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Conference Recommendations 117 like data. I think there is power in the personal story. How can we appeal to both the researchers and the policy makers DR. GOLDENBERG: What do primary care physicians think about psychiatric illness And is it stigmatized there Is the psychiatry clerkship a place where stigma reduction can happen, or does it happen just by exposure We talked a great deal about exposing people to patients with psychiatric illness. Is that a place where stigma reduction or promotion happens DR. TYLER: During the Cold War and first Gulf War, I studied fatal training accidents involving armored track vehicles in deployed organizations in Germany. What struck me the most was the wonderful way that soldiers of all ranks took care of each other in these perfectly horrible situations. I think there needs to be more examination of how that happens, and what makes it work. DR. BENEDEK: I was very much impressed by Dr. Pescosolido. What I learned from her was that we have made some progress regarding stigma in some pieces of mental illness, and we have gone backwards in others, particularly with substance abuse. I also would echo the importance of figuring out what causes people to drop out of treatment. What is the tipping point that makes people enter treatment It may be very different for different people. It is supposed to be different for different people. DR. NAIFEH: Are we trying to make it so that every single person who could potentially benefit from treatment is both willing and able to seek treatment, and stay in it for the full course Is that realistic Is it even desirable And if not, what are we willing to tolerate What is a realistic and desirable goal in terms of getting people to seek services and to stay in services At what point does the cost outweigh the benefits DR. GUIMMOND: As a child-focused person, I have been thinking about how children are integrating messages about mental health. There are so many concerns about over-treating or over-labeling kids. DR. BIGGS: What can we do to change the perception of threat that someone with mental illness might have or impose Ultimately, we are talking about helping the individual man or woman. The perspective I have is that there are three things that need to be kept in mind. How does he or she see the world How does the world see him or her And how does that person see himself That is the ultimate focus. MS. DICHTEL: From a nursing perspective, I think stories are important, and I think buddies are important. DR. SCHOR: I am not sure that we have emphasized a total workforce development approach. What skills do people need to have at different work force levels I have not heard risk communication mentioned. That may be primary prevention, but the way in which you discuss this risk may actually mitigate the impact of the injury and how it is perceived. I am not sure that we have emphasized that enough. DR. HOWE: Sonja Batten pointed out that from the focus groups, a reason for a person not getting treatment has to do with security concerns. What we have not addressed at all is the possibility of changing that structure. I may be optimistic but it can be changed. What I am talking about is the military’s structural policy of how it handles confidentiality. In the early days of HIV infection, there was a new policy that came out when it was essential for the military to identify the source of HIV. They made some new rules regarding confidentiality for people who would acknowledge, for example, that they were gay. Similarly, there used to be a concern about commanders going on fishing expeditions. That has been changed as a matter
118 Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism of policy very profoundly, so that it could be that inroads in those areas could make it easier for active duty persons to go for treatment. DR. SHALEV: Stigma is a bit of a heavy word. We are dealing with belief systems, so maybe we should more closely examine what people believe about themselves and others. It might be better if we use other words. DR. BATTEN: We need to work with people on developing more flexible ways of looking at the world, understanding there are lots of possible alternatives and interpretations. DR. HOLLOWAY: I recommend one further conference, primarily focused on barriers to care and forget stigma. Half the attendees of the conference should be officers who have commanding responsibility, NCOs, and at least a quarter of the professionals should be primary care doctors to consider these same issues. DR. URSANO: Great comment, both as an intervention and as an education activity for all at that conference. DR. ARNOLD: I would like to include in that conference people who have actually had these injuries, the consumer. DR. ESTROFF: Two concerns. One is that this is not a randomized controlled drug trial, and it is going to take a long time. Tom has heard me say this over and over at the Carter Center, and this sort of anxiety about measuring and doing is going to take a long, long time. I see the change from when I started teaching medical students 30 years ago to what I see now, and many of the things that we find problematic are no big deal to them. Gender issues, ethnicity, they are in a different place, and who knows why they changed, but it is going to take a long time. We should not expect that we will be able to see an effect like that in the time span of our studies, which are totally arbitrary in duration. Research is not the same thing as knowing and listening. It is not clear to me that there has been enough of that. It is just not a substitute. A survey and symptom scale is not going to tell you what you need to know, with all due respect, at the level that we need to know. DR. BROWN: In closing, we have achieved one of the primary goals of this conference, bringing people from different disciplines and fields together to build relationships and bridges between one another. Thank you so much for coming. DR. URSANO: I would like to thank everyone for your outstanding contributions.
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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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iv Alisha H. Creel, Ph.D. Assistant
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vi Kenneth W. Schor, D.O., M.P.H. C
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Executive Summary 1 Executive Summa
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Executive Summary 3 about stigma in
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Executive Summary 5 value, cost-eff
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Executive Summary 7 •• Reinforc
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Introduction 9 1 Introduction Mark
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Mental Health, Stigma and Barriers
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Stigma and Barriers to Care in Mili
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Stigma and Barriers to Care in Disa
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Stigma and Barriers to Care in Terr
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Conceptualizing Stigma and Barriers
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Mitigating Stigma and Barriers to C
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