Mental Health News You Can Use...

March 2006

This is the twelfth installment of the electronic update from SAMHSA's Resource Center to Address Discrimination and Stigma Associated with Mental Illness (ADS Center), a program of the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Mental Health Services*. We invite you to share this information with your friends and colleagues who share your interest in confronting stigma and discrimination associated with mental illness and to post this information in your own newsletters or listservs. Visit the ADS Center on the web at http://www.promoteacceptance.samhsa.gov.

The contents of this informational update do not necessarily represent the views, policies, and positions of the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, or the U.S. Department of Health and Human Services.

In this issue...

Archived SAMHSA ADS Center training teleconference - Stigma in the military: Strategies to reduce mental health stigma among veterans and active duty personnel

Upcoming training event: Mental illness and self-disclosure, April 2006

Hoge, C.W., et al. (2004). "Combat duty in Iraq and Afghanistan, mental health problems and barriers to care." New England Journal of Medicine, 351(1): 13-22

Us and them: The experience of mental health stigma

"Fit for Duty " by Clarence Jordan

March 2006 Spotlight

Archived SAMHSA ADS Center Training Teleconference

Stigma in the military: Strategies to reduce mental health stigma among veterans and active duty personnel

"Stigma is a real problem. It's a societal issue, but it is much more pronounced in the military." - Col. Thomas Burke, Director of Mental Health Policy, U.S. Department of Defense, Stars and Stripes, July 22, 2005

Like their civilian counterparts, many active-duty and veteran United States military personnel are faced with the prospect of having a mental illness. However, unlike ordinary citizens, the situations under which these individuals work and live impact profoundly upon their ability to maintain mental health. Soldiers training for and participating in combat experience high levels of stress that heighten anxiety and increase the chances for depression. Combat trauma, whether experienced in the form of bodily injury or fatigue from a constant exposure to threat, increases the likelihood of post-traumatic stress disorder (PTSD) and the possibility for poor performance or inappropriate conduct.

The impact of military reality on individual mental health is complicated further by the pronounced stigma associated with mental illness within military communities. Service members frequently cite fear of personal embarrassment, fear of disappointing comrades, fear of losing the opportunity for career advancement, and fear of dishonorable discharge as motivations to hide the symptoms of mental illness from colleagues, friends, and family. This silence and the attitudes and perceptions perpetuating it pose a significant challenge to those charged with making sure that the United States' fighting force is improving itself and taking care of its own members.

In response to this challenge, advocates from both within and outside of the U.S. military and the U.S. Department of Veterans Affairs are working to counter stigma and reverse the fear that causes soldiers and veterans to associate mental illness with personal and professional failure. Some programs, like the U.S. Air Force's suicide prevention initiative, provide a comprehensive approach to mental health education, training, and illness prevention that is made visible and acceptable inside military communities. Other programs seek to explore less stigmatizing methods of identifying illnesses and delivering mental health services by taking advantage of communication tools such as the Internet. Still other programs seek to promote the value of talking about illness by encouraging peer recognition and support for recovery from mental health problems.

The SAMHSA ADS Center explored these topics and more during its last live teleconference event on March 30, 2006. If you missed this training or you want to listen to it again, information on accessing a recording via the SAMHSA ADS Center's online teleconference archive is available at http://www.promoteacceptance.samhsa.gov/archtel.htm.

Upcoming Training Event

Mental Illness and Self-disclosure Teleconfernce, April 2006

On April 27, 2006, the SAMHSA Resource Center to Address Discrimination and Stigma Associated with Mental Illness (ADS Center) will host a teleconference exploring the complex considerations informing the personal decision to disclose or not to disclose information about mental health problems to other people. This training will be offered nationally via telephone and free of charge to all registered participants.

Registration information, a training summary, and presentation slides for this event will be posted on the Trainings section of SAMHSA ADS Center web site in April 2006. Please check the web site often for new information.

Featured Research Articles

Hoge, C.W., et al. (2004). "Combat duty in Iraq and Afghanistan, mental health problems and barriers to care." New England Journal of Medicine, 351(1): 13-22. [Free Text Article] Based on data collected from over 6,000 Army and Marine [Free Text Article]

Based on data collected from over 6,000 Army and Marine ground combat personnel deployed to Iraq and Afghanistan in 2003, this study determined that only 38 to 45 percent of soldiers meeting research criteria for having a mental disorder demonstrated an interest in seeking help for their problem. The study also found that only 23 to 30 percent of soldiers in the various research groups actually reported receiving professional mental health services during the previous year. In the interpretation of their experimental results, Hoge and his research team attributed these low help-seeking statistics (which closely resemble findings from other civilian studies) to prevailing beliefs within the military that the disclosure of a mental illness negatively impacts on career advancement and relationships with peers and commanders. Lending additional support to the researchers' interpretation, supplemental survey data further indicated that soldiers within the study group who scored positive for a mental disorder were two times more likely to demonstrate concern about being stigmatized by others.

Additional Research

Cawkill, P. (2004). "Study into commanders' understanding of, and attitudes to, stress and stress-related problems." Journal of the Royal Army Medical Corps, 150(2): 91-96.[NLM/Pubmed Abstract]

Dwyer, E. (2006). "Psychiatry and race during World War II." Journal of the History of Medicine and Allied Sciences, 61(2): 117-143. [NLM/Pubmed Abstract]

Gray, S.H. (2004). "Training psychotherapy elective for military psychiatry residents." Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry, 32(3): 432-439. [NLM/Pubmed Abstract]

Greer, M. (2005). "New kind of war." APA Monitor on Psychology, 36(4): 40. [Free full text document]

Hoge, C.W., J.L. Auchterlonie, & C.S. Milliken (2006). "Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq and Afghanistan." Journal of the American Medical Association, 295(9): 1023-1032. [NLM/PubMed Abstract]

Knox, K.L., et al. (2003). "Risk of suicide and related adverse outcomes after exposure to a suicide prevention programme in the US Air Force: cohort study." BMJ (British Medical Journal), 327(7428): 1367. [Free full text document]

Montgomery, N. (2005, August 4). "Military aims to remove stigma from seeking therapy for postcombat stress." Stars and Stripes. [Free full text document]

Pincus, S.H., & D.M. Benedek (1998). "Operational stress control in the former Yugoslavia: a joint endeavor." Military Medicine, 163(6): 358-362. [NLM/Pubmed Abstract]

Porter, T.L. & W.B. Johnson (1994). "Psychiatric stigma in the military." Military Medicine, 159(9): 602-605. [NLM/Pubmed Abstract]

Sammons, M.T. (2005). "Psychology in the public sector: addressing the psychological effects of combat in the U.S. Navy." American Psychologist, 60(8): 899-909. [NLM/Pubmed Abstract]

Models, Programs, and TA Tools

Us and Them: The Experience of Mental Health Stigma Michelle D. Sherman, Lance Evans, Ph.D., and Gene Hallford, M.A. Oklahoma City VA Medical Center South Central MIRECC University of Oklahoma Health Sciences Center

Us and Them: The Experience of Mental Health Stigma is a program for staff at Veterans Affairs (VA) medical centers that challenges beliefs about mental illness and promotes greater sensitivity. The program is delivered as a PowerPoint presentation and is supported by an accompanying facilitator's guide.

Due to the deleterious effects of mental health stigma, many people with mental illnesses never arrive at a mental health provider's office. Countless others who do seek help from a provider still experience a stigmatizing shame. In order to address these problems, the research team that developed Us and Them set out to examine the why and how of mental illness stigma using a qualitative methodology (i.e., focus groups and semi-structured interviews). In the spring of 2002, they started examining beliefs and experiences related to stigma among mental health providers at Veterans Affairs (VA) medical centers, a group of veterans currently enrolled in psychiatric treatment, and a group of veterans' family members. The resultant interview and focus group data suggested that stigma was associated with four central belief systems: responsibility (agent vs. victim), difference (maintaining cultural norms vs. allowing for difference), models of health (biomedical vs. biopsychosocial), and power of diagnosis (definitive explanations vs. useful generalizations). Based on these four systems of belief, the team derived five specific suggestions designed to help mental health providers address mental health stigma. The Us and Them program delivers its anti-stigma message to VA medical centers through a preassembled PowerPoint presentation and supporting facilitator's guide designed to take staff members stepby- step through all five stigma-reducing suggestions.

The Us and Them PowerPoint program and facilitator's guide are available at no charge. For more information, or to request a copy, please contact Dr. Allen Thomas at Allen.Thomas3@va.gov or Dr. Michael Kauth at Michael.Kauth@med.va.gov.

Additional Resources

The Air Force Suicide Prevention Program: A Description of Program Initiatives and Outcomes

This report, issued in April 2001, details the goals and accomplishments of the United States Air Force's suicide prevention program. The program, which first took shape in 1996, was developed in response to an alarming trend in suicide deaths among airmen during the first half of the 1990s. According to the report, suicide had become the second leading killer of Air Force personnel during this period of time, accounting for 24 percent of all deaths within the branch. The resulting program of prevention identified stigma reduction within the Air Force community as one of its primary objectives. Subsequent achievements made by the Air Force suicide prevention program prompted the President's New Freedom Commission On Mental Health to name it as a model program in their 2003 final report.

Click here to view the Air Force Suicide Prevention Program web site.

NAMI: Information for Veterans and Their Families

This fact sheet offers answers to frequently asked questions about veterans benefits, services for military families, veteran advocacy groups, and NAMI's role in advocating for the rights of veterans with mental health problems. [Free full text document]

National Mental Health Association: Operation Healthy Reunion

This public education and stigma reduction program specifically addresses the mental health needs of soldiers, their families, and their medical service providers. The program develops and distributes educational materials to the military community designed to "bust the stigma of mental health issues." These materials include information about reuniting with family members, adjusting to civilian life, depression, and post-traumatic stress disorder (PTSD). [View the web site]

Coping with the Stress of Ongoing Military Operations: Information for Military Families

In addition to describing signs of the emotional impact that combat deployment might have on members of military families, this fact sheet offers several simple self-care tips for reducing stress and anxiety. [Free full text document]

Starting a Self-help/Advocacy Group

Recent reports on mental health in the military, like the Air Force report above, stress the importance of fostering social support and "interconnectedness" within military communities in order to reduce stigma, promote help-seeking, and improve recovery outcomes for personnel experiencing a mental illness. Starting or joining a self-help support group can help service men and women and their families recognize that they are not alone by providing a space to make contact with other individuals and families who have experienced similar problems. This brochure, published by the National Mental Health Consumers' Self-help Clearinghouse, offers information on the effectiveness of self-help groups, as well as a list of the preliminary steps required to form such a group. [Free full text document]

In My Experience.

Fit for Duty by Clarence Jordan Navy Veteran

In decades past, insulated from the ravishes of the battlefield, the Navy typically had only to deal with the effects of long arduous tours or shipboard fires as the environmental factors affecting the psychological wellness of fleet personnel. Navy commanders concerned with whether or not an individual was fit for duty may have missed the subtle differences between sailors who had drinking problems and those who had deep-seated emotional disorders. Ship captains and commanders lacked models on which to base their opinions of whether or not a sailor may need to be referred to sick bay. This was exacerbated by the fact that most symptoms were likely to appear much further down the line than the immediate precipitating event.

Even though much more is known about mental illnesses in today's Navy, application of that knowledge, in my opinion, is no further along than it was in the Vietnam era. Then, people just simply didn't talk about mental illnesses aboard ship or shore commands. Whatever the manifestations of an illness were, chronic article 15's (Uniform Code of Military Justice punishment for a minor offense of misconduct) to assault was dealt with strictly as a disciplinary issue. Mitigating or extenuating circumstances (mental health issues) rarely were taken into account. In the eyes of commanders throughout the fleet, operational readiness (the fitness of those who serve) was defined along very narrow parameters.

Is there stigma around mental illness in the Navy? You better believe there is, but sleep disturbances, upset stomach, tremors, increased arousal, sweating, and hyper-alertness may well be associated with cowardice under fire rather than a mental illness. When I was on active duty, most individuals with this type of behavior would have been considered useless and weeded out in boot camp.Do you remember the movie, An Officer and a Gentleman? The term drop on request (DOR) includes a whole range of maladies from complaining about wanting to go home to physical or psychological unpreparedness for the rigors of military duty. My drill instructors in Aviation Officer Candidate School (AOCS) were an elite group of war-hardened, Marine non-commissioned officers who saw their role as one of transforming scuzzy civilians like me into rock-hard junior officers ready for flight training.

Gunny, our Gunnery Sergeant (a noncommissioned rank in the U.S. Marine Corps above staff sergeant and below master sergeant and first sergeant), missed the glory of combat and so decided to end his life. In essence, we romanticized his death in a manner that made him into a hero. I wonder, too, about my good friend Ron who DOR'd (quit) after graduating from the training squadron. He always appeared a bit strange to me. My own illness was far less obvious, primarily because the performance of my duties didn't warrant scrutiny- even though I was on my second failed marriage and known to miss muster (inspection) more than a day or two for personal reasons.

In hindsight, knowing what I do now about mental illness, I have doubts as to whether or not I would have sought help from a family counseling center or navy doctor. However, I have no doubt that, if given an opportunity, I would have sought help from a private practitioner on the outside. Most navy medical facilities I'm familiar with would have a great deal of difficulty guaranteeing confidentiality, and confidentiality is paramount, because promotions mean everything in the Navy; it's either move up or out. Disclosure of anything resembling a mental illness would have been the kiss of death given the competitive nature of moving up in rank.

When a career is on the line, men and women of the Navy are not likely to shoot themselves in the foot by letting their commanding officer know they have a mental illness. Until the Navy actually accepts that mental illness is like any other treatable illness, I see little hope for reducing stigma and the particular barriers it erects for those in the military.

Additional Experiences and Commentary

Carolla, B. (2003). "Mental health in the military: A community takes care of its own." NAMI Advocate, Spring Issue. [Free Text Article]

Fekete, D.J., (2004). "How I quit being a 'mental patient' and became a whole person with a neurochemical imbalance: conceptual and functional recovery from a psychotic episode." Psychiatric Rehabilitation Journal, 28(2): 189-194. [Pubmed Abstract]

Shapiro, J. (2005, May 27). "Guard suicide highlights risks for returning troops." Morning Edition [Radio broadcast]. Washington, DC: National Public Radio. [Listen to audio]

"The obstacles in getting help [Transcript excepts]." (2005, March 1). In Frontline: The soldier's heart [Television broadcast]. Boston: WGBH Boston. [View the web site]

Westervelt, E. (2005, March 31). "Soldier says Army ignored his mental health concerns." All Things Considered [Radio broadcast]. Washington, DC: National Public Radio. [Listen to audio]

Content in the InfoUpdate is current at the date of publication. Content and technology may change after the time of publication and affect the information presented here. If you are trying to locate a specific resource or research article, please contact the ADS Center directly.