The Stigma of Mental Health Counseling on Active Duty US Military Personnel

The Stigma of Mental Health Counseling on Active Duty U.S. Military Personnel

By

Alex Y. Lim

The Stigma of Mental Health Counseling on Active Duty US Military Personnel Contents

B C

Introduction .................................................................................................................... 3 Literature Review .......................................................................................................... 5 Social Stigma in Mental Illnesses ..................................................................................... 5 Myths behind the Stigma Associated with Mental Illness ................................................ 6 Effect of Stigma on People ............................................................................................... 8 Stigma in the United States Military ............................................................................... 10 Coping with the Stigma................................................................................................... 12 D. Theoretical/Conceptual Framework ............................................................................ 13 E. Definition of Terms ..................................................................................................... 14 F. Research Question ....................................................................................................... 15 G. Hypothesis ................................................................................................................... 16 H. Significance of the Study ............................................................................................. 16 References ........................................................................................................................... 18

The Stigma of Mental Health Counseling on Active Duty US Military Personnel B Introduction This paper explores the impact to stigma associated with having mental illness on active military personnel on their private and work lives. The social and psychological cost of suffering of the condition effectively places the combat-fatigued service member in double jeopardy as he or she suffers from the ailment while having to cope with a devalued place in society occasioned by the stigma society has cast on them (Corrigan & Watson, 2002). US Military service personnel have this fear that consulting a psychologist or a psychiatrist will push down their prospects for career advancement in the military. According to Navy Commander, Anthony Arita, PhD., this needless fear revolving around their psychological or mental problems being exposed to their superiors have occasioned significant worry that it could compromise their security clearances, prospects for promotion and even result in service dismissal (Dingfelder, 2009). Dingfelder (2009) in said that Arita, the director of clearinghouse, outreach and advocacy at the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury said: "There is the perception that if I do step forward there will be dire consequences" (Dingfelder, 2009, para. 4). Such fears are unfounded according to military experts, but they nevertheless

have fueled what amounts to a mental health crisis in the US military, where nearly a fifth of service members returning from recent regional conflicts and wars such as in Iraq and Afghanistan have been diagnosed with symptoms of major depression and post-traumatic stress disorder. Only about half of the returning service members with such issues have sought treatment, according to a study by Rand Corp (2008). This is around 300,000 service members with combat-induced mental health issues, says Terri Tanielian, who had co-authored with psychologist Lisa Jayrox, PhD a study which estimated that apart from the human cost, the nation can expect military

The Stigma of Mental Health Counseling on Active Duty US Military Personnel personnel with mental illness to cost nearly $6.2 billion in direct medical care and lost productivity within the first two years after a traumatic combat duty. This reality has not escaped military leaders, who rightfully worry that such invisible war damages could diminish the competence of the nations fighting force already stretched thin. Dingfelder (2009) observed that just about all the military agencies are now involved in their own wars fighting the stigma of seeking mental health services. For instance, the Defense Department recently revised its security clearance questionnaire so that people who seek mental health care for combat-related reasons do not have to report it. It is interesting to note that prior to this revision, when soldiers filled out securityclearance questionnaires, they were almost always told to just reply "no" to the dreaded Question 21 which asked: In the last seven years, have you consulted with a mentalhealth professional or consulted with another health-care provider about a mental health condition (Arnews, 2008) This is considered the appropriate answer when the soldier is receiving mental health counseling to deal with stress resulting from combat or to family and marriage issues. A no should also be the answer if the mental health counseling was not ordered by any court as a result of violence. This advice was contained in an All Army Activities (ALARACT) message guidance issued by Army G2 security division until an updates SF 82 questionnaire can be issued with a more appropriate working for question 21. It had to take two US Army generals who candidly share their post-traumatic stress disorder (PTSD) experiences in April 2009 for the Department of Defense (DoD) in the following month to launch a service-wide anti-stigma campaign to prompt ordinary military personnel to admit and recount their respective stories of seeking mental healthcare (Dingfelder, 2009). It reportedly cost the military $2.7 million; but that is just a drop in the billion dollar budget of the armed forces.

The Stigma of Mental Health Counseling on Active Duty US Military Personnel After all these decades of hiding behind the stigma, this can be considered a historic effort that could finally defang the societal stigma associated with seeking psychiatric or mental health care in the American cultural landscape, according to Mark Bates, PhD, interim director of the resilience and prevention directorate at the Defense Centers of Excellence (DCoE). He further stated that "what we are trying to do is bring home the message that physical health is just as important as mental health. We're creating mental health parity in the military" (Dingfelder, 2009, para. 9).

Literature Review Social Stigma in Mental Illnesses Deliberate or not, stigma is a form of branding or labelling on a person and is often

the result of misinformed stereotyping, nave attitudinal assumptions, and downright social prejudices that have the potential to damage or at least hinder recovery efforts from a mental illness (Whalen, 2006). In the area of health care, there is societal stigma attached to people known to suffer from mental illness as evidenced by their visits to or confinement in psychiatric institutions. Stigma has pernicious effects on the affected person and indications point to the fact the despite advances in modern psychiatric treatment, stigmatizing remains a problem in the 21st century and continues to grow at significant human cost to patients and their loved ones (Sartorius & Schulze, 2005). Not wanting to be stigmatized for seeking medical attention for their mental ailments, affected people often prefer not to seek psychological and psychiatric help, or at least not be seen by society. Being stigmatized as a nut case is the main barrier to seeking better mental health care with the attendant quality of life for people who have the illness, for their families, and for their communities. Despite all the modern advances over the last half century by the neurosciences, by social and psychological sciences, by research works

The Stigma of Mental Health Counseling on Active Duty US Military Personnel of behavioral treatment and by public health investigations the mystery of the brain barrier appear as impenetrable as ever. The typical symptoms of mental derangement manifest in people who have never consulted with a psychiatrist (Verdoux & Os, 2002). Could the stigma associated with being confined for observation in a mental hospital or being seen going in and out of a mental hospital create problems for a persons prospects in his or her education, social relationships, and career progression? The empirical evidences appear to support a resounding yes to the question. Whalen (2006) concluded from his studies that reducing or forever banishing stigma is among the greatest challenges facing mental health professionals, practitioners and health organizations. The current attitude in the literature on stigma reduction is that education is the best means of preventing and eliminating discrimination. Typically, successful educational campaigns have drawn upon facts and personal experiences. While facts can give the audience an overarching understanding of the impact of stigma, the stories of individuals who have mental illness can serve as a poignant reminder of the impact not only of the symptoms of mental illness, but also the negative associations tied to it. Myths behind the Stigma Associated with Mental Illness What exactly constitutes the prejudices behind the societal stigmatization caused by a perception of being mentally ill? A study conducted by Harding and Zahniser (1994) tabulated the significant perceptions that comprise the myths behind the stigma as presented in Table 1and the corresponding facts that belie each myth. A more comprehensive and purposive educational program may have to be deployed among organizations such as the military with the view to challenging the common misconceptions and myths behind the stigma most feared by patients suffered from mental illness. A similar point-by-point rebuttal than can boost the confidence of concerned

The Stigma of Mental Health Counseling on Active Duty US Military Personnel people (family, friends and colleagues of patient, along with the patient) combined with the benefits of continues contact the patient can help lift whatever debilitating stigma that is keeping the patient from seeking medical help (Watson & Corrigan, 2001. Table 1 Eight Myths and Corresponding Realities about Mental Illness Myth / Misconception
1 Once crazy, always crazy. People wont get over the condition

Facts
Long-term follow-up research points to the medical fact that even mental patients with the worst types of schizophrenia and other severe mental illness can lead normal productive lives after treatment. Mentally-ill people are as diverse as any other. To assert that all mentally-ill people are alike is no different from claiming that all Hispanics are the same. Severe mental distress such as manic-depression and schizophrenia may account for up to 8% to 10% of the population. That is about 640,000 people in a metropolitan area the size of Chicago, enough folks to fill Omaha, Nebraska and Des Moines, Iowa combined. Very, very few people with mental illness ever murder someone. In fact, persons with mental illness are usually no more violent than the rest of the population.

All persons with mental illness are alike

Severe mental illnesses are rare, just like lepers

The mentally ill are dangerous, one step away from a maniacal killing spree The mentally ill can never survive outside the hospital The mentally ill will never benefit from psychotherapy The mentally ill are unable to do anything but the lowest level jobs Bad parents and poor upbringing cause severe mental illness

The vast majority of persons with mental illness live personally successful lives in their community.

Carefully controlled research has shown that support and rehabilitation has significant impact on the lives of persons with mental illness Persons with mental illness perform at all levels of work, just like the rest of the population.

Schizophrenia and the other severe mental illnesses are biological diseases They are caused by genetic or other embryological factors, not mom and dad

Note. Adapted from Empirical Correction of Seven Myths about Schizophrenia with Implications for Treatment, by. C. Harding and J. Zahneser, (1994) Acta Psychiatrica Scandinavica, 90(384), p.141.

The Stigma of Mental Health Counseling on Active Duty US Military Personnel Effect of Stigma on People Stigmatization devalues a persons esteem both in their own self-perception and in the eyes of society. Stigma encapsulates both the bias and discrimination that can have negative economic, socio-political and psychological repercussion for stigmatized persons (Whalen, 2006). One of the most pernicious and insidious effects of stigma is the personal health costs behind a self-preservation effort not to be stigmatized. There is medical aggravation when people do not seek professional help in treating their mental illness for fear of acquiring the stigma if discovered (Sartorius & Schulze, 2005). The stigma creates a formidable psychological barrier to seeking medical help that is readily available to people impaired by mental illness. Research has shown that psychological distress and its psychiatric symptoms that hamper normal living are significantly treated with a variety of evidence-based practices (EBPs) in the field of psychiatric health care (Watson & Corrigan, 2001). However, fundamental to the success of any treatment is a willingness to be treated and that those afflicted must first actively seek out professional intervention or treatment. Unfortunately, as Whalen (2006), Sartorius and Schulze (2005) pointed out, apart from medical costs incurred in such interventions, many people are not prepared to pay the price in terms of social antipathy and ostracism arising from the stigma associated with being seen entering and leaving a mental hospital, let alone being known as actually undergoing psychiatric treatment. Many people opt not to pursue mental health services because they do not want to be labelled a nut case, nor suffer the societal prejudice and discrimination behind the label. Stigma ostracizes people from society like lepers in the past (See Table 1). The most prevalent attitude is that they are violent, dangerous and unproductive. Most of the unfounded perceptions are largely perpetuated by the negative portrayal of mental illness

The Stigma of Mental Health Counseling on Active Duty US Military Personnel in television and movies as well as newscasts (CMHA, 2006). These derisive attitudes influence the behaviour of mentally ill individuals. They may opt not to talk about their illness and not pursue treatment for fear of becoming a social outcast (Crocker, Major, & Steele, 1998; Miller & Kaiser, 2001). Stigma rears its ugly face most disquietingly in the workplace. Mentally ill people have been known to lose their jobs as they experience credibility issues and a concomitant loss of responsibility. Whalen (2006) indicated in his paper that 61% of people with mental illnesses are outside the labor force; 40% to 60% of those diagnosed with major depression are unemployed; 20% to 35% with anxiety disorder are without work; and 80% to 90% of those diagnosed with schizophrenia are unemployed. He also referred to an unnamed US survey stating that more than half of employers were reluctant to hire an applicant with a history of mental illness, while a quarter would readily dismiss an employee who had failed to disclose their pre-employment mental illness. Quinn (2009) cited a survey by Shaw Trust in the UK stating that more than half of employers would not hire anyone with known mental illness. A female worker in an engineering firm who was diagnosed with manic depression was advised by her manager to keep the diagnosis to herself and out of HR knowledge (Quinn, 2009). This consistent rejection is basically what comprises the fear of those who have been stigmatized or about to be get one. It has led afflicted persons to fill they are unemployable while those with employments live in constant fear about being found out. Those lucky enough to have some employment security are often stereotyped into simple menial jobs that are often not commensurate with their education or skills. Among them, only a third actively sought out professional medical help. It has been estimated that in general, one in 10 of these mentally-ill individuals are treated with some form of

The Stigma of Mental Health Counseling on Active Duty US Military Personnel medication or counseling (Whalen, 2006). This applies to both civilian personal in commercial and industrial firms as well as service members in the US military. Stigma in the United States Military A military commissioned report: Army: Health Promotion, Risk Reduction, Suicide Prevention (US Army, 2010) showed a dramatic increase in the number of recent cases of post-traumatic stress disorder (PTSD), from 2,931 in 2004 to 10,137 in 2007. What was more disturbing was the increase in suicide deaths among service members with PTSD, from 4.6% in 2005 to 14.1% in 2009. Despite this high prevalence of mental health issues, 87% of active duty service members did not seek care at 12 months after returning from war due mostly to an aversion to acquiring the societal stigma associated with mental illness (Kim, Thomas, Wilk, Castro, & Hoge, 2010). The gold book (US Army, 2012, p. 69)) adopts the American-heritage dictionary definition of stigma as a mark of shame or discredit. Stigma is seen as a barrier to care (Hooyer, 2012), adversely influencing the decision to seek psychological help among military personnel when suffering from mental health problems. No less than the US military recognizes the problem as documented in its Red Book (US Army 2010, p33) when it stated that stigma continues to be the biggest deterrent to seeking help. Although help-seeking behavior is increasing in the Army, many still believe that seeking behavioral health counseling would negatively impact their careers. A cross-sectional study was done by Kim et al (2010) surveying 10,386 active service members of the National Guard known to suffer from some mental health problems 3-12 months after a combat duty in Iraq. This study concluded that active duty service members with mental health problems had significantly lower rates of service utilization with significantly strong feelings of stigma and barriers to care. The study recommended improvements to the care of veterans towards addressing the stigma

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The Stigma of Mental Health Counseling on Active Duty US Military Personnel associated with receiving mental health care. Despite the high prevalence of mental issues reported among service members returning home from combat duty in Iraq and Afghanistan, research has shown that only around 50% of these psychologically damaged service members reported getting the proper mental health counseling within a year of returning (Hoge, Auchterlonie, & Milliken, 2006; Hoerster, Malte, Imel, Ahmad, Hunt, & Jakupak, 2012). Hoerster et al (2012) in a recent survey among US veterans of the Iran and Afghanistan wars pointed to perceived stigma as a barrier health care among service members afflicted with depression and PTSD as well as consequential alcohol abuse as impediments to seeking psychiatric help. The study recommended unconditionally that the US military should target war veterans diagnosed with mental illness in a comprehensive outreach program to ensure wider coverage. The low mental health care service utilization was due to stigma and perceived barriers to care. Hoge et al (2006) found that military personnel who met the screening thresholds for the mentally problematic reported feelings of stigma. Research on stigma in civilian populations asserts that stigmatized individuals who have internalized the social perception have lower self-esteem (Whalen, 2006; Crocker & Major, 1989) with many likely to be averse to treatment. In the military, stigma is defined in the Gold Book and Red Book as the perception among leaders and service members that help- seeking behavior will either be detrimental to their career or that it will reduce their social status among their peers (US Army, 2012, pp. 69, 72; US Army, 2010, Stigma in Glossary). Hoge et al (2004) revealed that service members own perceptions about PTSD, depression, and anxiety, were signs of psychological weakness and were the main barrier to seeking medical care. Hooyer (2012) showed that stigmatized service members suffer from discrimination within the military hierarchy which included the physicians assigned to treat them. PTSD has been stereotyped as a disease that turns otherwise competent

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The Stigma of Mental Health Counseling on Active Duty US Military Personnel service members into mentally disabled and unproductive service members. This stereotype revolves around the concerned soldier who attempts to get out of service and collect compensation, creating a second layer of stigmatization, the first being the stigma linked to seeking help. The afflicted soldier is now burdened to prove that his mental disorder is real and goes beyond the diagnosis by publicly displaying behavior consistent with the diagnosis. If this succeeds, the service member is seen by his peers and society as unfit in the military, but if it fails, as a fraud. Either way, the service member losses the battle to regain whatever self-worth he or she had. Coping with the Stigma Researchers have revealed that stigma creates added stress that further erodes an already diminished quality of life for the mentally ill person (Couture & Penn, 2003). It is for this singular reason that researchers have sought intervention methods for reducing stigma. One strategy espoused by Couture and Penn (2003) in this direction is a purposive interpersonal communication with mentally ill people and their families who can help in the process. Research shows that both retrospective and prospective contact tends to reduce stigmatizing views of persons with a mental illness. Several groups have championed various initiatives to reduce stigma and provide a more open atmosphere for mentally-ill people to obtain the needed professional attention. Whalen (2006) mentioned the Canadian Mental Health Association (CMHA) as sponsoring a program called Stereotypes, Trivializes, Offends, Patronizes (S.T.O.P) to significantly reduce the stigma among Canadian citizens suffering from mental illness. Its vehicle is a comprehensive educational campaign aimed at the youth sector based on studies that it is relatively easier to de-stigmatize mental illness among the youths than adults. Sartorius and Schulze (2005) discussed one such initiative with a global reach from a concerted program headed and guided by World Psychiatric Association and participated by several countries like

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The Stigma of Mental Health Counseling on Active Duty US Military Personnel Greece, Germany, Sweden, India, Spain, Nigeria, Uganda, United States, and United Kingdom. People generally have wide latitudes to respond to stressful stimuli, whether at work or at home. Conceptualizing stigma as a form of stress can provide significantly wider options for coping mechanisms that allow stigmatized people to overcome the societal prejudices associated with the stigma (Miller & Kaiser, 2001). A stigma is not a disease, but just a label that has profound effect only if the labelled person takes it seriously enough to adversely affect how he or she deals with everyday situations. Ignoring the label may sound easy, but this requires courage to go against social normative perceptions. Stigmatized people are generally aware of their devalued worth in the society they live in (Crocker, et al, 1998). It is a tribute to these people that many of them have learned to cope with the double jeopardy presented by both the illness and the stigma. Several theoretical models over the last three decades have attempted to explain the behaviour and psychology of people suffering from social stigma (Hansen, 2001). One such theoretical model that this paper will use to provide the contextual framework is explained the next section.

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D.

Theoretical/Conceptual Framework This study takes on the devaluation theory of Crocker and Major (1989) who

posited that people who have been stigmatized devalue or de-emphasize those dimensions in which they are perceived to be perform poorly. This effectively a denial coping mechanism by which stigmatizes people who are themselves devalued in the eyes of society attempt to maintain their self-esteem. A clear instance is when Afro-American students in all levels have consistently measured poorly in Scholastic Aptitude Tests (SAT) and other academic performance tests compared to their Asian and White

The Stigma of Mental Health Counseling on Active Duty US Military Personnel counterparts (Chapman, Laird, & Ramani, 2010; Borman & Rachuba, 2001). This psychological disengagement rationalizes these comparative failures that comfort many African Americans with the self-serving notion that these tests do not reliably measure their worth. Consequently, they de-emphasize academics and the associated performance measures (Schmader, Major, & Gramzow, 2001) since, if one cannot excel or do well repeatedly in one area, it is possible there is an inherent absence of opportunity or a persistent bias. Why bother recognizing it if it poses a threat to ones pride or self-esteem? The drawback to this coping theory is that devaluing an important societal dimension may lead to economic, socio-political, or cultural displacement or harm and further justify the misimpression by those who would stigmatize them. Perhaps more insidiously, the same devaluation could further hinder the stigmatized from improving on what causes the stigma. However, this drawback could be an advantage when the stigmatized devalues a misconception and rises above unfounded stigma, such as in the case of stigma associated with mental illness.

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E.

Definition of Terms

Mental Illness. The term is often interchangeably used with mental disorder. The National Alliance on Mental Illness (NAMI, n.d. para. 1) defines it as a medical condition that disrupts a persons thinking, feeling, mood, ability to relate to others and daily function [] (and) result(s) in a diminished capacity for coping with the ordinary demands of life. The same site categorizes major depression and post-traumatic stress disorder (PTSD) as among the forms of mental illnesses. Post-Traumatic Stress Disorder (PTSD). This is a behavioral or mental ailment arising from a failure to cope with a traumatic event which Yehuda (2002) characterize as a

The Stigma of Mental Health Counseling on Active Duty US Military Personnel situation that provokes fear, creates a feeling of helplessness, or horror in response to the threat of injury or death. Psychologist. The occupation is clinically defined as a healthcare professional who specializes in diagnosing and treating diseases of the brain, emotional disturbance, and behavior problems (Medicine, 2000, para. 1). Armed with either a doctoral degree (Ph.D.) or a masters degree (MA) in psychology, Psychologists use conversational therapy in treating their patients, and cannot prescribe medication which only a Psychiatrist can do. Psychiatrist. NAMI (20120, para. 1) defines the profession as a physician who specializes in the prevention, diagnosis, and treatment of mental illness. Like any doctor, a psychiatrist may undergo additional training to specialize in such areas as neuropsychiatry, addiction psychiatry, and child psychiatry, to mention some. Unlike psychologists, psychiatrists can prescribe medication. Stigma. Stigma is basically an opinion or judgement labeled or branded to an individual by other people or the society at large. The implications to the label are negative, often associated with disgrace or shame that is regarded by most members of the community as socially unacceptable (Aidsmap, 2012). The labeling devalues the stigmatized person in the eyes of others. Only a very thin border separates it from outright discrimination. Once the stigma elicits an action from someone, the action can be considered as discriminatory.

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F.

Research Question The study aims to answer the question: Among active military personnel, does

being publicly known as or seen to be a mental health patient stigmatize them in the eyes of society? The study explores the nature and extent of the stigma that has affected their lives, if at all, as a patient and soldier in private and in public.

The Stigma of Mental Health Counseling on Active Duty US Military Personnel

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G.

Hypothesis The study posits the hypothesis that military personnel publicly known as or seen

to be a mental health patient are socially stigmatized that has adversely affected their private lives as a patient and while still on active duty. Stated differently, this stigmatization resulting from having had consultations with a psychiatrist or mental health care practitioner has adverse effects in how service members deal with the daily challenges presented in both their work and private lives. The independent variable in the study is the frequency with which military personnel is seen by the community or by those around him to have consulted with or being treated for mental illness. Subjectively, the level of stigma can be gauged by the air of negativity as perceived by the soldiers when dealing with their peers or members of their communities. This is measured in the paper as the dependent variable.

H.

Significance of the Study The population which the study will sample for its primary data collection consists

of US military personnel in the armed forces stationed on a local military base. They are currently in active duty with some having had exposures in the latest wars in Afghanistan and Iraq. There is no question that military personal suffering from depression or dealing with stress resulting from some stressful or traumatic experience require serious medical attention if the US fighting force is expected to do a competent job should they have to rise to the call. As explored in the literature review section, there have been several studies in the last decade revealing the psychological damage to several military personnel in the US and the UK as a result of their engagement in the Iraq and Afghan wars. Crocker et al (1998)

The Stigma of Mental Health Counseling on Active Duty US Military Personnel have complained that our understanding of stigma remains weak and further research from as many angles of how it originates the better to eliminate the social stigmatizing forces in society as well as research into the affective and cognitive consequences of coping with the stigma. Most of these research works have taken place in controlled laboratories to ensure high internal validity of results, but what is needed is a more naturalistic research using qualitative assessments in as wide a sample base as possible to ensure close modeling of real-world experiences of stigmatized people (Hansen, 2001). This study uses this approach but focused on US military personnel on active duty.

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The Stigma of Mental Health Counseling on Active Duty US Military Personnel References Aidsmap. (2012). HIV, stigma and discrimination. (3rd ed). London: NAM. Retrieved from http://www.aidsmap.com/files/file1001097.pdf Arnews. (2008). Solders told to just say no to question 21. Retrieved from http://www.army.mil/article/9718/soldiers-told-just-say-no-to-question-21/

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Borman, G.D., & Rachuba, L.T. (2001). Academic success among poor and minority students: an analysis of competing models of school effects. Report No. 52, Center for Research on the Education of Students Placed At Risk (CRESPAR). Retrieved from http://www.csos.jhu.edu/crespar/techReports/Report52.pdf

Chapman, C., Laird, J., & Ramani, A.K. (2010). Trends in high school dropout and completion rates in the United States: 19722008: Compendium Report. National Center for Education Statistics, 2011-2012. Retrieved from http://nces.ed.gov/pubs2011/2011012.pdf

CMCH. (2006). Understanding mental illness. Canadian Mental Health Association. Retrieved from http://www.cmha.ca/bins/content_page.asp?cid=3&lang=1

Corrigan P.W., & Watson, A.C. (2002). Understanding the impact of stigma on people with mental illness. World Psychiatry, 1(1), 16-20. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1489832/

Couture, S., & Penn, D. (2003). Interpersonal contact and the stigma of mental illness: a review of literature (Abstract). Journal of Mental Health, 12(3), 291-305. Retrieved from http://informahealthcare.com/doi/abs/10.1080/09638231000118276

Crocker, J., Major, B., & Steele, C. (1998). Social stigma. In D. T. Gilbert, S. T. Fiske, & G. Lindzey (Eds.). The handbook of social psychology (4th ed), 2,504-553). Boston: McGraw Hill.

The Stigma of Mental Health Counseling on Active Duty US Military Personnel Crocker J., & Major, B. (1989). Social stigma and self-esteem: The self-protective properties of stigma. Psychological Review, 96(4), 608-630. Retrieved from http://www.atkinson.yorku.ca/~jsteele/files/04082317043617968.pdf. Dingfelder, S.F. (2009). The militarys war on stigma. American Psychological Association, 40(6), 52. http://www.apa.org/monitor/2009/06/stigma-war.aspx

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Hansen, J.J. (2001). Coping mechanisms of the stigmatized: methods of protective selfworth. Retrieved from http://www.heart-intl.org/Comp/CopingMechanisms.htm

Harding, C., & Zahniser, J. (1994). Empirical correction of seven myths about schizophrenia with implications for treatment. Acta Psychiatrica Scandinavica, 90, supplement 384, 140 -146. Retrieved from http://www.blackwellpublishing.com/journal.asp?ref=0001-690x

Hoerster, K.D., Malte C.A., Imel, Z.E., Ahmad, Z., Hunt, S.C., & Jakupak, M. (2012). Association of perceived barriers with prospective use of VA mental health care among Iraq and Afghanistan veterans. American Psychiatric Association, Psychiatric Services, 63(4), 380-82

Hoge, C.W., Auchterlonie, J.L., & Milliken, C.S. (2006). Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. JAMA 295, 10231032.

Hoge, C.W., Castro, C., Messer, S., McGurk, D., Cotting, D., & Koffman, R. (2004). Combat Duty in Iraq and Afghanistan, Mental Health Problems and Barriers to Care. The New England Journal of Medicine, 351(1), 1322

Hooyer, K. (2012). Going AWOL: Alternative responses to PTSD stigma in the U.S. military. A Journal of Collegiate Anthropology 4(1), 106-128. Retrieved from http://uwm.academia.edu/FieldNotesAJournalofCollegiateAnthropology/Papers/16 08015/Going_AWOL_Alternative_Responses_to_PTSD_Stigma_in_the_U.S._Mil itary

The Stigma of Mental Health Counseling on Active Duty US Military Personnel Kim, P.Y., Thomas, J.L., Wilk, J.E., Castro, C.A., & Hoge, C.W. (2010). Psychiatric Services 61(6), 582-88. Retrieved from http://ps.psychiatryonline.org/article.aspx?articleid=101416

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Miller, C.T., & Kaiser, C.R. (2001). A theoretical perspective on coping with stigma. Journal of Social Issues, 57(1), 73-92. Retrieved from http://www.uvm.edu/~psych/graduate/gen_exp/social/papers/theoretical_perspecti ve_on_coping_with_stigma.pdf.

NAMI, (n.d.). What is Mental Illness. National Alliance on Mental Illness. Retrieved from http://www.nami.org/Template.cfm?Section=By_Illness

Quinn, C. (2009). Mind over matter. The Guardian. Retrieved from http://www.guardian.co.uk/money/2009/jan/20/mental-illness-discrimination-atwork.

Rand Corp. (2008). One In Five Iraq and Afghanistan Veterans Suffer from PTSD or Major Depression. New Release, Rand Corporation. Retrieved 29 September 2012 from http://www.rand.org/news/press/2008/04/17.html.

Sane, (2012). What is stigma? Australia: SANE Stigma Watch. Retrieved from http://www.sane.org/stigmawatch/what-is-stigma

Sartorius, N., & Schulze, H. (2005). Reducing the stigma of mental illness: a report from a global programme of the World Psychiatric Association. Cambridge University Press. http://bilder.buecher.de/zusatz/22/22081/22081603_vorw_1.pdf

Schmader, T., Major, B., & Gramzow, R. H. (2001). Coping with ethnic stereotypes in the academic domain: Perceived injustice and psychological disengagement. Journal of Social Issues, 57, 93-112.

Tull, M. (2009). Reducing the Stigma of Mental Health Care in Veterans. Retrieved from http://ptsd.about.com/od/ptsdandthemilitary/a/stigmavets.htm

The Stigma of Mental Health Counseling on Active Duty US Military Personnel United States Army. 2010. Army Health Promotion Risk Reduction Suicide Prevention Report 2010. Virginia: Army Suicide Prevention Task Force, Headquarters, Department of the Army.

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United States Army. (2012). Army 2020: Generating Health and Discipline in the Force, Ahead of the Strategic Reset, Health Report. Washington, D.C.: United States Army

Verdoux, H. & van Os, J. (2002). Psychotic symptoms in non-clinical populations and the continuum of psychosis. Schizophrenia Research, 54(12), 5965.

Watson, A.C., & Corrigan, P.W. (2001). The impact of stigma on service access and participation. Retrieved from http://www.bhrm.org/guidelines/stigma.pdf

Whalen, D. (2006). The stigma associated with mental illness. Canadian Mental Health Association. Retrieved from http://www.cmhanl.ca/pdf/Stigma.pdf

Yehuda, R. (2002). Current concepts: Post traumatic stress disorder. The New England Journal of medicine, 346(2), 108-114. Retrieved from http://www.impact.arq.org/doc/kennisbank/1000010585-1.pdf