Talking about mental health problems

During his 23-year Army career, Robert, a former infantryman, served in Northern Ireland and the first Gulf War. Five years after leaving, he sought help for post-traumatic stress disorder, or PTSD:

"When your world is collapsing around your ears, you don't see it; other people see it for you," said Robert.

"It's easier to hide trauma when you're in the Forces. You don't talk about things but you have support because you're in a group of fellow soldiers."

People can develop PTSD after exposure to deeply shocking or life-threatening situations. With its characteristic flashbacks and feelings of isolation, the condition can lead to depression, alcoholism, drug misuse, and even suicide.

Nobody can be sure how many former servicemen and women are affected, but there is plenty of speculation that Iraq and Afghanistan veterans may experience problems later in life. The media often describes the problem as a 'timebomb', and that is not an unreasonable metaphor.

Often ten years or more passes before people seek help, and after so much quiet suffering their conditions may be extreme. The challenge for MOD and psychologists working with the Department is to make sure those affected come forward, defusing, as it were, the timebomb.

But why do conditions such as PTSD occur? Psychologists believe that some deeply shocking or life-threatening incidents may be more than the brain can cope with. Mentally unprocessed, vivid images and emotions become lodged in the victim's memory and, because they are so unpleasant, the person avoids dealing with them.

The result may be disturbing flashbacks, sleeplessness and depression, which can lead to alcoholism, drug misuse, relationship problems, and even suicide.

Pilot projects offer help

For Robert, the hardest part was coming forward and asking for help:

"It's too easy to bury these things under socialising, work or alcohol," he said. "Eventually you get to a stage where that doesn't help any more, and that's when you need the support that's there."

Robert's GP referred him to Doctor Graham Fawcett, a clinical psychologist now leading one of six MOD-sponsored mental health pilot projects for veterans.

The first clinic was launched towards the end of 2007 and the sixth and final one opened in Edinburgh recently. They are jointly run by MOD and local NHS trusts, and are open to any veteran.

Surprisingly, perhaps, there was no rush of sufferers seeking treatment. Professor Ian Palmer, Head of the MOD Medical Assessment Programme, based at St Thomas' Hospital, does not doubt that there is a problem, but he cannot help but wonder why victims are not 'banging down the door'.

The mental health charity Combat Stress says it is currently caring for around 4,000 veterans, and last year received 1,257 new referrals, an increase of eight per cent on the previous year, and 66 per cent since 2005. Sixty per cent of those seeking help are suffering from PTSD, they say.

MOD's Medical Assessment Programme has been providing mental health assessments for veterans since 2007:

"Initially," said Professor Palmer, "there was a lot of interest, but slowly the numbers have dwindled."

Over the past two years, Professor Palmer has seen around 140 veterans with mental health problems. Around 25 per cent were diagnosed with PTSD - interestingly, almost the same number had Obsessive Compulsive Disorder, or OCD.

Adjustment disorders

In 2007, the last full year for which there are figures, there were a total of 3,672 cases of mental disorder of which 180 were diagnosed as PTSD and more than 1,300 (nearly 40 per cent) classified as 'adjustment disorders'.

Professor Palmer is keen to get away from the idea that all veterans with mental health problems are suffering from PTSD:

"Although, if the label helps get people through the clinics' doors, then that is not a bad thing," he said.

He does not suggest that relatively few veterans have come forward because the scale of the problem has been overstated. It could be because those who need help are unaware of the service available to them, which must mean more publicity is needed. But that task is far from simple:

"Graham's clinic was advertised in London's Metro newspaper, and in Chelsea and Newcastle football programmes," said Professor Palmer. "But not one person called as a result."

Both are acutely aware of the difficulty of trying to publicise a service to people who may not want to have it:

"Asking people to come forward is like asking them to face their worst nightmare, and then talk about it," said Dr Fawcett.

In the first 18 months of operating his special clinic in London he has seen just 45 former military patients. The figures across all six pilot projects reach just a few hundred clients:

"Because they're mostly male and because they're military it takes quite a while to get them to the front door," said Professor Palmer. "Then they must be able to walk in quickly and get an assessment. If it's difficult, they bounce off again and you don't see them for years."

Dr Monica Thompson, who runs the traumatic stress clinic which hosts Dr Graham Fawcett's veterans' service, is keen to point out that this trend is not unique to the military. Her clinic was chosen for the pilot partly because it had led the response to the 7/7 bombings in London, dealing with members of the emergency services:

"Those people were doing exactly the same thing, thinking 'I'm a man, I'm weak for seeking help'," she said. "They had a culture in which they didn't talk about it. So we had to reach out to them."

Veterans Minister Kevan Jones recently visited the London clinic to help raise awareness of the pilot projects:

"I know it's hard to talk about mental health in the Armed Forces," he said. "But this service is here to help."

On the question of whether the Iraq and Afghanistan campaigns will lead to greater numbers of veterans needing help, the minister was frank:

"We don't know for sure, but what is important is that we have the right services in place to deal with them. That's why we are running these pilots and funding research."

The minister stresses the need to track former military personnel after they leave the Forces so that they can be helped if and when they need it. At the moment there is no system in place to ensure this happens:

"GPs need to routinely ask their patients whether they have served in the Armed Forces," said Mr Jones. "I'm hoping to announce a system whereby this will happen."

Psychologists Ian Palmer and Graham Fawcett are clear that people cannot be made to talk about experiences and problems. Indeed, trying to make them talk could make their conditions worse:

"Some experiences are so unpleasant that it's only natural people do not want to talk about them," said Professor Palmer.

For those who do come forward, the treatment usually offered is cognitive behavioural therapy, or CBT. This enables patients to reprocess their memories and challenge the emotions they evoke, such as shame or guilt:

"Talking often helps the symptoms subside," said Dr Fawcett. "Most of the people we see will never have had the chance to sit there and tell their story to someone who is listening intently. That alone can be a hugely therapeutic experience."

For further information visit www.veterans-uk.info

MOD/NHS mental health clinics

Staff at these centres can offer help to servicemen and women with mental health concerns:

• MOD's Medical Assessment Programme - 0800 1695401
• Midlands - 01785 257888 (Ext 5280)
• London - 020 7530 3666
• Cardiff - 02920 742062
• North East - 01388 646802
• South West - 01579 335226
• Scotland - 0131 2209920

This article is taken from the July 2009 issue of Defence Focus magazine - For everyone in Defence.