Sunday, May 9, 2010

Failure of the DoD’s ‘Real Warriors’ Campaign: Our Heroes War at Home – Carly Milliren

Introduction

“The [U.S. military] faces a battle over the life and death of its soldiers. The battle is not being waged in Iraq and Afghanistan, but in the minds and tortured souls of soldiers contemplating suicide [and suffering from mental illness]” (1). Mental illness and suicide have been long-standing issues in the U.S. military, but rates have been steadily increasing since the beginning of the wars in Afghanistan and Iraq with 2009 military suicide rates the worst since recordkeeping began in 1980. For every completed suicide in the military, there are five attempted suicides, taking a large toll on the mental health of our armed forces (2). Suicides in the military have reached epidemic levels, with approximately 120 a week according to a recent study (3).

The stigma surrounding mental illness is present throughout our society, but it is even more pervasive in the military. In a New York Times blog article from last year, Defense Secretary Robert Gates recognizes the stigma associated with seeking help for mental health issues in the military as well as the need to inform soldiers and veterans of the resources and support available to them (4). Suicide and mental illness are scary, even taboo subjects, but the even scarier fact is that this continues to happen on a daily basis as people do not seek help. Studies have shown that by decreasing the stigma associated with mental illness, people suffering from these illnesses have improved self-esteem. Reducing stigma associated with mental illness not only improves self-esteem but also increases care-seeking behavior (5).

Statistics are meaningful to assess the absolute effects of suicide and mental illness on our military, but individuals get lost in this sea of numbers. Anecdotal evidence is just as powerful, if not more so, in assessing the tangible toll that perceived barriers or lack of access to mental health care can have on soldiers, their families, and the military as a whole. Having recently had a first-hand experience with the suicide attempt of an active-duty soldier very close to me, I am very aware of the stigma attached to seeking help for a mental illness in the military until a situation has reached its boiling point and a person is literally in crisis.

In order to combat the stigma associated with seeking treatment and help for mental illness, the U.S. Department of Defense launched the ‘Real Warriors’ campaign in 2009. This multimedia education campaign encourages service members, veterans, and families to increase both awareness and use of psychological health care and associated resources. Real Warriors attempts to remove barriers often preventing service members from obtaining mental health treatment by providing information to soldiers as well as their families and employers on how to encourage them to get the help they need when they return home from deployment or reintegrate into civilian life. This campaign uses an array of communication and social networking tools including radio and TV public service announcements, posters, an interactive Web site, Facebook, Twitter, and other outlets. Included in these materials are personal stories of real service members who have sought treatment and are maintaining successful careers, both military and civilian. Resources and support for improved mental health and treatment of psychological concerns are also included. By stripping the stigma, this campaign hopes to encourage soldiers to get treated for mental illness in the same way that they would get treated for physical wounds (6, 7).

This campaign is great in providing a litany of mental health resources, however it falls flat in accomplishing its goal of stripping the stigma away from seeking help for mental health issues. The evidence that this campaign has done little to increase usage of mental health services and decrease rates of suicide is clear and convincing; it is written in the blood of our soldiers who have taken their own lives because they did not get the help they so desperately needed. The following presents my individual critiques of the campaign, followed by recommendations to improve the campaign to overcome these issues. By tweaking this campaign a bit it could hopefully reach its target audience more effectively in order to accomplish the ultimate goal of increasing utilization of mental health services in the military and simultaneously decreasing suicide.

Critique: Reinforcing the Macho Ideal

The military is its own culture and a macho ideal is central to this culture. It is also a male-centric culture in which power, manliness and courage trump sensitivity and acceptance. Seeking help for mental illness is considered cowardly and unmanly, in a way admitting defeat and weakness. Perceived consequences of seeking care by service members include being shunned by other members of the unit, including superiors, and even more severe consequences such as being discharged (3, 8). Instead of eliminating this macho ideal as a means of breaking down the stigma, the Real Warriors campaign actually glorifies and reinforces it.

The campaign materials including posters and the website contain pictures of soldiers in uniform toting guns – the quintessential macho personification – with the caption “Reaching Out Makes a Real Difference.” These stock photos may as well be ads to join the military, not combat the stigma surrounding mental illness. In addition, these pictures are harsh and masculine, and for the most part contain only images of male soldiers, and mainly only white men (6). Women and minorities in the military suffer from mental illness as well and the materials should be targeted toward these groups too (3).

Even the name of the campaign and the associated slogans reinforce this macho ideal presenting a case of public health branding gone wrong. Branding is an extremely useful way of inspiring interest in a public health activity or intervention (9). The materials echo the catch phrase of the campaign “Real Warriors. Real Battles. Real Strength.” This plays into the military culture, but in such a way that it emphasizes masculinity and brute strength, not the courage to come forward and seek treatment for a mental illness. The message that the slogan is trying to get across that seeking help for a mental illness is a sign of strength is blurred by the overarching suggestion of a masculine, warrior ideal. There is a distinctive difference between the term ‘warrior’ and the term ‘soldier;’ one which implies a permanent duty to make war. “Once a warrior, ALWAYS a warrior and […] warriors are bred, groomed educated and disciplined to conduct one and only one activity: making war. A soldier, I think, when not needed, returns to civilian life. But a Warrior?” (3). A soldier is not necessarily a warrior. Warriors are defined and identified by the battles in which they fight, and labeling those who come forward to be treated for a mental illness as ‘warriors’ is a permanent label from which one may never escape. In addition, soldiers who are suffering from mental illnesses which have no connection to their experiences in combat may not see themselves as warriors and thus may not choose to get help or use the resources available in this campaign.

Intervention: Take the Macho Out of Military

Instead of reinforcing this macho ideal, any campaign designed to promote increased awareness and utilization of psychological health services to improve the mental health and wellbeing of our military should break down this ideal and change the overall attitude toward seeking out mental health services. There are ways to positively brand this campaign without reinforcing the macho military ideal.

It is important to use the military culture to our advantage when designing a campaign to target service members, but using harsh images of battle goes a bit too far in trying to capture that feeling. The images used for this campaign should be softened, not necessarily feminized, but less harsh. I think just taking the automatic weapons out of the pictures would go a long way. If the message is that you don’t have to be a macho manly-man all the time and admitting mental illness is a sign of strength, get rid of the guns.

As for taking the machismo overtones out of the name of the campaign would strip the permanence from the title of ‘warrior.’ Although mental illness is permanent and must be treated for a lifetime, it is important to connote an ability to return to a normal life, a civilian life if a soldier chooses to do so (3). Soldiers can return to this life bearing scars both visible and invisible, without taking on a negatively associated label to go with them. Replacing the term ‘warrior’ in the name with the word ‘soldier’ is a small but significant change that can change the connotation of the name entirely while still maintaining the ultimate goal. Any soldier can be encouraged to get treatment, not just those who are suffering from the effects of combat stress. These changes soften the campaign just enough to still reach the target audience while teaching service members that it is OK to forgo the traditional manly ideal to get help for a mental illness.

Critique: Too Much Information in the Wrong Places?

The Real Warriors campaign website contains separate pages for active duty service members, members of the national guard and reserve, veterans, families, and health professionals with links to resources in order to get help for oneself, a family member, or friend. These pages list the signs and symptoms of PTSD or traumatic brain injury, what to expect before, after, and during a deployment, and what seems like an exhaustive number of resources to help in finding treatment including the phone numbers for the National Suicide Prevention Lifeline. There are also links to personal stories of soldiers who sought help for their mental illness, which may actually be this campaign’s best tool. Although this site contains a vast amount of resources, it almost seems like too much information that could also be found in other places and it is unclear how useful it is to simply provide an outlet to find links to resources in a single website (6). I

The better question than whether or not the materials are useful is whether people are actually using them. It does not really matter whether the resources are there if no one seeks them out. This campaign makes use of a wide variety of media outlets, which is a strength in providing information to a large and diverse group of people. Social networking sites including Facebook and Twitter bring news and information to the target audience, but it is difficult to determine if this audience is really being reached. Social networking can be a very powerful tool, both in traditional social networks of person-to-person contact and influence, but also in today’s world of social networks in which it seems that we are more connected than ever, just more remotely. Social networking can be used to spread information as well as change behaviors by spreading diverse phenomena through networks (10). Social networking media outlets like Facebook, Twitter, and MySpace are currently used by the Centers for Disease Control and Prevention to provide information and resources to the public regarding a variety of topics including H1N1 swine flu and the recent peanut product recalls, demonstrating the far-reaching power of social media for public health (11).

Interestingly, the Real Warriors Facebook page (which can be found at http://www/. Facebook.com/realwarriors) contains almost hourly updates with only rare instances of anyone actually taking notice and providing feedback. In fact, most of the few comments left on the page are something to the effect of “Maybe if we ended the war, this wouldn’t be such a problem,” which is clearly mocking the underpinnings of the entire campaign (12). The main campaign website also contains a ‘Twitter monitor’ for those who either do not have Twitter (I admit, I am the last person in my demographic to not have Twitter but I fail to see the need for a streaming update of everyone’s life; suffice to say I did not sign up to follow the campaign’s ‘tweets’) or do not want to follow the campaign via this method. However, it seems that bird has flatlined, with absolutely no updates in the monitor which makes it seem that maybe this page of the site is underused (6). Heading over to the actual Twitter site (which can be found at http://www.twitter.com/realwarriors) gives the same set of stories presented on the Facebook page, and again next to nothing in terms of feedback, despite having over 1,700 followers (13). In asking a few friends of mine who are current service members, veterans, or family members it seems that there is little knowledge of this campaign even among the very people it is trying to reach. None of the handful of people I asked had ever heard of the campaign and these are people exposed to the military life on a daily basis. From this information, it can only be concluded that try as it might, this campaign is simply not increasing awareness of mental health issues and resources simply because it is not being utilized. It would be interesting to know the number of visits to the website daily, but unfortunately this information was not available.

Intervention: Use Leadership to Your Advantage

Maybe Real Warriors use of social networking outlets is not putting information in the wrong places, it is just that this information could be communicated more effectively through these outlets. The website as well as social media are great, almost essential resources in today’s society. But how do we get the most out of them? Strong leadership is one of the military’s greatest assets and one which could certainly be advantageous in trying to communicate information and create a paradigm shift in thinking about mental health (3, 8).

In society at large, the use of strong leaders or celebrity advocates to promote healthy behaviors or screening for diseases have been extremely successful. For example, after then NBC’s “Today Show” anchor Katie Couric underwent a colonoscopy on live TV in 2000 to raise awareness of screening for colorectal cancer, the number of Americans who chose to get a colonoscopy jumped by more than 20 percent. Couric’s brave move in getting an uncomfortable and embarrassing exam on live television had a very positive effect on reducing stigma and fear of getting a colonoscopy (3).

By coupling this kind of advocacy of military leaders with the existing social media outlets used by Real Warriors, this campaign could reach more of our silently suffering soldiers and inspire real change. High-ranking generals and officers should be encouraged to speak out about their experiences with mental illness. These individuals are role models and should be utilized in breaking down the stigma surrounding mental illness. It is not just junior-ranking soldiers who suffer from mental illness, it may be any soldier. Leaders should demonstrate that getting help for a mental illness is a sign of courage, not weakness. Including the stories of these influential individuals in the website materials as well as Facebook and Twitter could have real power to inspire. People may be more likely to seek help if they realize that even these high-ranking officials have gotten help.

Critique: Passivity Requiring Rational Action

Both in the military and out, people with mental illness generally do not seek help until they are in crisis and contemplating harming themselves or someone else. Military mental health services are chronically underused and even when they are utilized it is rarely for early diagnosis and intervention. People seek out help only when they have no where else to turn. Active-duty soldiers suffer notoriously low rates of perceived need for mental health services (14). Unfortunately, Real Warriors does little to change this trend in care-seeking behavior and perception.

This campaign is passive, requiring service members or their family and friends to actively seek out information which may never actually translate into getting help. Just like handing out pamphlets about the dangers of smoking does not make people quit, providing a website with information about mental health resources will not make people seek out help in crisis or not.

A major flaw of this campaign’s design is its use of the Health Belief Model as a means of educating its target audience. The motivations of perceived susceptibility to mental illness or suicide, perceived severity of suffering from a mental illness, perceived benefits of being treated, and perceived barriers in the form of stigma feed into this model (15). The campaign is mainly targeting this latter aspect by removing the associated stigma, however use of this model assumes that thoughts are rational and always lead to action. This assumes that supplying people with enough information will force some realization and a desire to seek help, however knowledge does not always translate into action. The behavior itself that this campaign is trying to change, mainly suicide, is itself not rational, in fact it is one of the most irrational and impulsive acts one could even imagine. In the midst of a mental health crisis rational thoughts or actions may not even be in the realm of possibility. So how could we model the most irrational act with a theory designed to address rational behavior? The answer is we can’t, and we shouldn’t.

Intervention: Educate, Educate, Educate, but Most Importantly Help

The Real Warriors campaign may have been designed to better educate soldiers and their families of the stressors of the military life and resulting or exacerbated mental health issues, but this campaign suffers in its passive attempts to get people to seek out care. A more active approach to breaking down the stigma surrounding mental health and the barriers to seeking care would likely result in better outcomes in the form of fewer suicides and attempted suicides. As public health practitioners, we must design our campaigns in such a way that they target the people they are intended to help while getting at the core issue – that is behavior – in order to promote meaningful and healthy change from a bottom-up fashion. Education is only the first step in promoting mental health and decreasing the incidence of suicide in the military.

At Fort Campbell, Kentucky there has been a concerted and active effort to change the way soldiers think about mental health, from a weakness to a very real and ever-present part of the military life that should be dealt with instead of suffering in silence. A major part of this effort was educating leaders and Army doctors to be proactive about detect signs of trouble in their soldiers, before things reach a boiling point and escalate into suicide. Intense surveillance efforts in the form of monitoring data about substance abuse, issues with the law, etc. which may be trouble signs have also been stepped up in order to recognize problem areas before they get worse. One of the most important aspects of this program has been a shift to giving soldiers an outlet to facilitate one-on-one conversations with their superiors about how to think positively, become more self-aware, and deal with stress. So far these targeted efforts seem to be working by both making soldiers more aware of the resources that are there to help, but also by making them more likely to open up, combating the underlying stigma and having a real effect (8).

So what can we learn from Ft. Campbell? A proactive approach is much more productive than a passive or reactive approach for one thing, especially when promoting earlier care-seeking for mental health issues. For another, we cannot react to suicide by treating it like a rational act; by looking out for early warning signs of mental issues, it may be easier to detect and stop before a soldier is even contemplating suicide. In the past few years, the Department of Defense has implemented a population-wide mental health screening program for soldiers returning from Iraq and Afghanistan but people continue to fall through the cracks of this, or fail to get the continuity of care necessary (16). There must be some middle ground between the Real Warriors passivity and this mass screening program in order to encourage soldiers to get the help they need. A lesson can be learned from Ft. Campbell in that one-on-one conversations can go a long way. Coupling these conversations with the goals of the Real Warriors campaign to educate and inform would go a long way in accomplishing these goals. Perhaps platoon leaders, non-commissioned officers, and other superiors should be educated of the goals and resources available through the Real Warriors campaign, in particular the personal stories which can be found on the website. These stories represent the ideals of the campaign while also providing a means of connection with others who have been in a similar situation. These resources could be a jumping-off point for introspection about the brevity of a soldier’s own situation, perhaps making him/her realize that seeking help is a sign of strength instead of weakness.

Conclusion

The Real Warriors campaign is a great outlet of resources for service members and their families to find information about getting help with a mental illness, however this campaign falls flat in actually reaching its target audience and breaking down the stigma surrounding mental health care. By softening the image of the campaign, it will be better able to reach people in need by not reinforcing the macho ideal of the military culture which perpetuates the stigma associated with seeking help for a mental illness. Expanding upon the use of social media by using the military’s strong leadership hierarchy to this campaign’s advantage would also perhaps make more people take notice and inspire change. Lastly, coupling this education only campaign with more proactive mental health awareness and treatment campaigns such as the one happening at Ft. Campbell would go a long way in fostering positive conversations and introspection among soldiers who are suffering silently from a mental illness. From the high rates of suicide in the military, it is clear that something must be done to help our soldiers who are still waging deadly battles even at home.

REFERENCES

1. Hsia T. A Matter of Life and Death: Suicides in the Army. At War Blog 2010. http://atwar.blogs.nytimes.com/2010/03/26/a-matter-of-life-and-death-suicides-in-the-army/

2. Coogan J. Suicide claims more US military lives than Afghan war. World Socialist Web Site, 2010. http://www.wsws.org/articles/2010/jan2010/suic-j06.shtml.

3. Coleman P. War Trauma Is an Admission of Weakness in ‘Macho’ Army Culture: Army studies say one in three soldiers will return from Iraq with significant mental health problems, but the system isn’t there to help them. AlterNet 2008. http://www.alternet.org/world/79130/?page=entire.

4. Shanker T. Combating the Stigma of Psychological Injuries. At War Blog 2009. http://atwar.blogs.nytimes.com/2009/10/26/combating-the-stigma-of-psychological-injuries/.

5. Link B., E. Struening, S. Neese-Todd, S. Asmussen, and J. C. Phelan. Stima as a Barrier to Recovery: The Consequences of Stigma for the Self-Esteem of People With Mental Illness. Pshychiatric Services 2001; 52: 1621-6.

6. Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE). Real Warriors. Arlington, VA: Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury. http://www.realwarriors.net/.

7. Wilson E. ‘Real Warrior’ Describes Post-traumatic Stress. U.S. Department of Defense American Forces Press Service 2010. http://www.defense/.gov/news/newsarticle.aspx?id=57454.

8. Hall K. U.S. army base tries to stop soldier suicides. USA Today. 2010. http://www.usatoday.com/news/military/2010-04-24-army-suicides_N.htm?csp=34.

9. Blitstein J., W. D. Evans, and D. L. Driscoll. What is a public health brand? (pp. 25-41). In: Evans W. D. and G. Hastings, eds. Public Health Branding: Applying Marketing for Social Change. New York, NY: Oxford University Press Inc., 2008.

10. Christakis N. and J. Fowler. The Collective Dynamics of Smoking in a Large Social Network. NEJM 2008; 358: 2249-58

11. Centers for Disease Control and Prevention. Social Media at CDC. Atlanta, GA: Centers for Disease Control and Prevention, 2010. http://www.cdc.gov/socialmedia/

12. Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE). Real Warriors Facebook Page. Facebook. http://www.facebook.com/realwarriors.

13. Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE). Real Warriors Twitter Page. Twitter. http://twitter.com/realwarriors.

14. Sareen J., B. S. Belik, M. Stein, and G. Asmundson. Correlates of Perceived Need for Mental Health Care Among Active Military Personnel. Psychiatric Services 2010; 61: 50-7.

15. Edberg M. Individual Health Behavior Theories (pp. 35-49). In: Edburg M. Essentials of Health Behavior: Social and Behaivoral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.

16. Hoge C., J. Auchterlonie, and C. Millken. Mental Health Problems, Use of Mental Health Services, and Attrition From Military Service After Returning From Deployment to Iraq or Afghanistan. JAMA 2006; 295:1023-32.

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1 Comments:

At May 11, 2010 at 9:29 AM , Anonymous Jason Blanchette said...

I agree that it is best to take the weapons out of the pictures. And the best thing the Army has done about this issue is encouraging the direct leaders to communicate more one-on-one, especially overseas. It could be useful to use the high ranking officers in the campaign. But in the army and marines especially, there is a disconnect between the soldiers and the high ranking officers. The soldiers pride themselves in being warriors whereas the high ranking officers sit behind desks and earn medals for doing paper work. The high ranking sergeants, such as the Sergeant Majors, could connect with the lower ranking sergeants, but it is going to have to work its way down to the young troops through the young troops' direct sergeants. The sergeants have a tremendous influence on the entire military culture.

 

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