Evaluation%20of%20Current%20Operational%20Stress%20Management%20in%20the%20UK%20Military

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Evaluation of Current Operational Stress
Management in the UK Military

• Or.. the Seductions of Screening and the
  Disappointments of Debriefing

Major N Jones Academic Centre for Defence Mental
Helath
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What are we trying to achieve?
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We want to.

• Promote resilience, courage, independence,
  toughness etc.
• But at the same time encourage those with mental
  health problems to present when they need to

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We dont want to.

• Before deployment increase anxiety, increase
  risk avoidance and reduce confidence
• During reduce resilience, courage etc..
• After deployment increase helplessness,
  vulnerability and mental distress decrease
  resilience, coping and self efficacy swamp
  services with non mental health problems label
  people inappropriately
• Long time after cause mistrust, rumour and
  conspiracy add to the Pensions bill

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Lets keep a sense of proportion
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Primary mental health outcomes (Regulars only)
?
Hotopf et al. Lancet 2006 367 1731-1741
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Primary mental health outcomes (Regulars only)
Hotopf et al. Lancet 2006 367 1731-1741
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Non-military risk factors for PTSD (Op Telic)

• Some are more vulnerable than others.
• Being younger
• Lower education
• Being single
• Rank
• Childhood adversity

Iversen et al, Psych med 2008
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Military risk factors for PTSD (UK Op Telic)

• In theatre, some are more vulnerable than
  others.
• Being deployed for lt13 months in last 3 years
• Not receiving a homecoming brief
• Work in theatre did not match trade or experience
• Being in the Reserves
• Time spent in a forward area
• Thought that they might be killed
• Low morale

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What could you do to prevent psychological injury?

• Training
• Pre deployment screening
• Pre deployment psycho-education
• Post deployment psycho-education
• Decompression
• Peer group support (TRIM)
• Battlemind

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What could you do to prevent psychological injury?

• Pre deployment screening?
• Pre deployment psycho-education
• Post deployment psycho-education
• Decompression
• Peer group support (TRIM)
• Battlemind

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The seductions of screening!

• Save people and families from psychiatric
  disorder
• Save commanders from ineffective personnel
• Save the Chancellor from paying war pensions

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(No Transcript)
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UK Screening Study
Op Telic
Main Study, 2005 n1885 (69)
Screening study (completed 2002) n2800
Controls
Rona et al, BMJ 2006
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Test characteristics (n1885)
Positive Likelihood Ratio Negative Likelihood ratio Sensitivity Specificity Positive Predictive Value Negative Predictive Value
GHQ 2.7 0.69 0.42 0.85 0.39 0.86
PTSD 13.1 0.78 0.24 0.98 0.27 0.98
Caseness at baseline as a predictor of caseness
at follow-up
Rona et al, BMJ 2006
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Barriers to mental health screening qualitative
study

• Most people would not answer mental health
  questionnaires honestly to Defence Medical
  Services
• system leaks
• effects on career
• stigma
• Minority were seeking mental health care outside
  Defence Medical Services

French, Jones, Wessely, Rona, JMS 2004
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What could we do to prevent psychological injury?

• Training
• Screening
• Pre deployment psycho-education (briefing)?
• Post deployment psycho education?
• Decompression
• Post deployment psychological debriefing
• Peer group support (TRIM)
• Battlemind

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Pre-Operational Stress Briefing does it have any
effect?

• TELIC 1 RN RM regular personnel who are in
  Kings health and wellbeing study

• No significant differences in common mental
  health disorders, PTSD or alcohol misuse
• No differences for experiencing problems during
  or post-deployment or for marital satisfaction
• No evidence that a pre-deployment stress briefing
  reduced psychological distress
• The brief appeared to do no harm. Sharpley et al
  Occ med 008)

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The Sheffield trials of psycho education
High risk of PTSD - screened positive for acute
stress disorder (ASD).
No evidence that giving self help leaflets helped
Ratings of the usefulness of the self-help
booklet were very high in all groups
116 ASD pts received self-help booklet 111 ASD
pts did not 120 controls with no ASD did not
receive a booklet
PTSD, anxiety and depression all reduced in all
groups, BUT. No between group differences in
psychological symptoms or on ratings of quality
of life
Scholes et al Beh Res Therapy 2007
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Its not what you do but the way that you do it..
Stress Education and PCL score
Remembers as not useful
Does not remember having a brief
Remembers as useful
Langston, Greenberg, Iversen, Fear, Wessely Occ
Med 2008
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Prevention - Conclusion Part 1
The best prevention before deployment is
preparation for combat morale, leadership,
tough realistic training, military skills
etc..there is little evidence that mental health
services have much to do with it!
Well Warrior effect
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What could you do to prevent psychological injury?

• Pre deployment screening
• Pre deployment psycho-education?
• Post deployment psycho education
• Decompression?
• Post deployment psychological debriefing
• Peer group support (TRIM)
• Battlemind

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Decompression

• Can we assist recovery from Ops?

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Decompression Process Overview

• Those who fight together should unwind together
• Part of Post Operational Stress Management
• Often referred to as Third Location Decompression
• Currently for UK AF, takes place in Cyprus
• Now for all Iraq and Afghanistan formed units
• 796 personnel surveyed in 1st Wave
• 2nd wave of 6000 currently being analysed

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Process and Activities

• Cyprus
• Mental Health Brief
• Coming Home Brief
• Social Event
• Beach Activities
• Entertainment Show
• Access to Mental Health Personnel
• Booze!!

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Do any of the following areas concern you about
going home?
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Do you think that the decompression briefings
will make going home easier for you?
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Do you think decompression has been helpful in
letting you know how to deal with unpleasant
incidents that occur during a tour?
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I would not seek help for a mental health problem
because
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Have you had a deployment experience that was so
frightening, horrible, or upsetting that DURING
THE PAST MONTH you had..
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Traumatic Distress Symptoms

• 124 (16) of respondents endorsed 2 or more
  symptoms on the 4 Item PTS Scale. These are
  broken down as follows
• 4 Symptoms 21 (3)
• 3 Symptoms 40 (5)
• 2 Symptoms 63 (8)

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What is the natural history of PTSD?
PTSD caseness of patients directly involved in
a raid over time. Data from Richards (1997) The
Prevention of PTSD after armed robbery the
impact of a training programme within Leeds
Permanent Building Society.
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Prevention Conclusion Part 2

• Subjectively positive- Decompression generally
  helpful
• Stigma affects about a third of people
• About 1/6th have significant trauma Sxs very
  early on
• How do we signpost effectively to helping
  services and overcome stigma?

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They are back, they are decompressed.now what?
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Post Deployment Interventions for Operational
Stress Injuries
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Post deployment briefings useful?

• Military risk factors for psychological illness
• Thought might be killed
• Morale
• Time spent in forward area
• Being in the Reserves
• Not receiving a homecoming brief
• Work in theatre did not match trade or experience
  
• Being deployed for lt13 months in last 3 years

Adjusted odds ratio 1.84 with 95 CI of 1.3-2.62
Iversen AC Psychol Med. 2008
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What could we do to prevent psychological injury?

• Pre deployment screening
• Pre deployment psycho-education?
• Post deployment psycho education
• Decompression?
• Post deployment psychological debriefing
• Peer group support (TRIM)
• Battlemind

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Royal Navy TRiM Study

• Outcomes

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What is TRiM? (Traumatic Risk Management)

• Essentially a peer support programme
• General support
• Formal strategic planning as soon as possible
  after the incident
• Identifying all those at risk using a structured
  template
• Organising no intervention, individual and small
  group risk assessment
• Briefing (psycho education) to larger groups
• Risk assessments using a 10 item risk scale at an
  early stage, at 28 days and at a later time if
  early problems persist
• The strategy is embedded in continuous mentoring,
  general support and advice about self-management
• Referral when and if required.

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Target Groups Likely to be Exposed to Traumatic
Events
TRiM Overview
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Early Internal Referral
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TRiM Study
12 Ships Randomised to 2 conditions
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Harm Stigma

• Over a 12 to 18 month period, no evidence that
  TRiM does any harm.
• No evidence to suggest that it has altered
  stigmatising beliefs.
• Non-specific indications that of beneficial
  organisational outcomes (reduced disciplinary
  breaches) and benefits to mental health. (TRiM
  trained ships maintained mental health,
  non-trained got worse).

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Exposure to Trauma

• Few traumatic incidents and therefore TRiM was
  not used in anger very often.
• Very difficult to say anything about the risk
  assessment element (the key ingredient).

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Acceptability

• Those in contact with TRiM in practice generally
  found it acceptable and rated it more highly than
  other forms of in-service support after traumatic
  incidents.
• Junior ranks, (those at risk of developing mental
  health problems), were sceptical that their peer
  group could offer emotional support, less of an
  issue for Seniors and Officers.

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Signposting

• Most personnel had never heard of military mental
  health services!!! (a potential substantial
  barrier to accessing care!)

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Quality of Stress Briefs

• Only half of the sample remembered being briefed
  in anyway about stress.
• Those attending poor mental health briefings were
  more distressed than those receiving good
  briefings and those who had never been briefed at
  all.
• More effort is required in terms of training and
  quality assurance in relation to psycho-education
  within the Services.

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Alcohol

• Alcohol remains a significant issue in those
  surveyed high numbers of Navy personnel were
  drinking to excess and binge drinking. Their
  alcohol misuse was worse than age matched
  civilian samples.

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Corporate Approach to Stress

• The sample reported that the Navy had improved in
  its approach to stress by using TRiM.
• Most personnel, regardless of rank, would act
  appropriately if they were confronted with a
  distressed individual and would act to prevent
  harm and ensure safety.
• TRiM should become an option for the chain of
  command to utilise in support of their personnel
  but at present should not become SOP.

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Requirement for TRiM

• Within lower threat environments, such as the
  ships studied here, it seems unlikely that, from
  current evidence, the provision of TRiM could be
  regarded as an essential ingredient in the Royal
  Navy duty of care.
• TRiM may have positive effects on attitudinal
  change and morale in years to come and also that
  it is more likely to be of utility within high
  threat environments.
• Currently under investigation

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TRiM and Educational Strategies in PTSD

• Does TRiM improve practitioner/comander attitudes
  and behaviour?
• Examined the effect TRiM upon stigmatising
  beliefs, attitudes to stress and mental illness.
• Training significantly improved attitudes about
  PTSD, stress, and help-seeking in TRiM trained
  personnel.
• TRiM trained personnel were more likely to have a
  positive view of help-seeking for a mental health
  problem from TRiM trained personnel but were more
  likely to have a negative view of seeking help
  from command.
• TRiM could be a promising anti-stigma program
  within organizational settings and appears to do
  no harm.

Gould et al 2007
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What could you do to prevent psychological injury?

• Pre deployment screening
• Pre deployment psycho-education?
• Post deployment psycho education
• Decompression?
• Post deployment psychological debriefing
• Peer group support (TRIM)
• Battlemind

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BATTLEMIND TRAINING

• US site www.battlemind.army.net

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UK BATTLEMIND

• US Army phrase for their operational stress
  briefing interventions
• Training carried out at pre post deployment,
  for with spouse and also Bmind First Aid
• Post deployment Bmind aims to manage the
  transition from operations to returning home
• Uses Service Persons own experience positively
• Does not use an illness paradigm

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BATTLEMIND

• Buddies and unit cohesion Withdrawal
• Accountability Controlling Behaviour
• Targeted aggression Inappropriate aggression
• Tactical awareness Hypervigilance
• Lethally armed Locked and loaded at home
• Emotional control Anger/Detachment
• Mission security Secretiveness
• Individual responsibility Guilt
• Non-defensive (combat) driving Aggressive
  driving
• Discipline and ordering Conflict

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Background

• US Forces report promising results from
  comparative studies.
• BATTLEMIND Superior to CISD and Routine Stress
  Management
• Small Group BATTLEMIND superior to Large Group.
• Large Group Still Superior to Other Management
  Strategies
• Most Effective for Combat Arm Troops
• NB Successful in reducing the rise in mental
  ill health (not yet seen in UK forces).

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Battlemind after 4 months

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UK Battlemind Study

• Principle Investigator in post
• 19th June US delivered Bmind training at ACDMH
  as a precursor to Anglicise Training Package
• Deliver Battlemind v standard care in Cyprus as
  a cluster RCT
• Follow up at four months at home base
• Will aim to mainly examine formed units
• Pilot in autumn and ?trial next March-June

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Conclusions

• Before deployment little evidence that MH has
  much to offer
• Pre-deployment screening doesnt work
• Pre-deployment briefing appears to be ineffective
  
• Decompression, if done well, might help
• If done badly, certainly wont must avoid
  pathologising
• Post deployment psycho education might reduce
  symptoms
• TRiM remains unproven but shows initial promise
• BATTLEMIND looks clever but can it be
  translated?

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Read all about it Kings Centre for Military
Health Research www.kcl.ac.uk/kcmhr