might do to change mental illness and the vehicles they 

might employ to do so. There are three different processes for stigma change. Education 

is 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, “Shame 

on 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 that 

is contact. I agree with what was said earlier—if you had to throw all your money at 

something, contact is the thing to look at. 

Education tends to be a comparison between the myths of mental illness and the 

facts. For example, one of the myths of mental illness is that serious mental illness is 

rare. 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, depending 

on 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 realize 

that Chicago has about 64,000 people with schizophrenia. That is the same number 

of 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 67

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 “Get 

the violent crazies off our streets.” The problem with protest is that it tends to lead to 

a 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 them 

out of your head.” Like most people in the audience you probably have the Klond-

ike bear bouncing around in your head right now. The problem with trying not to 

think about something is that it actually raises its prominence in a group. There is an 

interesting study in which people were divided into two groups. One group looked at 

skin-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 dis-

order, 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 have 

a 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 in 

groups 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 did 

a randomized control trial with a sample of 152 people. The participants took a 

pretest 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 to 

treatment. Social psychiatrists call this stability, the idea that you are not stuck in 

your mental illness but you can get out of it. The control condition produced an 

interesting finding pertaining to social desirability. If I come around and ask you 

what 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 are 

thinking, “Well, he’s trying to show if I am a bigot.” 

Another study we did involved randomizing people into four groups; two were 

education groups and two were contact groups, each containing a responsibility 

group and a dangerousness group. The results are clear: contact has a huge effect 

over 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 to 

hit huge numbers. In vivo is a face-to-face approach and, therefore, localized to 

individual groups. 
68 Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism

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, Jes-

sie, 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 around 

with 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 of 

their national mandate. But when they do this, the PSAs are frequently relegated to 

timeslots 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 so 

these 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 in 

terms 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 have 

in common? They are all mentally ill. This is important because it challenges the 

underlying 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 the 

market and about three months later, they found a pretty significant increase of hits 

on 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 first 

question is whether that is a cost-effective way to continue to use that PSA. What is 

even 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 these 

websites are actually using them.

One of the things discussed today was direct-to-consumer advertising, and 

people opined that perhaps it has improved attitudes about people with serious 

mental illness. We did a study about three years ago randomizing people into two 

groups. One group was a direct-to-consumer advertising for Cymbalta and the other 

group was a direct-to-consumer advertising for a heart ailment. In both cases, the 

PSAs were embedded in the clutter of four other commercials. The only thing that 

differed 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 Care 69

self-help is a great way to go in terms of trying to decrease stigma. I mostly agree 

with that but I am struck by some perplexing data we found. We were part of an 

eight state multisite study that SAMHSA-CMHS just put out on consumer oper-

ated 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 is 

targeted locally. PSAs tend to target the overall population. What I think we need 

to 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 distressed 

people: the depressed employee, the suicidal adolescent, the panicked drug user, and 

the 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 in 

terms of analyzing stigma change. I hope today and tomorrow we have an oppor-

tunity 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 talk 

about 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 the 

things 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 with 

serious mental illness. We thought that when they started receiving disability pay-

ments 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 and 

civil rights, the “We’re just like everybody else” education that Pat Corrigan just 

discussed, 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 your 

inability to see my ability is your disability. We also need to challenge what is already 

established. 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, empower-

ment, recognition, self advocacy, and chemical imbalance, which I am delighted to 

see has a growing consensus that it was a failed strategy. One of the anthems is that 

stigma is the real disease, not schizophrenia or any other disorder. “I don’t want pity, 

I want rights.” This is politicizing rather than pathologizing.
70 Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism

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 a 

drawing from a Charlotte, NC newspaper displaying a man whose head is a bomb 

with ‘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 is 

interesting 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 two 

things, 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 that 

you get lost in it, that it is some kind of a maze. Part of the reason I want to raise this 

notion is that we have to recognize that even though there is a maze, people have 

some 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 and 

I know enough of my clinical colleagues who have serious reservations about the 

position 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 outpatient 

therapy at a public mental health clinic, and we asked them to tell us what the 

barriers to engagement were. I think you will see they look pretty familiar: “I’m 

going 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 is 

really important. Ron Kessler brought up the idea earlier that maybe after a disaster 

you 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 in 

which 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 are 

three 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 have 

a 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 this 

sense of selflessness, of putting others first, something we do not learn about very 

much 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 and 

privacy 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 when 

possible. 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 get 

caught 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 is 

a bill of rights for behavioral health care in the military. It outlines such items as 
Mitigating Stigma and Barriers to Care 71

“individuals should seek and receive behavioral health support to maintain fitness for 

duty without fear of stigma and discrimination, be taken seriously to receive dignity 

and respect from leaders, and receive screening and treatment without automatically 

affecting 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 five 

suicides 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 given 

that 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 reasons 

people 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 those 

people’s shoes.

In an attempt to wrap up, I want to point out that we need to stop this process 

of 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 attachment 

that we have seen recently with people who have Asperger’s saying, “Don’t take it 

away. 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 the 

wrong 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 to 

warriors 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 to 

have exposure to people who they honor and see as courageous. Can some of that 

generalize 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, and 

others on some anti-stigma work through our venue at the Carter Center. We have 

been looking at effectiveness of anti-stigma campaigns and the things that work 

and 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, 

In the end I have 

two questions for 

people to consider. 

Maybe we are asking 

the wrong question. 

Not “Why don’t you 

get treatment?” but 

“Why would you?”
72 Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism

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 of 

training 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 that 

is 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 which 

were 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 people 

of other cultures have. Culture was mentioned earlier. I think Paul Hammer was the 

first 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 member 

of the military, not only do you have thoughts and ideas from the greater culture 

that 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 that 

work. 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 not 

have 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 that 

are 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 to 

look 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 the 

importance of things like community, tribe, and family. Family was vital. When I was 

trained, 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 more 

individually focused than most people in the world. America is the outlier in many 

of the ways we conceptualize care, and the way in which we provide, organize, and 
Mitigating Stigma and Barriers to Care 73

deliver 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 reli-

gion 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 are 

some 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 compas-

sion and the manner in which these families worked things out in such a natural 

way. 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 a 

mental 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 end 

of the Vietnam War when we were receiving veterans home can tell you it is vastly 

different now than it was then, and in a good way. We did not do a good job of 

receiving those people home and we are still experiencing some of the effects of 

that. 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 these 

issues out into the sunlight so that we can understand them better and serve these 

people better on their arrival home. 

People are empowered as a group, not just as individuals, in the military environ-

ment, which once again speaks to culture. One of the overarching themes in any form 

of real, legitimate social change is the vital role of leadership. We have learned some 

other things in terms of mitigating stigma in the military. Soldiers who rate their 

leaders 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 not 

sure 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 rid 

of 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 and 

people 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 and 

first 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 the 

most 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 the 

information 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 time 

reconciling the fact that he also had PTSD. That raises a very troubling question. We 
74 Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism

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 other 

than 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 in 

a 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 the 

entire 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 such 

things as integrating mental health providers in primary care settings, embedding 

psychological health workers throughout the outfits and units, including deployed 

units. This is a great idea and I think it is already happening. 

The task force recommends developing DoD-wide curricula for psychological 

health as an integral part of all levels of leadership training for family members and 

all 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 over 

which they had absolutely no control. There is in fact, the illusion of choice projected 

backwards in time. Our brilliant cortex has the capacity to project back in time to 

see 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 blame 

and find fault with individuals. I am not talking from a legal perspective but from 

a societal perspective. “It is your fault” implies that there is something personally 

wrong 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 is 

something 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 and 

blame, 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 the 

concepts 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 

I also like the notion 

that mental illness 

is something that 

has happened to me 

versus who I am.
Mitigating Stigma and Barriers to Care 75

versus 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 impressed 

with the American public’s intelligence. I am not one of those people. 

DR. PESCOSOLIDO: No, I think that sometimes researchers go into research 

thinking, “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 think 

that they are unable to answer the questions that we ask or the things we want to 

know about.

DR. HOBFOLL: I have several thoughts. One, it has been discussed a number 

of times that, if you had the data, you would do it differently. I think that is in part 

true. For example, our surgeons ignore psychological stuff entirely except for the 

transplant 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 College 

of 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 is 

available 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 is 

something about the resistance to facts that is underlying much of this.

DR. HAMMER: I wanted to comment on Dr. Corrigan’s point regarding the 

effectiveness of contact. There is a program in San Diego called Kids Included 

Together, which encourages kids with disabilities to be included in after school and 

summer recreation programs. They implemented this in order to help benefit the 

kids that have the disabilities, but what they found was a concurrent benefit with 

the kids without disabilities who became much more tolerant, more effective, and 

more engaged with the kids with disabilities. The benefit was on both sides.

Kids Included Together counselors come to the YMCA and summer camp pro-

grams, 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 an 

interesting 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 Depart-

ment of Defense have been spearheading over the past couple of years. Chuck Engel 

piloted it, but now we have a large contract across the DoD. In Theater of War we 

are 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 a 

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

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 of 

the 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 are 

usually service members, family members, sometimes doctors, chaplains, and other 

professionals, can share how this relates to their experience. It is an innovative and 

powerful 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 important 

is that, although there is a large proportion of people in the military who are not 

seeking 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 or 

talking to a stranger about intimate things. That does not appeal to a large portion 

of 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 around 

the 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 the 

ones most affected by this. It is the ones who have a loved one at home or in their 

neighborhood who they know needs some assistance. They are able to learn ways 

that 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 have 

to expand our notion of what is therapeutic.

DR. HOLLOWAY: Charles Hoge commented on the blame culture. I want to 

raise the issue that such cognitive activity, along with its overall accompanying 

emotional consequences, is frequently supported by society as a delusion that we 

really 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 other 

in 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 the 

blame and guilt in the psychotherapeutic range. My point is that social structure and 

cultural 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 Bernice 

Pescosolido 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 77

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, the 

University of Rochester, and Doug Zatzick, University of Washington.

DR. BROWN: I really appreciate being invited to join this group. I am going to 

talk about some of the work that I am doing with my colleague Peter Wyman and 

other 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 integration 

of scientific work around prevention science and the methodology that goes with 

that. 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 that 

is what I would like to share with you.

The first thing I would like to do is ask two questions and have you raise your 

hand 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 have 

heard 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—that 

of 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 field 

has 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 of 

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

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 suggestion 

is that we should pause to consider using some of the traditional experimental and 

non-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 same 

kind of theme. Unfortunately, these disasters are going to be continuing and we need 

generalizable knowledge about what works and under what conditions. Particularly 

in the field of suicide prevention, we are facing very important struggles. I think that 

a number of the programs have at least the potential for doing harm. It is important 

to 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 do 

you do? When is any formal care virtually unavailable? I will describe the Sources of 

Strength 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 in 

the west. These are frontier areas, and if you actually go out west, you will see that 

the environments there are dramatically different from many of the other environ-

ments 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 gets 

a 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’s 

cell 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 virtually 

unavailable. 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 Care 79

risk factors for suicide. One name used is developmental epidemiology. Another, used 

in 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 of 

randomized trials. It really has a comprehensive resilience model. Access to mental 

health and medical systems is one of several components. It also includes spiritual-

ity, generosity, etc.—the things that appeal to the broadest number of kids. We have 

a model and 20 years of research looking at preventive interventions that target 

issues for kids: depression, drug abuse, family conflict, child abuse, and conduct 

disorder. 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 affect 

the 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 the 

standard setting were over 20%; in the Good Behavior Game, it was down to less 

than 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 with 

appropriate 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 a 

very high fidelity of that training. Another asset is that it has many nice statistical 

properties, including an improved statistical power over traditional wait list designs. 

The Dynamic Wait-Listed Design also improves the modeling and models for causal-

ity as well. We have been promoting this as a design strategy that might fit in some 

kinds 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 for 

treatment. The trial took place in a county that had an active mental health coali-

tion 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 is 

probably the single leading model for youth suicide prevention, as well as the most 

common one. The target is the intervention. Training is only at the level of the adult 

gatekeepers.

I will emphasize three things here. One is suicidal youth. We know from other 

data that almost all suicidal youth tell somebody in their networks that they are 

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

ing signs more effectively. It also trains them to directly ask kids whether they are 

suicidal, 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? This 

is 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 an 

idea that we have been calling a “surveillance model” and it does have the potential 

of 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 to 

improve 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 a 

large 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 stepped 

in with the support of NIMH and then later with SAMSHA funding to do this 

randomized 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 the 

school felt that something needed to be done. If there was a suicide that actually 

occurred 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 design 

offered, 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 we 

really need to do from a logistics point of view is to focus on smaller numbers of 

groups 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 set 

of 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. Logisti-

cally, the design actually increased the proportion trained in schools. It took much 

less 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 willing 

to 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 already 

engaged with students. Wendi Cross has done a great deal of work on identifying 
Optimizing Access to Care 81

those characteristics of who might benefit and who might not benefit from an 

intervention like this.

Another thing we did was ask the students, “Did you have a suicide attempt this 

past year?” and inquired what their likelihood was that if they were overwhelmed 

by 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 unwork-

able 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 for 

suicide 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 process 

of doing this with 18 schools. There is a focus now on giving the peer leaders in 

schools a major role in shifting the norms about suicide and getting kids connected 

with trusted adults. We also note that the mental health services themselves are not 

always 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 are 

connected to highly connected youth—the peer leaders. The peer leaders are con-

nected 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 give 

messages of hope and support to those kids who are suicidal. The key pieces are 

to 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 are 

also out there.

I will go back to the Sources of Strength. Mark LoMurray, who developed this 

intervention, has a message that he gives to both the adults and kids. He asks, “Sup-

posing 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 impor-

tant, 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 health 

systems available.

Our focus is looking at creating youth/adult partnerships to break down the 

code of silence. These things are measurable. This is looking at the complements 

that could happen within this social network. Both in Sources of Strength and 

gatekeeper 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 the 

same way for all the different schools. Some schools were randomly selected after 

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

It is important to start obtaining generalized knowledge during these unusual 

experiences 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 disaster 

settings. 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 is 

that 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 the 

transfer 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 up 

earlier today. The issue of stigma and disparities in care is a workforce education 

and 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 our 

own 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 and 

proven to be effective in that setting. Then, when we take them to communities we 

find 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 person 

delivering 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. This 

is the level that I am most interested in talking about today. It is as if there is a black 

box. 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 that 

satisfaction is not related to learning outcomes. Satisfaction is the one variable that 

everybody 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 the 

black box previously mentioned. One way to think about the model is in terms of 

phases starting with pre-training characteristics or variables, the training event itself 
Optimizing Access to Care 83

with 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 is 

a 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 in 

studies of training? Other pre-training variables are the trainer and trainee characteristics. Hendricks Brown mentioned something about this. There are studies that 

have looked at individual training characteristics, and we have examined some of 

these 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 the 

training. 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 primarily 

a “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 are 

conducting 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 or 

self-efficacy as a measure of attitudes. In terms of popularity, after satisfaction, the 

most frequently measured learning outcome is pre-post knowledge change. Change 

in knowledge is considered to be necessary for change in behavior, but the literature 

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

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 of 

knowledge 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 their 

enhanced 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 for 

brief behavioral rehearsal to compare to the training as usual. We found that this 

small group practice resulted in better gatekeeper skills demonstrated during an 

interaction 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 the 

ready?” We think that using technology may a good way to maintain established 

skills 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 in 

this 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 and 

skill development, you likely need to monitor and give feedback for maintenance. 

Sometimes people think that our providers, or parents, first line workers or outreach 

people are not going to want feedback. Yet it turned out in our study, with teachers 

and 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 in 

terms 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 actually 

what 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 and 

validity from our perspective. There have been some observational rating scales that 

have been developed for the treatment literature and we have developed measures 

for 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 their 

program delivery with the kids. Then, we objectively scored their behavior with the 

children in two ways. First, we coded adherence: Did they deliver the content they 
Optimizing Access to Care 85

were 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 to 

the 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 of 

objectively measured competencies such as empathy, pacing, and actively engaging 

children in learning. We think this discrepancy — between adherence and compe-

tence — 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, did 

these newly trained instructors go out and conduct trainings for others as expected 

by 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 this 

cost-effective? Perhaps. But, let us assume that we could get 100% of the people to 

carry out the training with others. Wouldn’t we want to know about the quality of 

the 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 trained 

in 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 are 

also 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 team 

is 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 a 

program’s effectiveness in communities. One is the population. If a program was 

developed with middle class, white children in a certain community, the evidence 

base that is cited for that program is based on this population. When you take the 

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

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 that 

exists 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 for 

complex 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 dissemi-

nation 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 that 

surrounded 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 was 

a 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 expo-

sures 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 a 

couple 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 care 

managers in the clinic, who did a fantastic job of engaging him around his primary 

concern. As the weeks went on it turned out that not only could he not sleep, but 

during the day he was consumed by memories. He was having nightmares and was 

ashamed 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 these 

interventions in non-specialty settings. Schools, primary care, forward field stations, 

disaster mental health tents. That is often where these early post-trauma interven-

tions occur. This is about access and being in the field. The first issue that comes 

up then as we move out of the mental health specialty sector is the development of 

evidence-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 care 

setting or post-disaster field setting?

The modification, the initial kind of issue we have around the table, is that we 

have services researchers in these funky settings and we have interventions that were 
Optimizing Access to Care 87

developed in specialty mental health. We need to know how that is going to come 

together because we want to hold on to our evidence base. We do not want to throw 

out 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 meet-

ing 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 and 

concerns of the population.

I will not get too much into Haiti, but I ended up in this mode with a population 

that 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 not 

know 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 the 

actual 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 inter-

vention, 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 much 

less 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 the 

stigma of having nightmares, memories, and wanting to be seen in a primary care 

clinic 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 can 

take 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 phenomeno-

logical 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 to 

think about theory. I agree with Sue Estroff, who said that theory is really important 
88 Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism

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 these 

incredibly 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 have 

a level head. I know also that there will be these intense moral conflicts raised by 

what 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 that 

you 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 no 

one. We threw the training out after two hours because everybody had lost a close 

friend 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 in 

this context is because you are looking for the 5 to 10% of the population that is 

going to be able to be resilient and carry the organization and the society through 

really 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 the 

training and then work within the healthcare organization long-term. That is what 

we are screening for.
Day 1 Discussion 89

9

Day 1 Discussion

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 and 

psychosocial, 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 in 

academia when we have to reference someone else’s theory. There is a great saying 

that 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 other 

good 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 is 

still a question to me. Each of these theories has the exposure, and then there are 

trajectories of resilience or resistance. It seemed like, and George Bonanno even 

admitted 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 have 

not 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 events 

are 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 to 

intervene.

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 not 

wander 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 these 

meetings to learn and to be challenged. We get into these battles which do us no 

good because it does not get us to the gestalt of trying to deal with the stigma and 

barriers that interfere with whatever theories we have, whatever practice we have.
90 Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism

DR. URSANO: You will now have about 30 seconds to think about this. We are 

going 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 to 

remember 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 the 

presenters today. What I would encourage the group to do is think about continuity 

of 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 back 

into 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 and 

not losing contact with the family’s needs. 

DR. THOMPSON: I will say these bullets: recovery, social inclusion, and the 

health opportunity ladder.

DR. SANTIAGO: I am a Navy psychiatrist in the Department of Psychiatry 

at 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 about 

changing 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 Pes-

cosolido’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 of 

clinical 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 your 

reputation. 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 much 

as 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, and 

I 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 91

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 for 

meaningful 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 later 

in their development?

DR. HOWE: I teach ethics at USUHS. I was struck by the many comments of 

what 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 like 

to pursue. The first one is structural. There were two speakers, one who spoke of 

the 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 com-

ments 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 health 

problems 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 it 

means 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 an 

area here that has yet to be explored in terms of health protection strategies. In our 

current 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 conversa-

tions. We fluctuate back and forth, and they are overlapping. One is at the clinical 

level where we talk about access to treatment. Then there is the public health discus-

sion, 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 science 

of 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 many 

of the rest of us have been doing that. It seems like the things that really need to be 

enhanced are social support, whether it is at the unit cohesion level or at the more 

general public level, and education. So many of the barriers involve lack of knowl-
92 Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism

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 you 

in 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 understand-

ing 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 stigmatiz-

ing, but now you cannot watch TV without having people telling you that they have 

it 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 are 

in 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 are 

huge training needs, and that training is labor intensive. Quite apart from time con-

straints, there are training and competency factors that are important. The answer to 

that may be something that Matt Friedman raised, which is technology. I think that 

web programs and soon to be iPhone apps—those kinds of things—can be put in the 

hands 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 the 

most impressive things that I saw recently was a one- or two-star general who came 

to 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 com-

ing 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 to 

change that overnight. Unless it comes from the top down, we are not going to see 

that kind of change.

DR. CREEL: I am in the Department of Preventive Medicine at USUHS. I want 

to think tomorrow about identity and social roles and how those play a role, and 

how 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 how 

that 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 address 

education and training and competencies in disaster medicine and public health at 

the 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 93

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 who 

live in other countries or are sitting amongst us definitely know that. I see that as a 

huge national security threat.

Let me take it on a different level. How do you de-medicalize stigma? My expe-

rience 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 hap-

pen, 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 not 

changed 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 short 

of implementation and change on these things?

DR. LINK: I come here with this interest in stigma and I get to look at it through 

different lenses and from different angles. One way is thinking about the military 

culture and also about what is done after disasters or terrorist attacks. One of the 

things I like about studying this area is that every time you take a different lens, you 

learn 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 be 

strongest higher up.

DR. ENGEL: Plus we have more money to go out and buy it ourselves some-

where else.

DR. WESSELY: I am the Brit. If I had my time again I would be a historian 

because 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 to 

recognize that at the moment either our products, or perhaps ourselves, still are not 

that 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 is 

what 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, col-

lateral repair or damage the entry and openness about stigmatized conditions in 
94 Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism

America’s heroes will have across the board or not—which way it is going to flow 

in 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 around 

collectivism, 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, the 

idea that stigma reinforces norms, that stigma extrudes, if you will, disease. There 

are potential ramifications of the idea that we could completely de-stigmatize some 

of 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 be 

awfully tough to completely take that out of the mix. If we do, we may find ourselves 

in 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 have 

to 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 is 

that 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 from 

research 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 this 

is not just a public health model or a clinical model; there might even be another 

level 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 about 

such 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 of 

problems. 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 in 

the 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 perspectives 

of 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 make 

what we have to offer available in a less illness-based kind of a model.
Day 1 Discussion 95

DR. SUTTON: It means so much to me and members of my team that each of 

you 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 look 

for 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 that 

fits 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 Army 

slogan “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 have 

a 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 lead-

ers 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 can 

assure 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 are 

so 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 some 

research studies, to a knowledge implementation system where we can actually move 

practice and policy.

DR. CROSS: I would be interested in having people talk a little bit about the 

difference 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 is 

the 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, ideas 

that 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 bad 

news is that we now all own it, and not just within this meeting. We will clearly only 
96 Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism

take a small piece of that which we will ever be able to touch. We have created a list 

that 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 the 

concept 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 justification 

that fall into the categories of education, training, research, leadership (policy), and 

then interventions — clinical and population. I look forward to moving to that level 

of discussion so that we take our ideas, digest them and come forward with what we 

would like to see changed and formulate that into recommendations in the proper 

category. Thank you all for an excellent day.
Conference Recommendations 97

10

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 two 

items 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 question 

of 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 of 

alcohol, 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 category 

of 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 police 

and firefighters, the question of performance in terms of national security is much 

more important than disease, because people get sacrificed as individuals in order 

to 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 and 

with 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 of 

psychosocial 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 we 

change 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 that 

your 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 is 

particularly important; 

it falls into the 

category of 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.
98 Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism

for us to think about. But effective for what, with which population, and for which 

target? One conclusion of this conference could be that barriers to care in the mili-

tary are pretty much like barriers to care outside of the military. We are leading the 

nation 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 dis-

ability 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 of 

families 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 onset 

of 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 a 

problem 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 our 

service 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 of 

cigarette 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 a 

prescribed 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 health 

counseling. This is not so different from the rest of the nation. What we have is the 

opportunity 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. Care 

for 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 of 

these 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 bar-

riers to care may be impacting performance and health of an individual member, as 

well as the organization.
Conference Recommendations 99

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 from 

1994, which asks things such as, “Is this for the entire population? Is it for those at 

risk, 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 all 

very helpful. If we were really good, we would take everything we say today and 

put 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 the 

agent, the vector, and the population. You could think of the agent as malaria, the 

vector 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 take 

anti-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 and 

stigma? 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 are 

going 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 question 

of impairment of function, and how will barriers to care address impairment of 

function, which is not the same as disability. Disability tends to be an attribute that 

usually 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 do 

the 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 bar-

riers 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 ques-

tion of care for care givers. 

Whenever clinicians use the word “manipulating,” it is usually a sign that the 

clinician 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 cre-

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

address research first. Why? Because, as Harry Holloway commented yesterday, 

research recommendations will require us to be more specific about what our 

operational variables are. We cannot talk about any of the others unless we become 

a 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 training 

or 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 the 

most 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 career 

consequences 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 be 

really 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, in 

particular, to look at fliers who seek and receive psychiatric care, because there is 

tremendous worry in that community around that topic. The data say that 80% of 

fliers 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 been 

some marvelous work on that many years ago by Card and others. We need to 

replicate that around the questions of health behaviors, and health risks, and their 

impacts 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 finished 

alcohol 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 paradoxes 

of 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 the 

civilian and the military population, which would be interesting to look at in terms 

of vocational consequences. Because there, I think, we are going to see a huge differ-
Conference Recommendations 101

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 some 

data for people who may be reluctant. Two, to actually look at how, and why, and 

where those changes were made. Given that every injury, including an injury to your 

psyche, is going to have some effect, if I am a reluctant soldier I want to know the 

ins 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 go 

through. If there were a way in which having resilience training was something to 

check 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 is 

that 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 telephonic 

psychotherapy without the therapist knowing who you are. I think both sides are 

being worked in that regard. 

The thing I wanted to say before, which occurred to me in regard to Sue Estroff’s 

comment. 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 of 

what 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 of 

people 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 of 

them say, “You know, on second thought, I would rather be depressed than go back 

to 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 of 

care? 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 and 

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

I think this should be relatively easy once we have a product that has the kind of 

value 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 the 

people 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 of 

psychiatrically 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 the 

minute he touches a Budweiser he suddenly has friends, and people are talking to 

him. 

There is a systematic approach already existent within the overall advertising 

community 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 of 

millions of dollars. They will admit, however, that they only want to move a very 

small 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 other 

variables. Several years ago, the Annals of Internal Medicine published a paper that 

analyzed the cost effectiveness of screening for depression in primary care. They 

evaluated 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 and 

hours 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 we 

put 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 of 

care, 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 103

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 or 

training. 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 the 

door. We are spending a great deal of money without any outcome. 

DR. KILPATRICK: I think we need research on how treatment can be made 

more 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 agents 

can address. I wonder what people think about psychological treatments that have 

good 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 we 

really 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 last 

leap 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 come 

in and take Viagra, because they anticipate a pretty specific positive effect. What kind 

of effects do people expect to get out of treatment? We focused on the negatives, but 

what 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, and 

into the realm of functioning. Of course, psychiatrists and psychologists still have 

a 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 make 

rank, 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 your 

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

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 those 

people 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 the 

status of being the person who stigmatizes. No one has more to contribute to this 

interaction 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 components 

of courage, bravery, strength, and camaraderie. People are trained in the culture, and 

then 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 the 

idea of talking about this as injury, rather than illness, because I think it works well 

in this narrative. One injury would be like physical maiming or injury. Another is 

psychic injury. The culture prescribes what happens when physical injuries and 

psychic 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 might 

also 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 this 

problem 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, the 

coaching model is a hot model right now within DoD, both in terms of resilience 

and in terms of networks. There are working efforts to build virtual coaches that 

would follow someone around during their entire career. These are right in line with 

efforts that we need to know more about, that are frequently moved forward faster 

than 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 fabric 

of 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 a 

universal 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 105

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 to 

prevent these problems. The difficulty is in the implementation, so some research 

on implementation and effective ways of doing this would be helpful. There is the 

Internet-based Depression Prevention intervention we have been doing. It seems to 

be 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 that 

is on the Internet. Apparently people who frequent the internet have much more 

difficulty understanding truisms that are actually real, authentic, and genuine. Part 

of the challenge is directing people to the right internet sources. Maybe some sort 

of Good Housekeeping Seal of Approval might be helpful; because I think the 

Depression 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 resource 

on that. The person running it is a gentleman named Chris Marshall. I have the 

website here. They talk about all sorts of important groups of people. They talk 

about 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 group 

that 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 to 

employers. 

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 spin 

that 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 and 

interest in stigma research. I think we want to really promote this group, promote 

and 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 product 

that we package must be effective. There is quite a bit of work to do in that regard. 
106 Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism

Treatment can be stigmatizing. Early in my career I studied antipsychotics. The main 

difference between the newer and the older agents is that with the older ones, you 

and everyone else knew your patient was on an antipsychotic because they were 

Parkinsonian. They could not smile or interact socially. It was a stigmatizing type 

of 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 not 

just 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, and 

that 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 four 

months of treatment resources that they really did not need. We are not yet at the 

level of defining the specific phenotype and circumstances that might benefit most 

from treatment. The point I am driving is that there is a variety of outcomes. If I just 

measure 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 a 

clinical paradox.

We are working with The Disparity Center and Spero Manson. We want to 

recruit 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 let 

me do my thing. What is your thing? I have all these different rituals I want to do 

in the Trauma Center, and I want to intervene with patients. For example, if I wake 

up 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 and 

recruit them into the study and randomize them.” Thirty patients consented to this 

protocol. 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 to 

focus 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 107

you want to go there, especially when we are dealing with soldiers, and airmen, and 

sailors. 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 is 

a lack of knowledge, then we have the education issues. If it is a belief, we have a 

whole 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 to 

get over the beliefs. 

Second point, if it is systemic stigma, then we have to look at what we have 

created. 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 types 

of 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 access 

to 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 and 

leverage them appropriately. The military has a tremendous range of resources we 

can 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 book 

by 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 in 

treatment. 

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 come 

with one presenting complaint and the next thing you know they are talking about 

something completely different. We have got to figure out how to get people to stay 

in treatment to successfully market treatment. 

In the U.S., only about 20% of the people who have a serious mental illness in a 

year 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 to 

do systematic studies to define best practices to keep people in treatment.

DR. PESCOSOLIDO: Recommendation one: I think we need to rethink some of 

our research questions and, at minimum, supplement the way that we think about 

some of these processes. First of all, it is not help-seeking. In our studies, 25% of the 
108 Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism

people who get into mental health treatment are coerced by the police and by their 

bosses. A third does not really understand how they got there, so I think we need 

to 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 to 

continue 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 a 

fictional 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 stages 

of their careers. Look at some of whom have had treatment, some of whom have 

exhibited 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 psychiatric 

illness you are considered not fit for duty, or not trustworthy. We can go beyond the 

belief 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 in 

terms 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 to 

circumvent 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 the 

term PTS without the D in the common parlance of the language. I like what Steven 

had 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 have 

your 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 a 

huge leap to drive all the way to the hospital. You do not have to leave the culture 

that you live in, and enter the medical culture. Once you cross the threshold of the 

hospital 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 are 

trained to be peer counselors. Part of that training involves leaders talking about 
Conference Recommendations 109

their own experiences with traumatic stress type symptoms. It is an incredibly pow-

erful 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 Master 

Sergeant talk about their symptoms is incredibly powerful. Encouraging leaders to 

talk about their experiences is very important. 

DR. SCHOR: I think that there should be a strategy for identifying the research 

needs. 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 to 

buy 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 the 

perspective 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 from 

the units that did not buy into what we did usually came to us fearing that their 

leadership did not understand, and did not care. Unfortunately, that often panned out 

to be true. From the leadership perspective, we need public service announcements 

from all levels of leadership. Leaders need to be able to tell their service members that 

coming to seek help, whether it is for mental or physical health, is compatible with 

the 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. Some-

times 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 individually 

and 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 bud-

dies and see if one’s perception of stigma and barriers to care is the same as their 

buddy’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 psycho-

logical 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 train-

ing with psychologically enhanced basic training. Let us look at the outcomes, based 

on 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 and 

demonstrate that, then we could begin to de-stigmatize psychological programming.

The second area of research I think is important is comparative research that 

looks at different ways of presenting treatment and making referrals. We do not 

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

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 is 

an 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 that 

getting videos of patients talking about treatment and sharing their reluctance to 

enter treatment are good teaching models. They are more effective than mastering 

models in reducing anxiety about entering treatment. There are also different ways 

of making referrals that are more effective, too.

DR. URSANO: Recall that our plan is to create a transcript from which we will 

develop 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 to 

bring up. Consider the questions of leadership, direction to leadership, the question 

of intervention, clinical or population-based. The truth of the matter is, we do not 

have 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 work 

in states know that. It is the same issue within DoD. General Chiarelli says, “I have 

a 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 disaster 

and 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 a 

disaster. 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 have 

seen 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 need 

to change our language. We may like naming our disorders, but people do not like 

the 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 distinguish 

between what is normal and abnormal? This stigmatizes people. People do not like 

to 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 111

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 get 

most 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 and 

implement 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 of 

resilience, life skills, and performance enhancement. Looking for a vehicle that 

allows 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 thing 

that is going to help. One thing that can be helpful is diarizing and journalizing in 

a 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, and 

work 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 is 

wrong. 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 we 

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

but it was telling us something that we should not ignore. How do you improve the 

product? 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 to 

mobilize the non-mental health sector that has higher credibility.

Point number three: It is pretty clear that targeting people, telling them they have 

a 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 to 

what 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 an 

appeal 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 with 

people 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 the 

foundation on which our campaign has been developed. We find individuals from 

a 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 in 

theater. 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 who 

intervenes. 

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 in 

which 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 113

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 the 

expertise 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 is 

where 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 very 

large like a base. There is a history of this in the military. It should accomplish three 

goals. Developing and testing implementation. Developing and testing effectiveness 

and inputting a quality-improvement control system so that you actually are improv-

ing 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 they 

train 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 we 

need 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 my 

country of Israel, we are struggling with some people who seem to be stuck with 

a 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 become 

so rewarding that people maintain them. I would recommend looking at the main-

taining 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 and 

several 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 idea 

that these recommendations are how to move the field forward, not necessarily 

things we ought to be doing. We might want to consider changing the sequence 

of the title that we are using. I have gone through a transformation preparing for 
114 Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism

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 discussion 

that 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 the 

world of research. There has also been a bias about medical systems and health care 

systems, because that is where most of the people here live. However, many of the 

concerns 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 that 

leadership 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 role 

of otherness, shame, blame, power dynamics, and those kinds of things as part of 

this dynamic. The final recommendation is that we make sure that we include a 

wide array of expertise as we begin to make recommendations to the field. Many 

of 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 our 

service 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 feel 

better 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 General 

cannot 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 me 

tell 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 psychological 

illness? 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 some 

people 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 115

fitness into this component? How do we think about reintegration more broadly, so 

that reintegration is not only to civilian life but also back to military life? All those 

transitions 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 have 

to change your job. You need some help getting back to your job. You might need 

help feeling like you fit the core values of your job. 

DR. TUMA: My recommendations will be framed as questions. I would like to 

know 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 can 

manage. 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 not 

been 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 to 

monitor what programs actually change beliefs and behaviors.

Third, I would like to know how to get rapid relief for people who do make it 

into care because I think it helps people continue care. Related to that, I would like 

to 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 have 

been 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 science 

of 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 of 

training 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 the 

setting 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 the 

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

care. Participation in self-help organizations can also help maintain participation 

in professional care. I think something is being overlooked in research, and it has 

been relatively overlooked in terms of partnerships, engaging people in services, and 

changing stigmatization.

One of the benefits of working with self-help organizations is that you then have 

a cadre of people who model outreach, as well as internal mutual helping. I felt for 

some 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 with 

existing organizations, as well as create new ones. Many self-help organizations were 

partnerships 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, or 

ordinary 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 television 

shows, 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 very 

practical 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” is 

an 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 to 

allow 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 child 

trauma, 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 and 

has had more than 60,000 users. There has not been evaluation of these kinds of 

methods 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 they 

be used as a reinforcer? I would recommend that there be some evaluation of these 

kinds 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 and 

studies are very important to us. I have observed that many policy makers do not 
Conference Recommendations 117

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 psychiatric 

illness? 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 care 

of each other in these perfectly horrible situations. I think there needs to be more 

examination 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 of 

mental illness, and we have gone backwards in others, particularly with substance 

abuse. 

I also would echo the importance of figuring out what causes people to drop out 

of treatment. What is the tipping point that makes people enter treatment? It may be 

very 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, and 

stay 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 outweigh 

the 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, and 

I 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 for 

a person not getting treatment has to do with security concerns. What we have not 

addressed 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 new 

policy that came out when it was essential for the military to identify the source of 

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

of policy very profoundly, so that it could be that inroads in those areas could make 

it 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 ways 

of looking at the world, understanding there are lots of possible alternatives and 

interpretations. 

DR. HOLLOWAY: I recommend one further conference, primarily focused on 

barriers to care and forget stigma. Half the attendees of the conference should be 

officers who have commanding responsibility, NCOs, and at least a quarter of the 

professionals 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 have 

actually 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 and 

over at the Carter Center, and this sort of anxiety about measuring and doing is 

going 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 find 

problematic 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 of 

our studies, which are totally arbitrary in duration. Research is not the same thing 

as 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 this 

conference, 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

DEFENSE CENTERS

OF EXCELLENCE

For Psychological Health

& Traumatic Brain Injury