Soldier, veteran, survivor
The stigma associated with psychiatric illness can be exacerbated in military culture, which often prides itself on a stoic response to extreme duress.
Mervyn Wynne Jones offers an insight into life in the armed forces and considers the challenges for civilian therapists engaging with this client group.
Why do people join the army? What does it mean to be a soldier and who chooses to become one? What makes these guys and girls tick? What is it like to be shot at, shelled, and to kill an enemy? How do soldiers find the courage to face death every day? What is garrison life like? Why do most soldiers love it and some hate it? Can soldiers ever fully adjust to ‘Civvy Street’ afterwards?
Volumes have been written about ‘being a soldier’ and it is beyond the scope of this article to attempt in any meaningful way to answer these questions. It is a complex subject area, not least because soldiering is such a multi-faceted profession, and a totally unique way of being. Much is made of the ‘way of a warrior’, but there is some truth in the saying. It is a culture in its own right, a vocation for many, a reason for being for others, a rite of passage for yet more, a sense of belonging for most, and a frame of mind for all.
Do soldiers enjoy war? This again, is a question that evades any definitive answer. Simplistically, the answer will often be ‘yes and no’, but this is to skirt the highs and the lows, the buzz and the boredom, the fear and the exhilaration and – in the context of psychological impact – both the damage and the development. Yes, development. By no means are all soldiers adversely affected by combat. Alexander and Klein note that military life offers much to many men and women and that surviving the brutalities of combat both physically and psychologically can often leave a legacy of positive outcomes.1 Author and Falklands war veteran Hugh McManners suggests that a soldier without war experience is much like a surgeon who has only practised his skills on cadavers.2 Further practice eventually becomes pointless and, for a soldier, there is an increasing desire to experience combat as a rite of passage.
Soldiering involves the most basic sharing of hardships, fear, exhaustion, comradeship and purpose. One experience of combat is often enough for most soldiers, suggests McManners, but many soldiers so enjoy the camaraderie that accompanies active service that they remain serving and, in their turn, become respected veterans. There is a collective tendency in military culture that leads to both a view of self as part of the group and a profound emotional investment in the group. Common adversity and the furnace of combat will, almost invariably, forge ties, mutual affection, trust, respect, pride, focus, drive and, above all, camaraderie and brotherhood that few outside the military – except perhaps firefighters, riot police and extreme mountaineers and expedition-goers – can ever begin to understand.
It is an unavoidable truism that military combat requires human beings to kill other human beings but, despite depictions to the contrary in popular literature and film, killing another member of our own species does not come naturally to humankind. Alexander and Klein suggest that, throughout history, combatants have fortified themselves with psychoactive substances, noting that hashish was used by the Muslim ‘Hashshashin’ in their wars against the Crusaders, that cocaine was favoured by the Incas fighting Pizarro’s conquistadores, that the jigger of rum was more than welcomed by British troops in both world wars of the last century, and that marijuana, alcohol and opiates brought psychological respite to US troops in Vietnam.1
While some individuals in our modern day army may genuinely enjoy combat, fighting an enemy on a battlefield presents, for most, profound emotional challenges, such as overcoming fear, witnessing death, seeing suffering and mutilation, and having to tolerate extremes of physical discomfort. And yes, this can – and all too frequently does – take its toll, in many different ways. Reactions are sometimes delayed for months, and even years. Veterans of Northern Ireland and the Falklands war are still reaching out for help today, some 15 or 20 years later.
Victims of post-traumatic stress disorder (PTSD) relive sights, sounds and even smells and, writes Brook,3 they will go to great lengths to avoid such reminders. They cannot sleep; they lack concentration, are suddenly startled, and can become aggressive, with outbursts of frustration and anger. Anger, equally, may remain bottled up inside. Anniversaries or similar watersheds may start the feelings off again. There can be a lack of interest in anything, and the future will look bleak. To avoid reminders, some resort to drugs and alcohol but such diversions are ineffective and do not last. Physical ailments can arise, and there can be a fear of crowds and other social encounters.
British frontline troops are nine times more prone to psychological trauma in today’s modern army than their military counterparts who are not sent to war and, citing figures compiled by the Ministry of Defence, the Guardian noted that some 4,000 new cases of mental illness were diagnosed among the UK’s armed forces in 2007, with those returning from Iraq or Afghanistan the most likely to suffer from post-traumatic stress disorder.4 Of these personnel, soldiers – ‘bayonets’, in army parlance, when succinctly and vividly describing the role of the infantryman – were more likely than members of the Royal Navy or RAF to have mental health problems, and women and lower ranks were more at risk than their male counterparts or officers.
A growing suicide toll among troops scarred by war was reported by the Daily Telegraph, which noted that unreported deaths could be significantly greater than the numbers recorded of those who took their own lives while still serving in the armed forces.5 Former soldier Robert Marsh was quoted thus: ‘Someone suffering trauma from a car crash is not the same as someone who has been blown up or had to scrape the brains of a best mate off his combat jacket, or watched children shot dead as human shields, or lived for six months in mortal fear of his life.’
The British Journal of Psychiatry6 noted the findings of an Oxfordshire study that suggested an increasing number of armed forces personnel are self-harming, particularly those aged under 25 and female, with the most common method being overdoses of painkillers, tranquillisers, sedatives or antidepressants. Alcohol played a significant role in many of the cases of self-harm. Alcohol has long been an often-notorious element of the armed forces culture and an Alcohol Concern Cymru report7 – while acknowledging that alcohol can create cohesion in military units where comrades have to rely absolutely on each other in often extremely dangerous situations – made clear the need for a radical shift in attitude towards alcohol as a mainstay of social activity, to diminish its pervasive impact on health and wellbeing among soldiers.
Soldiers who have served on operational frontline deployments to war zones will often have experienced some or all of homesickness, separation from family and friends, anxiety and helplessness as to events at home, sadness, depression, anger, stress, sleep disturbance, exhaustion, grief (for comrades and friends, or perhaps for someone at home), being involved in or witness to trauma and violence, seeing someone killed or mutilated and, importantly, dealing with having killed another human being. It can be tough for these soldiers for whom professionalism, pride, resilience and personal achievement are generally non-negotiable and, hitherto, the cornerstones of their very existence. It is particularly challenging thereafter for those countless veterans who are no longer within the military fold, significant numbers of whom may be feeling utterly adrift, alone and misunderstood.
A sea change in attitude
The reader is hopefully getting a glimpse of the individual – male or female, young or middle-aged – who might, just might, walk into the counsellor’s consulting room. That this might actually happen is in itself significant because, as Michael Stott notes in his article in this journal (see page X), soldiers can be private and non-confiding, and conceding vulnerability does not come easily to many. Moore and Penk8 note that stigma associated with psychiatric illness can be exacerbated in military culture, which often prides itself on a stoic response to extreme duress. Emotional responses in a veteran such as hyperarousal and nightmares – both symptomatic of PTSD – may be considered a significant frailty. Personnel may also discount their symptoms out of guilt or shame.
The military is a culture in its own right, a vocation for many, a reason for being for others, a rite of passage for yet more, a sense of belonging for most, and a frame of mind for all
There has been a sea change in attitude not only within Britain’s armed forces but also among the public at large about mental health issues among soldiers and veterans, and a variety of statutory and charitable services have been established to cater for the needs of this growing corpus of ex-forces clients. Augmenting long- established charities such as the Defence Medical Welfare Service, SSAFA (Soldiers’, Sailors’ and Airmen’s Families Association), and The Royal British Legion are newer ones such as Combat Stress and Help for Heroes. And NHS provision has developed considerably with, in Wales for example, the All Wales Veterans Health and Wellbeing Service, the latter specialising in trauma therapy. Thus far, the recommended therapeutic interventions for trauma presentation in military veterans – as recognised by the National Institute for Health and Care Excellence (NICE) – are trauma-focused CBT and EMDR.
Debate will long continue as to whether military veterans respond better to fellow veterans in a care environment or therapeutic setting. My own view is that if a civilian therapist makes a real effort to understand the military culture from whence his or her client came, is credible, confident and yet humble, is recognised as respecting confidentiality, and is seen to be congruent, non-judgmental and empathic, then he or she will be trusted and accepted. Veterans want and, indeed, need to be listened to, but the process can only work if they feel safe and, above all, understood. And this usually means their realising that the therapist has a sense of all that has been written thus far in this article, and much more besides. They come from a unique and distinctive culture, and often have experiences behind them that are anything other than the norm in day-to- day life as a ‘civvy’. Moore and Penk8 note that the veteran may, even before seeking help, have convinced himself that the non-military clinician is an outsider who cannot fully appreciate what he or she is going through, and any knowledge gap on the clinician’s part can therefore lead to a difficult and unproductive therapeutic relationship.
Veterans do generally respond very well to fellow veterans, and this has been the principle underpinning a new charitable venture called Change Step – a parade ground command, but a play on words too – that I have been instrumental in setting up in 2013. Change Step is a peer mentoring and signposting intervention offered across North Wales by the alcohol and substance misuse charity CAIS in tandem with the Royal British Legion (RBL) and the Wales NHS veterans therapy service, and is delivered by military veterans for military veterans. It really does work, reinforcing self-motivation and awareness, and values of pride and self-esteem, and many of the mentees go on to become peer mentors themselves. Acknowledging the concept of the ‘military family’, which embraces spouses and relatives who have shared the rigours of garrison life and operational deployment, and recognising the effect of veterans’ mental health issues on spouses, parents and carers, Change Step now has plans to broaden its client base to provide for those equally desperate relatives for whom the trauma of their loved one is a disruptive and often destructive daily occurrence. Change Step peer mentors are also trained as RBL caseworkers.
Support systems previously taken for granted by serving soldiers and their families are no longer accessible once back in ‘Civvy Street’, and the veteran approaching a counsellor will – in most instances – be anticipating an understanding of his or her having faced life-threatening situations, the unprecedented challenges arising from operational duty, the loss of close friends and comrades, extreme violence and stress, and the challenges inherent in then transitioning and adjusting to life as a civilian. The challenges for the counsellor can be considerable. Men generally are reluctant to seek therapy, and military men often regard it as a form of weakness, with the uncovering of inner fears and insecurities being seen as evidence of personal inadequacy. The potential for shaming such individuals, notes Hall,9 is quite high and any hint of this can result in anger and almost immediate termination of therapy.
The Soldiers’ Charity – previously known as the Army Benevolent Fund – states on its website (www.soldierscharity.org) that there has been a 30 per cent rise in the past two years of soldiers, former soldiers and their dependents seeking the charity’s help, and this is set to increase. Anger, anxiety, depression, post-traumatic stress, adjustment to life outside the armed forces, relationship and marital difficulties, and the effects of physical injury are all to be expected as presenting issues in the counselling room. It can rightly be argued that counselling any specific client group presents its own very particular challenges, but seldom is this truer than with soldiers and veterans. Helping these individuals can be extraordinarily rewarding, but due diligence in training and preparation is essential.
1. Alexander DA, Klein S. Combat-related disorders: a persistent chimera. Journal of the Royal Army Medical Corps 2008; 154(2): 96–101.
2. McManners H. On being a soldier. Undated. www.hughmcmanners.com/military/thinking-of-joining-the- army/being-a-soldier [accessed 9 July 2013].
3. Brook R. The stress of combat, the combat of stress. Eastbourne: Sussex Academic Press; 2010.
4. Taylor M. Mental illness cases in British forces neared 4,000 last year. The Guardian; 5 November 2008. www. guardian.co.uk/uk/2008/nov/05/army-iraq-mental-stress [accessed 9 July 2013].
5. HardingT,KirkupJ.Growingsuicidetollamongtroops. The Telegraph; 15 November 2007. www.telegraph.co.uk/ news/uknews/1569460/Growing-suicide-toll-among- troops.html [accessed 9 July 2013].
6. Hawton K, Harriss L, Casey D, Simkin S, Harrison K, Bray I, Blatchley N. Self-harm in UK armed forces personnel: descriptive and case-control study of general hospital presentations. British Journal of Psychiatry 2009; 194: 266–272.
7. Alcohol Concern Cymru. On the front line: alcohol and the armed forces. Cardiff: Alcohol Concern; July 2012. www. alcoholconcern.org.uk/assets/files/Wales%20factsheets/ On-the-front-line.pdf [accessed 9 July 2013].
8. Moore BA, Penk WE. Treating PTSD in military personnel. New York: Guilford Press; 2011.
9. Hall LK. Counseling military families: what mental health professionals need to know. Oxford: Routledge; 2008.