Most British troops should be out of Iraq by the summer, and their US counterparts should have left by next year. In Afghanistan, of course, it is a different matter, with no end in sight to the British presence and the new US administration under Barack Obama even considering a surge in numbers.
This geo-politicking is important for occupational health (OH) practitioners because of the effect six years of intense and often traumatic combat operations in both countries (a longer timescale than the Second World War) may already be having, and almost certainly will have in years to come, on thousands of ex-servicemen and women as they come back to civilian life and the workplace.
While the relationship between combat experiences and post-traumatic stress disorder (PTSD) has long been recognised, PTSD is seen on both sides of the Atlantic as one of the ‘signature’ conditions to come out of the conflicts in Iraq and Afghanistan.
As such, and as more veterans make the transition back to civilian life, it is something employers are being urged to take more notice of.
Support organisation Combat Stress, which tends to deal with the most serious and complex cases, has already reported a 53% increase in demand for its services in the past three years alone, with servicemen and women being referred in at a younger age (often as young as 20 or 21) and sometimes as early as 22 months after discharge.
Its findings echo that of the University of Manchester’s Centre for Suicide Prevention, which in March published a study suggesting that young ex-servicemen were three times more likely to kill themselves than their civilian counterparts. Veterans aged under 24 were at greatest risk, with those in lower ranks and with shorter careers most vulnerable.
Given that the average time lapse between someone being discharged and presenting with serious PTSD is 13 years, employers may increasingly find themselves on the sharp end of the issue in years to come, warns Combat Stress director of operations David Hill.
While military rehabilitation services (both for physical and mental injuries) have made huge progress in recent years, with the Healthcare Commission in March describing the Ministry of Defence’s trauma care and rehabilitation facilities as “exemplary”, once ex-forces personnel are out in ‘Civvy Street’, support can be more patchy.
“There is often still a lack of understanding and expertise on this within the NHS,” says Hill. “It is about delivering the right treatment at the right time in the right place, but at the moment the services are not that cohesive or joined-up.”
This lack of help was highlighted in February by Britain’s most highly decorated serving soldier, Lance Corporal Johnson Beharry, VC, who, while praising the “first class” treatment soldiers received in the Army, added that it was “disgraceful” that many veterans struggled to get appropriate treatment on the NHS when they came out into civilian life.
Beharry, who won his Victoria Cross for twice leading comrades to safety during attacks in Iraq, told the BBC that five years on from receiving a serious head wound he was still living with constant pain, nightmares, mood swings and unexplained rages. Yet even he once had to wait three hours in hospital to see an NHS doctor about his trauma.
His comments, which made national headlines, should at the very least help to move this issue up the agenda, argues Caroline Whittaker, senior OH lecturer at the University of Glamorgan and a lieutenant colonel in the Territorial Army.
“While there is a recognition of the traumatic circumstances that soldiers may be faced with and the exceptional demands they face in the line of their duty, Beharry’s comments have highlighted a need to open the debate on improved access to mental health services for all those in need across the whole of the population,” she says.
“For example, we know in occupational health that cognitive behavioural therapies (CBT) can be useful, but trying to access them is another matter.
“Criticisms should be used to open the debate on access to mental health support across the spectrum,” she adds.
Beharry is not alone in expressing concern on this issue. In February, the House of Commons Select Committee on Defence criticised the NHS for failing veterans with mental health needs. The identification and treatment of such veterans “relied as much on good intentions and good luck as on robust tracking and detailed understanding of their problems”, it found.
“If the NHS does not have a reliable way of identifying those who have been in the Armed Forces, then it already has one hand [tied] behind its back when it comes to providing appropriate clinical care,” the MPs concluded. “We repeat our belief that there must be a robust system for tracking veterans in the NHS, and this should feed into enhanced facilities for addressing their specific needs,” it added.
Perhaps not surprisingly, employers tend to be somewhat cagey when it comes to speaking about what is a sensitive subject. A number of employers known for their commitment to employing veterans declined to comment when contacted by Occupational Health.
While clearly some ex-forces’ personnel can find it hard to make the transition to civilian life, many others, given the skills, temperament and outlook they have developed within the military, cross over successfully.
For example, Terry Holloway, group support executive at Cambridge-based Marshall Aerospace, which employs about 4,000 people, many of them ex-Royal Air Force, points out that, within his organisation at least, there is really little difference between ex-military and civilian staff when it comes to their health issues. “For us it is more things such as repetitive strain injury, eyesight and hearing problems rather than psychological issues,” he says.
The whole area of access to appropriate healthcare once out in civilian life is a challenge, concedes MoD spokesman Paul Leat, not least because once veterans have left the military “family” they can easily fall beneath the radar.
“It is out of our control once they leave the forces and we are not in a position to influence employers,” he says. “There are a number of specific schemes that the Ministry of Defence is working on with the NHS to try to provide targeted care for those in the military where some of their mental health problems are related to combat,” he adds. These include ensuring war veterans are eligible for fast-track medical treatment by the NHS, as announced at the end of 2007 (though many veterans remain critical and say the reality is not matching the rhetoric) and the launch of a major study of brain injury among troops returning from Iraq and Afghanistan, announced last October.
More widely, the government has pledged that it will offer access to “talking therapies” to those who have been made redundant or recently became unemployed (whether civilian or ex-military). But perhaps the most significant development, at least in terms of its potential reach, is the pilot testing of six schemes that could offer veterans access to clinicians with expertise in post-conflict mental health issues.
The Community Veterans Mental Health Pilots, unveiled in late 2007, are due to be completed by the end of this year and, if deemed a success, could then be rolled out nationally. Each site is offering veterans access to a community mental health therapist, with veterans either referring themselves directly through their GPs, ex-services organisations, the Veterans’ Welfare Service or their social service departments.
The six pilot sites are run by South Stafford and Shropshire Healthcare NHS Foundation Trust, Camden and Islington Mental Health and Social Care Trust, Tees, Esk and Wear Valleys NHS Foundation Trust, Cardiff and Vale NHS Trust, NHS Lothian and Cornwall NHS Partnership Trust.
At the same time, three existing services are being used as comparators: Humber Mental Health Teaching NHS Trust, Northern Ireland Police Rehabilitation Retraining Trust, and The Ex-Services Mental Welfare Society, run by Combat Stress.
The intention is that the pilots will help with the diagnosis and treatment of anxiety, depression, alcohol and drug misuse as well as PTSD, and they will be visited regularly by Combat Stress through its network of 16 regional welfare officers around the country.
But for many of the most serious cases, the depressing truth is that by the time they cry for help, they will be long past the point of being able to hold down a job, says Hill.
“They will often be homeless, jobless or have suffered their family breaking down. A lot of the people we see will be at the chronic end of the spectrum,” he says.
The problems commonly associated with PTSD tend to be complex and enduring. Yet, Hill agrees with Whittaker, they can often be treated pretty successfully through the use of CBT on an outpatient basis.
“It is about enabling people to take a much greater degree of control of their lives with the aim of getting back into participating in society, and that includes getting them back into work,” he adds.
One of the big problems, at least from the employers’ point of view, is that many of the symptoms of PTSD – sleep disturbance, lack of concentration, mood swings and so on – can, when translated into a workplace setting, end up being dealt with as HR issues rather than health issues.
“A lot of employers do not recognise it,” argues Hill. “Some behaviours associated with PTSD are extreme and can present employers with problems. There may be, for example, outbursts of anger or sleep disturbance, which could lead to someone being late for work frequently.
“But something like that can be treated just as a disciplinary problem for the employer to deal with, and so they can run the risk that what is, underneath, a health problem, ends up being part of the disciplinary process.
“I doubt that the average employer, even if they have access to occupational health, would have an OH system that is sophisticated enough to deal with issues such as this,” he adds.
Hard to spot
Another complicating factor is that the severity of combat stress and the degree of limitation it brings will vary from one individual to another. And unless the employee reveals, or makes available information, that they have been diagnosed with post traumatic stress, the employer will have little way of knowing the condition is present.
“What employers and OH professionals should be doing is simply seeking advice from organisations such as ours and our welfare officers,” advises Hill. “Our officers can refer people or provide support and help to that individual. Or it may just be a case of giving some guidance to an employer if they have attracted a high number of veterans.
“Employers can also contact us directly or speak to one of our welfare officers to get advice about things such as what to look out for and how to deal with it, and how and when to refer on,” he adds.
US experience of post-traumatic stress disorder
In the US, where the numbers of military personnel serving and suffering injuries or trauma have been much greater than in the UK, a lot of work has been done to help employers support veterans with PTSD as well as traumatic brain injuries.
The US Department of Labor has even launched a specific initiative, America’s Heroes at Work to address the employment challenges of returning service members. A recent article by Michael Reardon, a senior policy adviser in the Department of Labor’s Office of Disability Employment Policy and a manager of America’s Heroes at Work, outlined some of the adjustments that employers can make to help accommodate workers with some of the most common symptoms of PTSD.
Memory problems: Provide written instructions, use wall calendars and task lists, provide verbal prompts, use electronic organisers, allow additional training time.
Lack of concentration: Reduce distractions, provide private space, allow employee to play soothing music, increase natural or full spectrum lighting, divide large assignments into smaller tasks, make daily “to do” lists.
Disorganisation: Use calendars to mark meetings and deadlines, use electronic organisers, assign a mentor.
Stress: Allow longer or more frequent work breaks, provide back-up to cover breaks, provide additional time to learn new responsibilities, restructure job to include only essential functions, allow time off for counselling, assign a mentor, provide positive reinforcement, provide disability awareness training to co-workers.
Dealing with emotions: Refer to employee assistance programmes, use stress management techniques to deal with frustration, allow telephone calls during work hours to doctors and others, allow frequent breaks.
Sleep disturbance: Allow employee to work one consistent schedule, allow for a flexible start time, combine regularly scheduled short breaks into one longer break, provide a place for the employee to sleep during break.
Muscle tension or fatigue: Build in “stretch breaks” during the work day, allow private space to meditate or do yoga, allow time off for physical or massage therapy, encourage use of any wellness programme.
Absenteeism: Allow for a flexible start time or end time, or work from home, provide straight shift or permanent schedule, modify attendance policy (for example count one occurrence for all PTSD-related absences, or allow the employee to make up the time missed), consider allowing teleworking.
Panic attacks: Allow employee to take a break and go to a place where they feel comfortable to use relaxation techniques or contact a support person, identify and remove environmental triggers such as particular smells or noises.
Headaches: Provide alternative lighting, allow breaks from computer or reading print work, practise stress-relieving techniques.