Scoping Review: A Needs Based Assessment and Epidemiological Community-Based Survey of Ex-Service Personnel and their Families in Scotland

SECTION 4: Outcome of the Consultation Process

4.1 Preface

The purpose of this section is to present the outcome of the consultation process, which was structured to identify issues associated with pre-Service factors, Service-related factors, transition-related factors, and post-Service factors in accordance with the Needs Map generated by the Veterans Agency^[142]. The issues highlighted here are those identified by those consulted as being of particular importance and are grouped according to general themes within each of the categories, although inevitably there is some overlap across these broad themes.

4.2 Method

• An important aspect of the consultation process was to obtain the views of a range of stakeholders on key issues relating to meeting the health and wellbeing needs of ex-Service personnel and their families in Scotland. These included representatives from the statutory and voluntary services, priority groups, and related agencies, military, clinical, and academic experts in the relevant domains, and key political figures informed in Veteran affairs. In addition to engaging with those user groups with established links, the consultation process also included those that have not engaged with formal initiatives in order to identify gaps which need to be addressed. A list of those who participated is provided in Appendix F.

4.3 Pre-Service factors

4.3.1 Pre-Enlistment Vulnerabilities

• It was generally felt that those who fared least well on leaving Service were those individuals from disadvantaged backgrounds who were recruited to the infantry and joined the UK Armed Forces in an endeavour to escape from life problems. For this minority group, military service was considered to have been successful in containing delinquent behaviour. On discharge, however, these individuals were regarded as being at high risk of social exclusion.

4.4 Service-related factors

4.4.1 Military Culture/Ethos

• Military life may represent a surrogate family in which close-knit bonds are forged, especially in operational units such as those in the Infantry. Whilst this, and the esprit de corps, represents a positive feature of military life, the extent to which the Services cater for almost every need of these personnel, in a highly ordered and structured environment, may foster unintendedly a dependency and a lack of self-determination. These outcomes may exact a penalty on demobilisation when ex-Service personnel lose that security and structure.
• The pursuit of the machismo ideal permeates military life. The participants emphasised that the Services (and, perhaps, the Infantry most of all) encourage denial of fear, emotional expression, and physical problems, including discomfort and fatigue. On the other hand, some individuals, it was reported, become masters of "throwing a sickie".
• "Toughness" is the prevailing ethic which is not one that readily accommodates the need to report mental health problems. This may be one of the reasons why the heavy use of alcohol is a common feature of military life. Particularly in Scotland, "being able to hold your drink" is associated with manliness. Also, alcohol may be used as a self-medication against emotional problems and fear. This dual role of alcohol is a likely source of many problems on demobilisation.
• To the military, to turn to their peer group is an acceptable source of support, hence the interest in TRiM and Battleminds. The participants did not challenge this use of peer support, but were concerned about the stigma that prevails in the UK Armed Forces concerning mental health problems and help seeking, which has resulted in the excessive shunning of mental health provision both within the military and the NHS.
• Concerns were also expressed about the lack of support for the partners of Service personnel whilst they were still serving, particularly in the case of those who were posted on an individual basis rather than as a unit.

4.4.2 Inter-Service Differences

• It was widely held that the Army personnel fare worst on demobilisation than do the personnel from the other two arms. This may be attributable to a number of factors. First, the RAF and the Navy may provide more opportunities for the development of skills and experience which are transferable to the civilian domain. Second, it may be that the Army is least likely to develop the capacity to think for oneself and to take responsibility for one's own actions, including self care.
• The Navy, in particular, has demonstrated a more realistic attitude to emotional matters and seems to be less dominated by the machismo philosophy. This is borne out by their enthusiasm to initiate and to develop TRiM. Naval personnel also seem to be keen on reunions and on the maintenance of contacts with former comrades through "Navy News" and "Rum and Ration", although the Army also has an informal system of tracking Veterans through "Facebook" and "Rumour".

4.4.3 Rank Differences

• There was widespread agreement that officers adjusted more successfully to their re-entry into civilian life than other ranks. Possible reasons for this were consistently identified: better education and training; higher levels of income; more rigorous selection for military service, and better social supports.

4.4.4 Gender Differences

• About 10% of the Armed Forces are female but very few participants spontaneously mentioned anything to do with female Veterans. However, inter-Service differences were noted. In the Navy, serving men and women are faced with the same issues on board Naval vessels. They enjoy the same level of seniority as do their male colleagues, and may be allocated the same duties as men. In the Army, however, females tend to be allocated duties in non-combat areas. (Although it was accepted that: (i) the "combat zone" can comprise a shifting matrix of engagements; (ii) female medics may be close to the areas of direct engagement, and (iii) there are female helicopter pilots who do fly in combat zones.) It was claimed that females and males in the RAF present with the same emotional problems with one exception, namely, males are more likely to suffer from post-traumatic stress (presumably related to the different levels of direct combat exposure). There was uncertainty, however, as to whether this picture was sustained in the longer term.

4.4.5 Operational Exposure

• Combat experience is widely acknowledged to be disturbing for most individuals, including "medics" (who have only about six weeks' training), as it entails (real or perceived) threat to life and exposure to gruesome sights and experiences.
• Significant advances in military prehospital care and trauma management have resulted in higher survival rates for severely injured personnel. Whilst this is a positive gain, it also generates a new major challenge in terms of long term physical and emotional adjustment for these survivors.
• In relation to service in Northern Ireland, a distinction was drawn between those who were local personnel and those who came from the mainland. It was argued that the psychological demands on the former were considerably greater because of various factors, including the fact that they had no respite from unremitting threats of violence to themselves and their families, and were required to live a life in a climate of fear and uncertainty.
• Peacekeeping was also identified as a difficult role because of its psychological demands, particularly where there has been inadequate training and if the rules of engagement and their operational roles have not been sufficiently defined. It was also reported to be difficult to cope with situations even when the rules of engagement were defined if they prevented troops from fulfilling what they felt was their primary role, namely the protection of others (as was the case in Rwanda).
• It was emphasised by some that, whilst combat exposure could be psychologically damaging, military life in general and combat in particular could be exciting and rewarding. However, this may lead to a "sensation hunger" on return to the more banal civilian existence. It may encourage them, for example, to be low in harm avoidance and to seek out ventures and experiences which are emotionally stimulating and exciting.

4.4.6 Mental Health Screening

• Currently, there is no mental health screening in the UK Armed Forces. There is a reliance on "health surveillance" and "psychoeducation". Participants acknowledge the problems associated with screening but were sympathetic to it in principle because they were not convinced that the current strategy was effective, particularly because of the influence of machismo and because individuals, neither in Service nor after demobilisation, show a willingness to present themselves for appropriate help for psychological problems.

4.5 Resettlement and transition

• Dissatisfaction with the efforts by the Services to facilitate the transition from military to civilian life was commonly reported. Some help and advice is provided, often in the fashion of voluminous documents. It was believed that these were commonly ignored as their relevance was not recognised at the time of their distribution.
• Some commented that the focus was not on forthcoming demobilisation but on current military duties and commitments. Time was not made sufficiently available to reflect on transition issues and to benefit from a full resettlement package.
• In particular, interviewees commented on the lack of preparation for dealing with emotional issues and conflict in civilian life: in relation to transitional issues, the military seemed to be principally concerned about employment issues.
• About 20,000 (about 10% of the full military complement) leave the Services annually. Early leavers and those discharged on medical grounds were considered to be among the most vulnerable to transition difficulties. To counter this circumstance, Dr Anne Braidwood, PCV-Medical Advisor, established a mentoring project for Early Service Leavers (Braidwood & Williams, 2009).

4.6 Post-Service factors

4.6.1 Time Out of the Services

• Differences between older and younger Veterans were identified. Older Veterans required more assistance with practical matters (such as mobility aids), and they made more use of the Regimental Associations. In addition, they were noted to have better social networks. On the other hand, unrealistic expectations regarding the availability of resources and ease of adjustment were more often reported among younger Veterans.
• It was felt that those who had served for only a short period (NB: about four and a half years is the current average of service) may be more vulnerable if they have failed to develop a sense of personal discipline and responsibility.

4.6.2 Barriers to Care

• Participants identified many barriers to the provision of mental health care for Veterans. Whilst not mutually exclusive, there are several sub-headings under which these can be presented.
  • Attitudes and behaviour of the individual
  • Once again, participants pointed to the extent to which stigma deters individuals from revealing their emotional difficulties. Because of their delay in seeking help, their problems become more entrenched and complex. Commonly, they seek help only when they reach a major crisis and/or when they are at their nadir in terms of resilience and ability to function. Prior to that, they use denial, alcohol and "relationship-hopping" as a means of coping.
  • Denial may be so profound that the individuals genuinely do not recognise they have a problem. Others in their lives may also collude in the same deception.
  • Alcohol, it was generally agreed, was a major problem. It masks the underlying problems and pathologies, but only temporarily. In the longer term, excessive alcohol use becomes a significant issue in its own right as it becomes associated with health, social, financial and behavioural difficulties (including criminality).
  • A frequent theme was that some ex-Service personnel, who harbour much anger, may be overly keen to avoid taking responsibility, preferring to blame the Services, and their Service experience, for their misfortunes and health problems. Because of their hostility towards their former employers, they divorce themselves from the opportunities for help which the military have provided.
  • Reports were commonly made of high rates of non-attendance and non-compliance with treatment.
  • An interesting assertion was made by some interviewees to the effect that some personnel (ranging from about 10-30%) who present allegedly with Service-related problems have never been a member of the Armed Forces. This phenomenon has also been reported in Vietnam Veterans, and, thereby, has contaminated some research findings and policies based thereon.
  • Some individuals emphasised the need to improve screening, especially by using former front line ex-Servicemen (as is the case with Veterans First Point).
  • Attitudes and behaviour of others
  • It was reported that some Veterans have difficulty in getting time off work to attend appointments with the mental health services.
  • Those who deliver such services do not necessarily regard ex-Service personnel as having any priority. Thus, priority of care for Veterans is not implemented consistently across the country.
  • Certain interviewees allege that some GPs do not ask, or even want to know about, the military records of their patients. As a result, casenotes are incomplete records of the individuals' histories. Even if GPs do display an interest in their patient's military histories, they cannot easily access the appropriate medical and work records. The lack of information was also regarded as a problem for others involved in helping ex-Service personnel, including charities and Regimental Associations.
  • Delivery of mental health services for Veterans
  • A common assertion was that Scotland generally suffered from a lack of specialist trauma services which engage suitably trained personnel who could treat Service-related conditions.
  • In terms of what constitutes "adequate training", it was emphasised that Veterans may pose a particular challenge: not only have they combat-related pathologies, they may have personality and adjustment problems, including those which antedate their Service duties.
  • Also, it was felt that there was a lack of understanding of the interaction between mental health and physical injuries (which are generally dealt with well), including traumatic brain damage.
  • Some reported that what services there are (voluntary and statutory) are sometimes in conflict with regard to what each should do to provide the most appropriate care for ex-Service personnel. Combat Stress was generally viewed as a treatment resource, but there were different opinions as to where and how it best fitted into an integrated system of care for Veterans.
  • Even in the absence of open conflict, the various agencies do not represent an integrated system. The referral process is insufficiently consistent and, generally, there is poor communication among these agencies. Favourable references were made, however, to the individual contributions of Combat Stress, Veterans First Point, the Veterans Agency, and SSAFA.

4.6.3 Areas of Particular Difficulty

• A number of social and environmental areas of difficulty were identified. Again, these sub-headings are not intended to be mutually exclusive.
  • Employment
  • Many ex-Service personnel have had no experience of applying for a job: the Armed Forces have been their only employer.
  • New prospective employers and those staff at Job Centres were alleged to display a lack of understanding of mental health issues in relation to Veterans. One consequence of this was a failure to recognise the difficulties in holding down a job when suffering from a mental disorder and the need for time off to attend out-patient appointments.
  • Housing
  • Local authorities were accused of being unsympathetic to the plight of ex-Service personnel. It was felt that other groups, such as substance misusers and asylum seekers, were accorded a higher priority than Veterans.
  • Finance
  • Personal debt was reported to be a significant problem; one which often prompts contact with the Regimental Associations, who do try to help.
  • The main problem appears to be the Veterans' inability to manage their own financial affairs - no doubt another legacy of the "dependency culture" which military life may unintendedly foster.
  • Support for partners
  • Commonly voiced was a view that partners (mainly female) of Veterans are not given sufficient credit for their supportive role. It was thought that they tended to be the ones who deal with most of the family problems which emerge on demobilisation.
  • Personal
  • Participants identified a number of personal conflicts which Veterans have to face. On leaving the Forces, they have to shed a special and valued identity: they have to re-establish themselves in a new world, one which may not wholly respect them for what they have been doing during their military service.
  • What self respect and self esteem they have developed during their military careers may not translate into civilian life.
  • The ordered and protective world of the military they lose, and they have to make their own decisions and take responsibility for them.
  • When things do not work out, many resort merely to blaming others for their misfortunes. Others may experience shame and a sense of failure.
  • Confrontation with the justice system was described by some interviewees as an expression of a "delayed delinquency".
  • Social exclusion
  • A significant number of Veterans become the victims of a downward social spiral. Without the structure and security of the military environment, they become subject to the misfortunes described below.
  • They may develop few coping skills.
  • Alcohol/drug misuse, unemployment, homelessness, debt, mental ill health, and broken relationships may all conspire to create a negative social image of them. In some cases, this may exacerbate an already negative or at least ambivalent societal view of the military due to their involvement in contemporary international conflicts, which evoke strongly conflicting opinions. Episodes of explicit stigma were exemplified by the interviewees.
  • The absence of formal homecomings and victory parades, in conjunction with adverse media comment about the current role of the military internationally, may reduce the Veterans' sense of worth and achievement. It also does not represent happy closure with regard to their military careers.
  • All of these factors above can lead to a sense of alienation, one which is not sufficiently counterbalanced because of their poor social network of support, in contrast to that which they enjoyed during their military life.