Cover Story

On the U.S.S. Kitty Hawk aircraft carrier, Lt. Justin D'Arienzo, PsyD, was the most popular guy in the lunch room. One after another, officers would sidle up to him to talk about their issues—often marital problems stemming from repeated deployments, or nightmares echoing the horrors they'd seen in combat.

"They were afraid to be seen going into my office, so they'd scoot next to me and say, 'Off the record, can I get your ear for a second?'" D'Arienzo recalls.

Why the secrecy? Many service members fear that seeing a psychologist will sink their careers, says Navy Cmdr. Anthony Arita, PhD. They worry—often needlessly—that their problems will get back to their bosses, endanger their security clearances and even result in their separation from the service, he notes.

"There is the perception that if I do step forward there will be dire consequences," says Arita, the director of clearinghouse, outreach and advocacy at the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE).

Those fears have fueled a mental health crisis, where about a fifth of people returning from the wars in Afghanistan and Iraq are reporting symptoms of post-traumatic stress disorder or major depression, and only about half seek treatment, according to a 2008 Rand Corp. study.

That's about 300,000 people and counting with combat-related mental health problems, says Terri Tanielian, who co-authored the study with psychologist Lisa Jayrox, PhD. In addition to the human cost, the wave of service members with mental illness will cost the country about $6.2 billion in direct medical care and lost productivity in just the first two years after they return from deployment, she says.

This disturbing reality, however, has not been lost on military leaders, who worry that these invisible war injuries could deplete a fighting force that's already stretched thin. So, independently and in a coordinated effort, every branch of the military is now fighting the stigma of seeking mental health services. For example, 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. In April, two Army generals stepped forward to share their struggles with PTSD. And, in May, the Defense Department launched a $2.7 million service-wide anti-stigma campaign, where ordinary service members will tell their stories of seeking help.

It's a historic effort, one that could even reduce the stigma of mental health care in American culture at large, says Mark Bates, PhD, interim director of the resilience and prevention directorate at the DCoE.

"What we are trying to do is bring home the message that physical health is just as important as mental health," he says. "We're creating mental health parity in the military."

Sea change

One recent change made by the Navy, says D'Arienzo, is scrapping a system by which service members were considered either "ready" or "ill" and unfit for duty—and psychologists were mostly responsible for people labeled ill. A new system, adopted last year, allows shades of gray, classifying people as ready, reacting, injured or ill—and military leaders, psychologists and chaplains can help people no matter where they lie on the continuum.

That means that even people in peak psychological shape can benefit from seeing counselors, says Bret Moore, PsyD, a former Army psychologist and two-tour Iraq war veteran, who encouraged soldiers under his care to assess the strength of their relationships and address any concerns before deploying to combat zones. More commonly, Moore treated people in the middle categories—those who were stressed and suffering, but not yet unfit for duty. He found that using a physical training analogy worked well in persuading them to come in for treatment.

"You do physical training every morning, let's do mental training once or twice a week," Moore would say.

Similarly, the Defense Department is sending the message to military leaders that it's normal to feel and react to the stress of combat, or even combat-support operations, says Bates. One way that's done is through conferences where high-ranking officials share their struggles with PTSD. In February, Army Maj. General David Blackledge, told reporters and troops about how he suffered from hyper-alertness and nightmares after surviving a convoy attack in Iraq where he watched as insurgents shot his interpreter in the head. In April, Brig. General Gary S. Patton and Gen. Carter Ham stepped forward and shared their stories of wartime trauma, and how they received help for PTSD symptoms without it harming their careers.

In fact, negative career consequences for seeking mental health services are fairly uncommon, says Col. Scott Marrs, PhD, chief of the Air Force's mental health division. A 2006 study, published in Military Medicine (Vol. 171, No. 11), found that only 3 percent of people who referred themselves for mental health treatment had a negative career impact, as compared with 39 percent of people who were referred by their commanders.

"Seeking mental health care doesn't harm your career," says Marrs. "It's not being able to do your job because of personal issues that can harm your career."

And while many service members worry that their security clearance will be revoked if they see a psychologist, less than 1 percent of those investigated for clearances are rejected solely on the basis of their mental health profiles, according to the Pentagon.

To further assuage people's fears, in May 2008, Defense Secretary Robert M. Gates announced that the Defense Department had revised "the infamous Question 21," on its security clearance questionnaire. Now, people who seek help for combat-related issues or who receive marital counseling don't have to answer "yes" when asked if they've ever "consulted with a health care professional regarding an emotional or mental health condition."

Of course, the few people who do lose their security clearances or jobs for mental health reasons loom large in the minds of their colleagues, says Air Force psychiatrist Lt. Col. Steven Pflanz, MD, commander of 579 Medical Operations Squadron at Bolling Air Force Base in Washington, D.C. "The one airman I recommend be discharged—everyone sees him go," he says. "The other 999 airmen who get treated and return to their units happy go back quietly."

A new anti-stigma campaign called "Real Warriors. Real Battles. Real Strength." aims to bring many of these successfully treated people out of the shadows to share their experiences. The campaign, which launched last month, uses public service announcements to explain that there are many effective treatments for mental health concerns and illustrates that seeking treatment will not harm your military career. The campaign also includes a Web site, with articles on psychological disorders and their treatment.

"We want to demonstrate that accessing care is an act of courage and connect service members to the many resources available to them," says Arita, who helped to design the campaign.

Culture clash

The Defense Department's coordinated efforts to root out stigma are admirable, but we don't yet know if they are effective, says RAND researcher Terri Tanielian. The armed forces have also increased the number of mental health care providers and made more people eligible for treatment, she says—both moves that are likely to lift the number of people who seek and receive care for mental health services.

"They are doing a lot to shift the culture and raise awareness of mental health problems in the military," she says.

Persuading the roughly 1.4 million active-duty military personnel that there's nothing shameful about mental disorders is an enormous task, and one that will require years of continuous attack on several fronts, including service member's attitudes and institutional barriers to seeking services, says Bates.

At the same time, the U.S. military is fighting two wars and many of its personnel are already stretched tissue-thin, notes D'Arienzo. If mental health is truly going to top the military's priority list, the Defense Department will need to up the numbers of psychologists it employs and pay them better, he says.

When D'Arienzo served on an aircraft carrier, he was solely responsible for the mental health of about 8,000 people. In comparison, the ship carried five physicians, four dentists and 40 medical assistants. As a result, D'Arienzo quickly found he didn't have enough time to see everyone.

"The military needs to put their money where their mouth is and start paying psychologists at the same level as they pay physicians," he says, noting that the overall salary for a Navy psychologist is about half that of a Navy physician. "That would send a clear message that the military culture values psychological health as much as physical health."

However, the biggest challenge, says Pflanz, will simply be changing people's minds.

"We are changing deeply held beliefs about mental health care," he says. "In America, the stigma about mental health care is still very strong. In some ways, we in the military are swimming upstream."

But if the military can succeed in convincing its ranks that even healthy people can benefit from counseling, that mental health is as important as physical health, and that there's nothing shameful about mental health problems, the rest of society may follow suit, Pflanz notes.

"In many ways, the military led the way toward racial integration in the '50s, perhaps we can do that for reducing the stigma of mental illness as well," he says.


Additional reporting for this story was done by Christopher Munsey.

To learn more about current efforts to curb stigma among military members and veterans, visit www.semperfifund.org/resources.html and www.realwarriors.net.

APA's advice to the military

Two years ago, the Defense Department reached out to APA for expert guidance regarding how best to destigmatize such mental disorders as post-traumatic stress disorder and to encourage military personnel to seek mental health care. APA responded with a set of scientific articles regarding the stigma surrounding mental disorders, along with contact information for APA member experts in the field. APA also recommended the following two courses of action: Increased confidentiality related to mental health treatment, whenever possible, and a public education campaign based on building resilience to help mitigate the effects of stigma. The latter recommendation derives from APA's prior experience with public education campaigns where an approach based on building resilience was much better received by populations such as firefighters and police than the more traditional notion of treating mental health problems.