1. Introduction PERCEPTIONS OF STIGMA AND OTHER BARRIERS TO SEEKING MENTAL HEALTH SERVICES AMONG VETERANS Ashley J. Nichols, Ruveanna A. Hambrick, Lauren M. Sparks, & Michelle B. Hill, PhD. University of North Georgia, Dahlonega, GA. The results for this presentation are a subset of a larger study that will examine the prevalence and manifestation of Post Traumatic Stress Disorder (PTSD) among a group of combat veterans. It examines whether elevated rates of externalizing behaviors following deployment could be explained by combat exposure and internalizing symptoms, such as PTSD symptoms, guilt, and moral injury. This study also examines the health of the social environment. The culture of the military values self-reliance and strength, and seeking mental health services stigmatizes one as weak (Bush et. al, 2011). According to Britt, stigma in the military is defined as the belief “that seeking treatment would be embarrassing, cause harm to their career, and/or cause their fellow unit members to have less confidence in them,” (2004). Consequently, a significant proportion of the veteran population who are in need of mental health care are choosing not to seek treatment at all. In addition, financial barriers and lack of knowledge of where to seek help prevents some veterans from doing so. Many combat veterans hold negative perceptions of mental health professionals and the delivery of mental health care (Ouimette et. al, 2011). Some combat veterans may also express concern about the potential effects a diagnosed mental disorder may have on their careers in the military (Britt 2012). A 2004 study found that those veterans whose self-report data were indicative of a mental health disorder were twice as likely to report concern about stigmatization and other barriers to seeking mental health care (Hoge et. al, 2004). A study conducted in 2009 found that veterans who rated their leaders more highly and had a more positive perception of unit cohesion were less likely to perceive barriers to care and express concern regarding the stigmatization of seeking mental health care (Wright et. al). # This study examines the in-country diagnosis of Combat Related Stress (CRS) and the perceived reaction of the veteran’s unit leadership to the CRS diagnosis at their forward operating base. Although the military provides a strict code of conduct in how one’s unit leadership should respond to CRS, current research has shown significant differences in veteran’s in-country experience from supportive to unaccommodating. Some soldiers are told to that such reactions to combat are signs of weakness. The effects of this dynamic in relation to the general stigmas perceived by veterans regarding the seeking of mental health services were analyzed in relation to the barriers that veterans have when attempting to seek mental health services. In the current research, beyond stigma, significant barriers have been related mostly to available services and understanding of combat by mental health providers. By researching these issues associated with seeking mental health care, we can better access why veterans do not seek help when experiencing symptoms of PTSD. Participants (n=21) were all veterans of the OIF, OEF, OND, or Desert Storm conflicts. There were 19 males and 2 females, and participants ranged in age from 23-49. The sample was representative of all ethnicities, marital status, educational levels, and SES. Date of last deployment ranged from 2004-2012. Demographic survey: The 12-item survey is used to gather data for participant characteristics with regards to age, gender, SES, marital status, branch of service and deployment. Internalized Symptomology. The Mississippi Scale for Combat-Related PTSD or M-PTSD is a 35-item self-report measure that assesses combat-related PTSD in veteran populations. Items sample DSM IV symptoms of PTSD and frequently observed associated features (substance abuse, suicidality, and depression). Respondents are asked to rate how they feel about each item using 5-point, Likert-style response categories. Ten positively framed items are reversed scored and then responses are summed to provide an index of PTSD symptom severity that can range from 35- 175. Cutoff scores for a probable PTSD diagnosis have been validated for some populations, but may not generalize to other populations (Keane, Caddell, & Taylor, 1988). Social Environment: This part of the instrumentation packet asks 4- items regarding Combat and Operational Stress Reactions (COSR) and what the combat veterans experience was during deployment because we hypothesize that this aspect of a soldiers social experience called Combat Operation Stress Reaction (COSR) may have an impact on their return and seeking services separate from stigma. The 12-item survey of the Multidimensional Scale of Perceived Social Support (MSPPS, Zimet et al., 1988) is on a 5-point scale and assesses the soldier’s social environment after deployment and upon reintegration. Three additional questions ask specific questions regarding after deployment unit connection and use of the support of mental health and significant relationship status since returning from war. Included in externalizing behaviors is the 10-item Self-Stigma of Seeking Help Scale (SSOSH) (Vogel, Wade, & Haake, 2006). Methodology Hypothesis Results and Conclusions References Britt, T. W., Wright, K. M., & Moore, D. (2012). Leadership as a predictor of stigma and practical barriers toward receiving mental health treatment: A multilevel approach. Psychological Services, 9(1), 26-37. doi:10.1037/a0026412 Bush, N. E., Bosmajian, C. P., Fairall, J. M., McCann, R. A., & Ciulla, R. P. (2011). afterdeployment.org: A web-based multimedia wellness resource for the postdeployment military community. Professional Psychology: Research And Practice, 42(6), 455-462. doi:10.1037/a0025038 Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat Duty in Iraq and Afghanistan, Mental Health Problems, and Barriers to Care. The New England Journal Of Medicine, 351(1), 13-22. doi:10.1056/NEJMoa040603 Ouimette, P., Vogt, D., Wade, M., Tirone, V., Greenbaum, M. A., Kimerling, R., &... Rosen, C. S. (2011). Perceived barriers to care among veterans health administration patients with posttraumatic stress disorder. Psychological Services, 8(3), 212-223. doi:10.1037/a0024360 Wright, K. M., Cabrera, O. A., Bliese, P. D., Adler, A. B., Hoge, C. W., & Castro, C. A. (2009). Stigma and barriers to care in soldiers postcombat. Psychological Services, 6(2), 108-116. doi:10.1037/a0012620 Scores on the Mississippi scale for PTSD ranged from 36 to 125 (M = 74.38, SD = 22.955). This potentially places 11 participants in the category of psychological distress (within the range of 60-112) and two potentially within the range of PTSD (112-148). In this sample, 8 responded that they experienced some form of battle distress. Only one individual was correctly identified and sent to the forward operating base. 5 believed they experienced COSR, but were never sent to the FOB. Two individuals received care as outlined in the military field manual, and three received none of the care outlined. On a positive note, four felt that their unit leaders provided reassurance and listened to them, although two reported that their unit leaders ignored the problem and hoped it would just go away. A correlation test was conducted to examine the relationship between unit leaders’ reaction to distress or COSR and perceived threat to self-confidence when seeking professional help. There was a significant correlation (r(19) = -.526, p =.017). Any negative reaction of unit leaders to the distress of soldiers within their unit correlates to higher perceived threat of self-confidence if professional help was sought (Figure 1). A one-way ANOVA was conducted to examine the effect of unit leaders’ reaction to distress or COSR on perceived stigma associated with seeking therapeutic assistance as represented by beliefs regarding one’s potential to be promoted within the military. A significant effect was found [F(1,18) = 6.05, p =.024]. Any negative reaction of unit leaders to distress of the soldiers within their unit was shown to predict negative perceptions of promotional potential in the minds of veterans. A one-way ANOVA was conducted to examine the effect of PTSD scores on perceived threat to self confidence when seeking professional help. A significant effect was found [F(1,19) = 5.31, p =.033]. Higher scores on the Mississippi Scale for PTSD corresponds to a higher perceived threat to self-confidence when seeking professional help. It is expected that those with PTSD will be more likely to perceive that a stigma exists within the military for those who seek mental health care. Discussion As of yet, our research is limited due to a small sample size. In the future, we plan to gather more data from a greater number of participants through non-random sampling. We will attempt to develop a deeper understanding of COSR in relation to PTSD and the ways in which the two differ in diagnostic criteria. It is our hope that this and future research will contribute to the cultural competency of mental health care providers so that they may better provide the assistance that is needed in the veteran population.