Journalist Tony Hall gives an overview of how the Cognitive Behaviour Treatment (CBT) is used within the armed forces to combat mental health issues.
In recent years the UK government and Ministry of Defence (MoD) have acknowledged that service in the Armed Forces should be publicly recognised and not be a cause of any personal or social disadvantage. The Armed Forces Covenant that is the tangible result of that intent was introduced into law in 2011. It encompasses all levels of welfare support from the transition from service to civilian life to the rehabilitation of the physically injured.1 The Covenant also broadens the nation’s welfare commitments by bringing issues of psychological health to the forefront of policy. In doing so MoD and Government have acknowledged that mental health is an essential contributor to the social stability and individual wellbeing of service personnel, veterans, and their families.
This commitment was first introduced as an integral part of a welfare strategy set out in the UK’s first Strategic Defence and Security Review (SDSR) in 2010. The SDSR in seeking to promote a more active engagement in psychological health gave official endorsement to a new mental health programme for the Armed Forces and veterans proposed by Dr Andrew Murrison, MP in his report ‘Fighting Fit’, published the same year.2
Murrison’s report laid out a future for the provision of mental health care based on established models within the NHS, delivered against guidelines and standards set out by National Institute for Health and Clinical Excellence (NICE) guidelines and Care Quality Commission (CQC). It acknowledged that the long term psychological care of serving and former personnel represented special challenges, in that the clinical care pathways had to be established by the MoD’s Defence Medical Services (DMS) at the onset of an illness and then referred over to the Department of Health, NHS and private sector health providers, if these service-related illnesses persisted and led to a medical discharge.
Post Traumatic Stress Disorder (PTSD) was singled out as an example of a chronic service-related illness that would require this new breadth of focus. ‘Fighting Fit’ recommended that the MoD develop PTSD screening tools and “that a mental health systems enquiry is built into routine Service medical examinations, discharge medicals and the medical examinations conducted prior to invaliding from the Service on the grounds of physical or mental incapacity. This will employ a series of structured questions designed to highlight common mental health problems such as depression and anxiety together with alcohol misuse and PTSD.” 3
Responding to these recommendations, MoD through DMS has now established 15 military run Departments of Community Mental Health (DCMH) in the UK and 5 at overseas bases. The DCHM’s provide both out-patient and in-patient assessment and care. The individual services have also responded. The Army for example now acknowledges that mental illness is both serious and disabling. It has raised awareness within its ranks by establishing a peer-group Trauma Risk Management (TRiM) model that supports personnel following traumatic incidence. It is a method of risk assessment recommended in the ‘Fighting Fit’ as a means of making mental health interventions acceptable, and reducing the stigma of mental ill-health among service personnel which the report emphasises strongly is “accustomed to viewing itself as mentally and physically robust.”
Treatment following diagnoses is now centred on community-based care and is delivered by the MoD in partnership with the Department of Health, and service charities including Combat Stress. This broadening out of care provision is necessary because there is currently no organised network of military mental health care across the UK, with the Government admitting that the NHS alone no longer has access to the type of specialist care that is required. 4
This shortfall has at least been acknowledged, and in response Government has begun a Community Veterans Mental Health Pilot project which is now established across six UK sites, while MoD has provided Combat Stress with £2m of new funding in support of its own Treatment Centres. Charities themselves are also collaborating. These efforts include the training of over 6,000 Armed Forces Community Mental Health First Aiders, through the MFHA for the Armed Forces Community project, now being undertaken by MFHA (Mental First Aid England) in conjunction with SSAFA (the Soldiers, Sailors, Airmen, and Families Association), The Royal British Legion and Combat Stress. 5
MoD is also taking practical steps to improve the skills of those engaged in mental health care and has recently awarded contracts for DMS personnel to train in the treatment of PTSD. According to DCMH figures for serving personnel, the last quarter of 2013 rates of PTSD in serving currently stand at 0.6 per 1,000, “and there was no significant change in the rate of PTSD compared to previous quarters.” 6 However, this particular anxiety disorder has proven itself to be chronic and capable of revealing psychological and physical problems, such as emotional withdrawal, insomnia, and anger, years after traumatic events took place. Its impact on the long term mental health of veterans has been recognised for that reason.
But while PTSD has proven itself a persistent cause of mental ill health and distress, it is treatable. NICE guidelines recognise the benefit of treatments such as Cognitive Behaviour Therapy (CBT); a ‘talking therapy’ that addresses a patient’s current difficulties through discussions with the therapist, to consciously change state of mind and ways of thinking.
CBT is a therapy that engages the patient to face mental problems, and in understanding them better. It stands as a symbol of the moves being undertaken now on many fronts to help and support personnel, veterans and their families to break the stigma of mental health and change for good our suffering in silence culture.
1 For progress in Covenant pledges 2013/14 see www.gov.uk/government/publications/armed-forces-covenant-annual-report
3 Ibid Page 3
4 See www.veterans-uk.info/mental_health/faq.html#vets11
5 See http://mhfaengland.org/instructor-training/instructor-armedforces/
6 Quarterly UK Armed Forces Mental Health: Presenting complaints at MOD Departments of Community Mental Health October 2012/13 -December 2013/14 www.gov.uk/government/uploads/system/uploads/attachment_data/file/300067/20131224-Mental_Health_Report_Q3_2013-2014_amended-U.pdf