Mental Health and the Military

Events in Afghanistan and numerous articles on post-traumatic stress disorder have caused me to visit the web site of the King's Centre for Military Health Research and read once more the Centre for Mental Health Report, Across the Wire: Veterans, Mental Health and Vulnerability (25 October 2010). Written by Matt Fossey, the report gives an over-view of the mental health of British military personnel and the support they receive under the military covenant.

The impression I get from watching the media is of large numbers of soldiers suffering the effects of post-traumatic stress as a result of the horrors of war. Fossey's report suggests this is not the case, with just one per cent of service personal each year discharged because of psychiatric problems. According to Fossey, only 20-25 individuals per year are discharged because they're suffering from Post-traumatic Stress Disorder (PTSD). I don't think these figures give a complete picture of the mental health of service personnel leaving the military. How many military personnel choosing to leave the forces are struggling with the effects of acute and chronic stress? How many of those disclose the fact? How many leave self-medicating with alcohol? Maybe the Ministry of Defence and personnel leaving the forces have a common interest in not acknowledging the role that chronic and acute stress might play in an individual's decision to leave the armed forces. I'm told by colleagues working with ex-military personnel that many do not get their PTSD diagnoses until many years after leaving the forces and that not many of those were discharged on health grounds.

In fact the Fossy Report does highlight a much deeper problem when it considers two surveys about the health of ex-service personnel. According to one survey of 9,990 UK veterans four per cent were living with PTSD - four times the rate for the general population. Another survey of 3000 veterans suggested a rate of 19%. These surveys also point to high rates for alcohol misuse and general mental health problems. Fossey argues that the mental health of ex-service personnel isn't bad when compared with the mental health of the general population. Throughout the report Fossey seems to play down concerns about the mental health of UK veterans, yet if the rate of PTSD amongst the general population was 19% (it's 10% in Israel) it would be a catastrophe.

Fossey refers to the history of PTSD and it's numerous manifestations (Railway Spine, Shell Shock and Battle Fatigue). It seems to me that the military are still reluctant to accept combat stress as a cause of mental disorder. Blaming the individual for 'buckling under pressure' certainly happened during the Second World War as Fossey points out:

During WWII, the unfortunate acronym ‘LMF’ (lack of moral fibre) was stamped on the medical cards of aircrew who, through reasons of extreme stress or trauma, were unable to perform their duties – a millstone for many in future civilian lives (Jones, 2006). The acronym LMF was only removed from usage in 1960 by RAF Psychiatry

Having read the excellent Trauma by Gordon Turnbull I'm sure that military psychiatry has advanced since the 1960s but Fossey reminds us of the role "personality factors" still play in explaining (and excusing) high rates of post-traumatic stress amongst the military:

While there can be no doubt that those suffering from complex PTSD have many needs, some authorities debate the nomenclature and suggest that personality factors (which have been mostly a result of pre-service experience) are more important determinants of health in such people than their military experiences.

It impossible to say whether or not these individuals would have developed PTSD had they not joined the military, but I'm pretty sure joining up increased the risk.

Fossey argues that there's one group amongst the military who do raise concerns. These are young men under twenty-four years of age with less than four years service. They leave because military life doesn't suit them, and because they have served for a short time they get less help with their resettlement than personnel with long service. This group of young people are 2-3 times more likely to commit suicide than the same age groups in the general and serving populations. Fossey's Report suggests we should direct more resources at those young people who leave the forces early rather than those who serve for a long time and experience numerous tours of duty.

Fossey is arguing in his report that the military tends to recruit low educational achievers from poor areas. Many of these men and women have pre-existing problems before they join. They are recruited and successfully changed by the military and have long and successful careers. A number, however, are unable to settle and are discharged. Their inability to serve is not due to their experience with the Forces but the pre-existing problems these young men already have with authority, alcohol, drugs and crime. A brief survey of the cases I am familiar with does indeed suggest long-standing problems that pre-date their military experience.

So, what can be said about the mental health of British military and ex-military personnel. Firstly, most individuals serve in the armed forces without suffering any serious mental health problems at all. Secondly, there is a significant minority who suffer alcohol addiction, supported to some extent by the military's drinking culture. Thirdly, there is another group, young men at risk of depression and suicide, if they leave the forces early and without an adequate resettlement plan. Fourthly, a minority of personnel - between 4 - 19% - are suffering from the symptoms of PTSD as a result of combat. It is these three groups that require resources, care and support.

Book Review: Trauma by Gordon Turnbull

This book will be a very pleasant surprise for readers anticipating a dry textbook on psychological trauma. Instead Turnbull has written a wonderfully engaging account of his career as a psychiatrist in the Royal Air Force and private practice as an acknowledged expert on post-traumatic stress disorder (PTSD). The reader is alongside Turnbull as he uncovers the ways exceptionally traumatic events affect individuals and how PTSD develops as a means of coping in the midst of overwhelming terror.

For Turnbull PTSD is a natural response to events outside normal human experience and the symptoms of PTSD are often part of the recovery process. But his pioneering work is treated with suspicion by senior officers in the military who prefer to blame the individual for a ‘lack of moral fibre’ rather than accept PTSD as a natural outcome of military conflict.

Turnbull pioneered his technique of psychological debriefing with members of RAF mountain rescue teams attending the Lockerbie disaster. He worked also with released British POWs after the first Gulf War and the hostages John McCarthy and Terry Waite. He argues convincingly that service men and women need time for decompression before returning to civilian life, so soldiers returning from Afghanistan stop off in Cyprus to recuperate before returning home. Turnbull advocates a group approach to recovery and recommends cognitive therapy, but he also embraces hypnosis and EMDR as methods for transforming right-brain sensory material into left-brain narrative and meaning.

Turnbull illustrates his book with fascinating case material. He learns as much about trauma from his clients as he does from research and colleagues. Indeed the high regard Turnbull has for his clients and his view that trauma can lead to emotional growth makes his book an optimistic account of psychological trauma. Counsellors and psychotherapists of all persuasions will be entertained and educated by its insights.