Qualitative and Quantitative Methods

REVIEW ARTICLE

Exploring positive pathways to care for members of the UK Armed Forces receiving treatment for PTSD: a qualitative study

Dominic Murphy1*, Elizabeth Hunt1, Olga Luzon2 and Neil Greenberg1

1King’s Centre for Military Health Research, King’s College London, London, UK; 2Department of Clinical Psychology, Royal Holloway University, London, UK

Objective: To examine the factors which facilitate UK military personnel with post-traumatic stress disorder (PTSD) to engage in help-seeking behaviours.

Methods: The study recruited active service personnel who were attending mental health services, employed a qualitative design, used semi-structured interview schedules to collect data, and explored these data using

interpretative phenomenological analysis (IPA).

Results: Five themes emerged about how participants were able to access help; having to reach a crisis point before accepting the need for help, overcoming feelings of shame, the importance of having an internal locus

of control, finding a psychological explanation for their symptoms and having strong social support.

Conclusions: This study reported that for military personnel who accessed mental health services, there were a number of factors that supported them to do so. In particular, factors that combated internal stigma, such as

being supported to develop an internal locus of control, appeared to be critical in supporting military

personnel to engage in help-seeking behaviour.

Keywords: Military health; PTSD; depression; pathways; stigma; barriers

*Correspondence to: Dominic Murphy, KCMHR, Weston Education Centre, Cutcombe Road, SE5 9PR

London, UK, Email: dominicmurphy100@gmail.com

For the abstract or full text in other languages, please see Supplementary files under Article Tools online

Received: 17 June 2013; Revised: 4 October 2013; Accepted: 20 November 2013; Published: 17 February 2014

S ince 2002, the UK and US military’s have con-

ducted highly challenging operations in Afghanistan

and Iraq. These military operations have been

the focus of a number of large-scale epidemiological re-

search studies, which have investigated the psychological

health of US and UK service personnel. Studies in the

United States have observed rates of post-traumatic stress

disorder (PTSD) in deployed personnel to be between

8 and 18% (Hoge et al., 2004; Smith et al., 2008). Further,

13% of participants met criteria for alcohol problems

and 18% for symptoms of anxiety and depression, with a

very high co-morbidity rate between these disorders and

PTSD (Riddle et al., 2007; Smith et al., 2008). This

increase in the rate of PTSD following deployment has

been replicated prospectively (Vasterling et al., 2006).

However, in the UK, the effects of the conflict upon the

mental health of service personnel have been quite

different.

The most extensive UK epidemiological studies of

service personnel since 2003 have been carried out at

King’s College London. This study is based on a

randomly selected representative sample of the UK

military, and in 2006, this study reported rates of PTSD

to be 4% and symptoms of common mental health

problems (including anxiety and depression) to be 20%

(Hotopf et al., 2006); higher rates of PTSD (6%) were

found in combat troops and reserve forces. These rates

remained reasonably constant at the second wave of data

collection in 2010 (Fear et al., 2010). However, figures

released by the Ministry of Defence (MoD) demonstrate

substantially lower rates of personnel accessing services

for these problems, between 4�4.5% and 0.8�1.2%, respectively, over the past 3 years (Defence Analytical

Services Agency, 2011). This is supported by research

that reported that only 23% of UK service personnel who

meet criteria for a mental health diagnosis are receiving

any support from mental health services (Iversen et al.,

2010). Of those who engaged in help-seeking, 77% were

getting treatment, with 56% receiving medication, 51%

psychological therapy and 3% inpatient treatment.

PSYCHOTRAUMATOLOGY EUROPEAN JOURNAL OF

�

European Journal of Psychotraumatology 2014. # 2014 Dominic Murphy et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 Unported (CC-BY 4.0) License (http://creativecommons.org/licenses/by/4.0/), allowing third parties to copy and redistribute the material in any medium or format, and to remix, transform, and build upon the material, for any purpose, even commercially, under the condition that appropriate credit is given, that a link to the license is provided, and that you indicate if changes were made. You may do so in any reasonable manner, but not in any way that suggests the licensor endorses you or your use.

Citation: European Journal of Psychotraumatology 2014, 5: 21759 - http://dx.doi.org/10.3402/ejpt.v5.21759

1

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A study within the UK Armed Forces followed up

service personnel who had been involved in a 6-year

longitudinal study, 3 years later (Iversen et al., 2005b).

The study observed that most ex-service personnel do

well once they leave. However, those who had a mental

health problem when they left the Armed Forces were

substantially more likely to be suffering from a mental

health problem and be unemployed 3 years after leaving

(Iversen et al., 2005b). In addition, having a mental

health problem predicted leaving the Armed Forces and

mental health status remained constant after leaving

(Iversen et al., 2005b).

As documented above, only a modest number of

military personnel experiencing mental health difficulties

are able to access treatment, and little is known about the

treatment experiences of military personnel who do

access services (Iversen et al., 2009). What we do know

is that many ex-service personnel are able to get treatment

from the NHS, which provides a range of specialist

services. Previous research has identified a number of

barriers that may explain the reluctance to access services

(Britt, Wright, & Moore, 2012; Gould et al., 2010; Iversen

et al., 2011; Kim, Thomas, Wilk, Castro, & Hoge, 2010).

These barriers broadly fit within three categories: internal

stigma (including self-stigma), external stigma (including

public stigma and mistrust in services), and access factors

(including lack of knowledge of available services).

Several trials have been conducted to improve the number

of people seeking treatment by aiming to reduce stigma.

A review of these trials concluded that there has been

little evidence of the efficacy of these interventions

(Mulligan, Fear, Jones, Wessely, & Greenberg, 2011).

The current study aims to investigate the specific

pathways to accessing mental health services for members

of the UK Armed Forces. In particular, to elucidate

factors that support individuals to access services, and

where barriers exist, how these are overcome. This is in

line with the agenda of military occupational mental

health services that have prioritised the importance of

supporting individuals to access services at the earliest

opportunity.

Methods

Setting & design This study utilised a sample of UK service personnel who

are accessing defence mental health services. Two military

departments of community mental health (DCMHs)

located in the south east of England were selected as

they were geographically close to the investigating team;

DCMHs provide services to all military personnel. The

MoD and RHUL ethics committees granted ethical

approval for this study.

A qualitative methodology was adopted for this study

due to the exploratory nature of the research questions

under investigation. The aim of the research questions

was to understand the lived experiences of participants

during their pathways to accessing mental health services,

and interpretative phenomenological analysis (IPA) has

been argued to be the most appropriate qualitative

analytic approach to do this (Smith, Flowers, & Larkin,

2009).

Participants A sample size of between 8 and 10 participants was

decided upon as informed by the selection of IPA (Smith

& Osborn, 2008). An ad hoc sampling strategy was used

for this study. The lead author (D. M.) met clinicians at

the DCMHs and explained the inclusion and exclusion

criteria. Clinicians were then requested to ask the clients

who met these criteria whether they wished to participate

in the study. Inclusion criteria for selection into the study

included having a diagnosis of either PTSD or depression

and currently receiving treatment. Individuals were not

selected if they were in the process of being medically

discharged from the military due to disciplinary reasons

(this exclusion criteria was requested by the MoD ethics

committee and the authors do not have access to the

reasons why service personnel were being discharged), or

if there was a clinical reason that meant it would not be

appropriate for the individual to take part in the study. In

general, these clinical reasons were if clients were new to

the service. Clinicians were concerned that the study may

be seen as an additional source of stress at a time when

clients were first engaging in treatment and could have

potentially created a barrier to their engagement in

treatment.

Materials A semi-structured interview schedule was used. Broadly,

the aim of the interview schedule was to understand the

different pathways that participants’ took to access

services, including which factors enabled them to do so,

and how they overcame potential internal and external

barriers. The interview schedule was piloted with three

individuals who were accessing defence mental health

services. The aim of this was to ensure that the questions

were understandable and to check whether additional

questions needed to be added. Following this, the inter-

view schedule was refined taking into account feedback

from a number of pilot interviews. This included advice

about removing a number of questions and clarifying the

stems of several questions.

Participants were also asked to complete two measures

to record symptoms of mental illness. The Post Traumatic

Checklist (PCL-C) is a self-report 17-item measure of the

17 DSM-IV symptoms of PTSD (Weather & Ford, 1996).

The PCL-C has been previously validated against a

clinical interview, which recommended using a cut-off

of 50 or more (Blanchard, Jones-Alexander, Buckley, &

Dominic Murphy et al.

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Forneris, 1996). The Patient Health Questionnaire (PHQ-

9) is a self-report measure that is based directly upon the

DSM-IV criteria for depression and includes nine items.

The PHQ-9 is scored from 0 to 27, and scores give an

indication of symptom severity; scores between 15 and 19

indicates moderate to severe depression and a score of 20

or above indicates major depression (Kroenke & Spitzer,

2002). Participants were also asked a number of questions

about their demographic characteristics.

Procedure Recruitment was carried out between March 2012 and

June 2012. The DCMH staff were approached, and the

inclusion and exclusion criteria for the study were dis-

cussed and a list of potential participants was drawn up.

After initial consent had been granted for their details to be

passed on from their treating clinician, potential partici-

pants were contacted to discuss the study, seek consent for

them to be recruited, and find a suitable date and time to

conduct the interview.

Analysis The first stage of data analysis was to collate the demo-

graphic characteristics and data collected through the

standardised measures (PCL-C and PHQ-9). The second

stage involved analysing the qualitative data in accordance

with published guidelines for conducting IPA (Smith &

Osborn, 2008; Willig, 2008). In brief, this involved working

through a number of different stages. The first stage was to

become familiar with the first participant’s transcript. The

second stage was to make initial notations for ideas

and themes in the text. The notations remained close to

the participant’s words. The third stage was to develop

emerging themes by re-reading the initial notations and

assigning labels. The aim of these labels was to capture the

essence of what the participant had described. The fourth

stage was to search for connections between emerging

themes. The list of labels was scrutinised and emergent

themes that appeared to be connected to each other were

grouped together under super-ordinate themes. Super-

ordinate themes were broader in scope than emergent

themes and contained a number of associated sub-themes.

This process was then repeated for the next participant’s

transcript. Once analysis had been completed for each

transcript, a final master list of super-ordinate and sub-

themes was generated. During this stage, differences and

similarities between cases were noted. At this stage, themes

between transcripts were grouped together and re-labelled

where appropriate.

Results

Sample Recruitment was carried out at two DCMHs. The sample

consisted of 8 participants, with four from each DCMH.

For the purposes of the study, participants were assigned

pseudonyms to protect their anonymity.

Data were collected on participants’ socio-demographic

characteristics to situate the sample; these are described in

Table 1. The majority of the sample were male (six out of

eight), in a relationship (7/8), had children (6/8), were

Other Ranks and not officers (5/8), were British (7/8) and

reported their ethnicity to be white (8/8). The ages of

participants ranged from early 20s to mid-50s, with the

majority or participants aged between mid-20s and mid-

30s. The lengths of service varied from 4 to 31 years, with

the mean length of service approximately 13 years. Nearly,

50% of the sample was in the Royal Navy and 50% was in

the Army.

Rates of mental health are reported in Table 2. The

results indicate that three of the participants reported

clinically significant levels of distress at the time of the

interview, as measured on both the PHQ-9 and PCL-C.

In addition, two further participants’ scores approached

the cut-offs that defined case criteria on both of the

measures. One of the inclusion criteria for the study was

that participants had a diagnosis of PTSD or major

depression. The observed variation in rates of distress

may be indicative of participants being at different stages

of treatment at the time the interviews were conducted.

Table 1. Socio-demographic characteristics of the sample

Participant Sex Age Relationship status Children Nationality Ethnicity Service Rank (officer or in ranks) Years in military

P1 Male 42 Divorced Yes British White Army Officer 23

P2 Male 51 Married Yes British White Navy Officer 31

P3 Male 34 Married Yes British White Navy Officer 14

P4 Male 30 Married Yes British White Navy Ranks 11

P5 Female 27 Partner No British White Navy Ranks 10

P6 Female 22 Partner No British White Army Ranks 4

P7 Male 31 Married Yes British White Army Ranks 4

P8 Male 35 Married Yes New Zealand White Army Ranks 6

Exploring positive pathways to care for members of the UK

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Results of qualitative analysis Five super-ordinate themes emerged from the data. Each

of these super-ordinate themes contained a number of

sub-themes; these are presented in Table 3.

Theme one: recognising something was wrong

A theme that emerged was that participants perceived it

had been difficult for them to recognise they were

experiencing mental health difficulties. This appeared to

result in participants ignoring early warning signs of

mental health difficulties and trying to carry on until it

was impossible for them to do so any longer.

Reaching a crisis point. The participants perceived

having reached a ‘‘crisis point’’ which meant they could

not ignore the mental health difficulties they were

experiencing any longer. What constituted a crisis point

differed between participants and was related to factors

in their environments.

P7: I can remember just being in such a state, I

mean, I was seriously disturbed, so there was so

many things that I felt, panic, terror, depression. I’d

be, go and find a quiet spot and just break down

and cry.

Difficulties experienced as physical symptoms. The par-

ticipants recalled that they first experienced physical

rather than psychological symptoms.

P1: So lots of things came together at that time.

My body was clearly screaming at me, I mean

there were lots, all through the years actually I had

lots and lots of not fully explained medical pro-

blems, which we now think were directly related to

PTSD.

Theme two: overcoming internal stigma

One of the super-ordinate themes that emerged from the

transcripts was related to how individuals perceived

overcoming internal stigma related to experiencing men-

tal health difficulties. Broadly, this fell into two areas:

overcoming feelings of shame about experiencing mental

health difficulties and the effect on self-esteem of being

prescribed psychiatric medication.

Shame. Participants spoke about feeling concerned that

they would experience stigma, in particular, being per-

ceived as ‘‘weak’’ by their peers. However, it appeared

that for the majority their fears were not realised, but

rather it was internal stigma they were experiencing.

Interviewer: So it sounds like you maybe had some

of those fears about stigma but they weren’t realised.

P1: But actually they didn’t, they weren’t real, they

didn’t, it’s not manifested itself. I think people are

much more aware now of it. I think the problem was

with me rather than with everybody else, it was the

anticipation of stigma, maybe that says more about

me than other people.

Table 2. PHQ-9 and PCL-C scores for sample

Participant PHQ-9 score1 Met criteria for PHQ-9 case PCL-C score2 Met criteria for PCL-C case

P1 13 No 41 No

P2 4 No 8 No

P3 0 No 8 No

P4 23 Major depression 80 Yes

P5 4 No 28 No

P6 12 No 40 No

P7 21 Major depression 71 Yes

P8 17 Moderate to severe depression 63 Yes

1PHQ-9 scored from 0 to 27: scores 15�19 indicates moderate to severe depression and a score of 20 or above indicates major depression. 2PCL-C scored from 17 to 85; scores above 50 indicates meeting criteria for post-traumatic stress reactions.

Table 3. Master list of super-ordinate and sub-themes

Super-ordinate themes Sub-themes

Recognising something

was wrong

Reaching a crisis point

Difficulties experienced as

physical symptoms

Overcoming internal stigma Shame

Stigma related to psychiatric

medication

Finding an explanation Trusted witness to difficulties

Psychological explanation

Getting a diagnosis

Not being alone Normalisation

Safe space

Sense of hope

Acceptance

Understanding

Control Autonomy

Communication

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Stigma related to psychiatric medication. Participants

highlighted the link between being offered medication

and internal stigma related from suffering with a mental

health difficulty. They discussed their ambivalence to-

wards medication. On the one hand, believing that

medication may help them, but on the other hand,

describing how taking medication meant there was

something wrong with you. Medication seemed to be

symbolic of having a mental illness that could no longer

be ignored.

P5: I kept saying, ‘‘I’m not going on medication’’

but I knew I had to, I knew I needed to in the end.

My mum, she’s always been on antidepressants and

I thought, I always said I’d never, ever wanna be like

that.

Theme three: finding an explanation

Participants highlighted the importance of being able to

find an explanation for their difficulties. By understand-

ing and accepting that their difficulties had a psycholo-

gical component, this supported participants’ to seek

help. How participants’ came to find this explanation

differed greatly.

Trusted witness to difficulties. Participants perceived the

importance of having a trusted witness to their difficulties

who could point out something was seriously wrong. This

supported participants to accept that their difficulties

were serious and that they needed to seek help.

P6: Yeah the first time round, I’ve got a very close

friend in the Paras, he’s a Liaison Officer. He

noticed that I was very down and I spoke differently,

very slowly and I just wasn’t really interested in what

he was saying and that’s not really me. I’m quite an

enthusiastic outgoing person and I changed quite a

lot the first time.

Psychological explanation. Participants described how

beneficial it was to be given a psychological explanation

for their difficulties. This may have been because it helped

them realise that their difficulties had a reason or a

function.

P2: Yeah, so I have to, like when I do anything I

have to sort of, I have to understand the mechanics

of it, so I asked the psychiatrist how does this

actually work? But if I understand the process is

find it really helpful.

Getting a diagnosis. Participants spoke about how

receiving a diagnosis was a crucial step for them in their

journey to seek help because it put a label on the

difficulties that they were experiencing.

P8: I think I was only officially told that, you know,

I think they said I had chronic PTSD and yeah it

was my nurse that told me and I don’t know and

then she told me, you know, she explained ‘‘These

symptoms that you’re having . . .’’ And obviously there was quite a few ‘‘Is all the signs.’’

P8: I was like ‘‘Jesus it must be that.’’ Then, I don’t

know it just made me really interested, I really

wanted, cause I knew what it was then and I was like

‘‘Right I can fix myself here surely.’’

Theme four: not being alone

Another theme that emerged was related to factors that

stopped participants feeling alone supported them to

seek, or continue, treatment for the difficulties they were

experiencing.

Normalisation. Participants spoke about the positive

experience of learning that the difficulties they were

experiencing were similar to those experienced by other

people.

P4: But it’s just looking into it, because when you

look into it you realise, hang on, they’re talking

about people going through this, this, this and this,

but that’s the same as me, so you start thinking, well

I’m not the only person here.

Safe space. What appeared common across the tran-

scripts was that having a safe space allowed participants

the opportunity to take a step back and realise something

was wrong; this then provided them with the motivation

to seek help.

P4: I was sick on shore for two weeks. During that

time it gave me time to actually rest in a secure

environment because I was at home, I had my family

around me. It was a secure environment. I didn’t

have to look over my shoulder. And it gave me a lot

of thinking time. I talked things through with my

wife and thought, something’s wrong here.

Sense of hope. Hope that things could improve was a

theme that emerged in seven of the transcripts. Most of

the participants recalled that hope was connected to

feeling that treatment was available to help them over-

come their difficulties.

P1: There was part of me that was relieved, but

there’s always part of me that, nobody’s harder on

me than I am and, but there was also huge relief. It

was, I realised that finally we may be able to do

something about this.

Acceptance. Participants spoke about the fear of not

being accepted by significant people in their lives because

of their mental health difficulties. However, it seems that

often these fears were based on internal beliefs and not

realised.

P5: I don’t even know why I was worried because I

know that they wouldn’t have ever judged me but at

the time that’s how I was feeling that they were

gonna judge me.

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Understanding. Participants talked about how impor-

tant it had been for them that other people understood

the mental health difficulties they were experiencing.

Participants spoke about how this had helped them not

feel alone as they could share their experiences with

someone who understood them.

P3: If I needed to talk to somebody about it there

was always somebody that was there to talk about

it. My wife really wanted to know, she’d phone me

after every session to see how it had gone. And

there’s a lot to take away from my sessions to share

with her. And so it’s a journey we’ve been through

together.

Theme five: control

Participants perceived that their mental health difficulties

had made them feel as if they were subject to an external

locus of control. In contrast, many of the participants

spoke of how helpful it had been for them when engaging

in help-seeking behaviour to feel an internal locus of

control about their treatment options.

Autonomy. Crucial to having a sense of control was

having autonomy over their treatment plans. Tom ex-

plained how he felt supported by his line manager

because they handed him control. This may be a very

different experience compared to other aspects of military

life, where typically service personnel have less control of

their day-to-day tasks.

P3: it was a case of, well what do you want rather

than them finding me something to do, what do you

want to do? So I was lucky in that respect.

Communication. Interviewed participants were worried

about how they might be viewed by their friends or

colleagues. They had mixed views about whether it was

better to share their experiences or not.

P1 talked about how it had been a useful process for

him to share his experiences with his line manager.

P1: Yeah, and once the PTSD thing had been

diagnosed, actually I was given a printout of the

initial session. And actually what I found the best

way was actually I showed it to my boss, I said this

is medically in confidence, but I said I want, I can’t

really explain it but read this, and he read that bit,

and from then on they couldn’t do enough, it was

just.

In contrast, other participants decided that it would

not be helpful to tell their colleagues.

P2: Not many people knew about it because I just

walked out of this meeting and I went for a beer

with an air force guy, a mate, and he just said take

some time off, and that’s what I did. And of course

they didn’t know that I then went and sought help.

So there wasn’t some sort of big showdown, which

you then had to confront going back to work.

Discussion The study explored which factors enabled serving mem-

bers of the UK Armed Forces experiencing mental health

difficulties to access care, and how they overcame

common barriers to do so. To the best of the authors’

knowledge, this approach to looking at stigma and

barriers to care has not been undertaken before with

the UK military.

We found that all of the participants spoke about

having to reach a crisis point before they sought help.

What was common between the crises was individuals

reaching the point where ‘‘something had to be done’’;

that is to say that the individual could not continue living

their life as they were. Many of the participants spoke

about a military culture that promotes the value of

‘‘cracking on despite a problem.’’ Whilst this may be

advantageous in many aspects of military life, the

participants spoke about how it led them to experience

very serious difficulties before they would accept that

they had a problem.

The majority of participants spoke about the presence

of physical symptoms prior to psychological symptoms.

It appears that participants expressed their psychological

distress through somatic symptoms. It has previously

been observed in military populations that physical

health difficulties are viewed as more acceptable than

mental health ones and that personnel are more likely

to attend appointments for the former, rather than the

latter (Rona, Jones, French, Hooper, & Wessely, 2004).

This finding is mirrored when looking between cultures

that have different explanations for mental illness, which

can lead to either the somatic or psychological expres-

sion of symptoms. For example, Chinese people have

been observed to be more likely to express symptoms

of depression somatically than north-Americans (Ryder

et al., 2008).

Overcoming feelings of shame about experiencing

mental illness was a common theme reported by partici-

pants. Many of the participants linked accessing mental

health services to their feelings of shame because this

meant they had a ‘‘problem.’’ In addition, by accessing

services it meant that their peers would also knew that

they had a ‘‘problem.’’ These two processes map on to

Corrigan’s theory of internal and external stigma (Corrigan,

2004). Participants spoke about how, over the course of

engaging with services, they were able to overcome their

internal stigma beliefs. For many, this process was related

to realising that their negative beliefs about mental illness

conflicted with the positive changes in their lives they

witnessed due to seeking help. Similarly, what seemed to

help the participants overcome their external stigma

beliefs was the realisation that their fears of rejection

from their peers were not actualised.

Three key factors that facilitated participants to engage

help-seeking behaviour emerged. The first of these was

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being supported to develop an internal locus of control

(Hiroto, 1974). Developing an internal locus of control

contrasted with how the participants described their lives

prior to seeking help; which for the majority, this period

consisted of feeling as if there was an external locus of

control. A relationship between an external locus of

control and anxiety and depression has been documen-

ted by other researchers (Vuger-Kovaèiæ, Gregurek,

Kovaèiæ, Vuger, & Kaleniæ, 2007). Furthermore, lower

levels of anxiety and depression have been observed in

individuals who report an internal, rather than an

external, locus of control (Jaswel & Dewan, 1997).

The second theme that participants reported as having

facilitated their accessing services was gaining a psycho-

logical understanding of their mental illness. This is

supported by previous literature within civilian popula-

tions that observed having a psychological understanding

predicted help-seeking behaviour (Deane, Skogstad, &

Williams, 1999). Whilst the mechanisms for this relation-

ship are unknown, from the current study it can be

hypothesised that a psychological explanation was more

culturally acceptable for members of the armed forces

than a biological explanation, which is associated with

more stigma. Indeed, many of the participants spoke

about how gaining a psychological explanation helped

allay their concerns about being ‘‘mad’’ and having

something ‘‘wrong with them.’’

Being well supported by their social networks was the

final theme described by participants as having facilitated

them to access mental health services. This finding is

supported by previous research within civilian popula-

tions that documented that individuals with mental

illness, who report better social support, were more likely

to engage in help-seeking behaviours (Briones et al.,

1990).

There are a number of limitations to this study. When

interpreting these results, it is important to acknowledge

that there may have been bias towards recruiting parti-

cipants with lower levels of psychological distress. There

was some evidence to support this in the scores reported

on the measures of psychological distress. This needs to

be interpreted carefully as there may have been a bias for

therapists to exclude potential clients if they deemed them

to be suffering from high levels of psychological distress,

or only suggest potential participants who they deemed

had shown significant improvement. Alternatively, it

could have been that only participants who had bene-

fitted from treatment were put forward, in which case

their positive experience of treatment, may have acted to

influence their recall of the factors that helped them

engage in treatment by framing this decision in a

potentially more positive light. It is regrettable that the

authors’ do not have access to information related to

stage of treatment, which may have allowed for further

exploration of this. Whilst there are good clinical reasons

for making these decisions, they could present limitations

to the findings of the current study because individuals

who have been identified as being most at risk of not

being able access services are those with higher levels of

psychological distress (Iversen et al., 2005a).

Conclusions The results of this study suggest that there are three key

areas that support individuals to seek help. The first of

these were factors that helped individuals recognise that

they were experiencing difficulties and help them realise

that these difficulties had a psychological component.

The second were factors that helped an individual feel as

if they were no longer alone to deal with their difficulties.

For example, this included feeling accepted and sup-

ported by their social network. The final area that

supported individuals to seek help was them feeling

empowered to do so by having an internal locus of

control. In PTSD, feelings of helplessness and power-

lessness are extremely debilitating. Clinically, factors that

promote an internal locus of control are very important

for reducing these feelings. The participants spoke about

how factors that promoted an internal locus of control

helped them overcome feelings of internal stigma. It is

interesting to reflect that the factors that promoted an

internal locus of control could also have acted to reduce

the distress caused by symptoms of PTSD by helping to

tackle feelings of helplessness, isolation and powerless-

ness. Understanding the relevance of these three factors

should help military commanders to plan effective

stigma-reduction programmes.

Conflict of interest and funding

There is no conflict of interest in the present study for any

of the authors.

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