Issues unique to ex-service personnel's narratives

There are over 140 trades in the British Army and, in most armed forces, an individual's job is integral to their identity. It is therefore important to contextualise ESP narratives. Different trades put different individuals and groups into differing brackets of risk. Each operational theatre provides unique physical and psychological threats, which vary across the geographical area of an operation and change with time. Those most frequently in dangerous situations are the combat arms and combat service arms. These are the infantry soldiers, tank crews and their direct supporting arms such as artillery, medics, signallers, engineers and air support at ‘the sharp end’. They are serviced by combat service support arms that include logistics, administrative, transport, electrical and mechanical engineers. The combat arms form about 25% of the army but less in the Royal Navy and the Royal Air Force (RAF). Although members of UK armed forces are frequently ‘in harm's way’, only a minority ‘close with the enemy’. In this cohort, of those who had had operational exposure, 16% had been in direct combat-related action and 20% in violent action short of combat. Nearly a third (29%) reported witnessing the death or the corpse of a comrade.

It is believed by most in the ex-service community that most individuals serve their time, are proud of their service and leave in good health. The social structure of military service acts as a potent ‘container’ of individuals with difficulties. ^{Reference Palmer24} In situations when this internal, horizontal and vertical support structure fails or is lost on leaving, individuals may have problems. Some end up in civil or military criminal justice systems, some in civilian and/or defence medical services. The mode of exit from UK armed forces can give valuable information about an individual's relationship with the military: 37% of the MAP cohort was involuntarily separated from service, not necessarily against their will. Involuntary separation means discharge on either medical or administrative grounds. Administrative discharge includes imposed redundancy, compassion, poor work, criminality, other disciplinary reasons and behavioural problems. Only 3% of MAP users were assessed in prison, which reflects the Defence Analytic Services and Advice (DASA) statistics, ¹³ and about a third reported involvement with civil and/or military criminal justice systems.

Medical discharge only occurs after a full occupational medical assessment and medical board. Some conditions may not be serious, although they may interfere with an individual's ability to undertake their workplace duties, but are likely to improve on exit, yet others will be severe and enduring. It is important that those individuals entitled receive their due. In this study, 55% of the MAP cohort were in receipt of a war pension. Those medically discharged are entitled to financial recompense when their condition is ‘attributable to service’, some of which may be exempt of tax, and medications for the condition are free.

Obsessive-compulsive symptoms

The important finding for those involved in assessing and treating serving and ex-serving personnel is the frequency of obsessive-compulsive symptoms and personality traits in these populations which, to date, seem to have been underexplored. Slater ^{Reference Slater25} noted that obsessional neurosis in soldiers seemed to be more closely associated with pre-existent personality traits than most other neurotic disorders. Of occupationally successful submariners in the US Navy cohort, 9% met criteria for obsessive-compulsive personality disorder, ^{Reference Moes, Lall and Johnson26} and one study found that officers may be more likely to possess obsessional ‘features’ than other ranks. ^{Reference Christen and Moore27} In another study, obsessive-compulsive, depressive and anxiety symptoms were more common in a cohort of Chinese officers over 30 years of age. ^{Reference Fu-Rong and Ya-Lin28}

The lifetime prevalence of OCD in the general population is about 2%, ^{Reference Karno, Golding, Sorenson and Burnam29} whereas a study of inductees into the Israeli Army revealed a point prevalence of 3.6% for OCD. ^{Reference Zohar, Pauls, Ratzoni, Apter, Binder and King30} No figures exist for the UK military. Most recruits join in late adolescence when obsessional symptoms, although common, ^{Reference Apter, Fallon, King, Ratzoni, Zohar and Binder31} may not be precursors of OCD. ^{Reference Maina, Albert, Bogetto and Ravizza32} Those attendees of MAP who enlisted at age 16 or 17 were no more likely to have obsessive-compulsive symptoms than attendees who joined at a later age. Currently, there is a debate as to how to conceptualise and classify this spectrum of symptoms. ^{Reference Abramowitz, Taylor and McKay33} Although it has long been accepted that obsessive symptoms may be triggered by traumatic events in childhood and adulthood, or exacerbated by a mental disorder, ^{Reference Lochner, du Toit, Zungu-Dirwayi, Marais, van Kradenburg and Seedat34,Reference Brown, Campbell, Lahman, Grisham and Mancill35} there is increasing cognitive psychological interest in the direction of the relationship. ^{Reference Watkins and Brown36-Reference van der Houwen, Stroebe, Schut, Stroebe and van den Bout39} It is well known that obsessional symptoms may be part of other mental disorders such as depression, but it became increasingly clear in this cohort that obsessional personality traits and accompanying symptoms were independent of the mental disorder and particularly prominent in those who had problems readjusting to civilian life. Rumination was of particular relevance to the clinical presentation in up to 30% of the MAP cohort and the rate of anankastic personality disorder was similar to a cohort of combat veterans with both PTSD and depression. ^{Reference Dunn, Yanasak, Schillaci, Simotas, Rehm and Souchek40} The relationship between PTSD, obsessional personalities and symptoms in serving and ex-service personnel is complicated. ^{Reference Bollinger, Riggs, Blake and Ruzek41,Reference O'Toole, Marshall, Schureck and Dobson42} In the MAP cohort, 16% of those with OCD had comorbid PTSD. Rumination needs to be distinguished from intrusive re-experiencing thoughts and when they coexist treatment can be difficult. ^{Reference Riggs43} Guilt, shame and remembrance of dead comrades were common ruminative themes in MAP attendees.

Obsessionality and service

All those who have served understand how success in the military requires acculturation to a society which has clear supra-ordinate goals, where hard work, trust, mutual support, interdependency and integrity matter and attention to detail can be the difference between life and death for peers, superiors and subordinates. All military forces therefore require certain levels of obsessionality to achieve their mission. Practically, those with obsessional traits would appear to form a ‘good fit’ with the military structure and organisation that provides them with unambiguous and transparent structure, routine, job descriptions, roles, measures of success and paths to advancement. Obsessional traits are particularly welcomed in logistics, engineering, administration, bomb disposal, accountancy, information technology, military police, intelligence collation, etc. At this time, it is a moot point whether some individuals are attracted, by dint of temperament, to such a life. Obsessive cognitions may be ‘introceptive’, in that obsessional rituals sooth internal anxieties, or ‘extroceptive’, where the hierarchical construction of an organisation, in this case the military, sooths the individual who feels safe in it and who may be keen that others ‘conform’ to likewise benefit.

As found in this study, MAP attendees’ histories reveal that, years after leaving service, some individuals continued to ruminate over issues of guilt and/or shame at real or imagined sins of omission or commission and of not wanting to ‘let the side down’. Remembering was a key issue for many who seemed to be ‘unable to let go’ of events for fear of forgetting, as opposed to intrusively remembering. One can imagine how those with obsessional patterns of thinking are more likely to be troubled by the nature of some military tasks, the context in which such tasks were accomplished and, for some, the existential dimension of such tasks.

Obsessionality and readjustment to civilian life

Personal clinical experience over 30 years and MAP attendees’ histories reveal that those with obsessive-compulsive traits are often rapidly promoted to positions of increasing responsibility. For some this can lead to increasingly unmanageable stress with the resultant belief they have become ‘unfit for purpose’. Some individuals, rather than seeking help in service, choose to ‘do the right thing’ and leave service prematurely (premature voluntary redundancy). On leaving, although those with obsessive-compulsive symptoms may find a job with an introceptive component, they are unlikely to find the same extroceptive organisational structure even in the police, prison, fire service, civil services or the like.

Observers, mainly civilian, talk of ‘institutionalisation’, implying that the military imposes its values, mores and working practices on (presumably) passive individuals, ignoring the raft of interactive social psychological processes and benefits involved in enlistment and acculturation ^{Reference Palmer44} as well as extensive help and advice available to every individual who runs into problems whether in service or after they have left. Although it is believed that the majority of ESP transit to civilian life without difficulty, every soldier who has acculturated to service will feel the ‘loss’ of family on leaving; those with obsessive-compulsive symptoms may perhaps feel this loss more keenly.

This unique study highlights the frequency of obsessive-compulsive symptoms in the ESP population seeking help and the complicated relationship of obsessive-compulsive symptoms with post-service mental ill health. It would seem important to look for details of obsessive-compulsive symptoms in those who experience difficulty readjusting to civilian life, have problems engaging with services or fail to benefit from psychological interventions. Dyslexia, educational and literacy issues, particularly in soldiers, may add to the burden of readjustment and an individual's ability to benefit from written material given to all before discharge from the services.

Recommended treatments

The psychopathology of the MAP cohort was complicated and reflected the frequency of childhood adversity known to exist in this population. ^{Reference Iversen, Fear, Simonoff, Hull, Horn and Greenberg45} Further NHS mental health service assessment and/or treatment was recommended in 86% of cases of which 57% were for CBT; 21% individuals required further medical assessment.

Criminal justice system

Of those who had been involved with the criminal justice system, 90% were in the army and of those 41% were infantry. Five individuals were assessed in prison and although there is no excess of violent crimes by ESP in prison, sexual offences are more common. ¹³ Additionally, 20% of the MAP cohort had self-harmed at some point.

Help-seeking

Despite the barriers, ^{Reference Moller-Leimkuhler46-Reference Noone and Stephens48} serving personnel's help-seeking and treatment seem similar to the general population. ^{Reference Iversen, van Staden, Hacker Hughes, Browne, Greenberg and Hotopf20} The average time from leaving service to MAP attendance was 12 years, similar to civilians. ^{Reference Wang, Berglund, Olfson, Pincus, Wells and Kessler49} Engagement with service was hampered for some by real or imagined guilt or shame at acts of omission or commission and remembrance of dead comrades. The average age of MAP cohort was 45 years, which suggests accepting the need for help may improve with age. ^{Reference Mackenzie, Gekoski and Knox50} All military medical records were available and 19% of the cohort had a record of in-service mental health involvement, 67% of whom had subsequent NHS follow-up.

Attribution

For hundreds of years British forces have undertaken war fighting and operations other than war. About 30% of the British army are combat arms (infantry, armour, artillery). Combat support arms work directly with combat troops, for example signallers, engineers and medics, and combat service support arms sustain them all. The threat differs with each type of operation, location, trade and the phase of the operation. Popular misconceptions about mental breakdown on war fighting operations exist. ^{Reference Turner, Kiernan, McKechanie, Finch, McManus and Neal51} Only about a third of attendees were directly involved in combat and/or violent action. About 1 in 10 had never deployed operationally. Roughly half said they had witnessed death and 1 in 4 reported having witnessed the death or dead body of a comrade. Two of the cohort had mental health problems while on duty.

The MAP was extended to examine concerns that ESP's mental problems were consequent on military service. The assumption that military service is the major aetiological factor may be erroneous. ^{Reference Boman52} Only 20% of diagnoses had an unambiguous link to military service, whereas 42% were unquestionably not attributable to service. The Howard League for Penal Reform ^{Reference Iversen, van Staden, Hacker Hughes, Browne, Greenberg and Hotopf20} and the leading UK NGO for homeless ex-service personnel, Veterans Aid, consider that their clients’ situation is ‘hardly ever’ a direct consequence of their military service (H. Milroy, 2012, personal communication) and PTSD is uncommon in this population. ^{Reference Johnsen, Jones and Rugg53}

Stories of military imposters regularly turn up in the British media, ^{Reference Gillan54} yet fabrication and exaggeration in the ex-service population is particularly difficult for those without military experience to identify. Although mental health professionals may seek to understand such behaviours, many in society, particularly military and ex-military personnel, see it as reprehensible, dishonourable and, at the very least, tarnishing the integrity of the ex-service community. This type of behaviour is not uncommon in the US veterans’ population, ^{Reference Freuh, Elhai, Gold, Monnier, Magruder and Keane5,Reference Burkett and Whitley55-Reference Frueh, Grubaugh, Elhai and Buckley57} and it was found in 13% of the only British survey of ESP seeking treatment for combat-related PTSD. ^{Reference Baggaley58} The figure for fabrication and/or exaggeration in MAP attendees is at least 10%. For example, being ‘unable to remember’ their service number (currently, army: other ranks 8 numbers, officers 6 numbers; Royal Navy: all ranks 6 numbers prefaced and ending with a letter; RAF: other ranks 8 numbers prefaced with a letter, officers 8 numbers ending with a letter) is most suspicious, particularly without organic brain damage or syndromes, as are vague and/or changing narratives. Some attendees said they ‘didn't want to’ or ‘couldn't’ talk as they had signed the Official Secrets Act, not in itself an impediment to therapeutic intervention. Some had been offered, yet not engaged with, evidence-based interventions, others had received evidence-based help which, unsurprisingly, had not helped them. Those of the MAP patients who fabricated their stories told of units or missions that did not exist, of tasks for which they could never have been trained (given their service history), of being ‘identified’ for ‘special duties’ or operations such as political assassinations, all narratives that are difficult for those without military experience to recognise as false.

Fabrication and exaggeration is commonplace in psychiatry but is seldom contemplated or discussed in consultations outside medico-legal, forensic, military and liaison practice. ^{Reference Spence59} Although DSM-IV warns that ‘Malingering must be ruled out in those situations in which financial remuneration, benefit eligibility or forensic determinations play a role’ (p. 427), ⁶⁰ it would be wrong to equate fabrication with malingering as such behaviours are multi-factorial in their genesis, from the fraudulent to the delusional. Examination of military and NHS records can be invaluable in identifying these behavioural patterns and corroboration of military service is recommended in the report into the UK Veterans’ Pilot Sites Study. ^{Reference Dent-Brown, Ashworth, Barkham, Connell, Gilbody and Hardy17}

Final comments

Ex-service personnel currently involved with NHS mental health services are likely to be middle-aged ex-soldiers (men). The overwhelming majority of those in contact with military or civilian criminal justice systems come from the army; however, the link between mental disorders and service is seldom straightforward. Although very few ESP will have psychotic illness, their needs are complicated, frequently falling short of entry criteria for many mental health teams yet outwith GPs/GP counsellor skills, which can reinforce ESP's stereotypes about civilian mental health services. Common psychiatric conditions occur in this group and the treatment is the same for civilians and ESP alike; it is not all PTSD, but alcohol misuse is high and, in a substantial number, obsessive-compulsive symptoms seem to be relevant to problems of readjustment to civilian life and could be screened for before leaving service.

Delay in seeking help is similar to that of civilians and barriers to care include male gender, pride, guilt, shame and remembrance of lost colleagues. Partners are frequently key in getting ESP to services. Those ESP who engage with services are as likely to do well as any other service user. Ex-service charities are helpful in pathways to care and offer many services unavailable to civilians. Understanding this population's needs is particularly important given their putative occupational antecedents and financial implications (for both the individual and the state). It is important to identify those individuals who are entitled to pensions and services so that scarce resources can be managed appropriately; corroboration of service is integral to this, aided further by service medical records.