Veterans' health and wellbeing: a distinctive Scottish approach

Chapter 3: Mental Health

Scotland’s role in treating those suffering from the mental effects of combat dates back to WW1 when Craiglockhart War Hospital cared for ‘shell-shocked’ men struggling with their experiences on the Western Front. Many, including famous war poets Wilfred Owen and Siegfried Sassoon, were given radical and sometimes controversial new treatments to address the devastating effects of extreme trauma and constant bombardment. The display at Edinburgh Napier University provides a fascinating record of this work and Scotland’s contribution in an important field.

Over the following decades the military recognised high risk groups within their ranks and worked hard to return affected individuals to duty whenever possible. However, amongst the general public there largely remained a reluctance to discuss mental health issues and as a consequence there were veterans who never sought or received the treatment and care they needed. It was only during recent conflicts in Iraq and Afghanistan that the impact of combat on the mental health of those who served was fully recognised. Thankfully, we now see far more extensive and effective support, less associated stigma and a growing acceptance that these wounds of war are no less debilitating than the physical ones.

It is, therefore, only right that in this report I acknowledge the significantly improved support for those suffering mental ill health after time spent in the Armed Forces. In recent years, veterans have been able to access a number of specialist – as well as mainstream – projects and services introduced to address their specific needs. Scotland has been in the vanguard in many instances. That said, many of the experts in this field that I have spoken to say there is still work to be done. This has been one of the main factors that motivated me to produce this report.

This chapter details some of the vital work being done in this area by both the statutory and charitable sectors, and then focuses on the future needs of veterans with serious mental health issues. It covers some of the key topics relevant to ensuring that Scotland maintains – and enhances – its well-earned reputation for innovative and compassionate care of its Service men and women, stretching all the way back to Craiglockhart Hospital in 1916.

Background

As I highlighted in a previous report, the vast majority of those leaving the military do so without severe mental health problems and cope well with the transition to civilian life. When problems occur they are most likely to be the same ones that can affect anyone in the wider population, such as depression, general anxiety or stress related disorders. The majority will be treated by local mainstream NHS services – typically through their GP – and it has been reassuring to hear consistently positive stories about the support received and the good outcomes achieved. There are, though, a number of individuals with serious, life-changing and distressing mental health problems after a career in the Armed Forces. It is only right they are the focus of medical efforts and are given the best treatment and support available; but it is equally important to counter exaggeration of the numbers of those seriously affected and not to allow myths to subsume the facts.

As this chapter focuses on those with the most complex and serious mental health conditions, I am reassured to note that they are able to access a number of impressive specialist services in Scotland. These deliver the type of ‘special’ treatment promised as part of the Covenant and Renewing Our Commitments. Such services should be cherished and never taken for granted.

Current Provision

Based on what I’ve observed in nearly four years as Commissioner and specifically on what my team and I have taken from our months of research and engagement on this topic, I support the finding from the 2016 Forces in Mind Trust Call to Mind: Scotland report, which stated:

“Arguably, Scotland has one of the most robust mental health and related provision for veterans in the UK, with a thriving specialist statutory and voluntary sector that has been supported and resourced by the Scottish Government”

This is a heartening assessment of the set-up in Scotland and one that has been borne out in the many conversations I have had about veterans and their mental health. The authors of that report and I have separately identified areas where more could – and should – be done to maintain or enhance this level of provision. It is, after all, important that we never stand still and allow our reputation to slip. Notwithstanding those opportunities for improvement, we ought not to lose sight of the overall positive position. It is evident that we have much good practice to protect for current and future generations and I would argue that the Scottish Approach to Veterans’ Health is intended to do exactly that.

The treatment and care for veterans with severe and enduring mental health conditions is delivered by a mixture of statutory sector providers, under the responsibility of Integration Authorities, and third sector providers. Some services sit within the mainstream and others are specialist.

Veterans in several parts of the country are able to access the network of NHS-led Veterans First Point (V1P) services. In addition, the Scottish Government currently funds, through an arrangement with NHS Ayrshire and Arran, nationally available specialist treatment at Combat Stress’ Hollybush House. I also heard from NHS Greater Glasgow and Clyde’s Head of Mental Health about how their veterans are treated within the range of mainstream services. Just one of these is the Anchor Centre in Govan which brings together specialist resources from different disciplines to treat those with complex mental traumas.

Alongside that key provision, there are a number of third sector organisations offering support. Legion Scotland and Poppyscotland are two of the most widely identifiable charities that work with veterans, complementing support provided by the statutory sector. Other smaller, but no less important examples, include the work of Horseback UK and Bravehound, both of which use animals to help veterans cope with their mental health problems. Beyond the traditional Service charities, organisations such as the Scottish Association for Mental Health ( SAMH) and Support in Mind Scotland provide help for veterans and others suffering from the widest range of mental health conditions. There are others besides. The Mental Welfare Commission for Scotland acts as ‘watchdog’ and ensures quality standards for care provision.

This mixture of provision – for both those suffering the most severe and enduring conditions, and more widely – adds up to a highly valued network for the veterans community.

Looking Ahead

Lest we get complacent about the level of support available to those struggling with mental illnesses, it is vital that we never forget the devastating impact that such conditions can have on individuals and their families. Both the Call to Mind: Scotland report and my own findings suggest that while Scotland has a range of services that have served the veterans community well, there are concerns that this support can be piecemeal on occasions and often quite limited for those with the most complex and difficult conditions.

Aidan Stephen, an ex-Army Major who served in Northern Ireland, Bosnia, Kosovo and Iraq over a 17 year career provides a graphic reminder of this. His testimony starts in 2003 and highlights the personal nature of these illnesses, the depths to which they can drag an otherwise fit and healthy individual, and the risks of unsuitable treatment. His is a traumatic story that reinforces the need for that ‘special’ level of support for those affected. Thankfully, Aidan has gone on to make a remarkable recovery, a testament to his own resolve and resilience, and to the help and support he received from many individuals and organisations. His full account can be read at Annex 2.

Aidan Stephen – Former Army Major

“A few months after returning from Iraq, I attempted suicide and spent five days in a coma. When I woke up, I was admitted to a military psychiatric facility in Germany. Most patients were relatives of soldiers, and the support I received wasn’t suitable to my needs.

“I returned to Scotland where my wife and I separated and I ended up living alone, isolated with little family support. I was still in the Army at this point and they were trying to figure out what to do with me. I was sent to the Priory in Glasgow, a civilian mental health unit which treats people with addictions and eating disorders. This was one of the worst decisions made. None of the staff were trained to deal with patients from a military background and none of my fellow clients shared my experiences, yet I had to participate in group therapy with them.

“One day, one of the patients said she was feeling low because she had eaten loads of chocolate cake. Whilst acknowledging that seemingly minor issues such as this can have a much deeper psychological root for some, I was suffering from night terrors and traumatic flashbacks to my time in the Army, and comments like this only increased the distance I felt between myself and everyone else at the facility, leaving me feeling even more isolated.

“In 2006 I was discharged and was in the care of civilian rather than military doctors. I returned to Edinburgh and continued to spiral, culminating in an incident where I threatened to kill myself and self-harmed in public. I was arrested and ended up on remand. A doctor I spoke with while there told me to get in touch when I was out and he made me aware of veteran-specific support services that he thought would help.

“This is where things finally started to turn around....”

Crucially, both the UK and Scottish Governments remain committed to the idea of ‘special’ consideration for veterans such as Aidan, who suffer mental ill health following military service. That commitment is one of the cornerstones of how healthcare is delivered in Scotland.

I also welcome the fact the Scottish Government acknowledges veterans as a distinct group, albeit briefly, in its 10-year Mental Health Strategy which was published in 2017. This states: “Armed Forces veterans, including those who have experienced trauma, may benefit from particular models such as peer support, combined with mainstream treatment. The Scottish Government will support efforts to meet the needs of veterans and their families, and local partnerships will want to consider how best to provide services locally for them.”

The Scottish Approach to Veterans’ Health is intended to take matters further still. Its guiding principles provide a framework for ensuring that the best of specialist and mainstream provision is protected and the long-term needs of those with severe mental health conditions are properly planned and met. Resolving issues such as security of funding, equality of access and long-term planning are critical to living up to the commitments made. Most importantly, doing so will offer reassurance to veterans who currently or will in the future rely on bespoke mental health services.

A Long-Term Action Plan

The Government’s Mental Health Strategy and Renewing Our Commitments provide an important statement of intent. However, given the specific commitments to, and sometimes unique needs of, veterans with severe mental health conditions, I believe there is a strong case for the creation of a separate Action Plan for the delivery of services.

The network proposed in recommendation 4 can provide the necessary expertise and governance to deliver such a plan, either as part of its core work or separately by a sub-group dedicated to mental health. The Action Plan would need to complement the Scottish Government’s national strategy and address the key topics set out in chapter 2 ‘Making it Happen’ and the ones that follow here. Ultimately, it should provide an articulation of how excellent, dedicated and sustained treatment will be delivered over the long-term, at a national level and locally by Integration Authorities. Quick referrals and early interventions should remain a central feature of that provision.

The following considerations – both structural and clinical – are the ones that featured most regularly during conversations with veterans and health professionals. Neither set is exhaustive but I hope they provide a useful starting point for those who may be responsible for delivering a long-term Action Plan. It will also be important that it reflects new issues and changing needs as they emerge.

Recommendation 5 – Mental Health Action Plan

The Scottish Government and NHS(S), through the network on veterans health (see recommendation 4), should produce a Mental Health Action Plan for the long-term delivery of services and support. Systemic issues of funding, collaboration, leadership, planning, governance and training of staff will be key.

Structural Considerations

The topics covered in detail in chapter 2 ‘Making it Happen’ will be central to any plan for mental health provision for veterans. They include, protecting and funding specialist services, collaborating with others, demonstrating leadership, embedding long-term planning, and providing governance. I don’t intend repeating any of that material but aspects are worthy of additional mention in this section as they apply to mental health care.

Funding

I say earlier that funding for specialist services is “disjointed and in some cases ad hoc”. This is particularly evident in the field of mental health, as demonstrated by the experience of V1P and Combat Stress which is indicative of the short-term and insecure nature of funding. This is in sharp contrast to arrangements for some physical health provision, particularly prosthetics clinics, and demonstrate a clear anomaly that demands an urgent review. I would expect the proposed network to consider this as a priority as failure to do so will only leave a worrying degree of anxiety amongst veterans and dedicated providers, while increasing uncertainty for a number of our most important services.

Geographical Inequalities

There is also a need for separate consideration of how specialist mental health services are delivered across different parts of Scotland. I have consistently argued that veterans and others should see no threat in the fact that services will vary across the country, depending on factors such as rurality and remoteness, population density and demand. This is a consequence of the system of local delivery and accountability that underpins health and social care provision in Scotland.

What I don’t consider inevitable or acceptable, though, is if the needs of all veterans with severe and enduring mental health conditions are not properly met. Should that be due to a lack of availability or delays in access then there is a clear question of inequality or disadvantage, which needs to be addressed.

Understanding of Veterans

Finally in this section, I would like to mention a recurring theme from veterans which suggest that health practitioners within the mainstream NHS do not always understand their specific needs and experiences. The implication is that those providing treatment and care are not as well equipped as they could be. Sharon Fegan, a psychological therapist, and Lauren Anderson, an occupational therapist, both from V1P Lothian, expand on this and their words are illuminating:

Sharon Fegan – Psychological and Occupational Therapist

“We have occupational therapist trainees who come to V1P for placements, so at a very early stage in their career they are learning how those from anex-Service background might differ from civilian clients, and the best ways to approach this. Considering ways in which this increased awareness could be replicated across all positions in the NHS would be a really positive step towards improving engagement with veterans”.

Lauren Anderson – Occupational Therapist

“Language is a hugely important aspect of treating the ex-Service community. Since I began working at V1P, I’ve picked up a great deal of military terminology which I previously didn’t know. Building a good relationship with veterans in a therapy context involves showing appreciation and respect for their background, and acknowledging that there are aspects of Service life you don’t know about, but which you hope to learn from them.”

While parts of the health system are clearly well attuned to veterans’ specific mental health needs there remains much to be gained from raising awareness, and increasing understanding, amongst as wide a network as possible, including GPs, mental health and allied health professionals.

Clinical Considerations

There are also a number of clinical considerations that will need to be incorporated into the Action Plan. Once again, this list is neither comprehensive nor exclusive but the topics are of sufficient importance to merit separate consideration and, in some cases, specific recommendations.

Post Traumatic Stress Disorder ( PTSD)

Discussions about PTSD often elicit strong responses amongst an Armed Forces and veterans community that can sometimes appear critical of the attitudes and support provided by the MOD and statutory services. Many believe the number of veterans suffering from PTSD is significantly under-estimated and there has been insufficient investment in their treatment and care over several years.

Academics at institutions like Kings College London and University of Glasgow have conducted numerous studies over the past 10 years or so to assess the incidence, impact and treatment of PTSD amongst serving personnel and veterans. These have provided an impressive statistical evidence base for policy-makers and have shown that rates of PTSD in military personnel are similar to the wider population, although there is a modest increase in risk amongst combat troops and deployed reservists. Their specific findings have sometimes been at odds with some of the anecdotal evidence provided by those who struggle daily with the condition or offer direct support to the veterans community. This has led to debate and understandably caused a degree of confusion amongst the general public.

Over the past few years there has been a growing recognition by politicians, officials and health professionals of the need for effective and more accessible treatment for any who have served in the military and subsequently present with PTSD. The result has been a much greater willingness to see them as deserving ‘special’ support and an increasing number of initiatives that provide relief to individuals and their families. In Scotland this treatment is provided by a combination of NHS(S) mainstream services, V1P and Combat Stress. These must be protected now and over the long-term.

Although the overall number of veterans who suffer from PTSD in Scotland is relatively small, it is still vital that a national Action Plan considers the needs of those most at risk. It should also take account of the current move away from residential programmes towards an increased emphasis on community-based treatment and support. This will shape future provision of care for a vulnerable and deserving group. The severe and long-lasting impact of the illness, its link with other physical and mental conditions, and the levels of public interest reinforce these points on many levels.

Suicide Risk

Without doubt, the most poignant and thought-provoking conversations I’ve had during my time as Commissioner were with June Black. Her words laid bare the challenges her son, Aaron, faced when he returned from Afghanistan in 2009 that ultimately led to him taking his life in 2011. Matthew Green, in his book Aftershock, tells Aaron’s story in the most moving way, leaving the reader to reflect on the sad and tragic loss of a young man.

We owe it to Aaron’s memory to redouble efforts to support current and former Service personnel struggling with their mental health to such a worrying degree that suicide feels like the only escape. It is also essential that family and friends who are affected by suicide receive appropriate bereavement support.

In that respect, it is heartening to note some of the MOD’s recent work, including the establishment of a 24hr Military Mental Health Helpline, and the publication of the Defence Mental Health and Wellbeing Strategy 2017-22. I have also been interested in NHS England’s Transition, Intervention and Liaison ( TIL) pilot, which seeks to improve mental health care for veterans and Armed Forces personnel approaching discharge. I believe NHS(S) should consider this latter initiative and work closely with organisations who have already invested time and resources in identifying and supporting those at increased risk of suicide.

NHS England’s Transition, Intervention and Liaison ( TIL) Mental Health service was set up in 2017 for

veterans and those Armed Forces personnel about to leave the military who might have mental health

difficulties.

The three elements that make up TIL are:

• A Transition service that is targeted at those about to leave the Armed Forces who may need continuity of mental health care during the transition process.
• An Intervention service that provides an assessment within two weeks of a referral which determines whether an individual has complex needs and, if so, provides an appointment with a clinician who has an expert understanding of Armed Forces life and culture. Veterans may also be supported by a care coordinator who can liaise with other services and organisations to ensure a coherent approach to their care.
• A Liaison function that supports those who do not have complex presentations yet would benefit from NHS care. They will be referred into local mainstream NHS mental health services where they will receive treatment and support.

Also of note, the Scottish Government intends to publish a Suicide Prevention Action Plan later this year. I have submitted a response to the consultation, highlighting veterans and their particular circumstances. An important aspect of identifying veterans within this plan will be the opportunity to extend the knowledge and understanding of the medical community on the challenges faced by some of our most vulnerable ex-Service men and women.

Finding 4:

The publication of the Suicide Prevention Action Plan by the Scottish Government later this year is a welcome step in ensuring everything possible is done to help anyone struggling with mental ill health. Vulnerable veterans, and their particular circumstances, will be an important consideration as the plan is developed.

Substance Misuse

All three Services are historically associated with a culture of heavy drinking and, while much has been done within the military to shift behaviours, alcohol misuse is still significantly higher than amongst the general population. Inevitably that culture extends into the veterans community which also reflects a national trend that has seen alcohol consumption increase significantly over the past few decades. This is a problem which the Scottish Government and others within the veterans community have done much to tackle nationally in recent years.

Alcohol misuse is often linked to poor mental health, with Combat Stress suggesting that almost 70% of veterans with PTSD also have drink-related problems. This organisation is currently piloting a Veterans’ Substance Misuse Case Management Service, which helps veterans access the most appropriate services to support their abstinence and prevent relapse. I will watch with interest as this scheme develops.

The misuse of powerful painkillers, including opioids and other synthetic drugs, amongst veterans has received significant attention in the USA. There is, however, a growing sense that self-medication using both prescription and non-prescription drugs amongst UK veterans is also on the rise. This parallels trends in the wider community.

To date, there is minimal research on the subject but my conversations with senior medical professionals and practitioners working for Help for Heroes have left me in no doubt that this could be a serious concern. Given the tendency in the UK to follow US trends, and the devastating effect of drugs misuse, I believe it is important that we quickly determine the scale and nature of the problem in Scotland. The Action Plan should include details about how this will be done and initiate measures to counter this worrying trend.

Recommendation 6 – Drugs Misuse

The Scottish Government and NHS(S) should assess the scale and nature of drugs misuse – especially prescription and non-prescription painkillers – amongst the veterans community in Scotland and introduce remedial measures. This should be taken forward by the Joint Group and network, and included as part of the Mental Health Action Plan.

Stigma, awareness and other barriers

Mental health problems can be hard for anyone to cope with but it is made worse by having to deal with stigma, ignorance and discrimination from others. There is a widely held perception that the stigma associated with admitting to struggles with mental health is a major factor in veterans being reluctant to seek treatment and support. However, it seems the reality is more complicated than this.

A 2017 report by King’s Centre for Military Health Research, Stigma and Barriers to Care in Service Leavers with Mental Health Problems, proposes that stigma is not a singular influence that prevents ex-Service personnel from seeking help for mental health problems. Failure to recognise that they have a mental health problem in the first instance, making the decision to seek help, and difficulty accessing and then maintaining support are all also contributing factors. This can be compounded when veterans live alone or have no-one to push them into seeking treatment. A recent study by Dr Margaret Bowes also identifies that the inherent culture of the Armed Forces may protect personnel from mental ill health during combat but then impede good recovery amongst veterans; in other words, the coping strategies required for good mental health may be at odds with the sort of resilience required to cope in battlefield situations.

Work has been undertaken in recent years by the MOD to overcome the challenges identified above. As attitudes in the military, amongst the veterans community and wider society have shifted, it has become evident that serving members of the Armed Forces and veterans now feel far more able to raise and discuss issues about their mental health. The increasing use of peer support workers by organisations like V1P and Help for Heroes has undoubtedly encouraged this and is widely regarded as good practice.

Nevertheless, for some, particularly those who served in less enlightened times, there may still be feelings of stigma attached to being mentally ill. I would like to make particular mention of the national programme See Me, funded by Scottish Government and Comic Relief and managed by SAMH and the Mental Health Foundation, which is aimed at changing negative attitudes and ending discrimination against all those with mental health problems. This work is important and I would expect an Action Plan to reflect this approach. I would also encourage any veteran who may be reluctant to seek help, to find out more about this programme and how it might benefit them.

During the past few years there have also been a number of initiatives aimed at improving awareness and understanding of the specific mental health challenges faced by some veterans. These have included education and information material produced by the Royal College of General Practitioners, NHS(S) and several charities. This has had an impact but I sense there is now need to refresh some of the content and renew efforts to disseminate it amongst as wide an audience as possible, including GPs, mental health specialists and allied health professionals.

This will be of particular importance to the 800 additional mental health workers that the Scottish Government has committed to funding over the next four years.

Recommendation 7 – Barriers to Accessing Services

The Scottish Government and NHS(S) should build on existing work aimed at reducing barriers to veterans accessing mental health services. This will include measures to address issues of stigma, seeking help, and improving awareness and understanding within the medical profession. This should be taken forward by the Joint Group and network, and included as part of the Mental Health Action Plan.

Conclusion

Throughout this chapter I have sought to emphasise that there are, thankfully, relatively few veterans who will experience severe mental health problems following their time in the Armed Forces. Furthermore, these problems are not always attributable to military service, with a proportion having been affected by adverse life experiences such as abuse, financial or relationship problems or as a victim of crime. Unfortunately for some, their time in the Services may have compounded their situation.

For those veterans who do suffer, there is no doubt that their lives can be devastated, sometimes for many years. Prompt access to the best possible treatment and support is vital in helping them to recover, and lead happy and fulfilling lives. We can be proud of the specialist and mainstream mental health services in Scotland and the role this plays in helping these individuals – and their families – achieve that aim.

We must, though, never allow complacency or lack of interest to compromise that level of provision and instead work to protect it for current and future generations. In that respect, I have concerns about the long-term sustainability of some of these services and the ability of some veterans to access them.

That is why I have called on the Scottish Government, NHS(S), local delivery organisations and partners to develop an Action Plan for the protection and long-term delivery of mental health services for veterans, especially those with severe and enduring conditions. In this chapter I have highlighted just some of the topics which should be considered and addressed as part of the creation of such a plan. There may be others that are worthy of inclusion, now and into the future as both services and needs evolve.