Table 3 Themes in veterans’ interpretations of the five dimensions of barriers to care continuum

Urban veteran in their 40s, positive screen for alcohol misuse or abuse, with prior VA mental health visits

“I think judgment and stigma is all perception about mental health. That’s all not knowing what you are talking about. People thinking you are crazy, not understanding and then use of drug and alcohol just to numb that.”

Rural veteran in their 60s, positive screen for depression, with prior VA mental health visits

“You’re not able to get help because you’re afraid of the stigma put on you by the outside world.. .. They all make sense to me. I’ve gone through many of these because of my alcohol and drug use. If I tell ‘em, “No,” they [healthcare professionals] keep pressuring me and pressuring me. And I get tired. So yeah, I smoke a joint every once in a while. I only smoke one joint. It seems to satisfy them.”

Rural veteran in their 30s, positive screen for alcohol misuse or abuse and depression, with prior VA mental health visits

“They [military leadership] tell you from the get go that once you go over there [mental healthcare services], it follows you.. . So then you think you’re gonna carry the stigma of being a mental health patients just ‘cause you went by there.”

Urban veteran in their 20s, positive screen for PTSD, with prior VA mental health visits

“It’s scary to go for mental healthcare because people automatically think that you are not stable enough to handle tasks in the military. And then if you say that you are seeking mental healthcare, they automatically write you off as not being capable. They don’t think that you are worthy or that they automatically just start discrediting you because you are seeking help. And in the military, they don’t think you should be able –they almost don’t want you to seek help. Even though they tell you to, they say the right things, but the actions of people who are appointed over us, their actions are a totally different way, and they back themselves up with paperwork and regulations, and they keep people scared.”

Rural veteran in their 30s, positive screen for alcohol misuse or abuse and depression, with prior VA mental health visits

“I guess the perception of healthcare, but I was getting healthcare while I was in the military. I would rather talk to a civilian than an actual military person, because I thought the military person in their head was thinking, ‘Suck it up, get back to what to you got to do.”

Rural veteran in their 60s, positive screen for alcohol misuse or abuse, with no prior VA mental health visits

“When I look at this [Group 1] I guess the title, ‘What names and label would you give this group of items’ [says to self], is something like… ‘Why I wouldn’t seek mental health care.’ I’ve always been worried, prior to-- what I did was with my employers, if they found out it was going to affect my job. I was afraid that I would either be passed over or thought less of. I worry about what others think, that’s me. I feel it is a weakness. It gives me a certain amount of anxiety.”

Rural veteran in their 50s, positive screen for alcohol misuse or abuse, with no prior VA mental health visits

“I don’t know why [but], suck it up mentality sticks out in my [mind],- because it’s,- so many times I’ve been told to ‘Suck it up,’ and just drag on. Don’t really care, we can’t address your issue. We can’t deal with you. You need to just – Let’s just wait until everything’s over with.. . Hopefully it’s all over with and you don’t need to come talk about it anymore.”

Urban veteran in their 40s, positive screen for PTSD and depression, with prior VA mental health visits

Interviewer: Are there other things you find yourself worrying about in accessing services that aren’t listed there?

“I would say, ah, worrying about being put in a mental hospital.

Interviewer: Worrying about hospitalization?

“Yes.”

Rural veteran in their 60s, positive screen for depression, with prior VA mental health visits

“So, learned to adjust to it because nobody believed me. So there again, trust. Some of us [veterans] we lie and some of us we lie very well, because I’ve seen guys here [VA] and I’ve seen ‘em at home, on the street, and it’s a different thing. I said [to other veterans], ‘Well, don’t ya remember [when you? 0:12:41].’ They say, ‘Aw that’s a different thing.’ I said, You lying, man.’ ‘No, I ain’t lying,’ [responds other veteran]. And I leave it alone because I don’t want anybody to ask me any questions, you know?”

Rural veteran in their 50s, positive screen for alcohol misuse or abuse, with no prior VA mental health visits

“To me it does because homelessness, health and injury, sickness. You could put that, this is kind of like why you’re there, not having steady employment, wow legal issues, wow that could go right up there. Having other priorities in life, I don’t know. Finances, childcare, cost of travel, travel distance equals cost of travel, transportation problems could equal distance, so I mean travel, all those thing could go together. All those are monetarily, personal, but these are all to me, personal issues.”

Urban veteran in their 20s, positive screen for PTSD, with prior VA mental health visits

“Homelessness, all of it. It’s everything that kinda are like big pictures to people, to me even. Cost of travel and childcare and finances. It’s just an overwhelming sense of, ‘I have so much responsibility, I don’t have help.’”

Urban veteran in their 40s, positive screen for PTSD and depression, with prior VA mental health visits

“Kinda thinkin’ the ‘health, injury, and sickness’ [doesn’t fit], but in a way it does kind of tie in with finances ‘cause if you get hurt then you’re out of a job.”

Urban veteran in their 30s, positive screen for depression, with prior VA mental health visits

“Even transportation problems if you don’t have transportation and the VA clinic is far – you’re not gonna get there.”

Urban veteran in their 40s, positive screen for alcohol misuse or abuse, with prior VA mental health visits

“I would say these are physical barriers [cost of travel, travel distance, transportation problems] to coming, getting help.. .. This might be a problem [finances] because you don’t know, you don’t have any steady income, you don’t know how much it’s gonna cost, I mean even if you’re a veteran.. .. I would say these are physical barriers to coming, getting help.”

Rural veteran in their 60s, positive screen for depression, with prior VA mental health visits

“When you say a problem with the system – you don’t know where the system starts and ends at.”

Urban veteran in their 40s, positive screen for alcohol misuse or abuse, with prior VA mental health visits

“That’s the problem with the VA, sometimes you have to wait three weeks, sometimes they don’t get you in right.. .. My boss, he’s always complaining about the VA, you know, how they misdiagnose and they just gave him the runaround, “Go to this office,” and then this guy says, ‘Go to that office.’”

Urban veteran in their 40s, positive screen for alcohol misuse or abuse, with prior VA mental health visits

“The VA just seems like they’re always short-staffed. I know because my unit is always short-staffed.”

Rural veteran in their 60s, positive screen for alcohol misuse or abuse, with no prior VA mental health visits

“My experiences—providers changing jobs, that’s been a problem for me. I’ve had a number of doctors going back and forth that have moved.”

Rural veteran in their 60s, positive screen for depression, with prior VA mental health visits

“I follow up, but sometimes it would be such a long time. And I will call and check and if I’m coming up here for something else I will. If I’m able to walk in – before I got these I used to have to drag myself along the rail and it has a lot of germs.”

Rural veteran in their 30s, positive screen for alcohol misuse or abuse, with no prior VA mental health visits

“These are all just stuff that, I hear this from people all the time. I just had a buddy of mine - his dad was a Korean veteran—he was havin’ all kinds of intestinal problems but didn’t know how to use any of the digital parts of the VA. Didn’t know how to get help and have somebody advocate for him or anything like that. And this guy was completely stressed out ‘cause his dad was gettin’ treated like shit in the VA because he didn’t know how [to navigate the system], and I gave him one phone number for DAV, and the advocate called him up and was like, ‘Hey, here ‘ya go.” Boom, boom, boom, boom. Within a week the guys care was completely turned around. Just because you gotta know the right channels. If you aren’t doing the rights things then you’re gonna get screwed with the VA.”

Urban veteran in their 40s, positive screen for alcohol misuse or abuse, with prior VA mental health visits

“People are going to slip. You gotta catch them before they get out.”

Urban veteran in their 20s, positive screen for PTSD, with prior VA mental health visits

“People who retire are often discredited when they go to seek help. People who are in the military are seen a lot quicker and faster, whereas veterans have to wait or they are put to the side--they are not a high priority.”

Rural veteran in their 60s, positive screen for depression, with prior VA mental health visits

“If they don’t follow up—. .. And, when they [VA providers] tell me that [providing care for younger veterans] I just, back up. ‘Cause I’m thinking they’re taking care of someone they [the government] can use. They can’t use me, I’m too old.”

Rural veteran in their 60s, positive screen for depression, with prior VA mental health visits

“This is the most important one, problems with getting service connected disability.. .. But the major one is learning how to get in contact [about benefits]. And when I applied this person [patient advocate] was workin’ with another DAV [Disabled American Veterans].. .. And, I went home and when I come back he [patient advocate] said, ‘You get started?’ I said, ‘No, I was turned down.’ I didn’t even know why. And so whatever he [patient advocate] did, within about three months I had something started then. But only because he did it. So this is a major problem.”

Rural veteran in their 30s, positive screen for alcohol misuse or abuse, with no prior VA mental health visits

“I mean I know that I can come here [to VA], but I have no knowledge as to what my benefits are. I know I have benefits, but I just don’t know what those are or how I can use ‘em.”

Urban veteran in their 40s, positive screen for alcohol misuse or abuse, with prior VA mental health visits

“Yeah, so my experience with the VA was better than most veterans. I was in Korea and they had a VA office there, so I did all my paperwork and I got all my information before I got out, so I was good. But the problem is that a lot of veterans don’t know that these resources are available. And so yeah, these all make sense.. .. And you know, no one wants to get mental health, there’s a stigma. So I’m gonna say, yeah this goes together, like information, like the VA has to be better at distributing information.. . It’s better to hand it out to people before they leave [the military], ‘cause once they leave the system it’s kinda hard to track ‘em down. People just disappear. So I don’t know how you would -- You could do outreach to rural areas, but someone living in Montana somewhere, I don’t know how you would reach out to them.”

Rural veteran in their 30s, positive screen for alcohol misuse and abuse and depression, with prior VA mental health visits

“‘Cause the VA doesn’t tell you about the kinds of [mental health] treatments that are available.”

Rural veteran in their 60s, positive screen for alcohol misuse or abuse, with no prior VA mental health visits

“I haven’t had the personal experience about going after the mental health care as I didn’t go to my VA to get my benefits until late in life.. .. I would think that a lot of people would have the lack of knowledge and understanding of how it works.. .. And I guess there probably could be a lot more knowledge about what kinds of mental health treatments are available, but I’ve never asked. So I don’t know what the brochures are and how… But I think it’s if you’re really there, you’re gonna find out, and or, there will [be] some key thing that comes up.. .”

Urban veteran in their 30s, positive screen for alcohol misuse or abuse, PTSD, and depression, with prior VA mental health visits

“It’s like the lack of transparency over mental health as far as, informing the people that need the services what services are provided.”

Urban veteran in their 30s, positive screen for depression, with prior VA mental health visits

“Lack of information, I guess? I mean we didn’t even know we were able to come to the VA until we were veterans for like 5 or 6 years. So for 5 or 6 years I was paying on my own for my mental health care ‘cause I had no idea that I could come here and get my medications and everything, so.”

Rural veteran in their 30s, positive screen for alcohol misuse and abuse and depression, with prior VA mental health visits

“Fear because of what others say. You heard they didn’t – In the military, that you’ll lose your security clearance if you go to mental health.”

Rural veteran in their 50s, positive screen for alcohol misuse or abuse, with no prior VA mental health visits

“I am not doing any kind of mental health, whatever, because everything you guys [VA providers] do, you type and you put it in this computer. And they said, ‘No, this is strictly confidential. Nobody will ever know.’ I said, ‘Well, what if the backing system just got hacked.’”

Rural veteran in their 60s, positive screen for depression, with prior VA mental health visits

“I was telling VA – I mean combat stories which I don’t tell. It’s been too long.. . When they [VA] ask these questions, ‘Why don’t you answer the questions?’ ‘Because I’m afraid.’. .. I might go to jail and be locked up too. That what I’m thinkin’ now. It’s not all over with.” – Vietnam Veteran

Urban veteran in their 30s, positive screen for depression, with prior VA mental health visits

“Being in active duty there is definitely punishment almost for asking even to receive mental healthcare. So I can see that you would be afraid of losing those things.”

Rural veteran in their 60s, positive screen for alcohol misuse or abuse, with no prior VA mental health visits

“And there’s a lot of guys that are working the system here. How they manipulate to try and get PTSD… But, maybe there [are], you know, you hear the stories [about veterans manipulating the system] and all of that. So, I don’t know what level I’m at, or where I’m at with things. All I know is, I have friends that – I call it walking a tight rope between reality and non-reality in what you’re doing.”

Rural veteran in their 60s, positive screen for depression, with prior VA mental health visits

“Because when they took me off my pain medication, I said, ‘Doc, you always tell us not to stop taking the medication until the doctor tell you. You done took all my medication that I’ve been getting for three or four years.’ But, they can never prove that I abuse it, and now, I found out that – from upstairs that it was being cut. Then I see some guys getting medication, ‘I’m gettin’ high tonight.’. .. I said maybe they have another problem, a different problem than I have. ‘You’re going to save me [from addiction]– but I’m still in pain.”