V. Karamanoli, K. Papachristopoulos
Background: Seeking mental help in military contexts seems to be the last choice for those who have psychological problems among military personnel. Personal and interpersonal factors are associated with the perception of stigma concerning seeking mental help, especially in the military, and research on potential barriers regarding the search for psychological help can provide useful conclusions for military services.
Purpose: The present research aims, by utilising Social Representation Theory, sought to capture military trainees’ different levels of concepts and constructs relating to the search for psychological support in the military.
Material and Methods: Participants, military trainees (N= 143) recorded their free associations concerning psychological help and the data provided were analysed according to the structural analysis model of social representation. Data analysis was conducted by utilising the content analysis method, and the corresponding criteria of frequency and rank of appearance.
Results: The central core that emerged by the social representation fell into the following categories: a) problems that military personnel face in the military environment, or outside it, and possibly leading to psychological problems and b) the efficacy of psychological support to members of the military services .
Conclusions: a) the structure of social representation differs based on the role and hierarchy of military personnel, b) the lack of military virtues appears to be a component of the social representation at different levels based on the military hierarchical thesis, c) Stigmatisation of the search for psychological support in the military is a component of the periphery. These results can provide concrete suggestions for psychological
services in the military.
Keywords: military personnel, stigma, psychological help
Introduction
Military personnel undertake duties with high risks which might often cause exposure to traumatic stimuli1 and are associated with mental
health problems affecting a person’s occupational functioning and the organization’s performance.2 Although military personnel are at high risk of
mental health problems, research findings indicate that military personnel and veterans do not seek needed mental health care since stigmatizing beliefs about seeking help for mental health problems are commonplace among military personnel.3,4 Holding such beliefs may influence the decision to seek help, particularly when social position and relationships with colleagues may be adversely affected.5 Thus, it is critical for the research of military psychology to identify factors that interfere with the use of mental health services for this population, and where possible, intervene to reduce barriers to care.
Military services members tend to refrain from seeking psychological help as in this way they manage to avoid being characterized as ill and feeling
embarrassed.6 Military personnel and veterans, even if they suffer from psychological problems, do not seek help7, since seeking mental help on several occasions seems to be the last choice for those who have psychological problems in the army.8 According to research only a percentage of 38-45% of the military personnel and marines who scored high on indication of mental difficulty exhibited willingness to seek mental help.9
Military personnel often have a self-perception of an elevated sense of power and by experiencing symptoms of mental discomfort and mental disorder they may frequently be associated with a sense of weakness and emotions of shame.10 Research has illustrated an important mediation concerning public stigma and the willingness to seek help. It is self-stigma that might mediate the relationship between perceived public stigma and attitudes toward seeking help as well as a willingness to seek help.11 Public stigma affects the decision to seek help and may have as much or more to do with the internalisation of societal messages about what it means to be mentally ill12 or to seek psychological services. According to Vogel the internalisation can lead to shame and loss of self-esteem13, and the attempt to avoid those feelings may have the most direct effect on individual attitudes toward and willingness to seek counselling.11 Research has shown a significant relationship between shame and avoiding treatment.6 Participants who expressed a sense of shame from personal experiences with mental illness were less likely to be involved in treatment while family shame was also a significant predictor of treatment avoidance in the same study.14 Social representations of mental illness could influence and reduce the image of self, self-esteem and the perception of self-efficacy.15,6,16
One of the major obstacles related to reluctance of seeking mental help is a perception of stigma, which is defined as “a barrier that discourages individuals and their families from seeking help”.17 A longstanding stigma associated with having mental health problems is particularly strong and makes addressing mental health issues more difficult for people in the military culture. We need to underline the fact that personnel wishing to pursue a military career face additional restraints for fear of being taxed with having a mental health problem that could impede career progress and with lacking confidentiality.18
Three key contexts that promote stigma can be delineated: institutional, public, and self. Institutional stigma has been defined as arising from the “policies of private and governmental institutions” that either intentionally or unintentionally “restrict opportunities [and] hinder the options of people with mental illness”.19 Public stigma reflects the knowledge, attitudes, and beliefs about mental health treatment and the prejudicial and discriminatory behaviours described above, coming from friends, family, coworkers and the public. Public stigma for seeking mental help is associated with the perception that the person who seeks help is undesirable20, or that he/she is perceived as “crazy” . Together, the institutional and public contexts make up the broader military context. Self-stigma is most commonly defined as the “internalisation of public stigma” and was often associated with a “loss of self-esteem and self-efficacy”.21 Recent research suggests that stigma at the individual level mediates the relationship between negative attitudes, beliefs, and behaviours of the public and attitudes toward and intentions to seek help and treatment22,23 and
other research suggests that women are more likely to seek professional help than men.1
This research aims to study the social representations for different categories of military personnel to whom psychological support applies (soldiers in the unit, trainees in the military school, military officers). The method is the structural approach of social representation as developed by Vergès.24 Social representations which permit the apprehension and interpretation of social reality25, are collectively constructed consensual forms of thinking, shared by the members of a social group.26,27 According to Abric28 social representations are cognitive organizations. Rouquette & Rateau consider social representations as sub-systems of a wider ideological system which can define other narrower sub-systems like attitudes.29
Social representation theory maintains that social psychological phenomena and processes can only be properly understood if they are seen as
being embedded in historical, cultural and macro social conditions. A social representation can be conceptualised as a system of values, ideas and
practices that function as the means to establish an order which will enable individuals to orient themselves in their material and social world and to
enable them to communicate.30 The concept of social representation can be seen as a tool for studying the “organisation of common knowledge”31 with words as indicators and two components are integrated into the representation: a cognitive and a social one.32 Social Representation research attempts to overcome the shortcomings of those currently widespread theories and approaches in social psychology which are based on methodological individualism and on an epistemology which functionally separates the subject from the object.33Thus, social representation
researchers observe talk and action which is related to a social phenomenon or object and contrary to social cognitive approaches, it is presupposed that an object is social not by virtue of some immanent characteristics, but by virtue of the way people relate to it. Hence, according to Moscovici, subject and object are not regarded as functionally separate but a person or a group behaviour puts the object in the context of the subject’s activity.30 In other words, for an object to figure in a group’s world, i.e. to be an object for a group, it must be socially represented. As a consequence, social representation theory is a social constructivist as well as a discursively oriented approach.34
Given the above theoretical background, the present study is aimed to capture the thought of military trainees about seeking psychological support in the military. Precisely, the study aims to investigate the presence of representational differences concerning a) a soldiers’ seeking of psychological
support in the unit, b) military trainees’ seeking psychological support in military school, c) military officers’ seeking psychological support. The main
research questions focus on the core element of social representations concerning psychological help in the army and potential differences on how
military students conceptualise psychological help on different contexts (soldiers in the unit, trainees in the military school, military officers).
Hypotheses
H1. The structure of military trainees’ social representation concerning the search for psychological support in the military could be different depending on the role, the level of the hierarchy, the responsibilities of military personnel and the duties of the military personnel. H2. Lack of military virtues, which constitute the core of military identity, is expected to differ according to the military personnel that constitute the object of
the representations. H3. Although seeking psychological support should be associated with Stigmatisation, military personnel don’t refer to it and therefore it is not expected to be included in the central core of the representations.
Methodology
Participants
Participants were 143 military male students from Greece (Ν=143) randomly selected, aged 18-21 years old. Thirty seven of the participants aged 18 years old were students of the 1st year (25.7%), 36 of them aged 19 years old studying at the 2nd year (25%), 33 of them aged 20 years old studying at the 3rd year (23%), and 38 of them were aged 20 years old studying at the 4th year (26.4%).
Initially, an official consent about research procedure was delivered as provided. The data regarding military trainees’ representation of seeking
psychological help in the military for three groups (military trainees, soldiers in the unit and military officers) were collected using the method of free
associations according to the structural model of the representation.24 Participants were instructed in Greek to write down the first three words that come to mind when hearing the following phrases:
“Psychological support in the unit”, b) “Psychological support in a military school”, c) “Psychological support for military officers”.
Data analysis was conducted based on the method of content analysis which allows the categorization and the quantification of participant’s free association.35,36 A system of categories was developed following the criteria of exhaustive, exclusiveness, homogeneity, objectivity, fidelity, competence, productivity. Two researchers, separately and simultaneously, developed a categories’ system in order to adhere to the criteria of objectivity. These two categorisation systems were compared with each other and a joint way was commonly decided.
A system of 10 categories was developed in Greek for all three following representations: i) problems (difficulty, pressure, financial problems, personal
problems etc.), ii) emotions (homesickness, melancholy, loneliness, stress, monotony, fear etc.), iii) positive evaluation and results (help, useful, necessary) iv) lack of military virtues (weakness, lack of adjustment, impotence, etc.), v) stigma and consequences (stigmatising, taboo, marginalisation, devaluation etc.), vi) mental illness (crazy, madness, mentally ill etc.), vii) psychological terminology (psychology, doctor, medications etc.), viii) devaluation of mental health service (useless, flavourless, strange, symbolic etc.), ix) military terminology (unit, soldiers, commander, military, viewpoint etc.), x) process of psychological help (dialogue, communication, questions, support etc.), xi) other (unknown, perhaps, coexistence etc.). Afterwards the data and the categories were translated into English and a bilingual researcher translated them vice versa in order to confirm the accuracy of translation.
After content analysis was conducted, we proceeded to a structural approach of military trainees’ social representations of “psychological help”: a) to soldiers in the unit, b) to trainees in the military school, and c) to military officers” by applying Vergès’s method.24
This specific method relies on the juxtaposition of two criteria: a) the frequency of the specific category, and b) the rank of its appearance, indicating that a word belonging to a specific category is the 1st, 2nd, or the 3rd association proposed, so the important and salient elements of the examined representations are identified. The mean frequency and the mean rank of appearance were calculated. All categories with a frequency higher than the mean frequency are regarded as major elements of the representation. All categories with a rank of appearance lower than the mean rank are regarded as strong elements. The categories were then cross-tabulated in a 2×2 matrix. In the top left cell the elements of both high frequency and strong rank of appearance are presented. Those elements compose the central core of the examined representations. The bottom right cell includes rare
elements of high rank and identifies the peripheral elements of the representation. In the top right cell the elements of high frequency are presented and low rank in the bottom left cell present the elements of low frequency and high rank of appearance, which indicate the dynamic zone of the representation that is, the zone susceptible to change and evolution.
Results
Structure analysis of participants’ free associations on the three themes proposed by the research led to three tables which indicated` the core, the periphery and the dynamic zone of the military trainees’ representation about psychological support in the military.
In respect of the psychological support provided to soldiers in the unit positive evaluation of mental health service and results, problems and lack of
military virtues compose the central core of the social representation (see table 1). More precisely, the category of positive evaluation of mental health
service that was represented by words such as help, very good help, support, correct, excellent, necessary was found to be the most frequent (141) and the strongest (1.67) category of this representation. The category problems represented by words such as oppression, difficulty, problems, tiredness, compulsion is frequent (64) and strong (1.85). Also the category lack of military virtues represented by the words impotence, unsuitability, shirker, lack of adjustment, is frequent (41) and quite strong (1.90).
Stigmatisation and consequences are found to be in the periphery of the social representation “psychological support for soldiers in the unit” as
well as the categories named “devaluation of mental health service”, “military terminology”, “emotions”,
Table 1: Military trainees’ representation of psychological support in the unit: stigma is considered as a narrow category
(N=143)
TABLE CAN BE VIEWED IN FULL DOWNLOAD
“process of psychological support”, and “psychological terminology”. More precisely the category of Stigmatisation and consequences represented by the words humiliating, taboo, stigmatised, discrimination is not so frequent (12) and seems to be weak (1.97). As far as the category of psychological terminology is concerned, it is represented by the words psychology, doctor, phone line, psychologist, psychiatry, is more rare (10) and weak (1.98). Words like useless, symbolic, waste of time, waste of money are included in the category devaluation of mental health service 34 times with mean rank 1.92. Words like unit, soldiers, hazing, military, order, commander, service of soldier, duty, lieutenant, outpost, viewpoint, captain, are composing the category military terminology 34 times with 1.92 mean rank of appearance. Words like disappointment, pain, melancholy, stress, shame, bitterness, loneliness, represent the category emotions 20 times with 1.95 mean rank of appearance. Words like dialogue, trust, questions are representing the
category process of psychological help 23 times with 1.95 mean rank of appearance. Finally, words like mentally ill, mental illness, crazy, craziness represent the category mental illness 14 times with 1.97 mean rank of appearance. A remarkable comment to be made is that social representation’s dynamic zone has no elements, a sign of the stability of the social representation.
Results concerning military trainees’ social representation about psychological support in military schools attest that the central core of the
social representation is composed of items belonging to the categories positive evaluation and results, difficulty, psychological terminology, devaluation of mental health service (see table 2). The category of positive evaluation and results of psychological support in military school includes words such as improvement, solution, mental recovery etc. which are both most frequent (109) and most strong (1.75) and therefore constitute the central core of the representation, along with the category difficulty which has high frequency (48) and low rank of appearance (1.89) including words such as problems, difficulties, deadlock, pressure, oppression etc. Moreover, categories psychological terminology and devaluation of mental health service are constituent elements of the central core with relatively high frequency (43) and the same rank of appearance (1.90). This category is composed by words such as doctor, psychologist, psychiatrist, sanatorium, psychoanalysis, line of psychological support and words concerning their psychology lectures: names of teachers, professors, lessons, lectures, methodology.
The remaining categories appear in the periphery, namely lack of military virtues, mental illness, emotions, stigma and consequences, process of
psychological help and military terminology, in a way that no dynamic zone is recorded in this social
Table 2: Military trainees’ representation of psychological support in the military school: stigma is considered as a
narrow category (N=143)
TABLE CAN BE VIEWED IN FULL DOWNLOAD
representation. More precisely, lack of military virtues (frequency:32, rank of appearance 1.93) appear in the representation with words such as: lack of durability, unsuitability, lack of confidence, lack of adjustment, weak, weakness, useless, giotas (meaning without military qualifications), collapse etc. While mental illness (frequency: 28, rank of appearance 1.94) appear with words like ill, illness, hospital, crazy, mad etc. Emotions (frequency: 25, rank of appearance 1.94) are represented with words such as: homesickness, pain, fear, stress, love, compassion, insecurity, sadness etc. Stigma and consequences (frequency: 22, rank of appearance 1.95) are represented in the representation by words like taboo, ridicule, marginalisation, discrimination, expulsion etc. Process of psychological help (frequency: 21, rank of appearance 1.95) is presented in the representation by words like discussion, communication, honesty, questions, interview, optional etc. Finally, military terminology (frequency: 15, rank of appearance 1.97)
is represented by words like military, BSE (meaning basic military education), ASEI (meaning high military schools), 414 (meaning military psychiatric clinic), war, class of command, aces (meaning students in the first class). It is interesting that no dynamic zone is observed in this representation and the stability of this representation could be interpreted with consideration of the stability of their opinion about themselves and their abilities.
Results indicate that the central core of trainees’ social representation about psychological support for military officers is composed by the following categories: a) positive evaluation and results (frequency: 152, rank of appearance 1.65) with words like improvement, relief, support, positive, effective etc., b) problems (frequency: 70, rank of appearance 1.84) with words helpless, duty, responsibilities, career, tiredness etc. Dynamic zone is composed by categories a) emotions (frequency: 37, rank of appearance 1.91) (i.e pressure, stress, despair, indignation, compassion) and b) lack of military virtues (i.e. failure, weakness, unmilitary, impotence/ frequency: 27, rank of appearance 1.95). The periphery of the social representation is composed by the following categories: a) devaluation of mental health services (frequency: 35, rank of appearance 1.92) with words such as unnecessary, ridiculous, funny, mockery etc., b) mental illness (frequency: 20, rank of appearance 1.95) with words like complex, mad, crazy etc., c) psychological terminology (frequency: 13, rank of appearance 1.98) with words like psychology, psychologist, psychiatrist, medicine etc. d) stigma and consequences (frequency: 11, rank of appearance 1.97) with words like taboo, discrimination, stigmatised, disgrace etc., e) process
of psychological support (frequency: 8, rank of appearance 1.98) with words like free psychologist, confidence etc., and f) military terminology
(frequency: 6, rank of appearance 1.99) with words like lieutenants, officers, free of duty etc. (see table 3).
Discussion
Empirical knowledge of mental health–related beliefs that serve as barriers to mental health service use is critical to inform ongoing efforts to reduce
Table 3: Military trainees’ representation of psychological support for military officers: stigma is considered as a narrow
category (N=143)
TABLE CAN BE VIEWED IN FULL DOWNLOAD
barriers to care within military personnel. According to the results of this research the central core of military trainees’ social representation about the
psychological support in military environment falls into the categories: a) problems that military personnel face inside or outside the military environment, and may cause psychological problems and b) efficacy of psychological support in the military.
It is observed that within the central core of the social representation appear not only the problems that may lead someone to seek psychological help,
but also the positive evaluation and the results of the mental health service in the military for all three populations surveyed. The acknowledgment of
mental health’s service value by putting the category of positive evaluation of mental health service and the results represented by words like help, very good help, support, correct, excellent, necessary is a very interesting result and seems congruent with the results of previous research which indicates that military personnel’s burden of seeking psychological support is fear of self and public stigma.3 Nevertheless, recognition of mental health services’ efficacy fully mediates the relationship between fear of stigma and attitude towards the seeking of mental help.3
The central core of military trainees’ representation for psychological help in the military school includes notions related to devaluation of mental health services. This result, along with the presence in the central core of the notions related to recognition of mental health services’s efficacy create an obvious contradiction. It seems that military trainees may conceptualize seeking psychological help as a sign of military disability during their ongoing development of “new” social identity as military personnel.
They are trained under high pressure to enhance their psychological hardiness but this process is not yet completed, thus creating a contradiction
about military virtue of strength and the reality of several problems to be transcended. Hence, the representation of a useless service of psychological
support may help them to strengthen their military identity. They may believe that psychological support is not connected to military virtues since it is a common belief among them that problems they are confronted with are part of their reality trying to be strong and militarised.
Congruent to the interpretation that the representation of military trainees is related to their military identity is the fact that the category lack of
military virtues belongs to the central core for the soldiers seeking psychological support, who have less military education compared to military trainees and they are not prepared to be military personnel, so they are not militarised enough. In addition, the fact that in the category lack of military virtues is found to be the dynamic zone of the social representation concerning officers’ seeking psychological support, and could be interpreted as a sign of military incompetence for an officer.
An interesting result is that mental illness which in the past was the main reason for someone to seek psychological support, in the representation for
military personnel who seek psychological support is presented in the periphery of all three military populations. It forces us to reconsider the main role that the military environment plays and potentially the importance that other elements have in such an environment (i.e. lack of military virtues).
Items indicating devaluation of mental health services are in the periphery for soldiers and officers. These results about differentiation of the structure
of social representation depends on the role of military personnel to confirm the 1st hypothesis of the study. The main conclusions derived by this contradiction are that: a) the acceptance that adjustment to military environment is difficult and any member of the staff could utilise psychological
help in order to handle this situation, b) military trainees could more easily accept that other military personnel should need psychological help but not themselves. This conclusion is drawn since category “devaluation of mental health services” is recorded in the central core of the representation about seeking psychological support in the military school. Images of self-perception of power, of capability to confront and cope with all the problems on their own, of high self-esteem and high self-confidence that build the image of the capable military official may mediate this representation.
Lack of military virtues is a) in the central core for soldiers who seek psychological support in the unit, b) in the dynamic zone for officers who seek
psychological support, and c) in the periphery for military trainees. It is obvious that lack of military virtues differs according to the military personnel and which consist of the object of the representations, confirming our 2nd hypothesis.
Stigmatisation is presented in the periphery for all three categories, as expected, since stigma as a notion is not very popular in military personnel,
confirming the third (3rd) hypothesis of this study. This common indication for all three representations makes us believe that this result should be
investigated in future research by considering the content of military stigma concerning those seeking psychological support and not only its
representation. It would be interesting to investigate the causes of stigma, its frequency, its correlation with other personality or emotional variables, such as narcissism, obsession, anxiety, optimism etc.
The limitations of this study are that: a) participants were only military trainees, thus the results may not be generalized to all service members in Greece, so it would be useful for future research to be addressed to other military personnel also, b) the way the questions of the free association were structured couldn’t produce results that clearly concern the image of the person who seeks psychological help in the military. Perhaps future research should illustrate issues of self-stigma representations which could involve issues of self-image, self-esteem and the perception of self-efficacy which are very important in military training. Also a variable that could influence representation of participants seeking psychological support in the military environment could be the hypothesis of the social desirability about the military personnels capacities to grapple on their own with
any difficulty, so it would be interesting to clarify this aspect in the future. In addition, future studies could look at a) the way that military personnel’s
social identity influences the representation of ingroup or out-group identity and b) the intention of seeking psychological support at different levels of military personnel.
