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

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 improving
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 maintaining
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