The fact that stigma (being marked or believing one is marked as disgraced) is a primary barrier to veterans seeking help to overcome the destructive psychological effects of trauma is a cultural phenomena which is easy to see, widely acknowledged, and also evidenced by research (Hoge et al., 2004). As is often pointed out, stigma has two manifestations: the belief by others that the need for psychological help is a sign of essential inferiority, and the same belief held by the self (Corrigan, 2004). Both are important, but self-stigma can be the most damaging.
Efforts to overcome stigma related to psychological problems, for veterans in particular, seem to have focused on three approaches: (a) viewing the psychological effects as a normal response to an abnormal situation; (b) interpreting the effects as a medical rather than a characterological problem (e.g., “Not all wounds are visible”); or (c) framing the seeking of help as a responsibility of the individual to fulfill his or her own potential—in other words, recognizing that seeking help takes strength (e.g., “It takes the strength of a warrior to seek help.”). All of these have had some success, yet the problem of stigma persists as a barrier to treatment-seeking among veterans (Hoge, 2010).
One explanation for the persistence of stigma lies in the human tendencies that produce prejudice and stereotyping, for stigma is in that family. In my view, modern society has succeeded in reducing some kinds of prejudice and stigma. Some irrational beliefs, however, are more difficult to reduce than others because they at times facilitate adaptive functioning. For example, the military requires intentionally putting one’s life at risk for a cause that (one hopes) is worth that potential sacrifice. This is done in order to overcome the rational fear/terror and pain (both physical and emotional) necessary to function in a combat situation. For soldiers, it appears that the motivation to push through fear is enhanced by the even greater fear of being stigmatized. Failure to act rationally from a personal survival point of view (that is, to intentionally face death) is seen as a profound sign of weakness, and leads to exclusion from the valued group. Once the battle is over and its stress has done its damage, the well-established message that acknowledging the need for psychological help is unacceptable is now no longer necessary to the mission. However, it is ingrained, still active, and may serve to immediately block some of the pain of the war experience. But that fear of stigma now causes a new problem, the failure to obtain needed help to overcome the pain of war and achieve civilian goals.
Although the three approaches mentioned above may be helpful as generally applied, a way of potentially amplifying these benefits has been included in a U.S. VA/DoD PTSD treatment program to help sustain and improve treatment motivation. It also may become valuable to help others needing, and not receiving, treatment seek this out. It is this approach that I want to share with the readers of this article.
In this approach, first the meaning of stigma, its relationship to stereotyping, and the three traditional responses to it mentioned above are introduced. Next, the way in which veterans may have used stigma beneficially, to overcome the extreme challenges of training and deployment is presented. Then stigma is acknowledged to be humanly inescapable. It is surmised that everyone knows and acknowledges, at least in private, that we all tend to form prejudicial opinions, and even enjoy them. We will irrationally root for the home team and, at least slightly demean our rivals if not downright vilify them. I think all veterans know that even if they diminish their negative self-beliefs to effectively get help, there will be some little part of them that at least sometimes whispers that they wish they had the “strength” to not need help.
Once this human limitation is acknowledge a plea is made that if one is to stigmatize, at least one should “get it right”. (Perhaps the reader will see that some humor is intended, which means that rapport has to be established before delivering the message accompanying this approach). Part of the approach involves directly addressing the stigma that resides within the veteran and therefore the language used reflects what people say to themselves, and what they sometimes hear from others. This allows a resonance often missing in the purely logical arguments against stigma.
Three categories of stigma are presented, which roughly correspond to the three categories of DSM IV PTSD symptoms. (Fortunately, it is not expected that a revision will be necessary to reconcile the current approach with the forthcoming DSM-5). Along with the more accurate representation of the problem a therapeutic path toward resolution also is offered. These categories are offered in a framework which implicitly acknowledges the “wound” base and the normality of the stress reaction.
1. Current stigma term: "Crazy Vet"
More accurate term: Stuck Transferer
This is the stigma associated with re-experiencing symptoms. “Stuck Transferer” refers to the idea that flashbacks, reexperiencing, and nightmares are manifestations of unprocessed memory. In Horowitz’s (1976) terms, memory has not moved (transferred) from short term to long term storage. More recently this has been conceptualized in terms of declarative and non-declarative memory. In the version presented to veterans this is called moving from “reliving” to historical or intellectual memory.
2. Current stigma term: "Asshole"
More accurate term: Pain Blocker
This one is about anger/rage – of the unwanted, regretted variety. Based on over 30 years of discussion with combat veterans, I endorse the old idea (e.g., Sullivan, 1954; Virgil, 19 BCE, 2006) that the anger reaction is a way of trying to hide sadness, fear and/or pain. Thus, in a very simplified form, the choices are:
a) exhibiting the “weakness” of dealing directly with the fear and sadness from the trauma situation, or
b) exhibiting the “weakness” of the anger to hide it.
Of course, sometimes people who hide their fear or sadness do not need anger to do so, they can just wall it off with numbness or callousness, which can spread out to also block their positive feelings. Alcohol, drugs and other addictive habits also help construct this wall. As I tell my veteran clients, “If your idea of strength is to go through life without emotion, and to define anyone who does not want to do so as weak--that is, to stigmatize them--then even if I disagree, who am I to argue?”
Since we have already used “crazy vet”, a good second choice for inaccurately stigmatizing someone with the anger reaction would be “asshole.” Again, this would be unnecessarily imprecise. The better stigma insult might be “pain blocker”, and it would have the added benefit of also applying to the person with no demonstrated anger, or other visible emotions.
3. Current stigma term: "Weak"
More accurate term: “Bum” Amygdala
Hyperarousal is a general term for one of the symptoms clusters of PTSD. It refers to extreme emotional reactivity, sometimes seen as an exaggerated startle response or “jumpiness”. It is reasonable to believe that living through extreme stress, especially for long periods of time, leads to changes in the nervous system. I don’t think that this is fully understood, but the idea is that the biological systems that get us “up” in order to take on continued and extreme threat are changed and become over-reactive. We then become over-reactive in our emotions and behavior, with extreme startle responses, and some of the problems mentioned above. This, obviously, is a simplification.
If general hyperarousal is the problem, until the systems can repair themselves or be repaired (sometimes through memory transfer), the survivor of trauma will have to learn and practice ways to compensate and to “dial it down” every day. For now, research suggests that instead of using the term “weak” saying one has a “bum amygdala” (Shin et al, 2006), one of the parts of the brain associated with fear reactions, would be the more proper stigmatizing insult.
As mentioned previously, the ideas described here have been welcomed by veterans and active duty military undergoing PTSD treatment in a federal health care center. Based on this experience, I think it is reasonable to believe there might be value in presenting this ideas to others who are wrestling with stigma that is interfering with the pursuit of needed treatment. One caveat is that the nature of the intervention, includings its obvious exposure component and intended humor, could lead to misinterpretation of the approach. Therefore, it is advised that the person presenting these ideas to veterans be seen as having the standing to talk frankly about the issues involved. The author’s position of being known to veterans in the treatment program as a sympathetic long-term practitioner with combat veterans undoubtedly helps in this regard. In addition, a version of this paper directed to veterans is available at HowardLipke.com/Stigma. As one can see from the title of that version, “I Don’t Give a Rat’s Ass What Other People Think”, potential readers are well-prepared in advance for its tone.
Corrigan, Patrick W. (2004) How stigma interferes with mental health care. American Psychologist,59(&), 614–625.
Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D., & Koffman, R. L. (2004) Combat duty in Iraq and Afghanistan, mental health problems and barriers to care. New England Journal of Medicine, 351, 13 – 22.Hoge, C. W. (2010) Once a Warrior, Always a Warrior. Guilford CT: Globe Pequot Press.
Horowitz, M. (1976) Stress response syndromes. New York: Jason Aronson/
Shin, L. M., Rauch, S.L. & Pitman, R. K. (2006) Amygdala, medial prefrontal cortex and hippocampal functioning in PTSD. Annals of the New York Academy of Sciences: A Decade of Scientific Progress, 1071, 67 – 79.
Virgil. (2006, Robert Fagles, trans.) The Aneid. NY: Penguin.
Dr. Howard Lipke has worked with combat veterans in VA medical centers since 1972, when he was a VA psychology trainee. Since retiring from the VA in 2009 he has continued this work in a variety of ways in a part time clinical and consulting practice. He has been a member of ISTSS since 1989.