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
However, the issues I have to deal with and the decisions I have to make in the first
24 hours are life and death issues. Mental health concerns, while important, do not rise
to that level of importance.” Well, excuse me. When I got over the narcissistic injury of
this, I realized that this was a problem. My colleagues and I have not been doing the
job that we should do in defining where we can contribute and what our behavioral
health concerns are. In fact, the behavioral choices that people make in these kinds
of situations are very much life and death decisions. I realized then how important it
was to make sure that we correct some assumptions about what our jobs are and can
be in these situations.
I have been in this field for many decades and my view is that things are improving.
One of the ongoing frustrations I have is that much of the improvement in the field
does not seem to be systemic. It seems to be personality dependent: who is sitting in
what chair at what time and who is sitting in the chair across from him or her at that
same time. When that constellation changes, a great deal of good work gets undone
or forgotten. I am not sure what to do about that. It has gotten better but we have a
long way to go.
I want to end with some suggestions. One is that we need to more broadly define
our contribution. Getting in and doing individual interventions with people is important
work, and I do not want to trivialize it. We also need to do more consultation and
leadership training. One of the areas that I have been involved with more intensely in
the last couple of years is trying to integrate behavioral health principles with messaging
and communication. I think that is where there is a whole lot of bang for the buck
and where I want to put some of my energies. It is an exciting area. Systems design
and preparedness is another area where we have something to contribute.
We need to continue to increase the evidence base. When you look at where the
evidence basis comes from and how it has advanced, probably 90% of it comes from
the people in this room; we need to keep doing that. The more our consultation
and systems design is based on evidence rather than on marketing or belief, the better
off we will be. We need to get to and stay at the table somehow. We need to have a
presence in discussions about systems issues, whether it is in emergency management
or public health. If you are not invited, go anyway. If you do not make a fool out of
yourself, you might get invited back. Get there and stay there somehow.
I also think that part of what we need to keep in mind when we are dealing
with these other systems is how to make other people’s jobs easier. That will get us
incorporated and invited back. The FEMA-funded program that I administered for
many years is now almost 40 years old, and once you work with people long enough,
they begin to tell you the truth. This program was not generated by a humanitarian
concern. It was generated because at that point there were one-stop shops for people
to come in and apply for FEMA assistance. People were getting upset and crying in
those situations, and FEMA personnel did not know how to handle them. People were
so distraught that they could not fill out the forms. They wanted us to solve that stress
based administrative problem for them and it was the birth of something that has gone
on for many decades.
There are many fantasies about what we do, including a belief that our job is going
to make other people’s jobs more difficult or complicated. We always need to go into
these systems discussions with an eye toward how we are going to solve a problem
for the people who we are doing business with. And then we need to push for parity.
We need to continue to advocate within these other systems to ensure that behavioral