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Article Contents

Introduction, conclusions, implications for future research, acknowledgment, supplementary material, conflicts of interest statement.

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Systematic Review of the Military Career Impact of Mental Health Evaluation and Treatment

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Richard E Heyman, Amy M Smith Slep, Aleja M Parsons, Emma L Ellerbeck, Katharine K McMillan, Systematic Review of the Military Career Impact of Mental Health Evaluation and Treatment, Military Medicine , Volume 187, Issue 5-6, May/June 2022, Pages e598–e618, https://doi.org/10.1093/milmed/usab283

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Military leaders are concerned that active duty members’ fear of career impact deters mental health (MH) treatment-seeking. To coalesce research on the actual and perceived consequences of MH treatment on service members’ careers, this systematic review of literature on the U.S. Military since 2000 has been investigating the following three research questions: (1) is the manner in which U.S. active duty military members seek MH treatment associated with career-affecting recommendations from providers? (2) Does MH treatment-seeking in U.S. active duty military members impact military careers, compared with not seeking treatment? (3) Do U.S. active duty military members perceive that seeking MH treatment is associated with negative career impacts?

A search of academic databases for keywords “military ‘career impact’ ‘mental health’” resulted in 653 studies, and an additional 51 additional studies were identified through other sources; 61 full-text articles were assessed for eligibility. A supplemental search in Medline, PsycInfo, and Google Scholar replacing “career impact” with “stigma” was also conducted; 54 articles (comprising 61 studies) met the inclusion criteria.

As stipulated by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, studies were summarized on the population studied (U.S. Military Service[s]), sample used, intervention type, comparison group employed, outcome variables, and findings. Self-referred, compared with command-directed, service members appear to be less likely to face career-affecting provider recommendations in non-deployed and deployed settings although the data for the latter are not consistent. Of the two studies that tested if MH treatment actually negatively impacts military careers, results showed that those who sought treatment were more likely to be discharged although the casual nature of this relationship cannot be inferred from their design. Last, over one-third of all non-deployed service members, and over half of those who screened positive for psychiatric problems, believe that seeking MH treatments will harm their careers.

Despite considerable efforts to destigmatize MH treatment-seeking, a substantial proportion of service members believe that seeking help will negatively impact their careers. On one hand, these perceptions are somewhat backed by reality, as seeking MH treatment is associated with a higher likelihood of being involuntarily discharged. On the other hand, correlational designs cannot establish causality. Variables that increase both treatment-seeking and discharge could include (1) adverse childhood experiences; (2) elevated psychological problems (including both [a] the often-screened depression, anxiety, and posttraumatic stress problems and [b] problems that can interfere with military service: personality disorders, psychotic disorders, and bipolar disorder, among others); (3) a history of aggressive or behavioral problems; and (4) alcohol use and abuse. In addition, most referrals are self-directed and do not result in any career-affecting provider recommendations. In conclusion, the essential question of this research area—“Does seeking MH treatment, compared with not seeking treatment, cause career harm?”—has not been addressed scientifically. At a minimum, longitudinal studies before treatment initiation are required, with multiple data collection waves comprising symptom measurement, treatment, and other services obtained, and a content-valid measure of career impact.

Despite the awesome power of the F-22 fighter jet, the M-1 Abrams tank, or the Ohio-class submarine, the most valuable and complex weapon in the U.S. Military’s armament is the human weapon system. 1 The human weapon system “shares common features with all other weapons. It is fallible, influenced both positively and negatively by external factors, and requires periodic maintenance. 2 ”

However, the human weapon system has some unique features that make it exceptionally challenging to maintain. First, military leaders primarily rely on each human to maintain himself or herself. Second, humans have the autonomy to choose avoiding needed maintenance unless performance is so degraded that commanders order them to specialized services (e.g., mental health [MH] treatment). Third, humans have self-awareness and may conclude that the needed maintenance may result in their being excised, thus leading to active avoidance.

Thus, despite U.S. Armed Forces’ leadership making human resources risk management top priorities in the 21st century, 3 suicide and MH problems continue to be crucial concerns in maintaining operational readiness. 4 To this end, both public health campaigns 5 and research 6–8 have been conducted on reducing MH treatment stigma.

Yet stigma is only of many barriers in service members’ (SMs) complex and multi-faceted decisions about pursuing MH treatment. Part of the calculus is whether there are actual career ramifications of pursuing treatment (and what they are). This is not an idle threat to military members; in 2014, a RAND report identified 203 U.S. Military policies that contribute to MH treatment stigma and to direct negative career consequences. 6 Furthermore, direct career implications vary by military career field. For example, in the U.S. Air Force, duty restrictions related to MH treatment pursuit can be incurred by those with jobs involving nuclear, biological, and chemical weapons (i.e., the Personnel Reliability Program), pilots of both traditional and remotely piloted aircraft, and security forces.

Furthermore, the perception that there are career consequences may ultimately guide behavior, regardless of whether there truly are career ramifications for pursuing MH treatment among active duty members experiencing psychological or behavioral problems. Thus, any investigation of the career impacts of instigating MH treatment must consider both the actual and the perceived consequences.

Finally, the earliest studies in this area focused on active duty members receiving MH treatment and investigated whether being self- versus command-referred was associated with career-impacting recommendations. The DoD Psychological Health Center of Excellence’s guidance on career concerns 9 has used this literature to stress the importance of seeking treatment early.

Thus, we conducted a systematic review of research on the career impact of receiving MH treatment. Given that policies differ across time, historical context, country-based policies, and active duty versus National Guard, Reserve, or veteran status, we limited our search to the literature on the active duty U.S. Military published since January 1, 2000.

This systematic review sought to synthesize and critically evaluate studies addressing the following three research questions:

Is the manner in which U.S. active duty military members seek MH treatment associated with career-affecting recommendations from providers?

Does MH treatment-seeking in U.S. active duty military members impact military careers, compared with not seeking treatment?

Do U.S. active duty military members perceive that seeking MH treatment is associated with negative career impacts?

Search Strategy

We conducted a systematic search of Google Scholar for relevant studies from January 1, 2000 through December 15, 2020. Search terms were “military” and “career impact” and “mental health” or “behavioral health” (The search was later replicated in Medline and PsycInfo.). A supplemental search in Medline, PsycInfo, and Google Scholar replacing “career impact” with “stigma” was conducted in April 2021. The review protocol can be found in Online Supplement 1 . Relevant articles located from (1) the reference lists of included articles, (2) those citing included studies, and (3) content-area expert suggestions were also reviewed.

Study Selection

Articles were selected for inclusion based on the following criteria: (1) published in English, (2) published or released between 2000 and 2020, (3) reported findings on U.S. active duty SMs, and (4) empirically studied actual or perceived career impact of MH treatment. Exclusion criteria included (a) findings on National Guard, Reserve, veteran, or military dependent populations and (b) failure to separate results for active duty participants from other participants. The search was conducted December 2020–January 2021.

Two researchers (E.L.P. and A.M.P.) reviewed titles and abstracts for eligibility ( n  = 703). Full-text articles ( n  = 61) were assessed for eligibility: 27 clearly met inclusion criteria, 23 did not investigate career impact and were excluded, and 34 were labeled as “maybe” being eligible, so two Ph.D.-level researchers (R.E.H. and A.M.P.) independently coded these articles on the eligibility criteria (agreement = 100% regarding eligibility). Thirty-eight articles met eligibility criteria, plus an additional 16 from the supplemental search, for a total of 54 studies.

The number of studies screened, assessed for eligibility, and included in the review, with reasons for exclusions at each stage can be found in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 10 flowchart in Figure 1 . Following PRISMA guidelines, 10 a table structure was created with the following elements: authors, population, sample, intervention type, comparison group, outcomes, and study findings. Data were extracted from the original reports by E.L.E. and reviewed by R.E.H. Table I provides the complete study characteristics.

PRISMA Flow Diagram for Systematic Review of Military Career Impact of Mental Health Treatment.

Studies of the Association between Mental Health Treatment Seeking and Career Impact/Perceptions of Career Impact

Abbreviations: AD=active duty, DoD = Department of Defense, E= enlisted, MH = mental health, NCO = non-commissioned officer, O=Officer, SM = service member, WO=warrant officer

Population— USAF = U.S. Air Force; USA = U.S. Army; USCG=US Coast Guard; USN = U.S. Navy; USMC = U.S. Marine Corps.

Sample— N ( n of major subgroups); population, random, convenience; describe how obtained.

Mental health evaluation and treatment from services that document contact. Note where services received: during deployment or at duty station (Excluded: chaplains, military family life counselors, embedded support technicians.).

Comparison: Those not receiving MH evaluation and treatment; within MH-treatment seekers.

Outcomes: (1) Separation / discharge; (2) Career change; (3) Job limitations: (a) duty limitation (including Personnel Readiness Program disqualifications, arming use of force [weapons carrying] requirements, flight status limitations, and other profiles; (b) security clearance denial; denial of Permanent Change of Station locations/ deployments; (c) other; (4) Perceptions of impacts (i.e., outcome is not of job limitation but instead the assessed personnel’s perception of career impacts); (5) Other.

Career-affecting recommendations from mental health treatment providers: (a) temporary change of duty, including duty restrictions; (b) occupational changes, including career retraining or loss of special statuses such as flight status and Personnel Reliability Program; and (c) discharge.

Non-career-affecting recommendations from mental health treatment providers: (a) no contact with commanders required; (b) return to duty; (c) recommendations that commanders provide small adjustments or support; and (d) recommendations for additional treatment outside of the outpatient mental health clinic.

Research Question #1: Is the Manner in Which U.S. Active Duty Military Members Seek MH Treatment Associated with Career-affecting Recommendations from Providers?

Five of the eight studies investigating research question #1 used Rowan and Campise’s 11 operationalization collapsing MH provider recommendations in two overarching categories. First is “career-affecting recommendations” from MH treatment providers: (1) temporary change of duty, including duty restrictions; (2) occupational changes, including career retraining or loss of special statuses such as flight status and Personnel Reliability Program; and (3) discharge. Second is non-career-affecting recommendations: (1) no contact with commanders required, (2) return to duty, (3) recommendations that commanders provide small adjustments or support, and (4) recommendations for additional treatment outside of the outpatient MH clinic.

Treatment not during deployment

As shown in Table I , three studies used outpatient MH treatment records to investigate this research question with non-deployed SMs. The two studies with the best statistical power 11 , 12 found that airmen who were command-directed to MH treatment were significantly more likely to receive career-affecting recommendations from providers (39%-86%) than were airmen who were self-referred or command-encouraged (3%-28%). In addition, self-referred, compared with command directed, airmen were more likely to be treated for something other than a psychiatric problem (i.e., a V-code—“Other Conditions That May Be a Focus of Clinical Attention”). The third, small ( N  = 35) study 13 found that career-affecting recommendations were not related to Marines’ demographic, military, and clinical-presentation characteristics. An additional study by Hoge 14 studied the career impact of inpatient hospitalization, with soldiers treated for psychiatric problems significantly more likely to be separated than those treated for non-psychiatric problems.

Treatment during deployment

As shown in Table I , four studies used outpatient MH treatment records to investigate this research question with deployed SMs. Christensen and Yaffe 15 found that deployed airmen, regardless of referral type, were significantly more likely to receive duty restrictions than non-deployed airmen. Nevertheless, duty restrictions were relatively rare in both settings (16% vs. 10%, respectively). Conway 16 found that SMs deployed to Iraq who sought MH treatment were more likely to be separated early for both medical and legal/involuntary reasons. Rowan et al. 17 also found that duty restrictions in soldiers deployed to Afghanistan were rare (10%), comprising about half of all career-affecting recommendations (19%). Replicating the previously discussed non-deployment studies, they found that career-affecting recommendations were least likely for self-referred soldiers, compared with command-encouraged and command-directed soldiers. In contrast to Ghahramanlou-Holloway et al.’s 13 small study of non-deployed U.S. Marines, Rowan et al. 17 found that the severity of deployed soldiers’ clinical diagnoses was associated with the likelihood of receiving a career-affecting recommendation. Finally, Varga and colleagues 18 found that, among deployed soldiers, pre-deployment MH treatment reduced the odds of a soldier receiving a career-affecting recommendation in theater by 58%, even after controlling for demographics and the number of previous deployments.

Research Question #2: Does MH Treatment-seeking in U.S. Active Duty Military Members Impact Military Careers, Compared with Not Seeking Treatment?

Unlike research question #1, which focused on outcomes within treatment seekers, research question #2 focuses on comparing SMs who do, and do not, seek treatment. Two studies, both “study 2” in their respective papers by Ghahramanlou-Holloway and colleagues, 12 , 13 investigated this question in prospective, case-controlled studies of 3.5-5.67 years. Each identified a sample of MH treatment-seeking SMs ( n s  =  40-332) and matched them on rank, time in grade, and military occupational specialty with randomly selected SMs ( n s  =  138-1,147). Outcomes for both studies were (1) remaining on active duty; (2) change to security clearance change; (3) discharge because of (a) completion of service, (b) voluntary separation, or (c) involuntary separation. The Marine Corps study 13 also investigated legal action, including non-judicial punishment, and the Air Force study 12 also investigated medical board evaluations.

Both studies found no significant differences between MH-treatment seekers and matched controls on changes to security clearances. Both studies found that treatment seekers were more likely to be discharged; the Air Force study, 12 with more statistical power to detect differences, found that treatment-seeking airmen were more likely to receive an involuntary or force-adjustment separation, whereas the Marine Corps study 13 found no differences. In unique analyses, the Air Force study 12 found that MH-treatment seekers were more likely than controls to receive a medical board evaluation, and the Marine Corps study 13 found that MH-treatment seekers were more likely than controls to (1) to spend less time in the military following their initial MH treatment visit and (2) to face legal action (including non-judicial punishment). Regression analyses indicated that legal action was related to discharge even after controlling for seeking treatment; thus, treatment-seeking and legal action contribute unique, additive influences on the likelihood of discharge. 12

Research Question #3: Do U.S. Active Duty Military Members Perceive that Seeking MH Treatment Is Associated with Negative Career Impacts?

Forty-six publicly available studies quantitatively investigated perceptions among active duty SMs that seeking MH treatment could negatively impact their careers. Twenty-eight quantitative studies assessed attitudes of SMs at their permanent duty station, 13 studies assessed attitudes during or while returning from deployment, and 5 assessed attitudes in specialized populations (e.g., medics, nurses, and military sexual assault survivors).

First, in the non-deployed surveys of randomly selected SMs between 2001 and 2018, 19–26 the proportion believing that MH treatment-seeking would harm their careers declined from nearly half in 2002 to a fairly stable 33%-37% since 2008; endorsement rates were higher (27.4%-65.6%) for those who screened positive for an MH disorder. 19 , 20 , 27–32 Endorsement rates were lower (13.0%-27.8%) in the eight Army Land Combat Studies, 32 a pre-deployment study of soldiers at one installation published in 2008 33 , a 2008-2009 study of soldiers previously deployed to Iraq and Afghanistan, 31 and in a 2015-2016 study of soldiers stationed in Korea. 34 Second, a 2016 DoD-wide survey 35 linked the professed likelihood of seeking MH treatment associated with concern about career impact. Third, of particular note (because it involved perceptions of actual, not hypothetical, career impact), a 2011 DoD-wide survey found that one in five SMs who had accessed MH services in the previous year believed it had a negative effect on their careers. 19 Finally, two qualitative studies of sailors 36 and soldiers 37 found evidence convergent with the quantitative studies.

The 13 studies during or immediately following deployment produced lower proportions of perceived harm to careers. 38–50 Still, a sizable proportion (26.2%-42%) of randomly selected SMs assessed in theater in Iraq and Afghanistan (or soon after returning) screening positive for an MH disorder agreed that seeking treatment would harm their careers.

Finally, the five quantitative 51–56 and qualitative 56–58 studies of specialized populations produced similar results.

Summary of Evidence

This systematic review extracted results from 61 studies from 54 research reports. Studies addressed one of three research questions related to the actual or perceived career impact of military members receiving MH treatment.

Research question 1 (provider recommendations)

The research on this topic began (in 1996 59 , before the period reviewed here) by investigating types of referrals to MH treatment and providers’ career-affecting recommendations. The largest non-deployment studies 11 , 12 showed that self-referred patients are less likely to face career-affecting provider recommendations (whereas a very small study 13 did not find differences). This has been interpreted to mean that intervention early in the trajectory of a disorder will prevent career harm from seeking MH treatment. 9 , 11–13 Although this hypothesis may be correct, the studies did not isolate early help-seeking from late help-seeking, merely self- vs. command-directed referrals. In both of the larger studies, 11 , 12 self-referred SMs were more likely to receive a V-code (“Other Conditions That May Be a Focus of Clinical Attention”) diagnosis. Although this may indicate that self-referred members get help before their problems even reach diagnosable levels, it may be that they have low-level problems that never would have reached diagnosable levels. For instance, Lorber and colleagues’ study, 60 using data from two U.S. Air Force-wide randomized surveys, found that SMs’ symptoms (across internalizing- and externalizing-problem types) clustered into six classes—five ordinally arrayed classes (“very low” to “very high” internalizing- and externalizing-problems) and an additional “extremely high externalizing” class. Although it is possible that, left untreated, some problems worsen, it is highly likely that most of the self-referred SMs are from Lorber’s “very low” and “low” problem classes (constituting 83% of the population) and that their V-code or no-diagnosis problems would have never worsened into the type of problems that result in career impacts. Likewise, the finding that soldiers who were hospitalized for psychiatric reasons were four times more likely to be discharged than those hospitalized for non-psychiatric reasons 14 (47% vs. 11%) may imply that MH problems need to be caught early or it may be that extremely severe psychiatric problems lead to career impacts, whereas very mild ones or non-psychiatric ones are much less likely to.

The results from studies for deployment are less cohesive. Rowan et al.’s 17 study of soldiers in Afghanistan replicated the home-duty station findings that self-referred SMs were least likely, and commander-directed members most likely, to receive career-affecting recommendations. Varga et al. 18 found that those who received pre-deployment MH treatment were less likely to receive career-affecting recommendations after seeking treatment during deployment, seemingly bolstering the “getting help early is career protective” hypothesis. However, other studies are less sanguine about the career impact of seeking MH treatment during deployment. Christensen and Yaffe 15 found that deployed SMs were more likely to receive duty restrictions (traditionally classified as a career-impacting recommendation) than were non-deployed members, and this held for self-referred members; likewise, Conway et al. 16 found that MH treatment during deployment was associated with early separation for both medical and legal/involuntary reasons. Thus, one possibility is that deployment is a moderator that changes how help-seeking relates to career impacts, but the findings to date are not sufficiently consistent to declare that. Other possibilities include (1) SMs self-refer during deployment for different reasons than they do at their home duty stations, including purposefully desiring early discharge, and (2) the stress of combat deployment interacts with pre-existing vulnerabilities to produce different outcomes than under less stressful, non-deployed conditions.

Research question 2 (career impact of seeking, versus not seeking, treatment)

The heart of the interest in career-impact investigations is to test if MH treatment negatively affects military careers. Air Force 12 and Marines 13 studies by Ghahramanlou-Holloway et al. are the only studies to truly investigate this question, matching treatment seekers with demographic controls (at 1:4 ratio) and examining career impacts over 3.5-5.67 years. Although there was no impact on security clearances, those who sought MH treatment were more likely to be discharged than those who did not. 12 , 13 The well-powered Air Force study found that (1) treatment-seekers had an increased likelihood of medical board evaluations and involuntary discharge, and (2) seeking treatment and being subject to legal action (including command discipline) provided unique, additive predictivity of future discharge. However sobering, as we will discuss below, these findings do not establish that seeking MH treatment caused the increase in the probability of discharge.

Research question 3 (perceptions of the career impact of seeking treatment)

In DoD-wide studies, over one-third of all non-deployed SMs, and over half of those screening positive for psychiatric problems, believe that seeking MH treatment will harm their careers. This belief is less common, but still substantial, for deployed SMs in combat theaters (26%-42%). These findings are of particular concern because fears over career impact have been shown to dissuade treatment-seeking. 35

Even more troubling to those promulgating the message that MH treatment will not harm careers is the finding in the 2011 DoD-wide ( n   > 34,000) Health-Related Behaviors Survey that over one in five SMs who sought treatment believe that it had, in fact, negatively effect on their careers. Although this is a single question in a single study, the rigor of the study’s method and its size indicate that research fleshing out impacts on those still on active duty is needed.

Limitations

As with any study, this systematic review has limitations. First, although we used multiple approaches to comprehensively locate the literature, our search may have omitted studies. This is especially likely with military research, where findings are often not in traditional journal publications or even indexed reports such as from RAND. Second, this nascent area has yet to produce a controlled study that has tested if, all other things being equal, seeking MH treatment itself causes career impacts. In the next section, we will discuss what such a study would entail.

Human weapon systems differ from other weapon systems in that they are both autonomous and are charged with their own monitoring and maintenance. The U.S. DoD has expended considerable effort to destigmatize MH treatment-seeking 6 and to convince human weapon systems that they will not be harmed by seeking help.

Nevertheless, Kokx and van Kempen’s 61 phrase neatly summarizes the 61 studies in this review: “A fact is a fact, but perception is reality.” Over half of SMs screening positive for problems, and over one-third overall, believe that seeking help harms careers. Even more sobering is that over 20% of SMs who actually sought help believe it harmed their careers. Their perceptions are not wholly dissimilar from the facts amassed in this review. Seeking mental treatment is associated with a higher likelihood of having a medical board evaluation and being involuntarily discharged. This increased occurrence cannot be explained solely by behavioral problems in some members leading to both legal/command action and command-directed MH referrals because MH treatment and legal/command action each contribute unique predictive power to treatment-seekers’ increased likelihood of discharge.

Yet, there are facts supporting MH treatment-seeking, namely, in the short run, most referrals are self-directed and do not result in command contact, let alone providers’ career-affecting recommendations. For the vast majority of treatment-seekers, there is no risk.

So, what is the reality? Quite unsatisfyingly, the essential question of this research area—“does seeking MH treatment, compared with not seeking treatment, cause career harm?”—has not been addressed scientifically. The perception studies (research question 3) addresses opinions, not facts. The within-treatment-seekers studies (research question 1) cannot provide facts about seeking treatment because it only studies treatment-seekers.

Only the two studies addressing research question 2 can provide facts regarding the essential question. Because it would be unethical to randomly assign SMs with psychological problems to treatment versus treatment-prohibited groups, the research designs have necessarily relied on observational, not experimental, methods. However, such correlational designs cannot establish causality because there are three possible ways to interpret their findings 62 that seeking MH treatment predicts a greater likelihood of discharge 3.5-5.67 years. First, MH treatment may negatively impact careers. This cannot be ruled out given Ghahramanlou-Holloway and colleagues’ studies. 12 , 13 This possibility may apply more to some career fields than others, which needs further exploration. Second, the reverse causality—negative career impact could cause SMs to seek MH treatment—can be ruled out by these studies because seeking MH treatment preceded career impacts by years. Third, other variables may be causing both MH treatment-seeking and the increased risk for discharge, thus producing the correlation between the two. This is highly likely and has not been studied or controlled. Variables that increase the incidence of both could include (1) adverse childhood experiences; (2) presence of psychological problems (including both the often-screened depression, anxiety, and posttraumatic stress problems, as well as other problems that can interfere with military service [e.g., personality disorders, psychotic disorders, and bipolar disorder]); (3) a history of aggressive or behavioral problems; and (4) alcohol use and abuse.

Four implications for future research are most salient. First, research question 1 (provider recommendations) has been thoroughly studied. However, the inference from these studies that early attention to psychological problems protects against negative career impacts must be directly tested. This question cannot be tested by examining only treatment-seekers but must be incorporated into a larger, pre-treatment longitudinal study. Second, relatedly, the essential question—“Does seeking MH treatment, compared with not seeking treatment, cause career harm?”—must be studied with research designs that can actually address the question. At a minimum, longitudinal studies before treatment initiation are required, with multiple data collection waves comprising symptom measurement, treatment and other services obtained, and a wide array of career impacts. We provide examples of research designs in Online Supplement 2 . Third, fact-based investigations could learn from, and improve on, perception-based studies. Perception studies have often measured career impact with a single Likert-scaled question (e.g., agreement with “It would harm my career.”). Although single items are the most practical operationalizations for large surveys, scales have superior psychometrics. 63 Brown and Bruce 64 created a similar construct, career worry, comprising nine Likert-scaled items created by the authors: receiving MH treatment would “hurt my ability to get promotion,” “reduce my chances of being deployed,” “negatively impact my security clearance,” “negatively impact my job performance,” “hurt my chances of getting back into the military,” “negatively impact my relationships,” “increase the chances of my losing my job,” “put me under greater scrutiny,” and “negatively impact my ability to increase my pay.” Many, but not all, of the items in “career worry” would operationalize the “career impact” construct. Given the perception of one-in-five SMs who received recent MH treatment that it hurt their careers, 22 it is important to (1) conduct a qualitative study of SMs (from all services and with breadth regarding military career specialties and ranks) who have received MH treatment and ask them to generate ways in which they felt their careers were positively and negatively impacted; (2) cull the list of positive and negative impacts; and (3) conduct a content validity study comprising both SMs and experts (e.g., military psychologists, military MH researchers, commanders, and SMs serving on medical evaluation boards). Content validity, which is best incorporated into the earliest stages of measure creation, is a form of construct validity. Haynes et al. 65 define it as “the degree to which elements of an … instrument are relevant to and representative of the targeted construct….” Relevance refers to how well the items match the construct’s components; representativeness refers to whether the final items are proportional to the components of the construct. Participants would rate the potential item pool on relevance and representativeness. Fourth, such a content validity study could provide an evidence-based career-impact operationalization/measure that could be used in both actual- and perceived-impact studies. That is, operationalization of career-impacting MH provider recommendations, 11 operationalizations of military services’ actions, 12 , 13 and single-item questions of anticipated career harm provide important, but incomplete, data on career impact.

In conclusion, the next generation of studies should (1) develop and use content-valid measures, and (2) directly test the field’s “essential question.” Suggestions for such studies can be found in Online Supplement 3 .

Thanks to Col. Jennifer Chow (who instigated this review) and Col. Larry Kroll for their insightful comments.

Supplementary material is available at Military Medicine online.

Contract from U.S. Air Force to Cherokee Insights, LLC; this activity funded under subcontract 29700-0005, Item 3.3.1.1 to New York University.

None declared.

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The views expressed are solely those of the authors and do not reflect the official policy or position of the U.S. Air Force.

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Research on the Motivation for Choosing the Military Career

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The following article examines the structure of the motivation to choose the military career as well as the satisfaction from it. It analyses the main factors influencing on the choice of this profession as well as the interrelationships between them. The article sets out the specific reasons for a career in the Army and the results of the survey would contribute to the improvement of the attractiveness of the military career and attracting motivated military staff

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Military and Veteran help-seeking behaviors: Role of mental health stigma and leadership

James j. mcguffin.

Department of Psychology, University of North Texas, Denton, Texas, USA

Shelley A. Riggs

Emily m. raiche, daniel h. romero.

Mental health stigma has been identified as a barrier to help-seeking in the United States. This may be particularly salient for military personnel who tend to report higher mental health stigma than the general population. Evidence suggests that both supportive and destructive military leadership are related to service members’ attitudes toward seeking help. In the current study, a sample of military service members and Veterans (N = 232) completed an online survey regarding mental health stigma, previous experiences with military leaders, and mental health help-seeking behaviors. Findings indicated that destructive and supportive leadership experiences were significantly related to self stigma, public stigma, and help-seeking. Military members and Veterans who experienced destructive leadership were more likely to report internalized mental health stigma, which decreased the likelihood of seeking help. Supportive leadership, on the other hand, was associated with greater likelihood of seeking help for mental health concerns, and was indirectly related to help-seeking through lower self-stigma. Findings suggest that the military leadership style plays a significant role in service members’ and Veterans’ willingness to seek assistance for mental health concerns.

What is the public significance of this article?--- Mental health stigma is a significant barrier to help-seeking in the United States, and is particularly salient in military settings. Findings suggest that both destructive and supportive military leadership styles contribute to how service members’ and Veterans’ view mental health/illness and psychological treatment, and these associations differed by military branch. Military leaders and decision makers must understand the significant power leaders have on their troops’ psychological adjustment and closely examine how they train their leadership force in order to ensure the safety and well-being of all military personnel.

Mental health stigma is one of the strongest predictors of help-seeking behavior (Clement et al., 2015 ). In Western cultures, an estimated 52–74% of the individuals with a mental disorder do not seek help (Alonso et al., 2004 ; Kessler et al., 2001 ; Wittchen & Jacobi, 2005 ). Yet delaying treatment for mental health concerns is related to worse outcomes for major depressive disorders, anxiety disorders, bipolar disorder, and psychosis (Boonstra et al., 2012 ; Dell’Osso, Glick, Baldwin, & Altamura, 2012 ). The National Comorbidity Survey found that “concern about what others might think” was a key barrier to seeking mental health treatment (Kessler et al., 2001 , p. 996). In a systematic review, Clement and colleagues concluded that stigma was a moderate barrier to help-seeking, ranking behind confidentiality concerns and access to treatment. However, military personnel ranked mental health stigma as a much greater barrier to care than civilian populations. Military leadership seems to play a crucial role in how service members cope with stress (Bliese & Castro, 2000 ; Bliese, Ritzer, Thomas, & Jex, 2001 ; McGurk et al., 2014 ), and their likelihood to seek help (Britt, Wright, & Moore, 2012 ). The current study examined relationships between mental health stigma, perceptions of military leadership, and mental health help-seeking behaviors in a sample of military service members and Veterans (SMV).

Mental health stigma can be parsed into two components: public stigma and self-stigma (Vogt, 2011 ). Public stigma is the concern that mental health problems will be viewed unfavorably by others, while self-stigma is one’s own detrimental personal beliefs about people with mental illness, including oneself. Previous research on public stigma identified three themes regarding societal beliefs about mental illness: “authoritarianism” (i.e., people with mental illness are irresponsible/unreliable), “fear and exclusion” (i.e., people with mental illness are dangerous and should be isolated), and “benevolence” (i.e., people with mental illness are naïve and incompetent) (Corrigan & Penn, 1999 ; Couture & Penn, 2003 ). If these attitudes and beliefs about mental illness are internalized by individuals with psychological problems, self-stigma can develop. Self-stigma presumably lowers self-esteem, which can decrease the motivation to seek treatment (Mechanic, McAlpine, Rosenfield, & Davis, 1994 ). Furthermore, people are less likely to seek help if they believe that they are the cause of their own problems (Cooper, Corrigan, & Watson, 2003 ).

Although public and self-stigma occurs in the general population (Clement et al., 2015 ; Kessler et al., 2001 ), mental health stigma is a highly salient cultural interdiction in the United States (US) military (Greene-Shortridge, Britt, & Castro, 2007 ; Hoge, Auchterlonie, & Milliken, 2006 ; Tanielian et al., 2016 ). SMVs who encountered dangerous environments, suffered injury, and/or were at risk of serious injury or death have an increased probability of developing depression and post-traumatic stress disorder (PTSD; Schwarzbold et al., 2008 ; Thomas et al., 2010 ). However, evidence suggests that many SMVs in need of care are unlikely to seek help (Gould et al., 2010 ; Kim, Thomas, Wilk, Castro, & Hoge, 2010 ) or follow up with a psychological referral compared to a medical referral (Britt, 2000 ). Some of the stigma surrounding mental health and treatment is fueled by the military culture’s judgment of a mental disorder as a personal weakness and/or something service members should have control over (Nash, Silva, & Litz, 2009 ).

Greene-Shortridge et al. ( 2007 ) proposed a model to explain how public stigma, self-stigma, and other barriers to care may affect military personnel’s ability to access mental health care. Specifically, SMVs who develop psychological symptoms may perceive distancing or blame from other unit members. The behaviors of others along with previously held beliefs about society’s perception of mental illness contribute to the development of public stigma. When these messages and previously held beliefs about mental illness are internalized, SMVs experience self-stigma, which contributes to efforts to hide and/or suppress emotional distress.

As part of the VA initiative to improve service utilization, a comprehensive review identified public stigma as one of the most salient concerns for SMVs, noting few studies at the time examining self-stigma in military and Veteran populations (Vogt, 2011 ). In a large qualitative study conducted across six different military installations, active duty personnel reported that public stigma regarding the attitudes and perceptions of their leaders and whether their careers would be negatively affected were some of their main concerns about seeking treatment (Tanielian et al., 2016 ). As researchers turned their attention to self-stigma, findings indicated that soldiers who received mental health treatment had lower self-stigma than soldiers who had not received treatment (Skopp et al., 2012 ). Similarly, in a study examining different stigma perceptions in a military sample (i.e., career consequences, differential treatment of others, self-stigma, and stigmatizing others who seek treatment), self-stigma was the only unique predictor of premature treatment termination (Britt, Jennings, Cheung, Pury, & Zinzow, 2015 ). Importantly, Wade et al. ( 2015 ) reported that self-stigma fully mediated the relationship between public stigma and attitudes/intent to seek help.

Military leaders are responsible for the physical and psychological well-being of their troops (Castro & Adler, 2011 ; Castro, Thomas, & Adler, 2006 ; Greenberg & Jones, 2011 ), and their behaviors are associated with how service members cope with stress in dangerous environments (Bliese & Castro, 2000 ; Britt, Davison, Bliese, & Castro, 2004 ; McGurk et al., 2014 ). Researchers examining management styles across different work contexts have identified two leadership styles: supportive and destructive leadership (Aasland, Skogstad, Notelaers, Nielson, & Einarsen, 2010 ; Mitchell & Ambrose, 2007 ; Tepper, 2000 ). Generally, supportive leader behaviors include frequent contact with subordinates, praise for employee’s work, and an emphasis on workplace safety. Conversely, destructive leader behaviors include publicly embarrassing subordinates, favoritism, and delegating extraneous tasks to “look good” to their superiors. In other words, supportive leaders are concerned with the professional and personal development of their subordinates, while destructive leaders are more likely to use their subordinates as tools to further promote their own careers. These leadership behaviors are differentially associated with subordinates’ overall performance, motivation, and health (Aasland et al., 2010 ; Duffy, Ganster, & Pagon, 2002 ; Tepper, 2000 ; Tepper, Moss, Lockhart, & Carr, 2007 ).

Although the majority of research on destructive and supportive leadership behaviors has utilized civilian samples, researchers have also looked at leadership styles in a military setting. Leadership behaviors appear to be associated with the development of psychological symptoms among troops following combat, particularly PTSD. Among the 960 junior enlisted soldiers in 74 platoons on duty in Iraq or Afghanistan, soldiers in units exposed to high levels of direct combat and low supportive leadership by noncommissioned officers were over twice as likely to meet the criteria for PTSD (23%) than those with high combat and high supportive leadership (9%) (McGurk et al., 2014 ). Military leader behaviors are not only associated with the development of mental illness in their troops, but they may also be linked to their subordinates’ likelihood to seek help for mental health concerns. After finding that supportive leadership behaviors reduced the number of perceived barriers to care and destructive leadership was associated with increased stigma, Britt et al. ( 2012 ) suggested that embarrassing unit members in front of others could create a work environment where troops feel anxious about seeking help due to fear of public humiliation for having a mental illness. Additionally, evidence suggests that the leaders themselves experience self-stigma, which reduces the likelihood of seeking mental health care (Hamilton, Coleman, & Davis, 2017 ) and possibly influences their subordinates’ beliefs.

Current study

Leadership seems to play a crucial role in how service members cope with stress (Bliese et al., 2001 ; Bliese & Castro, 2000 ; McGurk et al., 2014 ), their level of mental health stigma (Greene-Shortridge et al., 2007 ; Skopp et al., 2012 ; Tanielian et al., 2016 ; Vogt, 2011 ), and their likelihood to seek help (Britt et al., 2012 ). As one of the first investigations examining leadership, stigma, and help-seeking among SMVs, the current study extended the literature by exploring interrelations among perceptions military leadership and mental health public and self-stigma to help us better understand service members’ help-seeking behaviors. We hypothesized that: (H1a) high destructive leadership is significantly associated with high public and self-stigma, and (H1b) is indirectly related to low help-seeking intentions via paths through high public and self-stigma, and (H2a) supportive leadership is significantly associated with low public and self-stigma, and (H2b) is indirectly related to high help-seeking intentions via paths through low public and self-stigma.

Participants and procedure

The current study was part of a larger project that examined the psychological and relational functioning of an SMV sample. After receiving approval from the university’s Institutional Review Board to ensure confidentiality and protection of human subjects, participants (N = 232) were recruited via online social media sites (i.e, Facebook, Twitter, etc.) and in-person at local Veterans of Foreign Wars and American Legion posts. Participants provided consent before completing an anonymous Qualtrics survey, and received a debrief notice at the end including mental health referral sources. As an incentive, one dollar per participant was donated to the Fisher House Foundation, a nonprofit organization supporting SMV families.

The sample included both active duty ( n = 73; 31.5%) and Veteran ( n = 159; 68.5%) service members with an average of 9.5 years served ( SD  = 7.49 years; Range = 1–36.6 years). Approximately 70% ( n = 163) of the sample reported at least one foreign deployment, almost two-thirds of which were to a war zone ( n = 145; 62.5%), with the rest having never been deployed ( n = 70; 30%). Participants were predominantly male ( n = 166; 71.6%) with a mean age of 37.72 ( SD  = 11.17). Table 1 presents sample characteristics, including race/ethnicity, military branch and rank, and number of deployments.

Demographic characteristics

The Background Information Questionnaire-Military Version (BGI-M; Campbell & Riggs, 2015 ) gathers demographic data and information regarding military background (e.g., branch, rank, deployment information, etc.), as well as relationship and mental health history.

Help-seeking

To assess participants’ help-seeking behaviors, we used the General Help-Seeking Questionnaire (GHSQ; Wilson, Deane, Ciarrochi, & Rickwood, 2005 ). Participants indicated the likelihood that they would seek help from 10 different sources (e.g., intimate partner, friend, family, mental health professional, doctor, minister, no one, etc.) on a 7-point response scale ranging from Extremely Unlikely (1) to Extremely Likely (7). Scale score was computed by averaging across items with higher scores indicating greater likelihood to seek help for personal or emotional problems (M = 33.33; SD = 10.22). The GHSQ demonstrated reliability and validity in a broad range of contexts (Wilson et al., 2005 ). In this study, Cronbach’s alpha for the GHSQ was .89.

We used 26-items taken from the Military Stigma Scale (MSS; Skopp et al., 2012 ) to measure Public Stigma (e.g., “A person seeking mental health treatment is seen as weak”) and Self-Stigma (e.g., “My self-confidence would be harmed if I got help from a mental health provider”). Items were presented to respondents with a 4-point response scale ranging from Definitely Disagree (1) to Definitely Agree (4). Some items were reverse coded to help identify inconsistent responding (e.g., “My self-esteem would increase if I talked to a therapist”). Scale scores were computed by averaging across items with higher scores indicating greater levels of Public (M = 23.32; SD = 7.84) or Self-Stigma (M = 9.36; SD = 3.41). Both the public and self-stigma subscales demonstrated good reliability and validity in military populations (Skopp et al., 2012 ). The Cronbach's alpha coefficient for both scales was .99.

We used the 6-item Noncommissioned Officer Leadership Scale – Short (NCOLS-S; McGurk et al., 2014 ) to assess participants’ perceptions of their military superiors’ Supportive Leadership (e.g., “Are concerned about the safety of their troops”) and Destructive Leadership (e.g., “Embarrass troops in front of other unit members”). Participants rated the items on a 5-point response scale ranging from Strongly Disagree (1) to Strongly Agree (5). Scale scores for each variable were computed by averaging across items with higher scores indicating greater levels of Supportive (M = 10.70; SD = 2.88) or Destructive Leadership (M = 9.36; SD = 3.41). Using three items each to measure supportive (α = .77) and destructive (α = .76) leadership, McGurk et al. reported that the short version of the measure performed similarly to the original measure in terms of reliability and validity. In this study, Cronbach’s alpha was .73 for the Supportive Leadership scale and .77 for the Destructive Leadership scale.

Data were analyzed using SPSS Version 25.0. Missing data were examined (<5% for each measure), and missing values were imputed using mean substitution. Skewness and kurtosis for key variables were within acceptable limits. Table 2 provides means, standard deviations, and correlations. Preliminary analyses indicate that most demographic variables were unrelated to key variables. However, ANOVA results showed significant group differences between military branch and help-seeking ( F [3, 228] = 2.76, p = .04), self-stigma ( F [3, 228] = 2.94, p = .03), supportive leadership ( F [3, 228] = 3.12, p = .03), and destructive leadership ( F [3, 228] = 2.64, p = .05). Post-hoc findings indicated that Marines were less likely to seek help and perceived more destructive leadership than Soldiers, Airmen, and Sailors; they also reported significantly more self-stigma than Airmen and Soldiers, as well as less supportive leadership than Soldiers. As a result, the military branch (Marines vs other branches) was controlled for in primary analyses.

Correlations, means, and standard deviations

* p < .05, ** p < .01, *** p < .001

For primary hypothesis testing, each variable was converted to standardized z -scores. Path analyses using PROCESS Model 6 in the PROCESS 3.0 macros for SPSS, tested study hypotheses. As predicted and shown in Figure 1 , we found direct effects between destructive leadership and both self ( t [227] = 2.33, p = .02) and public stigma ( t [226] = 6.19, p < .001). Also, there was a significant indirect effect between destructive leadership and help-seeking through self-stigma, with a bootstrapped partial indirect effect of −.06 (95% C.I. β [−.14- −.01]) but no indirect effect emerged for public stigma. Thus, perceptions of more destructive leadership are associated with higher self and public stigma, and through the exacerbation of self-stigma, participants reporting higher destructive leadership are less likely to seek help for mental health concerns. Overall, this model explained 24% of the variance in help-seeking ( R 2   = .24).

Standardized regression coefficients for the relationship between destructive leadership and help-seeking as mediated by self and public stigma. The standardized regression coefficient between destructive leadership and help-seeking, controlling for stigma, is in parentheses

In support of hypotheses (H2a, H2b), the second path model (see Figure 2 ) also showed significant direct effects from supportive leadership to lower self-stigma ( t [227] = −3.07, p = .002) and public stigma ( t [226] = −5.29, p < .001), and greater help-seeking ( t [227] = 1.92, p = .05). After controlling for stigma in the model, the relationship between supportive leadership and help-seeking was non-significant (95% C.I. β [.02-.18]). A significant indirect effect emerged in the path between supportive leadership and help-seeking through self-stigma, with a bootstrapped standardized indirect effect of .08 (95% C.I. β [.02-.15]). In other words, perceptions of supportive leadership were significantly associated with low self and public stigma, and through the reduction of self-stigma, participants reporting more supportive leadership were more likely to seek help for mental health concerns. Overall, this model explained 24% of the variance in help-seeking ( R 2   = .24).

Standardized regression coefficients for the relationship between supportive leadership and help-seeking as mediated by self and public stigma. The standardized regression coefficient between supportive leadership and help-seeking, controlling for stigma, is in parentheses

The current study contributes to our knowledge of military leadership styles in relation to public and self-stigma, and SMVs’ likelihood to seek help for mental health concerns. Overall, the results supported hypotheses that military leadership styles are associated with public stigma and self-stigma, and partially supported predicted indirect effects on help-seeking behavior. The present findings lend weight to previous research (Britt et al., 2012 ; McGurk et al., 2014 ), building further evidence that military leadership styles are worthy considerations in the mental health and well-being of SMVs. Current findings and their implications are discussed below.

As predicted, destructive leadership was associated with higher self and public stigma, and was indirectly related to low help-seeking through high self-stigma. In this sample, SMVs who perceived destructive leadership were more likely to endorse internalized stigma that decreased their likelihood of seeking mental health assistance. Conversely, perceptions of supportive leadership were associated with greater likelihood of seeking help for mental health concerns, and were indirectly related to help-seeking through lower self-stigma. Current findings suggest that different leadership styles among officers and senior enlisted personnel could promote or conversely counter mental health self-stigma and indirectly influence the likelihood of service members and Veterans seeking help. Longitudinal research with a more robust sample is needed to substantiate mediation by self-stigma over time.

The findings are consistent with the only other study to date exploring leadership and mental health stigma in a military context, which found that destructive leadership was associated with increased stigma and supportive leadership was related to less perceived barriers to treatment (Britt et al., 2012 ). However, the results did not support a hypothesized indirect effect of public stigma in either path model despite a significant direct correlation with help-seeking intentions in preliminary analyses, implying that other variables in the model accounted for the effects of public stigma. Wade et al. ( 2015 ) found that self-stigma fully mediated the relationship between public stigma and attitudes/intent to seek help in a sample of active-duty service members referred for neuropsychological assessment. Current findings similarly suggest that self-stigma may be a more powerful or more proximal predictor of service members’ help-seeking behaviors than public stigma. These results shed light on the potential influence of military leaders with respect to perceived stigma among their subordinates and whether troops seek the mental health care they need. In particular, SMVs who encountered more destructive leadership may experience shame and self-blame for their distress, which can make them less likely to seek help. Conversely, troops who received more supportive leadership may be less likely to have negative self-attributions when experiencing distressing psychological symptoms, which could increase the likelihood they will seek psychological services when needed.

Notably, preliminary analyses documented intriguing differences between Marines and other military branches. Specifically, Marines reported they were less likely to seek services for mental health and had more destructive leadership than members of all other military branches. Marines also reported significantly more self-stigma than Airmen and Soldiers, and less supportive leadership experiences than Soldiers. Although Marines represented 15.9% of current sample, which exceeds the 12.1% proportion of Marines in the total 2018 US military force (Department of Defense [DoD], 2018 ), the actual number of Marines in this sample was minimal ( n = 37) and thus these findings may not generalize to the larger population of Marines. There is a dearth of empirical studies examining the unique subcultural differences between branches of the US military, with a recent comprehensive review of stigma as a barrier to care in the military finding no studies that analyzed branch differences (Sharp et al., 2015 ). With little to draw from, an explanation for this finding must wait for future research that includes a cross-branch examination of these psychological constructs. In particular, considering that Marines have the highest ratio of enlisted members to officers (7.7:1) among the four main US military branches, which together averaged 4.1 enlisted personnel for every officer on Active Duty (DoD, 2018), researchers may want to explore whether this discrepancy is relevant to various leadership styles or possibly overburdened officer leadership in different branches, which may contribute to a delegative versus transformational (i.e., by example) style of leadership.

The current study is limited by a cross-sectional design, which cannot identify directionality nor yield causal conclusions. Furthermore, the sample was mostly comprised of Veterans (68.5%), and despite no significant differences between Veterans and active-duty troops in preliminary analyses, the sampling method and sample size should give pause before generalizing broadly to both service members and Veterans. For example, the use of self-report measures in an online survey introduced the possibility of biased reporting; in particular, retrospective self-reports of military experiences for Veterans who have been out of the service for an extended time may not accurately assess their experiences. In addition, a report of hypothetical help-seeking from any source may not reflect actual help-seeking behaviors and does not tell us specifically about seeking therapeutic treatment. Due to high rates of stigma in SMV populations (Greene-Shortridge et al., 2007 ; Hoge et al., 2004 ; Tanielian et al., 2016 ), there is also the possibility that potential participants high in mental health stigma opted not to participate in a research study about mental health. Future studies may benefit from longitudinal designs that follow military personnel across time to more accurately assess their ongoing experiences of leadership behaviors, changes in public and self-stigma as a result of these experiences, and tangible help-seeking behaviors (e.g., receiving psychological treatment). For instance, a cross-sequential design with a larger stratified sample of SMVs across the major military branches will allow sophisticated statistical modeling approaches and closer examination of differences related to demographic diversity (e.g., sex, race, age) and military characteristics (e.g., active-duty vs Veteran, branch, rank, deployment), as well as within-leader variation in levels of destructive and supportive leadership behavior.

In conclusion, findings from this study underscore the potential systemic influence of leadership behaviors on military and Veteran troops’ mental health stigma and likelihood of seeking psychological treatment and suggest areas for future investigation with larger representative SMV samples. Importantly, research on destructive and supportive leadership styles can inform military leadership training and policy in ways that might prevent or ameliorate psychological distress among SMVs, and reduce the mental health stigma of seeking help for that distress if it develops. Military leaders and decision makers in each of the service branches may benefit from examining how they train their leadership force and the potential effects different types of leaders have on their troops’ psychological well-being, self-stigma, and help-seeking behavior. As a step in the right direction, the Defender’s Edge (DEFED) program was designed to reduce mental health stigma utilizing a strength-based philosophy. After embedding a psychologist within a US Air Force Security Forces unit, Bryan and Morrow ( 2011 ) found that the DEFED program promoted increased trustworthiness and utilization of both formal and informal services with the psychologist. Similar programs to train leaders on the mental health needs of their troops may be highly beneficial in reducing unit stigma and increasing access to and use of psychological treatment. Future studies should also further examine subcultural differences in leadership and mental health stigma, which may provide important information about differential experiences between military branches that can inform prevention and treatment planning.

Acknowledgment

This study was based on the dissertation research of the first author, utilizing data from a larger research project. At the time of the research, all authors were affiliated with the University of North Texas. Currently, James McGuffin, Ph.D., is a U.S.A.F. Veteran currently working in private practice; Shelley Riggs, Ph.D., is a professor at Sam Houston State University; Emily M. Raiche, Ph.D., is a Postdoctoral Fellow at the Counseling Center of New England, Lifestance Health and Cpt Daniel H. Romero, Ph.D., is serving in the US Army. Please address all correspondence to Shelley A. Riggs, Ph.D., at [email protected].

Funding Statement

This work was supported by the University of North Texas.

Disclosure statement

No potential conflict of interest was reported by the author(s).

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Systematic Review of the Military Career Impact of Mental Health Evaluation and Treatment

Affiliations.

• 1 Family Translational Research Group, New York University, New York, NY 10010, USA.
• 2 Air Force Medical Readiness Agency, United States Air Force (via a contract with Analytical Services and Materials [USA]), JBSA Lackland AFB, TX 78236-1025, USA.
• PMID: 34322709
• DOI: 10.1093/milmed/usab283

Introduction: Military leaders are concerned that active duty members' fear of career impact deters mental health (MH) treatment-seeking. To coalesce research on the actual and perceived consequences of MH treatment on service members' careers, this systematic review of literature on the U.S. Military since 2000 has been investigating the following three research questions: (1) is the manner in which U.S. active duty military members seek MH treatment associated with career-affecting recommendations from providers? (2) Does MH treatment-seeking in U.S. active duty military members impact military careers, compared with not seeking treatment? (3) Do U.S. active duty military members perceive that seeking MH treatment is associated with negative career impacts?

Materials and methods: A search of academic databases for keywords "military 'career impact' 'mental health'" resulted in 653 studies, and an additional 51 additional studies were identified through other sources; 61 full-text articles were assessed for eligibility. A supplemental search in Medline, PsycInfo, and Google Scholar replacing "career impact" with "stigma" was also conducted; 54 articles (comprising 61 studies) met the inclusion criteria.

Results: As stipulated by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, studies were summarized on the population studied (U.S. Military Service[s]), sample used, intervention type, comparison group employed, outcome variables, and findings. Self-referred, compared with command-directed, service members appear to be less likely to face career-affecting provider recommendations in non-deployed and deployed settings although the data for the latter are not consistent. Of the two studies that tested if MH treatment actually negatively impacts military careers, results showed that those who sought treatment were more likely to be discharged although the casual nature of this relationship cannot be inferred from their design. Last, over one-third of all non-deployed service members, and over half of those who screened positive for psychiatric problems, believe that seeking MH treatments will harm their careers.

Conclusions: Despite considerable efforts to destigmatize MH treatment-seeking, a substantial proportion of service members believe that seeking help will negatively impact their careers. On one hand, these perceptions are somewhat backed by reality, as seeking MH treatment is associated with a higher likelihood of being involuntarily discharged. On the other hand, correlational designs cannot establish causality. Variables that increase both treatment-seeking and discharge could include (1) adverse childhood experiences; (2) elevated psychological problems (including both [a] the often-screened depression, anxiety, and posttraumatic stress problems and [b] problems that can interfere with military service: personality disorders, psychotic disorders, and bipolar disorder, among others); (3) a history of aggressive or behavioral problems; and (4) alcohol use and abuse. In addition, most referrals are self-directed and do not result in any career-affecting provider recommendations. In conclusion, the essential question of this research area-"Does seeking MH treatment, compared with not seeking treatment, cause career harm?"-has not been addressed scientifically. At a minimum, longitudinal studies before treatment initiation are required, with multiple data collection waves comprising symptom measurement, treatment, and other services obtained, and a content-valid measure of career impact.

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339 Military Essay Topic Ideas & Examples

🏆 best military topic ideas & essay examples, 👍 good essay topics on military, 📃 interesting topics to write about military, 🥇 most interesting military topics to write about, 💡 simple & easy military essay titles, 🎓 good research topics about military, ❓ military research questions.

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• African Union Military Force in Darfur Conflict The other criticism highlighted in the video is the use of a powerless African Union force to deal with the difficult conflict that faced the people of Darfur.
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IvyPanda. (2024, March 2). 339 Military Essay Topic Ideas & Examples. https://ivypanda.com/essays/topic/military-essay-topics/

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IvyPanda . (2024) '339 Military Essay Topic Ideas & Examples'. 2 March.

IvyPanda . 2024. "339 Military Essay Topic Ideas & Examples." March 2, 2024. https://ivypanda.com/essays/topic/military-essay-topics/.

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IvyPanda . "339 Military Essay Topic Ideas & Examples." March 2, 2024. https://ivypanda.com/essays/topic/military-essay-topics/.

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Gender in Sports: Challenges, Impacts and Pathways to Equity

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Gender bias in sports is a longstanding issue that affects athletes and women in leadership positions across all levels of competition. Despite significant progress in gender equity initiatives, disparities persist in media coverage, funding, sponsorship, coaching opportunities, and leadership roles. The bias not only impacts the visibility and financial support for women but also influences their psychological well-being, career longevity, and overall experience in sports. This Research Topic aims to address the critical problem of gender bias in sports. It seeks to provide a platform for analyzing the effects of gender bias on athletes, leadership positions, and sports organizations. It aims to explore the role of media and cultural perceptions in perpetuating gender disparities, as well as evaluate and highlight effective policies and initiatives that have successfully promoted gender equity. By gathering diverse perspectives and evidence-based research, this collection strives to identify practical strategies for overcoming gender bias and promoting inclusivity within sports environments. The ultimate goal is to foster dialogue, inform policy-making, and inspire actionable solutions that will contribute to reducing gender disparities and advancing equity in sports at all levels. This Research Topic invites contributions that explore various aspects of gender bias in sports, including but not limited to: • Disparities in media representation and coverage • Inequities in funding, sponsorships, and resource allocation • Gender differences in coaching opportunities and leadership roles • Psychological impacts of gender bias on athletes • Economic analysis of gender disparities in professional sports, the Olympic Games, and the Paralympic Games • Intersectional perspectives on gender bias We welcome all types of manuscripts and papers focusing on underrepresented groups, innovative solutions, and practical applications are particularly encouraged.

Keywords : Gender bias, sports equity, professional sports, amateur sports, collegiate sports, economic impact, intersectionality, media representation, psychological effects, policy initiatives, pay gap, leadership

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