AIR WAR COLLEGE AIR UNIVERSITY HEALING THE OPERATIONAL ENVIRONMENT: ENCOURAGING MENTAL HEALTH HELP-SEEKING BEHAVIOR by Carlos J. Brown, Lt Col, United States Air Force A Research Report Submitted to the Faculty In Partial Fulfillment of the Graduation Requirements Advisor: Maj (Dr.) Aron R. Potter, USAF, BSC, ABPP 10 FEB 2016 DISTRIBUTION A. Approved for public release: distribution unlimited. DISCLAIMER The views expressed in this academic research paper are those of the author and do not reflect the official policy or position of the US government, the Department of Defense, or Air University. In accordance with Air Force Instruction 51-303, it is not copyrighted, but is the property of the United States government. ii Biography Lt Col Carlos J. Brown enlisted in the United States. Army in 1985 and received his commission in the Army Aviation Branch 1994 as a distinguished military graduate from the Arizona State University Army ROTC program. Since 2003 he has served as an Air Force HH- 60G Rescue helicopter pilot. He served as a Capitol Hill Fellow for Texas Congressman Solomon P. Ortiz, as well as staff assignment as the Personnel Recovery/Special Operations Branch Chief on the Air Staff. His operational assignments include Director of Operations for the 66th Rescue Squadron, Nellis Air Force Base, Nevada and most recently commanded the 512th Rescue Squadron at Kirtland Air Force Base, New Mexico, responsible for all helicopter training in the United States Air Force. He is currently a student assigned to the Air War College, Air University, Maxwell AFB, AL. iii Abstract The purpose of this professional studies paper is not to reinvent the multitude of existing mental health programs and tools available to squadron commanders. The intent is rather to refine the operating environment between the unit-level and base-level resources in an effort to debunk the stigma of help-seeking. The intent is also to increase awareness of the current mental health dilemma facing our post 9/11 force and to offer recommendations for commanders at multiple levels in order to create a climate that promotes greater mental health and wellness. I initially frame the problem by examining the percentage of overall Americans affected by mental illness. Then, I examine both the civilian and United States Air Force (USAF) suicide rates. I will demonstrate that suicide rates are a uniquely-useful indicator of problematic mental health issues – particularly at times when mental health concerns may remain masked in many individuals due to social stigmas. I next discuss causal factors that reinforce the stigma surrounding help-seeking within the military. Additionally, I utilize the Comprehensive Airman Fitness program’s effectiveness as an example of an existing strategic framework within the USAF that promotes a healthy balance within the mental, physical, social, and spiritual health of Airman. Lastly, I provide examples of recommend changes to the current operating environment, also referred to as work place environment. When combined with the existing commander’s mental health “toolkit” these changes will build increased rapport between squadron members and mental health personnel. Moreover, this will more fully integrate mental health personnel within operational units. While there is no panacea, the intent is to continue to debunk the stigma associated with help-seeking, allowing our Airmen to maintain both a personal and professional balance in order to achieve their full warfighting potential. iv Both the DoD Task Force on Mental Health (2007) and the DoD Task Force on the Prevention of Suicide Among Members of the Armed Forces (2010) identified the stigma of mental illness as a significant issue preventing service members from seeking help for mental health symptoms or disorders.1 Introduction The word stigma is defined as a mark of shame or discredit. When applied to social acceptance, specifically in the area of mental health, stigma serves as a distinguishing mark of social disgrace. Many Americans who suffer from mental illness and stigma are challenged on two fronts. On one front they struggle with the symptoms and disabilities that result from the mental illness. On the other front, they are challenged by the stereotypes and prejudice that result from misconceptions about mental illness. Just as in American society, stigma for help-seeking exists within military communities. The Department of Defense (DoD) has long recognized the need for programs that address the mental health and wellness of our service members. These programs are even more critical as the current generation of Airmen, who have joined or served in the post 9/11 era, face mental health issues amplified by the effects of over a decade-and-a-half of continuous combat operations. The combined effects of repeated deployments, increased workload at home station, and the everyday stressors associated with being a military member all can affect a service member’s mental well-being. Additional stressors such as reduction in the force, diminishing operating budgets, frequent family moves, changes brought on by the information age, and the escalating pace of military life have also taken a toll on the mental well-being of a large portion of the United States Air Force (USAF). Based on these factors, Congress, senior DoD officials, and Air Force leadership have recognized the criticality of mental health services and have 1. Joie D. Acosta et al., Mental Health Stigma in the Military, RAND Report RR 426 (Santa Monica, CA: RAND, 2014), 1. attempted to set appropriate policies and establish programs to improve the mental health of our warfighters. Despite these efforts, 2014 was recorded as having the highest suicide rate in the USAF since statistics have been recorded by the DoD. This data reflects the fact that the Air Force is challenged in meeting the mental health demands of our population. This poses a direct leadership challenge for squadron commanders, as Air Force Instruction (AFI) 1-2 Commanders Responsibilities states, “Commanders are charged with the codified authority and responsibility to promote and safeguard the morale, physical well-being, and the general welfare of Airmen in their charge.”2 Thesis Leaders at all levels have a continuous obligation and responsibility to change the stigma that surrounds mental health. I argue that squadron commanders are in the best position to debunk the stigma that surrounds mental health Squadron commanders have first-hand day-to- day interaction with Airmen and direct influence over their lives. This requires emphasis at all levels of command, to include increased personal interaction of mental health professionals in order to facilitate the cultural shift that will positively reinforce help-seeking behaviors. Continuous process improvement and education is critical in order to fully support squadron commanders with meeting the command responsibilities that they are given. One precursor for removing stigma is for squadron commanders to be intimately familiar with the mental health resources available and offer opportunities for squadron members to build rapport with local mental health professionals. First, a review of the current literature will frame the magnitude of the problem by examining mental health challenges within the military compared to the civilian population. Next, I will examine the barriers for help-seeking within the military 2. Air Force Instruction (AFI) 1-2, Commander’s Responsibilities, 8 May 2014, 2. 2 and identify causal factors that reinforce stigma for Airmen. Then, I will examine command climate and how work place environmental factors can also play a role in perpetuating stigma. Additionally, I will review the USAF’s Comprehensive Fitness program, in order to draw knowledge from a historical perspective. Lastly, as a former squadron commander, I will offer my own perspective and make intuitive recommendations based on that experience which can serve as examples of ways to refine the operating environment. This paper’s objective is not to recommend an additional regulatory requirement or another mandatory training event to compete with the multitude of other mandatory requirements; more importantly, the objective is to generate thought. The goal is to generate introspective thought and provide some simple concepts, that senior leaders, commanders at all levels, and mental health professionals may utilize to increase focus on the interpersonal dimension of the operating environment in order to finally dispel mental health stigma within our service. Defining and Framing the Stigma Challenge Mental health is defined as a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.3 When a person’s mental well-being is challenged and not identified or if left untreated, mental illness may develop. Mental illness affects a large percentage of Americans in the United States. The National Institute of Mental Health estimates that, “One in four adults−approximately 61.5 million Americans−experiences 3. World Health Organization, “Mental health: a state of well-being,” accessed 02 October 2015, http://www.who.int/features/factfiles/mental_health/en/ 3 mental illness in a given year.”4 While this statistic represents the aggregate for Americans, military mental illness statistics are often presumed to be somewhat less, based on the fact that military members are screened for mental health disorders upon entry. Therefore, the incidence of some mental health disorders common among the civilian populace may not be as prevalent amongst military populations. Conversely, mental health challenges such as post-traumatic stress disorder (PTSD) may be more prevalent per capita in the military, than in the civilian population. Comparisons between the overall American population and military samples can be made for suicide rates, as well. This comparison is important, because a likely correlation between suicide and mental health will be demonstrated later. A correlation between suicide and poor mental health, while seemingly obvious, is especially important to the topic of help-seeking in the military. The importance of this correlation is based on the fact that while suicides are easily identifiable and can be tracked, one of the central problems with mental health is that instances of it are often unknown until it is too late, based on the associated stigmas identified in this paper. Department of Defense Suicide Event Report (DoDSER)5 and the Armed Forces Medical Examiner System (AFMES) data as of June 30, 2014, counted 259 suicides among Active Component service members and 220 suicides among Reserve and National Guard service members. The Active Component suicide rate was 18.7 percent per 100,000 service members. The final numbers according to the DoD’s 2014 (4th Quarter/Active Duty) Suicide Information Report, reflected suicides by service to be 122 in the Army, 53 in the Navy, 34 in the Marine Corps, with the Air Force losing a total of 59 Airmen. Air Force losses represented the highest 4. National Institutes of Health. “National Institute of Mental Health. (n.d.). Statistics: Any Disorder Among Adults.” accessed 02 October 2015, http://www.nimh.nih.gov/statistics/1ANYDIS_ADULT.shtml 5. Department of Defense Suicide Event Report, Calendar year 2013 Annual Report,” (http://t2health.org/sites/default/files/dodser/DoDSER_2011_Annual_Report.pdf, 2013), 5. 4 incidence of suicide in the Air Force since tracking began in early 2000’s.6 Used as a frame of reference, comparisons can be made between the Centers for Disease Control suicide statistics for the civilian population and those of DoD military members. In 2013, the most recent year for which the Center for Disease Control data was available, 41,149 civilian suicides were reported. Statistically this resulted in 12.6 civilian deaths per 100,000 (making suicide the 10th leading cause of death for Americans).7 Comparatively, the suicide rate for the Department of Defense Active Duty component was 22.7 per 100,000 service members. The collective statistics for the National Guard and Reserve component was 24.2, with the Reserve at 19.3 and the National Guard at 28.1 suicides per 100,000 service members.8 Additionally, according to the National Alliance on Mental Illness, research has found that about 90% of individuals who die by suicide experience some form of mental illness.9 The correlation between occurrences of suicide and mental illness likely suggests that the latter is also on the rise, despite the trend being masked based on an unwillingness to self-identify and seek help. This is a telling statistic, suggesting based on the significant increase in suicide that there is a large amount of mental illness currently within military populations. Additionally, if an appreciable number of applicants with mental health problems are screened out prior to entry into the military, then it can be deduced that a large portion of mental health problems began after the service member enlisted or was commissioned. 6. Richard Sisk, “Air Force Must Do More to Curb Record Number of Suicides, Cody Says,” Military.com, accessed 16 September 15, http://www.military.com/daily-news/2015/09/16/air- force-must-do-more-to-curb-record-number-of-suicides-cody-s.html 7. American Foundation for Suicide Prevention, “Facts and Figures,” accessed 20 December 15, https://www.afsp.org/understanding-suicide/facts-and-figures. 8. Department of Defense Suicide Event Report, Calendar year 2012 Annual Report. http://www.dspo.mil/SuicideData/DoDSERAnnualReports.aspx, 2012, ix. 9. National Alliance on Mental Illness, “Risk Factors for Suicide,” accessed 20 December 15, https://www.nami.org/Learn-More/Mental-Health-Conditions/Related-Conditions/Suicide 5 While the DoD and the Air Force have implemented policies and programs that have proven effective when utilized, something is causing an increase in the occurrence of mental illness in the military despite efforts to mitigate the challenge. Examination of the military culture may highlight contributing factors that inhibit Airmen from seeking assistance. Causal Factors The stigma of mental health is not a recent phenomenon in either the civilian or military population. This can be traced back to ancient times where beliefs about mental illness centered on the idea that those suffering were possessed by evil spirits.10 There are many reasons why Airmen do not seek help and avoid mental health services. Literature suggests that the most frequently noted causes of stigma are: the dissonance between self-image when asking for help and the military’s cultural image of the “warrior ethos,” concerns over impact to career, command climate, and the role of trust. Review of the literature also highlights that this phenomena continues today. Those suffering from mental illness are often stereotyped by society as being dangerous, unpredictable, responsible for their illness, or generally incompetent.11 This type of stigma in the civilian population can lead to active discrimination, such as excluding people with these conditions from employment, social, or educational opportunities. The stigma of mental health treatment in the military creates the same detrimental effect on military members based on the stereotype that members who seek treatment are weak. These perceptions of weakness derive from the belief that mental health treatment violates the 10. Museum of Health Care, “Mental Health: Tracing the History of Stigma,” accessed 02 October 15, https://museumofhealthcare.wordpress.com/2014/07/15/mental-health-tracing-the- history-of-stigma. 11. Patrick W. Corrigan, Benjamin G. Druss, and Deborah A. Perlick, “The Impact of Mental Illness Stigma on Seeking and Participating in Mental Health Care,” Association for Psychological Science, Vol 15 (2014): 42-43. 6