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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 Pescosolido’s data. We are doing a great deal of anti-stigma stuff, and I am not confident that much of it is that effective, so I would like to drill down a little deeper on that. DR. BELL: Something we learned from the Institute of Medicine suicide report and Dr. Satcher’s youth violence report is that risk factors are not automatically predictive due to protective factors. Also, there is apparently a split in the states about using marijuana to treat PTSD and I think we need to discuss that tomorrow. DR. CORRIGAN: The question I would like to ask is where are the consumers today DR. SHALEV: I have the perspective of a person responsible for delivery of clinical service. I live in Jerusalem, where for a third of the population, the ultra- Orthodox, 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
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FORUM ON HEALTH AND NATIONAL SECURI
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From the Conference Series: FORUM O
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9 Day 1 Discussion ................
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ii Bruce G. Link, Ph.D. Professor,
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Mental Health, Stigma and Barriers
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Stigma and Barriers to Care in Mili
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