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: Psychological Therapy in Prisons

Harvey, J. and Smedley, K. (eds.) (2010) Psychological Therapy in Prisons and Other Secure Settings, Abingdon, Willan.

This book will be of particular interest to those counsellors and psychotherapists working within the criminal justice system. It contains an introduction and ten very well written chapters on therapy in prisons and secure institutions.

The early chapters describe a prison system struggling to cope with very high levels of psychological distress amongst an expanding prison population. The consequences of increasing demand and the reforms introduced to improve mental health services are expertly discussed in chapter two of the book.

The next four chapters describe how specific therapies can be used in secure settings. There are chapters on attachment-based psychodynamic psychotherapy, cognitive behavioural therapy with adolescents, cognitive analytic therapy with young adults and systemic therapy. Each chapter provides an outline of the model being used, its evidence base and its application. A case example is used to demonstrate the strengths of each approach and are a particularly interesting read. The problems inherent in providing therapy in prisons are discussed. One author describes prison as an ‘anti-therapeutic’ environment. The tension between security and care is a theme throughout the book.

The remainder of the book focuses on trauma work in prisons, there is a critical examination of therapeutic communities and an excellent final chapter evaluating the effectiveness of offender programmes. The chapters on therapeutic practice with women and therapy with black and minority ethnic people raise important issues that go beyond the context of prisons and secure hospitals. The chapter on race and the failure of the prison service to recognise the needs of black and minority ethnic prisoners is extremely powerful.

The book gives a particular view of psychotherapy in prisons as something practised by psychologists if it’s practised at all. The approaches discussed tend to be cognitive or psychodynamic. Neither Counsellors nor the humanistic approach feature in the book and Carl Rogers is mentioned once only - on page 250 – the book is 254 pages long! There’s no mention either of the work done by the chaplaincy or the listeners service - prisoners trained by the Samaritans to support their peers – which is currently under threat because of cuts in the prison budget. The book lacks a concluding chapter, which could have brought the key issues together and reflected on the overall picture. Despite these criticisms the book is an extremely interesting read and highly recommended for those interested in the health and care of prisoners or therapy with forensic populations.

The Lobotomists on BBC Radio Four

I have just listened to an excellent BBC radio programme on the history of the Lobotomy. Hugh Levinson, the producer and presenter, has written a BBC News article about the programme here.

The programme was about the short lived idea that patients living with mental illness could be cured if only the connections between the frontal lobes and the rest of the brain could be severed. The operation (called a Leucotomy in Britain) involved drilling holes into the patient's skull just behind the eye sockets and below the temples, and then inserting a long spike, like an overly long ice-pick, into the brain to make cuts behind the frontal lobes. One commentator observed that the procedure contradicts the standard medical view that cutting healthy tissue tends to make things worse not better.

The programme featured three famous exponents of the procedure: Egas Moniz in Portugal, Walter Freeman in the States and Sir Wylie McKissock in the UK.

The Lobotomy was popular throughout the 1940s and into the '50s. The programme estimated, for example, that within that short period Sir Wylie McKissock carried out 3000 lobotomies. He would even tour provincial hospitals at the weekends operating on patients. Freeman also was an advocate of the procedure, even making a movie to advertise the benefits of the operation.

Shockingly there was no research done into the procedure and no follow up investigations to see how patients recovered after surgery. The Lobotomists convinced themselves that about a third of patients were helped by the surgery whilst the rest were no worse for it. There was no evidence for this and in fact many patients suffered catastrophic harm as a result of the treatment. With the discovery of anti-psychotic medication in the 1950s the practice faded. The history of medicine is full of such horrors.

The Pain of OCD

The Dorset Echo provides an insight into the terrible distress of severe OCD

Mr Shaun Nutman, a thirty-three year old family man, was driven to stab himself in the chest because of depression, anxiety and Obsessive Compulsive Disorder. His wife said disturbing thoughts attacked her husband’s mind “like a machine gun”. According to the Dorset Echo, the coronor, Mr Michael Johnston, said he needed evidence that Mr Nutman intended to kill himself to record a verdict of suicide and gave a narrative verdict instead as he believed Mr Nutman was in “such distress from his obsessive compulsive behaviour that he probably really hardly knew what he was doing.” The coronor was critical of the care Mr Nutman received.