The mental health and well-being of veterans has been and continues to be a primary concern and focal point for providers and policy-makers. Veterans, in particular those who have seen combat, have been found to have an elevated prevalence of mental health problems, most notably depression and posttraumatic stress disorder (PTSD)1-4. Veterans with mental health issues such as depression have also been found to have an exponentially higher suicide rate than that of the general population5. Despite efforts to assist veterans with mental health concerns, many veterans continue to go untreated and available healthcare resources are underutilized, resulting in untold costs to individuals, families and society6. New approaches are needed to help connect these veterans with mental health services and to prevent individuals from ‘slipping through the cracks’. In the current study, the researchers explored a novel approach to identify veterans at risk and refer them to formal systems of care. Specifically, bartenders at Veterans of Foreign Wars (VFW) posts were examined in terms of their perceived ability and potential to help veterans exhibiting symptoms of mental illness. The findings from this study are important, as VFW bartenders may be able to play a key health promotion role for veterans in need.
Veterans’ Mental Health
In 2009, it was reported that there were over 23 million veterans of the United States (US) military7. In terms of health, the concerns and needs of veterans are largely reflective of demographically similar groups in the general population; however, there are differences specific to the veteran population, most notably in terms of mental health. As previously mentioned, depression and PTSD have been found to be especially problematic for veterans1-4. Studies have found depression rates to be as high as double the rates for the general population2,8. PTSD rates have also been found to be significantly higher for veterans, particularly for those who were injured or who saw heavy combat 9,10. This pattern of elevated mental health problems in US veterans has also been found in certain groups of veterans internationally (e.g., Korean war veterans in Australia11), yet not in others (e.g., Dutch peacekeeping veterans12). This may be due to qualitative and contextual differences in the service experiences of these groups. Despite the disparities in these outcome studies, the trauma experienced by many veterans may place them at greater risk of mental health problems. The costs of these problems are widespread, including higher rates of suicide, poorer physical health, substance abuse, increased homelessness, and negative impacts on relationships and family life 13.
To serve the health needs of veterans, the Veterans Health Administration (VHA) has developed into the largest single provider of care in the US, serving an estimated 5.5 million veterans annually. In terms of mental health services, the VHA has identified PTSD, depression, and suicide as key foci and are in the process of developing comprehensive programs and services to address these problems, including inpatient and outpatient care, disease-specific services, psychotherapy, and individual and family counselling 14. While the VHA attempts to make programs accessible and to reach out to veterans in need, there is some evidence that veterans are not fully utilizing their benefits. In a self-reported, national survey, almost 22% of veterans indicated that they were not aware of their VHA benefits, 20% did not believe that they were eligible, and over 2% did not know how to apply for benefits6. While the VHA has transformed itself into a highly competent provider of health care, it is evident that additional steps are needed to ensure that veterans are aware of and are able to access their benefits.
The Gatekeeper Model and VFW Bartenders
Drawing from the literature on the gatekeeper model, there is some evidence that informal support systems and networks may have the capacity to link veterans with formal mental health services. The gatekeeper model was originally developed in the US in the 1970’s to organize and train non-professionals (e.g., mail carriers, hairstylists) to identify problematic situations for older adults and to refer them to formal service providers. The gatekeeper model is built around the notion that informal social exchange tends to happen more frequently than formal social exchange (e.g., doctors appointments), thereby placing informal social contacts in a better position to notice problems 15. Borrowing from attachment theory and the concept of interpersonal trust, individuals may find greater intimacy and sharing in their exchanges with individuals that they see on a regular basis and have built relationships over time 16,17. Research has largely supported the theoretical underpinnings of the gatekeeper model, as well as the effectiveness of community gatekeepers for older adults 18. Preliminary studies have also found that the gatekeeper model may be effective in suicide prevention in the workplace as well as veterans and their families 19,20.
In the current pilot study, the researchers explore a novel approach to identifying potential gatekeepers for the veteran population – VFW bartenders. The VFW is a non-profit organization that focuses on advocacy and service to veterans and their families. Most VFW posts also typically have designated clubs or halls that serve as areas for socialization and meetings and employ bartenders to serve their patrons21. In many respects, the VFW is similar to the Royal British Legion in the UK and the Returned and Services League of Australia. VFW bartenders, in particular, were the focus of the current study for several reasons. First, veterans are the primary patrons of these establishments. Second, bartenders have long been thought of as “a protean composite of counselor, psychiatrist, father confessor, advisor, and mediator (p. 93)”22. While anecdotal evidence exists supporting the notion of ‘bar-room therapy’, very little scholarly research has been conducted in this area. Only a few studies have moved beyond the problem of alcohol abuse and have examined bartenders’ roles as de facto psychosocial helpers and gatekeepers. These researchers found that bar patrons raised serious personal problems with bartenders who, in turn, typically reacted by listening and trying to be lighthearted. The bartenders also reported that they could be more effective if they were better equipped to deal with the problems presented by patrons23. This evidence begins to suggest that bartenders may play a role in helping patrons with their problems. However, questions remain in terms of bartenders’ perceived ability and potential to identify significant mental health issues and to link their patrons with mental health care professionals. In response to these questions, this pilot study had the following specific aims:
- To explore the helping relationships of VFW bartenders and their veteran patrons.
- To examine the degree to which VFW bartenders are able to recognize symptoms of two specific mental health issues in their veteran patrons – depression and PTSD.
- To gauge VFW bartenders’ knowledge of veterans’ services, their willingness to help veterans in need, and their interest in receiving additional training in mental health.
Sample Prior to sampling, the study received ‘exempt status’ (informed consent waived) from the university institutional review board. Sampling was a multi-step process in this study. First, 300 VFW posts were randomly selected from an internet directory of VFW posts located in the state of Ohio. Letters containing explanations of the study and survey forms were then mailed to each post. Since posts typically employ more than one bartender, multiple surveys were mailed to each post. As an incentive for participation, VFW posts were notified that four randomly selected participating posts would receive a donation of $50. Approximately 3 weeks after mailing the surveys, follow-up phone calls were made to those VFW posts that did not return surveys to determine the following:
(a) whether posts received the surveys; (b) whether posts requested that the surveys be re-sent; and (c) whether or not the posts actually had a bar. For those posts that did not receive the first mailing, a second mailing was sent. Of the 300 posts contacted, bartenders from 32 posts returned the surveys, 3 posts indicated that they did not have a bar, and 36 posts could not be reached by mail or phone (e.g., mail returned to sender, phone numbers not listed). Excluding those posts that did not have a bar and those posts that could not be reached, the overall post participation rate was approximately 12.3% (32 participating posts out of 261 eligible posts). Since some posts returned multiple surveys, the final sample consisted of seventy-one VFW bartenders (N = 71) working in 32 VFW posts.
As this was an exploratory pilot study, the measures developed and utilized were simple and probing in nature. The survey instrument consisted of 16 items and one open-ended question designed to gauge the following (for the complete questionnaire, see Appendix A): Demographic characteristics – Bartenders were asked to provide their age, gender, race/ethnicity, education level, length of employment at the VFW, and whether or not they had ever received formal training in counselling or mental health.
Relationships and roles – Bartenders were asked to describe the closeness of their relationships with the veterans and the types of roles that they play in the lives of the veterans (e.g., friend, like family, stranger).
Veterans’ problems – Bartenders were asked about the frequency with which they perceived veterans would share their problems, as well as the types of problems that they shared (e.g., family, work, physical). This typology of problems was derived from previous studies of bartenders 23.
Ability to recognize problems – Bartenders were asked about their self-reported ability to recognize symptoms of two mental health issues that have been found to be problematic in the veteran population: depression and PTSD. Responses were grouped as low (1-3), moderate (4-7), and high (8-10).
Helping responses – Bartenders were asked to identify the types of helping responses and techniques that they employed when veterans shared their problems. Responses included, for example, offering support and sympathy, listening to their problems, giving advice. This typology was derived from previous studies of bartenders 23. Veterans’ services – Three final items asked bartenders if they were familiar with veterans’ programs and services, whether they would be willing to refer veterans to VA services, and whether they would be interested in participating in training programs to augment their helping abilities.
Additional information – A final open ended question provided bartenders with an opportunity to share more about their experiences of working with veterans.
The exploratory nature of this study and the simplicity of the measures dictated that the researchers would only run basic level analyses on the quantitative data. SPSS 17.0 software was used to generate descriptive statistics and frequencies to help illustrate the helping behaviors and potential of VFW bartenders and their veteran patrons. The qualitative data obtained from the final open-ended question was examined for thematic content and used in an auxiliary, illustrative fashion in discussing the quantitative findings from this study 24.
The final sample consisted of 71 (N = 71) bartenders working in 32 VFW posts from across the state of Ohio. Bartenders were typically middle age (75.7% age 31-60), White (100%), women (88.7%) who were educated at the high school (or equivalent) level (57.7%) and had been working as bartenders at the VFW for an average of almost 7 years (M = 6.8; SD = 6.7 years). In terms of mental health training, 89.7% reported that they had not received any formal training in this area. Bartenders reported that they were either close (54.3%) or very close (18.6%) to their veteran patrons and typically felt that their relationships were that of friend (88.7%) or family (73.2%). Veterans reportedly shared their problems with bartenders often (54.95%) and these problems were primarily related to family (88.7%), physical (81.7%), or work (74.6%) issues. In reaction to these problems, bartenders predominantly used three basic responses: offering sympathy and support (88.7%); trying to cheer up the veterans (80.3%); or simply listening as the veterans expressed their concerns and issues (73.2%). Bartenders indicated that they were only moderately able to identify symptoms of depression (65.7% moderate ability) and far less able to identify symptoms of PTSD (42.9% low ability; 42.8% moderate ability). While an overwhelming majority of bartenders (80.6%) were willing to refer their veteran patrons to the VA, 20.3% were not familiar and only 36.2% were somewhat familiar with the services offered to veterans in their community. When asked whether they would be interested in additional training to help them recognize problems in their veteran patrons, 59.7% of the bartenders responded in the affirmative.
In popular culture, bartenders have often been depicted and thought of as confidants and counsellors to patrons seeking company, comfort, and advice over a drink. In this study, we examined the degree to which this depiction is accurate in terms of relationships between VFW bartenders and their veteran patrons and the ability of bartenders to assist veterans with mental health issues. Bartenders were found to have close, family-like relationships with the veteran patrons and responded in empathic, supportive ways when veterans shared their problems. While bartenders’ perceived ability to recognize problems varied and their knowledge of services was limited, they appeared to be personally interested in helping their veteran patrons and may be in an ideal position to serve as gatekeepers to the VHA healthcare system. These findings are reflective of anecdotal evidence and the limited empirical findings that exist regarding the helping roles and capacities of bartenders in general public settings 23. The findings from this study are primarily descriptive in nature and, as such, tend to be self-explanatory. In this discussion, we will focus on certain characteristics of the VFW that differentiate this setting from general public settings and discuss the potential gatekeeping or liaison role that these bartenders may play in connecting veterans with community mental health services.
Three unique characteristics support the idea that VFW bartenders have the capacity to connect veterans to necessary mental healthcare services. First, many of the VFW bartenders in this study had worked in their clubs for many years (M = 6.8 years) which allowed them to establish long-term, close relationships with their veteran patrons. As one bartender stated, “It’s not just a job here; it is a second home with an extended family.” This notion of “family” carries through in bartenders’ willingness and desire to help the veterans. Another bartender remarked, “It’s a very personal, small community, and people take care of each other.” This private club atmosphere may be quite different from bars in the community where both staff and patrons come and go with greater frequency. The environment of VFW posts and the closeness of the relationships between VFW bartenders and their veteran patrons form a natural helping environment where veterans can share problems and bartenders can direct them to professional help 25.
Second, the veterans who frequent VFW clubs have common experiences and access to a common system of care and support. This is much different from bar patrons in the general public area. VFW members have all served in foreign military conflicts and, as such, they may share some of the ramifications of their service, such as mental health issues. Veterans also have access to the VHA health care system, which again differentiates this group from the general public arena. These factors are critical in understanding how VFW bartenders can help this group. It would be impractical to expect bartenders in the general public arena to understand the myriad of mental health problems faced by patrons off the street and to understand the many health care systems available in the community. VFW bartenders, on the other hand, could realistically be expected to learn about the specific mental health issues facing veterans (e.g., depression, PTSD), as well as the services and programs offered by the VHA.
Finally, VFW bartenders work under the umbrella of one central organization. This again differentiates them from bartenders in the general public area. While researchers can suggest that all bartenders receive training in mental health, there is little in terms of organizational support to mandate such training. The VFW organization, on the contrary, is a national entity that can dictate policy to the state VFW organizations and their posts. This factor supports the idea of a national training program for all VFW bartenders. The findings from the present study also lend preliminary support for such training, as the majority of VFW bartenders indicated that they were not very familiar with the programs and services offered through the VHA, yet they were interested in receiving additional training on the problems faced by veterans and the resources available to them.
As in the training of any layperson concerning health and mental health, caution should be taken to ensure that bartenders do not overstep their role. Diagnosing a person with depression or PTSD is a difficult task and should only be undertaken by trained health professionals. The findings from the present study do not suggest that bartenders could or should serve as professional counsellors; rather, they should be viewed as potential gatekeepers to formal helping systems such as the VA and the VHA. This point should be vehemently stressed in any training program for laypersons and reinforced periodically through refresher trainings.
There are several limitations to consider in understanding and applying the findings from this pilot study. First, the response rate to the survey was relatively low, with only 12.3% of contacted VFW posts responding. This may have resulted in a degree of response bias. VFW bartenders who were most interested in helping their clients may have been more likely to respond to the survey. The resulting sample was also quite small and homogeneous in terms of geographic location and race. This limits our ability to generalize these findings to more diverse populations. In addition, the measures used in this study were solely descriptive and rather simple in nature. In the future, researchers should consider more complex measures to build on the findings of the present study. Finally, this study focused on bartenders who, quite obviously, serve alcohol. Substance abuse has been reported as another significant health issue for veterans 26. It may be contradictory to expect bartenders to respond to depression and PTSD as they may be concurrently facilitating substance misuse and abuse. On the other hand, veterans may be more likely to share their problems, issues, and concerns in this setting. Mental health care providers may need to adopt a strategy of meeting clients “where they are”, similar to outreach programs that have been found to be effective in locating and serving homeless veteran populations.
VFW posts provide veterans with opportunities to find camaraderie, receive social support, and continue their service to others. Within this environment, VFW bartenders appear to play an important role in listening to and potentially helping with the problems presented by their veteran patrons. The findings from this pilot study suggest that VFW bartenders may have the capacity to be more effective in assisting veterans with mental health concerns by linking them to mental health care services, such as those offered through the VHA. The development and implementation of simple, cost-effective training programs may hold the key to maximizing the helping abilities of VFW bartenders. With such training and support, VFW bartenders have the potential to help find ‘healing tonics’ for veterans – more powerful than any drink in the bar.