[Issue #19] Why We Don’t Get Help
An attempt to answer a reader’s question (longread)
“Stigma against mental illness is a scourge with many faces, and the medical community wears a number of those faces.”
-Elyn R. Sacks
I’ve had the luxury and privilege of exchanging stories, ideas, and experiences with some of you dear readers and amongst a thread of conversation via email, a reader asked me,
“Why do so many veterans struggle to seek help?”
This week, I’ll attempt to tackle an answer.
I worked the night shift in the middle of nowhere, Colorado, long before gay marriage was a federal right or BetterHelp.com existed. Netflix was still shipping DVDs and the base I worked had exactly two stop lights.
I was active duty Air Force at the height of the “War on Terror” between the years 2003 and 2009. Ironically, when I first arrived at my base, it was the first time I felt any sense of true freedom.
I volunteered to join the Air Force after 9/11. Being thrown into a world of silent expectations, militant adherence to ridiculous rules, and an understanding that stifling oneself was in the greater interest of the whole group was like an earthquake for my already shaky identity. Meaning, being one united was rewarded while being an individual was resented and it’d make a lot of enemies.
Growing up feeling unseen and unheard, shame compounded. Joining the Air Force felt like a liberating way to take back control of my own life, which had been fraught with my suicide ideation, family cycles of addiction, discreet violence, and my eagerness to be perfect and please. Freedom felt so close.
I couldn’t wait to go to war.
I was elated when I got my Airman’s Coin and I cried as the jets flew overhead. But, somehwere along the way, the continued need to stifle my sexuality, if I hoped to survive, eroded my sense of self. Going to the only gay bar in town felt like a life/death of career decision each time I walked through the doors. One night at the bar, while dancing in the shadow of the dance floor to the only music played in gay bars (EDM), I saw two fellow female airmen, one a Staff Sergeant, and we all made a pact with each other never to tell a soul at work - we knew what we’d sacrificed having joined in the first place, and getting kicked out would leave us without many viable options of future careers.
The fear of being found out loomed like some stalker behind bushes. Word gets around a small Air Force base in the middle of nowhere with nothing to do. We worked more than we didn’t, and we spent more time with our fellow Flight (team) members than we did our own families, most of us. We didn’t all like each other, but there was a mutual respect, especially after you deployed. Getting deployed was rewarded with added money to your paycheck (upwards of thousands of dollars per month) while in a combat zone, a nice “atta boy!” from everyone on flight, new ribbons to tack onto our dress blues (and the allure of potentially earning a medal while at war, like a Bronze Star or a Purple Heart), and the privilege of riding around solo during shift, on patrol, instead of stuck in some metal box or gigantic building filled with expansive hallways and locked rooms we’d never get to see the inside of.
One evening, I felt the overwhelming sense of dread that gets muddled when suicide crosses your mind. I was 20 or so, and I had the strong urge to end my internal suffering. But something in me (my wise self?) whispered and I picked up the phone at the post I was working (one of the entry gates) and asked for the only Staff Sergeant on flight I trusted. When she came to talk to me, I told her the truth.
That Staff Sergeant will forever hold a special place in my heart because she met me with such kindness and genuine compassion. What happened after that, though, was anything but kind or compassionate.
Any apparent weakness is judged, and people are marked bad, then shunned, ostricized, bullied, and other negative social outcomes. A mental health diagnosis held nearly the same weight as being a closeted lesbian, and, much like my sexuality, a mental health diagnosis would effectively end my career, or at the very least, put me behind my peers, working posts solo, and a significant loss of respect and perceived ability to do my job among my peers and leadership. There was already ample evidence and a long history of bullying, ostricizing, and the like, proving my anxiety and hesitance in telling any leadership was warranted.
Knowing all of this, I called for help anyway. I was immediately taken off flight and stripped of my weapons, sent to a mental hospital for a two week stay (which was further traumatizing and incredibly isolating), then, once I got back to work, I worked at the admin building for months before I was finally allowed to go back to my real job (one I despised, which fed into my depression), before ultimately deploying to Iraq a number of months later.
While my personal experience may seem unique, I’m here to tell you, it’s unfortunately not. There are elements of my personal history that parallel trauma incurred by others and more universal experiences of such. Far too many combat veterans are afraid to seek help because of the fallout from even entertaining the idea of getting help.
In 2018, females (or those identifying as such) made up only 16% of the enlisted ranks and 19% of the officer ranks across branches of the United States military (this data, though, does not include the Coast Guard). That leaves the rest of the rank-and-file filled with mostly heterosexual males (or those identifying as such). That means “locker room” talk and a “boy’s club” mentality was (and, I’m guessing, still is - trans people are no longer allowed to volunteer to serve their great democratic nation, as of 2016, and as a society we tend to ban what we don’t understand instead of getting curious and finding compassion for the other) pervasive. Feeling your feelings in the military is 100% not encouraged. At least, not while I was in the service. But, if the Veteran’s Affairs department is any indication of progress within the United States military and attempts to re-humanize us war vets, my hopes have been long dashed.
I mean, women’s health care only became a thing within the VA within the last 10 years and women have been serving in the United States military since Loretta Walsh enlisted in the U.S. Navy in 1917! That’s nearly 100 years!
Now, present day, studies have been done on the rates of depression and PTSD, in an attempt to answer our reader’s question of why we don’t get help. One such study, published in 2010, in the scientific journal Psychiatric Services, was large, studying more than 15,000 combat troops. The study, entitled “Stigma, Barriers to Care, and Use of Mental Health Services Among Active Duty and National Guard Soldiers After Combat” explored the mental health and PTSD symptoms in both National Guard and Active Duty combat troops (who had been deployed to Iraq) post-deployment at 3 and 12 months. The study concludes:
“Iraq war veterans report high rates of mental problems postdeployment that increase in the months after return. In a large longitudinal study of soldiers returning from Iraq and Afghanistan, [researchers] reported significantly higher rates of mental health concerns three to six months after deployment, compared with rates reported immediately after deployment. They also found that although National Guard and active duty soldiers reported similar rates of mental health concerns immediately after deployment, National Guard soldiers reported higher rates than active duty soldiers three to six months later.”
And the same study goes on to further explain (and does a succint job at lending evidence toward an answer to our question) the actual or perceived barriers to care:
“Presumably, the low rates of service utilization are due to stigma and perceived barriers to care. [The study] found that soldiers who met screening criteria for mental problems were twice as likely as soldiers who did not meet screening criteria to report feelings of stigma. Research on stigma in civilian populations asserts that individuals who perceive the stigmatizing behaviors of others as legitimate will have lower self-esteem. This belief and internalization of stigmatizing behaviors is likely to reduce treatment seeking by soldiers with mental illness. Even if soldiers have not internalized stigma, specific barriers to care, such as lack of time or transportation difficulties, might also prevent soldiers from seeking treatment.”
But, it’s not just the worry of what others may think, or the stigma of mental health itself that always stops someone from seeking (oftentimes, much needed) mental health treatment. There are so many various factors impacting someone’s ability or willingness to get treatment such as cost, lack of insurance, lack of choice, transportation availability, time out of busy schedules, trust in therapists or therapy itself, access to needed care, openness to diagnosis and treatment, awareness of one’s own emotional state or mental health troubles, openeness to different therapeutic modalities and medications…the list goes on.
A large factor, for me, in being able (willing) to get the help I needed was (and still is at times) my wife and my support network. Recovery of any sort is difficult, and recovering from PTSD or complex trauma is no less taxing or exhausting. The work feels, seems, endless. The work is hard and time-consuming. So is my anxiety. So is my PTSD. So is my depression. Social support is the antidote to PTSD, overall. Having good friends that have your back on the good days and the bad days truly makes all the difference.
Stigma kept me from seeking mental health treatment for a long time, after joining the miltary. Stigma no longer stops me from getting the help I need, whatever that looks like. Or my fear of being “weak”, or a fear of being perceived any certain way.
Another study, “Veteran-Centered Barriers to VA Mental Healthcare Services Use” resulted in what was coined “5 dimensions of barriers to care”, which were:
“…worry and concerns about what others think; personal, financial, and physical obstacles; confidence in the VA healthcare system; navigating VA benefits and healthcare services; and, privacy, security, and abuse of services.”
So, stigma, cost, pain or physcical ability, the VA’s reputation, concerns for self, and mis-use of resources.
What about women veterans versus male veterans? Are there differences or other obstacles to care? The British Medical Journal sought to answer this question and conducted a small research study, “Female Military Veterans Face Additional Barriers Accessing Mental Health Support” which states the following:
“Although only a minority of both male and female veterans are accessing support, females appear to have additional barriers to overcome when seeking help, such as negative gender stereotypes and a lack of recognition of their veteran status.”
But, what about outside of combat veterans or the VA healthcare system? Are people more likely to seek help in the civilian world?
Nope.
Published in 2013, the abstract of the study Mental Illness Stigma, Help Seeking, and Public Health Programs, which aimed at reducing the stigma attached to mental health diagnoses, reported the following:
“Globally, more than 70% of people with mental illness receive no treatment from health care staff. Evidence suggests that factors increasing the likelihood of treatment avoidance or delay before presenting for care include (1) lack of knowledge to identify features of mental illnesses, (2) ignorance about how to access treatment, (3) prejudice against people who have mental illness, and (4) expectation of discrimination against people diagnosed with mental illness.”
And, in 2017, another study, looking at the mental health gap in low and middle-income countries, entitled “Challenges and Opportunities in Global Mental Health: A Research-to-Practice Perspective,” came up with a similar outcome:
“Globally, the majority of those who need mental health care worldwide lack access to high-quality mental health services. Stigma, human resource shortages, fragmented service delivery models, and lack of research capacity for implementation and policy change contribute to the current mental health treatment gap.”
A systematic review article entitled “Exploring Barriers to Mental Health Services Utilization at Kabutare District Hospital of Rwanda: Perspectives From Patients” published in March of 2021, sought to evaluate the current literature in hopes of bridging the mental health care gap plaguing mid and low-income countries:
“Barriers to mental health interventions globally remain a health concern; however, these are more prominent in low- and middle-income countries. The barriers to accessibility include stigmatization, financial strain, acceptability, poor awareness, and sociocultural and religious influences. Exploring the barriers to the utilization of mental health services might contribute to mitigating them.”
It turns out, we humans care very much about what others think of us. So much so, we disregard our own mental, physical, and emotional health in the name of something other than ourselves, like jobs which require hard physical labor for 13 hours a day, or drinking a 2 liter of Mountain Dew with breakfast, or not wearing your seatbelt/helmet/other protective gear. All because we don’t want to be inconvienenced or for our “friends” to think we’re weak!
The other trouble with seeking mental health help is the perceived (or lack of) needed intervention, medication, or therapy. I didn’t know I had PTSD for a long time. Then, when I got diagnosed, it nearly broke my heart. I felt beyond weak. I felt like a failure. Like I let everyone down.
We don’t chastise ourselves when we’re down with the flu, or if we sprain an ankle. Yet, dare our minds be anything other than, what? Happy? Filled with unicorns and sprinkles? The future, where everything is bound to be perfect?
Our minds, like our bodies, can be injured, too. Being thrown out of a windshield while an SUV is mid-air and tumbling like a gymnast definitely impacted my body. But it impacted my mind, too. Does that make me weak?
Going to war is not weak. Making it back home with all the physical parts you left but with more anger than you know what to do with does not make you, or me, weak. Having nightmares about shit we don’t want to remember does not make us weak. Being unable to control your urge to drink every Saturday night is not a weakness, it’s an illness. Seeking a math tutor for college algebra does not make me stupid or weak. Having depression does not mean I am incapable of change. Getting a divorce, telling your son “no” to that loan, quitting your job, all of these things are not showcasing some weakness. These are instances that showcase our very fragile and limited human experience.
Compassion, curiosity, and an ability to see the strength and courage it takes to ask for support and help with mental health issues is our only way forward. While access to mental health services has exponentially increased over the past decade, the types of medications, therapeutic modalities, and subconsious biases that exist have been incredible barriers to access for a large portion of the American (and global) population. Soon, I’ll be researching and covering atypical “medications” and the standard, run-of-the-mill, big-pharma medications typically prescribed for mental health conditions such as depression, anxiety, PTSD, bi-polar disorder, and other diagnoses.
If you, or someone you know, is reticent or hesitant to seek the help they need, I’ve provided some resources below and will be putting together an entire resources section in the near future.
And, if you have any questions or subject/topic ideas, please send them over or leave them in the comments! I reply to every email I get, generally within a couple of days, and I enjoy hearing from you (my contact info is at the bottom of this post)!
The world may be filled with assholes, but maybe if people were more able to access the help and support they need, there’d be fewer assholes and we wouldn’t get so triggered.
This week, I’m curious about your own mental health and any struggles with it you may have had, or are having now. Have you, at any point, been hesitant to seek mental health treatment? If so, why? Journal it in private, send me an email, or leave a comment below.
“The bravest thing I ever did was continuing my life when I wanted to die.”
-Juliette Lewis
Resources
The U.S. Department of Health and Human Services offers a National Mental Health Helpline
For veterans and their caregivers: find an intensive PTSD or other treatment program through the Wounded Warrior Project
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Thank you so much for writing about your experience so honestly. I never get tired of hearing people's story, not least because it helps me understand and find greater compassion for my husband, who has his own war (and PTSD) story.
I've been in therapy on and off for 20+ years, for my own "stuff" and the enormous challenge of dealing with the fallout of my husband's "stuff." My medical records list a bunch of fun diagnoses: depression, anxiety, OCD, eating disorder. I don't care about the stigma and I'm open about it every chance I get. (I've also done a ton of work, and spent a decade on various medications, which nearly killed me, so it's no small thing for me to report that I am mostly healed from all of those things -- my anxiety will never go away fully, I still struggle with disordered eating, but I have found ways to come back from the other things.) For me, therapy is simple emotional hygiene -- I wouldn't go without taking a shower or brushing my teeth, nor would I go without therapy. I am so thankful there are people in the world willing to help, and that I can access those resources.