[Mental Health Stigma: An Influencing Factor in Healthcare Utilization by Veterans of the German Armed Forces]. / "Treffer im Kopf" ­ Stigma psychischer Erkrankungen als Einflussfaktor auf die Inanspruchnahme von Hilfsangeboten durch VeteranInnen der Bundeswehr.

THEORETICAL BACKGROUND AND OBJECTIVE OF THE STUDY: Mental illness stigma is a barrier to healthcare utilization. This study is the first to research the connection between mental illness stigma and the use of healthcare by veterans of the German Armed Forces. An overview of perceived stigma components in this sample is provided that should help understand how these factors influence healthcare utilization. METHODS: 43 interviews with veterans of the German Armed Forces were conducted. The resulting data were analyzed in several coding steps. It was investigated whether the stigma experience of veterans of the German Armed Forces could be well illustrated by the theory-based stigmatization model of Link and Phelan. A set of hypotheses on stigma and healthcare utilization based on the data were developed. RESULTS: All stigma components according to the model of Link and Phelan were found in the sample. Internalized stigma, perceived public stigmatization, vocational disadvantage and social exclusion as well as feared misunderstanding of the military past in the civilian sector were reported as main stigma-relevant barriers to the use of healthcare. CONCLUSIONS: Recommendations for interventions are given to decrease mental illness stigma in this specific group of former soldiers.

Fighter, Corpsman, Partisan an Attempt to Typify Former Soldiers Based on their Coping and Defense Mechanisms.

This work strives to develop a typological classification of the use of conscious and unconscious defense and coping mechanisms based on methodically and structurally collected data from a qualitative survey of 43 former soldiers in Germany. Seven coping and defense types were identified: the Fighter, the Comrade, the Corpsman, the Strategist, the Partisan, the Self-Protector and the Infantryman. The types identified differed with regard to the accumulation, combination, and use of their conscious and unconscious defense and coping mechanisms in the superordinate areas of behaviour, relationships, emotions, reflexivity and time focus. The typological classification could offer psychotherapeutic interventions tailored to individuals and their defense and coping mechanisms, which could lead to improved therapy use and compliance.

Understanding health care avoidance and initial help-seeking behavior in German veterans: a theory of planned behavior.

OBJECTIVE: To gain initial insights into salient beliefs of former German soldiers (veterans) about the use of mental health services. DATA SOURCE: Narrative interviews with former German soldiers (veterans) were conducted in 2016. DATA COLLECTION/EXTRACTION METHOD: Forty-three interviews were transcribed and analyzed thematically based on the theoretical framework of the theory of planned behavior. From within the behavorial, normative, and control beliefs, the salient beliefs were identified. PRINCIPAL FINDINGS: Four groups of salient beliefs were identified, described, and named: "Autarky", "Ineffectiveness", "Heteronomy", and "Incapacity". CONCLUSION: Interventions and campaigns addressing these four specific groups of beliefs may lead to higher health service use rates. However, as a result of methodological limitations of the study design, the conclusion remains tentative.

Stigma and its impact on the families of former soldiers of the German Armed Forces: an exploratory study.

BACKGROUND: Military families who have a family member with a mental illness see themselves confronted with many demands. Stigmatization is one of these challenges. Stigmatization affects not only the individual who suffers from a mental illness but also other family members via stigma by association and vicarious stigma. Stigma by association occurs when mental illness stigma spills over to individuals associated with an individual with a mental illness. Vicarious stigma describes the suffering of family members when they note the impact of stigma on their relative with mental illness. As a societal phenomenon, stigma plays out in social interactions and might therefore influence the social networks of families. It is also associated with healthcare utilization. METHOD: Narrative interviews were conducted with 15 family members (partners, spouses, parents and children) of former soldiers of the German Armed Forces with a service-induced mental illness. The transcribed interview data were analyzed using a thematic analysis approach, in which codes were formed and emerging themes were systemized. Relationships between stigma, the families' reactions to it, its effects on their social relationships and its interference with their healthcare utilization were analyzed. RESULTS: This study provides a detailed description of how relatives of former German soldiers with mental health problems experience stigma by association and vicarious stigma. Their perceptions are shown in a model that describes stigma-related attitudes, reactions to them and their effects on the social relationships of former soldiers' families. These families felt stigmatized because of the former soldiers' mental illness (mental illness stigma) and the military context in which it occurred (former soldier stigma). They reacted with nondisclosure, anger, acceptance and self-blame. Stigma was associated with smaller and weaker social networks that were characterized by social exclusion, self-segregation and conflicts with extended family, friends and colleagues. Stigma also affected the families' healthcare utilization. CONCLUSIONS: Urgently needed anti-stigma campaigns, particularly in the civilian context, should address the stigmatization of both mental illness and the military participation of the families affected. They should consider the needs of both former soldiers with a mental illness and their families.

[Barriers to treatment-seeking among German veterans: expert interviews]. / Barrieren der Inanspruchnahme von Psychotherapie ehemaliger Soldatinnen und Soldaten der Bundeswehr (Veteranen). Eine Expertenbefragung.

BACKGROUND: The number of service members of the German armed forces suffering from deployment-related mental health problems is increasing. However, less than 50 % seek professional help, and there is little knowledge about the barriers to treatment-seeking. METHODS: The article presents data gathered by the Delphi technique combined with focus groups from 55 health service experts regarding the evaluated barriers to treatment-seeking among German veterans. FINDINGS: According to the interviewed experts, major contextual barriers to treatment-seeking include: 1) intimidating processes and structures, 2) actual stigmatization and discrimination, and 3) health service deficits. Major individual barriers to treatment were: 4) health beliefs, self-perception and fear of stigmatization, and 5) avoidance behavior related to psychopathology. In addition, there is another both contextual and individual barrier, i.e., 6) information deficits. INTERPRETATION: Individual internal factors like the soldiers' self-perception and their fear of being stigmatized were considered important barriers to treatment-seeking. The experts' opinion about avoidance behavior related to psychopathology and deficits in health services and information coincides with international findings. Compared to research in other countries, actual stigmatization and discrimination were regarded to be an important barrier in itself. According to our findings daunting/intimidating processes and structures like time-consuming and complex expert medical reports rather seem to be a German phenomenon.