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In a study of barriers to mental health treatment among recent OEF/OIF Veterans who screened positive for PTSD but resisted treatment services, Veterans only infrequently pointed to stigma as a reason for resisting treatment. The majority of Veterans who participated in the study had not accessed the VA health care system for treatment of any type before participating in the study, and none had accessed PTSD treatment despite screening positive. Participants agreed to an hour-long telephone session with a trained Ph.D. psychologist to discuss beliefs about seeking treatment. During the session, organized from a cognitive-behavioral framework, participants were asked about their PTSD symptoms, coping skills, beliefs about symptom improvement and beliefs about seeking PTSD treatment. Thoughts about seeking PTSD treatment were discussed in detail, allowing for potential modification of these beliefs. Sessions were tailored and individualized. For example, one participant modified the belief that he could not tolerate talking about his traumatic event, stating that "it's really hard to talk about that day but I think about it all the time even though I don't want to and might as well try to get help."
Beliefs about PTSD treatment elicited during the telephone sessions were analyzed and grouped according to theme. Four themes emerged, with the first two themes accounting for over 80 percent of discussions. The two most frequently discussed barriers to treatment related to expectations of treatment (i.e., don't want a medication, don't want group therapy) and emotional readiness (i.e., don't feel emotionally ready to discuss traumatic event). 1 The two other themes that emerged from the data included stigma and logistical issues, such as time and distance to the VA.
Arguably, one of the most frequently cited statements regarding barriers to mental health treatment among returning military personnel is that a stigma persists within military culture toward mental health treatment. 2 While stigma may have historically been a reason for resisting treatment, recent years have seen a significant effort to eradicate the perception among our warriors. For example, military leaders have come forward and admitted their own struggles with symptoms of PTSD. In addition, and perhaps importantly, our culture has responded enthusiastically as troops return home and talk about traumatic memories. In the new age of technology, we have been able to give voice to our warriors and their stories, and our warriors have received the support of family members, friends, and fellow warriors. The perception of stigma associated with PTSD and PTSD treatment might be in flux within military cultures, although stigma may still very well exist for other mental health conditions such as depression and/or addiction.
A change in the perceptions of stigma associated with PTSD and PTSD treatment does not necessarily mean higher treatment rates among OEF/OIF Veterans. Indeed, interventions to improve mental health treatment utilization among Veterans are still warranted. Much of the current work focuses on improving rates of mental health treatment engagement, both initiation and adherence, among VA users identified as in need of treatment when assessed during a visit to primary care. Yet, requiring Veterans to go through primary care to gain access to specialty mental health care may decrease the number of Veterans who seek PTSD treatment.
Many Veterans are willing to seek treatment, but they do not fully trust the treatment system, which might be understandable in view of the realities and sometimes the complexities of using VA health care. Given that the most frequently cited barrier to treatment was Veterans' preference not to be prescribed a medication to treat PTSD, any process that requires a route through primary care may not be in Veterans' best interests. Co-location of services may improve initial engagement rates, but VA needs to do more to ensure that Veterans receive an adequate dose of preferred evidence-based treatments.
Regardless of system changes that may occur within VA, it is important to remember that Veterans make decisions regarding the need for treatment on their own. Decisions regarding treatment engagement and retention are not made easily or lightly. In fact, Veterans continually revisit the decision based on a combination of beliefs about their perceived severity of need, expectations on symptom improvement, and perceptions about providers. While it may be unwieldy to conceive of a treatment system that is individually responsive to Veterans, Veterans make individual decisions on whether or not to engage or continue to engage in the VA health care system. Future outreach and/or retention interventions should be responsive to individual complexities.
Stecker, T. et al. "Barriers to Treatment Seeking among Veterans of the Wars in Iraq and Afghanistan Who Screen Positive for Posttraumatic Stress Disorder,"Psychiatric Services, 2013; 64(3):280-3.
Hoge, C.W. et al. "Combat Duty in Iraq and Afghanistan, Mental Health Problems, and Barriers to Care," New England Journal of Medicine 2004; 351(1):13-22.