The Predictive Effects of Work Environment on Stigma Toward and Practical Concerns for Seeking Mental Health Services

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1 MILITARY MEDICINE, 181, 11/12:e1546, 2016 The Predictive Effects of Work Environment on Stigma Toward and Practical Concerns for Seeking Mental Health Services Niwako Yamawaki, PhD*; Clinton Kelly, MA*; Brooke E. Dresden, MS*; Gregory L. Busath, PhD ; Christina E. Riley, MS* ABSTRACT The purpose of this exploratory study was to investigate factors in the work environment of the U.S. military that influence barriers toward seeking help from mental health. In particular, this study investigated the effects of gender, pay grade, satisfaction of work, coworkers, leaders, and perceived hostility in the workplace on practical concerns for and stigma toward seeking help from mental health services. A sample of 22,792 was drawn from the 2012 Workplace and Gender Relations Survey. The results revealed the crucial roles of work environments for stigma toward seeking help from mental health services. Being female or an officer are significant predictors for greater stigma toward and practical concerns that impede seeking help from mental health professionals in comparison to being male or an enlisted officer. Furthermore, higher workplace hostility, lower satisfaction toward leaders, coworkers, and one s work were all significant predictors for greater stigma toward and practical concerns for seeking help. This study revealed the vital roles of work environments in the military that influence stigma toward and practical concerns for seeking help from mental health professionals. Some implications and recommendations for prevention and intervention for underutilization of mental health services are discussed. INTRODUCTION Even after more than a decade of war in Afghanistan and Iraq, the biggest risk to our nation s soldiers and veterans exists at home. According to the Department of Veteran Affairs, in 2012 there were 349 active duty suicides, more than the 295 combat deaths recorded that year. 1 Over 80% of U.S. service members return from combat experience increased psychological stress and estimates vary from approximately 8% to 20% of veterans meeting criteria severe enough to establish post-traumatic stress disorder (PTSD) compared to community sample prevalence estimates from 3% to 6%. 2,3 Greenberg et al 4 attest that military soldiers are, indeed, an at-risk group who are vulnerable to mental illness. These problems are all serious threats to military services and occupational functionality. 5 As such, the Department of Defense has recognized the need for services and counseling for veterans and has attempted to create awareness and implement new mental health programs. Although awareness appears to be increasing and mental health programs are more readily available, 6 only 23% to 40% of veterans who returned from service in Iraq and Afghanistan with psychological problems reported seeking help from available programs. 7 Today, mental health resources are readily available, and military workers could benefit from psychological treatment 8 ;nevertheless, there appear to be barriers to seeking them out. One of the most studied barriers is stigma toward mental illness. 9 In particular, stigma *Department of Psychology, Brigham Young University, 1094 SWKT, Provo, UT Department of Psychological Science, Northern Arizona University, 5 East McConnell Drive, SBS No. 228, Flagstaff, AZ AMSUS The Society of Federal Health Professionals, 2016 doi: /MILMED-D toward help seeking from professionals is a serious and salient concern for underutilization of the available resources in the military. For instance, one study found that most veterans participating in a combat-related PTSD focus group reported avoiding treatment at some point in order to avoid the label of mental illness. 10 These results suggest that stigma regarding help seeking has a serious influence on help-seeking behavior. This fear of stigma may be heavily influenced by the military work environment, which demands professionalism and self-control that one must exhibit complete control over his or her environment and emotions. 11 In fact, Greenberg et al 4 assert that the organizational barriers prevent military personnel from receiving mental health services. They concluded that there is substantial evidence that such barriers still exist in the military and that stigma for receiving treatment is one of the crucial obstacles for helpseeking behavior. Yet, to our knowledge, there is no study that examines the relationship between specific work environmental factors and stigma toward help seeking. Therefore, he purpose of this study is to explore the relationship between work environment and problems in help seeking. In particular, the potential effects of gender, pay grade, workplace hostility, and satisfaction of leaders, coworkers, and work on stigma toward and practical concerns that impede seeking help were explored. Stigma and Work Environment Stigma regarding mental illness in the military has been talked about and conceptualized in many ways but has most recently been described as a 3-stage process. 7 The first stage involves cognitive, emotional, and behavioral components as the individual experiences salient psychiatric symptoms or receives a formal diagnosis of his or her own. 8 In the second stage, negative stereotypes regarding mental illness are e1546

2 elicited by the cues in stage 1. These negative stereotypes often involve the idea that people with mental illness are violent, incompetent, or at fault for their condition. 8,12 The third stage occurs when the individual endorses these negative stereotypes and has a negative emotional reaction. 8,13 This stigma is especially harmful for military personnel with access to lethal weaponry because the common stereotype that individuals with mental illness are violent and/or incompetent is directly harmful to their self-perception as a soldier. 9 It is not only harmful to their self-perception, it may also influence their overall work environment. Work environment has a strong influence on military workers as they live and work together and often lack very basic privacy. 14 As such, they may fear that they would be treated differently by their leaders/coworkers or that their leaders/coworkers would have decreased confidence in their ability to perform if they seek help. 5 In fact, 65% of Marines believe that receiving psychiatric services would cause them to be seen as weak and 64% believe they would be treated differently by their unit leaders if they sought help. 4 Overall, half of Marines believe that their careers would be harmed if they sought treatment. Military workers may also equate asking for help to an admission of failure or weakness, which has been shown to predict decisions to seek treatment over time. 15,16 As such, military workers may shirk mental health resources because they believe that seeking help may be damaging to their career, and they wish to avoid being labeled. 8 While stigma regarding help seeking is also pervasive for civilian workers, meta-analyses reveal that minorities, youth, men, and individuals in military and health professions are disproportionately impeded by stigma. 17 On the basis of this review of the literature, we chose to explore work environment factors, such as workplace hostility, pay grade, workers satisfaction with their leaders, coworkers, and work in general as factors which may have a strong influence on military members fear of being stigmatized when they seek professional help. Effective leadership and unit cohesion have been shown to be associated with lower levels of stigma. 18 Therefore, if analyses reveal a negative impact from work environment, this would convey that work environment affects help-seeking decisions. These specific factors, then, could instead potentially be utilized to create a more positive environment in which individuals feel more comfortable seeking treatment. Practical Concerns and Work Environment Additional barriers to seeking help are practical barriers, such as the lack of information regarding where and how to utilize available resources, being unaware of resources, having inadequate transportation or financial resources to access the help, or an inability to schedule time to seek help. 4 A hostile work environment, where individuals may be dissatisfied with leaders, coworkers, and work, may influence practical concerns that impede seeking help from professionals. For example, Einarsen et al (1994) 19 and Vartia (1996) 20 found a significant association between workplace hostility and low satisfaction with leaders, coworkers, and work. This dissatisfaction may lead to deficient internal communication, such as undersupplied information, lack of mutual conversations, and a poor communication climate in which mental health and mental health resources are never discussed. 20 Therefore, we also explored the influence of work environment on practical barriers to professional help seeking. METHOD The Defense Manpower Data Center (DMDC) conducts surveys for the Office of the Secretary of Defense to assess the attitudes of Department of Defense employees on a variety of personnel issues. This exploratory study used data from the basic survey dataset of the DMDC 2012 Workplace and Gender Relations Survey of Active Duty Members 21 to assess the effect the work environment has on an employee s decision to seek out mental health services. The 94-question survey was conducted in 2012, and respondents consisted of 108,478 active duty members of the Army, Navy, Marine Corps, and Air Force. In order to provide more accurate estimations of population values and avoid biased results, disproportionate stratified random sampling procedureswereusedtomake adjustments for selection probability, nonresponses, and known population values. To make the proper weighting adjustments, the sample was divided into 255 strata based on the cross-classification of five stratification variables (military branch, pay grade, gender, race/ethnicity, and deployment status). This approach ensures that smaller groups have adequate representation by having an analytical weight assigned to each stratum. After eliminating nonresponses (73.65%) and incomplete (i.e., completed less than half the survey questions) or ineligible responses (5.3%), there were a total of 22,792 responses included in this study, for a total response rate of 21.0%. Table I provides a summary of the demographic information of the participants Measures Of the 94 survey questions, this exploration used data from two demographic variables and five survey questions. The demographic variable of race/ethnicity was not included because DMDC removed the variable from the public release data file and only provided an overall summary of this information. Except for gender, a brief overview of each of the variables included in the study is provided subsequently. Pay Grade Pay grade was originally divided into three groups, with the first including enlisted pay grades E1 to E4, the second including the enlisted pay grades of E5 to E9, and the third including the officer levels of W1 to W5 and O1 to O6. e1547

3 TABLE I. Demographic Information of Participants Demographic N Percentage Gender Male 11, Female 11, Military Branch Army 4, Navy 3, Marine Corps 10, Air Force 4, Pay Grade E1 E4 8, E5 E9 9, W1 W5, O1 O6 5, Race/Ethnicity Non-Hispanic White 13, Non-Hispanic Black 3, Hispanic 3, Other Minority 2, Deployment Status Deployed Past 12 Months 6, Not Deployed Past 12 Months 16, The E1 to E9 pay grades were combined into one group representing enlisted military members. This variable in the final analysis therefore had two groups, enlisted military members (E1 E9) and officer military members (W1 W5 and O1 O6). This essentially converted the pay grade variable into a dichotomous rank variable of enlisted military members and officers. The variable name of pay grade was retained in order to be consistent with the original variable name provided in the DMDC survey. Workplace Hostility Workplace hostility is a composite that provides the average score of nine statements assessing the amount of anger or hostility in a work group. Participants used a 5-point Likerttype scale (1 = Never to 5 = Very Often ) to respond to the following: How often during the past 12 months have you experienced any of the following behaviors where coworkers or supervisors... Two example statements are Took credit for work or ideas that were yours and Did not provide information or assistance when you needed it. The 9-statement scale has a Cronbach s α of Higher scores indicate a greater workplace hostility. Leadership Satisfaction Leadership satisfaction was measured by four items and is a composite that provides the average score assessing leadership s commitment to a positive work environment and quality work. Participants used a 5-point Likert-type scale (1 = Strongly Disagree to 5 = Strongly Agree ) to respond to the following: How much do you agree or disagree with the following statements about the people in your work group? Two example statements are The leaders in your work group are more interested in looking good than being good (reverse-coded) and You would go for help with a personal problem to people in your chain of command. The 4-statement scale has a Cronbach s α of Higher scores indicate a greater leadership satisfaction. Coworker Satisfaction Coworker satisfaction was measured by five statements and is a composite that provides the average score of those statements assessing the helpfulness and relationships with coworkers. Participants used a 5-point Likert-type scale (1 = Strongly Disagree to 5 = Strongly Agree ) to respond to the following: How much do you agree or disagree with the following statements about the people in your work group? Two example statements are There is very little conflict among your coworkers and The people in your work group tend to get along. The 5-statement scale has a Cronbach s α of Higher scores represent greater satisfaction with their coworkers. Work Satisfaction Work satisfaction was assessed by four questions and is a composite that provides the average score, thereby assessing the use of valuable work skills and work enjoyment. Participants use a 5-point Likert-type scale (1 = Strongly Disagree to 5 = Strongly Agree ) to respond to the following: How much do you agree or disagree with the following statements about the work you do at your workplace? Two example statements are Your work makes good use of your skills and You like the kind of work you do. Higher scores demonstrate greater work satisfaction, and this four-statement scale has a Cronbach s α of Stigma Toward Help Seeking and Practical Concerns That Impede Help Seeking From Mental Health Services These dependent-variable questions consisted of 12 statements that asked participants to use a 5-point Likert-type scale (1 = Strongly Disagree to 5 = Strongly Agree ) to respond to the following: How much do you agree or disagree with the following statements that might affect your decision to receive counseling or service if you ever had a problem? Higher scores indicate that the statement is more likely to affect the decision to seek counseling. Before creating a composite score from the 12 statements, a factor analysis with a promax rotation was performed. The results indicated that two factors emerged in relation to the mental health questionnaire: concern for stigma associated with seeking help (stigma scale) and practical concerns that impede seeking help (practical concerns scale), such as lack of transportation, getting time off work, and difficulty in scheduling. This two-factor solution fit well and accounted for 71.75% of the variance. The stigma scale consisted of 4 of the 12 statements and had a Cronbach s α of An example statement from this factor is, It would harm my career. The practical concerns scale consisted of 8 of the 12 statements and had a Cronbach s α of An example e1548

4 statement from this factor is I don t know where to get help. Higher scores represent greater endorsement of stigma toward seeking help and higher exhibition of practical concerns that impede seeking help. RESULTS Table II shows the means, standard deviations, and zeroorder correlations between all variables analyzed. Two simultaneous multiple regressions, using the weighted stratification process described in the method section, were conducted on the stigma scale and practical concerns scale as dependent variables and gender, pay grade, workplace hostility, coworker satisfaction, work satisfaction, and leader satisfaction as predictor variables. As for the stigma scale, all predictor variables were significant (F [6, 1,187,733] = 58,337.52, p < 0.001, R 2 adj = 0.23) (see Table III). That is, being female or an officer is significant predictors for greater stigma associated with seeking help in comparison to being male or an enlisted officer. Furthermore, higher workplace hostility, lower satisfaction toward leaders, coworkers, and one s work were all significant predictors for greater stigma associated with seeking help. Another multiple regression analysis also revealed the same patterns for the practical concern scale (F [6, 1,205,264] = 41,763.82, p < 0.001, R 2 adj = 0.17) (see Table IV), indicating that all 6 variables contributed significantly to the prediction of practical concerns to receive mental health services. DISCUSSION The purpose of this exploratory study was to investigate factors in the work environment that influence barriers toward seeking help from mental health professionals in the U.S. military. In particular, this exploration investigated the effects of gender, pay grade, satisfaction of work, coworkers, and leaders and perceived hostility in the workplace on practical concerns for and stigma associated with seeking help from mental health services. Given that investigations that identify specific work environment factors associated with help seeking is scarce in the current literature and that this is the first step to address the vital role of work environment in the military, the findings from this study are TABLE II. useful to overcome such barriers, ameliorate underutilization of much-needed services in the military and lead to future research that investigate this topic further. The results revealed the crucial role of work environment for stigma associated with seeking help. In particular, perceived hostile work environment, satisfaction with leaders and coworkers, pay grade, gender, and job satisfaction were all significantly associated with stigma associated with seeking help. These results indicated the vital role of social support in the workplace that influences one s stigma toward help seeking. The benefit of social support for one s psychological well-being is well documented in current literature. For instance, researchers found that social support, such as from family, coworkers, and supervisors, was a significant protective factor against burnout. 24 In the military, such support is also associated with the occurrence of mental illness. Jones et al 25 revealed that greater levels of perceived unit cohesion, morale, and good leadership were all associated with lower levels of PTSD among U.K. Armed Forces personnel. Social support is not only a buffer against mental illness but also a facilitator for receiving treatment. According to Vogel et al, 26 of those participants who sought psychological help, approximately 75% had someone recommend that they seek help. Furthermore, one of the most influential factors to overcome barriers to seek help from mental health professionals was having family and friends strongly encourage U.S. soldiers to get help. 27 Britt et al 28 also found the role of leaders behavior vital; indicating that positive leadership behaviors were predictive of one s positive decision to seek treatment. The results from the present study validated the effect of social support at, such as support from leaders and coworkers, on stigma associated with seeking help. Since extensive educational programs seemed to have an effect on reducing the stigma related to receiving mental health care, it is vital to continue educating workers to be acquainted with stigma toward mental illness. It should be noted that previous research on social support from leaders and utilization of care shows conflicting results. That is, some studies reveal that social support from supervisors can have detrimental effects. 29,30 In particular, Kickul and Posig 31 uncovered that high emotional support from Descriptive Statistics for and Zero-Order Correlations Between Variables Used in the Study M SD Gender a Pay Grade b 0.17 Workplace Hostility Coworker Satisfaction Work Satisfaction Leader Satisfaction Stigma Practical Concerns a Gender (male = 1 and female = 2). b Pay grade (enlisted military members = 1 and military officer members = 2). All correlations are statistically significant at the p < level. e1549

5 TABLE III. Multiple Regression of Personal and Workplace Variables on Stigma Toward Seeking Help Variable β b SE t 95% CI Unique Variance c Gender a to <0.001 Pay Grade b to Workplace Hostility to Coworker Satisfaction to Work Satisfaction to Leadership Satisfaction to a Gender (male = 1 and female = 2). b Pay grade (enlisted military members = 1 and military officer members = 2). c Unique variance was computed using the squared semi-partial correlation. All p values were statistically significant at the p < level. supervisors is significantly related to greater emotional exhaustion. They attest that it may happen because the emotional support is not accompanied by tangible assistance. Thus, providing emotional support with tangible assistance, such as information about where to get help, process of getting help, is a crucial factor to success in reducing stigma in the education programs. The results also indicated that a positive work environment, such as satisfaction with leaders and coworkers, predicted the practical concerns that impede individuals from seeking help from professionals. That is, individuals who were less satisfied with their leaders, coworkers, and job were less likely to know where to get help, schedule an appointment with care providers, and have adequate transportation to receive professional help and felt greater difficulty in getting time off from work in comparison to individuals who were more satisfied with leaders and coworkers. This is particularly problematic because, as aforementioned, getting tangible assistance and information about these practical issues from leaders accompanied with emotional support is vital to overcoming barriers to receiving needed help. Therefore, it is essential to train and educate both leaders and workers to provide not only basic knowledge of mental illness but also tangible information about how and where to get help. A workplace hostility or workplace bullying, in which sabotaging, excluding, gossiping, yelling, criticizing excessively, interfering with job performance, etc., has become prevalent and a reality for many employees in both public and private organizations. 32 Researchers have revealed disturbing findings about the negative consequences of TABLE IV. workplace bullying, such as workers withdrawal, absenteeism, productivity, turnover, or lack of trust. 33,34 One of the noteworthy findings from this study is that such a hostile work environment was the most significant predictor of stigma associated with help seeking. Military workers express concerns about potential career consequences due to struggling with psychological problems. For instance, a previous study revealed that veterans fear that mental health records from the Veterans Health Administration could be leaked. 35 Indeed, some female veterans decided to seek professional help outside the Veterans Health Administration due to concerns about harming their careers. 35 Furthermore, soldiers who exhibit severe symptoms of mental illness were far less likely to report an interest in seeking help and were more prone to report concerns about professional relationships with coworkers or supervisors. 36 When workers have such realistic concerns for their career stability, job security, and relationships with their coworkers and leaders, it is extremely difficult for them to trust anyone in a hostile work environment. This lack of trust due to workplace hostility may exacerbate their fear of potential detrimental career consequences caused by seeking help from mental health professionals. Consequently, they would perceive that their leaders and coworkers will see them in stigmatic ways, such as being treated differently, being blamed, and being seen as weak. Furthermore, they may also not trust professionals because they think that their care would not work and that they may jeopardize their work security. Such explanations make sense and are well supported by another finding from this study: officers tended to show greater stigma toward seeking help in comparison to enlisted officers. In general, Multiple Regression of Personal and Workplace Variables on Practical Concerns that Impede Seeking Help Variable β b SE t 95% CI Unique Variance c Gender a to Pay Grade b to <0.001 Workplace Hostility to Coworker Satisfaction to Work Satisfaction to Leadership Satisfaction to a Gender (male = 1 and female = 2). b Pay grade (enlisted military members = 1 and military officer members = 2). c Unique variance was computed using the squared semi-partial correlation. All p values were statistically significant at the p < level. e1550

6 military officers are college educated and draw a larger salary than their enlisted counterparts. Therefore, there is too much to lose for officers by seeking help in comparison to enlisted officers. Workplace hostility was also the most significant predictor for practical concerns that impede individuals from seeking professional help. It is speculated that communication might be broken down in such an environment because individuals are fearful of being sabotaged, excluded, gossiped about, yelled at, criticized excessively, and having their job performance interfered with. Thus, workers do not have adequate knowledge of and information about how and where to get help. Given that workplace hostility also influences individuals poor psychological well-being, it is urgent to provide comprehensive intervention programs to ameliorate hostile work environments by increasing awareness of workplace hostility, assessment, intervention, and finally, reevaluation and debriefing. 37 Past research has revealed that men tend to have more negative attitudes toward mental health professionals, 38 underutilize mental health services, 39 and report having greater stigma associated with seeking help 40 than women. One of the most cited possible explanations related to negative attitudes and stigma toward seeking help is the role of traditional Western male gender roles. That is, men may see seeking help as conflicting with male gender roles, which demand men to be strong, in control of emotions and problems, and be able to handle any psychological concerns without help from professionals. 40 Indeed, Yamawaki 41 found that masculinity/femininity, rather than participant s sex, was the most significant predictor of attitudes toward mental health services. However, contradictory to previous studies, the findings from the present study revealed that female military personnel in the present study were more likely to report greater stigma and practical concerns that impede seeking help from mental health services than did male military personnel. This is an unexpected finding and our explanation might be entirely speculative. However, women in the military, which is a quintessentially masculine institution, may have to adopt masculine gender roles in order to survive in the environment where dominance of male personnel and masculine ethics exist. Furthermore, masculine traits are viewed as synonymous with being a good solider. 42 Thus, women may have to work harder to prove that they are strong, in control, and able to handle any stress without help in comparison to men in an unquestionably masculine organization such as the military. It is crucial to encourage women to participate in prevention and outreach programs to ameliorate stigma toward seeking help in the military. The present study is not free from limitations. First, the overall variance explained in the two dependent measures was not very high: 23% and 17% for stigma and practical concerns, respectively. That means that there are other factors that should be examined to further understand soldiers attitudes toward help seeking. For instance, researchers found that some psychological factors, such as fear of treatment, and personality factors, such as self-concealment and self-disclosing, all inhibit help seeking. 43 Further data should be collected by including such factors to expand our understanding of help-seeking attitudes. Another limitation is that the dependent variables are only attitudinal variables and do not measure actual behavior. In one study, level of psychological distress and gender were the only significant predictors for actual help-seeking behavior. 44 Although attitudes toward help seeking have been significant predictors of actual help-seeking behavior, 43 the majority of studies that examine actual behavior used college students. Further study is indispensable to explore the factors that correlate with actual help-seeking behavior using military personnel. Finally, these findings may be simply indicative of a negative overall view of most things in life. 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