Many Shades of Green: Assessing Awareness of Differences in Mental Health Care Needs Among Subpopulations of Military Veterans

Abstract

The current study sought to examine access to services by various veteran subgroups: racial/ethnic minorities, females, rural populations, and LGBTQ (Lesbian, Gay, Bisexual, Transgender, and Queer). Generally, the Veteran Service Officers (VSOs) interviewed for this study did not feel that these subgroups were well served by the program and treatment options presently available, and that other groups such as males and urban veterans received better access to necessary psychosocial and medical care. This research extends studies that explore overall connection to services by further demonstrating barriers to receipt of services by specific subgroups of veterans, particularly those at risk for involvement in the criminal justice system.

Keywords

veterans mental health care minority populations LGBTQ rural veterans

Introduction

An old adage among military veterans holds that “all veterans are green.” This phrase is intended to convey the deep bond among military personnel that transcends demographic characteristics. However, the variety in shades of green within the veteran spectrum is becoming increasingly pronounced. Although the overall veteran population is decreasing, multiple subpopulations of veterans are increasing by sheer numbers and by visibility through growing awareness (Veterans Affairs, 2016). Specifically, the shades of diversity within the veteran community are appearing in greater relief with respect to race, ethnicity, gender, sexual orientation, and geographic dispersion (Kirby, Thie, Naftel, & Adelson, 2010; Veterans Affairs, 2016). However, regardless of what shades of green may best be assigned to a given veteran, one homogenizing factor remains: A notable percentage of veterans are at high risk for social and mental health problems, and the majority of veterans who return from deployment experience some level of difficulty reintegrating to family and social life (Begić & Jokić-Begić, 2001; Belanger et al., 2011; Jacobson et al., 2008; Jakupcak et al., 2007; Silver, McAllister, & Arciniegas, 2009; Wheeler, 2007). The growing diversity of the veteran population is relevant to the development of responses to these psychosocial and health care needs because different subgroups have disparate proclivities to accessing care, differing degrees of need, various levels of resiliency, and distinct recovery experiences.

Simultaneously, the treatment community is underequipped to respond to justice-involved veterans’ psychosocial needs (Priester et al., 2016), and many veterans do not seek Veterans Health Administration (VHA) services (Vaughan, Schell, Tanielian, Jaycox, & Marshall, 2014). The growing diversity among veterans exacerbates problems with access to culturally informed care (Saha, Beach, & Cooper, 2008), which may compromise the quality of treatment and may adversely impact some veterans’ motivation to seek help (Flores, Gee, & Kastner, 2000). Although Blonigen and colleagues (2016) find that veterans generally have access to services that address the risk-need-responsivity (R-N-R) model often used to guide offender rehabilitation (see Bonta & Andrews, 2007), it is not known whether access is equally attainable and culturally appropriate to subgroups of veterans, or whether those in a position to advocate for services on behalf of veterans accurately perceive their needs. The concurrence of veterans’ psychosocial and mental health care needs and obstacles to care places certain veterans at higher risk for involvement in the criminal justice system, further stressing the need for services (Blodgett, Fuh, Maisel, & Midboe, 2013; Boivin, 1987; Greenberg, Rosenheck, & Desai, 2007; Hafemeister & Stockey, 2010; Orth & Wieland, 2006; Shaw, Churchill, Noyes, & Loeffelhoz, 1987).

In the current study, we examine Pennsylvania veterans’ access to mental health care through the lens of Veteran Service Officers (VSOs). Pennsylvania is home to one of the largest veteran populations in the United States and hosts robust, three-tiered VSO programs. VSOs at the state, county, and nonprofit levels serve as liaisons between veterans and health care and share a common mission to maximize veterans’ access to the benefits and services they need. We assess state, county, and local VSOs’ awareness of veterans’ needs across a diverse spectrum of veteran subgroup demographics and what preconceptions may influence those perceptions. We propose that culturally competent VSOs could more readily help veterans overcome impediments to mental health care and serve as role models for social service providers in other fields. Finally, we suggest that increasing awareness of the shades of green within the veteran community can help level the landscape for more veterans as they navigate the often challenging terrain of mental health care which, in turn, may reduce their risk of involvement with the criminal justice system.

Prior Research on Veteran Access to Treatment

A growing body of research examines the extent to which racial/ethnic minorities, women, rural inhabitants, and persons who identify as Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ) have distinct experiences with respect to the onset of mental health symptoms, access to care, and the treatment they seek for their mental health concerns. Veterans are all “green” in the sense that they share a common identity after they have worn the cloth of the Nation in its defense. But the nuances of that identity and the gradation of green derive from more than veteran status. Veteran life, and the inextricably related veteran experience with health care, depends in large part on demographic characteristics other than military service. Veterans’ race/ethnicity, gender, geographic residence, sexual orientation, and prior life experiences shade their identity as a veteran in ways that impact their interactions with veterans’ benefits, most notably mental health care. Subgroups of veterans face different hurdles to appropriate care, and understanding the different needs and experiences of those subgroups can inform the campaign to address the various treatment needs of veterans in a culturally competent way.

Racial and Ethnic Minorities

As of 2013, minorities comprised 21% of the total veteran population. Their numbers are expected to grow significantly over the next 30 years, despite projections that the overall veteran population will decrease by almost half by 2043 (National Center for Veterans Analysis and Statistics [NCVAS], 2014). Not only are the numbers of minority veterans on the rise; in general, African American and Hispanic veterans are more likely than their White counterparts to report poor health (Villa, Harada, Washington, Damron-Rodriguez, 2003). As a group, Hispanic veterans have higher instances of posttraumatic stress (PTS) than White veterans,¹ yet they have lower rates of accessing care and greater barriers to receiving treatment (see Duke, Moore, & Ames, 2011; Loo, Fairbank, & Chemtob, 2005). For reasons that are not clear, Hispanics are more likely than other service personnel to be misdiagnosed. Manifestations of PTS, such as back or stomach pains, are more likely to be attributed by Hispanics than by others to physical, and not psychological, ailments (Cañive, Castillo, Tuason, Tseng, & Streltzer, 2001; Pole, Best, Metzler, & Marmar, 2005; Ruef, Litz, & Schlenger, 2000). Next, Hispanic culture traditionally places a high value on relying upon family (familismo) which may translate into fewer instances of formal help-seeking (Cañive et al., 2001; Dohrenwend, Turner, Turse, Lewis-Fernandez, & Yager, 2008; Pole et al., 2005). A lack of cultural competency and understanding of ethnic differences in help-seeking behaviors by employees within the VA health care system also may contribute to Hispanics relative low rates of access treatment. For example, a study of perceived barriers to mental health treatment by Hispanic and Native American veterans found that both groups experienced difficulty discussing personal matters due to feelings that the VA does not understand their needs, mistrust of the VA system, and a lack of outreach to these cultural communities (Westermeyer, Cañive, Thuras, Chesness, & Thompson, 2002).

Female Veterans

Women presently comprise approximately 8% of the veteran population, and it is predicted that this percentage will double over the next 30 years (NCVAS, 2015). Of those, anywhere from 40% to 75% have been deployed; many in what are considered to be combat zones (Dutra et al., 2010; Street, Vogt, & Dutra, 2009). In general, female veterans’ reintegration experiences following deployments are more complicated than men’s experiences. Female military members generally are younger and of lower socioeconomic status than civilian women of the same age (Adler-Baeder, Pittman, & Taylor, 2005). Military women are more likely to be single mothers and/or divorced (Joint Economic Committee, 2007), and female veterans’ postdeployment experiences are more likely than men’s to be impacted by familial stressors and their family roles (Kelly, Nilsson, & Berkel, 2014). Women also are far more likely than men to experience military sexual trauma (MST) and thus to suffer PTS as a result of MST (Goldstein, Dinh, Donalson, Hebenstreit, & Maguen, 2017; Vasquez, 2011). Women appear to be more strongly impacted by combat-related stressors, past trauma, and victimization during deployment (Plushy et al., 2014). In a systematic review, Crum-Cianflone and Jacobson (2014) highlight the dearth of data available on gender differences in veterans’ experiences and, while reinforcing the need for further study, they cautiously conclude that women have a moderately higher risk for experiencing postdeployment PTS.

Rural Veterans

It is estimated that about 24% (or 5.3 million) of all veterans live in rural areas, and more than a third (36%) of veterans with a service-related disability reside in rural communities (VHA Office of Rural Health, 2014; Weeks, Wallace, West, Heady, & Hawthorne, 2008). Although veterans living in rural areas share many of the same health concerns with their suburban and urban counterparts, they face a number of challenges that are unique to their geographies (Hofferth & Iceland, 1998; Weeks et al., 2004; Weeks, Wallace, Wang, Lee, & Kazis, 2006). Qualified veterans have access to a network of providers through the VHA, but doing so can be challenging for those who live far from referral centers, which are located primarily in urban areas (Weeks et al., 2004; Weeks et al., 2006; West & Weeks, 2009). Rural communities often lack sufficient infrastructure (such as buses, train, or car services) to meet their transportation and social service needs (Hofferth & Iceland, 1998). Compounding the problem, veterans often lack social networks through which they might arrange transportation or carpool needs (Hofferth & Iceland, 1998; Pietrzak, Johnson, Goldstein, Malley, & Southwick, 2009). On the provider side, it is challenging to recruit and retain qualified medical providers in geographically remote areas. The VHA Office of Rural Health (2014) estimates that only 9% of physicians practice in rural areas, despite the fact that 20% of Americans reside in such locations (see also Weeks et al., 2004). Rural veterans also are less apt to have private insurance and more likely to have more complicated health care needs, which can make providing comprehensive care especially challenging (Weeks et al., 2006; Weeks et al., 2008; West & Weeks, 2009).

LGBTQ Veterans

There are over 1 million veterans (and approximately 66,000-75,000 active service members) who would describe themselves as being part of the LGBTQ community (Cameron et al., 2011; Simpson, Balsam, Cochran, Lehavot, & Gold, 2013). LGBTQ veterans may have experienced unique stressors during military service, including the need to conceal personal information, harassment, and the fear of being discharged for their sexuality (Cochran, Balsam, Flentje, Malte, & Simpson, 2013). Research suggests that LGBTQ individuals are prone to overall lower health status and higher rates of smoking, substance abuse, mental illness, sexually transmitted diseases, depression, PTS, and suicidal thoughts or behavior (Cochran et al., 2013; see also VHA Office of Health Equity, 2011). LGBTQ service members also experience higher levels of MST when compared with heterosexual service members (Mattocks et al., 2013). It is not clear whether LGBTQ veterans utilize VHA services at the same rates as the general veteran population or whether they experience unique barriers to services (Simpson et al., 2013). However, research shows that approximately one quarter (25.6%) of LGBTQ veterans eschewed using at least one VHA service due to concerns of stigmatization. They most frequently avoided individual counseling, general outpatient medical care, and dental care due to expressed concerns that staff or other patients would not accept their sexuality (Simpson et al., 2013).

Current Study

Despite the evidence demonstrating distinguishable and distinctive needs among these veteran subgroups, and the general trend toward cultural competency in health care (Lecca, Quervalu, Nunes, & Gonzales, 2014; Saha et al., 2008), there is scant research on veteran subgroups and their access to treatment. As such, one of the objectives of the current study was to examine perceptions among VSOs of veteran subgroups’ mental health and tangential needs, including access to care, information about services, and treatment success. Building on our prior research, which suggests that VSOs² are an underutilized resource for justice-involved veterans in need of treatment (Douds & Ahlin, 2015), we explore how VSOs identify and address the needs of veteran subgroups in Pennsylvania—home to more than 1 million veterans (U.S. Census Bureau, 2016).

Methods and Samples

Data for the study are drawn from a Needs Assessment of veterans across Pennsylvania conducted between May 2013 and December 2014. For the current study, we examine data collected from three focus groups and a statewide web-based survey of VSOs.³ VSOs were the key respondents for this study because, as front line liaisons with veterans, they help bridge the gap between veterans and treatment services, particularly among recalcitrant, estranged, or hard to reach subpopulations and those at risk for involvement in the criminal justice system. VSOs are virtual clearinghouses for linking veterans with services they need, including transportation to VA appointments, enrollment in community based therapeutic programs, and access to housing vouchers. Employed by the state, nonprofits, or local municipalities, VSOs provide veterans with assistance across multiple domains. Their breadth of knowledge about their communities, the VA, and services available to veterans, as well as their interactions with veterans at the neighborhood level, render them uniquely situated to provide a litmus test for determining the extent of the needs of veterans.

The focus group participants were recruited from exhaustive lists of all qualified VSOs maintained by the Department of Military and Veterans Affairs’ (DMVA) Office of the Deputy Adjutant General for Veterans Affairs (ODAGVA), including all VSOs employed by the DMVA; all County Directors of Veterans Affairs; and all recognized independent veteran service organizations (IVSOs), including the American Legion, Veterans of Foreign Wars, AMVETS, Disabled American Veterans (DAV), Military Order of the Purple Heart, and Vietnam Veterans of America. Three focus groups were conducted: one with a sample of DMVA VSOs, one with a sample of county VSOs, and one with a sample of independent VSOs. A total of 26 VSOs participated in the three 90-min focus group sessions, and the participants were mostly male (69%). Focus groups transcript notes were analyzed using open and axial coding strategies consistent with the principles of grounded theory (Charmaz, 2006).

The initial sampling frame for the VSO web survey included 165 VSOs from all subsets of VSOs in the Commonwealth, including VSOs from the ODAGVA, County Directors of Veterans Affairs, and IVSOs. Nine VSOs were determined to be ineligible for study participation due to retirement, death, or change of employment, resulting in a final sample size of 156 VSOs for the web survey. A total of 78 completed surveys were received (50% response rate).

Results

The following reports the results of this study with respect to VSOs’ involvement in facilitating PTS and other behavioral health services and the extent to which those efforts speak to needs specific to one or more subpopulations. We begin with an examination of the focus group findings.

At first, VSOs in this study reported that they were not familiar with the concept of “subpopulations” based on race/ethnicity, gender, geography, or sexual orientation. Instead, they spoke of the special needs of a few subsets of veterans, in particular homeless, recently deployed, and combat disabled veterans. When asked to distinguish among racial/ethnic minority, female, rural, and LGBTQ veterans, most balked. They explained that “we treat them all—one size fits all,” “a veteran is a veteran, period,” and “we are all shades of green.” Upon further probing, VSOs reluctantly discussed distinctions in health service needs among these subpopulations, but it was not a comfortable topic for most. Overall, it appeared culturally acceptable among VSOs to recognize subpopulations that are distinct due to distinguishing military experiences, but not due to intrinsic or geographic characteristics. All VSOs insisted that there are no differences in service needs or service provision that relate to race or ethnicity, but that failure to seek treatment was a common phenomenon. Many VSOs observed that veterans they served needed to set aside their reservations and be more accountable for their own care. As one VSO reluctantly observed, “sometimes the vets just need to get out of their own way.” This VSO was loathe to blame the veterans for not seeking treatment, but once he opened the door to conversation about the role veterans play in their own care, several others joined.

The focus group data were divided into two main groups. The first category addressed how VSOs might improve veterans’ experiences vis-à-vis their probation and parole officers (see Douds & Ahlin, 2015). The other group of response categories was relevant to the main goal of the present study, which is to assess awareness about differences in therapeutic needs. Using the focus group data to identify important areas of inquiry, we addressed the following three topics in the web survey: (a) descriptions of veterans’ service needs, (b) descriptions of what services VSOs provide directly to veterans, and (c) gaps among veterans’ service needs and VSO service delivery.

In examining the results of the web survey, we begin with a description of veterans’ service needs. The majority of VSOs (n = 71) participating in the web survey said that they were familiar with the behavioral health needs of veterans, and 84.5% (n = 60) reported that they recalled at least one occasion when they had assisted a veteran with a specific behavioral health service. Of these 60 respondents, most indicated that they provided referrals or “access” to support groups (81.7%; n = 49). Over half also provided referrals or access to hotlines, mental health therapy, and therapeutic counseling (see Figure 1).

Figure 1.

Behavioral health assistance provided by VSOs.

In an effort to flesh out these issues among the VSOs, they were asked to identify which, if any, subgroups of veterans are well served by VSO programs and which subgroups they perceived as underserved. More than 70% of VSOs reported that the majority of their clients were predominantly older (served prior to 9/11), male, and White. These VSOs perceived that the most underserved veterans were Native Hawaiian, American Indian, and Alaska Native and Pacific Islander, with only 4.9% reporting that they served these groups “well” (Figure 2). Without discussing cultural competency or why there was a difference in access to care by racial and ethnic minorities, the VSOs overwhelmingly agreed that racial and ethnic minority veterans did not receive the same quality of care as their White counterparts. However, these findings may be related to the relatively low representation of those populations in the state at large. Only 0.5% of the entire Pennsylvania population fits one of these categories (U.S. Census Bureau, 2016). None of the data collected spoke to differences in need by race or ethnicity, and none of the data indicated that the VSOs tailored their behaviors to veterans’ race or ethnicity. However, VSOs perceived that Hispanic and African American veterans were not as well served by VSO programs as Whites.

Figure 2.

VSOs’ populations well served (by number of VSO reporting).

Less than half of participating VSOs reported that their offices provided services specifically for female veterans (44.1%; n = 30), and only a few offered assistance with filing claims related to MST (17.9%; n = 5). One VSO reported that his office employed female counselors, provided sexual assault counseling, referred veterans for sexual assault and trauma counseling, and advised on gender-specific benefits through the VA. Almost 40% of VSO offices had female VSOs available to deal specifically with issues and claims of female veterans (39.3%; n = 11). IVSOs were most likely to indicate they offered gender-specific services (53.8%; n = 14), while county VSOs were least likely (34.4%; n = 11). Half of ODAGVA staff reported that they facilitated services specific to female veterans (50.0%; n = 5).

VSOs consistently insisted that no distinctions were made among veterans with regard to services or benefits. The VSOs in this study spoke with pride about their “blinders” with regard to race and gender. They explained that “a veteran is a veteran,” and that as VSOs they “do the same thing for all veterans, and [] don’t care what (the veteran) looks like or what (gender) they are.” One VSO repeatedly insisted that “men and women are the same.” The VSOs appeared to be attempting to convey that they were fair; that they served all veterans equally. However, they did not seem to be aware of gender-specific treatment and reintegration needs. Many VSOs (53.8%; n = 42) shared suggestions to improve services for female veterans. More than one-third focused on the need for more or better outreach to female veterans (35.7%; n = 15). Additional training and knowledge of female-specific issues were also mentioned by service officers (14.3%; n = 6). One VSO noted, “good resources exist via the VA for female vets. Education about the availability of these resources would be helpful.” Other suggestions for improvement included adding more female VSOs (n = 4), female counselors (n = 3), and females in veteran centers (n = 1), as well as offering gender-specific programs (n = 1).

Statistically, it is highly likely that at the time of the web survey, LGBTQ veterans resided in Pennsylvania and came into contact with the VSOs. However, none of the VSOs in this study were aware of ever having interacted with an LGBTQ veteran through their work, though interestingly 5.1% of VSOs perceived that LGBTQ veterans are well served. Most VSOs suggested that LGBTQ veterans were among those who are most underserved, but they did not share any insights or foundational facts for these opinions. This topic yielded the least information of all areas of inquiry.

One third of VSOs said they worked with veterans in rural counties (32%); 10% served veterans in urban counties; 9% served veterans in suburban counties. A small percent (19%) reported working in geographically diverse counties, while 30% said they serve veterans in all counties, and 66% reported that they assisted veterans from inside and outside of Pennsylvania. No VSOs perceived that there were differences in mental health needs among rural veterans, only that there were differences in access to behavioral health services. VSOs described transportation as a critical need for rural veterans. Specifically, they said that transportation in their rural areas was not reliable or convenient. They described cases where veterans waited at bus stops for hours to get to medical appointments because buses only ran at certain times. Although DAV provided free transportation for veterans in some of these areas, there were often not enough cars or vans to meet demand.

The data also provided a means to develop recommendations to address the gaps among veterans’ service needs and VSO service delivery. The most prevalent need identified was education. VSOs in this study clearly were either unaware of many subgroups among the veterans they were serving, are not providing enough outreach to inform all veterans about the services available for their use, or are not conveying their tolerance for subgroups to improve self-identification of specific needs. A recurrent topic evidenced by the data was that VSOs needed to better promote their services to the veteran population while educating veterans about the varying services available for subgroups. Increasing awareness and recognition of the psychosocial, medical, and logistical hurdles facing veterans, particularly subgroups at risk for subpar access to treatment, serves to aid veterans in their resettlement process and allows for a proactive approach to addressing factors that are often precursors to involvement with the criminal justice system.

It is also apparent that the VSOs themselves would benefit from education or awareness training on the specific needs of these subpopulations of veterans. The research literature underscores the disparate nature of veterans’ therapeutic needs across demographic characteristics, and offers some guidance on improving services to attain cultural competency. Therefore, the oversight or failure of VSOs to recognize subgroup differences and needs suggests that the “one size fits all” preconception about veterans as a whole rather than expressing acceptance of various shades of green may be limiting development of and access to culturally competent care (see Steenkamp & Litz, 2014).

Discussion

Access to culturally competent health care by diverse subgroups is a real concern. Efforts to promote equitable care among at least some subpopulations of veterans have risen to the national level. For example, federal and nonfederal programs have taken aim at improving access to care for veterans in rural areas, as evidenced through the VA’s development of localized and regionalized rural care initiatives (Weeks et al., 2004; Weeks et al., 2006). In addition, Congress established the Rural Veterans Care Act of 2006 to investigate methods of improving rural health care, providing care closer to rural areas, and promoting more effective care through evidence-based practices (VHA Office of Rural Health, 2014; Weeks et al., 2008). However, it is not clear how many other veteran subgroups fall through the cracks and do not receive optimal access to services. The results from our study suggest there are four key areas where additional attention should be focused to continue reducing the disparities in access to care among subgroups of veterans: (a) individual-level education of veterans themselves to promote self-knowledge and self-advocacy, (b) VSO-level training and education to mitigate bias and improve cultural competencies, (c) broader training of medical and social services personnel outside of traditional veteran networks, and (d) training and education of criminal justice professionals. We address each of these in turn, paying particular attention to the subpopulations discussed above.

Veteran Self-Awareness and Self-Advocacy

Research establishes that patients need to be self-aware and self-advocating. They must understand the scope of their own needs, which can be particularly challenging for those dealing with head trauma, depression, subconscious denial or avoidance, or feeling as though their particular needs and associated treatment are not different than the prevailing veteran. In the context of Vietnam veterans, one team applied the phrase “emotional amnesia” to describe the phenomenon by which veterans fail to pursue mental health care in a timely fashion because they either are not aware of their needs or are suppressing that awareness as part of a larger psychological response to their military experience (Shatan, 1973). External advocates such as VSOs can facilitate linkages to care for these types of veterans by becoming educated on the signs of need, and the likelihood that veterans may not realize what they need (see Goldman, Nielsen, & Champion, 1999; Sayer et al., 2009).

Foremost, as the number of women in the military continues to grow and as the policy permitting female assignment to combat position expands, the needs of women veterans will demand more analysis. Compared with men, younger and minority veteran women have a higher prevalence of delayed care or unmet needs, and they tend to underutilize VA health care (Washington, Bean-Mayberry, Riopelle, & Yano, 2011). Furthermore, issues related to the gender-sensitivity of health care workers present another barrier for female veterans (Washington, Kleimann, Michelini, Kleimann, & Canning, 2007). Women who experienced direct and indirect combat exposure may be less likely than other groups of patients to use VA services if they feel it is male-oriented (see Kelly et al., 2008; Owens, Herrera, & Whitesell, 2009).

Relatedly, though not exclusive to females, research increasingly demonstrates that numbers of veterans experience MST. Although MST was not identified as a major concern among our sample, data on rates of sexual assault in the military are growing (Rosen & Martin, 1998; Street, Gradus, Giasson, Vogt, & Resick, 2013; Veterans Administration, 2015). Experiences related to MST have long-term physical and emotional effects, and they can impact future need and use of health services. For example, Kelly and colleagues (2008) found that although those who experienced MST were more likely to use VA care, they were less satisfied with the services than other patients because it was not geared toward females and they had difficulty accessing female-specific services. Additional inquiry is necessary to determine whether veteran survivors are disclosing their need for trauma-informed treatment and whether providers such as VSOs are asking the right questions to determine the need for such services.

Expanding VSO Competencies

Although patient-centered or culturally competent health care has received widespread attention in recent years, much remains to be determined about its effectiveness and whether using such practices transcends the civilian/military divide. It is also unclear whether practices need to be adapted further to meet the needs of those whose identities intersect across subgroup boundaries. Relatedly, veterans may recognize that they do not feel like their old selves, but they may not have the detachment or self-awareness to relate that sense of being “off” with a mental health condition. Again, VSOs and similarly situated caseworkers can help veterans recognize their own needs by learning about correlates of need that are specific to veterans (and specific to veteran subpopulations) then facilitating access to a caregiver who can give veterans professional help with recognizing their conditions and receiving appropriate treatment.

Surprisingly, there was little mention among our sample of any specific services to support veterans who identify as LGBTQ. With the repeal of the Don’t Ask, Don’t Tell (DADT) policy in 2010, more military personnel are openly serving in the various branches of the United States Armed Forces. The data for the current study were collected after DADT, though perhaps the veterans with whom the VSOs worked had adopted the mantra of DADT prevalent during their period of service and carried the rhetoric of DADT with them into retirement or separation from the military. Veterans and VSOs also may continue to subscribe informally to DADT, and veterans may be unaware that disclosing their culturally oriented needs may increase VSOs’ ability to facilitate better care.

Promoting Awareness Across Medical and Social Services Communities

Veterans are not required to self-disclose their military history when seeking care outside of the VA, but they need to understand that knowledge of their military service may improve all caretakers’ (those within the VA and those that are community based) ability to manage their unique constellation of experiences and treatment needs. Medical and social services professionals should take the initiative to ask about such experiences when working with new patients and clients. Encounters with persons seeking help or assistance through a community care network of providers should include a series of brief questions about military service, veteran benefits eligibility, and whether the patient/client identifies with any of the various subgroups identified in this study.

Concurrent with this outreach effort, providers need proper education on the distinguishing mental health care needs of veterans in general, and specifically those who belong to one or more subgroups. Medical and social service professionals must undertake continuing education (CE) as part of their annual professional licensing. Part of their annual CE could cover veterans’ deployment cycles, the implications of serving in theaters of war, how modern military experiences differ from prior generations, and how various mental health services can be tailored to amplify access to programs. Furthermore, community groups would benefit from working together and across disciplines to create a multi-pronged approach to veteran care.

Reaching Criminal Justice Professionals

The predominant concern for our respondents revolved around access to behavioral health care, without particular concern for whether the veteran was an offender. However, access to such treatment and analogous support services can mitigate the risk of veterans becoming involved in the criminal justice system. Experiences such as traumatic brain injury, homelessness, PTS, and other psychosocial health problems can increase risk of offending behavior among veterans (see Tsai, Rosenheck, Kasprow, & McGuire, 2013). Additional work needs to be done to inform criminal justice practitioners at all levels—police, courts, and corrections—to screen for veteran status during all encounters to identify veterans and direct them toward appropriate veteran-centric care.

Building on the focal area address in the prior section, the recently developed Veterans Treatment Court (VTC) model provides a context for a multi-pronged approach to addressing the needs of justice-involved veterans across myriad social service providers. Although rapidly proliferating across the United States, VTCs remain in their nascent period. It may be too soon to understand their impact on access to mental health care, recidivism, or other psychosocial concerns; however, there is evidence to suggest they provide a milieu in which justice-involved veterans can access services in a culturally supportive environment, which may influence their decision to seek treatment (see Ahlin & Douds, 2016). Outreach to local jurisdictions to encourage funding for VTCs and to educate criminal justice practitioners about the benefits of veteran-centric care should be a priority to closing the gap in access to psychosocial and mental health care among veterans.

Limitations

Although this study provides insight into the need to educate veterans, VSOs, and other social service providers about subgroups within the veteran population and how culturally competent care is lacking, the results should not be generalized to the larger VSO community and requires replication in other regions. Instead, readers should consider whether the information collected here can be transferred or applied to another environment or situation (Krueger & Casey, 2000). The qualitative research methods used for the first stage of the Needs Assessment allowed for in-depth, flexible consideration of data shared by focus group participants and the qualitative nature of this research provides rich, detailed responses upon which to address these issues among a larger and more diverse sample of respondents. Furthermore, the study does not address the veteran perspective of access to care, in general, or for specific subgroups such as those addressed in this study—racial/ethnic minorities, women, rural inhabitants, and LGBTQ—either individually or as intersectionalties of these various shades of green.

Conclusion

Although the need for therapeutic support is apparent, a number of barriers may prevent veterans from obtaining much-needed behavioral health services. First, many veterans hold negative beliefs about mental health care (Pietrzak et al., 2009). Specifically, Tanielian and colleagues (2008) found that about 45% of veterans in their study were concerned about negative side effects from mental health drug therapies. Further, about one quarter of the respondents in their survey did not think that even good mental health care was effective or would be confidential (see also Stecker, Fortney, Hamilton, & Ajzen, 2007). Analogously, embarrassment and the perception of being perceived as “weak” or “crazy” are significant barriers to seeking assistance for mental health issues (Jakupcak et al., 2007; Mittal et al., 2013). Education of VSOs and other therapeutic providers and social service agents is essential to break down the stereotypes associated with seeking treatment as a veteran in general and more specifically if one falls into one of the many subgroups explored in this study. VSOs, treatment providers, and ancillary support systems could provide an essential role in communicating the long-term benefits of treatment and reducing the stigma associated with accessing care, while also bridging the gap in access to services.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was conducted, in part, with support from the Pennsylvania Department of Military and Veterans Affairs (DMVA).

Notes

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