41 2 TREATMENT SEEKING IN THE MILITARY - A QUALITATIVE STUDY The first limitation was the relatively low diversity in terms of age and rank between participants, with a majority of older and higher-ranking soldiers. It is possible that improvement has already been made to decrease the treatment gap within the younger generation of soldiers, but that this is not yet visible for the older generation. Findings of a British study also indicate that help seeking is already improving (36). Second, risk of self-selection bias cannot be ruled out, as participants freely signed up for the study knowing what the study was about. Third, a limitation of using a focus group study is the lack of anonymity while discussing a sensitive topic. It is possible that participants only provided socially desirable answers. As discussed in the procedure section, the first author was familiar with two participants (both soldiers without MHC/SA), also forming a risk for socially desirable answers. However, as described above, several measures were taken to ensure confidentiality and allow participants to speak freely. Conclusions and implications for practice and future research The findings suggest that the treatment gap can be diminished by involving social support and encouragement from family, peers, supervisors, and mental health professionals. Future research should investigate if interventions built upon increased support, and improved clarity about where and how to find help are effective in lessening the treatment gap. A starting point for clinical care would be to implement interventions that have already been proven effective in other countries that target social support, such as the peer-to peer programs and programs for military families implemented in the U.S. (37, 38). Importantly, the study also highlighted the substantial barrier to treatment seeking formed by stigma. Especially, the fear of negative career consequences (structural discrimination), social rejection (public stigma), and the ‘strong worker’ workplace culture (self-stigma) are important obstacles for seeking help. Clinical care should try to implement interventions targeting stigma that have proven to be effective in other armed forces, for example the online help seeking stigma-reduction intervention which targets self-stigma (39). The high agreement across different perspectives on these barriers implies that help seeking actually does pose a risk for negative career consequences and social rejection, and that a key to closing the treatment gap can also be found in taking measures to overcome these adverse outcomes from occurring. Future intervention studies and policy measures should thus also focus on the barriers found in the present study, in order to decrease the treatment gap and improve health and sustainable employability.
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