Stigma

Several types of stigma were described among the literature as barriers to help-seeking: internalised stigma, anticipated stigma and public stigma.23 27 34 35 Internalised stigma refers to veterans’ negative beliefs regarding MH problems and treatment-seeking, such as feeling ashamed.34 36 Furthermore, there was also an internalised belief that seeking treatment would make veterans appear ‘weak’.31 In addition, there were several negative stigmatising beliefs held by veterans in regard to MH, such as believing those with MH problems cannot be counted on or take care of themselves.28 Internalised stigma suggests that veterans’ own negative beliefs regarding MH are a barrier to help-seeking behaviour, as having these beliefs would impede on wanting to seek help for MH problems due to fear.22 29 34 36 However, internalised stigma has, on occasions, been found to not be significantly associated with poor help-seeking.28 37 This lack of significant effect could be due to a veteran’s perceived need for care, mediating the relationship between internalised stigma and help-seeking.35

Anticipated stigma refers to stigma that veterans would expect to receive from others.34 38 As many as 29.9% of veterans believed that, if they had a MH problem, their friends and family would feel uncomfortable around them.28 Further literature reported that veterans’ lack of help-seeking was due to fear of a MH problem interfering with their career and career prospects.22 25 This would suggest that anticipated stigma from others may hinder veterans from wanting to seek help for an MH condition due to fear of how others would perceive them.

Public stigma refers to a belief that the general population would perceive them as ‘damaged goods’.25 29 33 39 Veterans were often concerned with the stigmatising labels that are associated with MH issues, such as being viewed as ‘crazy’, with as many as 44% of veterans agreeing that accessing treatment would make them appear weak.21 32 Despite this, only 12% of veterans agreed that they themselves would view others as weak if they sought treatment.21 Public stigma was particularly prominent in veterans within the homeless population who believed that, due to their homeless status, they would be more likely to be treated poorly, which hindered their motivation to receive help for any MH concerns.33 In addition, veterans also felt that they were stigmatised by the general public due to any MH problem that has been induced by their service, as they believed that some civilians view their service as an ‘adventurous vacation’, with some even viewing them as murderers.38

However, Cerully et al 37 found a lack of longitudinal data for assessing the relationship between MH stigma, particularly within the veteran population. Data consisted of a small number of studies which found no relationship between self-stigma and treatment-seeking. However, self-stigma was found to be positively related to treatment attrition. This suggests that much of the literature we currently have regarding stigma and help-seeking behaviour in the veteran population employed a cross-sectional and self-reported method of data collection, which holds the limitations of being less objective and makes it difficult to make causal inferences. Furthermore, there is lack of research regarding stigma among female veterans, although it has been found that female veterans have significantly lower levels of internalised stigma than male veterans.40

Military culture, identity and characteristics

Military culture and identity prescribes to the idea that soldiers should be heavily self-reliant, with a frequently cited emphasis on stoicism.27 29 31 41 This identity means that veterans often cite the military culture of prioritising fulfilment of a mission over personal discomfort as well as of sickness being regarded as a sign of weakness.22 32 39 41 42 This sense of pride that veterans hold and their belief that admitting they need MH support would mean they were no longer a ‘hero’ suggest that veterans do not seek help due to a sense of honour.25 38

Female veterans are often overlooked in the literature, potentially due to them being a smaller population within the military. However, studies have indicated that female veterans report higher pressure to uphold the reputation of female service members, citing that women are often not taken seriously within the military.40 43 Many female veterans have adopted the same attitudes as male veterans in not wanting to appear weak.40 43 Subsequently, female veterans feel the need to ‘prove’ their strength with a sense of competitiveness towards their male counterparts, with one female veteran suggesting that men are in fact better at encouraging help-seeking than women within the military.29 43 However, from a quantifiable data point, no gender differences were found, suggesting that help-seeking behaviours across both genders in military veterans were the same,31 43 although there has been some research which suggests men have more negative beliefs towards MH than women.28 However, these gender differences within the veteran population are significantly under-researched.

Help-seeking behaviour may also be attributed to history of operational deployments and unit characteristics particularly when it comes to combat exposure.26 It has been found that every increase of 1 SD when measuring veterans’ combat exposure increased their likelihood of using a veteran service by 81%.26 This can be supported by a US study by Krill Williston et al,28 who found that veterans who served on active duty reported more negative beliefs about treatment-seeking than those who were in the national guard or reserves. In addition, when comparing veterans who deployed to different warzones, veterans who were deployed to Operation Enduring Freedom (OEF) or Operation Iraqi Freedom (OIF) were significantly more likely to dislike talking in groups, feel that treatment makes them appear weak and that previous attempts at treatment did not help compared with veterans from the Vietnam War.31 This may also be due to combat exposure or the experiences on those particular deployments. Furthermore, painful self-conscious emotions, such as guilt and shame, were found to be significantly associated with emotional control and self-reliance for veterans who had been deployed to a warzone, suggesting that those who had higher combat exposure may be more likely to attempt to self-treat any MH problems, likely due to military attitudes of self-reliance.27 44 Further Vietnam veteran research indicated that veterans who did not want to be in the military or deploy did not seek help for any veteran-related issues.45 Therefore, this may also be the case for those who were recruited for national service in the UK or any other form of military conscription. In addition, veterans from the OEF/OIF deployment had much greater perceptions that they would not fit into the US Department of Veterans Affairs, further highlighting that deployment and unit characteristics have an effect on help-seeking behaviour.46

Access to health services

Help-seeking behaviour appeared to be hindered by difficulties in access and usage of MH services. Accessibility was quite a prominent problem, with veterans discussing issues such as transportation, lack of appointments available as well as staffing issues.30 32 Veterans reported a dissatisfaction with their encouragement to seek help on leaving the military as well as with the services that were available, specifically for veterans.32 36 42 This lack of US veteran-specific services led to veterans believing that the civilian healthcare providers would not understand what they were going through and that it would be difficult to discuss such problems with a stranger.22 30 36 This meant that veterans prioritised ‘basic needs’ over seeking MH treatment, such as housing and employment.29 Further concerns regarding accessibility can be found within the veteran homeless population, such as having no form of identification or a place where they can be regularly contacted.33

There were also concerns regarding privacy and security.27 30 32 36 Some veterans reported distrust of the healthcare system and fearing what may be done with confidential information.30 32 36 In addition, veterans reported that services were non-responsive and ineffective and have limited resources to be able to deal with problems outside of business hours.27 30 The reasons for holding this belief may be due to previous experiences with the healthcare system, where some veterans have reported being discharged when they were still in need of help.22 42

Health service facilitators and symptom severity

Veterans who were able to recognise that they had a problem were more than seven and a half times more likely to be interested in receiving help.20 This suggests that recognition of a problem is a facilitator of help-seeking behaviour.30 47 In addition, the severity of the symptoms that a veteran is experiencing can also facilitate help-seeking behaviour, with veterans often commenting that the problem would have to be ‘severe’ for them to seek treatment.22 Research indicated that depression severity is significantly positively correlated with MH treatment usage, meaning that those with more severe depression were more likely to seek treatment.24 26 34 45 This symptom severity was also associated with a veteran’s perceived need for care, where encouragement from a veterans’ support network can increase the potential of a veteran to seek help.27 39 Furthermore, veterans’ perceived need for care was usually due to no longer being able to self-manage the symptoms that they were experiencing.22 42 This would suggest that veterans experiencing severe symptoms regarding their MH would motivate them to seek support for their MH concerns as they would also be more likely to recognise that there was a problem, particularly if they felt they were no longer able to self-manage their symptoms.

The accessibility of MH services was discussed as a potential facilitator of help-seeking.27 30 32 36 Veterans revealed that MH treatment would be more easily accessible if the first point of contact could be a telephone call or via online communication, as well as being more accessible outside of working hours, where veterans were likely to need additional support.27 36 This accessibility was also facilitated when veterans held beliefs that were more treatment-encouraging, such as believing getting help was socially acceptable, that the opinions of other people did not matter, that treatment is helpful and that those who are encouraging help-seeking are trustworthy.30 42 In addition, veterans’ views on how the MH services could be better conducted to facilitate help-seeking appeared to differ drastically, with some emphasising the need for inperson contact and others believing online services would be more ideal to combat the barrier of fearing their confidential information would be shared as this format would allow for anonymity.32 36 Furthermore, Vietnam veterans reported wanting a more professional environment for when they receive treatment, with other veterans stating that they did not feel comfortable discussing their MH in a hospital-like environment.42 The facilitators and barriers to help-seeking are provided diagrammatically in Figure 2.

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Figure 2

Identified barriers and facilitators of veterans’ help-seeking behaviour.