Gala True, PhD is a medical anthropologist and folklorist whose research employs community engaged research approaches to improving access to and engagement in care. She has spent the past 5 years collaborating with U.S. Veterans of the wars in Iraq and Afghanistan on participatory action research to reduce barriers to care and improve post-deployment reintegration. She recently received funding from the Department of Veterans Affairs to build on that work through a photovoice project to engage Veterans with traumatic brain injury and their family members in efforts to improving patient-centered care in VA and community health settings.
Dr. Gala True’s work focuses on the use of visual and narrative methods in community engaged research, particularly with veterans of the wars in Iraq and Afghanistan. Her recent work has focused on understanding barriers to mental health care for veterans, and how we can address those barriers both within the VA and outside the VA. Using a community-based participatory approach, her work actively engages veterans and is very heavy on the advocacy side.
About the Work
CPHI: Tell us about how you got started working with veterans.
GT: I received my PhD in folklore from Penn, so from the very beginning of my training there was always an emphasis on the power of people being able to share their stories, and the importance of understanding how identity and community impact the way that people think about health, healing, and illness. From the moment I started at the VA about 8 years ago, I absolutely loved working with veterans. No matter how many times I think I’ve heard their stories, they’ll look at it from a different angle and say something powerful – I feel like I’m constantly learning.
“No matter how many times I think I’ve heard their stories, they’ll look at it from a different angle and say something powerful – I feel like I’m constantly learning.”
CPHI: How has this worked helped you describe public health challenges faced by veterans?
GT: The biggest public health concern comes from the fact that what a veteran is experiencing may be different from someone who didn’t serve, whether it’s a physical health problem, a mental health problem, or a work-related issue like transitioning back into the workforce. Health professionals and healthcare organizations need to be aware of what the special issues might be for veterans, and also what the resources are. There is an abundance of community and VA resources along with government funding and effort behind meeting the needs of veterans, but the issue is often about connecting veterans to these services.
CPHI: Describe your current research and advocacy projects.
GT: Currently, my work focuses on the use of visual and narrative methods in community-based research, particularly with veterans of the wars in Iraq and Afghanistan. I have done a life-story study with veterans who served in Iraq and Afghanistan to understand how they see trauma experiences during deployment to combat. The work focuses on how they see those traumas as fitting within the life-course of their entire life, and how they think about moving forward and recovering from those traumas. I have directed a photovoice project, using community based participatory research methods, with veterans who served in Iraq and Afghanistan, and it’s been going on for about 3 years now and has been very heavy on the advocacy side.
CPHI: Can you provide examples of the types of products that result from these projects?
GT: The first kind of products that came out of the project was this exhibit of veterans’ photo narratives that tell their stories of military service and homecoming and seeking care and moving forward with their lives after military service. The advocacy part has been that veterans in the project have remained very engaged in thinking about what could be done to improve post-deployment care for themselves, their veteran colleagues, and their community, and what could be done to support reintegration into their communities. We present together to healthcare providers and policymakers both within and outside VA, to advocate for the healthcare and reintegration needs of post 9-11 veterans.
Understanding Barriers to Care
CPHI: How have the stories helped understand barriers to healthcare among veterans?
GT: Veterans’ reflections on how their military service and experiences impact on their physical and mental health have led to a more nuanced understanding of the barriers they face to getting the healthcare they need– mental healthcare in particular—and how we can address those barriers both within the Department of Veterans Affairs (VA) and outside the VA. In a recent paper in Qualitative Health Research, we found that veterans talked about stigma as a barrier to care, but it was a much more complicated concept for them, and some of the stigma they were talking about was the stigma they encountered from health care professionals.
CPHI: Can you discuss the barriers to mental healthcare described in your recent paper?
GT: A few common themes have come up with in the paper we just published. Some of these themes include:
#1: Aspects of military culture and identity can deter health seeking
The military is a total institution where you go in with the purpose to break down your civilian identity and build you back up into the identity of the soldier, Marine, Airman, etc. Veterans are taught not to complain about physical ailments, and in fact to blast through any pain, and this can contribute to them being resistant to acknowledge mental health symptoms or distress. There is also this de-emphasis in the military on the needs of the individual, and an emphasis on stoicism and self-reliance, which gets solidified during deployment. Veterans who are deployed will often be so focused on survival and watching out for the person to their right and to their left that they’re not thinking about their own health. There’s a concept called ‘battlemind,’ which is like a state of mental toughness that’s instilled during military training, solidified during deployment, but also continues beyond coming home; it can really have an impact on how veterans view their symptoms or report them to others.
#2: Symptoms and coping strategies as barriers to care
A lot of veterans come up with short-term coping strategies for things like insomnia, anxiety, panic attacks, and depression through alcohol, drugs, and self-isolation – ‘I’m going to stay in my apartment and won’t go out, then I won’t have any bad encounters.’ Unfortunately, their symptoms and coping strategies can be impediments to getting mental healthcare. For example, sometimes someone will have an appointment, but he/she will wake up and will feel incapable of getting in the car or dealing with the stressors of driving, going in confined spaces, or going into a healthcare setting. Veterans are very self-aware that those are short-term solutions – they don’t think ‘oh this is great! – Rather, they don’t necessarily know how to get from the short-term coping mechanisms into treatment or into longer-term, more adaptive coping mechanisms.
“There’s a concept called ‘battlemind,’ which is like a state of mental toughness that’s instilled during military training, and that state of ‘battle mind’ is really solidified during deployment, but also continues beyond coming home. “
#3: Negative healthcare encounters may deter treatment
A lot of veterans have stories about going to seek help and coming up against bureaucratic issues in terms of scheduling an appointment, feeling judged by people within the healthcare system, and having what might be thought of as “anti-patient centered care experiences” – such as women being perceived as they couldn’t possibly have been in a combat situation. Veterans discussed being stereotyped during healthcare encounters where they would be very well-groomed and well-dressed externally, but internally they were falling apart; they would hear comments from healthcare providers such as “well, you can’t be doing that badly—you’re young and fit.” There is a tendency in mental health to assess grooming and eye contact as signs of whether or not someone is in distress. This doesn’t take into account that many veterans continue to carry themselves with a military bearing long after separation from the service, even if they are experiencing mental health issues.
CPHI: How is Sandra Bloom’s (2013) work on the concept of sanctuary trauma relevant to your findings?
GT: I first heard about Bloom’s concept of sanctuary trauma from a colleague, and it felt very relevant to the narratives we were hearing from veterans about negative healthcare encounters they experienced when seeking treatment for their post-traumatic stress. Essentially, the concept outlines what happens when someone who has experienced a trauma seeks help, and they have negative encounters with the people and institutions that are supposed to be helping them; it’s deeply re-traumatizing for many patients, and can deter them from seeking further care. For example, veterans described how traumatizing it could be to be asked questions about suicidal thoughts, symptoms of post-traumatic stress, and experiences of military sexual trauma or combat related traumas. While providers might see these questions as routine—and they are important questions to ask—veterans observed the damage that can happen if they aren’t asked in the right language and the right setting. It’s a great argument for the importance of patient-centered care.
Benefits and Relevance in the Field
CPHI: What are the benefits of this methodology for veterans?
GT: Photovoice is a really powerful way to get into topics such as stoicism, the ‘battle mindset’, and self-identity. Veterans are able to reflect on these topics, articulate them, and then share them with each other. Additionally, using the photos and photovoice method allows veterans to reflect in a way that survey-based studies haven’t necessarily been able to dig into. For this project, a really important part of photovoice was the idea of empowering veterans and enabling them to be collaborators in the research.
“For this project, a really important part of photovoice was the idea of empowering veterans and enabling them to be collaborators in the research.”
CPHI: How are these findings relevant to public health and healthcare practitioners?
GT: First, we provide military competency training to providers and use real stories to help illustrate the gap between what providers know about military culture, what veterans might have experienced during a deployment, and what resources are available for support. We focus some of our efforts on non-VA providers since about half of veterans who are coming home from these recent wars are seeing providers who are outside the VA.
The other part is to try to make the VA a more patient-centered place for these recent combat veterans. We’ve been doing that by presenting our findings nationally to VA healthcare providers, staff and leadership. Additionally, our photovoice exhibit travels to different VAs and this encourages dialogue between VA providers and staff with veterans about creating more veteran-centered care.
CPHI: What new/upcoming projects are you working on?
GT: We just received a 3-year award from the VA to continue this work with veterans who served in Iraq and Afghanistan, but with a focus on veterans who experience mild to moderate traumatic brain injury. These individuals make up a population that has a lot of unmet needs and photovoice will be an important means for them to access and describe their experience. The most exciting part of this new project is the inclusion of a care partner for each veteran, such as a family member, or close friend who’s most involved in supporting them in community reintegration. Their stories and experiences are just as important as the veterans’ but often go unheard.
CPHI: How can I find out more?