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Research Questions

  1. What does mental health stigma mean in the military context?
  2. What is the prevalence of mental health stigma in the military, and what are its medical and societal costs?
  3. What does the scientific evidence base show about the most-promising program and policy options for reducing stigma?
  4. How well do U.S. Department of Defense (DoD) programs and policies align with what the evidence base shows?
  5. What priorities should DoD consider to enhance and refine stigma-reduction efforts?

Despite the efforts of both the U.S. Department of Defense (DoD) and the Veterans Health Administration to enhance mental health services, many service members are not regularly seeking needed care when they have mental health problems. Without appropriate treatment, these mental health problems can have wide-ranging and negative impacts on the quality of life and the social, emotional, and cognitive functioning of affected service members. The services have been actively engaged in developing policies, programs, and campaigns designed to reduce stigma and increase service members' help-seeking behavior. However, there has been no comprehensive assessment of these efforts' effectiveness and the extent to which they align with service members' needs or evidence-based practices. The goal of this research was to assess DoD's approach to stigma reduction — how well it is working and how it might be improved. To address these questions, RAND researchers used five complementary methods: (1) literature review, (2) a microsimulation modeling of costs, (3) interviews with program staff, (4) prospective policy analysis, and (5) an expert panel. The priorities outlined in this report represent a first step for where additional program and policy development and research and evaluation are needed to improve understanding of how best to get service members with mental health disorders the needed treatment as efficiently and effectively as possible.

Key Findings

Mental Health Stigma Is a Process

  • Mental health stigma is a dynamic process by which a service member perceives or internalizes a brand or marked identity about himself or herself or people with mental health disorders. This process happens through an interaction between a service member and the key contexts in which he or she operates: public, institutional, social, and individual.
  • Four immediate outcomes are empirically linked to stigma: coping mechanisms, interpersonal outcomes, attitudes toward treatment seeking, and intentions to seek treatment.
  • The literature has theoretically linked four long-term outcomes to stigma: well-being, quality of life, treatment initiation, and treatment success. The authors could not empirically link these, however.

Current U.S. Department of Defense Stigma-Reduction Efforts Are Aligned with Best Practices and May Be Contributing to a Decline in Self-Reported Stigma

  • DoD's approach is broader than stigma reduction and encompasses minimizing barriers to mental health care. This assessment shows that that approach is consistent with best practices and may have contributed to declines in self-reported perceptions of stigma in a subset of the military population.
  • Most of the stigma-reduction programs currently implemented by DoD target stigma in the public context.
  • Policy language barring service members with mental health disorders from career opportunities could create paths for discrimination. Tensions exist between the privacy of service members seeking mental health treatment and the need for commanders to assess unit fitness.
  • Some policies support universal educational stigma-reduction programs but not more-targeted programs for those in mental health treatment.
  • Few measures of self-stigma in the military exist, and no DoD-wide measures of military mental health stigma are currently being collected.

Recommendations

  • DoD should convene a task force to explore the tensions between a command's need to know a service member's mental health status and treatment history and the need for privacy.
  • DoD should improve stigma-reduction interventions by exploring interventions that directly increase treatment-seeking; considering evidence-based approaches to empowering service members who have mental health concerns to support their peers; designing new or adapting existing intervention-delivery mechanisms to minimize operational barriers for service members seeking treatment; embedding stigma-reduction interventions in clinical treatment; and implementing and evaluating stigma-reduction programs that target service members who have not yet developed symptoms of mental illness.
  • DoD should improve policies that contribute to stigma reduction by providing better guidance for policies in which a mental health disorder or treatment prohibits job opportunities or actions and by reviewing the stigmatizing language identified in policies to determine whether it should be removed.
  • DoD should improve research and evaluation related to stigma reduction by assessing the modifications made to existing programs that begin to address stigma and other barriers to care; examining the dynamic nature of stigma and how it interacts with internal and external conditions over time; improving measures of prevalence to improve tracking of stigma and other barriers to care; and reviewing classified departmental and service-specific policies to determine potential implications for mental health stigma and discrimination.

Table of Contents

  • Chapter One:

    Introduction

  • Chapter Two:

    Defining Stigma in the Military Context

  • Chapter Three:

    Prevalence of Mental Health Stigma in the Military

  • Chapter Four:

    Societal Costs of Mental Health Stigma in the Military

  • Chapter Five:

    Promising Programmatic and Policy Approaches to Reducing Stigma

  • Chapter Six:

    U.S. Department of Defense Programs to Reduce Mental Health Stigma

  • Chapter Seven:

    U.S. Department of Defense Policies Related to Stigma

  • Chapter Eight:

    Key Findings and Priorities for Improving the U.S. Department of Defense's Approach to Stigma Reduction

  • Appendix A:

    Methods for Literature Review

  • Appendix B:

    Definitions of Mental Health Stigma

  • Appendix C:

    Prevalence of Stigma in the General U.S. Population

  • Appendix D:

    Detailed Methods for the Modeling Approach

  • Appendix E:

    Program Descriptions and Analysis

  • Appendix F:

    Policy-Analysis Methods

  • Appendix G:

    Policies with Implications for Stigma

  • Appendix H:

    Policies That Contain Negative Terminology with Implications for Stigma

  • Appendix I:

    Methods Used to Conduct the Expert Panel to Refine and Vet Priorities for Mental Health Stigma Reduction in the U.S. Department of Defense

This research was sponsored by the Office of the Assistant Secretary of Defense for Health Affairs and the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury and conducted within the Forces and Resources Policy Center of the RAND National Defense Research Institute, a federally funded research and development center sponsored by the Office of the Secretary of Defense, the Joint Staff, the Unified Combatant Commands, the Navy, the Marine Corps, the defense agencies, and the defense Intelligence Community.

This report is part of the RAND Corporation research report series. RAND reports present research findings and objective analysis that address the challenges facing the public and private sectors. All RAND reports undergo rigorous peer review to ensure high standards for research quality and objectivity.

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