the prevention, recognition and treatment of … · brigadier general sutton and her staff at dcoe....

Matthew Wesson Winston Churchill Travelling Fellowship USA Nov-Dec 09

The Winston Churchill Memorial Trust

Fellowship Category – Treatment & Rehabilitation of Traumatic Injuries

The prevention, recognition and treatment of operational stress

injuries in US Army serving personnel

“The hidden scars of their wounded warriors”

Report by Lieutenant Matthew Wesson PG Dip, Grad Dip, BA(Hons), Dip HE, RN(MH)

Churchill Fellow 2009

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Contents

Acknowledgements 3

Introduction 4

Aims 4

Background 5

Itinerary Outline 6-7

Itinerary Details 8-21

Reflections 22-24

Recommendations 25-33

References 34-36

Important Note

The views expressed and recommendations made in this report are those of

the author and do not reflect the official policy or position of the MOD or any

institution with which the author is affiliated.

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Acknowledgements

Firstly my sincere thanks go to the Winston Churchill Memorial Trust for awarding me this fellowship and with it an amazing opportunity. It is a great honour to be able to become a Churchill Fellow and I really hope that my fellowship has lasting benefits. Thank you to the office staff for their prompt and helpful assistance on the logistical issues of managing my fellowship.

There are many people in the UK that have helped make this fellowship a success. In particular I would like to mention, Surg Cdr Neil Greenberg for putting me in contact with so many of his US colleagues. Also thanks to Surg Capt Rob Ross and Surg Cdr Martin Randle for giving me the month away from my desk so that I could undertake the trip. Thanks as well to Surg Cdr Sharpley and Dr Gould for some great references.

In the US there were literally dozens of people who played a part in putting my hectic schedule together and looking after me when I was there. Thank you to all the staff in each facility I visited for both their time and hospitality. There are too many to mention everyone who helped me but they should know who they are and I’m hugely grateful to them all. I would like to give special thanks to Colonel Andy Jose and Colonel Stuart Campbell. The staff at WRAIR especially Maj Jeff Thomas and Maj Oscar Cabrera. The staff at WRAMC particularly Ward 53 (especially Dr Lande and Dr Freidlander), the Psychiatric Liaison team and the chaplaincy staff (especially Lt Col Gales). Joe Rollo and The Prince George’s County Police Department. Lt Cdr Jeffery Cook and the staff at the National Naval Medical Centre. Bob Gifford and the staff at CSTS. Brigadier General Sutton and her staff at DCoE. Dr Tom DeGraba and the staff at NICoE. The National Centre for the Intrepid. The staff at AMEDD, the WTU and ACEP at Fort Sam Houston.

There were also a few other individuals who played a particularly big part in the planning and execution of my fellowship. Rick Keller at WRAIR for coordinating most of the DC element of the schedule, which took an inordinate amount of emails. Maj Tim Carroll in overcoming some big logistical issues for me at AMEDD. The hospitality of the whole Battlemind Training Team was amazing, especially Duane Meyer and Andy Lopez who looked after me so well throughout my time in San Antonio. I hope to be able to return the favour one day.

Lastly, thank you to my wife Claire for all her support. She not only had to put up with my stress levels due to endless hours on the internet trying to bring the schedule together. But she also had to cope with our 2 year old son and being heavily pregnant whilst I was away. As always, I’m in your debt.

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Introduction

I am a Cognitive Behavioural Psychotherapist, EMDR Consultant and Registered Mental Health Nurse. I have been in the Royal Navy for nearly 18 years and am a Lieutenant within the Queen Alexandra’s Royal Naval Nursing Service. My clinical role is to provide mental health assessment and treatment to serving military personnel. I have completed operational tours of Op Telic (Iraq) and Op Herrick (Afghanistan). Since the late nineties I have had a particular interest in the treatment of traumatic stress. I have presented at international conferences and been published on the issue.

I applied for the Winston Churchill Travelling Fellowship under the category ‘The treatment and rehabilitation of traumatic injuries’ to broaden my knowledge in this area and to bring back what I learnt for the benefit of myself and the UK Defence Mental Health Service.

Fellowship Aims

When I applied for the Winston Churchill Travelling Fellowship my original aims were as follows:

To learn more about how the US Army Medical and Behavioural Health Services prevent and treat post traumatic stress injuries in their serving personnel. To exchange ideas, knowledge and information with my American colleagues around the prevention and treatment of post traumatic stress injuries in armed forces personnel.

To spend time with the US Army’s Medical and Behavioural Health Services and other related agencies in achieving the aim. It is hoped that both US and UK services can learn from each others’ experiences. This may then lead to improvements in the provision of our psychological support to serving personnel, as well as forming the basis for the long-term relationship of information exchange between these two pioneering military mental health services.

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Background

Traumatic Stress Injuries and the Military

Military personnel who are exposed to traumatic events during operations are at risk of developing symptoms of traumatic stress. Such psychological reactions have a long history within the military. They have been recognised as far back as the American Civil War as ‘irritable heart’, in World War I as ‘soldier’s heart’ or ‘shell shock’, and in World War II as ‘combat neurosis’ (Kinzie & Goetz, 1996). The Vietnam War caused record numbers of soldiers to develop traumatic stress problems as a result of their experiences in combat (Solomon, 1995). However, Post Traumatic Stress Disorder (PTSD) was not officially recognised until the third edition of the Diagnostic and Statistical Manual (DSM-III; APA, 1980) where it was classified as an anxiety disorder. PTSD is thought to develop when the person processes the traumatic event and its consequences in a way that generates a sense of current and serious threat (Ehlers & Clark).

More recent research in military personnel has shown that soldiers who have deployed to Iraq or Afghanistan are at a high risk of developing mental health problems including traumatic stress injuries such as PTSD (Hoge et al 2004, Rona et al 2007).

Now that traumatic stress injuries and PTSD are recognised as inevitable consequence of modern warfare there is much interest into how this can best be managed. A two-prong approach is often taken. The importance of early detection in PTSD has been widely acknowledged (Guess 2006, Heinrichs et al 2005, Lee et al 2005) and authors have indicated the potential benefits of early intervention (Bryant 2007, North 2001, Weisaeth 2001). Therefore, education and briefing programmes are often used to improve the recognition of post-traumatic stress reactions to ensure prompt treatment where appropriate. They are also used to encourage help-seeking behaviour and reducing the stigma often experienced when asking for help. Once diagnosed, facilities should be set up to provide the most effective treatments to serviceman or women, hence giving them the best chance of recovery. Within the UK the National Institute for Health and Clinical Excellence (NICE, 2005) has issued PTSD treatment guidelines detailing which approaches have the strongest research base demonstrating their efficacy. These include Cognitive Behavioural Therapy (CBT) models and Eye Movement Desensitisation & Reprocessing (EMDR).

The US produce a lot of the research in the area of combat-related PTSD and their military are pioneers in the prevention of traumatic stress injuries, so it was my first choice as the location for my travelling fellowship.

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Itinerary Outline

Sat 14th Nov - Depart UK / Arrive Washington DC

Mon 16th Nov - Walter Reed Army Institute for Research (WRAIR), Silver Spring

Tue 17th Nov - Prince George’s County Police Department Mental Health Team

Wed 18th Nov - Defense Center of Excellence (DCoE), Rosslyn and Silver Spring

Thu 19th Nov - National Naval Medical Centre (NNMC), Bethesda

Fri 20th Nov a.m - National Intrepid Centre for Excellence (NICoE), Bethesda

p.m - Centre for the Study of Traumatic Stress (CSTS), Uniformed Services University of Health Sciences (USUHS), Bethesda

Mon 24th Nov a.m - Chaplaincy Department, Walter Reed Army Medical Centre (WRAMC), Silver Spring

p.m - Outpatient Psychiatry, Ward 53, WRAMC

Tue 25th Nov - Trauma Recovery Programme, Outpatient Psychiatry, Ward 53, WRAMC

Wed 26th Nov - Trauma Recovery Programme, Outpatient Psychiatry, Ward 53, WRAMC

27th – 30th Nov - Thanksgiving Weekend

Mon 1st Dec - Psychiatry Consult Liaison Service (PCLS), WRAMC

Tue 2nd Dec - WRAIR

Wed 3rd Dec - Travel to San Antonio (SA), Texas

Thu 4th Dec - Battlemind Training Office, Army Medical Department Center & School, (AMEDDC&S), Fort Sam Houston, SA

Fri 5th Dec a.m - Department of Community Mental Health, Warrior Transition Unit (WTU), Fort Sam Houston

Fri 5th Dec p.m - Center for the Intrepid, Fort Sam Houston

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Thu 10th Dec p.m - Army Center for Enhanced Performance (ACEP), Fort Sam Houston

Mon 7th – Fri 11th Dec - Combat Operational Stress Control (COSC) course, Hilton Doubletree, San Antonio

Sat 12th Dec - Depart SA, Texas

Mon 13th Dec - Arrive UK

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Itinerary Details

Monday 16th November WRAIR

I arrived in DC on Sat 14th after 20 hours of travelling and I had Sunday to recover. I did manage to catch the Metro into DC to orientate myself and see some sights like the Washington Memorial.

Today (16th) was my first day of the fellowship and I visited Walter Reed Army Institute of Research (WRAIR). The day was spent meeting the teams, sitting in on their weekly meeting and finalising my plans for the next couple of weeks. I also went up to the Walter Reed Army Medical Centre, which is a very large military hospital. I met some different teams who I’m going to spend some time with next week. A productive day and it was good to see the last parts of the itinerary come together.

Tuesday 17th November - Prince George’s County Police Department Psychological Support Team

I had a great day spent with the Prince George’s Police department. I was hosted superbly by Joe Rollo, a licensed social worker who is part of their psychological support team. He explained their role in looking after their police officers. He has a special interest in how to best look after the police officers who are also military reservists or military veterans.

Joe organised for me to spend time with various police officers who were ex-servicemen or reservists to get their view point. I even got to go on a couple of ‘ride alongs’ in a police car, which were fortunately relatively uneventful.

Both their reservists and veterans spoke of the difficulty in adjusting to homecoming after their tours. They did not feel particularly supported by the Army or Marines on their return, especially if they were reservists or had left the military on completion of their tour.

Some of the policemen I spoke to were reservist helicopter pilots and they offered me a flight with the police helicopter. It was a great opportunity and I was able to take in some amazing views of DC at night. It was a long 12 hour day but well worth it. All round a valuable and enjoyable day, and I

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WRAIR


received some valuable insights from the perspectives of reservists and veterans.

Although the US military has some great veteran support mechanisms, it would appear there are still difficulties in adjusting to homecoming when someone does not have a formal mental health problem that warrants seeking help via the Veterans Affairs (VA).

Wednesday 18th Nov – DCoE

Today was spent with the Defense Center of Excellence at the offices in Silver Spring & Rosslyn. I first met with Brigadier General Sutton, the Director of the newly formed DCoE. I sat in on a Traumatic Brain Injury (TBI) meeting finding out about some new research and recommendations they have about the management of mild TBI (mTBI) in theatre.

I then went to their Silver Spring office and met some other members of the team. First I met with Dr Miguel Roberts, a clinical psychologist working in the Psychological health directorate who helps write guidance on the implementation of guidelines in the management of TBI and PTSD by Primary care providers.

I then met Maj Megumi Vogt, the TBI Clinical Standards of Care director who is helping produce guidance on the management of mTBI in theatre. I then briefly met with Dr Sonja Batten who is the deputy director and a psychologist to discuss the work of DCoE in general.

It’s a relatively new department looking at the standards of care for psychological health and TBI across the whole military.

My final meeting was with Dr Mark Bates the director of the Resilience and Prevention Directorate looking at the provision of resilience training across the military. It was relatively early on in the development of policies across the whole directorate but they had some interesting developments.

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Brig Gen Loree Sutton


Thursday 19th Nov - National Naval Medical Center, Bethesda

Today was really interesting. I was hosted by Lt/Cdr Jeffrey Cook the department head of the Psychological Health and TBI Programme.

We discussed the provision of care at length throughout the day. Clearly their prevalence of TBI (around 17% I think) is particularly high and it’s a high profile condition that’s getting a lot of funding. I spoke to some of the neuro psychologists including Dr Linda Rice that are involved in administering the psychometric tests to diagnose mTBI.

Their treatment of PTSD is largely similar to ours and based at out-patients but with patients often staying in barracks on the camp. They run groups and individual evidence based treatments such as prolonged exposure and Cognitive Processing Therapy (CPT). All the clinicians have been trained in these techniques by training provided in or purchased by the hospital, and they run weekly clinical supervision groups as well. These treatments are delivered by psychologists and licensed clinical social workers. They don’t use EMDR as they say there isn’t enough of an evidence base! Lt Cdr Cook is going to send me some of their protocols for the group PTSD treatment which is just being developed. They also use bio feedback a lot as their main self soothing technique to be used alongside exposure work. They also complement other aspects of PTSD like anger management and stress management groups.

Interestingly they split their services into the Wounded Warriors services and these are purely for those returning from operations. Non-deployment related conditions and dependents are seen by a different service. This means they have very short waiting lists and can offer intensive treatments.

They also seem to medically pension many more personnel for PTSD and TBI. There also appears to be a problem with secondary gain due to the comprehensive benefits offered to veterans that have been medically discharged.

I also met with Dr Christina O’Brien who is the service chief of the consultation liaison service that works with people on medical wards in a way very similar to those in Birmingham, UK. She doesn’t carry out specific interventions or treatments but is able to support injured service personnel and signpost them into MH care when and where appropriate. It was another busy but very interesting day.

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NNMC

NNMC Entrance


Friday 20th November a.m - NICoE

This morning I was invited to a meeting of the newly formed National Intrepid Centre of Excellence in Bethesda. This is currently being built to provide initial rehabilitation of TBI wounded warriors who will stay there for 2-3 weeks before moving to their own facilities when they are stable enough.

It’s a project purely funded by charitable donations and the support of the Fisher family.

The meeting was led by Dr Tom DeGraba (Deputy Director NICoE) and it was about the use of technology to support wounded warriors, in particular those with cognitive deficits. The technology was both ingenious and impressive. It included devices that are available in office stores (e.g., portable keyboards, vertical mouse) as well as computer programmes that can read aloud text from books and magazines, along with devices designed specifically for individuals by specialists.

Money doesn’t seem to be a problem when injured soldiers are involved and they will do all they can to support servicemen adjust to work and social life in or out of the military with their disabilities. The Occupational Therapists (OT’s) are heavily involved in this and are highly committed to getting patients to the highest level of funding available. It is interesting how many facilities, departments and programmes are set up purely for those returning from Iraq and Afghanistan, and separated completely from the care of other service personnel and their dependents.

Friday 20th November p.m - CSTC

I then went to visit Bob Gifford, (psychologist, Executive Officer) who works at the Centre for the Study of Traumatic Stress which is a research facility attached to the Uniformed Services University of Health Sciences which is close to the Naval Hospital. I learnt about some of their research (e.g. looking at medications for PTSD and meta-analysis of what timelines PTSD will or will not resolve naturally). Their main aim is in the generation and dissemination of knowledge about traumatic stress.

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Artist’s Impression of NICoE

Artist’s Impression of NICoE


Several of the staff had been to Fort Hood in a consultancy basis helping coordinate their PH support, care and provision for service personnel, their partners and children. They stick with the principles of avoiding medicalising presentations but help agencies to highlight high risk personnel, and also how to coordinate responses amongst agencies in a disaster such as this. It’s interesting to hear they don’t condone CISD either and only recommended psychological first aid and to utilise the support of systems already in place. They kindly gave me a couple of books on disaster management which will be an interesting resource.

I now have the weekend off and I am looking forward to some rest as well as doing some sightseeing.

Monday 23rd November - Walter Reed Army Medical Centre (WRAMC)

This morning I met up with the Chaplain Lt Col Gales of WRAMC to discuss the Chaplains clinical education package. It was interesting to hear more about what their role is in supporting patients with PTSD both in the hospital as well as in other bases and on operations. Largely their role is the same as those back in the UK in providing the spiritual element of holistic care to the patient. They have a role in the delivery of Battlemind (a psychological briefing programme) so they are not only important in helping the wounded warrior but also helping prevent PTSD through education and support at the time of trauma.

In the afternoon I went to the out-patient psychiatric ward at WRAMC to arrange spending some time meeting with clinicians involved in and observing their traumatic stress management programme. This will allow me to compare their interventions to both what I witnessed at the Naval hospital but also to what we offer to serving personnel at home.

Tuesday 24th November - Trauma Recovery Programme, Out-patient Psychiatry, Ward 53, WRAMC

Today I spent the day with the trauma stress out-patient management programme. I got to discuss the elements of the programme with the clinical director who is an ex-army psychologist. It involves a mixture of group and individual interventions which were all evidenced based. Their individual interventions include bio-feedback, CPT, Prolonged Exposure (PE) and EMDR. Their groups include stress management, anger management, motivational enhancement, recreational therapy, art and occupational therapy. These are run by a mixture of nurses and psychologists. It is a weekly rolling programme that most people attend for 2-4 weeks before moving to just out-patient individual sessions usually twice a week.

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I was able to participate in the emotional regulation group. Not much of the planned content was covered in the group but some of the patients used it to verbalize some of their frustrations while others were clearly able to offer valuable peer support and guidance.

I also got to observe one of their Multi-Disciplinary Team (MDT) meetings. It was interesting to see how many of their patients had dual diagnosis of both physical and other mental health conditions including Major Depressive Disorder, Bi polar, and mTBI. Most of the patients on the programme had previously been an in-patient in either Germany (casualty receiving facility) or WRAMC or both, and the majority will be medically discharged out of the services.

They also seem to use a lot of medication to treat individuals in comparison to the UK, especially compared to our use of medication for PTSD. It is rare for somebody to be treated with medication for PTSD in the UK but here it appears standard practice for this condition.

I also got to sit in a meeting about redesigning the motivation enhancement (ME) element of the programme. It seems their programme is constantly evolving and always based on published research (e.g. papers on use of ME groups for PTSD). They are also very keen on always collecting outcome measures where possible.

Wednesday 25th November - Tuesday 24th November - Trauma Recovery Programme, Out-patient Psychiatry, Ward 53, WRAMC

Today I was back on the out-patient ward spending some more time with the trauma programme staff. I managed to sit in on another couple of groups. The first was an emotional regulations group. It was a structured group led by a psychologist which was psycho-educational in nature. Most of the group was spent discussing the ABC of managing emotions (anticipatory event, behaviour and consequences) and went to help people talk through ways that they could recognise when emotions or sensations were being triggered and take positive action to control or minimize these.

The second group was a Crisis management group but was more supportive in nature and less structured. It was led by what ever the patients brought to the group. This was facilitated by a nurse practitioner. However, their nurse practitioners are primarily involved in medication management as many of them are able to nurse prescribe.

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WRAMC


I then spent some time with the clinical psychologist who is part of a research trail into the effectiveness of virtual reality in treating PTSD. It’s used in conjunction with a small part of normal exposure work and together with some cognitive elements around session 5. The treatments are supposed to last 12 sessions but they’ve often had to use more due to the severity and multiple trauma nature of most of their subjects (just 8 to date). The data is promising but it is felt it will not be superior to other treatments and probably be recommended as an adjunct to standard treatment (PE, CPT, Cognitive Therapy [CT]).

I was able to try out the equipment which seemed very much like a video game although the sounds and smells seemed very realistic. I think that some people may find it of benefit but certainly not everyone. It may also help people get more confidence towards the end of treatment (like a future template in EMDR). The scenarios are very limited and differ minimally between the Afghanistan and Iraq scenarios. You can have a scenario of riding in a Humvee or walking on a patrol. The therapist can add in motor fire, IEDs, explosions, and noises as appropriate for that individual’s trauma experience. It will be interesting to see the published data from the trial and actually trying it out was a great opportunity.

Monday 1st December - Psychiatry Consult Liaison Service (PCLS), WRAMC

Today I was with the PCLS for another really interesting day at Walter Reed Army Medical Centre. This team’s role is to make contact with all the wounded warriors that return from theatre with physical injuries. Their interventions are generally brief but really important in supporting the individual adjust to being back and to often significant injuries.

They provide support for as long as the soldier is an in-patient and will refer on where necessary. They carry out screening of all personnel as well as providing daily support via their team of psychiatrists, psychologists, nurse practitioners and social workers. They provide support to the families in the form of a weekly group. They also run a weekly group for injured personnel. In addition they link in with child and adolescent services to provide assessment and support to injured warriors children. In all, it is a very comprehensive service.

Other aspects they are involved in include providing liaison to any medical patient within the hospital with psychiatric or mental health related issues. They also provide psychiatric liaison for the Emergency Department.

During my time I was able to observe morning and afternoon rounds of the team. I was able to escort one of the army psychiatrists on his patient visits and be present during the trauma team’s ward round in which there is a

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psychiatric input. I also spent time discussing the use of hypnotherapy for anxiety and pain management (an intervention used a lot in the team). I also sat in on MDT discussions and patient consultations.

This is another example of a really comprehensive service that tries not only to support those in need but helps avoid service personnel ‘slipping through the net’ by seeing and screening all returnees.

Thursday 26th November – Sunday 30th November – Thanksgiving Weekend

As all federal facilities were shut over this period it gave me a chance to recover from a hectic first 2 weeks of the fellowship. It also gave an opportunity for sightseeing. I was able to see many of Washington DC’s famous landmarks including some of its many military memorials.

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Marine Corp Memorial Iwo Jima Statue

United States Navy Memorial

Arlington National Military Cemetery


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Capital Hill

The FBI BuildingNational Cathedral

Washington Monument

The Churchill Hotel

Lincoln Memorial


Walter Reed Army Institute for Research – WRAIR – 1 Dec 09

I was hosted by Maj Oscar Cabrera and Maj Jeff Thomas at WRAIR for another interesting day. I learnt about some of their research and in particular the findings from their Mental Health Advisory Team who go into theatre once per year and carry out research on deployed personnel looking at various MH issues. These include comparing PTS and MH symptoms to length of deployment/time at home/number of tours. They compare the effect of leadership in platoons on stress levels. They look at the effect of deployments on marriages, amongst other aspects. I was able to get a PowerPoint of some of their

most recent findings. We were able to discuss the Battlemind research and further research around this issue.

I spent time with the sleep laboratory staff finding out about some of their findings around optimal sleep levels and the advice they have given Command on sleep hygiene.

In addition I gave a presentation on the UK Defence MH services and some of the research that has been coming out of the Academic Centre of Defence Mental Health (ACDMH) at Kings College London (KCL), which was well received.

Wednesday 2nd December – Travel from Washington DC to San Antonio

Thursday 3rd December - Battlemind Training Office, Army Medical Department Centre & School (AMEDDC&S), Fort Sam Houston

After making the trip from Washington to San Antonio, Texas the day before I spent this day with the Battlemind training team. They deliver various aspects of the Battlemind training to Behavioural Health (BH) providers in the Army, Navy and Air Force as well as to Chaplains.

This includes Traumatic Event Management (including Battlemind Debriefing – similar to Critical Incident Stress Debriefing [CISD]), Battlemind deployment brief training and Battlemind life cycle briefing training. The training is well packaged and looks professional. Although only the post deployment briefings and Battlemind debriefing have research evidence proving their efficacy, there is planned research looking at the life cycle elements.

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AMEDD Badge

The AMMED Centre & School


The key advantage seems to be that it all comes under one package with a common message of utilising the service persons resilience. This is in comparison to the usual illness model of most stress management presentations. They sometimes suffer from mission creep and other agencies wanting to take on the Battlemind product but

generally this is well advanced of anything on offer in the UK (bar TRiM briefing).

They have given copies of various resources including training booklets and CDs of presentations, which will be great to spend more time examining when I get back to the UK.

Friday 4th December a.m - Warrior Transition Unit (WTU), Fort Sam Houston

I started the day with one of the psychologists from the PTSD treatment training team at his clinic at the Warrior Transition Unit. I had managed to spend some time with his team the previous day. They are a small team of psychologists and licensed social workers that deliver PTSD training to other Behavioural Health providers. This includes EMDR, PE and CPT. This means they don’t have to buy in training like we do in the UK and helps ensure the delivery of evidence based treatments for PTSD. However, they did admit because they are so small they have no way to ensure the continuity of high quality treatment or adherence to treatment guidelines once the clinician has completed the

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Fort Sam Houston – Home of the Combat Medic

Me outside CFI


course. But that aside, this is an approach I believe we should be taking in the UK as they are able to devise training protocols specifically for combat related PTSD.

I was able to spend time with the social work manager of the Warrior Transition Unit (WTU) which provides out-patient mental health care to wounded warriors from Brooke Army Medical Centre. Although a clinical service they come under the control of the executive in Fort Sam Houston and that enables them to keep good links with the command on the management of soldiers.

The WTU’s main remit is in risk management but they are also involved in the treatment of personnel and their dependents with mental health problems including PTSD. It seemed to work in the similar way to our DCMHs with a key difference that their Social Workers carry out the work that our

community mental health nurses do. Their psychiatric nurse practitioners seem to be mainly hospital based and heavily involved with the prescription of medication and delivery of medical model based care.

Friday 4th December p.m - Centre for the Intrepid (CFI), Fort Sam Houston

In the afternoon I was fortunate enough to take a tour of the Centre for the Intrepid which is the US version of the UK rehabilitation facility at Headley Court. Its creation was fully funded by donations private and public and built in just 16 months.

The running of CFI is now funded by the DoD. Not surprisingly the facilities are state of art.

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A military leg amputee on the CFI Waverider

Computer Assisted Rehab at CFI

Receiving a AMEDD Medal of Excellence from Maj Tim Carroll for my presentation on UK

Defence Mental Health at the COSC Course


These include a $1.5 virtual reality training room that helps train people to use their prosthetic limbs and is able to recreate Iraqi landscapes as well as jet skiing! Their pool includes a wave rider so people can practice surfing whilst working on their core conditioning.

It includes a Behavioural Health section but I wasn’t able to speak to them during the visit which was a shame. However, I was told they work closely with

the physiotherapists and provide mental health care when and where appropriate. It’s a truly amazing facility and gives their brave wounded warriors the best chance of recovery.

Monday 7th – Friday 11th December - Combat Operational Stress Control Course (COSC)

1st day - The first day of the 5-day long COSC course. It is being held at the Doubletree Hotel Hilton Hotel in San Antonio as there is not enough space at AMMEDC&S! Today largely involved a meet and greet of the other course attendees finding out about their operational experience and backgrounds as well as the learning aims for the course. It also involved finding out more about COSC doctrine, learning about the Air Force and Marines COSC programmes, as well as some course administration. The COSC course is the pre-deployment course for all behavioural (mental health) providers. COSC is the name of the deployed team in theatre.

2nd day - The day started with my presentation on UK Military Mental Health (MH), which was well received. We then had presentations from the Surgeon General’s department on BH policy initiatives. We had a presentation on ‘Soldier 1st’ which is an initiative to train laymen soldiers through a 3 day training course in being able to spot MH problems and knowing who to refer the soldier to (e.g., Chaplains, MH). It’s similar to TRiM but without the traumatic focus.

We spent sometime on Traumatic Event Management and started to cover some training in Debriefing. It’s used a lot here and similar to TRiM but instead it is seen as a medical role and is facilitated by BH providers and chaplains. We also had a presentation on

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http://matthewwesson.wordpress.com/2009/12/08/combat-operational-stress-control-course-cosc-mon-7-dec/

http://matthewwesson.wordpress.com/2009/12/08/combat-operational-stress-control-course-cosc-mon-7-dec/

With the Battlemind Training Staff and their Winston Churchill Commemorative Coin


Resilience training which was some basic tips on keeping ourselves well emotionally, mentally, physically, socially and spiritually.

3rd day - Today we covered Operational MH triage and stabilisation, Sexual Assault Prevention training, Dealing with Substance Misuse in Theatre, Management of TBI, Suicide Reporting, and Briefing Commanders on MH issues. It was another interesting and interactive day. I have most of the briefs copied on PowerPoint which will be useful to show other colleagues when I return.

4th day - Today’s COSC course included information about the in-theatre research that their COSC teams can carry out on the request of the command. This can produce some very useful feedback for commanders and be a great way for MH providers to link in to the command. It also included presentations from Chaplains on their role (and the role of the Chaplain’s assistant) in theatre. This is very similar to the UK and they have close links to the MH providers.

Thursday 10th December p.m – Army Centre for Enhanced Performance (ACEP)

I was also fortunate enough to visit the Army Centre for Enhanced Performance. This is a team that was originally started in West Point academy training of high performance athletes at the Army College in sports psychology. It is now expanded into units across the Army providing Positive Psychology training to service personnel including recruits and soldiers in the Warrior Transition Programme. I managed to get a workbook that included some of their positive psychology exercises and have there website details as well. Their works include goal setting, imagery, energy (stress) management techniques like bio feedback, amongst others. It was really interesting how many of the techniques I’ve used with patients in the past can be utilised in a non-clinical setting to enhance performance.

5th day COSC - We learnt more about the restorative projects that the COSC teams use in theatre. They are 1-3 or 7 day projects that involve individual sessions with MH providers as well as classes in subjects like stress management, life skills and anger management. The idea is to give some brief respite and then return them to duty, much the same as our philosophy on operations.

Saturday 12th December – Travel to UK. Sunday 13th December – Arrive in UK.

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Reflections

My first general reflection on my fellowship was the size and quality of their military medical and mental health facilities in comparison to the UK. This was something I was expecting (seeing as everything is big in the USA!) but I was still taken aback by it. Clearly their military is much larger than ours. Their Army is around a million whereas ours stand at about 100,000. Therefore their military medical support needs to be much greater. However, they clearly have much more financial support than our armed forces. According to 2005 statistics the USA spend over 4% of their GDP on their military whereas the UK spends only 2.6% (CIA, 2007). However, we are still often ‘punching well above our weight’ in numerous operations around the world due to the high calibre of our military personnel.

Another important reflection was on the level of public support their military personnel get. Although recent conflicts have led to a change in the public perceptions of our military we still lag well behind the Americans in this regard. An enduring memory I will have is during an Ice Hockey game in Washington when 18,000 people gave an American soldier a standing ovation to thank him for his service! Everywhere I went there were military offers or discounts from businesses along with signs of support for their troops. You also cannot fail to be impressed by the Centre for the Intrepid rehabilitation facility which was built entirely from public donations. I feel this level of support can make a real difference to the morale and retention of our military personnel and any opportunity that can be taken to improve this in the UK should be grasped.

When considering the prevention and treatment of traumatic stress injuries, the most significant reflection is in how many similarities there are between the two militaries. Even after you take into consideration the funding, size and cultural issues there are far more similarities than differences. This is undoubtedly a positive finding from my visit. The similarities seem to have developed through the sharing of best practice that has clearly improved over recent years. I know that the Walter Reed Army Institute for Research and the Academic Centre for Defence Mental Health collaborate in research and initiatives. For example we have now started to carry out Operational Mental Health Needs Evaluation in theatre and this is due to the success of the US Mental Health Assessment Teams. We are also trialling aspects of the US Army’s Battlemind programme for use with UK military personnel returning from operations.

However, as I alluded to earlier, the amount of funding the US allocate to the treatment and prevention of traumatic stress appears significantly more than ours. They consider PTSD and mild TBI as the ‘signatures’ of wars in Iraq and Afghanistan and clearly they are allocating a lot of funding into this area. I am unsure how much our services with continue to deliver the same kinds of high standard care in the area of traumatic stress injuries with such significant funding differences.

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Another reflection was around the issue of medication in the treatment of PTSD. When it comes to psychological treatment of PTSD both countries are using evidence based approaches such as Prolonged Exposure, Cognitive Processing Therapy, Cognitive Therapy and EMDR. However, it appeared that in the US military they also tend to use medication a lot alongside ‘talking therapies’. It is relatively rare in the UK military for someone suffering from PTSD to be on medication. If they are, it tends to be just one form of anti-depressant like an SSRI. However, in the US most the patients I heard about were on multiple medications. There seemed to be 2 main reasons for this. Most of the patients I heard about at the treatment facilities seemed to have some form of dual diagnosis such as major depressive disorder, bipolar disorder or mTBI as well as PTSD. Therefore, the medications may be a reflection of a more complex presentation. Or it could be that patients are more readily diagnosed in the US (even though both countries use the same diagnostic criteria, e.g., DSM IV or ICD 10) and hence they are given more medications to treat the different diagnoses.

I also felt that the increased prescribing of medication was a reflection of a cultural issue throughout the USA and not just in the military population. It seemed that Americans are much more accepting of prescribed medications for the treatment of mental health conditions. In the UK most people are still reserved and sceptical about their use with most people opting for ‘talking therapies’ instead of medications if they are available. This may be due to the fact that in the US pharmaceutical companies are allowed to advertise prescription only medication on television. Nearly every advert break on TV included a message from a drug company about one of their products advising the viewer to talk to their doctor about their drug. Maybe this has led to a greater acceptance of medications for the treatment of mental health conditions to the point that an American will expect to come away with some form of tablet after seeing their doctor. I’m not suggesting that either approach is superior but there were definitely cultural differences around this issue. It will be interesting to see if the UK view towards medication changes over the forthcoming decades to one similar to the US, as it has done around so many other issues.

An issue somewhat linked to this is the role of the mental health nurse in the US military compared to the UK. In the US, the psychiatric nurse practitioner is usually based within an in-patient setting. They are heavily involved in medications due to their prescribing abilities and because of this they are still very much within a medical model approach of mental health care. The military mental health nurse in the UK seemed to be most closely aligned to their licensed social worker in the US. Both of these professional groups seem to spend most of their clinical time assessing and providing psychological treatments for service men and women with mental health problems.

Another difference is the use of screening tools on all US military personnel both post deployment and annually. Research in the UK has shown that this is not effective at spotting operational stress injuries in UK service personnel (Rona et al, 2006). However, in the US it is a strategy used

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extensively to highlight personnel at risk of developing problems and also the statistics generated from them are used to shape future medical and mental provision.

During the Combat Operational Stress Control course a surprising finding for me was how much in-theatre substance misuse is a problem within the US military. This can be in the form of prescribed or illicit drugs, solvent or alcohol abuse, or steroids. US Army behavioural health providers have specific training and protocols on the management of such cases, and it is a problem they will probably encounter and have to manage during their time on deployment. Within the UK this kind of problem is extremely rare and hence FMHTs have little training or preparation to deal with such an issue.

Finally, I feel the benefits and reflections from my visit may come to fruition long after this report is written. One of the best parts of the fellowship was having the opportunity to create good working relations with numerous American military clinicians during my visit. This will allow the sharing of best practice and development of joint approaches in treatment and prevention of traumatic stress injuries in the future. Although there is clearly strong links already in the military mental health research fields this is not as evident amongst the mental health clinicians in the two countries. Hopefully my fellowship will help to improve this.

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Recommendations

Prevention

Operational Stress Briefings

The area I was most impressed with when investigating the US Army’s strategies around the prevention of traumatic injuries was the Battlemind project (soon to become Sustainment Resilience Training under the Comprehensive Soldier Fitness Programme). Battlemind brings together all educational aspects of traumatic and deployment stress in a single, coordinated and corporate approach. The Battlemind approach encourages the utilization of a soldier’s resilience instead of being based on an illness model that is the basis for many other stress education lectures. Elements of the Battlemind programme have been shown to be effective at reducing post-traumatic stress and depressive symptoms and lower levels of stigma (Adler et al, 2009). The UK mental health services are now trialling the post-deployment Battlemind briefings with troops returning from operations and we await the outcome.

All the Battlemind presentations and associated materials are standardised and professionally produced. The accompanying website is modern and engaging. They have produced briefs not only for pre and post-deployment but also ‘life-cycle’ briefs for delivery through the service person’s career, and also briefs for families to help with post-deployment transition. As a result the Battlemind product is known and accepted throughout the Army as standard procedures in the management of traumatic and deployment stress.

The US Army now have a Battlemind training office based in the Army Medical Department & School aimed at training fellow mental health practitioners how to deliver these briefs. However, an acknowledged drawback is that they do not have a system currently in place to monitor the ongoing delivery of these briefs once the initial training is complete. Therefore, they can not guarantee ‘quality control’ of the briefs. UK research has shown that poorly delivered briefs are worse than no brief at all (Greenberg et al, 2009).

Recommendation 1: The UK Defence Mental Health Services develop a standardized, corporate and professional package which incorporates all briefings involved in operational stress management along with associated materials (e.g. handouts, leaflets, website). Once this is implemented the delivery of the briefs are regularly monitored and evaluated to ensure that high standard presentations are maintained.

Traumatic Event Debriefing

Following some research that showed individual psychological debriefing is not effective and can even be harmful to victims of traumatic events (for examples see Bisson et al, 1997; Rose et al, 2001; Rose et al,

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1999), in 2000 the UK Surgeon General decreed that debriefings should not be used in the UK military (SGD, 2000). However, in contrast group debriefings are still widely used in the US military after traumatic events and are usually facilitated by US military mental health practitioners. Within the Army this is usually in the form of a Battlemind Debriefing. They point out that the previous research was carried out following debriefing of individuals and that there are significant benefits to using group debriefing within a military environment. It is seen as being consistent with the occupational context of the armed forces, can enhance the group support process, it normalises responses and takes a recovery model approach. There is also now evidence pointing to the effectiveness of Battlemind debriefing in reducing post-traumatic stress and depressive symptoms and sleep problems with military personnel (Adler et al, 2008; Adler et al, 2009).

In the UK military the equivalent of Battlemind debriefing is Traumatic Risk Management or TRiM. This is a peer-led risk assessment process and is similar to Battlemind debriefing in many ways. They both minimise the degree to which the traumatic event are recounted (therefore reducing the chances of retraumatising) but instead focus on resilience and recovery from the traumatic event. Research of TRiMs effectiveness has showed that it is neither harmful nor beneficial to psychological health or stigma but there were some modest occupational benefits, however the trial was not carried out in a hostile environment where it is likely to be of most benefit (Greenberg et al, 2010).

TRiM risk assessments are usually carried out by fellow peers and not medical or mental health practitioners. This has the advantage that service personnel are more likely to speak openly in front of peers and also avoids medicalising normal post-trauma responses. However, peer risk assessment is not always appropriate and available on operations.

Anecdotal evidence from my operational experience is that sometimes there is not a peer available because the entire unit has been affected by an incident. Sometimes personnel prefer to have a ‘professional outsider’ facilitate the debrief instead of a ‘peer’ from HQ who they may worry is more concerned with whether correct protocols were carried out during the incident than how the team is coping. In addition, often medical personnel are involved in traumatic events and will speak the support of their mental health colleagues who they consider their peers. Therefore, it may be time to broaden the potential scope of TRiM to include the training of all deployable military mental health practitioners to advanced and preferably instructor level. This would enable them to be able to provide knowledgeable input to traumatic event management including, where appropriate, TRiM risk assessments.

Recommendation: The feasibility of training all deployable military mental health practitioners to an advanced or instructor level in TRiM should be investigated.

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Mental Health Practitioners Pre-deployment training

During my travelling fellowship I was lucky enough to attend the Combat Operational Stress Control Course. This is the pre deployment training that all their Behavioural Health (Mental Health) clinicians attend including psychiatrists, psychologists, social workers, psychiatric nurse, psychiatric technicians amongst others. It even includes Chaplains and Chaplains assistants. It was a week long course that involved many aspects of providing mental health care on operations (see pages 20-21 for more details).

Although I don’t think we would require a week long training package for our FMHT members prior to deployment, I do think we should have more formalised pre-deployment training than is currently offered. The new operational competencies should help with pre-deployment training. I am also aware that there are now more mental health scenarios within the pre-deployment medical exercise at Strensall Camp, which is definitely a good thing. Those scenarios should also include not just the medical management of issues but how to liaise effectively with command on how to manage personnel with mental health problems in theatre. This can be particularly useful for junior staff in an FMHT or for reservists who may not have experience from their NHS work in the types of liaison required on operations. Also, from my experience of the pre-deployment training at Strensall Camp, there are aspects of the week’s programme which are not particularly relevant to members of an FMHT. Therefore, there may be the possibility to include specific pre-deployment briefs for the FMHT during these slots instead. Standardised pre-deployment reading material could be provided to the FMHT as well to assist in their professional and personal preparation. I acknowledge that there is the Operational Mental Health course available for military nurses, however this is not delivered as a pre-deployment programme and is only attended once in the person’s career. Pre-deployment training has the benefit that it is delivered very soon before the nurse’s operational tour.

Recommendation: To investigate into whether there can be more specific and standardised pre-deployment training for members of an FMHT each time they deploy.

Mental Health Training and Education

Along with Battlemind the US Army’s training of personnel on mental health issues appeared to be far more centrally coordinated and professionally produced than that of the UK military. In addition to Battlemind they have other projects that aim to increase soldier’s knowledge and recognition of mental health problems, as it is acknowledged that stigma is a major reason why service personnel do not seek help. One such project is the Soldier 1st programme. This is similar to TRiM in that it is a peer-led system but it goes beyond traumatic stress. It involves training non-medical personnel in being able to spot difficulties in their colleagues and signpost them towards help. This is in recognition of the limited number of behavioural

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health providers in the US Army compared to the amount of troops, and is another way of helping getting soldiers the right kind of help when needed.

The UK may not need to go as far as this system but we should certainly be looking to increase the knowledge and skills of our medical assistants as they are in the front line of medical support to service personnel. They should be able to better recognise mental health problems and know when and how to signpost them to the appropriate help. Current tri-service education of medical professions on issues around military mental health is ad hoc and varies in quality and content. There is a need to standardise the content and structure of the briefs so we can ensure parity across all of the UK Defence medical services. Now with a lead service heading up UK Defence mental health, this may be the time that we have the coordination across the 3 services to make this possible.

Recommendation: The training of medical professionals in military and operational mental health needs to be standardised.

In-theatre Operational Mental Health Surveys

One tool that an Operational Stress Control Team (Field Mental Health team equivalent) has is the ability to carry out simple in-theatre surveys of mental health issues in units at the request of Command. This allows them to give feedback to the executive on issues such as morale and the current concerns amongst their troops during stages of a deployment. If requested by Command they can then offer suggestions or resources to help improve these areas. Due to the limited numbers of clinicians in a FMHT this may be more difficult to put in place for the UK. However, it is worth investigating whether something could be designed which is not too labour intensive (e.g., using analysis software) but can still give useful and current feedback to Command. If we have this facility it could help to create positive links to the Command, which is an important role for any operational mental health team.

Recommendation: The feasibility of designing and carrying out in-theatre FMHT surveys should be investigated.

Warrior Adventure Quest

This is a project that uses high-adrenaline adventure training opportunities coordinated with mental health input to help improve morale, unit cohesion and teamwork and manage risky behaviours. It is used both pre and post deployment and importantly it includes mental health aspects like homecoming/readjustment briefs and practicing after-action debriefs. Adventure training is often carried out by UK units when they return from post-deployment leave. This could provide another good opportunity to incorporate TRiM strategies or mental health briefs into this evolution.

Recommendation: Incorporate aspects of WAQ into unit’s post deployment adventure training.

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Positive Psychology and Enhanced Performance

Overcoming the stigma of mental health and help seeking have been shown as significant issues for US and UK armed services (Hoge et al., 2004; Langston, Gould, & Greenberg, 2007) with many service personnel not even knowing that a Defence Mental Health service exists. My visit to the Army Centre for Enhance Performance demonstrated to me that this in an area that defence mental health could exploit to improve our profile and publicise our services in a positive light. Many practitioners in defence mental health already have skills in areas such as visualisation, relaxation, stress management, goal setting and mindfulness, and therefore courses or briefs in positive mental health and performance enhancement could be generated and delivered with our current expertise. I realise many clinicians already struggle with high workloads and caseloads, however if resources were increased in the future this could be an area of potential development.

Recommendation: UK Defence Mental Health services to consider offering briefs and education in positive psychology and performance enhancement to help reduce stigma around mental health and advertise the UK Defence Mental Health service.

Treatment

Evidence-based treatment approaches

I was impressed that both countries mental health facilities were largely providing evidence based treatment for PTSD. However, I did get the impression that the US clinicians were more committed to regularly reviewing those individual and group treatments and altering them in line with new research and also in using their clinical findings or outcomes to publish their own research findings. They also had their own trainers that could run courses in the military versions of EMDR, CPT and PE. In spite of this, they did acknowledge they struggle to ensure clinicians facilitating groups or carrying out individual therapy were consistently delivering high standards of care in accordance with treatment protocols.

I feel we should have mechanisms in place to ensure that evidence-based approaches are being used and that there is some quality control to ensure treatment fidelity. Regular use of live supervision of clinician’s treatment sessions should be mandated to help with this. The new NHS Improving Access to Psychogical Therapy (IAPT) programme (Department of Health [DoH], 2007) has shown that this is possible and we could look to mirror their processes to assist in setting this up. Also, regular and centralised guidance should be issued to DCMH on developments in traumatic stress injury treatment approaches.

Recommendations: The use of live supervision should be mandated for PTSD treatment sessions to ensure treatment fidelity. Regular, centralised guidance should be issued on developments in PTSD treatment. The UK Defence Mental Health Service should be giving clinicians the opportunity to

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become trainers in PTSD treatment so we no longer have to buy in that training. Opportunities should be to carry out PTSD treatment outcome research within DCMHs.

Outcome measures

The treatment facilities and programmes that I visited during my fellowship were clearly committed to monitoring outcomes. This was usually using standardised and empirically validated questionnaires. The practice in the UK is much more variable and usually dependent on the individual clinician or local DCMH policy. I am aware that this issue is currently being investigated however; we could potentially start collecting useful outcome data now. This could easily be done by mirroring the free measures currently being used within IAPT services (Clark et al, 2008). These simple questionnaires measure symptoms as well as occupational and social functioning. We could quickly produce valuable data on the effectiveness of interventions which could help to shape the future provision of services.

Recommendation: All DCMHs should start to collect uniform outcome measures in line with IAPT services, whilst we await more formal guidance on this issue.

Wounded Warriors

An interesting observation from my visit was that the US Army split their military medical services, including their mental health services, between deployment and non-deployment related injuries and conditions. Their deployment related injuries are all under the umbrella of the ‘wounded warrior’ services and are clearly very well supported and funded. Their non-deployed services include care for families and dependents. I did not spend any time with the latter services so cannot comment on their standard or provision, but they weren’t as well advertised as wounded warrior services. In the UK we could consider whether post-traumatic injuries from operations have priority on mental health treatment waiting times. Splitting services is an interesting concept. In reality I think they are probably benefits and disadvantages for both systems but perhaps this does warrant some consideration.

Recommendation: Consideration given to the prioritisation of operational mental health injuries over non-operational mental health problems.

m-TBI

This is a potentially controversial area. There has been research both in the US and UK stating that although m-TBI or mild concussion syndrome symptoms are common, their associations are complex and involve more than just blast exposure (Fear et al, 2008; Hoge et al, 2008). Numerous associations with other disorders such as PTSD, depression and physical health problems have been shown, therefore screening is not recommended.

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However, the efforts and finance that are going into the area of TBI in the US is staggering.

As stated earlier, they consider TBI as one of the signatures of the wars in Iraq and Afghanistan. Whether they are creating a potential problem for themselves is yet to be seen. Due to the high profile of m-TBIs this might be leading veterans to convincing themselves that they have an m-TBI and subsequently seek treatment or compensation for it, where they may be suffering another condition that could be effectively treated. Even using the term m-TBI alludes to a serious condition that may not occur if the term concussion was used instead. However, it is important that we watch US developments in this area. Gulf War syndrome showed us that issues such as this (which often originate in the US) can be seized on by the UK media causing significant problems for our military medical services.

Recommendation: The UK management of mTBI or mild concussion syndrome should not change at this time but we should keep track of the research and developments coming out of the US due to this condition’s high profile.

Sleep research

Sleep is a vital part of a service person’s functioning whilst on operations. The WRAIR sleep laboratory has been producing important research that has been used to generate guidance and policy on sleep management for use throughout the US Army. This has then helped to dispel certain myths often held by those in command around sleep. For example, their research has shown that ability to carry out mental and physical tasks decreases significantly if someone is consistently getting less than 7 hours sleep per 24 hours (Belenky et al, 2003), which is contrary to the widely held belief amongst Command that soldiers can effectively function on 4 hours sleep per night. They also demonstrated that banking sleep prior to subsequent sleep restriction periods reduces impairment and improves recovery (Rupp et al, 2009). These are important findings that Command should be made aware of. Future sleep research at WRAIR will be looking at what are the optimum times to get this sleep within a 24 hour period (e.g., 2 x 4 hours which are line with a person’s circadian rhythms).

Recommendation: The development of standardised Sleep Management guidelines for use within the UK military based current research and the recommendations of WRAIR and the US Army.

Formalised Restorative Packages

The US Army’s Combat Operational Stress Control teams offer formalised in-theatre restorative (24-72 hours) and reconditioning (up to 7 days) packages to those suffering the effects of combat stress injuries or combat fatigue. Both allow short term rest and recuperation but focuses strongly on returning the soldier to duty afterwards. This may be useful to

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include similar guidance within the standard operating procedures (SoPs) of a FMHT.

Recommendation: Consideration given to the inclusion of Restoration and Reconditioning programmes into the SoPs of the FMHT.

Bio-feedback

Although relaxation techniques are not a recognised treatment of PTSD, the ability to self-sooth is an important skill for many patients to master before embarking on PTSD treatment. Bio-feedback is used a lot in the US as an adjunct to PTSD treatment and all the clinicians that use it were very enthusiastic about its benefits for patients. The utility of this technique in the UK should be further investigated, with at least one DCMH trialling the equipment and reporting back on their findings.

Recommendation: Bio-feedback machines to be trialled in a DCMH as an adjunct to evidence based PTSD treatment to see if it increases their efficiency and effectiveness.

Virtual Reality PTSD treatment

This is currently being trialled in the US and it may have utility with combat-related PTSD as a novel and effective treatment. The findings of the trial will be published in due course.

Recommendation: We should consider the recommendations and conclusions of this trial to see whether we should consider using it in the UK as an adjunct to other PTSD treatment or as an approach in its own right.

Hypnotherapy

This was used heavily by the Psychiatric Liaison Team in the management of pain and anxiety in physically injured service personnel. Clinicians and patients alike were very positive about its use.

Recommendation: The evidence base for the use of hypnotherapy for pain relief in physically injured patients should be reviewed to see whether the military community mental health nurses working at places like Selly Oak and Headley Court should be trained in this technique.

Group Therapy

Group therapy was used a lot in the treatment facilities in the US alongside individual exposure work for PTSD. They provided peer support and a psycho-educational aspect to individual treatment plans. It is doubtful whether any UK DCMH receives enough PTSD referrals to run a trauma recovery group but some DCMHs do run groups of other kinds. For example, DCMH Portsmouth run structured closed groups for anxiety and anger management. They also run an open and unstructured support group. There

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is a lack of evidence for the effectiveness of the latter type of group. What the Trauma Recovery Groups in the US demonstrated to me is that you can have effective open but structured group therapy which can be based around a fixed weekly programme incorporating evidence based approaches.

Recommendation: Consideration should be given to making the DCMH Portsmouth Support Group an open but structured weekly group programme based on evidence-based approaches such as CBT in helping people manage problems like low mood, motivation and poor sleep.

Summary

These are my personal views and reflections from a hugely rewarding experience. They are not opinions or recommendations of the MOD or any other institution I am associated with. I realise that there may be various logistical reasons why my recommendations cannot be carried out; however I do hope that some will be able to be put into place. If nothing else I gained a massive amount from my travelling fellowship and it has already had a positive impact on my own clinical work. I hope to continue to pass on what I have learnt from the fellowship for many years to come, and thanks again go to the Winston Churchill Memorial Trust for providing me with this fantastic opportunity.

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the prevention, recognition and treatment of … · brigadier general sutton and her staff at dcoe....

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