The present review addresses the perceived stigma associated with admitting mental illness and seeking mental health treatment. Research on the public stigma associated with mental illness is reviewed, indicating that the public generates stereotypes of mental illness, which may lead to discrimination of those individuals with mental illness. The internalization of these public beliefs result in self stigma which leads the individual to experience low self esteem and self efficacy. This process of stigmatization in both public and self, is what causes the mentally ill individual to reject the provided mental health treatment.
Under the influence of the military, these mentally ill individuals are more prone to stigma barriers in mental health treatment. Within the military it is understood that there is a high demand of reediness and responsibility, which is threatened by the stereotypes incapability associated with mental illness, resulting in an exposure of “weakness” for the mentally ill individual. Soldiers in efforts to avoid this consequence will deal with there psychological symptoms independently rather then facing the consequences that might entail in seeking professional treatment.
The term invisible wound was established in order to change the belief of a physical and tangible injury acceptable but not an emotional injury. Efforts to reduce the mental health stereotype and promote mental health treatment have included testing possible interventions, which can be applied in future military personnel with psychological problems. The interventions are directed towards improving one area of stigma and include Cognitive Behavioral Therapy and improvement in leadership quality and unit cohesion. Starting on October 2001, 1.64 million soldiers were deployed to serve either in OEF, Operation enduring Freedom or OIF, Operation Iraq Freedom. Upon their return, close to half of these soldiers reported symptoms of mental health problems. The prevalence of mental problems in the US military was larger then it has ever been.
The Military personnel screening positive for PTSD was at a rate of 0.2% in 2002 and in 2008 increased to 21.8%. Additionally, during these years rates of Alcohol abuse went from 1.1 %- 7.1% as well as the rates of Depression going from 2.3%- 17.4%. Unfortunately, along with the rise of PTSD, Alcohol abuse, and depression the increase rate of military suicide followed Kim et al. (2010). As a result measures were taken in order to reduce mental health barriers and improve the accessibility of mental health care within the military personnel. In 2008, The National Defense Authorized Act was passed which extended the eligibility of receiving VA health care benefits from 2 to 5 years post deployment. Although the potential barrier of accessibility was adjusted the gap military utilization of mental health treatment still remained.
Through the studies identifying mental illness and prevalence in the military, researchers have found that the rate of positive screening mental illness is inconsistent with the rate in utilization of mental health services. Hoge et al. (2004) conduced a study measuring the mental health problems in 3,201 OIF and OEI military personnel. The study found that of the soldiers and marines who met the criteria for a mental health illness only 23- 40% reported actually receiving professional mental health care treatment. Interestingly, only 38- 45% of those positively screened reported an interest in receiving any form of treatment.
If healthcare is delivered, then what leads these suffering military personnel to reject the advised mental health care attention? This article will argue that the perceived stigma in mental illness is a major factor contributing to the lack of utilization of the mental health care provided.
The forms of Stigma:
In order to understand the role stigma plays in mental health care utilization of military personnel, we need to fully understand stigma of mental illness. Research of mental health stigma within the military context often relates and applies findings of the general stigma of mental illness in order to entirely understand how it. Corrigan & Penn (1999) defined stigma as, an overall negative attitude or stereotype about a person. The research of stigma agrees with this definition but also differentiates between the two different forms of stigma, self- stigma and public stigma.
The findings of Ben- Zeev et al., (2012) although focuses on stigma within the military context, agrees with the definition of stigma given from Corrigan and Penn (1999) but also explains that public stigma is the rejection of mental illness as a result of society endorsing stereotypes. Originally, these negative perceptions of mental illness start off minimal but eventually turn into false facts, resulting in the formation of public- stigma.
Within the study, public stigma is explained to be the main source of stigma. Within the research of Ben- Zeev et al., (2012), the three stages of the conception of stigma are also explained. The first stage occurs when the individual is exposed to the illness through explicit cues, whether personally experiences the mental illness symptoms such as (intense emotional distress or flashbacks) or if he or she hears about a fellow members mental illness.
In the second stage, these stigmatizes cues produce negative beliefs of what the public has generated about people with mental illness such as incapable, dangerous and at fault. Although the second stage indicates knowledge of the various negative perceptions, only in the third stage are these perceptions believed. After this process the stigma is endorsed and as a result generates negative reactions against those suffering such as condescension or discrimination and will impact the individual with mental illness. Awareness of public stigma results in self- stigma, where the public stereotypes becomes internalized and made into facts by the individual with mental health problems.
This internalization of negative beliefs will cause the individual to apply the negative stereotypes to him or herself impacting how they view themselves. Mechanic et al., (1994) found that the consequences of self -stigma will cause the individual to experience a loss of self-esteem and self- efficacy. Although the study of Mechanic et al. (1994) was specific to the general stigma of mental illness, the findings from the research have been described within the mental illness stigma in the military. Wright et al, (2007), which findings agrees with the findings of Mechanic et al. (1994), consisted of surveying 680 soldiers on their perceptions on mental health stigma it the military.
After selecting from those who screened positive for mental illness the results found that self-stigma attacks the individual’s self perception generating self loathing thoughts such as, I am a pitiful soldier and I have failed my responsibility of being a soldier. Further results in this study found that the self-stigma, resulting in low self -esteem and self- efficacy will cause the soldier to have harder time seeking professional help. Studies have shown that in order prevent the consequences of stigma soldiers will reject the referral to seek treatment. The symptoms the solider may encounter such as insomnia, flashbacks, and severe anxiety will go untended to, in order to avoid formal diagnostic. Researchers have defined this reaction as label avoidance. Individual avoids the occurrence of formal diagnostic due to the consequences a label of mental illness might entail (Ben- Zeev et al., 2012).
Consequences of seeking treatment, specific to military environment: Many researchers have focused their study on understanding the specific nature of stigma of mental illness in relation to military personnel. Studies have shown that military service members are prone to the negative consequences of stigma due to the expressed concern of how they are viewed by other service members and commanders. Hoge et al., (2004) found that soldiers indicate a strong concern on how they are perceived by their peers and leaders. Further results of the study link high levels of concern to the potential stigma associated with mental illness. Furthermore, the worry of being “treated differently” among other military personnel was reported in the study of Wright et al., (2007).
The study found this worry of discrimination to be a major concern and cause of soldiers refusing mental health treatment. Research has explained that the mental illness stereotypes such as violence and incompetence pose a threat to the high expectations and demands, specific to the nature of the military. Wright et al., (2007) findings agree and explains that the soldiers are expected to be capable and reliable of completing relatively challenging assignment and if viewed as incapable would not be relied on by others. Soldiers, struggling with mental illness, fear the reality of receiving different treatment or being passed for duties and promotions.
This fear that seeking help for mental illness may harm the individuals career had been understand to be another linking factor as to why soldiers decide against seeking mental health care treatment. Many studies have found that due to stigma, soldiers will also undergo the fear of exposing weakness and as a result, reject mental health care. Due to the high demands and expectations of soldiers, the military leaves little room for areas of weakness. This contestant state of exhibiting strength in character creates less acceptance of mental illness due to the stereotype of weakness attached to it.
The study of Kim et., (2010), conducted a cross sectional study of 10,386 US army soldiers within three and twelve months following their deployment. These soldiers were surveyed on their perceptions of the potential barriers to care where they report a major barrier was due to the consequence of being “seen as weak”. They feel that once a soldier was to seek treatment for his or her mental illness, they fear that others who endorse the stereotype will see them as weak.
To emphasis the stigma of weakness researchers apply the research conducted on general mental illness stigma in order to further explain the stigma of being seen as weak in military contexts. Corrigan et al.,(2000) in the research conducted on stigma, found that mental illness can be judged by others in terms of controllability. The idea that mental illness is controllable places more responsibility of the symptoms of mental illness on the person with the illness. This concept of controllability can be applied to the fear of being seen as weak within the military. When others view mental illness as controllable they often judge them and generate the stereotype that mental illness is a weakness.
The term invisible wound has become predominantly used among the military expressing mental health aftermath of the war. Research has showed that physical injury tends to be more accepted then the psychological injury of combat. The term invisible wound attempts to reduce the stigma of mental illness by emphasizing that mental trauma is no less severe then physical injury. Britt et al. (2000) analyzed mental health problems in a service unit returning from a peacekeeping mission. Those who screened positive for psychological problems expressed that they felt more discomfort in discussing their mental health status then any medical problems.
Although those screening positive would benefit from psychological treatment, they might feel that it is not as important as a physical injury and therefore neglect to seek professional treatment. This perception among military personnel of physical injury being more acceptable then military injury is exposing the stigma and its negative effects of dealing with mental illness. The term “invisible wound” allows for more attention to be given to anemotional trauma by indicating that just because the wound is not physical or tangible it should still be considered an injury.
Through the research conducted on stigma and barriers to mental health care, interventions to improve the utilization of mental health care in military personnel have been tested among the soldiers returning from Operation Enduring Freedom, and Operation Iraq Freedom. Interventional research has found that In order for a soldier to admit the psychological symptoms and treat their mental illness studies have shown that he or she needs to in the right environment and around the right people in order to do so. A soldier will probably feel more comfortable discussing their psychological status amongst individuals that they feel confident in and trust.
In the attempts to reduce stigma, researchers explored the correlation of stigma on leadership quality. Britt et al., (2000) found that amongst the soldiers who reported a higher perception of leadership quality had lower levels of perceived stigma. Wright et al., (2007) study agreed with the findings in Britt et al., (2000). The results in Wright et al., (2007) study additionally found that those who expressed high unit cohesion ratings were associated with low levels of stigma. The results of both the studies emphasis the importance in positive relationships, within the individuals with mental illness and his/ or her leaders and unit members. Additional findings on efforts to reduce stigma apply the method of Cognitive Behavioral Therapy.
Stecker et al., (2011) tested a Cognitive Behavioral intervention, attempting to show a reduction of stigma in mental illness. Those screened positive for mental disorder, underwent a brief CB session in order to modify the destructive beliefs of mental illness. Destructive thoughts for example would be “ nothing will ever change so why would I bother trying”. The CB session encouraged constructive thoughts such as “ I can learn more about myself by talking to others”. Each session was accommodated to the individual’s personal perceived stigma. The results that after the CB intervention sessions were administers the surveys showed dramatic decrease in levels the perceived stigma of the participant and followed the increase in the participants intention of seeking mental health treatment. This CB intervention was a measure to reduce stigma of mental health and increase the rate of care.
Research has indicated a gap within the utilization of military mental health care. There is increase in rates of mental illness within the military due to Operation Endurance Freedom and Operation Freedom Iraq. Further results have shown that the rates of military usage of the mental health care do not match the increase rate of mental illness. Studies have suggested the lack of mental health care is due to the stigma associated with mental illness. Military service member continue to suffer from mental illness without seeking help due to the prevalence of mental health stigma within the military. Within the research in stigma of mental illness, stigma is shown to have many different forms.
Researchers have explained how due to the combination of public and self -stigma soldiers are reluctant to seek treatment for their mental illness. Although having a mental health problem is not easy, the solders reject treatment due to the consequences it might entail due to specific the culture of the military. The soldiers fear the reality of discrimination from other service members as well as and being viewed as weak due to the stigma of mental illness. The perception of mental illness being seen as not as important as physical injury has resulted in the new term of indivisible wounds, which attempts to change these stereotypes. Interventions on how to reduce stigma in the military have been tested in order to improve future views of mental illness within the military.