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

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


1
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
2
What are we trying to achieve?
3
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

4
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

5
Lets keep a sense of proportion
6
Primary mental health outcomes (Regulars only)
?
Hotopf et al. Lancet 2006 367 1731-1741
7
Primary mental health outcomes (Regulars only)
Hotopf et al. Lancet 2006 367 1731-1741
8
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
9
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

10
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

11
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

12
The seductions of screening!
  • Save people and families from psychiatric
    disorder
  • Save commanders from ineffective personnel
  • Save the Chancellor from paying war pensions

13
(No Transcript)
14
UK Screening Study
Op Telic
Main Study, 2005 n1885 (69)
Screening study (completed 2002) n2800
Controls
Rona et al, BMJ 2006
15
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
16
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
17
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

18
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)

19
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
20
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
21
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
22
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

23
Decompression
  • Can we assist recovery from Ops?

24
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

25
Process and Activities
  • Cyprus
  • Mental Health Brief
  • Coming Home Brief
  • Social Event
  • Beach Activities
  • Entertainment Show
  • Access to Mental Health Personnel
  • Booze!!

26
Do any of the following areas concern you about
going home?
27
Do you think that the decompression briefings
will make going home easier for you?
28
Do you think decompression has been helpful in
letting you know how to deal with unpleasant
incidents that occur during a tour?
29
I would not seek help for a mental health problem
because
30
Have you had a deployment experience that was so
frightening, horrible, or upsetting that DURING
THE PAST MONTH you had..
31
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)

32
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.
33
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?

34
They are back, they are decompressed.now what?
35
Post Deployment Interventions for Operational
Stress Injuries
36
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
37
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

38
Royal Navy TRiM Study
  • Outcomes

39
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.

40
Target Groups Likely to be Exposed to Traumatic
Events
TRiM Overview
40
Early Internal Referral
41
TRiM Study
12 Ships Randomised to 2 conditions
42
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).

43
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).

44
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.

45
Signposting
  • Most personnel had never heard of military mental
    health services!!! (a potential substantial
    barrier to accessing care!)

46
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.

47
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.

48
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.

49
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

50
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
51
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

52
BATTLEMIND TRAINING
  • US site www.battlemind.army.net

53
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

54
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

55
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).

56
Battlemind after 4 months

57
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

58
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?

59
Read all about it Kings Centre for Military
Health Research www.kcl.ac.uk/kcmhr
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