Eckroth Research Paper NSG534

Running Head: THE STIGMA OF PTSD1

The Stigma of PTSD in the Military:

Is Our Leadership Strong Enough for Self-Reflection?

Katherine R. Eckroth

Rush University

NSG 534

Dr. Ruth Fiedler

October 7, 2013

THE STIGMA OF PTSD 2


The Stigma of PTSD in the Military:

Is Our Leadership Strong Enough for Self-Reflection?

Posttraumatic stress disorder (PTSD) continues to plague

mankind, as it has since the beginning of civilization. Its

impact on United States service members (SM) is of particular

interest, as they reintegrate with civilian populations having

polarized societal and economic issues. The potential for

societal fallout is great, as this disorder affects not only the

individual, but the family and society surrounding them.

SMs face an increased risk for developing this disorder due

to the nature of their work. PTSD in the military has been

addressed through several theories, historically, according to

the needs of the government and military leaders (Nash, 2009).

The original medical model diagnosis was replaced with the term

hysteria, an intentionally stigmatizing label that relieved

governments of their responsibility for disability payments and

decreased wartime psychiatric casualty evacuations (Nash, 2009).

In 1980, the DSM replaced hysteria with PTSD and adopted a

normalization model (Nash, 2009). Unfortunately, this has done

little to address the chronic and long-term disability associated


with the diagnosis (Nash, 2009). Recent research supports a

remedicalization model, but Nash warns that military leaders and

public policy makers fear that this may increase medical

evacuations from war zones and disability compensation from the

Department of Veterans Affairs (2009). Stigma has been identified

as the major barrier affecting mental health care for SMs

(Walker, 2010).

Society is well aware of the stigma associated with PTSD and

mental health care. Everyone seems to be asking how we can

address it, yet it continues. Many avenues have been explored and

attempted, yet stigma persists. This author believes that if it

can be imposed, as it was in the military, it can, also, be

exposed and diminished.

This writing addresses how stigma is affecting the

development and progression of PTSD in the military and veteran

populations and what is being done or may be considered to

mitigate it. Many challenges present in the study of veteran

populations. There is an expansive age, specialty, and experience

range to consider. Because many individuals may not present for

care or receive diagnosis for years after acquiring a combat


stress injury, active-duty and retired or separated veterans are

included in this overview.

An initial literature review of 17 peer-reviewed articles

was narrowed to eight after six opining editorials and two

studies were excluded to meet the documented requirements. Two

literature reviews, three cohort studies, one experimental study,

and one expert opinion, based on both professional and research

experience, are included in this review. Each is qualitative in

nature, except for Bruner’s document addressing the

pathophysiology of PTSD.

Let’s begin with how the military uses the normalization

model to approach care. Bruner’s article supports combating

stigma with an educational emphasis entailing a holistic

perspective regarding the pathophysiology of PTSD (2011). A

normalization model is adhered to as readers are enlightened

about the individual roles of the autonomic nervous system,

brain, threat, and memory and how their cumulative responses

affect the entire body’s balance. The authors concur that

symptoms arise from a physical core and are the normal adaptive

changes that occur when one is exposed to combat stress (Bruner,


2011). The implied goal is to utilize psychoeducation and skill

training to assist veterans, presenting with combat stress

injuries, and their family members in recognizing that these are

normal responses (Bruner, 2011). This supports that they are not

defective or crazy in order to assist them in building trusting

relationships, identifying triggers, regulating the stress

system, and encouraging hope and change through a holistic

process (Bruner, 2011).

We will move on to what occurs during deployment. Major Alan

D. Ogle illustrates the provision of Combat and Operational

Stress Control (COSC) services in Afghanistan from 2007 to 2010

and the services that were utilized (2012). “COSC includes a

broad spectrum of actions by commanders, noncommissioned

officers, chaplains, medical and behavioral health (BH)

personnel, and others to prevent and treat stress injuries and

impairments in deployed SMs and units as a whole” (Ogle, 2012).

COSC teams consist of a provider (a psychologist, social worker,

or psychiatrist) and an enlisted mental health specialist, for

which no further definition was offered (Ogle, 2012).


Each of the 12 teams established a clinic at a Forward

Operating Base (FOB) and would travel to circulate throughout

other FOBs (Ogle, 2012). One larger team operated at a theater

hospital, Bagram Air Base, while another worked at the Freedom

Restoration Center, where a three day in-residence program of

structured recuperation including scheduled sleep, meals, and

physical exercise, resiliency development classes, and

individualized support was offered (Ogle, 2012). U. S. Army BH

Officers (BHO), either social workers or psychologists, along

with their BH technicians were, also, deployed as part of their

brigades (Ogle, 2012).

COSC operations were established to “influence operations to

build cultures of psychological self-aid and buddy care” but not

intended to be mental health care (Ogle, 2012). This was

implemented through supportive and educational interactions with

SMs and consultation and collaboration with unit leaders,

chaplains, and others (Ogle, 2012).

Help in place (HIP) consisted of “checking in” with and

recommending a relevant class or appointment for SMs known to be

experiencing stressors (Ogle, 2012). Psychoeducational classes


were group-based with topics of sleep hygiene, tobacco cessation,

stress management, anger, compassion fatigue, and resiliency

(Ogle, 2012). Trauma Event Management (TEM) focused on supporting

healthy grieving in SMs and units as they faced the reality of

returning to duty (Ogle, 2012).

Individual appointments were, sometimes, available and were

consistent with a “fairly standard” mental health appointment,

focused on assessment, interviews, and educational, skill

training, psychotherapeutic, or pharmaceutical interventions

(Ogle, 2012). If the SM’s symptoms responded quickly, they were

diagnosed with Combat Operational Stress Reactions, and if they

did not, they received the diagnosis of a behavioral health (BH)

disorder (Ogle, 2012). Return to duty was high (Ogle, 2012).

Ogle concludes that combat stress reactions were the primary

reason for seeking COSC care, but that most SMs involved in

direct combat did not need or desire BH care immediately

afterward (2012). Increased intensity to combat exposure and

presence of casualties, especially unit members, SMs, civilians,

and children, resulted in increased COSC seeking care (Ogle,

2012). Occupational specialty to mission match is related to


psychological preparedness (Ogle, 2012). The least presenting

issue was that of secondary gain, not consistent with the view

that most SMs “only go to mental health to get out of work” or be

evacuated (Ogle, 2012). The largest percentage of SMs who

received a BH disorder diagnosis had a pre-existing Axis 1

disorder (Ogle, 2012). Ogle recognizes that COSC encountered

significantly higher rates of depression and anxiety than the

Joint Mental Health Advisory Team (JMHAT7) did and offers that

the active seeking of those in need may have influenced this

(2012). There was, also, a very high prevalence of sleep

difficulties (Ogle, 2012).

The author admits that stigma, structural, and

organizational barriers continue to exist, especially for those

screening positive for depression, anxiety, or acute distress

(Ogle, 2012). He suggests that educating SMs of all ranks through

a normalization model and building a culture of self-aid and

buddy care endure and be of aid when combat stress reintegration

begins (Ogle, 2012).

All Soldiers are processed through the Soldier Readiness

Program (SRP) within the first week that they return from


deployment (Hoyt, 2011). They are screened for BH distress and

current life stressors and may initiate a same-day appointment

with a BH provider (Hoyt, 2011). If this occurs, a plan of care

must be in place before the active-duty SM can go on leave and

the National Guard of Reserve SM can be demobilized and released

home (Hoyt, 2011). SMs are, again, screened 90-180 days after

return from deployment through the Post-Deployment Health Re-

Assessment (PDHRA), where the SM can, again, meet with a BH

provider (Hoyt, 2011). The option of meeting with a BH provider

is intended to reduce stigma and promote support for BH issues

(Hoyt, 2011).

The Re-Engineering of Systems of Primary Care Treatment for

the Military (RESPECT-Mil) program and placement of

psychologists, offering consultative services, in primary care

settings offer additional screenings for BH problems (Hoyt,

2011). Uniformed providers may function as command consultants in

response to concerned commanders for SMs unwilling to self-

initiate treatment (Hoyt, 2011). These consultants assist with

alternative treatment and support models before resorting to a

mandatory command-directed evaluation (Hoyt, 2011). The author


supports the normalization model in addressing the stigmas

connected to seeking treatment and one’s military career through

treatment of subclinical symptoms of PTSD and prevention of their

progression (Hoyt, 2011).

Hoyt realizes that stigma regarding BH treatment is well-

entrenched in the military culture (2011). He concludes that

providers must overcome stigmas and improve the treatment offered

to SMs returning with PTSD (Hoyt, 2011).

Despite these interventions, substantial evidence exists

that stigma discourages SMs from seeking treatment (Walker,

2010). Up to 50% of those that develop a BH problem from combat

trauma experience do not seek help, and one study showed that 40%

of those asked would not trust a returning stress casualty

(Walker, 2010). The emphasis on individual heroism and group

loyalty within the military opposes the admission of

vulnerability (Walker, 2010).

Brown and colleagues present survey results of 577 Soldiers

over the age of 18 during a one-year period (2003 to 2004), who

previously screened positive for depression, anxiety, and PTSD

three months after returning from deployment (2011).


Their univariate analysis suggested that perceived unit

stigma was related to an increased likelihood of interest in

receiving help, and that increased deployment satisfaction was

related with lower interest in receiving care (Brown, 2011).

Respondents recognizing a current BH problem had greater than 7.5

odds of being interested in receiving help, but only 49.1% of

those were interested in receiving help (Brown, 2011). Of those

not recognizing a problem, only 11.1% were interested in

receiving help (Brown, 2011).

The multivariate analysis, also, revealed that those with

higher perceived unit stigma were more interested in receiving

help, but found that no unit or deployment characteristics were

related to an interest in receiving help (Brown, 2011).

Individuals with more stigmatizing attitudes toward others with

BH problems showed a nonsignificant trend with reduced interest

in seeking help. Of special note is that those responding with a

rank of E7, or Sergeant First Class (SFC), or higher were

significantly less likely to be interested in receiving help than

those with a rank between E1, Private (PVT)-E4, Corporal (CPL) or

Specialist (SPC) (Brown, 2011).


Negative views of treatment and the stigmatization of others

with mental health issues were related to less interest in

receiving help (Brown, 2011). Recognition of a mental health

issue is limited in value if one perceived that the care provided

is not trustworthy of efficacious (Brown, 2011). Internal

barriers may prevent one from seeking help, especially if one

does not view themselves as the type of person who needs

assistance, as possibly reflected by higher ranking individuals

showing less interest in receiving help even though they screened

positive (Brown, 2011). These individuals may, also, have

concerns regarding their careers (Brown, 2011).

Pietrzak and colleagues analyzed whether OEF/OIF veterans

who met screening criteria for PTSD, depression, or alcohol abuse

endorsed higher perceived barriers to care and stigma than those

without positive screens (2009). The sample was identified

through a review of Veterans Administration (VA) documents

(Pietrzak, 2009). Those screening positive were younger and

scored higher on both perceived stigma and barriers to care

scales. Positive screens for PTSD were found to predict both

stigma and barriers to care, while positive screens for


depression, anxiety, and alcohol use disorders interacting with

PTSD were not significant (Pietrzak, 2009). Unit support and

negative beliefs surrounding mental health care were, also, found

significant in predicting stigma and barriers to care (Pietrzak,

2009).

Brown (2011) and Pietrzak (2009) each found that negative

beliefs regarding mental health care were associated with less

likelihood of seeking help. However, Pietrzak (2009) reported

that perceptions of decreased unit support were associated with

increased stigma and barriers to care, while Brown (2011)

concluded that no unit or deployment characteristics were related

to an interest in receiving help.

Rosen and companions, also, surveyed veterans identified

through VA documents, who received a diagnosis of PTSD within the

past two years (2011). Approximately one-third of participants

indicated that stigma concerns were “moderately” to “very much”

reasons for not seeking care through the VA for personal

problems, although 88% of them wanted help (Rosen, 2011). Those

with greater impairment or desire for assistance were more likely

to initiate care through Vet Centers than the VA (Rosen, 2011).


Global negative attitudes regarding BH care did not present as

substantial barriers for the use of psychotherapy by VA patients

with PTSD (Rosen, 2011).

The strength of these studies lie in the fact that they

address a pervasive problem and explore opportunities to identify

and respond to its causes. Each require leadership buy-in and

participation.

Unfortunately, there are many limitations to this research,

as it remains explorative and qualitative in nature. Furthermore,

questions of bias or conflict of interest may be raised, as each

of the authors is affiliated or employed by the Department of

Defense (DOD) or Veterans Administration (VA), and several

oversee the various programs mentioned throughout the literature.

Generalizability is not afforded due to the complexity of

procuring samples and the possibility that those most affected by

stigma may not have participated in the studies. Hoyt and Bruner

provide overviews, but no efficacy regarding their implemented

programs and hypotheses.

A brief overview of programs intended to prevent stigma and

the response to stigma in veteran populations has been provided


thus far. This view, in its totality, raises further questions

that warrant further research and discussion, in that each of the

authors endorse refractory stigma.

Jonathan Shay, a leading clinician in combat trauma,

addresses his work with an emphasis on leadership, unit cohesion,

training, and secondary trauma (2009). He believes that the key

issue for psychologically wounded combat veterans is the

destruction of their capacity for social trust (Shay, 2009). Shay

emphasizes that the quality of leadership is critical to the

prevention of combat stress primary injury, and states, “The main

way you prevent the complications of combat trauma is by

functionally expert, ethical, and properly supported leadership

at all levels” (2009). He questions, “Why should something so in

harmony with the ideals of the military services, expert,

ethical, and properly supported leadership be so hard for them to

realize” (Shay, 2009)?

He explains that moral injury occurs when someone holding

legitimate authority violates what is right in a high stakes

situation, and that culture determines what is right and

legitimate and who holds authority (Shay, 2009). Shay is,


particularly, critical of the Diagnostic and Statistical Manual

(DSM) criteria for PTSD, considering it as intentionally creating

a loophole to deny a proper diagnosis for those suffering from

PTSD (2009). We must, also, acknowledge the role that secondary

trauma plays (Shay, 2009).

As veterans reintegrate with civilian populations, providers

must be knowledgeable regarding military culture and the issues

affecting these unique individuals. Knowledge and experience can

empower us to overcome obstacles and provide evidence-based

empathic care.

Ogle (2012) and Pietrzak (2009) emphasize the importance of

educating those in leadership roles. Each of the articles

reviewed implicate leadership as crucial to combating stigma,

essentially, because no program is efficacious without it in

dealing with the dynamic natures of both stigma and PTSD.

It is alarming that those screening positive with a rank of

E7 or higher were significantly less likely to be interested in

receiving help, and may illustrate a disconnect between senior

leadership and junior personnel. Furthermore, the dependency

culture of the military leads to limited self-reliance (Walker,


2010). All subordinates are dependent upon their leadership in

the military, especially in a combat environment. Negative

beliefs that encourage internalized barriers may be reflected by

higher ranking individuals. This is extremely important, because

recognition of a mental health issue is limited in value if one

perceives that the care provided is not trustworthy of

efficacious (Brown, 2011). Perhaps, the presence of moral injury

can be attributed to this?

Is the normalization model that the DOD and policy makers

depend on overwhelming the VA system and perpetuating mental

health issues in veteran populations by their disregard of the

true nature of PTSD? Moreover, are the myriad of programs and

ambiguity in DSM criteria imposing a lack of standardization and

understanding with intentional uncertainty, elevated costs, and

ineffective solutions?

Rosen suggests the services that veterans receive could

depend on enabling system treatment factors, as well as the

individual’s predisposing characteristics (2011). The barriers of

enrollment and diagnosing PTSD were not included in these

studies, but could very well influence stigma. Whether


participants felt that they could overcome any of these barriers

and actually receive care or if any facilitators were present to

counteract the barriers were not studied.

Regardless of the results, change cannot occur in the

military without leadership buy-in. It may benefit us to explore

each of these issues further and focus on senior military

leadership BH issues and acceptance. If military leaders and

policy makers cannot or will not recognize these issues and seek

help themselves, stigma will continue its unabated course.

References

Brown, M. C., Creel, A. H., Engel, C. C., Herrel, R. K., & Hoge,

C. W. (2011). Factors

associated with interest in receiving help for mental health

problems in combat veterans

returning from deployment in Iraq. Journal of Nervous & Mental

Disease, 199 (10),

797-801.


Bruner, V. E., & Woll, P. (2011). The battle within:

Understanding the physiology of war-zone

stress exposure. Social Work in Health Care, 50 (1), 19-33.

Hoyt, T., & Candy, C. (2011). Providing treatment services for

PTSD at an Army FORSCOM

installation. Military Psychology, 23 (3), 237-252.

Nash, W. P., Silva, C., & Litz, B. (2009). The historic origins

of military and veteran mental

health stigma and the stress injury model as a means to

reduce it. Psychiatric Annals, 39,

789-794.

Ogle, S. D., Bradley, D., Santiago, P., & Reynolds, D. (2012).

Description of combat and

operational stress control in Regional Command East,

Afghanistan. Military Medicine,

177 (11), 1279-1286.

Pietrzak, R. H., Johnson, D. C., Goldstein, M. B., Malley, J. C.,

& Southwick, S. M. (2009).

Perceived stigma and barriers to mental health care

utilization among OEF-OIF veterans.


Psychiatric Services, 60 (8), 1118-1122.

Rosen, C. S., Greenbaum, M. A., Fitt, J. E., Laffaye, C., Norris,

V. A., & Kimmerling, R. (2011).

Stigma, help-seeking attitudes, and use of psychotherapy in

veterans with diagnoses of

posttraumatic stress disorder. Journal of Nervous & Mental Disease,

199 (11), 879-885.

Shay, J. (2009). The trials of homecoming: Odysseus returns from

Iraq/Afghanistan. Smith

College Studies in Social Work (Haworth), 79 (3-4), 286-298.

Walker, S. (2010). Assessing the mental health consequences of

military combat in Iraq and

Afghanistan: A literature review. Journal of Psychiatric & Mental

Health Nursing, (9),

790-796.

Eckroth Research Paper NSG534

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