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Section 6: Barriers to Seeking Care

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Section Contents

  1. Stigma
  2. Access
  3. Additional Issues for Certain Population

I served in Baghdad from April 2003 to May 2004…September of 2003 I was sent for treatment …I met with a Major there a couple of times who put me on three different antidepressants. For those of you who have been there, you know how difficult this is. For one, just the PTSD and Combat Stress Control is a huge stigma that generally isn't viewed too kindly by the chain of command. Add to this the fact that I was an NCO in charge of a combat engineer team who prided themselves in their “sapper” skills.

But the other difficult part is actually getting the antidepressants you were prescribed. For us, there wasn't a pharmacy anywhere nearby; you had to go to the Green Zone.

Lejeune, Chris. From his blog on The VetVoice Diaries.

Researchers have found that among the military service members who have returned from Iraq and Afghanistan and report symptoms of post traumatic stress disorder or major depression, only slight more than half have sought treatment (Tanielian and Jaycox 2008). Barriers to seeking care fall into two general categories: stigma and access (Hoge et al. 2004).

1.   Stigma

Three unique types of stigma pose barriers to treatment (Sammons 2005):

Public Stigma refers to the public (mis)perceptions of individuals with mental illnesses. Over half of surveyed soldiers who met criteria for a psychological health problem thought they would be perceived as weak, treated differently, or blamed for their problem if they sought help (Hoge et al. 2004; US DoD Task Force on Mental Health 2007).

Self Stigma refers to the individual internalizing the public stigma and feeling weak, ashamed and embarrassed.

Structural Stigma refers to the institutional policies or practices that unnecessarily restrict opportunities because of psychological health. Service members repeatedly report believing that their military careers will suffer if they seek psychological services. They believe that seeking care will lower the confidence of others in their ability, threaten career advancement and security clearances, and possibly cause them to be removed from their unit (US DoD Task Force on Mental Health 2007).

The Army has made a concerted effort to reduce the stigma associated with psychological health issues and the efforts seem to have had a positive effect. Based on the Army’s annual survey of soldiers in theater, fewer soldiers who met the screening criteria for a mental disorder report that stigma affected their decision to seek treatment in 2007 than in 2006. However, the levels remain unacceptably high as over half of male soldiers in Iraq who meet the screening criteria were concerned that they “would be seen as weak” and 40 percent believed that their leaders would blame them for the problem (US Army Surgeon General 2008) (Exhibit 4).

Exhibit 4: Perceived Barriers to Seeking Mental Health Services, 2006 and 2007

Factors that Affect the Decision to Seek Mental Health Treatment



I would be seen as weak



Members of my unit might have less confidence in me



My leaders would blame me for the problem



It would harm my career



It would be too embarrassing



Source: Data from MHAT-V 2008

2.   Access

Even when service members or veterans decide to seek care, they need to find the “right” provider at the “right” time. As described in section 5, this is not always possible. When care is not readily available the “window of opportunity” may be lost.

In contrast to the data collected by DoD on barriers to mental health care, there is currently a dearth of information on barriers to care for OIF/OEF veterans seeking VA care. VA publishes patient satisfaction data, but by definition this data only reflects the views of veterans who have overcome whatever barriers that exist and succeeded in gaining access to care. A feedback loop which includes the systematic collection of data on the perception of consumers about the ease of access to care is crucial to identify and decrease barriers to care. No such mechanism for VA care currently exists.

A recurring survey of a national sample of OIF/OEF veterans, including those who do not currently utilize VA services could identify barriers to care, such as: distance from required specialized services; availability of specified types of service including early intervention services; bureaucratic obstacles to accessing care; user friendliness; clinic hours and policies; perceived stigma and concerns with impact on job or reserve unit status; and lack of information about what services are available.

3.   Additional Issues for Certain Populations

A.   Culturally Diverse Populations

Little attention has been paid to the unique needs of culturally diverse populations with PTSD. Despite high rates of PTSD, African-American, Latino, Asian, and Native American veterans are less likely to use mental health services for several reasons:

Cultural competency of providers: A study of Native American and Latino veterans identified several barriers to VA services: 85 percent felt “VA care-givers know little about ethnic cultures," and 79 percent felt that “VA care-givers have problems talking with ethnic veterans" (Nugent et al. 2000). Although little research on the issue specifically focuses on veterans, studies in the civilian sector suggest that individuals are more likely to follow through with therapy if the clinician and client are matched ethnically (Norris and Alegria 2005). The scarcity of minority providers makes this unlikely for most nonwhite veterans. In addition, many intervention materials are unknowingly embedded with cultural expectations and unsubstantiated assumptions about such issues as time orientation, social and occupational commitments, family structure, and gender roles.

Stigma: Compared to white veterans, African-American veterans are more likely to feel shame and guilt for their PTSD. Latinos are more likely to believe that asking for help will bring dishonor to their families. These responses are exacerbated because both groups are more likely to feel that a health provider has judged them unfairly (Norris and Alegria 2005).

Linguistic access: Although most service members and veterans are fluent in English, their family members may have limited English proficiency. Given the important role of families in encouraging veterans to seek services and in locating those services, multilingual outreach and family support is necessary. VA-wide publications such as “VA Benefits” are available in several languages. However, most material, including outreach material, is developed by local or regional VA entities (such as a Vet Center or a VISN), and those entities develop materials in languages other than English at their discretion. The VA Center for Minority Veterans encourages, but cannot require, that materials be available in other languages.

B.   Women

Women make up about 10 percent of the US forces in Iraq and Afghanistan. Some of these women have been returning from Iraq not only with combat-related trauma, but also with Military Sexual Trauma (MST). Although estimates vary, between 13 percent and 30 percent of women veterans experienced rape,  and a higher percentage experienced some type of sexual trauma over the course of their military careers. The sexual trauma combined with combat trauma makes women far more likely to experience PTSD (Yeager et al. 2006).

The military’s response to individual reports of MST, and the barriers that women face in reporting this trauma, is beyond the scope of this report. VA has established a number of programs to address the impact, including Military Sexual Trauma counseling, Women Veterans Stress Disorders Treatment Teams, and MST centers.