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Stigma and Barriers to Care in Military & Veteran Populations 27 tremendously so it is about making sure that when we are working so hard to bring them in they are going to have a good experience. DR. HOGE: I think it is both. The reality is that there is a huge benefit in seeking treatment. What we do in mental health and the incredible programs that have been stood up in DoD and VA in particular, is extraordinary. The reality, though, for many individuals who seek treatment within our system is that they have negative experiences. There are some fundamental assumptions we make about the nature of treatment, treatment effectiveness, and the application of evidence-based practices. For many individuals evidence-based treatments are inflexible and end up being detrimental because every individual has an extremely personal experience requiring a tailored approach. There is no way we can tell that individual what they need in order to get over that experience, to integrate it into who they are now, to once again have meaning, joy, and purpose in their life. I sometimes try to get my residents and cofacilitators in PTSD groups to do a moratorium on the terms, “You need to. It’s important to consider. You need to consider.” They almost become completely incapable of speaking when you do that. DR. RUZEK: I work in the VA system at the National Center for PTSD. There are people who actually do engage in treatment. In many different treatment programs within the VA the normative experience is an attitudinal change. It would be very interesting to see studies of people moving through the treatment process and how that affects their views of mental health participation. In fact, what we usually find in VA PTSD treatments are a range of experiences, including negative ones. People who pass the threshold of five or six visits end treatment with tremendously positive views of the treatment experience, the treatment providers, the caring of the providers, their views about the importance of disclosure, and their willingness to disclose. One of the untapped tools for us to change attitudes towards treatment is to better capture those success experiences, to magnify the perceptions of benefit, and change the perceptions of what happens in treatment. We ought to be videotaping testimonials about treatment. It is possible that the stigma of treatment inhibits those successfully treated individuals from having conversations with the body of veterans who are not seeking treatment. We want to get veterans and active duty treatment participants talking about their treatment experiences. DR. LINK: I am speaking as a stigma researcher and coming back to the exchange that Sue Estroff and Matthew Friedman had. Perhaps the facts about treatment capacity are disputed, but the extent to which capacity has not developed through history could be due to stigma. Also, regarding the concern that if everybody came to treatment we would not be able to take care of everyone, we might consider a shift in our frame of reference. I was interested in thoughts about the culture and whether you can imagine helpful interventions that have to do with the culture of the soldiers and how they deal with each other. We could explore not just what clinicians can do, but what the context can do to help with these kinds of problems. DR. RADKE: I am the State Medical Director for the Minnesota Department of Human Services and Chief Medical Officer for State Operated Services. We run all the disability programs in the state. My perspective is from the public mental health sector. Obviously, we know we are running a fragmented, discontinuous, gap-filled system, or lack of a system. In spite of that people come to treatment or they are brought to treatment. The point I want to make is that a person with schizophrenia does not come to treatment or get brought to treatment because of their psychosis.
28 Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism We have a threshold, a barrier, stigma, a fear of the system that has to be overcome by tremendously difficult and painful behaviors. They never end up in the hospital because they are psychotic. They end up at the hospital because of their behaviors. Those behaviors have either become overwhelming for the individual or overwhelming for the society. Those behaviors have gotten so painful and have produced so much suffering for the family or the individual that stigma is overcome by the fear of loss of control. That is a powerful point because it is not what we should be doing in our society, but that is what we do. We have a threshold, a barrier, stigma, a fear of the system that has to be overcome by tremendously difficult and painful behaviors. You would not say that about somebody who needs surgery or an internal medicine clinic, but you can say that about somebody coming to the mental health system. That worries me a great deal because no matter what we do—fill all the gaps, become continuous, comprehensive, resolve the fragmentation—if we do not resolve the barrier of stigma and the fear of the system, we will only bring people in when their pain and suffering is such that they cannot resist coming. DR. URSANO: Alan Radke’s comments also touch on the differences between internalizing and externalizing disorders, and how they may be affected. I know Ron Kessler has data on some of those issues.
Page 1 and 2: FORUM ON HEALTH AND NATIONAL SECURI
Page 3 and 4: From the Conference Series: FORUM O
Page 5 and 6: 9 Day 1 Discussion ................
Page 7 and 8: ii Bruce G. Link, Ph.D. Professor,
Page 9 and 10: iv Alisha H. Creel, Ph.D. Assistant
Page 11 and 12: vi Kenneth W. Schor, D.O., M.P.H. C
Page 14 and 15: Executive Summary 1 Executive Summa
Page 16 and 17: Executive Summary 3 about stigma in
Page 18 and 19: Executive Summary 5 value, cost-eff
Page 20 and 21: Executive Summary 7 •• Reinforc
Page 22 and 23: Introduction 9 1 Introduction Mark
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Page 64 and 65: Conceptualizing Stigma and Barriers
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Optimizing Access to Care 77 8 Opti
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Center for the Study of Traumatic S
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