It's Okay To Change: Mental Health Stigma, Mental Health Care and Suicide Prevention Among Military Personnel and Veterans

Dr.Craig J. Bryan

Four years ago this month I returned from Iraq, which was sort of my last big mission as a military psychologist before "becoming a civilian." As a psychologist I was interested in trauma and suicide long before my deployment, but there's something very different about listening to a Soldier tell the story of his buddy's death while he's still lying in a hospital bed having fragments of metal removed from his leg as compared to hearing the same story in your clinic in the U.S. two years after the fact. It was also in Iraq that I first stood over the body of someone who had died by suicide, feeling a mixture of helplessness, grief and anger; an experience that had, for me as a suicidologist, been merely an intellectualized concept. Four years ago, psychiatric disorders and suicide became personal to me.

Suicide is the fatal outcome of psychological injury. I should stress, however, that not all psychological injuries sustained by military personnel and veterans occur during deployments. For many of the service members and veterans I've worked with, the psychological injuries occurred during childhood at the hands of an abusive or demeaning parent; for others it was sustained within the context of a recent breakup or a financial crisis. Indeed, more than half of service members who die by suicide never deployed or saw combat. The good news is that we have very effective treatments for the full range of psychological injuries that lead to suicide. The bad news is that very few service members or veterans will receive them.

Clinic-based mental health services have been expanded dramatically for service members and veterans over the past decade across both the public and private sectors. Mental health treatment is arguably more accessible and affordable for service members and veterans now more than ever, due in large part to community mental health professionals and agencies offering free or significantly reduced-cost services. Although admirable, these efforts are not enough, and too many psychological injuries remain untreated.

One of the primary problems is that the expansion of mental health services has largely occurred in traditional, clinic-based settings that are unlikely to be accessed by most service members and veterans due to pervasive mental health stigma. Only a very small proportion of service members who die by suicide (16%) visited a mental health care professional within the month preceding their deaths. Despite our decades-long battle with mental health stigma among service members and veterans, we have yet to see much success, primarily because we have failed to consider the issue of mental health treatment and stigma from within the context of the military culture. In the military, we value strength, mental toughness, elitism and self-sufficiency, but the culture of mental health is deficiency-oriented and values emotional vulnerability, which contradicts the core identity of many service members and veterans. We mental health professionals need to adopt a multicultural approach to working with service members and veterans, and to change how we deliver our services to better fit with military cultural norms, instead of asking service members and veterans to abandon their identities and conform to our standards.

From my perspective as a mental health professional, an even bigger tragedy is the realization that when service members and veterans do overcome mental health stigma and access care, they are still unlikely to receive the best treatments available. This is not a DOD or a VA problem; this is a problem of our mental health care system as a whole in the US, which continues to perpetuate the myth that all psychological treatments are equally effective, and that any treatment is better than no treatment. What we actually know, however, based on decades of research, is that trauma victims who receive prolonged exposure (PE) or cognitive processing therapy (CPT) for PTSD are three to four times more likely to experience full remission from PTSD. These better outcomes occur regardless of the trauma, whether rape, violent assault or combat. Early findings further suggest that PE and CPT reduce suicidal ideation among military personnel with PTSD. And just within the past month, preliminary data presented at the American Psychological Association's annual convention indicate that brief cognitive behavioral therapy (BCBT) for suicidal military personnel contributes to a 50% reduction in suicide attempts and significant reductions in PTSD symptoms as compared to traditional mental health care approaches. In short, some treatments work better than others, and are more effective at helping service members and veterans.

For many of us, the service members and veterans who are suffering from these psychological injuries are family members and friends. And some of them are dying from their injuries. Improved access to mental health care without improved quality of care will do little to prevent suicide among service members and veterans. As mental health professionals we must therefore commit ourselves individually and collectively to learning and using these better treatments that we know can help service members and veterans live lives that are worth living. It's okay for us to change.

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