Wounded Warriors with PTSD: A Compilation of Best Practices and Technology in Treatment

Apr 5, 2014 | Article, Volume 4 - Issue 2

Mary Alice Fernandez, Melissa Short

This article offers mental health counselors a compilation of best practices and technology in the treatment of combat veterans suffering from post-traumatic stress disorder (PTSD). The goal is to increase counselors’ awareness of the resources available to enhance their repertoire of tools and techniques to assess, diagnose, case-conceptualize and treat the growing population of combat veterans with PTSD. The National Center for PTSD provides guidelines for diagnosing PTSD using the DSM-5. PTSD is now recognized as a trauma disorder related to an external event rather than an anxiety disorder associated with mental illness. The authors describe assessment tools and treatment strategies for PTSD validated on veteran populations. The paper also highlights new technology and mobile apps designed to assist in the treatment of combat PTSD.

Keywords: combat PTSD, trauma disorder, treatment of combat veterans, National Center for PTSD,  mobile apps

Volunteering to serve one’s country during wartime is an act of heroism, and counselors working with combat veterans are in a unique position to honor these heroes. Combat veterans have offered the supreme sacrifice and some are paying a price by suffering from combat post-traumatic stress disorder (PTSD). The task of providing mental health services to a growing veteran population and their immediate family members is complicated by the lack of accessible services and the complexities of the disorder. To begin to address this challenge, Senator Jon Tester (D-MT) recently introduced legislation focused on improving access to mental health counselors by tasking the Department of Veterans Affairs (VA) with recruiting more licensed professional mental health counselors (Tester, 2013).

This article offers an overview of resources available to mental health counselors to assess, case-conceptualize, diagnose and treat a growing population of combat veterans with PTSD. The goal is to increase the awareness of both beginning counselors and more experienced counselors of new therapies as well as best practices in treating combat PTSD. The compilation of resources begins with diagnostic criteria, assessment tools, and evidence-based practices, including new technologies for treating PTSD, and culminates with a list of resources available to counselors and veterans.

Diagnosing PTSD

Changes in the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-5) place PTSD under a new heading, Trauma and Stressor-Related Disorders, and remove it from the DSM-4 anxiety category. This new DSM-5 categorization de-stigmatizes PTSD because it recognizes PTSD as a trauma disorder related to an external event rather than an anxiety related to mental illness (Staggs, 2014). The DSM-5 provides eight clear criteria for diagnosing PTSD, beginning with identifying a traumatic event (criterion A) and then noting behavioral symptoms related to PTSD. It organizes symptoms into four clusters: intrusions (criterion B), avoidance (criterion C), negative symptoms (criterion D), and arousal (criterion E) (American Psychological Association, 2013). In order for a client to meet the full criteria for a PTSD diagnosis, his or her symptoms must last longer than a month (criterion F), must prevent him or her from functioning well in significant area(s) of life (criterion G), and cannot be due to physical factors such as a medical condition or substance use (criterion H).

The National Center for PTSD (2014a) provides guidelines for diagnosing PTSD using the DSM-5. Criterion A (stressor) indicates that the person was exposed to at least one of the following: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence. The person must persistently re-experience at least one of the intrusion symptoms (criterion B) of the traumatic event and one of the avoidance efforts (criterion C) of distressing trauma-related stimuli. Two negative symptoms or alterations in cognition or mood (criterion D) and two alterations in arousal and reactivity (criterion E) that began or worsened after the traumatic event must be present for a diagnosis of PTSD.  Although symptoms may occur soon after the event, a person does not qualify for a PTSD diagnosis until at least six months after the traumatic event. An individual with PTSD will experience high levels of either depersonalization or derealization (National Center for PTSD, 2014a).

Nussbaum’s (2013) brief version for diagnosing PTSD begins by asking the following:

What is the worst thing that has ever happened to you? Have you ever experienced or witnessed an event in which you were seriously injured or your life was in danger, or you thought you were going to be seriously injured or endangered? (p. 90)

If the client answers in the affirmative, the counselor is to ask these questions: “Do you think about or re-experience these events? Does thinking about these experiences ever cause significant trouble with your friends or family, at work, or in another setting?” (Nussbaum, 2013, p. 90). Nussbaum (2013) provides a set of questions for each cluster and its associated symptoms to guide the process of diagnosis.

Assessment Tools

Ottati and Ferraro (2009) describe three assessment tools, validated on veteran populations, to screen for combat-related PTSD: the 17-item self-report PTSD Checklist (PCL), the 35-item self-report Mississippi Scale for Combat-Related PTSD (M-PTSD), and the Clinician-Administered PTSD Scale (CAPS). The PCL was recently updated to 20 items to reflect the changes in DSM-5. PCL-5 is a self-report measure that takes 5–10 minutes to complete and may be used to screen, diagnose and monitor changes during and after treatment of PTSD (Weathers et al., 2013). The M-PTSD uses a 5-point Likert scale to rate PTSD symptoms and related symptoms of substance abuse, suicidal ideation, and depression. It provides a PTSD symptom severity index with scores ranging from 35–175. The M-PTSD has not been revised since DSM-3, but may still be useful since it was normed with veteran populations (National Center for PTSD, 2014b). CAPS is a diagnostic structured interview that also measures the severity of symptoms and was recently revised to assess the DSM-5 PTSD symptoms. CAPS-5 is a 30-item questionnaire that takes 45–60 minutes to administer and yields a single score of PTSD severity (Weathers et al., 2013).

Other instruments are available to counselors for consideration. The PTSD Symptom Scale, Interview Version (PSS-I) with 17 items is a shorter clinical interview comparable to CAPS (Peterson, Luethcke, Borah, Borah, & Young-McCaughan, 2011). The PSS-I can be administered in about 20 minutes by a trained lay interviewer, and each item consists of a brief question so that an initial assessment can be made in shorter time (Peterson et al., 2011).The Emotion Regulation Questionnaire (ERQ) assesses differences between expressive suppression and cognitive reappraisal during treatment intake and discharge (Boden et al., 2013). The ERQ assessment assists the counselor in targeting and reducing maladaptive regulation strategies within the context of PTSD treatment in order to help the veteran develop alternative coping skills (Boden et al., 2013). The Quick Test for PTSD (Q-PTSD) is useful for identifying individuals with a true disability (Morel, 2008). Q-PTSD is a time-efficient method of detecting malingering in veterans applying for disability; it may be used by the counselor as an initial assessment of the disorder (Morel, 2008).

Other useful instruments can be incorporated into a treatment plan, such as a strengths-based assessment, depression inventory, substance abuse assessment, and insomnia inventory. Seligman (2011) also recommends the Post-Traumatic Growth Inventory (PTGI) for use with veterans. The 21-item PTGI “measures the extent to which survivors of traumatic events perceive personal benefits, including changes in perceptions of self, relationships with others, and philosophy of life accruing with their attempt to cope with trauma and its aftermath” (Tedeschi & Calhoun, 1996, p. 458). Seligman (2011) suggests that trauma often sets the stage for growth; a counselor may use the PTGI to facilitate veterans’ understanding of the conditions under which growth can happen.

Making a diagnosis of PTSD requires assessing symptoms and also gathering data from multiple assessments, a structured interview, and other knowledge of the client in order to make an evaluative judgment that leads to the development of a sound treatment plan (Ottati & Ferraro, 2009).

PTSD Treatment

Cognitive behavioral therapy (CBT) is unanimously endorsed as the best-practice treatment for PTSD by the VA and the Department of Defense (DOD; U.S. VA & U.S. DOD, 2010), the International Society for Traumatic Stress Studies (Foa, Keane, & Friedman, 2000), and the American Psychiatric Association (Ursano et al., 2010). Tramontin (2010) specifically states that the VA supports Prolonged Exposure (PE) therapy and Cognitive Processing Therapy (CPT).

In CPT and CBT, counselors challenge clients’ automatic thoughts connected with trauma. Through the use of written narratives in CPT, counselors target issues of safety, trust, power, control and self-esteem. Counselors also work with veterans to identify and label feelings as they work through impasses in their stories (Moran, Schmidt, & Burker, 2013). Exposure therapy is an evidence-based practice for many types of trauma including PTSD. According to Rauch, Eftekhari, and Ruzek (2012), PE therapy reduces PTSD symptoms and aids in treating comorbid issues. Rauch et al. (2012) explain that PE therapy consists of four components: psychoeducation, in vivo exposure, imaginal exposure, and emotional processing. Psychoeducation can help those suffering from trauma to understand their PTSD (Rauch et al., 2012). In vivo exposure consists of literally confronting the variables associated with the trauma (i.e., people, places and things; Rauch et al., 2012). Imaginal exposure involves reliving the memories associated with the trauma and engaging the accompanying emotions (Rauch et al., 2012). Emotional processing involves the counselor posing open-ended questions to the client in order to elicit both the emotions the client felt associated with the trauma and present emotions (Rauch et al., 2012).

Virtual reality exposure. In recent years, a new development of a virtual reality exposure therapy has surfaced. Albert “Skip” Rizzo developed a program titled “Virtual Iraq,” a virtual reality simulation designed to assist in the treatment of PTSD (Virtually Better, Inc., 2013). Rizzo developed the program after stumbling upon a video game called “Full Spectrum Warrior” that was originally created to train military service men and women. According to Rothbaum, Rizzo and Difede (2010), the current generation of military service members may be more comfortable participating in virtual reality treatment than conventional talk therapy, due to its similarity to gaming. After viewing several videos that demonstrate the Virtual Iraq system, the authors understand the connection between the exposure to trauma variables in PE and the exposure to trauma variables in virtual reality programs. Sharpless and Barber (2011) found several studies demonstrating the efficacy of virtual reality in treating veterans.

The protocol for virtual reality treatment involves veterans selecting a traumatic combat experience that relates closely to their most severe PTSD symptoms (McLay et al., 2012). Counselors create a realistic experience for the veteran by utilizing various sensory components of the virtual reality environment. Clients then use their senses and are immersed into the virtual reality world where they relive their trauma. Following the treatment, the counselor and the veteran process the material that surfaced in the exposure (McLay et al., 2012). In a study using virtual reality exposure therapy, McLay et al. (2012) found that “75% of participants experienced at least a 50% reduction in PTSD symptoms” (p. 635).

In addition to Virtual Iraq, Virtually Better, Inc. (2013) has developed other programs, including Virtual Vietnam, Afghanistan, Airports, and the World Trade Center. During a phone interview with Emilio Coirini, Director and Business Developer at Virtually Better, Inc., the interviewee stated that a soldier who suffers PTSD costs the government about $50,000 a year to treat, with the average treatment lasting 20 years. In contrast, the virtual reality system costs only about $30,000 with clinical training (E. Coirini, personal communication, November 16, 2012). At the time of the interview, there were about 70 systems installed throughout the United States, and Coirini explained that it is possible to receive grants for the cost of the system.

Animal-assisted treatment. In contrast to the relatively new use of virtual reality technology, animals have been assisting persons with disabilities for many years; there are a growing number of organizations that provide trained animals, specifically canines, to veterans who suffer from PTSD. According to Thompson (2010), in order to qualify as a service animal, the animal must undergo training to do work or perform helpful tasks. McConnell (2011) conducted a study that found that having a pet can provide meaningful social support that improves lives. One organization, Pets for Vets, provides animal companions to veterans with PTSD who are capable of caring for a pet. Pets for Vets states the following (2014):

Our goal is to help heal the emotional wounds of military veterans by pairing them with a shelter animal that is specially selected to match his or her personality. Professional animal trainers rehabilitate the animals and teach them good manners to fit into the veteran’s lifestyle. Training can also include desensitization to wheel chairs or crutches as well as recognizing panic or anxiety disorder behaviors. (para. 2)

Animals have been therapeutic partners to persons with disabilities for generations, and they are now serving wounded warriors.

Utilization of mobile phone applications. While researching other tools to help in treating PTSD, the authors discovered a few mobile applications available for both the iPhone and the Android that are well-developed, user-friendly and comprehensive. The first application, PTSD Coach (U.S. VA, 2014b), is elaborate in design, taking into account potential areas of concern for those who suffer from PTSD. The four main divisions of the application include Learn, Self-Assessment, Manage Symptoms and Find Support. The learning division of the application provides a comprehensive base and answers questions such as What is PTSD? and Who develops PTSD? In addition, the learning division includes answers regarding who should seek professional assistance and possible treatment protocols. The questions in the professional care subsection include Will it really work? and What if I am embarrassed about seeking help? The self-assessment section gives a person insight into the possibility of having PTSD. An example of an evaluative question is, “In the past month how often have you been bothered by disturbing memories, thoughts or images of the traumatic experience?” Users can track the history of their symptoms and schedule assessments to take periodically to provide a comparison of improvement or decline. When utilizing the manage symptoms option, users can select a mental state such as sadness or hopelessness, and the application will provide a suggestion to improve mood, depending on mood severity. Finally, users can set up their own support network, get support immediately or find professional care by choosing the finding support option. (The Apple phone app version may be found at https://itunes.apple.com/us/app/ptsd-coach/id430646302?mt=8, and the Android version may be found at https://play.google.com/store/apps/details?id=gov.va.ptsd.ptsdcoach.)

Another application, T2 Mood Tracker (The National Center for Telehealth and Technology, 2014), aids individuals in keeping track of their moods, which they can then report to their medical or mental health professional(s). The application can be used as a daily tool to track a client’s mood, keep notes regarding stressors, and chart a graph of the information provided. The initial screen asks whether the user would like to rate anxiety, depression, general well-being, head injury, post-traumatic stress, or general stress. The user selects one of the previously stated fields and is then required to rate several factors associated with the chosen field. The user can then graph results, create reports, save reports, or view notes. The application is user-friendly and simple in design, yet intricate enough to help the user and counselor in developing treatment protocols. (The Apple phone app version may be found at https://itunes.apple.com/us/app/t2-mood-tracker/id428373825?mt=8, and the Android version may be found at https://play.google.com/store/apps/details?id=com.t2.vas.)

A third application worthy of acknowledgement is the PE Coach, developed by the VA (2014a). The PE Coach requires a counselor trained in PE therapy. According to the National Center for PTSD (2014c), the PE Coach is a treatment companion that helps the client and counselor work through the PE treatment manual. The features of this application include the following: learning about PE therapy and the most common reactions to trauma, recording therapy sessions for personal use, setting reminders for homework and future therapy appointments, tracking tasks between sessions, practicing breathing exercises, and tracking PTSD symptoms. Currently, anecdotal accounts from veterans indicate that the mobile applications are helpful (U.S. DOD, American Forces Press Service, 2012). (The Apple phone app version may be found at https://itunes.apple.com/us/app/pe-coach/id507357193?mt=8, and the Android version may be found at https://play.google.com/store/apps/details?id=org.t2health.pe.)

Conclusion

Wendling (2008) reported results from an online survey administered to mental health practitioners after they had attended a conference called “Healing the Scars of War.” She found that most counselors did not understand military culture or appear to follow best-practice guidelines. The authors hope this paper serves to increase understanding of this critical area.

Technology makes it possible to access information about military families and resources to serve this special population. The VA has PTSD videos, training courses, and other materials available to inform counselors of the needs and unique cultural experiences of a diverse veteran population experiencing PTSD.

The resources identified (see Table 1) can be readily accessed by counselors and veterans to begin the therapeutic journey. We, the authors, salute the wounded warriors and continue to fight for their healing as they have fought for freedom.

Table 1

Informative Resources about Veterans and PTSD

References

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National Center for PTSD. (2014a, January 3). DSM-5 criteria for PTSD. Retrieved from http://www.ptsd.va.gov/professional/PTSD-overview/dsm5_criteria_ptsd.asp

National Center for PTSD. (2014b, January 3). Mississippi Scale for Combat-Related PTSD (M-PTSD). Retrieved from http://www.ptsd.va.gov/professional/assessment/adult-sr/mississippi-scale-m-ptsd.asp

National Center for PTSD. (2014c, January 28). Mobile app: PE coach. Retrieved from http://www.ptsd.va.gov/public/materials/apps/pecoach_mobileapp-public.asp

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Pets for Vets. (2014). Healing vets and saving pets. Retrieved from http://pets-for-vets.com

Rauch, S. A. M., Eftekhari, A., & Ruzek, J. I. (2012). Review of exposure therapy: A gold standard for PTSD treatment. Journal of Rehabilitation Research & Development, 49(6), 679–687.

Rothbaum, B. O., Rizzo, A., & Difede, J. (2010). Virtual reality exposure therapy for combat-related posttraumatic stress disorder. Annals of the New York Academy of Sciences, 1208, 126–132. doi:10.1111/j.1749-6632.2010.05691.x

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Sharpless, B. A., & Barber, J. P. (2011). A clinician’s guide to PTSD treatment for returning veterans. Professional Psychology: Research and Practice, 42(1), 8–15. doi:10.1037/a0022351

Staggs, S. (2014). Symptoms & diagnosis of PTSD. Retrieved from http://psychcentral.com/lib/symptoms-and-diagnosis-of-ptsd/000158

Tedeschi, R. G., & Calhoun, L. G. (1996). The posttraumatic growth inventory: Measuring the positive legacy of trauma. Journal of Traumatic Stress, 9(3), 455–471. doi:10.1002/jts.2490090305

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Thompson, M. (2010, November 22). Bringing dogs to heal. Time, 176(21), 54–57. Retrieved from http://p2v.org/wp-content/uploads/2010/11/p2v-time-web.pdf

Tramontin, M. (2010). Exit wounds: current issues pertaining to combat-related PTSD of relevance to the legal system. Developments in Mental Health Law, 29, 23–47.

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U.S. Department of Veterans Affairs. (2014a). PE coach [Mobile application software]. Available from https://itunes.apple.com/us/app/pe-coach/id507357193?mt=8 or https://play.google.com/store/apps/details?id=org.t2health.pe

U.S. Department of Veterans Affairs. (2014b). PTSD coach [Mobile application software]. Available from https://itunes.apple.com/us/app/ptsd-coach/id430646302?mt=8 or https://play.google.com/store/apps/details?id=gov.va.ptsd.ptsdcoach

U.S. Department of Veterans Affairs, & U.S. Department of Defense. (2010). VA/DoD clinical practice guideline for management of post-traumatic stress. Washington, DC: Management of Post-Traumatic Stress Working Group. Retrieved from http://www.healthquality.va.gov/ptsd/cpg_PTSD-FULL-201011612.pdf

Ursano, R. J., Bell, C., Eth, S., Friedman, M., Norwood, A., Pfefferbaum, B., … Benedek, D. M. (2010). Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder. Arlington, VA: American Psychiatric Association. Retrieved from http://psychiatryonline.org/pdfaccess.ashx?ResourceID=243186&PDFSource=6

Virtually Better, Inc. (2013). Virtual Iraq. Retrieved from http://www.virtuallybetter.com/virtual-iraq/

Weathers, F. W., Blake, D. D., Schnurr, P. P., Kaloupek, D. G., Marx, B. P. & Keane, T. M. (2013). The clinician-administered PTSD scale for DSM-5 (CAP-5). Retrieved from http://www.ptsd.va.gov/professional/assessment/adult-int/caps.asp

Wendling, P. (2008). Knowledge gap exists on best practices for PTSD. Retrieved from http://www.thefreelibrary.com/Knowledge gap exists on best practices for PTSD.-a0199814983

Mary Alice Fernandez, NCC, is an assistant professor at Texas A&M University – Corpus Christi. Melissa Short is a doctoral student at Walden University Online. Correspondence can be addressed to Mary Alice Fernandez, 6300 Ocean Drive, Unit 5834, Corpus Christi, TX 78412-5834, mary.fernandez@tamucc.edu.

The Implications of Attachment Theory for Military Wives: Effects During a Post-Deployment Period

Apr 4, 2014 | Article, Volume 4 - Issue 2

Kristin A. Vincenzes, Laura Haddock, Gregory Hickman

Past research has indicated the negative and positive impacts of deployment on military wives.  Furthermore, research has indicated the need to further understand the different deployment stages, specifically the post-deployment period. The authors examined Bowlby’s and Ainsworth’s attachment theories, specifically separation anxiety occurrence as experienced by stay-behind wives during their husbands’ post-deployment period. Purposive/volunteer sampling was used to survey 57 military wives currently experiencing the post-deployment period. A linear regression analysis produced a significant positive relationship between duration of deployment and the wife’s psychological distress during the post-deployment period. As deployments increased in duration, specifically to longer than 6 months, the levels of psychological distress significantly increased.  Implications for counselors and researchers are addressed. 

Keywords: post-deployment, attachment, military wives, separation anxiety, deployment

Between 2001 and 2012, the U.S. government sent 2.4 million soldiers to Iraq and Afghanistan (U.S. Department of Veteran Affairs, 2012). According to Demers (2008), deployments affected both the soldier and the stay-behind wife (over 56% of the soldiers reported being married according to the Department of Defense, 2012). The couple’s relationship may play an intricate role in identifying effects that a deployment could have on a stay-behind wife. Specifically, stay-behind wives may have both positive and negative experiences in response to prolonged separation from their husbands (Barker & Berry, 2009; Demers, 2008; Morse, 2006).  

This study focuses specifically on wives of male soldiers, and applies Bowlby’s and Ainsworth’s attachment theories (Ainsworth & Bell, 1970; Bowlby, 1969) to military wives’ post-deployment experiences. Bowlby (1969) asserted that an accumulation of early attachment experiences create expectations for future relationships. Over 40 years ago, Ainsworth and Bell (1970) identified three primary types of attachment: secure, avoidant and ambivalent. More specifically, the researchers found that children with an ambivalent attachment style exhibited anxiety following separation when the mother returned, going near the mother, but also exhibiting signs of anger by pushing her away (Ainsworth & Bell, 1970). In comparison, children with a secure attachment welcomed their mother’s return, and children with an avoidant attachment showed little interest in their returning mother (Ainsworth & Bell, 1970). Robertson and Bowlby (1952) also examined the idea of separation anxiety, identifying specific infant stages of attachment. The three phases an infant goes through when separated from their mother include protest, despair, and denial or detachment (Robertson & Bowlby, 1952).

The three separation anxiety phases may be applied to attachment issues that military wives experience during and after their husbands’ out-of-country deployment (Basham, 2008; Riggs & Riggs, 2011). The first phase, protest, occurs when a child is separated from his or her mother, with sadness and anxiety presenting as the most common initial emotional reactions. The protest phase is linked to pre-deployment and deployment time periods, as wives often feel numb, angry and abandoned due to an upcoming or current separation from their husbands (Pincus, House, Christenson, & Adler, 2001). Furthermore, wives also may experience sadness, loneliness and anxiety during this phase (SteelFisher, Zaslavsky, & Blendon, 2008).

The second phase of separation anxiety is despair, characterized by feelings of extreme sadness (Riggs & Riggs, 2011; Robertson & Bowlby, 1952). A wife may often go through similar stages of grief and mourning when her husband is deployed (Pincus et al., 2001). Initially a wife may be in denial that her husband is gone, believing that she will be fine and that he is only away for a few days’ training (Pincus et al., 2001). As time passes, she may experience depression and withdrawal as she realizes that her husband will not return for a long time, if at all (Vormbrock, 1993).

The nature of the military deployments to Iraq and Afghanistan are characterized by continual life-threatening experiences, coupled with the absence of any “safe” place (Demers, 2008). Constant media coverage spotlights the dangers of deployment to active combat zones and undoubtedly impacts a wife’s ability to trust that her husband will safely return (Demers, 2008). Wives have reported being in constant fear for their soldiers’ safety, which may result in feeling helpless throughout the deployment (Demers, 2008; Spera, 2009). Eventually, a wife may begin to accept that her husband is gone, and transfer her love to someone else, such as a child or different partner (Morse, 2006).

The final phase of separation anxiety, denial or detachment, can occur during both the deployment period and the post-deployment period (Morse, 2006). Robertson and Bowlby (1952) postulated that this last phase serves as a defense mechanism, which wives utilize when their husbands abruptly rejoin their families (Pincus et al., 2001; Riggs & Riggs, 2011). Anxiety combined with excitement has been found to impact the restabilization of the couple (Morse, 2006; Pincus et al., 2001). Attempting to regain a physical and emotional connection with one another after a long, seemingly permanent separation has been found to be extremely stressful, resulting in struggles with communication, coparenting, returning to pre-deployment routines, and marital intimacy (Orthner & Rose, 2005).

Additional challenges during the post-deployment period may entail negotiating new roles and boundaries within the family system, household management, financial status, parental rejection and new social supports (Drummet, Coleman, & Cable, 2003). If the husband returns and attempts to resume roles that existed prior to his deployment, it may diminish the stay-behind wife’s feelings of worth and accomplishment, since she successfully managed the various facets of daily life in her husband’s absence (Drummet et al., 2003), further straining the attachment between the couple. Although each endured the deployment simultaneously, the experiences were likely uniquely and vastly different from one another (Pincus et al., 2001).

Purpose

This quantitative study examined how stay-behind wives experience separation anxiety, through examining the relationship between duration of deployment and psychological distress during post-deployment. The theoretical framework for this study focused on attachment between a husband and wife and how a couple cope with separation. Surveys of wives were conducted during the post-deployment period in an effort to capture data from the time that couples were reattaching. For the purposes of this study, post-deployment is defined as the 12-month period after the husband has returned from deployment.

Research Design

A nonexperimental, correlational design was chosen for this study. In order to gain access to a multitude of military wives, there was no specific inclusion criteria with regard to the soldier’s branch in the military, rank, or if the husband was active duty, Reserves, or National Guard. In order to attempt to control for the potential confounding variable of gender, this study included only stay-behind wives. Stay-behind wives may or may not have children. Finally, stay-behind wives must currently be in the post-deployment stage; therefore, the husbands must have returned from their deployment within the past 12 months (Vincenzes, 2013).

Data Collection

The sampling method used for this research was volunteer purposive sampling. Inclusion criteria included the following: female, currently married and experiencing the post-deployment period (within the 12 months since her husband returned from the deployment), and a deployment that had lasted 6 or more months. Approximately 30 original e-mails were sent out to military advocacy groups, current military wives, the Army Wives Network, and a military advocacy group called Pennsylvania Americans showing Compassion, Assistance, and Reaching out with Empathy for Service members (PA C.A.R.E.S.). These individuals were asked to forward the initial e-mail soliciting military wives for the current study (Vincenzes, 2013).

If individuals agreed to volunteer for the study, they immediately received a background questionnaire, which assessed the duration of deployment (independent variable). Duration of deployment was operationalized as the total number of months that the soldier was deployed, from the day he left until the day he returned (Vincenzes, 2013). Furthermore, the participants took the Depression Anxiety Stress Scales (DASS-21; Lovibond & Lovibond, 1995), which was used to operationally define the dependent variable of psychological distress. The DASS-21 is a 21-item Likert scale survey and consists of three subscales (Depression, Anxiety, and Stress). In addition to individual scores on the subscales, the assessment provides an overall global psychological distress level, which was the score this particular study used. The reliability for this measure was high with a .93 internal consistency on the overall global scale (Henry & Crawford, 2005). In addition, the DASS-21 illustrated good convergent and discriminant validity as compared to the Hospital Anxiety and Depression Scale and Personal Disturbance Scale (Henry & Crawford, 2005).

Results

Of the 145 participants who responded to the survey, 48.9% (n = 68) met the criteria, but 14.7% (n = 10) had missing data. Thus, the final data sample contained 40% (n = 58) of the participants who volunteered. The inclusive sample accurately depicted the dispersion of active duty military (56.9% Army, 22.4% Air Force, 12.1% Navy, and 1.4% Marine Corps); however, fewer participants were associated with the National Guard (5.2%) and Reserves (1.7%) than expected.

The age of the wives ranged from 21–47 (M = 31.2, SD = 6.7), and 50% were 29 years old or younger. The majority of the participants (93.1 %) had some years of college (only 6.9% had a high school diploma/GED or less). Furthermore, 29.3% had some college, but no degree; 20.7% had an associate degree, 31% had a bachelor’s degree, and 12.1% had a graduate degree. With regard to employment status, 53.4% of the participants were not employed and 46.6% were employed. The number of years couples were married ranged from 1–20 (M = 7.2, SD = 5) and 48.3% of the participants had been married 5 years or less. The number of children under 17 who lived in the household ranged from 0–4 (M = 1.5, SD = 1.3) and 51.7% had either no children or one child. The length of deployments ranged from 6–16 months (M = 9.5, SD = 2.8). Finally, the length of time since the husband returned from deployment ranged from 0–12 months (M = 6.0, SD = 4.2).

The study’s null hypothesis stated that in the population under investigation, the proportion of variance in post-deployment psychological distress level explained by the duration of deployment (as measured by the DASS-21) was zero. Linear regression analysis predicted psychological distress from the duration of husband’s deployment. Results from the analysis indicated that duration of deployment significantly predicted psychological distress: F(1, 57) = 5.384,  p = .024, R=.296, Adj. R² = .071. Duration of deployment accounted for 8.8% of the variance in psychological distress and was positively related to psychological distress ( = .296, sr ² =.088). Based on these results, the null hypothesis, which stated that distress levels would be zero or not change following longer deployments, was rejected. Thus, as the duration of deployment increases, the psychological distress levels for stay-behind wives also increases.

Discussion

This study confirmed prior research and extended existing literature regarding attachment theory as it relates to stay-behind military wives. For example, researchers have found that when husbands are deployed or away on military duties for several months, the wives not only demonstrate feelings of anger during the deployments, but that their feelings of anger persist even after their husbands return from deployment and military duties (Pincus et al., 2001; Riggs & Riggs, 2011; Zeff, Lewis, & Hirsch, 1997). Indeed, the findings from this current study supported prior research, as the author found a positive relationship between deployments of increasing length and an increase in distress levels among stay-behind military wives. Although this study did not specifically evaluate wives’ anger, other researchers have found that high distress levels are correlated with the development of anger among military wives (Drummet et al., 2003).

The results of this study illustrate that post-deployment is indeed very stressful for the wife, particularly when the husband was deployed for 6 months or more. Since deployments lasting 6 or more months significantly predicted psychological distress for the wives, it may be that as deployment length increases, stress levels also may increase, resulting in a wife emotionally withdrawing from her husband. The findings from this study support prior research that has identified the coping strategy of emotional withdrawal, which results from psychological distress and may enable the wife to continue her daily life, while also creating a new support system and sense of emotional equilibrium (Pincus et al., 2001).

Some stay-behind wives function well on a daily basis while their husbands are deployed; however, other stay-behind wives appear to struggle with their husbands’ deployment (Riggs & Riggs, 2011). Such research supports the notion that wives who made secure attachments while growing up may be better able to cope with military separations (Riggs & Riggs, 2011). It should be noted, however, that only in the past several years have some deployments lasted up to 15 or 16 months (Sheppard, Malatras, & Israel, 2010). The length of deployments, especially 6 or more months, may significantly alter the ability of stay-behind wives to successfully cope, regardless of their attachment styles. Further research should examine the impact of lengthy deployments (e.g., 6 or more months) on stay-behind wives’ ability to cope as it relates to attachment style, as there may be a point of diminishing returns at which, regardless of one’s attachment to her parents growing up, the ability to cope disappears.

Vormbrock (1993) predicted that as the duration of deployment increased, so too would distress levels during the couple’s reunion. This was hypothesized to be due to the continual unavailability of the attachment figure. The current study supports Vormbrock’s theory in that participants’ reported distress levels during post-deployment were significantly higher (p = .023) as deployment duration increased. Perhaps when the husband is gone for 6 months or more, the potential for the marriage to grow apart or detach may increase. Vormbrock (1993) found that wives can successfully focus on the brevity of their separation as a means of coping; however, as the deployments increase in length, it may affect wives’ ability to maintain the mentality that this separation is only temporary. Deployments that require the couple to be apart for 6 or more months may result in the wife feeling that the separation is more permanent. The longer the husband is away, the more independent the wife may become by creating new schedules and ways of doing things (Morse, 2006; Pincus et al., 2001).

Although this research elaborated on the relationship of the post-deployment period and distress among stay-behind military wives, there are some limitations to the study. The first limitation may be a self-selection bias, which may have impacted the internal validity. More specifically, since participants were volunteers, some individuals may have extremely negative feelings toward the military and may have opted not to participate. This could have inadvertently skewed the population sample, thus impacting the results. Indeed, researchers have discussed that volunteer samples may have biased tendencies as a motivation for their participation in a specific study (Frankfort-Nachmias & Nachmias, 2008). In addition to self-selection bias, an instrumentation threat could be present, as this survey relied on participants’ honesty. Another possible limitation is that this study was a regression study, which relies on the correlational nature of two variables. Perhaps there are extraneous variables that could be moderating or mediating the relationship of deployment length and distress level among stay-behind military wives.

Conclusions and Implications

Despite existing limitations, this study supported research regarding military deployment as a significant concern for military families, as well as for military leaders who rely on the husbands of these stay-behind wives to provide national security. As surveys within the last decade indicate that nearly 60% of American military members are married (Sierra & Kemp, n.d.), the results of this study also offer further insight into the contextual factors that are part of a therapeutic treatment intervention. Military couples are unique and a counselor’s awareness of needs particular to this group is imperative for therapeutic success.

The current research found a positive correlation between the duration of deployment and stay-behind wives’ psychological distress levels during post-deployment. This finding corroborates the research on separation anxiety for children, particularly when children illustrate signs of detachment from their mother following a separation. Attachment figures may include other vital individuals in one’s life, especially for military couples. Since many military couples do not live close to immediate biological family members, the wife may solely depend on the husband to meet her emotional, physical and social needs, just as an infant child often relies on their mother to meet these same basic needs. With this in mind, the notion of separation anxiety may not be just applicable to young children but also adults, particularly military wives.

Counselors may want to educate stay-behind wives on separation anxiety and assist them in processing their experiences, as well as recognize wives’ desire for a stable, secure relationship and assist them to this end. Furthermore, since deployments are unpredictable and out of the wives’ control, it may be helpful for counselors to assist the wives in gaining a greater sense of control throughout their daily lives. Just as counselors often recommend that children with separation anxiety have a consistent routine, as well as partake in positive social activities, it also may be helpful to encourage stay-behind wives to create predictable routines that include engaging in various social events with friends and/or other military wives.

This study also has implications for further research regarding the human services industry (e.g., clergy, educators) who directly work with such military families. One might assume that not all soldiers or their wives experience deployment the same way, and thus counselors must be prepared to individualize interventions and compose treatment plans according to the needs of the individual as well as needs as a couple. For example, the post-deployment period may entail negotiating new roles and boundaries within the family system. Wives frequently experience the emotion of celebration for the return of their husbands, while also feeling confusion over what it will mean to share a home again after becoming more independent. This experience of boundary ambiguity can be very confusing for wives who recognize that their husbands are physically present, but who are still transitioning toward psychological acceptance that he is present.

Role ambiguity may increase if the couple is not comfortable communicating with each other regarding roles, responsibilities and needs. Simultaneously, a soldier may feel disconnected and unaware of how to reengage without interfering with the family’s new roles. Thus, helping professionals must be prepared to work with the couple on strengthening basic communication skills and nurturing a climate that facilitates safe and transparent information exchange.

Future research could evaluate the experiences of deployed husbands in terms of understanding how the distress level of their stay-behind wives impacts their duties while deployed. Such research might have national security implications. In addition, future research could examine deployments of 6 months or more regarding the struggles, challenges, resiliency, social and psychological effects, educational outcomes, parenting styles, and attachment of the deployed husbands, the stay-behind wives, and their children.

One particular variable that may moderate the relationship between duration of deployment and psychological distress is the stay-behind wife’s social support system. Larsen and Kia-Keating (2010) found that a social support system significantly aided resiliency for stay-behind wives who experienced a military deployment. Furthermore, a wife’s well-being was positively impacted by having a mentor who had previously experienced a deployment herself (Larsen & Kia-Keating, 2010). This brings up an interesting perception of what social support may be necessary for a military wife. Whereas some social support indices examine tangible support (i.e., someone to help around the house), the stay-behind wife may need a social support that relies more on reducing emotional stress.

Future research could qualitatively explore the social support construct further by interviewing stay-behind wives and identifying the indices of social support that they deem important in terms of reducing stress during the post-deployment period. Such a qualitative process could then lead to the quantitative development of a more valid measure of social support necessary to reduce stress for stay-behind military wives, and therefore indirectly for their deployed husbands. Perhaps such a study could examine whether social support serves as a moderating or mediating influence on the relationship between deployment length and psychological distress of stay-behind wives. Such research could have both positive and negative implications for their families, the military, and society at large, as American society depends greatly on its military for national security.

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Kristin A. Vincenzes, NCC, is an Assistant Professor and Director of the Clinical Mental Health Counseling program at Lock Haven University. Laura Haddock, NCC, is a Core Faculty member and CES Program Coordinator at Walden University. Gregory Hickman is a Core Faculty member at Walden University. Correspondence can be addressed to Kristin A. Vincenzes, 401 N. Fairview Street, Courthouse Annex Room 301, Lock Haven, PA, 17745, KAV813@lhup.edu.

Mental Health Service Providers: College Student Perceptions of Helper Effectiveness

Apr 4, 2014 | Article, Volume 4 - Issue 1

Ashley M. Ackerman, Richard A. Wantz, Michael W. Firmin, Dawn C. Poindexter, Amita L. Pujara

Undergraduate perceptions of the overall effectiveness of six types of mental health service providers (MHSPs) were obtained with a survey. Although many mental health services are available to consumers in the United States, research has indicated that these services are underutilized. Perceptions have been linked to therapeutic outcomes and may potentially serve as barriers to treatment. The results of the present study illustrate a range of perceptions and highlight the value of educating future consumers and practitioners about the roles of various MHSPs in providing mental health services. Future research is proposed.

Keywords: mental health provider, student perceptions, consumers, underutilized, practitioners

At the 2013 National Conference on Mental Health, President Obama called for a national discussion on mental health:

We know that recovery is possible; we know help is available, and yet, as a society, we often think about mental health differently than other forms of health. You see commercials on TV about a whole array of physical health issues, some of them very personal. And yet, we whisper about mental health issues and avoid asking too many questions. In many cases, treatment is available and effective. If there’s anybody out there who’s listening, if you’re struggling, seek help.

(The White House, 2013, 3:20)

To address this plea for mental health awareness at the national level, there is a need for research that identifies and targets the barriers that prevent individuals from seeking mental health services. The goal of the present study was to gain more insight regarding perceptions of the effectiveness of MHSPs. Results of this study offer a baseline for future research that could investigate how these perceptions influence help-seeking behaviors.

According to the National Institute of Mental Health (NIMH; n.d.), about one in four American adults has a mental disorder that can be diagnosed. Mental illness is the leading cause of disability (NIMH, 2012), and suicide is the eighth leading cause of death in the United States (Russell, 2010). MHSPs (e.g., counselors, marriage and family therapists [MFTs], psychiatrists, psychiatric nurses, psychologists, social workers) offer critical services to their clients, advocate for mental health awareness, and stress the significance of the de-stigmatization of mental illness to the general public. Despite the services available, fewer than 37.9% of adults with mental illnesses receive treatment (Office of Applied Studies, 2009). This statistic reveals some important research questions: Do individuals avoid seeking mental health services because they do not believe the service providers can effectively treat them? Do people seek help from some MHSPs more than others because they believe them to be more effective?

According to World Health Organization’s 2001 report, the effectiveness of mental illness and substance abuse treatment has been well documented and has dramatically improved over the past 50 years. The 1995 Consumer Reports survey on the effectiveness of psychotherapy empirically supports the assertion that consumers benefit substantially from psychotherapy (Seligman, 1995). Participants in the study answered questions about the effectiveness of the treatment they received, how satisfied they were with the therapist’s treatment of their problems, and how their emotional state changed from the beginning to the end of therapy. Of the 426 participants who were feeling “very poor” when they began therapy, 87% reported that they were feeling “very good” or “good” by the time of the survey. No specific modality of psychotherapy was shown to be more effective than any other. Participants reported that primary care physicians were as effective as the other mental health practitioners in the short term, but significantly less effective in the long term. Those who sought treatment from a mental health professional rather than seeing only a primary care physician reported more improvement in the following domains: ability to relate to others, ability to cope with everyday stress, enjoying life more, personal growth and understanding, self-esteem, and confidence (Seligman, 1995). Still, when individuals are struggling with mental health issues, they most commonly consult their primary care physicians (Mickus, Colenda, & Hogan, 2000; Murstein & Fontaine, 1993).

Research conducted by Deen, Bridges, McGahan, and Andrews (2012) offers insight into the role that cognitive factors play in the utilization of mental health services. Participants in their study were presented with vignettes that described depressive episodes and asked if they would seek help from (a) a medical doctor and (b) a counselor or therapist for the presented problem. Participants also were asked if they believed that seeing a medical doctor or counselor would help alleviate the presented problem. A higher perceived need for medical doctors over counselors or therapists was reported. Medical doctors were perceived by participants as more useful and had more favorable therapeutic outcome expectancies than counselors or therapists (Deen et al., 2012).

Furthermore, a five-year study conducted by Su, Tsai, Hung, and Chou (2011) evaluated non-psychiatric physicians’ accuracy in recognizing disorders. In each case, the researchers recorded the primary care physician’s impression and referrals based on psychiatric diagnosis and then compared them with a psychiatrist’s final diagnosis. When the primary care physician was able to recognize psychiatric diagnostic criteria or common symptoms (e.g., low mood, loss of interest and negative thinking, acute confusion, consciousness disturbance, hallucination), this information was recorded as correct recognition. Five common psychiatric diagnoses were chosen for analysis: (a) depressive disorder (major depressive disorder and dysthymic disorder), (b) anxiety disorders, (c) substance use disorders, (d) delirium, and (e) psychotic disorders (schizophrenia, schizophreniform disorder, and brief psychotic disorder). Su et al. (2011) reported that the overall diagnostic accuracy rate was 41.5%. Substance abuse disorders were the most accurately diagnosed by physicians (70.2%) and psychotic disorders were the least accurately diagnosed (9.7%). The most common psychiatric symptoms that patients report are depressive symptoms, yet the detection of depression by physicians (31.4%) is historically low (Su, et al., 2011).

Although pediatricians are instrumental in assessing and diagnosing the children’s mental health and behavioral challenges, they often state that their medical training does not fully prepare them to treat patients with learning disabilities, attention deficit disorders, mental retardation, substance abuse issues, or psychosocial problems (Russell, 2010). Clients who are seeking mental health services often perceive their primary care physicians and pediatricians as competent in providing mental health services, despite their lack of training on these specific issues. Moreover, many individuals suffer needlessly due to their primary care physicians’ lack of education regarding mental disorders (Tse, Wantz, & Firmin, 2010).

MHSPs have tremendous overlap in the populations served, disorders treated, and services offered (Hanna & Bemak, 1997). The helping professions are represented by diverse training standards, licenses, specialties, philosophies and histories (Fall, Levitov, Jennings, & Eberts, 2000). Although professional diversity allows for the treatment of a wide range of ­issues, this also can cause confusion regarding which type of MHSP a client should consult in a time of need. While perceptions of the competence of helping professionals can greatly affect utilization of services (Firmin, Wantz, Firmin, & Johnson, 2012), a review of the literature indicates that misperceptions are common.

Perceptions of MHSPs and Therapeutic Outcomes

Perceptions of MHSPs are important factors in the treatment outcomes of counseling (Firmin et al., 2012). According to Wampold (2001), client expectancy concerning the effectiveness of counseling accounts for 15% of the therapeutic outcome, and factors that clients carry into counseling (e.g., perceptions of MHSP competence and expertise) account for an astounding 40% of the therapeutic outcome. The therapeutic alliance alone accounts for 30% of the outcome of treatment (Wampold, 2001). Client perceptions of an MHSP’s competency in regard to treating specific needs have an effect on the therapeutic alliance as well as clients’ ability to facilitate positive changes in their lives. According to Meyer et al. (2002), client expectancy concerning the effectiveness of counseling is critical and often sufficient for inspiring positive change for the client. As far back as 1973, Frank asserted that counseling is most effective when both the client and counselor believe in the effectiveness of the intervention. Based on past analyses of the link between the expectancy factor and the therapeutic alliance, and their effect on treatment outcomes, the authors propose that creating more awareness and more positive perceptions of the overall effectiveness and accessibility of MHSPs would ultimately increase positive outcomes in counseling.

Undergraduate Students as Future Professionals and Help Seekers

College undergraduates’ perceptions of MHSPs are important for a number of reasons. First, the future of the helping profession depends on the incoming generation of undergraduate students, who are making decisions regarding which fields they will work in, and who may consider the helping professions. Career choices are related to well-being and overall life satisfaction (Steger & Dik, 2009). According to Roese and Summerville (2005), the most frequently identified life regrets for Americans involve their educational choices. Because educational choices have been consistently linked with life satisfaction, the accuracy of undergraduate perceptions of MHSPs merits more in-depth exploration.

Attending college can be a major life transition for students, accompanied by new pressures, stress, and surfacing mental health concerns. Most mental disorders are identifiable before or during the traditional college age of 18–24 (Kessler et al., 2005). According to the National Institute on Alcohol Abuse and Alcoholism (NIAAA, 2012), about four out of five college students consume alcohol. About half of the college students who drink partake in binge drinking. Around 25% of college students disclosed academic consequences because of their drinking (e.g., missing class, falling behind, performing poorly on assignments, receiving lower grades overall). These statistics indicate an increasing need for mental health and substance abuse counseling among college students. Universities provide a number of resources to their students, yet they are underutilized (Watkins, Hunt, & Eisenberg, 2012). Research focused on undergraduate perceptions of MHSPs could encourage more utilization of MHSP services, potentially motivate more students to join the MHSP workforce, and support a more accurate overall perception and portrayal of the effectiveness and competence of MHSPs. Since perceptions have been linked to help-seeking behaviors, a primary goal of the present study was to gain insight into how college students perceive the effectiveness of the various MHSPs.

Method

Participants

Data was collected from participants who were enrolled in a general psychology course at a private Midwestern university (N = 261). Participants were surveyed regarding their perceptions of MHSPs. The general psychology course provided a sample spanning a cross section of the university’s 100 academic majors.

Participants represented the freshman, sophomore, junior and senior class levels (M_age= 18.5; range = 17–55 years). Our study included 167 women (64%), 92 men (35%), and two participants that did not report gender (1%). The sample consisted primarily of Caucasian students (91%), while 9% were identified as ethnic minorities. Two participants opted out for undisclosed reasons. Participants reported home residences in 34 U.S. states (including 33% OH, 10% MI, 7% IN, and 6% PA).

Instruments

A self-administered questionnaire was developed for the present study in order to evaluate six MHSPs (e.g., for various clinical situations, source of knowledge, and characteristics). Participants were asked to respond to the following question: In general, what is your opinion about how overall effective each of the following MHSPs (counselors, MFTs, psychiatrists, psychiatric nurses, psychologists, and social workers) would be with helping a mental health client? Response options were based on a 4-point Likert-type scale: 1 (positive), 2 (neutral), 3 (negative), or 4 (unsure). The survey asked each participant to designate which MHSPs he or she would recommend for several clinical situations using a 3-point Likert-type scale: 1 (Yes, I would recommend this MHSP), 2 (No, I would not recommend this MHSP), or 3 (Not sure, not familiar with this MHSP). Participants also were asked to identify a source from which they had learned about the MHSP. A 3-point Likert-type scale was utilized to indicate if the source information was presented in a: 1 (positive), 2 (neutral), or 3 (negative) way. Lastly, participants categorized MHSPs based on the following: personal attributes (e.g., competent, intelligent/smart, and trustworthy); job-related activities (e.g., diagnose and treat mental and emotional disorders, and prescribe medication); requirements (e.g., can be in independent private practice, doctoral degree required to practice, and over-paid); or not familiar with MHSP.

Procedure

An initial pilot study was conducted in order to address and resolve ambiguities before the final survey was administered. A total of 12 students participated in the pilot survey; data obtained from the initial study were not included in the present research.

The survey was administered anonymously and was designed to take 20–25 minutes to complete. MHSPs were presented randomly throughout the survey as suggested by Sarafino’s (2005) protocols. IRB approval for the study was obtained prior to data collection and informed consent was obtained. Participants elected to complete, partially complete, or not complete the survey. The survey was administered during regular class time with no extra credit or other incentives awarded for participation, providing little chance for coercion.

Results

Analyses focused on participant perceptions of the overall effectiveness of MHSPs in working with a potential mental health consumer. The following is a ranked list of the MHSPs from most positive to least positive by the frequency of perceptions: counselors, psychologists, psychiatrists, MFTs, social workers, and psychiatric nurses. A visual comparison of participant responses is provided in Figure 1. The frequency of participants reporting negative perceptions ranked from highest to lowest in the following order: social workers, MFTs, psychiatric nurses, psychiatrists, counselors and psychologists.

When participants were asked to identify their opinions in regard to the overall effectiveness of each of the MHSPs in helping a mental health consumer, participants selected the “don’t know” option as follows: psychiatric nurses (17.6%),  MFTs (8.8%), psychiatrists (7.3%), psychologists (5.7%),social workers (4.2%), and counselors (3.1%).

Figure 1. Undergraduate perceptions of the overall effectiveness of MHSPs.

Since the same participants rated each of the MHSP categories, t-tests were used to compare category means as represented in Figure 2. As expected, the data suggests significant differences in perceptions of MHSPs’ overall effectiveness when comparing the means from each MHSP category. Perceptions of the overall effectiveness of MFTs (M = 1.63, SD = .703) were significantly more negative than the perceptions of the overall effectiveness of professional counselors (PC; M = 1.35, SD = .532); t (234) = 5.648, p < .001, as well as the overall effectiveness of psychologists (M = 1.40, SD = .539); t (226) = 4.05, p < .001. MFT overall effectiveness (M = 1.63, SD = .703) was perceived to be significantly more positive than psychiatric nurse overall effectiveness (M = 1.54, SD = .624); t (203) = 2.104, p < .05. Counselor overall effectiveness (M = 1.35, SD = .532) was perceived to be significantly more positive than psychiatrist overall effectiveness (M = 1.52, SD = .612); t (238) = –3.589, p < .001. Psychiatrists were perceived as less effective overall (M = 1.52, SD 612) than psychologists (M = 1.40, SD = .539); t (236) = 2.934, p <.01.

Figure 2. A comparison of the category means of the perceptions of overall effectiveness of MHSPs (lower scores are more positive).

Social workers received the highest percentage of unsure student responses (36.8%), followed closely by psychiatrists (36.4%), and MFTs (34.9%). These findings suggest the need for information and advocacy for these MHSPs in particular. Data from the present study also suggest that social workers have the highest amount of variance in participant responses (.520), while MFTs rank second (.486). For this study, variance is possibly an indication of misinformation and discrepant beliefs regarding the effectiveness of the MHSPs. Counselors had the least amount of variance (.281) when compared to the other MHSPs, suggesting that participants had more similar perceptions of counselor overall effectiveness when compared to the variance in perceptions of the other MHSPs.

Discussion

The U.S. Surgeon General’s 1999 report on mental health stated to the American people that “the efficacy of mental health treatment is well-documented,” and recommended to “seek help if you have a mental health problem or think you have symptoms of mental illness.” (U.S. Department of Health and Human Services (UDHHS; 2000, p. 13). The report further stipulated that stigmatization of mental illness is the greatest obstacle the United States faces in furthering the progress of individuals seeking mental health services (USDHHS, 2000). The present study highlights the need for the advocacy of MHSPs. Specifically, social workers, MFTs, and psychiatric nurses were perceived as significantly less effective overall than psychiatrists, counselors, and psychologists. This coincides with Consumer Reports’ 1994 Annual Questionnaire in which 4,000 subscribers who received some kind of mental health care between 1991 and 1994 responded to questions about their mental health care. This survey showed that participants were satisfied seeing social workers, psychologists, or psychiatrists (“Mental Health,” 1995). Those seeing a marriage and family therapist were slightly less satisfied (“Mental Health,” 1995). Overall, this report provided a positive recommendation to seek MHSPs for mental health issues.

Consumer Reports’ 2009 Annual Questionnaire once again queried its subscribers on the efficacy of mental health providers working specifically with depression and anxiety (“Depression & Anxiety,” 2010). This survey of 1,544 respondents, who had sought help for depression, anxiety, or other mental health problems between January 2006 and April 2009, found that psychologists, social workers, and licensed professional counselors were all equally helpful in providing relief for depression and anxiety (“Depression and Anxiety,” 2010).

Of concern from the present study is that for all MHSP categories, significant percentages of the participants reported a total absence of knowledge regarding MHSP overall effectiveness. This is one reason we recommend that counselors and counseling professional organizations (e.g., AMHCA, ACA, ACCA, CACREP, NBCC) increase their emphasis on professional advocacy.

In a broader sense, research regarding the methods through which people learn about MHSPs could identify more specific opportunities and venues for advocacy. The American College Counseling Association (ACCA) provides marketing strategy suggestions for reaching university faculty, staff, administrators and students: campus publications; campus television and radio shows; flyers posted around campus; e-mails; sponsoring anxiety, depression, and eating disorder screening days; table tents and banners in the cafeteria and student center; sponsoring career counseling week; guest speakers for classes and organizations; distributing brochures around campus; sponsorship and programming for Mental Health Awareness Month; developing mental health “theme of the month” campaigns; placing counseling advertisement kiosks in heavy traffic areas around campus; and hosting an open house (Mattox, 2000). These types of marketing actions are imperative and could be extended beyond university campuses. For example, public service announcements targeted toward specific consumers, mass media campaigns and the use of social networking for advocacy might be effective ways of reaching the increasingly tech-savvy generation. This approach could potentially be instrumental in decreasing the stigmatization of individuals who seek treatment for mental health-related issues and increase the awareness of services that are available.

The Council for Accreditation of Counseling & Related Education Programs (CACREP) could enhance activism for the helping professions by requiring students to demonstrate advocacy at both the master’s and doctoral levels. The American Counseling Association (ACA) and the American Mental Health Counselor’s Association (AMHCA) can direct ongoing advocacy efforts by increasing the ease of access to information related to the effectiveness of MHSPs for undergraduates. Counseling organizations can provide support for young professionals who are interested in joining the helping profession by empirically validating and improving perceptions of the overall effectiveness of MHSPs.

Limitations and Future Research

Future researchers are encouraged to explore the specific attitudes and perceptions that serve as barriers to the utilization of mental health treatment. Researchers should consider delineating therapeutic outcomes based on the specific type of provider (e.g., counselors, MFTs, psychiatrists, psychiatric nurses, psychologists, social workers). Of particular interest would be comparing the actual therapeutic outcomes of MHSPs to student perceptions of MHSP competence in treating specific mental disorders. The helping professions also could explore the perceptions of the overall effectiveness of MHSPs in comparison to those of primary care physicians.

Participants in the present study were not asked if they had received mental health services themselves. This is an important limitation to consider since perceptions of the effectiveness of MHSPs are likely influenced by firsthand experiences. In much the same way, a lack of familiarity or experience with MHSPs could potentially influence perceptions. The sources by which individuals learn about mental health–related issues could identify specific areas that can be utilized for advocating for the helping professions. For example, do people learn about mental health issues from movies, television, the Internet, commercials, newspapers, books, magazines, classes, friends, family members, firsthand experiences, or other sources? Is the information that individuals receive from these sources providing a foundation for accurate perceptions of the effectiveness of MHSPs? How do the attitudes founded on information from various sources influence help-seeking behavior? Research on these topics might provide further direction for professional advocacy.

Another limitation of the current study is that participants attended college in one geographical location. Though the participants represented 34 of the 50 states and spanned a wide range of academic majors, the results of the present study cannot be generalized to other types of institutions nationwide. All participants in this sample were undergraduate students, and therefore the results cannot be generalized to other populations. Confounding effects associated with the limitations of collecting data from a single university could be reduced by studying a larger and more nationally representative sample of private and public institutions or by comparing and contrasting results from various regions of the country. Perceptions of the general population should be explored for more generalizable results. On a final note, an important limitation of the present study is that only 9% of the participants identified themselves as ethnic minorities. We recommend further investigation of ethnic minority perceptions of MHSPs. Future studies also could focus on socioeconomic status, marital status, sexual orientation, age and gender as moderating variables.

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Ashley M. Ackerman is a graduate student at Wright State University. Richard A. Wantz, NCC, is a Professor of Counselor Education at Wright State University. Michael W. Firmin, NCC, is a Professor at Cedarville University. Dawn C. Poindexter is a graduate student at Wright State University. Amita L. Pujara, NCC, is an Adjunct Instructor at Wright State University and Life Therapist at South Community Behavioral Health Care, Inc. Correspondence can be addressed to Richard A. Wantz, Department of Human Services, College of Education and Human Services, 3640 Colonel Glenn Highway, 108V AL, Wright State University, Dayton, OH 45435-0001, richard.wantz@wright.edu.