Waging war on stress

Preparations
for a possible war with Iraq are under way, yet many veterans are still feeling
the psychological ramifications of the last Gulf war. How much can the Army’s
OH department teach us about dealing with very stressed personnel?  By Nic Paton

A
decision is expected soon in a court action that could have pro- found
ramifications on how the British Army manages stress among its troops.

It
has been estimated that the class action taken by some 1,900 veterans of the
Falklands, Gulf War, Northern Ireland and peace-keeping operations in the
Balkans, could result in compensation payments of more than £500m.

The
action, which has been running for the best part of two years, revolves around
the veterans’ claim that they are suffering from post-traumatic stress disorder
(PTSD) because they were not properly treated by the Army.

Long
gone are the days when soldiers suffering nervous or mental conditions were
simply accused of cowardice and shot, but some of the cases being heard
certainly do not reflect well on the military authorities.

Take
Royal Highland Fusilier Barry Donnan, who, as a 17 year old, was sent to the
Lockerbie plane crash site in December 1988, where he was instructed to pick up
pieces of bodies, but was offered no counselling afterwards.

Three
years later, he was equally traumatised during the Gulf War, when he witnessed
the burial of hundreds of Iraqi soldiers in a mass grave. On his return, he
went absent without leave, was court-martialled and sentenced to 112 days in
the Military Corrective Training Centre in Colchester. On his release – again
with no offer of counselling or mental assessment – he was deployed to Northern
Ireland.

Repercussions
of combat stress

Symptoms
of combat stress can include feeling tense and shaky, appearing dazed or
confused, loss of concentration, a loss of morale, insomnia, fear and anxiety.
In severe cases, soldiers feel depressed or suicidal and have slower reaction
times. Stress can also have a severe impact at home, leading to marriage
break-up, alcoholism, violence and mental breakdown.

In
1998, the Government’s Social Exclusion Unit estimated that one in four
homeless people was a former member of the armed forces. And in 2000, another
UK charity, Crisis, published a study which estimated that up to 25 per cent of
rough sleepers were once part of the UK armed forces.

Yet,
the British Army is one of the few organisations of its size that has a stress
management policy, says the Ministry of Defence (MoD), as well as having a
comprehensive OH service in place.

The
MoD’s deputy adjutant general drew up a stress-management policy in 2001 that
recognised stress as a debilitating condition for the first time, and that
managing it was a core function of leadership among commanders. The policy also
made it clear that there is a difference between stress and stress-related
disorders.

Health
and safety training is now mandatory, including presentations on recognising
and preventing stress and how individuals in command can deal with it.

UK
Minister for Veterans’ Affairs Dr Lewis Moonie, discussing the court action in
the House of Commons last year, emphasised that PTSD (see box, p18) had been
recognised internationally as a medical condition since the 1980s.

"Measures
now in place to combat PTSD in the armed forces have evolved and been enhanced
over a number of years to reflect our improving knowledge of the condition, its
effects and the best methods of remediation. Each service runs active
programmes aimed at prevention and treatment. Measures include pre-deployment
and post-deployment briefings and, when practicable, availability of
counselling," he explained.

He
added that two new defence community psychiatric centres have been established
in England and Scotland. Additionally, parts of the armed forces, particularly
the Royal Marines, are exploring ways of detecting PTSD at a very early stage.

The
Marines’ Combat Stress Project – under retired captain Cameron March – is
looking at ways of training front-line troops, NCOs and commanders to recognise
the symptoms of stress in both themselves and their colleagues, and to react to
it. Training can also help them differentiate between a soldier who is simply
being ill-disciplined and one who is suffering from a stress-related disorder.

Army’s
approach to OH

The
Army’s approach to occupational health as a whole was put under the spotlight
last February in a study published in the Journal of the Royal Society of
Medicine.

It
looked at the Army’s decision in 1998 to introduce ‘gender-free’ training and
whether it had had any effect on levels of medical discharge, particularly of
women compared to men. The research found women recruits were up to eight times
more likely to be discharged with back pain, tendon injuries and stress
fractures than their male counterparts.

When
it comes to managing OH, the Army has what it describes as "an integrated
primary healthcare service", linking Army GPs with OH support through unit
medical staff.

There
are specialist occupational medicine staff available higher up the scale, at
command level in some regions. It also plans to establish OH staff at primary
care level.

The
military loves its acronyms, and it is no exception for OH.

Assessments
are carried out through a process known as PULHHEEMS – Physical capacity, Upper
limbs, Locomotion, Hearing, Eyesight, Mental capacity and Stability.

During
medical examinations, grades are given that are matched to a PULHHEEMS
employment standard (known as a PES) which is used to outline any functional
limitations on a soldier’s employment because of a medical problem, but without
disclosing confidential medical information to the employer.

Soldiers
can be temporarily downgraded and put on light duties if the condition is not
too bad or, if it is more serious, permanently downgraded through a medical board
assessment, although the Army stresses this is not in itself a bar to promotion
and progression.

If
a soldier is deemed medically unfit to carry out any form of military duties,
and is unlikely to become so for the foreseeable future (usually 18 months), he
or she is medically retired or discharged.

Managing
stress

Outside
the medical arena, the Army established a UK Army Welfare Service (AWS) in
April 2000.

While
a similar service existed before, the AWS in its current form now has 20 teams
of volunteers across the UK, comprising three to four soldiers in each.

They
are designed to provide back up for the community psychiatric nurses who are
deployed on operations to brief soldiers. The AWS will begin work once a
soldier has returned to barracks.

There
is also a network of information centres similar to Citizen Advice Bureaus that
started up in the late 1980s. There are approximately 80 centres the UK –
mostly based near family accommodation and barracks – which are able to answer
questions and provide information.

Within
NATO, innovative work is taking place to manage stress that could have
implications for UK forces.

The
US Army, drawing upon lessons learnt from the Gulf and Balkans campaigns, is
developing a programme of intervention to improve psychological resilience
among troops and lower the number of psychiatric casualties.

This
includes developing tools to measure stress in the field, establishing a
suicide surveillance system, identifying factors that lead to high rates of
mental disorders and developing psychological screening and debriefing in the
field.

Further
down the line, the programme intends to develop ways of identifying vulnerable
soldiers within both training and operational environments, strategies of
assessment and intervention and ways of implementing these strategies across
the military.

The
US Army is also working with the Austrian and German armies to develop a
protocol to assess voice changes under stress, making it easier to separate the
physical from psychological when it comes to measuring stress.

NATO
has also set up an exploratory team of psychologists and psychiatrists to look
into issues of stress and psychological support. The work is still at an early
stage, as the terms of reference and a programme of work were only drawn up
last September.

Next
April, the group will meet to unveil its views on psychological support in
modern military operations. Areas set to be addressed will include assessing
psychological stress, the psychological preparation of military personnel,
screening, psychological support during and after deployment, support for
families and how best to organise support.

Pressures
of peace-keeping

It
has been recognised that the increased pace of operations since the end of the
Cold War has added to stress levels, and that peace-keeping operations can be
just as stressful as combat operations, according to Dr Martin Deahl, civilian
consultant psychiatry adviser to the RAF and a consultant at Shelton Hospital
in Shrewsbury.

Deahl
explains that soldiers might witness atrocities against women and children and
be powerless to intervene, and may also be away from their families for long
periods of time.

Research
by the Canadian Army found that its veterans of the peace-keeping operation in
Croatia suffer from stress-related illnesses at rates at least three times
higher than those found in the population at large.

Often
soldiers suffering from stress are not even given a medical discharge and,
consequently, slip through the net, says Commodore Toby Elliot, chief executive
of the ex-Services Mental Welfare Society, also known as Combat Stress.

"We
have far more people on our books with clinical depression than PTSD," he
says.

"It
is the commanders who are responsible for identifying this [stress]. If they
think they have a chap with a problem, they can get help early on and get
doctors involved. If not, before you know it, you have a badly damaged man on
your hands," he adds.

The
military is hamstrung by the fact there are so few health professionals to turn
to. According to UK MoD statistics from the beginning of 2002, there were only
11 fully-trained consultant psychiatrists and 81 registered mental health
nurses serving in the Defence Medical Services.

The
‘warrior culture’ of stiff upper lip, inability to recognise that someone is
wounded unless there is something physically wrong and a refusal to discuss
emotional problems still remain, even if barriers are beginning to be broken
down, argues Deahl.

Putting
strategies, protocols and systems in place all help but, at the end of the day,
the best solution to tackling stress is to get mental health professionals as
far forward and accessible as possible, he says.

"We
are trying to work along the lines of coaching rather than the medic teaching
people," adds Deahl.

 www.army.mod.uk/soldierwelfare/supportagencies/aws/AWS_Home_Page.htm
– Army Welfare Service homepage

www.combatstress.com – The Ex-Services
Mental Welfare Society, Combat Stress, which specialises in helping those of all
ranks from the armed forces and the Merchant Navy suffering from psychological
disability as a result of their service.

www.ncptsd.org – The National Center for
Post-Traumatic Stress Disorder (PTSD)

Post-traumatic
stress disorder – the facts

According
to the US-based National Center for Post-Traumatic Stress Disorder (PTSD), one
of the leading research bodies on the condition, the definition of PTSD is:
"a psychiatric disorder that can occur following the experience or
witnessing of life-threatening events".

These
can include military combat, natural disasters, terrorist incidents, serious
accidents, abuse (sexual, physical, emotional, ritual), and violent personal
assaults such as rape.

Sufferers
often relive their traumatic experience through nightmares and flash-backs.
They may have difficulty sleeping and feel detached or estranged.

Symptoms
can be severe enough and last long enough to significantly impair their daily
life.

Other
common symptoms include survivor guilt, irritability, marital disharmony,
sudden angry outbursts, depression, nervousness and anxiety, joint and muscle
pains, emotional numbness, poor concentration and phobias about daily
activities.

Treatment
normally begins only when the survivor is safely removed from a crisis
situation. Strategies generally include educating trauma survivors and their
families about how people get PTSD, how it affects survivors and loved ones,
and other problems commonly linked to PTSD symptoms.

Families
and sufferers are also taught to understand that PTSD is nothing to be ashamed
of; it is a medically-recognised anxiety disorder.

Other
treatments include exposure to the event via imagery, allowing the survivor to
re-experience the trauma in a safe, controlled environment, while also
carefully examining their reactions.

Patients
will be encouraged to examine and resolve their strong emotions – such as
anger, shame, or guilt – common in PTSD, and there will be teaching to cope
with post-traumatic memories, reminders, reactions, and feelings without
becoming overwhelmed or emotionally numb.

According
to the Center, trauma memories usually do not go away entirely as a result of
therapy, but become manageable with new coping skills.

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