By: Diane Manwill, EDM is the Senior Associate for Mental Health Services to the Armed Forces, American Red Cross

Since the beginning of the conflicts in Afghanistan and Iraq, Robin Williams has been entertaining our troops. When he chose to end his own life, this brilliant and bright soul, who gave us all so much happiness with his acting and comedy, left us dumbfounded. How could a man be so broken on the inside but on the outside give us all so much happiness? We know Robin Williams had been in treatment for some time, and we can’t imply what he was thinking or feeling at the time he chose to take his life. Perhaps one more stressor—a Parkinson diagnosis– was insurmountable.  If this could happen to someone as beloved as Robin Williams, what obstacles prevent someone, in treatment, takes their life or someone from seeking treatment? The questions that have arisen from this tragedy can help us examine the barriers to seeking mental health treatment, allowing us to identify policies and programs to break down these barriers and prevent suicide.

Currently, there are about 21 million veterans in the U.S. with 2.6 million who served in the Iraq and Afghanistan conflicts. Today nearly 1.7 million of these are seeking care either at the VA or in their communities.  Of those, 15-20% meets the criteria for PTSD, but only about half have sought treatment.  Regrettably, a common consequence of psychological health disorders among service members is suicide.

Before 2008, the suicide rate in the military remained below the national average, but it has slowly increased; now surpassing the civilian rate.  Since that time, reports by the Department of Army have showed a dramatic increase over the national average of 20 suicides per 100,000 people in comparison to civilian rates at 14 per 100,000. Higher still are the rates among Reserve and National Guard members at 30-34 per 100,000. The report, identified relationship problems, military or work stress, legal issues, high risk behaviors, and medical conditions to be principal risk factors among their soldiers for suicidal behavior. In addition, alcohol or substance abuse, limited support systems, and prior suicide attempts were salient to the military population.

Though mental health care has become more mainstream the stigma of seeking help still impacts military members for whom it would be a huge benefit. A mental health diagnosis carries implications of being different–labeled “crazy” or “broken.” There is also fear that going to counseling means you need help and or you are ”weak,” or that having a diagnosis carries repercussions and may affect your job or career.  People generally believe that mental health treatment will be ineffective or that going to a friend or family member is more effective then seeking mental health care.

In 2012, Blue Star Families did a random online survey of 5,100 military and veteran families on topics such as finance, employment, mental health, and suicide. Of those surveyed 9% of military spouses and 18% of service members reported they had ever considered suicide. Of these, one third of service members and one quarter of spouses did not seek counseling. The study identified three factors that deterred seeking treatment: first, counselors were neither culturally sensitive nor competent in the military lifestyle; second, services for mental health were not easily available; and third, mental health clinicians were not specially trained to work with members of the military.

Additionally, in 2014 an Iraq Afghanistan Veterans of America (IAVA) survey of 2,089 service members who served in Iraq, Afghanistan or both asked if they were getting the mental health care they needed. 73% reported they did not, citing the following reasons:  the stigma in seeking help is too great, they have access to care but choose not to seek it, and they do not have access to high quality of care. And for those who indicated they had a mental health injury, more than half were not seeking care because they did not want to be perceived as different, they believed that seeking treatment would affect their military career, or they preferred talking to family or friends rather than health care professionals.

We do a disservice by lumping all of these individual issues into the broader concept of stigma without addressing each element of what individuals believe about mental health.  And there are repercussions that providers need to be transparent about and eliminate these external consequences and repercussions as much as possible.  Above all, the fear of repercussions is the number one barrier to getting treatment.

Over the past 14 years, there has been a lot of experimentation with treatments and supports, and some are quite promising, especially with families. In the past, very little screening was available; now there are pre- and post- health assessments and reassessments for service members in primary care clinics. These health assessments help to identify early symptoms of distress such as changes in sleep, appetite and mood. There has also been an enormous change in identification and implementation to expand the systems of care for military families. Mental Health professionals have been imbedded in primary care clinics as a part of a multi-disciplinary team. We need to not only focus on what is most effective but also on our ability to roll them out to the entire community who serves the military.

Community mental Health therapists who treat military families must become culturally sensitive and cognizant of not only the hardships but the strengths that allow families to thrive under critical stressors. Resilience for military families is the ability of the family to overcome the difficulties and challenges of deployment and reintegration and in the face of these stressors while functioning with few disruptions and general well-being. Providers treating military families should gain knowledge about the military and the military family.

Many individuals who have attempted suicide identified feelings of hopelessness, isolation and not feeling a part of a group; other symptoms such as sleep disturbances, anxiety, financial difficulties, unemployment and relationship issues were also factors. Increasing feelings of belongingness, feelings of worth, pain management and targeting sleep disturbances are specific and effective interventions.  Additionally, research tells us that using peer support and targeting the whole family systematically is an effective treatment option.  We teach soldiers to help their buddy, to never leave a marine, why don’t we teach them that this same strength comes from reaching out and seeking help like when on the battlefield. Robin Williams showed us his brave face with laughter and love; whether that’s in service of humor in his case or in service to being a strong soldier. The motivation for not seeking care and the tragic result is the same.  His loss and the loss of all our warriors who choose to take their lives leave us saddened and heartsick. We have much to learn from service members and their families, and we owe it to them to give them the best possible care.

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