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

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Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism
need and did not obtain services, we find that employment does not matter but insurance
does. Insurance does not matter for perceiving need, but it does differentiate
between those who get service and those who do not. What you find is that those
who have public insurance or no insurance are much less likely to get services than
those with private insurance.
Moving now to perceived need for mental health services I am going discuss factors
that are much more objective than people reporting perceived need. I am going
to look at event exposure, stressors, PTSD, depression, and generalized anxiety. The
good news is that the people who we might think objectively would need services
are the people who do actually report needing services. We found about a threefold
greater likelihood of reporting need in those who have PTSD, depression, anxiety,
a number of stressors, and a number of traumas. There is a dose-response relationship
between being exposed to traumatic events and actually getting services among
those who report need. This is likely due to the availability of services arranged by
government and not-for-profits for the people who are most severely exposed.
What emerges from this event is that men, minority groups, and persons with
low social support are the people who are expressing concerns about stigma overall,
while minority racial groups report low outcome expectations. Health insurance and
psychopathology matter in this context, while predicting need is actually not predicting
access to services, and this is quite concerning. Across these varied contexts of
disaster, trauma and war, if we are to make a difference in this area we need to get
more sophisticated in parsing out the barriers to care among different vulnerability
groups in order to identify just what we need to overcome. Thank you.
DR. HOBFOLL: First, I would like to thank Drs. Brown and Ursano and Mary
Lee Dichtel. I want to begin by stating that I think the first point of this meeting
may be some meaning that is beyond what we could get by reading the important
presentations of Dean Kilpatrick and Sandro Galea. If someone as smart and experienced
as Matthew Friedman and myself and a few others disagree, that is really an
interesting point to get at, to advance. I want to get us to argue a bit more, therefore
I am going to try to say a few things that will cause argument.
Uncle Sam is getting older, and America is facing some large problems in dealing
with disasters, terrorism, and trauma on the world stage. The FALLS model
expands the principles and parameters of the adaptation process in the Conservation
of Resources model and stands for Fitting, Adaptation, Limitations, Leniency, and
Selection. First is fitting. Resources do not just fit demands. Humans are active and
our institutions and culture are active in fitting. Fit is a verb. Resources often need
to be molded or altered to fit. How do we mold and alter our institutions and our
culture itself in order to fit demands The distance of resources of any group to new
demands makes this fitting more or less difficult. If you are in the group that has
lots of resources, you make the transition rather quickly and easily. If you are in
the group that does not, there will be many more impediments. A great example of
unexpected fitting of resources is when the Mohawk Indians moved from Canada
in the early 1900s to build skyscrapers. Someone realized that although they had
never been up in a skyscraper or even seen one, hardly anyone had at that time, they
were not scared of heights and they needed jobs. They had a little bit of a resource,
but a great deal of adaptation was required to go find them, bring them in, and
train them.
Second is adaptation. Adaptation is a process of successive approximations, not