The Military, the Media, and Post-­‐Traumatic Stress Disorder: An Analysis of Media Framing and Post-­‐9/11 Service Members’ Decisions to Seek Help M. Todd Hunter American University A Capstone Project Presented to the Faculty of the School of Communication in Partial Fulfillment of the Requirements for the Degree of Master of Arts in Strategic Communication Supervisor: Prof. Caty Borum Chattoo April 24, 2014 FRAMING PTSD COPYRIGHT © Michael Todd Hunter 2014 All rights reserved. To obtain permission to use material from this work, please submit a written request via email to: m.todd.hunter@gmail.com. 2 FRAMING PTSD For my Heroes: The Men and Women of the United States Military Semper Fidelis 3 FRAMING PTSD ACKNOWLEDGMENTS I would like to express my sincerest gratitude to Prof. Caty Borum Chattoo for guiding me through this capstone experience. Your enthusiasm, encouragement, and commitment to always making yourself available to answer my questions helped turn an unorganized idea into a capstone that I am extremely proud of. You are a true leader in every sense of the word, and I am forever appreciative of your guidance. To my parents, grandparents, aunts, uncles, and brother, I cannot, nor ever will be able to, adequately thank you enough for everything you have done for me throughout my life. Your love and support has carried me further than I could ever go by myself, and for that I am forever grateful. To my fellow veterans and current active-­‐duty service members, thank you. Thank you for raising your hand when no one else would. Thank you for sharing your food, shelter, and water, and shedding your blood, sweat, and tears with me. Thank you for teaching, guiding, and mentoring me, and for watching my six for eight-­‐and-­‐a-­‐half years. Thank you for everything else you’ve done and will continue to do for our nation. I am forever grateful and humbled by your service and sacrifice. You are the best this country has to offer, and it was the greatest honor of my life to have served alongside you. Finally, to my wife, Karen, thank you for everything you have done to keep our family functional while I was stuck on the computer doing schoolwork throughout the past year. I know carrying the load was not always easy for you, yet you still managed to support me and keep me going day after day. You are the most amazing, beautiful woman I have ever seen, and I am equally as lucky to have you for a wife as Brody (and soon Riley) is to have you for a mother. You are my life, and I love you more with every passing day. 4 FRAMING PTSD ABSTRACT Post-­‐traumatic stress disorder (PTSD) is an anxiety disorder that affects nearly 30 percent of the 2.5 million American service members who have deployed to Iraq and Afghanistan. Considering many of these individuals may never seek treatment, understanding media frames surrounding PTSD and how they influence post-­‐9/11 veterans’ decisions to seek mental help is invaluable. Therefore, this study focuses on civilian and military media frames surrounding PTSD and these frames’ role in post-­‐9/11 service members’ decisions to seek treatment. This mixed-­‐method study presents the results of a content analysis of PTSD coverage in two leading national newspapers (The New York Times and USA TODAY) and multiple U.S. Department of Defense online news outlets (U.S. Department of Defense, U.S. Navy, U.S. Air Force, and U.S. Marine Corps) published between December 2011 and March 2014, as well as in-­‐depth interviews conducted with three post-­‐9/11 veterans about their decisions to seek treatment for PTSD. Major findings include: a) civilian media more often frame those with PTSD as abnormal; b) military media works to encourage those with PTSD to seek treatment; and c) stigma is a major factor in seeking treatment. This research can help inform civilian media outlets, the U.S. military, and individual service members about the differences between civilian and military media portrayals of PTSD, and it can help identify alternative media frames that may encourage post-­‐9/11 service members to seek treatment. 5 FRAMING PTSD TABLE OF CONTENTS INTRODUCTION .................................................................................................................................................... 7 LITERATURE REVIEW ........................................................................................................................................ 9 PTSD Overview & History .................................................................................................................................................. 9 ‘Othering’ Theory ................................................................................................................................................................ 10 Stigmatization and Discrimination Against PTSD in the Military ................................................................ 11 Barriers and Determinants for PTSD Treatment ................................................................................................. 12 The Branding of PTSD ...................................................................................................................................................... 14 Framing Theory .................................................................................................................................................................. 16 Impact of Mass Media Coverage and Framing of Mental Disorders ............................................................ 18 METHODS ............................................................................................................................................................. 20 CONTENT ANALYSIS ......................................................................................................................................................... 20 IN-­‐DEPTH INTERVIEWS ................................................................................................................................................. 23 RESULTS ................................................................................................................................................................ 24 CONTENT ANALYSIS ......................................................................................................................................................... 24 The Abnormal Frame ........................................................................................................................................................ 24 The Supportive Frame ...................................................................................................................................................... 25 Additional Results .............................................................................................................................................................. 26 IN-­‐DEPTH INTERVIEWS ................................................................................................................................................. 27 “Not Me” .................................................................................................................................................................................. 28 Experiences May Differ .................................................................................................................................................... 29 Doing the Work ................................................................................................................................................................... 31 Not Helping ........................................................................................................................................................................... 33 DISCUSSION ......................................................................................................................................................... 34 Major Frames ....................................................................................................................................................................... 34 ‘Othering’ Those Without PTSD ................................................................................................................................... 36 “Not Me” .................................................................................................................................................................................. 36 How to Reduce Stigma ..................................................................................................................................................... 37 CONCLUSION ........................................................................................................................................................ 38 REFERENCES ........................................................................................................................................................ 41 APPENDICES ........................................................................................................................................................ 47 Appendix A: Code Book .................................................................................................................................................................................. 47 Appendix B: In-­‐Depth Interview Questions .......................................................................................................................................... 49 6 FRAMING PTSD INTRODUCTION Since the Global War on Terror began in 2001, more than 2.5 million American service members have deployed to Iraq and Afghanistan (Adams, 2013). While some of these soldiers, sailors, airmen, and Marines have returned home unscathed, others bear physical or mental injuries ranging from missing limbs to post-­‐traumatic stress disorder (PTSD), an anxiety disorder that can occur in the aftermath of a traumatic event such as combat. In reporting on these wartime phenomena throughout the past 13 years, the American news media have fueled two prominent – yet opposing – narratives concerning veterans in today’s society. One is about well-­‐trained, hard-­‐working, disciplined, and experienced veterans who can be counted as valuable assets to private businesses and organizations (Eisler, 2012). The other portrays disabled, broken, violent, and traumatized veterans who pose risks to themselves and others, or require constant care and supervision (Eisler, 2012). However, despite the efforts of the media, 84 percent of post-­‐
9/11 veterans and 71 percent of the American public still believe that the general population of the U.S. has little or no understanding of the problems military members face (Pew Research Center, 2011). This statistic is an illustration of the current military-­‐civilian divide that exists in the United States. While there is no empirical data to the exact figure, various studies have estimated anywhere from four to 20 percent of American veterans are afflicted with PTSD (Ousley, 2012). However, in 2012, the U.S. Department of Veterans Affairs revealed that nearly 30 percent of post-­‐9/11 veterans have been diagnosed with PTSD, while other research shows these veterans wait years to seek professional help for PTSD, if they seek it at all (Reno, 7 FRAMING PTSD 2012; Sayer, et al. 2009). The purpose of this capstone is to determine how the framing of combat-­‐related PTSD shapes post-­‐9/11 veterans’ decisions to seek professional mental help for the condition. To do so, this research will focus on how PTSD is framed by the media and the military, and explore the following research question: What are the differences between civilian media and the U.S. military’s framing of post-­‐
traumatic stress disorder, and what role do these differences play in post-­‐9/11 service members’ decisions to seek mental help? There may be little or no published research on the differences between civilian media frames and military institutional frames of PTSD, nor any published research on how these differences affect post-­‐9/11 service members’ decisions to seek mental help based on each group’s respective portrayals of PTSD. Therefore, this capstone will lay a foundation for these issues to be further researched. This research will also help inform the U.S. military and individual service members about the differences between how civilian and military media portray those afflicted with PTSD, and help identify frames that may encourage post-­‐9/11 service members to seek mental help. This capstone is organized in the following ways: First, a literature review will provide an overview of PTSD and its history, the impact of mass media representation of mental disorders, how sufferers of PTSD are stigmatized and discriminated against in the military, the barriers and determinants for PTSD treatment for service members, and the branding of PTSD. Framing and “othering” will also be explored to provide a theoretical 8 FRAMING PTSD framework to this research. Finally, this paper details the methods of a content analysis between civilian and military frames of PTSD, as well as in-­‐depth interviews with three post-­‐9/11 service members with PTSD, and then presents the results of the research. The paper concludes with a discussion of significant findings and recommendations for practice and future research. LITERATURE REVIEW PTSD Overview & History According to the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, post-­‐traumatic stress disorder (PTSD) is classified as a trauma-­‐ and stressor-­‐related disorder. Diagnostic criteria for PTSD include past exposure to traumatic events involving actual or threatened death, serious injury, or sexual violence; intrusion symptoms such as distressing memories or dreams; persistent avoidance of stimuli associated with the traumatic event; negative alterations in cognitions and mood; and marked alterations in arousal and reactivity (American Psychiatric Association, 2013). To constitute a diagnosis, symptoms must persist for one month following the trauma, cause significant functional impairment, and not be attributable to the physiological effects of a substance or another medical condition (APA, 2013). Diagnosis of PTSD serves to interpret, categorize, and measure the condition, as well as facilitate treatment, treatment financing, and disability compensation for the condition (Fisher & Schell, 2013). 9 FRAMING PTSD The term “post-­‐traumatic stress disorder” has evolved throughout the years as societies have recognized that some individuals exhibit a range of problems after exposure to traumatic events such as war (Fisher & Schell, 2013). Fisher and Schell (2013) found: Terms used in the United States prior to “PTSD” include “soldier’s heart” during the Civil War era, “railway spine” during the late 19th century, “shell shock” and “war neuroses” during the World War I era, and “combat fatigue” during the World War II era. (p. 3) The condition became informally recognized as “post-­‐Vietnam syndrome” as American service members returned home from the Vietnam War (Dean, 1997). However, formal recognition of the condition took years of advocacy and collaboration between mental health professionals and several groups representing traumatized individuals, including Vietnam veterans (Scott, 1990). In 1977, the Vietnam Veterans Working Group mobilized the support of psychiatrists researching psychological impacts of war and proposed adding the diagnostic category that would eventually be labeled PTSD (Bloom, 2000). It was not until 1980 that the American Psychiatric Association formally recognized PTSD as part of the third edition of its Diagnostic and Statistical Manual of Mental Disorders (APA, 1980). “Othering” Theory Johnson et al. (2004) define “othering” as “a process that identifies those that are thought to be different from oneself or the mainstream,” which can ultimately reinforce and reproduce positions of domination and subordination. Kirschner (2012) further 10 FRAMING PTSD asserts “othering” is “simultaneously sociocultural, cognitive, and affective, and has both ethical and epistemological dimensions,” while Breen, Devereux, and Haynes (2008) note: The Other does not exist independently. Constructed as the binary opposite of ‘us,’ the Other is inherently a product of ‘our’ imagination. The Other is created as that which we are not, our negative. Where we are normal the Other is abnormal. Where we are healthy the other is pathological. Where we are acceptable, the Other is taboo. ‘We’ become both “the positive and the neutral” (de Beauvoir, 1989). These devices, used to construct the Other as our opposite, also have the common effect of creating the Other as a threat – to stability, to health, to order, to safety. (p.2) This theory dates back to the early 1950s when it was originally developed and applied to feminist theory (Johnson et al., 2004). Contemporary scholars, however, have examined “othering” in relation to numerous other groups such as minorities, immigrants, and people with disabilities – including mental disorders such as PTSD (Johnson et al., 2004). As such, common phrases used to describe post-­‐9/11 veterans afflicted with PTSD include but are not limited to: crazy, violent, unstable, homeless, unemployed, suicidal, drug addicted, and alcohol dependent. Additionally, Johnson et al. (2004) notes victims of “othering” can be labeled, marginalized, excluded, or discriminated against. Stigmatization and Discrimination Against PTSD in the Military Goffman (1963) explains that a stigma is the negative evaluation resulting from a social label, and those who are stigmatized are devalued, dehumanized, and typically rejected from mainstream inclusion. Thus, in the hyper-­‐masculine military culture, service 11 FRAMING PTSD members can sometimes fear the stigma associated with asking for help (Robinson, 2004; Hoge et al., 2004). Many troops fear seeking help for PTSD because they believe the diagnosis will have a negative effect on their careers (Fisher & Schell, 2013). While the U.S. Department of Defense rejects this viewpoint from an official perspective, the practical truth is that these troops’ fears are legitimate. For example, the U.S. military uses information received about psychiatric diagnoses and mental health treatment as part of its personnel evaluations to determine who is fit for deployment (Fisher & Schell, 2013). Service members who are not deemed deployable can be held stateside while their unit leaves for a scheduled deployment. As a consequence, their absence could possibly inconvenience or irritate others, in turn damaging professional reputations, personal relationships, and personnel evaluations. Additionally, service members who are held back do not receive the financial benefits provided to those who deploy (Fisher & Schell, 2013). Beyond the scope of the military, a PTSD diagnosis could also be used against military members in other civil affairs. The diagnosis could potentially be used in court during divorce proceedings to suggest the PTSD-­‐afflicted service member not be given custody of his or her child or children (Fisher & Schell, 2013). Barriers and Determinants for PTSD Treatment Sayer et al. (2009) conducted a study to identify barriers and facilitators affecting treatment initiation for PTSD amongst both Vietnam and post-­‐9/11 veterans. The researchers conducted the data collection through in-­‐depth interviews with 44 U.S. war veterans who submitted disability claims to the U.S. Department of Veterans Affairs (Sayer 12 FRAMING PTSD et al., 2009). Sayer et al. (2009) found seven main barriers to treatment: avoidance of trauma-­‐related feelings and memories, values and priorities that conflict with seeking treatment, treatment-­‐discouraging beliefs, healthcare system concerns, knowledge barriers, access barriers, and an invalidating post-­‐trauma sociocultural environment. While many of these barriers are attributed to lack of knowledge and distrust in the VA and other healthcare systems, a major treatment-­‐discouraging belief was the perceived stigma of having a mental disorder and the fear of societal rejection. Some participants expressed fear that others, including friends, family, employers, colleagues, and others within their social circles, would view and treat them as if they were weak, incompetent, or crazy (Sayer et al., 2009). One post-­‐9/11 veteran summed it up: It took a while to get me into treatment because I had a very negative view at first on getting help… I guess it was kind of a view that to see a psychologist was for people who were weak, couldn’t take care of themselves, couldn’t deal with day-­‐to-­‐
day life. (Sayer et al., 2009) Sayer et al. (2009) also found four main facilitators for veterans to seek treatment: recognition and acceptance of PTSD, treatment-­‐encouraging beliefs, system facilitation, and social network facilitation and encouragement. In other words, veterans who received peer support and had access to informal counseling were more likely to seek professional help for PTSD. Converse to participants’ fear that their social networks would view them as weak or crazy, these social networks often played a key role in getting participants into treatment by providing encouragement, recognizing PTSD’s symptoms, assisting participants in finding resources for help, and even scheduling their appointments (Sayer et al., 2009). Further, encouragement from Vietnam veterans was instrumental in 13 FRAMING PTSD promoting the seeking of treatment among post-­‐9/11 veterans because this encouragement was viewed as an endorsement from a peer group that it is acceptable to seek help (Sayer et al., 2009). The Branding of PTSD As the American Psychiatric Association was preparing to publish the fifth edition of its Diagnostic and Statistical Manual of Mental Disorders, U.S. Army leadership requested that the association drop the “D” from the PTSD diagnostic label because the term “disorder” is stigmatizing and dropping it would encourage more service members to seek help (Fisher & Schell, 2013). While the association considered adding a subcategory of PTSD, to be called “combat post-­‐traumatic injury,” and also discussed changing the name of PTSD to “post-­‐
traumatic stress injury,” the U.S. Army’s request to simply remove the term “disorder” was never fully considered (Fisher & Schell, 2013). This request, and the resulting discussion, did prompt the debate on whether the term “injury” is less stigmatizing than “disorder” (Fisher & Schell, 2013). While there is no evident empirical evidence supporting the use of either term, Fisher and Schell (2013) argue that the term “injury” may well in fact create further stigmatization as injuries are seen as permanent. Among Fisher and Schell’s (2013) numerous arguments against changing the name of PTSD is that the term “injury” refers to physical trauma rather than the mental and emotional harm experienced by those with PTSD. Additionally, those who do not engage in direct ground combat – pilots, health professionals, chaplains, to name a few – but are just as likely to experience something that 14 FRAMING PTSD may cause PTSD, might mistakenly perceive the term “injury” as something that results from physical harm, thus curbing their willingness to seek help (Fisher & Schell, 2013). According to Fisher and Schell (2013): We believe that altering the label or acronym – without making more wholesale changes to how the disorder is defined, how diagnosed individuals are treated, or how the military uses information about diagnosis and treatment – is unlikely to generate dramatic changes in treatment-­‐seeking or treatment-­‐utilization. (p. 9) Prominent military figures disagree despite the American Psychiatric Association’s decision to retain PTSD’s label as a disorder, and have informally begun to use the term “post-­‐traumatic stress” or “PTS” because they feel it is less stigmatizing and thus encourages the seeking of treatment (Fisher & Schell, 2013). Retired Army Gen. Pete Chiarelli, the service’s former vice chief of staff, notes, “If you are a 19-­‐, 20-­‐, 21-­‐year-­‐old kid, you don’t want to be told you have a disorder” (Kime, 2014). Additionally, former President George W. Bush believes, “Post-­‐traumatic stress is not a disorder. Post-­‐traumatic stress, or PTS, is an injury that can result from the experience of war. And like other injuries, PTS is treatable” (Kime, 2014). Fisher and Schell (2013) present the counterargument that service members experiencing PTSD symptoms could assume said symptoms are characteristic of a less severe “PTS” and therefore might not feel treatment is needed. Further, labeling PTSD as anything other than a disorder may create challenges for the military healthcare system, the U.S. Veterans Health Administration, and the medical and insurance industries as a whole (Fisher & Schell, 2013). Fisher and Schell (2013) note 15 FRAMING PTSD that nonstandard terminology might result in confusion among healthcare providers or lapses in care. Framing Theory Framing theory is an integral part of humanities, political and social science, and media studies. In 1987, Gamson and Modigliani defined framing as “a central organizing idea or story line that provides meaning to an unfolding strip of events” (Gamson & Modigliani, 1987). Consequently, “the framing and presentation of events and news in the mass media can thus systematically affect how recipients of the news come to understand these events” (Price, Tewksbury, and Powers, 1995, p. 4). Hallahan (1999) further simplifies the media’s role in framing it by asserting that although mass media is not necessarily effective in telling people what to think, media is effective in telling people what to think and how to think about it. Prior to the latter two statements, Dr. Robert Entman (1993) asserted there had yet to be a “general statement of framing theory that shows exactly how frames become embedded within and make themselves manifest in a text, or how framing influences thinking.” When applied to the media, Entman describes framing theory as an unconscious method of: Selecting and highlighting some aspects of a perceived reality and make them more salient in a communicating context, in such a way as to promote a particular problem definition, causal interpretation, moral evaluation, and/or treatment recommendation for the item described. (p. 55) More recently, framing scholars have made attempts to structure and define framing 16 FRAMING PTSD study with principles and methods that can be operationalized on any topic of study. Scheufele (1999) identifies the study of news framing as it encompasses three primary stages: mental framing, group framing, and content framing. Mental frames are the result of processing perceived frames when consuming news, which act like filters to help organize and form ideas and opinions. We gather group frames collectively as a culture. They may be expressed as stereotypes, or frames we apply to the information we receive based on how we were raised, where we grew up, and our cultural beliefs. Content frames can clearly be described using this content analysis of framing Native Americans in The Boston Globe (Miller & Ross, 2004): Content frames are the products of the specific group(s) that produce cultural products. As cultural products, news media contain a limited range of content frames because the structure, norms, and practices of the media reflect and reinforce the elite group frame in which individual journalists and news organizations participate. Factors like print deadlines (Hofstetter, 1976), story form, journalistic routines (Shoemaker & Reese, 1996), business considerations (Hofstetter, 1976), and editing (Liebes, 2000) privilege certain content frames (Van Dijk, 1991). In addition, journalists depend on certain sources, interpretations, and perspectives to facilitate their work (Ghanem, 1996; Gitlin, 1980; Perkins & Starosta, 2001; Weston, 1996). The resulting content frames emerge not from intentional bias but from unintentional yet explicit content choices, “keywords, stock phrases, stereotyped images, sources of information, and sentences that provide thematically reinforcing clusters of facts or judgments’’ that reflect the group frame of the culture that produces them (Entman, 1993). (Miller & Ross, 17 FRAMING PTSD 2004) Prior to this study, news framing of individuals was largely unresearched. Since news and content frames have the power to influence how individuals understand and discuss the world around them (D’Angelo & Kuypers, 2010; Scheufele, 1999; Reese, 2001), it can be assumed that they would have the same influence on individuals and how they understand other individuals in the news. It can also be assumed that news frames do the following four things: define effects or conditions as problematic, identify causes, convey a moral judgment of those involved in the framed matter, and endorse remedies or improvements to the problematic situation (Entman, 1993). Impact of Mass Media Coverage and Framing of Mental Disorders A 1991 survey of adults in the U.S. cited mass media as their most frequent source of information about mental disorders (Wahl, 1995). Wakefield (1992) defines a mental disorder as “the failure of a person’s internal mechanisms to perform their functions as designed by nature impinges harmfully on the person’s well-­‐being as defined by social values and meanings” (p. 373). Sieff (2003) notes that images of mental disorders appear in news stories, entertainment, and advertising with great regularity, and that media coverage of mental disorders has been overwhelmingly negative and inaccurate over time. The mass media are an important source of information about mental health and have an important role in cultivating perceptions and stigma (Wahl, 2004). A 1957 study that examined representations of mental disorders in newspapers, magazines, and television observed that those afflicted with mental disorders were perceived as different than “normal” people and described as “dangerous, dirty, and unintelligent” (Taylor, 1957). 18 FRAMING PTSD Other studies have found that mental disorders are often linked to violence and crime in media (Sieff, 2003). According to Klin and Lemish (2008): The common perception is that those afflicted with mental disorders (not just those who suffer from schizophrenia) are dangerous; developmentally disabled, of low intelligence, have communication disorders, or all of these; are dysfunctional; and do not contribute as workers as they lack desire or are lazy. (p. 435) Corrigan and Penn (1999) further state negative social attitudes toward those with mental disorders are a key mental health and social problem. Such attitudes interfere with the social integration of those who suffer from mental disorders and could be a cause for discrimination (Klin & Lemish, 2008). Concerning PTSD, Eisler (2012) notes a major narrative of mass media is that post-­‐
9/11 veterans are broken, traumatized individuals who have behavioral health issues that require constant care and supervision. Ousley (2012) cites the March 2012 murder of 17 Afghan villagers at the hands of Army Staff Sgt. Robert Bales as one example that has reignited the inaccurate perception of post-­‐9/11 veterans with PTSD as ticking time bombs. Ousley (2012) further asserts, “This stereotype is not only detrimental for soldiers trying to reintegrate back into the civilian work force, but also for those who are suffering from PTSD and do not seek treatment because of the attached social stigma.” Assuming that negative framing of mental disorders in the media (Sieff, 2003) contributes to misperceptions and hostile attitudes toward those afflicted with a mental disorder such as PTSD, then positive framing may be able to produce positive perceptions, reduce stigma, and contribute to a change in public attitudes toward mental disorders. 19 FRAMING PTSD METHODS To determine the differences between how civilian media and U.S. military media frame post-­‐traumatic stress disorder, and the role those differences play in post-­‐9/11 service members’ decisions to seek mental help, this research utilized a mixed-­‐method approach consisting of a content analysis and in-­‐depth interviews. CONTENT ANALYSIS First, a content analysis was conducted to determine the differences between civilian media and the U.S. military’s framing of post-­‐traumatic stress disorder. To accomplish this, print articles from the websites of two leading national civilian newspapers – The New York Times and USA TODAY – determined by daily circulation (Alliance for Audited Media, 2013), were compared with news articles from the U.S. Department of Defense’s official website (Defense.gov), as well as the official websites of the U.S. Navy (Navy.mil), U.S. Air Force (AF.mil), and U.S. Marine Corps (Marines.mil). The following search terms were utilized in each outlet’s main search tool: “PTSD” AND “military” AND “post traumatic stress disorder” AND “post-­‐traumatic stress disorder” Search results were then filtered by type (news articles) and a customized date range of publication – December 18, 2011, the date of U.S. combat troop withdrawal from Iraq (Logan, 2011), through March 1, 2014. USA TODAY’s search engine yielded 123 results, 13 of which were deemed unusable because they were either videos or did not mention PTSD, leaving a population size of 110 articles. The initial search on The New York Times website yielded 107 results, however, 20 FRAMING PTSD The New York Times’ website will only allow its end-­‐user to view the first 30 results of any search. Three of the available 30 articles were then deemed unusable, also because they did not mention PTSD, leaving a population size of 27 articles from The New York Times. This brought the total population size of civilian news articles that could be coded to 137. On the military side, the U.S. Department of Defense website yielded 14 results that matched the search criteria, while the U.S. Navy produced 75, the U.S. Air Force returned 16, and the U.S. Marine Corps generated 20. This brought the population size of military news articles that could be coded to 125. News articles from the U.S. Army’s official website were omitted because search results could not be narrowed down to a reasonable number. A coding instrument was then crafted to analyze 16 different data points within the articles to determine the differences in framing between the two types of news articles. A copy of the codebook is included in Appendix A on page 47, but highlights from the analysis include: •
PTSD treatment and barriers to treatment •
Language that encourages individuals to seek help for PTSD •
Specific information on where to go/what to do for PTSD treatment •
Portrayal of those afflicted with PTSD as troubled individuals •
Stigma associated with PTSD •
PTSD as an acceptable condition •
Portrayal of those with PTSD as “others” 21 FRAMING PTSD After the coding instrument was produced, the table referenced below, from Krejcie and Morgan (1970), helped determine the number of articles that needed to be sampled to achieve a 95 percent confidence level Table 1 While 137 civilian news articles were deemed to be codeable, 102 were coded to achieve the specified confidence level – all 27 available articles from The New York Times and 75 from USA TODAY. Of the 125 codeable military news articles, 95 were coded to achieve the same objective – all articles from the U.S. Department of Defense, U.S. Air Force, and U.S. Marine Corps, and 45 from the U.S. Navy. This brought the total number of coded news articles to 197. A further breakdown of the sampling size of each category of news articles is provided below: 22 FRAMING PTSD Table 2 USA TODAY NUMBER OF ARTICLES USED IN CODING 75 The New York Times 27 CIVILIAN TOTAL U.S. Department of Defense 102 U.S. Navy 45 U.S. Air Force 16 U.S. Marine Corps 20 MILITARY TOTAL 95 TOTAL 197 NEWS OUTLET 14 IN-­‐DEPTH INTERVIEWS Subsequent to the content analysis, in-­‐depth interviews were conducted with three post-­‐9/11 veterans afflicted with PTSD concerning their decisions to seek professional help for the condition. Interview recruitment was conducted through email correspondence, as the researcher and participants had established prior professional relationships during the researcher’s preceding eight years of service as an active-­‐duty United States Marine. It was through these relationships and conversations that knowledge of the participants’ PTSD diagnoses was gained. Interviews took place aboard or in the surrounding area of Fort George G. Meade, Maryland, in March 2014. All three of the interview subjects were males – two were white and the other identified himself as multi-­‐racial – and were enlisted during their service, meaning they were not commissioned military officers. The ages of the interviewees were 23 FRAMING PTSD 26, 34, and 41-­‐years old respectively. Two of the interviews took place at the interviewees’ places of business, while the other took place at the home of one of the interview subjects. Pseudonyms were assigned to each interviewee to ensure confidentiality. A copy of the interview questions is included in Appendix B on page 49. RESULTS CONTENT ANALYSIS While coding this content analysis, the total number of “yes” and “no” answers for each coding instrument data point was translated into a percentage to determine disparities between the points. Consequently, two predominant frames concerning PTSD’s representation in military and civilian news articles were found. The Abnormal Frame The abnormal frame portrays those with PTSD as divergent from social norms or unlike “normal” people. Evidence suggests civilian news articles are much more prone to employ this frame than the military. Indeed, more than twice as many of the civilian news articles in this study describe those afflicted with PTSD as troubled – unemployed, homeless, alcoholic, drug addicted, divorced, violent, or suicidal – the same group of characteristics that can lead to the “othering” of post-­‐9/11 veterans with PTSD. Additionally, almost ten times as many civilian articles depict service members and veterans living with PTSD as “ticking time bombs” or “ready to snap.” 24 FRAMING PTSD Table 3 70"
60"
63#
50"
Percentage'
of'
Articles'
40"
Civilian'
30"
Military'
31#
20"
19#
10"
2#
0"
Troubled"
The Supportive Frame Ready"to"Snap"
The supportive frame works to eliminate stigma surrounding the condition and encourages those who may need PTSD treatment to seek it. Evidence suggests military news articles are significantly more likely to exercise this frame than civilian newspapers. In fact, nearly ten times as many military news articles used language that encouraged people to seek help for PTSD, while 33 percent of military articles provided PTSD sufferers specific information on what to do or where to go in order to seek treatment. Zero civilian news articles did the latter. Additionally, almost ten times as many military news articles portray PTSD as an acceptable condition to have after having been through an experience such as combat. 25 FRAMING PTSD Table 4 60"
50"
52"
48"
40"
Percentage'
of'
Articles'
Civilian'
33"
30"
Military'
20"
10"
0"
5"
Encouraged"
0"
Treatment"Info"
5"
Acceptable"
Additional Results Roughly half of civilian and military news articles portrayed the anxiety, nervousness, or hyper-­‐vigilance associated with PTSD as a “social hindrance” for its sufferers, while both types of articles mentioned the stigmas associated with PTSD at a disparity level of 10 percent. The citation of previous research or the need for further PTSD research, and the idea or mentioning of recovery from PTSD were inversely correlated though, as more than twice as many civilian news articles mentioned research and more than twice as many military news articles mentioned recovery. Additionally, each type of article identified specific individuals with PTSD at a relatively similar rate, while military articles mentioned the importance of families’ roles in dealing with PTSD 50 percent more often than their civilian counterparts. 26 FRAMING PTSD Table 5 60"
50"
40"
52#
50#
46#
45#
35#
Percentage'
30"
of'
Articles'
45#
45#
37#
36#
Civilian'
Military'
20"
22#
24#
17#
10"
0"
Social"
Hindrance"
Stigma"
Research" Recovery" Identi=ied" Families"
Individual"
IN-­‐DEPTH INTERVIEWS In-­‐depth interviews were utilized to help reveal the U.S. military’s social and organizational nuances concerning PTSD and post-­‐9/11 veterans’ decisions to seek help. Common themes found amongst the three participants were: !
Individuals’ beliefs that they could not have PTSD !
Experiences within the military differ for everyone !
The belief that the military is working to reduce stigma associated with PTSD !
The belief that civilian media is not helping reduce stigma associated with PTSD 27 FRAMING PTSD “Not Me” All three interviewees revealed that they disregarded the possibility they could have PTSD prior to seeking treatment. This viewpoint was due to the participants’ prior perceptions that those with more combat-­‐centric military occupations were more prone to experiencing the condition than they were, or that the condition was not debilitating enough for them. “Sebastian,” a 23-­‐year Air Force veteran, described his line of thinking prior to his PTSD diagnosis: “There’s no way I could have PTSD, because I’m a journalist, right? I did stories on (Medal of Honor recipient) Sal Giunta. Sal’s a friend of mine. I’ve heard Sal’s story. I’m like, ‘This guy – he could totally have PTSD!’ He’s killed more people than I’ve seen with flesh wounds. So I know these stories about all these fantastic warriors. Of course they have PTSD. It couldn’t be me.” While Sebastian began having sleeping and memory issues two years after his second deployment to Iraq, he only seriously considered the fact he could have PTSD after he took a course that would certify him as being able to teach the signs and symptoms of PTSD to other service members. After conducting a self-­‐evaluation, Sebastian learned he was a strong candidate for having PTSD and sought mental health treatment. “Elijah” said he got his first clue something may wrong a couple months after he returned home from Afghanistan. An unexpected fireworks display near his home caused him to drop to the floor for cover due to the sound of the explosions being reminiscent of incoming mortar fire. He said the experience caused him to shake for 30 minutes afterward. Elijah was confused by his response: 28 FRAMING PTSD “I didn’t see anyone get hurt and I didn’t see anyone die, so I was wondering why I would have any symptoms. Nothing really bad happened to me.” Elijah decided to get help after he acted out of character during a verbal argument with his wife, and his nightmares started becoming more frequent. He said he just wanted to sleep normally and didn’t want his wife to ever see him “lose it” again. “Jacob” simply felt the condition did not affect him to the point where he needed help: “I just didn’t think I had a problem. Plain and simple. I knew there were little things but there was never really anything that was stopping my function as a husband, as a father, or even keeping me from doing my job.” Jacob sought help years later, but was not as lucky as Elijah and Sebastian with his dealings with the military medical system. Experiences May Differ All three participants agreed that experiences on deployments, experiences with the military medical system, and the severity of PTSD’s symptoms differ from individual to individual. In fact, Sebastian, who is now retired, said his two deployments to Iraq were completely different. His first deployment saw him staying in a Westernized hotel that had three restaurants and two nightclubs where fellow service members drank alcohol nightly, whereas conditions during his second deployment were far more serious: “In 2003, I only saw casualties when I was out at a combat support hospital. In 2007, I saw them almost every day. 2007 was way worse.” 29 FRAMING PTSD Echoing Sebastian’s sentiments concerning the dangerous conditions that developed after the initial stages of the Iraq War, Jacob noted the unit he was embedded in lost 11 Marines during its 2006 deployment to Ramadi, Iraq: “I felt like I wanted to shit my pants every time I left the wire (base).” Elijah, who is still an active-­‐duty Marine, deployed to Afghanistan in 2012. A majority of the experiences that caused his PTSD involved indirect mortar fire landing near him on various bases throughout the country. Further disparities exist in each of the participants’ experiences with the military medical system. Elijah’s dealings getting psychiatric help have been relatively easy. He got his first appointment with a doctor soon after coming forward in 2013 and has regularly met with a behavioral health specialist ever since. Sebastian, on the other hand, has yet to receive a disability rating decision from the U.S. Department of Veterans Affairs (the VA) despite already retiring from the service. He claims the medications the VA has put him on in the past will push his rating from 50 to 100 percent because of the damage they have caused. Still, Jacob’s situation may be the most perplexing. After returning home from Iraq, Jacob was sent to attend a conference while the rest of his unit conducted post-­‐deployment health assessments mandated by the U.S. Department of Defense. These assessments are used to identify those who are at a high risk of having PTSD. Upon returning from the conference, Jacob was sent to attend a school that had minimal contact with the military. From there, he was sent to an overseas U.S. Air Force base for three years before heading to his final duty station in Maryland. It was there – more than five years after his deployment – that someone finally realized he had not completed a post-­‐deployment health assessment. 30 FRAMING PTSD “I’m answering all these questions ‘How do you feel about this?’ ‘Have you seen any of this?’ Blah, blah, blah, blah, blah. I’m going, maybe I do, but at this point I’m already separating from the Marine Corps.” -­‐Jacob Jacob did not have an appointment with a counselor until almost a year and a half after he separated from the Marine Corps. He says the VA determined there was not enough evidence to officially diagnose him with PTSD, even though he had been dealing with symptoms for more than six years since deploying. “Some people deal with things better than other people do. I coped. Life was happening. It was time to move on.” -­‐Jacob Jacob’s thoughts aptly illustrate Sebastian’s view that PTSD is a spectrum disorder: Sebastian: Just think, have you ever put a gun in your mouth? Researcher: No. Sebastian: Yeah, me neither. But there are people among us who have, and they have PTSD too. Doing the Work Participants agreed there is still stigma associated with PTSD in the military, in part because of the condition’s classification as a disorder: “There’s a stigma when you have a mental disorder. That person is different, there’s something dirty or ugly about what they’re suffering from. But when you clean it up and call it something else, it doesn’t sound as dirty.” -­‐Jacob “I feel more comfortable saying I have post-­‐traumatic stress as opposed to PTSD. Disorder is just a crappy word.” -­‐Elijah 31 FRAMING PTSD Yet, there is a census among participants that the military is working diligently to eliminate PTSD stigma. Jacob saw this approach first-­‐hand when a co-­‐worker asked for help: “The efforts I saw to get him aid and to make sure he was cared for gives me the perspective that we’re taking a more active approach in ensuring these guys get the help they need.” Sebastian agreed, and, along with the other participants, feels one way to eliminate the stigma is having PTSD sufferers come forward to share their stories: “There’s still a stigma. It may seem like I waited until my twilight years to go look for help for PTSD. However, I see a lot of people do that and a lot of people struggle until their last couple years in and then they seek help. We are now getting more and more people at higher and higher levels saying we need to do something about this and there is nothing wrong with PTSD.” Participants also felt continued education and training surrounding on how to recognize the symptoms of PTSD can help reduce the stigma surrounding the condition: “The military side was almost like muscle memory. I’d been to so many briefings and done so many Power Points that once I realized that these were symptoms, I knew I needed to go get it taken care of.” -­‐Elijah “You go through training as an NCO (noncommissioned officer) to recognize the signs of suicide in your junior troops. What’s so different about doing that with PTSD?” -­‐Jacob 32 FRAMING PTSD Not Helping Collectively, participants believe civilian news media is one of the main contributors to stigma surrounding PTSD: “I think the civilian media portrays everybody in the military to have PTSD. We’re drunks, we’re rapists, we’re killers, we gamble, we’re all these horrible traits. I don’t think the civilian media is doing a good enough job at advocating for people with PTSD. I say that because if they did, there’d be a bigger calling for supporting these VA claims, and these VA benefits, and it’s still a trickle instead of a gush of support.” -­‐Sebastian “I think they (civilian news media) acknowledge that PTSD’s a problem and they try to shed light on it, but also sometimes I think they’ll use it to spin a story if anything happens that has anything to do with a vet. And I think the first thing they look for is ‘did he deploy?’ or ‘did he suffer from PTSD?” -­‐Elijah As a result, participants concurred in their belief that the American public does not understand combat-­‐related PTSD: “Less than one percent serve, less than one percent have a connection to someone serving in the military to know and see what these people come back with. The vast majority has an awareness of it based on what the media has portrayed it to be, so the only reality they have about it is the homelessness or violence that they see. They don’t see anything else because they don’t have a connection to it.” -­‐Jacob 33 FRAMING PTSD DISCUSSION This study demonstrated the differences between how civilian newspapers and official U.S. Department of Defense news articles frame post-­‐traumatic stress disorder (PTSD) and explored the role these differences play in post-­‐9/11 service members’ decisions to seek mental help. The discussion that follows first addresses the two major frames found during this research, speculates about why these frames exist, and reflects upon their roles in veterans’ decisions to seek treatment. It then discusses “othering” theory and how the theory applies to PTSD, the military, and the public. The discussion closes by examining participants’ pre-­‐treatment beliefs that they did not have PTSD, followed by suggestions on how to reduce stigma surrounding the condition. Major Frames The two major frames found during this research are not surprising considering Eisler’s (2012) assertion concerning the two prominent narratives surrounding post-­‐9/11 veterans in today’s society. The supportive frame, which this research found more often in military articles, is a product of military public affairs doctrine laid out in Joint Publication 3-­‐61 (Joint Chiefs of Staff, 2010). This set of guidelines outlines fundamental principles and guidance, as well as the role of public affairs in U.S. Department of Defense strategic communication efforts (Joint Chiefs of Staff, 2010). One such role is to utilize available military outlets to disseminate command information to troops (Joint Chiefs of Staff, 2010). Therefore, as long as the U.S. military makes efforts to reduce stigmas surrounding PTSD, official military news articles, such as the ones utilized in this research, will continue to employ supportive framing in order to encourage troops to seek help for the condition. 34 FRAMING PTSD Alternately, civilian media outlets more often utilize the abnormal frame surrounding post-­‐9/11 veterans with PTSD. This is also no surprise considering the nature of civilian journalism may be to sensationalize in order to sell newspapers and increase digital readership. As such, civilian media may more easily exaggerate conditions, events, or other phenomena without regard to damaging or promoting stigma surrounding certain groups, such as those with PTSD. For example, following the April 2, 2014, shooting at Fort Hood, Texas – which occurred subsequent to the primary research contained in this capstone – that left four dead (including the gunman) and 16 injured, civilian media outlets such as CNN, Huffington Post, and McClatchy DC were quick to publish articles linking the shooter, Spc. Ivan Lopez, with PTSD, even though there is no proof Lopez suffered from it. Huffington Post later published a map showing where veterans with PTSD committed violent crimes, while McClatchy DC went as far as publishing a map showing where veterans with PTSD lived – reminiscent of local government maps indicating the locations of criminal sexual offenders. Veterans groups and other readers later lambasted these outlets for their misleading representations that those afflicted with PTSD are violent and dangerous, prompting Huffington Post to remove its graphic and issue an apology. McClatchy DC, however, did not follow suit. Despite these inaccurate portrayals of PTSD, and contradictory to the beliefs of interview participants that civilian news media is a main contributor to stigma surrounding the condition, some civilian news organizations are seemingly beginning to make concerted efforts to help reduce PTSD stigma following the recent shooting at Fort Hood. These efforts can be seen in various articles published by USA TODAY, FOX News, and Business 35 FRAMING PTSD Insider to name a few, which reinforce the ideas that sloppy media coverage of the shooting is irresponsible and only serves to promote stigma and reinforce stereotypes that veterans should be feared because they are violent and forever broken by war (Szoldra, 2014). Accordingly, it can be surmised that the abnormal frame, which is more often employed by civilian media, perpetuates stigma surrounding PTSD that may keep post-­‐
9/11 veterans from seeking help, whereas the supportive frame, utilized more often by official U.S. Department of Defense outlets, could more effectively reduce stigma by encouraging service members to seek treatment. “Othering” Those Without PTSD While one of the data points within the content analysis of this research showed that “othering” those with PTSD occurred more than twice as frequently in civilian news articles, in-­‐depth interviews revealed this may a two-­‐way phenomenon, as all three veterans who were interviewed referred to or insinuated that civilians do not understand veterans or PTSD, and therefore are part of a group which is unlike themselves. This “othering” of civilians suggests that veterans may be as equally culpable as civilians for the current military-­‐civilian divide that exists in the U.S. Granted, interview questions posed toward participants specifically inquired about distinctions between the two groups. “Not Me” Particularly noteworthy is the common viewpoint among all three in-­‐depth interview participants that, prior to seeking treatment, they could not be afflicted with PTSD because they had the perception they had not been through enough traumatic events 36 FRAMING PTSD to warrant having the condition. This perception could be based on preconceived notions of what kinds of situations, and the frequency at which these situations were encountered, would warrant a PTSD diagnosis. Considering Sebastian’s assertion that PTSD is a spectrum disorder, meaning it affects different individuals in different ways and at varying intensity levels, and Jacob’s argument that people have different abilities in which they handle and cope with trauma, there is little doubt as to why some do not believe they have PTSD. How to Reduce Stigma This research yielded a census of two major methods of reducing PTSD stigma. First, there is a glaring disparity between the motivations behind the American Psychiatric Association’s decision to retain the word “disorder” in PTSD in the newest edition of the Diagnostic and Statistical Manual of Mental Disorders, and the attitudes of service members and veterans – one of the condition’s most prominent demographics – toward PTSD. As outlined in Fisher and Schell’s 2013 report, psychiatrists involved in determining mental disorder criteria believe that dropping the term “disorder” from PTSD is unlikely to generate dramatic changes in treatment-­‐seeking or treatment-­‐utilization. However, Jacob and Elijah, along with previously mentioned military leaders and countless others, have verified that the term “disorder” is stigmatizing, and dropping the ‘D’ from PTSD would encourage more individuals to come forward for help. Additionally, Kime (2014) notes the stance of Dr. Matthew Friedman, a psychiatrist and former executive director of the VA’s National Center for PTSD, who declared, “PTSD is PTSD. To change it to PTSI would reverse 32 years of research and not reduce stigma or 37 FRAMING PTSD increase treatment seeking.” This quote illustrates the stance that those involved with researching and classifying PTSD are more dedicated to preserving their own research than helping de-­‐stigmatize the condition for others. If psychiatrists were truly concerned with the well-­‐being of individuals who are afflicted with a condition which they study, these mental health professionals would more seriously consider the voices of their patients and drop the “D” from PTSD in order to reduce stigma. This research suggest the other major method that can help reduce PTSD stigma is prominent figures who have been diagnosed with the condition coming forward to say it is perfectly acceptable to seek help – or just to educate the public on what PTSD is to promote understanding of the condition. News coverage following the recent Fort Hood shooting provided a perfect execution of this idea when former Marine Sgt. Dakota Meyer, a Medal of Honor recipient, appeared on FOX News Channel to address the irresponsible and unfounded claims made by various civilian media outlets that the Fort Hood shooter was afflicted with PTSD. During the interview, Meyer declared: Going out and shooting your own friends, your own people, that’s not PTSD. PTSD does not put you in the mindset to go out and kill innocent people. The media is labeling this shooting PTSD, but if what that man did is PTSD, then I don’t have it. (Gearty, 2014) CONCLUSION This research employed a mixed-­‐method approach consisting of a content analysis of PTSD coverage between two leading national newspapers and various U.S. military news outlets aimed at identifying the differences between civilian and military media frames 38 FRAMING PTSD surrounding PTSD. In-­‐depth interviews with three post-­‐9/11 veterans with PTSD were then utilized to help determine the role these differences play in post-­‐9/11 service members’ decisions to seek treatment. Among the major findings, this study identified two main frames surrounding PTSD coverage in civilian and military news articles. The abnormal frame, more prominent in civilian news articles, portrays those afflicted with PTSD as divergent from social norms, unlike “normal” people, or troubled – meaning unemployed, homeless, alcoholic, drug addicted, divorced, violent, or suicidal. Conversely, the supportive frame, more often employed by military media, works to eliminate stigma surrounding the condition and encourages those who may need PTSD treatment to seek it. Furthermore, stigma and the classification of PTSD as a disorder play significant roles in post-­‐9/11 veterans’ decisions to seek help. One of this study’s key limitations was the lack of a second coder during the content analysis to analyze the articles and confirm the reliability of the data and results. Additionally, time constraints precluded the analysis of more articles, which could undoubtedly strengthen the study's findings. Similarly, since only two leading national civilian newspapers were included in the study, the selection of additional newspapers would likely have resulted in different findings. Moreover, this study was also not only limited by the population of interview participants, but by the fact that all three interviewees shared the same military occupation during their service. Incorporating the views of service members from various fields within the military would most certainly have yielded additional meaningful results. 39 FRAMING PTSD Because studying PTSD frames and their role in post-­‐9/11 veterans’ decisions to seek treatment is relatively new, possibilities exist for variations of or improvements upon this study for future research. First, a more focused study of media frames surrounding PTSD that digs deeper into the nuances of post-­‐9/11 veterans thought processes could result in a specific set of suggestions to help media professionals more accurately report on such situations. Additionally, because this study only focused on newspaper coverage, studying depictions of PTSD in magazines, trade publications, films, or television programs could provide a wealth of additional information for this issue. While there may be little or no published research concerning the framing of PTSD, nor any published research on how these differences influence post-­‐9/11 service members’ decisions to seek treatment, this capstone helped lay a foundation for these issues to be further researched. This research can also serve to inform civilian media outlets, the U.S. military, and individual service members and veterans about the differences between civilian and military media portrayals of those afflicted with PTSD, and help identify frames that may encourage post-­‐9/11 service members to seek mental help. With nearly 30 percent of the 2.5 million American service members who have deployed to Iraq and Afghanistan being afflicted with post-­‐traumatic stress disorder (PTSD), and considering many of these individuals may never seek treatment, understanding how different media frames surrounding PTSD affect post-­‐9/11 veterans’ decisions to seek treatment is invaluable. By understanding how veterans perceive a mental health condition and determining what factors play into their decisions to take action, media outlets may consider taking different approaches to how they report on PTSD in order to help ensure sufferers step from the shadows of silence to the light of treatment. 40 FRAMING PTSD REFERENCES Adams, C. (2013, March 19). 2.5 million went to war in Iraq and Afghanistan; many returned with lifelong scars. Amarillo Globe-­‐News. Retrieved from http://amarillo.com/news/latest-­‐news/2013-­‐03-­‐19/25-­‐million-­‐went-­‐war-­‐iraq-­‐
and-­‐afghanistan-­‐many-­‐returned-­‐lifelong-­‐scars. Alliance for Audited Media. (2013). Top 25 U.S. newspapers for March 2013. Retrieved from http://www.auditedmedia.com/news/research-­‐and-­‐data/top-­‐25-­‐us-­‐newspapers-­‐
for-­‐march-­‐2013.aspx. American Psychiatric Association. (1980). Diagnostic and Statistical Manual of Mental Disorders (3rd ed.). Washington, D.C.: American Psychiatric Association Press. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington, D.C.: American Psychiatric Association Press. Bloom, S. L. (2000). Our hearts and our hopes are turned to peace: Origins of the International Society for Traumatic Stress Studies. In Shalev, A.Y., Yehuda, R., and McFarlane, A.C. (eds.), International Handbook of Human Response to Trauma. 27-­‐50. Breen, M. J., Devereux, E., & Haynes, A. (2008). Public exercises in othering: Irish print media coverage of asylum seekers and refugees. (Pre-­‐Published Version). Retrieved from: http://dspace.mic.ul.ie/bitstream/10395/1390/2/Public Exercises in Othering%3A Irish Print Media Coverage of Asylum Seekers and Refugees(Pre-­‐
Published Version)(Book Chapter).pdf. Corrigan, P. W., & Penn, D. L. (1999). Lessons from social psychology on discrediting psychiatric stigma. American Psychologist, 54(9), 765-­‐776. 41 FRAMING PTSD D'Angelo, P. (2002). News framing as a multiparadigmatic research program: A response to Entman. Journal of Communication, 52, 870–888. D'Angelo, P., & Kuypers, J. A. (2010). Doing news framing analysis: Empirical and theoretical perspectives. New York: Routledge. Dean, E. T. (1997). Shook Over Hell: Post-­‐Traumatic Stress, Vietnam, and the Civil War. Cambridge, MA: Harvard University Press. Eisler, D. (2012, August 5). The dangers of a sensationalist portrayal of veterans. The New York Times. Retrieved from http://atwar.blogs.nytimes.com/2013/08/05/the-­‐dangers-­‐of-­‐a-­‐ sensationalist-­‐portrayal-­‐of-­‐veterans/ Entman, R. M. (1993). Framing: Toward clarification of a fractured paradigm. Journal of Communication, 43, 51–58. Entman, R. M. (2003). Cascading activation: Contesting the white house’s frame after 9/11. Political Communication, 20, 415-­‐432. Entman, R. M. (2004). Projections of power: Framing news, public opinion, and U.S. foreign policy. Chicago, IL: University of Chicago. Fisher, M. P., & Schell, T. L. (2013) The role and importance of the ‘D’ in PTSD. Retrieved from http://www.rand.org/content/dam/rand/pubs/occasional_papers/OP300/OP389/
RAND_OP389.pdf. Gamson, W. A., & Modigliani, A. (1987). The changing culture of affirmative action. Research in Political Sociology, 3, 137-­‐177. 42 FRAMING PTSD Gearty, R. (2014, April 6). Linking Fort Hood shooting to PTSD hurts vets trying to heal, says Dakota Meyer. FOX News. Retrieved from http://www.foxnews.com/us/2014/04/06/linking-­‐fort-­‐hood-­‐shooting-­‐to-­‐ptsd-­‐
hurts-­‐vets-­‐trying-­‐to-­‐heal-­‐says-­‐dakota-­‐meyer/. Goffman, E. (1963). Stigma: Notes on a Spoiled Identity. New York: Simon and Schuster. Hallahan, K. (1999). Seven models of framing: Implications for public relations. Journal of Public Relations Research, 11(3), 205-­‐242. Hautzinger, S., & Scandlyn, J. (2014). Beyond Post-­‐Traumatic Stress: Homefront Struggles with the Wars on Terror. Walnut Creek, CA: Left Coast Press. Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to dare. The New England Journal of Medicine. 351, 13-­‐22. Johnson, J. L., Bottorff, J. L., Browne, A. J., Grewal, S., Hilton, B. A., & Clarke, H. (2004). Othering and being othered in the context of health care services. Health Communication, 16(2), 253-­‐271. Joint Chiefs of Staff. (2010). Public Affairs (Joint Publication 3-­‐61). Retrieved from http://www.dtic.mil/doctrine/new_pubs/jp3_61.pdf. Kime, P. (2014, March 18). Bush: Drop the ‘D’ in PTSD. Military Times. Retrieved from http://www.militarytimes.com/apps/pbcs.dll/article?AID=2014303180051. Kirschner, S. R. (2012). How not to other the other (and similarly impossible goals): Scenes from a psychoanalytic clinic and an inclusive classroom. Journal of Theoretical and Philosophical Psychology, 32(4), 214-­‐229. 43 FRAMING PTSD Klin, A., & Lemish, D. (2008). Mental disorders stigma in the media: Review of studies on production, content, and influences. Journal of Health Communication, 13, 434-­‐449. Krejcie, R. V., & Morgan, D. W. (1970). Determining Sample Size for Research Activities. Educational and Psychological Measurement, 30, 607-­‐610. Logan, J. (2011, December 18). Last U.S. troops leave Iraq, ending war. Reuters. Retrieved from http://www.reuters.com/article/2011/12/18/us-­‐iraq-­‐withdrawal-­‐
idUSTRE7BH03320111218. Miller, A., & Ross, S. D. (2004). They are not us: Framing of American Indians by the Boston Globe. Howard Journal of Communications, 15(4), 245-­‐259. Ousley, J. (2012, April 12). Soldiers continue to struggle with public perception of PTSD. Veterans United Network. Retrieved from http://www.veteransunited.com/network/soldiers-­‐continue-­‐to-­‐struggle-­‐with-­‐
public-­‐perception-­‐of-­‐ptsd/. Pew Research Center. (2011). Iraq and public opinion: The troops come home. Retrieved from http://www.pewresearch.org/2011/12/14/iraq-­‐and-­‐public-­‐opinion-­‐the-­‐
troops-­‐come-­‐home/. Philo, G. (Ed.) (1999). In G. Philo (Ed.), Message received: Glasgow media group research 1993-­‐1998. Harlo: Addison Wesley Longman. Price, V., Tewksbury, D., & Powers, E. (1995, November). Switching trains of thought: The impact of news frames on readers’ cognitive responses. Paper presented at the annual conference of the Midwest Association for Public Opinion Research, Chicago, IL. 44 FRAMING PTSD Reese, S. D. (2001). Framing Public Life: A bridging model for media research. In S. D. Reese, Framing Public Life: Perspectives on media and our understanding of the social world. Mahwah, NJ: Erlbaum. Reno, J. (2012). Nearly 30 percent of vets treated by V.A. have PTSD. The Daily Beast. Retrieved from http://www.thedailybeast.com/articles/2012/10/21/nearly-­‐30-­‐of-­‐
vets-­‐treated-­‐by-­‐v-­‐a-­‐have-­‐ptsd.html. Robinson, S. L. (2004). Hidden toll of the war in Iraq: Mental health and the military. Center for American Progress. Washington, D.C. Sayer, N. A., Friedemann-­‐Sanchez, G., Spoont, M., Murdoch, M., Parker, L. E., Chiros, C., & Rosenheck, R. (2009). A qualitative study of determinants of PTSD treatment initiation in veterans. Psychiatry: Interpersonal and Biological Processes, 72(3), 238-­‐
255. Scheufele, D. A. (1999). Framing as a theory of media effects. Journal of Communication, 49, 103-­‐122. Scott, W. J., (1990). PTSD in DSM-­‐III: A case in the politics of diagnosis and disease. Social Problems, 37(3), 294-­‐310. Sieff, E. M. (2003). Media frames of mental illnesses: The potential impact of negative frames. Journal of Mental Health, 12(3), 259-­‐269. Szoldra, P. (2014, April 12). Why the scaremongering about murderous veterans is ridiculous. Business Insider. Retrieved from http://www.businessinsider.com/ptsd-­‐
violence-­‐2014-­‐4. Taylor, W. L. (1957). Gauging the mental health content of the mass media. Journalism Quarterly, 191-­‐201. 45 FRAMING PTSD Wahl, O. F. (1995). Media madness: Public images of mental illness. New Brunswick, NJ: Rutgers University Press. Wahl, O. F. (2004). Stop the presses. Journalistic treatment of mental illness. In L.D. Friedman (Ed.), Cultural sutures. Medicine and media, Durkheim, NC: Duke University Press. Wakefield, J. C. (1992). The concept of mental disorder: On the boundary between biological facts and social values. American Psychologist, 47(3), 373-­‐388. 46 FRAMING PTSD APPENDICES Appendix A: Code Book 1. Article Author Civilian – A1 Service Member – A2 2. Source New York Times – B1 USA Today – B2 Marines.mil – C1 AF.mil – C2 Navy.mil – C3 Defense.gov – C4 3. PTSD Expert Spokesperson Doctor – D1 Medical professional – D2 Military Officer -­‐ D3 Military Enlisted -­‐ D4 VA Representative – D5 Legislator – D6 Veteran Organization Rep – D7 None – D8 4. Article names specific individual with PTSD Yes – E1 No – E2 5. Article mentions military families/spouses Yes – F1 No – F2 6. Article mentions PTSD treatment Yes –G1 No – G2 7. Article mentions recovery from PTSD Yes – H1 No – H2 8. Article mentions barriers for PTSD treatment Yes – I1 No – I2 47 FRAMING PTSD 9. Article encourages people to seek help for PTSD Yes – J1 No – J2 10. Article provides info on where to go/what to do for PTSD treatment Yes – K1 No – K2 11. Article mentions research/studies on PTSD Yes – L1 No – L2 12. Article portrays PTSD as a social hindrance (anxiety, nervousness, hyper-­‐
vigilance, etc.) Yes – M1 No – M2 13. Article portrays those with PTSD as troubled (Homeless, Drug addict, Alcoholic, Family problems, divorce, Unemployed, suicidal, violent) Yes – N1 No – N2 14. Article mentions stigma associated with PTSD Yes – O1 No – O2 15. Article portrays PTSD as acceptable Yes – P1 No – P2 16. Article portrays those with PTSD as “ticking time bombs” or “ready to snap” Yes – Q1 No – Q2 48 FRAMING PTSD Appendix B: In-­‐Depth Interview Questions 1. Why did you choose to serve in the military? 2. What were your impressions of the military before you joined? 3. What was boot camp and job training like? 4. Where was your first duty station? 5. Where else have you been stationed? 6. Have you ever deployed to a combat zone? When, where, and how many times? 7. What was your experience(s) like? 8. How did you feel when you returned home? 9. How do you view the military now? 10. How have your military experiences changed you? 11. Please give me your personal definition of PTSD. 12. Where do you draw your personal definition of PTSD from? 13. In your view, how does the civilian news media portray PTSD? 14. How does the military portray PTSD? 15. What are some stereotypes of PTSD? 16. Have you or someone you know been diagnosed with PTSD, or do you expect someone of having PTSD? 17. Why did you/they seek professional help? 18. What barriers were there to getting help? 19. What are your/their symptoms? 20. When did you/they know you/they needed PTSD treatment? 21. Do you believe PTSD is stigmatized within the military? If so, why? 49 FRAMING PTSD 22. What do you are the biggest factors in stigmatizing PTSD? 23. What do you think could be done to de-­‐stigmatize PTSD? 24. What is your definition of a mental disorder? 25. Do you consider this person/yourself to have a mental disorder? 26. Do you think the American public understands PTSD? Why or why not? 50