Sep 30, 2014
When facing mental health problems, many service members choose not to seek needed help because of the stigma associated with mental health disorders and treatment. Not seeking appropriate mental health care can negatively impact the quality of life and the social, emotional, and cognitive functioning of affected service members. The stigma of seeking mental health treatment in the military persists despite the efforts of both the U.S. Department of Defense (DoD) and the Veterans Health Administration to enhance mental health services. The service branches have been actively engaged in developing policies, programs, and campaigns to reduce stigma and increase service members' help-seeking behavior.
RAND sought to provide a comprehensive assessment of the effectiveness of these stigma-reduction efforts to evaluate their alignment with service members' needs and evidence-based practices and to offer recommendations on how the efforts might be improved. We started by defining what mental health stigma means in the military context, as well as assessing its prevalence in the military and the medical and societal costs. We then looked at what the scientific evidence base shows about the most-promising program and policy options for reducing stigma and evaluated how well DoD's program and policies align with that evidence base. Finally, we identified priorities for DoD to consider in an effort to enhance and refine its stigma-reduction efforts.
Defining mental health stigma in the military is critical to understanding how best to address the challenges it presents. Mental health stigma is a dynamic process by which a person perceives or internalizes a negative image about himself or herself or people with mental health disorders. This process happens through an interaction between a person and the key contexts in which he or she operates: public (i.e., military culture and norms), institutional (i.e., military policies and programs), social (i.e., family and friends), and individual.
Through literature review and our own analysis, we found that four immediate outcomes are empirically linked to stigma: coping mechanisms for stress, interpersonal outcomes (e.g., self-esteem), attitudes toward treatment seeking, and intentions to seek treatment. Additionally, the literature has theoretically linked four long-term outcomes to stigma: well-being, quality of life, treatment initiation, and treatment success; however, these outcomes could not be empirically linked through either literature or our analysis. (See figure.)
Overall, current stigma-reduction efforts within DoD are aligned with best practices and may be contributing to a decline in self-reported stigma. For example, DoD's approach to addressing this challenge goes beyond just stigma reduction and encompasses a broader approach to minimizing barriers to mental health care. This approach is consistent with best practices and may have contributed to declines in self-reported perceptions of stigma among a subset of the military population. Another finding of note is that most of the stigma-reduction programs currently implemented by DoD target stigma in the public context.
Our analysis also identified some challenges to DoD's efforts, including the existence of policy language barring service members with mental health disorders from career opportunities, which could create paths for discrimination, as well as tensions between policies that protect the privacy of service members seeking mental health treatment and the need for commanders to assess individual and unit fitness. Additionally, some policies support universal educational stigma-reduction programs but do not support more-targeted programs for those who are already seeking mental health treatment.
To improve the effectiveness of DoD's stigma-reduction efforts, RAND makes the following recommendations: