stigma and barriers to care - Uniformed Services University of the ...

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