From civvy street to theatre of war
How did your own military service influence your later career and philosophy?
I served as an army officer on a short service commission with The Queen’s Dragoon Guards, in England, Germany (during the ‘Cold War’) and Northern Ireland (at the time of the H-block riots and Bobby Sands’ hunger strike). I didn’t know it at the time, but it was the best possible preparation I could have had for my later life as a military psychologist. From the moment I graduated from University College London in 1990 I was knocking on the army’s door telling them that they needed to put psychologists into uniform (the last uniformed psychologists served in World War II). I’m delighted that, nearly 25 years later, in April last year, Captain Duncan Precious became the first-ever clinical psychologist to be commissioned into the British Army [see tinyurl.com/captdpr]. I’m absolutely convinced about the role that psychology and psychologists have to play in defence.
What’s the extent of the problem with veterans’ mental health?
'It’s big. Our research tells us that up to 20 per cent of veterans suffer from psychological health problems. That’s over half a million people from an estimated three million veterans according to the British Legion. A worryingly large number, given that service personnel start out as fit, healthy and selected through rigorous training. Veterans are also strongly represented in the criminal justice system and in the homeless population. And the tragic thing is that there is no one person in the Westminster government who’s coordinating all this. It falls between several stools of the Ministry of Defence, the Department of Health, the Department of Justice, and so on. And the other problem is that the vast majority of people in the NHS and the Third Sector, on whom the care of veterans falls when they leave the services, know very little about what a veteran is, what experiences they have had, and what their needs are.
In 2010 the Coalition’s ‘programme for government’ promised extra support for veterans’ mental health needs. Are they delivering on that promise?
Partially. Yes, there is extra funding for Combat Stress Community Mental Health Nurses and a 24-hour helpline, and there is some specialist commissioning funding for a residential Combat Stress pilot treatment programme too. But when it comes to delivering equity and parity of NHS and local authority veteran mental health and support services, we’ve still got a long, long way to go. Veterans, in theory, get priority treatment in primary care (but seldom do in practice) and do not get any preferential treatment in secondary care, where it is needed. There is widespread agreement that the Armed Forces Covenant is not delivering what it could or should.
To what extent can you determine – and to what extent is it important – whether it is service that causes mental health problems, or that those attracted to the armed forces may be predisposed to such issues?
That’s a good question and, as psychologists, we know a good deal about predisposing and vulnerability factors, provoking factors and precipitating factors. It’s true that the armed forces, particularly the army and particularly the ‘teeth arms’ such as infantry, traditionally recruit from areas of high unemployment and social deprivation when individuals may be seeking to leave behind abusive and difficult pasts in the search for a better future, let alone a wage. At the same time, many parts of the forces recruit robust, balanced individuals to train for some of the more demanding roles. So, of course, it’s a combination of the two, as it often is, but the rigours of deployment – particularly repeated and prolonged tours where there is daily or near daily exposure to death and injury (and this has certainly been the case in Afghanistan) – absolutely take their toll, however prepared and resilient the individual concerned.
There’s also the question of whether it is the service that’s the issue, or the coming back to ‘civvy street’. I note your paper on deployment in Iraq actually being associated with improved mental health.
The paper that I wrote about how going to war can be good for you followed a group of specially selected, highly trained, highly motivated soldiers (paratroopers) on their first deployment to Iraq in 2003. They went to carry out tasks that they had been specifically trained for, carried them out successfully, with minimum loss of life and limb and returned to the UK relatively quickly, and yes, their scores on pen and paper measures indicated that their mental health had improved over their deployment. But that is, sadly, not the norm, and our research indicates that troops exposed to danger on a regular basis suffer the consequences, especially if they are young, junior and inexperienced.
Coming back to ‘civvy street’ is indeed a huge problem. I found it difficult enough returning from Belfast to Birmingham in 1981 after less than five years’ service. For people who have given 22 plus years of service the necessary adjustments are immense. You are leaving behind not just a job, but a way of life where everything is provided – food, entertainment, pay, clothing, accommodation – and where your whole social network is based. It’s a huge wrench.
Alcohol must play a part… I have read soldiers’ accounts describing life as ‘a bunch of lads’ playing ‘the ultimate extreme sport’, ‘drinking and drinking and drinking and having a laugh’.
It’s true that drinking huge amounts of alcohol has been considered as normal for far too long and, in many cases, is expected and forms part of initiation rituals, rites of passage, celebrations and commiserations. The MoD and the three individual services – Navy, Army and Air Force – are finally beginning to get the message; things are changing slowly. When I was a young cavalry officer, a gin and tonic before lunch was common on weekdays in the mess. That’s almost unheard of nowadays.
Are veterans more receptive to some forms of mental health intervention than others? I note you use EMDR, which has often been controversial.
I do use EMDR, and when I first heard of it 20 years ago I was hugely sceptical... until I started using it. I’ve been using it ever since, and it’s a most remarkable form of therapy and, in my experience, much more powerful than the CBT in which I had been trained in initially – although it is my view that EMDR is, in fact, a particular type of cognitive behavioural intervention rather than something completely different. The military and veterans respond extremely well to EMDR because you don’t have to speak if you don’t want to, and it is particularly effective for the treatment of trauma where flashbacks and nightmares predominate, although it can also be very effective in more complex cases where shame and guilt are involved. The MoD love it too because it’s a NICE-approved intervention for the treatment of trauma, along with trauma-focused CBT.
Some years back we discussed a special issue of The Psychologist on military health, but it was scuppered when colleagues in the MoD raised concerns about how it would be received. Is this still an issue that prevents psychologists in the area sharing their good practice?
No. Not at all. Things have moved on massively and there is now a proposal to form a Military and Defence Psychology Section in the British Psychological Society, which would be a real result after such a long campaign to have one. Just in time, too, as we celebrate a century of military psychology in the UK in 2015. Military and defence psychologists, of all hues, are often right at the cutting edge of practice, as you would expect, and the formation of a Section, amongst other things, would really help in the promotion of our area of work.
Presumably psychologists of many different persuasions have a role to play in veterans’ mental health.
You’re absolutely right. When I was appointed head of clinical psychology for the MoD, we expanded the service to include counselling psychologists and health psychologists in addition to the clinical, forensic and neuropsychologists that we already had. And there are huge numbers of occupational and research psychologists in the MoD too – in the Royal Navy, British Army and Royal Air Force, in MoD Main Building and in the various research and training establishments. It’s absolutely fascinating and highly rewarding work, and I would commend it to anyone.
And perhaps input doesn’t have to be ‘formal’ psychology – is there a role for innovative therapies such as gardening, running, et cetera?
Of course. Perhaps running isn’t that innovative after all though. It’s one of the things that all military people do, and they are very good at knowing when they need to go for a long therapeutic run or to ‘beast’ themselves in the gym. When deployed out in theatre, in an alcohol-free environment, ‘fizz’, as physical training is known, is incredibly popular as people engage in ‘Op Massive’ in the gym in order to return to the UK with a muscle-bound, honed, tanned body to impress their partners with. Gardening, though, is, actually, really beneficial as well. I’m mainly involved in veteran psychological health and social care research and delivery these days and am a supporter of two charities that have projects up and down the country where veterans work alongside horticultural therapists. I’ve seen them at work and am a big fan.
I know you’re a religious man. Do you ever find it hard to reconcile this with your military involvement and scientific beliefs?
I am. I happen to be a Christian and an Anglican Franciscan Tertiary (that is to say a lay member of a religious order within the Church of England), but I really do believe that everybody has a spiritual side to them regardless of whether they have a faith or not, and that the ‘spiritual’ in ‘biopsychosociospiritual’ is an extremely important, and often forgotten, component. No, I don’t find it difficult to reconcile my faith with my scientific beliefs at all. I’m not a fundamentalist and I am absolutely sure that the God that I believe in works through science and that science provides a way in which we can, perhaps, also learn more about God.
With regard to my work with the military, I very much believe in the ‘just war’ philosophy and that it is, sadly, necessary to have an armed force available to use as a last resort to prevent terror or tyranny. I really felt that when I was a soldier in the Cold War. The presence of very large numbers of conventionally armed troops in Germany was a real deterrent to any conflict, and I am pleased to have played my very small part in all that.
Do your own personal and professional interests chime with your priorities for the next year, as incoming President of the British Psychological Society?
In much the same way as I’ve been fighting over the last quarter of a century for a resurgence in military psychology, I’m going to use my term as President to seek a higher profile for the profession, a stronger voice for psychology and greater influence on policy and practice. But I’d also like to see better access, equality and transparency for our Society too.
What do you think is holding us back from having this profile, voice and influence?’
Perhaps it just hasn’t been seen as a priority. But I know, from what several members of the Society have said to me since I was elected as President Elect, that they would like the BPS to be more prominent, not only in the media but having a real voice and influence on policy and legislation. This is all now in the Strategic Plan and we have the necessary mechanisms to underpin it. We just need to be a lot more reactive, and much quicker at reacting too, telling people what we, as psychologists, know about an issue in question and demonstrating what psychology has to offer in the area. And, of course, this will require a lot of proactivity and planning and targeted communication too. I see the Society’s Boards as having a crucial role, as well as our policy advice and press team and, of course, The Psychologist.
Sounds like you’ve got your work cut out! How are you going to find any time for yourself?
I’m ruthless about the way in which I handle e-mails and social media and have very firm boundaries. Downtime, alone or with family and friends, is incredibly important. I find running and singing and playing music really restorative and enjoy learning foreign languages for fun too. It’s going to be a heck of a year, but I’m going to give it my best shot.
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