EDITORIAL: Embracing the Diversity of Military Social Work James G. Daley Anthony M. Hassan Special Issue Co-editors This special issue illustrates the wide diversity of the field of military social work. Military social work has spanned more than 60 years (Daley, 1999; Maas, 1951; Rubin, Weiss, & Coll, in press) and social workers were working initially in World War I as Red Cross staff (Harris, 1999). Uniformed social work officers serve in the Army, Navy, Air Force, Coast Guard, Guard/Reserve, and Public Health Service in a wide range of jobs. Civilian military social workers work within many social service programs serving the military, veterans, and their families. Many countries have uniformed and civilian social workers and programs to aid and care for the military and their families (Daley, 2003). Despite a diverse range of programs provided by and often developed by military social workers, very little is shared in the professional literature or identified as “military social work.” In recent years, there has been a rapidly growing emphasis on the challenges of military personnel, veterans, and their families. Textbooks have begun to multiply, particularly focused on military families (e.g., Blaisure et al., 2012; Everson & Figley, 2011; Hall, 2008; Martin, Rosen, & Sparacino, 2000) and on the impact of war (Kelly, Howe-Barksdale, & Gitelson, 2011; Pryce, Pryce, & Shackelford, 2012; Slone & Friedman, 2008). Intervention protocols are being suggested (e.g., DeCarvalho & Whealin, 2012; Whealin, DeCarvalho, & Vega, 2008). Special issues of journals have highlighted military concerns and coping (e.g., Smith College Studies in Social Work, 2009) and a chapter on military social work in each edition of the Encyclopedia of Social Work is noteworthy. There have been some significant efforts to sharpen the vision of what military social work is. The Council on Social Work Education (CSWE) formed a series of committees and developed a guideline called Advanced Social Work Practice in Military Social Work that identified competencies in military social work (link to CSWE document is http://www.cswe.org/File.aspx?id=42466). The document includes a broad definition of “military social work:” Military social work involves direct practice; policy and administrative activities; and advocacy including providing prevention, treatment, and rehabilitative services to service members, veterans, their families, and their communities. In addition, military social workers develop and advance programs, policies, and procedures to improve the quality of life for clients and their families in diverse communities. Military social workers provide assistance and treatment in the _______  James G. Daley, Ph.D., is an Associate Professor at the Indiana University School of Social Work, Indianapolis. Anthony M. Hassan, Ed.D., LCSW, is a Clinical Associate Professor and Director at the Center for Innovation and Research on Veterans & Military Families (CIR), School of Social Work, University of Southern California. Copyright © 2012 Advances in Social Work Vol. 13 No. 1 (Spring 2012), i-iv Daley, Hassan/EDITORIAL ii  transition from military to veteran status, including a continuum of care and services for military personnel and their families (CSWE, 2010, p. 2). This special issue strives to further strengthen the public awareness of the complex issues and program initiatives facing our servicemembers, veterans, and their families. Nedegaard and colleagues report on the key issues navigated in a multi-national mental health program for troops in Afghanistan. Van Breda outlines the military social work approaches and thinking in South Africa. Issues of military families are well represented including child-parent relationship training for military families (Jensen-Hart et al.), single parent issues (Blanchard), spousal communication (Ponder & Aguirre), and building marital resilience (Ponder & Aguirre). The effects of trauma on military women are explored (Osborne et al.). Community resources are explored such as a home-based reintegration program for military families (DeVoe et al.) and building better informed civilian providers of care for military or veterans (Luby). Veterans issues are well represented with articles on rural veterans (Stotzer et al.), developing a student veterans study and helping veterans in academic settings (Smith-Osborne), assessing PTSD in older veterans (Yarvis et al.), and strategies for helping veterans (Hazle et al.). Beder’s article discusses hospital-based social workers working in military hospitals and the issues of compassion fatigue. Whitworth and colleagues outline a framework for teaching military social work in a school of social work. In sum, this special issue provides for the reader a rich sampler of military social work. Each area is a portal to understanding a portion of the vast terrain that is military social work. There are other initiatives evolving. The Council on Social Work Education (CSWE) is seeking to develop a list of schools of social work that have educational content on military social work (ranging from a course to a full concentration in military social work). There have been special panels focused on military social work at CSWE’s annual conferences, the Society for Social Work and Research annual conferences, and various regional workshops on helping military, veterans, and/or their families. There is a multidisciplinary military and family collaborative called the Alliance of Military and Veteran Family Behavioral Health Providers (http://www.ecu.edu/che/alliance/) that is developing suggested resources for clinicians that work with military personnel, veterans, and their families. First Lady Michelle Obama has made military families a priority and developed Joining Forces (http://www.whitehouse.gov/joiningforces) to support and recognize the issues of military families. In short, the topic has transformed from a benignly neglected field of practice to a hot topic in the country. There are good reasons for the heightened attention. This country has been in a prolonged series of “operations” (e.g., Operation Iraqi Freedom (OIF), Operation Enduring Freedom (OEF)) that have produced more than ten years of combat with an all- volunteer force. The military demands are delivered by a small proportion of our population (commonly called “the 1%” indicating that only one percent of the population is serving in the military). The November 21, 2011 edition of Time magazine called the servicemembers “the other 1%” and defined them as “an army apart.” The basic message is that combat veterans are transformed by the experience and return to face an isolated adaptation in hometowns that are not certain how to relate. Further, the National Guard and Reserve troops have an unprecedented volume and frequency of deployments. Unlike ADVANCES IN SOCIAL WORK, Spring 2012, 13(1) iii   active duty troops who return to a military base, the Guard/Reserve often return to small communities naïve to what the military person has been through and insensitive to the struggles the military families have endured throughout the deployment. Troops are facing repeated deployments, extension of time on deployments, and loss of civilian jobs when they return home. Post traumatic stress disorders, traumatic brain injuries, and suicides have risen in military personnel. The organizations to support and care for veterans are seen at times as a poor fit for veterans with OEF/OIF issues and identity. Some young OEF/OIF veterans see the Veterans Administration (VA) programs as not geared for their needs. The American Legion and Veterans of Foreign Wars organizations are finding many of the young veterans as hesitant to join. Young OEF/OIF veterans have created their own support system in the Iraq and Afghanistan Veterans of America (http://iava.org/). The VA has developed special OEF/OIF programs and separate check in procedures. The VA is preparing for the inevitable onslaught as the 2.4 million veterans will possibly seek benefits and care. According to IAVA, each year 300,000 individuals complete their military service and there is a growing backlog on claims for benefits (http://iava.org/). Families of servicemembers and veterans are often stressed and can feel isolated during the deployment cycle (Matsakis, 2007; Pavlicin, 2003; Pryce, Pryce, & Shackelford, 2012). They are the primary support system and are caught between the servicemember’s struggles and the naïve view of the community. Financial strains, the accordion experience of deployments, and monitoring the wellbeing of the children often fall on their shoulders. Support systems targeted to military families can range from family support centers to only phone advice depending on their location. When servicemembers transition to veterans, the family struggles with benefits and the servicemember’s new identity as a veteran. Often there are few resources targeted for the family within the VA system. Military social work deals with all the issues described above from individual, to family, to community. Servicemembers and veterans rely on our commitment and expertise in creating safety nets for them as they navigate the care systems that are available to ease their challenges. The articles in this special issue are exemplars of efforts to understand and assist servicemembers, veterans, and their families. This generation of veterans needs the help of every social worker and each of us needs to be better trained and savvy to the needs of these veterans. Our work has truly just begun. References Blaisure, K. R., Saathoff-Wells, T., Pereira, A., MacDermid-Wadsworth, S., & Dombro, A. L. (2012). Serving military families in the 21st century. New York: Routledge. Council on Social Work Education. (2010). Advanced social work practice in military social work. Alexandria, VA: author. Daley, J. G. (1999). Social work practice in the military. New York: Haworth Press. Daley, J. G. (2003). Military social work: A multi-national comparison. International Social Work, 46(4), 437-448. Daley, Hassan/EDITORIAL iv  DeCarvalho, L. T., & Whealin, J. M. (2012). Healing stress in military families: Eight steps to wellness. Hoboken, NJ: John Wiley & Sons. Everson, R. B., & Figley, C. R. (Eds.). (2011). Families under fire: Systemic therapy with military families. New York: Routledge. Hall, L. K. (2008). Counseling military families: What mental health professionals need to know. New York: Routledge. Harris, J. (1999). History of Army social work. In J. G. Daley (Ed.), Social work practice in the military (p. 3-22). New York: Haworth Press. Kelly, D. C., Howe-Barksdale, S., & Gitelson, D. (Eds). (2011). Treating young veterans: Promoting resilience through practice and advocacy. New York: Springer Publishing Company. Maas, H. S. (Ed.). (1951). Adventure in mental health: Psychiatric social work with the armed forces in World War II. New York: Columbia University Press. Martin, J. A., Rosen, L. N., & Sparacino, L. R. (Eds.). (2000). The military family: A practice guide for human service providers. Westport, CT: Praeger. Matsakis, A. (2007). Back from the front: Combat trauma, love, and the family. Baltimore, MD: Sidran Institute Press. Pavlicin, K. M. (2003). Surviving deployment: A guide for military families. St. Paul, MN: Elva Resa Publishing. Pryce, J. G., Pryce, D. H., & Shackelford, K. K. (2012). The costs of courage: Combat stress, warriors, and family survival. Chicago, IL: Lyceum Books. Rubin, A., Weiss, E. L., & Coll, J. E. (in press). Handbook of military social work. Hoboken, NJ: John Wiley & Sons. Slone, L., & Friedman, M. J. (2008). After the war zone: A practical guide for returning troops and their families. Philadelphia, PA: Perseus Books. Whealin, J. M., DeCarvalho, L. T., & Vega, E. M. (2008). Clinician’s guide to treating stress after war: Education and coping interventions for veterans. Hoboken, NJ: John Wiley & Sons. Author’s note: Address correspondence to James G. Daley, Ph.D. Indiana University School of Social Work, 902 W. New York St., Indianapolis, IN 46202. E-mail: [email protected] Social Work with Veterans in Rural Communities: Perceptions of Stigma as a Barrier to Accessing Mental Health Care Rebecca L. Stotzer Julia M. Whealin Dawna Darden Abstract: The nearly decade long efforts in the Global War on Terror have led to increasing numbers of Veterans of the armed services returning to rural locations, but little is known about their needs. However, recent research suggests that rural Veterans face a host of issues, but perhaps more importantly, are facing heightened levels of stigma in rural areas related to their health and mental health. This paper examines how mental health stigma in the military may feed into stigma in rural communities and serve as an additional barrier for Veterans in rural areas who are struggling with mental health concerns. Recommendations for the unique role of social workers in serving these Veterans, as well as addressing community issues around stigma, are addressed. Keywords: Mental health stigma; Veterans; OIF/OEF; rural social work; barriers to care INTRODUCTION The Global War on Terror’s nearly decade of conflict in the Middle East has resulted in an increased number of Veterans returning from deployments with a variety of mental health issues. However, help for those issues is not evenly distributed across Veterans. Over 40% of the Veterans of the wars in Iraq and Afghanistan are from rural areas, and existing research shows that rural Veterans Health Administration (VA) patients report poorer mental health status and reduced access to care compared to VA patients in urban or suburban areas (e.g., Weeks, Kazis, Shen, Cong, Ren, Miller, et al., 2004; West & Weeks, 2006). Obviously, logistical factors, including longer waiting periods, limited choice of health professionals, and poorer public transportation, limit access to and use of services in rural settings (Aisbett, Boyd, Francis, Newnham, & Newnham, 2007). However, efforts by the VA to overcome logistical barriers by expanding services to rural areas have not led to the expected increase in service utilization (Fisher, 2003). Identifying logistical barriers answers questions about whether or not a Veteran can access care, but offers little insight into whether or not a Veteran will access care. This information is particularly troubling given the research that demonstrates the high level of need among rural Veterans. Research has suggested that Veterans located in rural settings generally have worse health-related quality of life than Veterans living in urban locations (Weeks, et al., 2004). Although in greater need of mental health care services, rural Veterans face many challenges to receiving care that are different from _____________ Rebecca L. Stotzer, Ph.D., is an associate professor at the Myron B. Thompson School of Social Work, University of Hawai`i, Mānoa. Julia M. Whealin, Ph.D., is a Clinical Psychologist at the National Center for Posttraumatic Stress Disorder, Pacific Islands Division, VA Pacific Island Health Care System, Honolulu and an adjunct associate professor at the Department of Psychiatry, John A. Burns School of Medicine, University of Hawaii, Honolulu. Dawna Darden, MSW, is a doctoral student at the Myron B. Thompson School of Social Work, University of Hawaii, Honolulu and has an appointment at the National Center for Posttraumatic Stress Disorder, Pacific Islands Division, VA Pacific Island Health Care System, Honolulu. Copyright © 2012 Advances in Social Work Vol. 13 No. 1 (Spring 2012), 1-16 ADVANCES IN SOCIAL WORK, Spring 2012, 13(1) 2 urban Veterans. Few studies have looked beyond the logistics of care delivery in rural settings to understand the reasons why rural Veterans may or may not choose to utilize existing services. In non-Veteran populations, rural people have been identified to have three main factors that can act to prevent them from accessing care: sociodemographic factors (e.g. gender, age, and marital status), illness-related factors (e.g. comorbidity, psychological distress), and attitudinal factors (e.g. stigma, stoicism, self-efficacy; Jackson, Judd, Komiti, Fraser, Murray, Robins, Pattison, & Wearing, 2007). Of these three factors, attitudinal factors are the least understood, but research suggests that the more stigma a rural-dwelling person perceives, the more their reported negative attitudes toward help-seeking (Wrigley, Jackson, Judd, & Komiti, 2005). Research focusing on rural communities and their attitudes toward mental health and mental health services, as well as existing research on military culture and attitudes toward mental health and mental health services, suggests that rural Veterans may face significant social challenges in attaining services in their communities. Both sets of cultural values, rural and military, emphasize stoicism, self-reliance, and negative attitudes toward help seeking, as well as issues related to privacy concerns, confidentiality, and heightened perceptions of community-based stigma. Given social work’s unique place and expanded role in rural environments, particularly in community mental health (e.g., Jerrell & Knight, 1985; Landsman, 2002; Riebschleger, 2007), rural social workers can serve as a key point of outreach, advocacy, and treatment for rural Veterans. However, there is little social-worker specific information currently available to help guide providers in their attempts to serve active military, national guard, reserve, and Veteran populations (Savitsky, Illingworth, & DuLaney, 2009). The purpose of this paper is 1) to review existing research on mental health stigma, 2) to outline the significant challenges that rural Veterans face compared to urban counterparts, and 3) to offer suggestions for social workers working in rural areas to facilitate rural Veterans finding and receiving the benefits and treatments they earned following their service to their country. STIGMA AND MENTAL HEALTH Stigma concerns negative stereotypes, social status loss, and discrimination related to a particular perception of difference (Link & Phelan, 2001). It is a multidimensional concept that brands certain classes of people as inherently “different.” Goffman (1963) argued that stigma “spoils” a person’s identify, and asserted that “we believe the person with a stigma is not quite human. On this assumption we exercise varieties of discrimination through which we effectively, if often unthinkingly, reduce life chances” (p. 5). Jones, Farina, Hastorf, Markus, Miller, and Scott (1984) explained that we all are “marked” in some way, whether it is simply having blue eyes, being tall, etc., but stigma is the application of a negative valuation on that mark. Thus, stigma is based on assumptions, stereotypes, and value judgments about this marked identity that are shared among a wide population as well as understood by the person bearing the marked identity. Stigma toward those with mental health issues has been found to be pervasive and often severe (Wahl, 1999). A variety of negative stereotypes have been applied to people Stotzer, Whealin, Darden/VETERANS IN RURAL COMMUNITIES 3 struggling with mental illness, such as the perception that mental illness leads to violence, even though research suggests that people with mental illness are not more violent than the general population (Levin, 2001). Mental illness has been called a “concealable” stigma, because in most cases it is not obvious to a stranger (Hinshaw, 2007). A person who is dealing with mental health concerns often spends a large portion of mental and emotional energy attempting to conceal their mental health concern, and attempting to judge others’ opinions and perceptions of their behaviors (Smart & Wegner, 1999). A large motivator for keeping their mental health concern concealed is to avoid a label being applied to them. The desire to maintain concealment can result in refusal to acknowledge an issue or pursue mental health treatment to avoid being affiliated with the stigmatized group (Corrigan, Watson, Byrne, & Davis, 2005). This desire to conceal an identity that is stigmatized is pervasive, even when disclosure can result in many mental health benefits and well-being (Chaudoir & Quinn, 2010). In a general population, greater perceived and self-stigma is related to reduced help-seeking from professional sources (Barney, Griffiths, Jorm, & Christensen, 2006). Although most populations are aware of, and suffer the consequences of mental health stigma, military-related populations are at particular risk for experiencing the negative effects of stigma, and as a result, avoid seeking care to prevent real or imagined discrimination and/or loss in social status. Veteran and Military-related Mental Health Stigma Traditionally, the military services have embraced normative beliefs consistent with the masculine gender role identity. Traditional attitudes common in military groups include valuing independence, self-reliance, competition, power, strength, and emotional control. Although recent outreach and education efforts by the military and VA have begun to change this culture (e.g., Adler, Bliese, McGurk, Hoge, & Castro, 2009; Reivich, Seligman, & McBride, 2011), traditionally military groups tend to eschew mental health services. Instead, coping tactics viewed as suitable means for dealing with stress include behaviors such as emotion suppression and substance abuse (Lorber, & Garcia, 2010). Not surprisingly, conformity with masculinity norms is associated with less use of health care services (Boman & Walker, 2010). The belief that one ought to be able to handle mental health problems on their own continues to be a commonly reported barrier to care (e.g., Sayer, Friedemann-Sanchez, Spoont, et al., 2009; Stecker, Fortney, Hamilton, et al., 2007). Beliefs held by Veteran and military groups suggest that this belief may most strongly reflect concerns about the mental health attitudes of, and potential discrimination by, others, as opposed to internalized beliefs. In one of the most comprehensive studies about Veterans and mental health stigma to date, Hoge, Castro, Messer, McGurk, Cotting, and Koffman (2004) evaluated Active Duty Soldiers and Marine units returning from Iraq or Afghanistan (N= 6,153) to identify specific barriers to mental health care. The most commonly endorsed items indicating stigma included “My unit leadership might treat me differently” (36.5%), “I would be seen as weak” (35.4%), “Members of my unit might have less confidence in me” (34.2%), “It would harm my career” (27.0%), followed by “There would be difficulty getting time off from work for treatment” (26.3%). Their findings ADVANCES IN SOCIAL WORK, Spring 2012, 13(1) 4 indicated that the majority of the returnees acknowledged a need for help with mental health issues (78-86%). However, less than one third of returnees (13-27%) who acknowledged a need for help accessed available mental health services. When asked about the barriers to obtaining treatment, the service members classified as in need of mental health care endorsed negative stigma about treatment as the greatest barriers to service utilization (Hoge, et al., 2004). Warner, Appenzeller, Mullen, Warner, and Grieger (2008) had similar findings in a study of 2,678 soldiers deploying with a brigade combat team, soldiers (n=2,678) reported their concerns were that “Members of my unit might have less confidence in me” (20.8%), “My unit leadership might treat me differently” (22.4%), “It would harm my career” (18.5%), and “I would be seen as weak” (17.8%). These perceptions of stigma from unit members and superiors have direct behavioral effects. Among previously deployed national guard soldiers who screened positive for PTSD, depression, or alcohol dependence, many reported significant discomfort reporting mental health symptoms and a belief that their superiors would not encourage mental health treatment (Kline, Falca-Dodson, Sussner, Ciccone, Chandler, Callahan, & Losonczy, 2010). Additionally, 59% of this group indicated that they did not report symptoms during military Post-Deployment Health Reassessments in order to avoid “medical hold.” Nearly half of those screening positive for PTSD and almost 90% of those screening positive for alcohol dependence reported no treatment in the past 12 months (Kline, et al., 2010). Recent research with OEF/OIF military populations (e.g., Wright, Cabrera, Bliese, Adler, Hoge, & Castro, 2009) suggests that military community attitudes and internalized-stigma are two interacting factors that influence service members’ willingness to get help. Thus, there is a tremendous need to better understand factors known to impact Veterans’ decisions to access mental health care. Notably, Active Duty Service Members and Veterans with mental health problems, arguably those most in need of care, are up to twice as likely as those without mental health problems to report stigma as a barrier to health-care use (e.g., Hoge, et al. 2004). Pietrzak, Johnson, Goldstein, Malley and Southwick (2009) examined beliefs about the effectiveness of mental health care in a sample of 272 predominantly reservist and national guard OEF/OIF Veterans in Connecticut. The participants who screened positive for a psychiatric disorder scored higher on scales measuring perceptions of stigma and logistical barriers to care. Additionally, negative beliefs about the effectiveness of psychotherapy and psychotropic medications predicted increased stigma and barriers to care. Negative beliefs about mental health care were also associated with decreased likelihood of psychotherapy and medication visits. In a sample of Vietnam and OEF/OIF Veterans, Stecker, Fortney, Hamilton, and Ajzen (2007) found that the belief that one “ought to be able to handle mental health problems on their own” was the most commonly reported barrier to care. In a qualitative study examining the determinants of PTSD treatment initiation in Veterans (Sayer, et al., 2009), pride in self-reliance was a strong deterrent to treatment seeking. These studies highlight the concerns of service members, and the degree to which they are attuned to perceptions of mental health stigma in their environments. In addition, the elevated levels of psychological problems reported by new OEF/OIF Veterans Stotzer, Whealin, Darden/VETERANS IN RURAL COMMUNITIES 5 emphasize the need to reduce the stigma as members of this population separate from the military and return to civilian communities. To date, however, relatively little research has been conducted to assess the link between civilian community factors and perceptions of stigma and barriers to care. However, an emerging body of research suggests that rural communities may have a heightened level, or produce the perception of a heightened level, of mental health stigma. Rural Culture and Perceptions of Community Stigma Most studies evaluating rural populations do not attend to the contextual community characteristics of rural settings that likely play a role in impacting individual attitudes about and willingness to use mental health services (Boyd, Hayes, Sewell, Caldwell, Kemp, Harvie, et al. 2008; Jackson, et al., 2007). The source of stigma does not appear to be the mental health system itself, but rather the communities’ beliefs and attitudes about mental health (Crawford & Brown, 2002). Evidence suggests that rural residents incorrectly underestimate the prevalence of mental health problems in their communities (Bartlett, Travers, Cartwright, & Smith, 2006), perhaps implicitly contributing to the stigma by demonstrating a “that doesn’t happen here” attitude. Regardless of severity of mental illness symptoms, and despite similar rates of mental illness, rural residents are also less likely to access mental health services than urban residents (Dahlberg, Fosell, Damstrom-Thakker, & Runeson, 2007). This may be due in part to the high levels of perceived stigma in rural communities, where rural residents with mental health problems still strongly identify with their rural communities and want to belong (Ekeland & Bergem, 2006). Although the perception of stigma has been found in the general population as a barrier to seeking services (e.g., Barney, et al., 2006), in rural settings, recent research has identified fundamental, contextual factors that result from characteristics of social networks that impact help-seeking and service use (Boyd, et al., 2008). For example, in rural settings, community members, despite being separated by many miles due to geographical constraints, can have intimate knowledge of each other’s lives due to local gossiping networks (e.g., Aisbett et al., 2007; Parr & Philo, 2003; Parr, Philo, & Burns, 2004). This is the opposite social geographical characteristics experienced in urban settings, where community members may be physically proximate but are often socially distant from each other. As a result, contextual factors of rural settings – including a combination of being socially visible and having strong social networks – have the potential to heighten both community social stigma and internalized stigma related to use of mental health services. Research on non-Veteran populations supports the role of contextual factors in impacting attitudes about and use of mental health services (e.g., Boyd, et al., 2006; Boyd, et al., 2008). Wrigley et al. (2005) found that the two main reasons not to seek help from a general practitioner for mental health problems were 1) embarrassment (see also Hoyt, Conger, Valde, & Weihs, 1997) and 2) not knowing who to seek help from. At the same time, they found a relationship between perceived stigma such that those who reported higher rates of perceived stigma also demonstrated more negative attitudes toward help seeking, drawing a link between stigma and its impact on help-seeking. To ADVANCES IN SOCIAL WORK, Spring 2012, 13(1) 6 give additional evidence for these qualitative results, another study asked rural residents to evaluate a vignette of a man exhibiting symptoms of mental illness, and 67% of rural residents said he would be discriminated against in their community (Bartlett, et al., 2006). In Hoyt et al. (1997), when “place” and both measures of stigma and loss of privacy were entered into the same regression model, the effects of place disappear, suggesting that issues of embarrassment related to confidentiality and anonymity moderate the relationship between place and help-seeking. Qualitative studies consistently reveal that recognition as a person with a mental health issue via a community’s informal social networks has a stigmatizing effect. One qualitative study of rural and urban adolescents indicated that those in rural settings identified rural gossip networks as limiting anonymity. In addition, among rural adolescents, fear of social stigma and exclusion after revealing a mental health problem was seen as a barrier to obtaining services (Quine, Bernard, Booth, Kant, Usherwood, Alperstein, et al., 2003). In another study of rural college students, participants noted that gossip networks and social visibility within rural settings play an extremely influential role in stigmatizing those who had received mental health services (Aisbett, et al., 2007). Furthermore, qualitative studies that have been done with non-Veteran populations suggest that those in rural settings are more likely to see those who use mental health services as weak and that their use of services suggests a lack of self-reliance (Boyd, Aisbett, Francis, Kelly, Newnham, & Newnham, 2007). For example, Wrigley, Jackson, Judd, and Komiti (2005) found that more negative attitudes toward help-seeking for schizophrenia and depression were related to higher endorsements that these problems were caused by a weakness in character. Fuller, Edwards, Proctor, and Moss (2000) found that a rural culture of self-reliance was composed of two features, first, not being allowed to be weak, and second, being suspicious of outsiders (including mental health providers from outside the community). This attitude leads to stigma and decreased probability that rural people will label their mental distress as a mental health problem. Fuller et al. (2000) suggested that even in the cases where rural residents recognize their mental distress despite the stigma, they may still not see the “system” as a source of help because of their resistance to be seen as the community “nutcase.” When broken apart, attitudes about the importance of stoicism and general self-efficacy were found to be important predictors of help seeking (Judd, Jackson, Komiti, Murray, Fraser, Grieve, & Gomez, 2006). However, the values of self- reliance are not insurmountable. For example, having sought help in the past for mental health concerns was related to more positive attitudes toward help-seeking (Jagdeo, Cox, Stein, & Sareen, 2009), though this may not be a consistent relationship for men, who may be more prone to believe in agrarian values (Hoyt, et al., 1997). These studies highlight how rural community values and attitudes that prevent help-seeking can be assuaged by positive interactions with mental health systems. There was evidence that in rural settings many people felt that the resources available to them were inadequate or of poor quality, hence keeping them from seeking help. Human and Wasem (1991) in an overview of rural health concerns in the United States wrote that there is often a difference between accessibility, which is whether or not a client is able to access services, vs. acceptability, which is whether or not a service is