29 2 TREATMENT SEEKING IN THE MILITARY - A QUALITATIVE STUDY INTRODUCTION Globally, millions are exposed to stressors at work that increase their vulnerability to develop Mental Health Conditions and Substance Abuse (MHC/SA) (e.g. soldiers, policemen and doctors) (1). Specifically, soldiers have an increased risk for MHC/SA after deployment (2) and research shows that 60% of soldiers with MHC/SA, who could benefit from treatment, do not seek treatment (3), leading to a treatment gap for MHC/ SA. Leaving MHC/SA untreated poses a threat to sustainable employment through a higher risk for sick leave and unemployment (4, 5). Beside negative consequences that affect wellbeing on individual level, there are high economic costs involved when leaving MHC/SA untreated (6). In order to reduce the treatment gap, it is essential to examine causes of non-treatment seeking. Multiple reviews have examined barriers and facilitators for treatment seeking (7-9), with one of the main barriers being concern about stigma (3, 10). There are different types of stigma, and in line with previous research (11) the current study will focus on three types. (1) Public stigma – members of the general population endorse prejudice and discrimination against individuals with MHC/SA (12), (2) self-stigma – occurs when individuals with MHC/SA internalize the negative stereotypes and prejudices held by the general public (13), and (3) structural discrimination – rules/regulations which either intentionally or unintentionally disadvantage individuals with MHC/SA (14). For example, US Marines indicated being afraid that receiving treatment would cause them to be seen as weak (public stigma) and cause them to be treated differently in an unfair way (structural discrimination) (15). One main facilitator has been found to be supportive leadership (11). Although research, both quantitative and qualitative, has been conducted on barriers and facilitators of treatment (9), it remains a complex phenomenon and more research is needed (3, 16). Existing research has focused on perspectives of soldiers with MHC/SA, largely ignoring perspectives of soldiers without MHC/SA and military mental health (MH) professionals (7-9), whilst they play a significant role in the decision to seek treatment. First, soldiers without MHC/SA potentially hold negative views (public stigma) and influence others in deciding to seek treatment (17). Second, they may develop MH/SAP themselves in the future, making it relevant to explore what would determine their treatment seeking. Third, existing research has shown that generally, (civilian) MH professionals hold stigmatizing attitudes towards patients with SA (e.g. perceive them as dangerous or responsible for own SA) which negatively influences treatment outcomes (18). Finally, military MH professionals have influence on how mental health care is provided, and can potentially take away certain barriers. As they can be part of the solution, it is valuable to examine their perspectives. Using a multi-perspective approach can validate and extend earlier findings, providing more insight into the complex decision to seek treatment. The aim of the current study
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