MILITARY VETERAN MENTAL HEALTH
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In this page I hope to to provide you with useful information about veterans’ mental health that I have learned from working with veterans for the past few years, as a therapist and also as a researcher.
We all have mental health and we all need to manage it effectively. However there are a few extra challenges for veterans. These include:
More extreme and traumatic events whilst at work than the average civilian. This includes whilst deployed to conflict zones of course, but this doesn’t have to be the case due to the nature of military work and environments. Not every veteran develops Post Traumatic Stress Disorder (PTSD) after experiencing traumatic events but whether you do or not, traumatic events can be life altering. Many veterans also experience Moral Injury which causes deep and destructive feelings of guilt, shame and betrayal. More details on Moral Injury, PTSD and complex PTSD below. Many veterans have lost at least one military friend during or after service and sometimes this has involved difficult circumstances which are hard to process.
Difficulty with the transition between military and civilian life. This might include loss of role, structure, purpose, status and belonging, as well as feeling angry at how civilians and civilian life operates. I have met veterans who find these difficulties are ongoing years after leaving the military.
Military culture around experiencing, expressing and coping with emotions. There is a hyper-masculine culture within the military which creates an illusion that only weak people experience emotions and strength is associated with being able to carry on no matter what. This is unrealistic. Those who hide or avoid their emotions and ‘soldier on’ crash eventually, often after leaving the military.
Veterans tend to be compassionate to others (or at least in my experience) BUT when it comes to being compassionate to yourselves it is a different story. I have heard harsher self criticism in veterans than in any other therapy setting. This may be partly due to the high standards of behaviour and competency that the military encourages, but as with my previous point, this can go too far and end up making you unhappy.
Many veterans I have seen in therapy have had a tough upbringing, with some already experiencing trauma before entering the military. Lots of veterans have also had further exposure to traumatic events after service, particularly if they went on to have certain jobs such as within civilian police services.
Common ways that veterans learn to cope with emotions and problems (some of which are learned during military service) include avoidance, becoming withdrawn, drinking alcohol excessively to block out the difficult feelings, having rigid ways of doing things to keep from feeling unsafe and aggressive behaviour. This can lead to a number of further problems such as relationship issues, breakdown of the family, exclusion from society, homelessness, entering into the criminal justice system and devastatingly in some cases, suicide.
It is very important to seek the right help as early as possible. This can help avoid some of the above consequences which eventually come from avoidant coping strategies.
Welcome Veterans
The NHS have a mental health service in England that is just for veterans. It’s called Op Courage. This is free to access for all veterans and you can refer yourself by email or phone. See link below for the contact details for the service that covers your area.
Mental health support for veterans, service leavers and reservists - NHS (www.nhs.uk)
Op Courage includes 3 services:
Transition, Intervention and Liaison Service (TILS)
TILS is the first contact for all veterans referred to Op Courage. TILS will arrange an assessment with you where they will ask about the difficulties you are having so they can make a plan that helps you access what you need. This might include practical support, support for family members, and mental health support and therapy for yourself. Staff at TILS have expertise about local services for veterans and can make onward referrals and recommendations. They can sometimes provide practical and therapeutic support within their service.
Veterans’ Complex Treatment Service (VCTS)
The VCTS is a psychology led therapy service, only accessible through TILS. Psychology led services do not require you to have a particular diagnosis to access help. TILS will refer you to VCTS if you meet their criteria – which is that you have military attributable mental health difficulties and that you have already tried the local services available to you.
I worked for VCTS in East of England for 3 years and would highly recommend the service that they offer.
High Intensity Service (HIS)
The HIS provide more intensive input for a small number of veterans who are really struggling and may be at risk of harm to self, from others or to others. They provide this support while it is needed, usually on a short term basis until life gets more stable. They can support with issues such as housing and access to mental health input within your local community mental health team.
Other Veteran Services
I have encountered a lot of organisations and charities who provide different aspects of support for veterans. For some of them, I have had mixed reviews from veterans I have worked with and therefore I am hesitant to make specific recommendations globally. Instead I make recommendations for specific support on an individual basis as one of the outcomes of assessments and therapy work I do. However, a good resource for finding support which is available or local to you is the Veterans Gateway website or app. See website link here.
Services for Veterans
Services I Provide
I have informed you about NHS services which are free to access because it is the right thing to do to let you know this is available to you. However I am of course happy to hear from you if you want to access private assessment and therapy services.
I am not a veteran myself, and have been asked many times why I have an interest in veterans. As a psychology nerd I have been interested in different cultures and trauma for a long time anyway, both of which apply to veterans as a client group. But my interest in veterans really established when I was working on a large scale mental health research study for Cardiff University a few years ago. By chance I ended up interviewing a lot of veterans diagnosed with PTSD who had decided to take part in the study with the aim of helping others suffering in the same way (credit to Mark Birkill for referring them). Being welcomed into veterans homes, interacting with them (which often involved a brew and a banter) and hearing their stories interested me like nothing I have experienced before, and made me feel proud of and loyal towards helping veterans. I feel like what you put into your service should be matched with excellent support from civilians when you return to us needing our help. At that time I was a researcher, not a therapist. When I later trained as a psychologist I decided to specialise in trauma therapy and veteran mental health, and I have had no reason to stop doing so since. I hope that now I am working privately veterans will value my experience, training and skills that I’ve picked up along the way.
I am well educated in the effects of trauma and other difficulties on the body and brain, so provide this education as part of any work I do with veterans. I am experienced in teaching individualised coping skills which help veterans to manage triggers and symptoms. I have worked with many veterans on finding meaning, a positive identity and avenues for personal development that improve the experience of life. And finally, I am trained and competent in the following approaches for working with trauma processing:
Eye Movement Desensitisation and Reprocessing (EMDR) therapy, including the Flash technique
Trauma focused Cognitive Behavioural Therapy (CBT) approaches
Compassion Focused Therapy (CFT)
Narrative Exposure Therapy (NET)
As a clinical psychologist, I am trained to integrate these approaches and more, to create a unique treatment plan based on each clients needs.
For further information on my services click here and further information about me, my training and experience click here.
Contact me for more information on what we could achieve by working together
Common Mental Health Problems for Veterans
What psychologists mean by ‘trauma’ when talking about mental health is the impact of an extreme event which has an emotional shock that makes it hard to process. Extreme events have an impact on several overlapping areas of our wellbeing:
Physically / Biologically - the brain and body have a powerful response to threats. We have built in safety mechanisms and after trauma we are extra careful not to be caught out by unexpected dangers again, so react to every perceived danger and automatically prepare to fight, run, freeze or shut down (depending on the situation) just in case. This reaction quickly creates sensations that most people find unpleasant - like heart racing, muscle tension, sweating, difficulty sleeping (sleeping leaves us very vulnerable when under threat!) and difficulty focusing attention. Even thinking about the traumatic event when safe and comfortable can quickly trigger off these sensations, there doesn’t necessarily have to be a real threat to your safely. Having all of this going on in your brain and body is often exhausting, experiencing it can leave you feeling like you are shutting down and unable to operate.
Psychologically - there are changes in our minds after trauma. Even one extreme event can lead us to see ourselves, others and the world in a totally different way. The memory of what happened can feel like it is stuck, so aspects of it go around in your mind over and over again, unable to process through it. This makes it hard to engage in what’s happening around you and life in the present day. We might experience this in the form of flashbacks, intrusive thoughts or images, and nightmares. This stuck processing usually comes with unpleasant emotions and thoughts that we find it hard to cope with.
Socially & Environmentally - trauma has a big impact on relationships and how we interact with the outside world. It is certainly hard to do much interacting while disturbing memories repeat over and over in your mind. What you have experienced and how you feel might be hard to talk about, as it might not be relatable for people in your life. The experience you had may make it hard to trust people. It is also common to find intimacy with loved ones difficult after traumatic events. In addition, the world can seem a more dangerous place after trauma, and avoiding risk or reminders of the traumatic situation are natural reactions. This can leave you increasingly isolated from others and from the outside world.
It is very common to experience some or all of the above following a traumatic event. For many people the unpleasant effects of trauma reduce in coming weeks and months as the brain and body gets used to not being in danger any more. For some people though the symptoms don’t ease off, or they may have a delay in starting, sometimes years after the event has passed. Psychologists work with individuals to find possible explanations for this, because most people question why it is happening to them.
Post Traumatic Stress Disorder (PTSD)
You may have heard of the term PTSD. This is a diagnosis, which is a name psychiatrists give to people for when trauma sticks around and causes problematic, lasting effects. If you want to find out more about the PTSD diagnosis see the NHS website here.
A diagnosis is not needed for accessing therapy to help with the effects of trauma, however some people want to have an official name for what they are going through.
Complex PTSD (c-PTSD) / Complex Trauma
Complex PTSD includes all of the above effects of trauma, which are included in the PTSD diagnosis. The ‘complex’ part refers to the effects of trauma being more extreme - making it hard to keep relationships going, to manage emotions (which often include shame and guilt) and to feel worthy as a person. Complex trauma usually comes from experiencing a lot of traumatic events over our lifetime, or living with an ongoing traumatic situation, such as being abused and unable to escape it, responding to extreme events on a daily basis (such as in roles in the military or police), or being captured and mistreated.
Trauma
I think of moral injury as a type of trauma. It is a reaction to traumatic events where there are moral implications of what you have done, seen, had done to you or been involved in. Sometimes this is as part of what you were asked to do, or due to what you or others did when put in a very stressful or dangerous situation. Moral injury often becomes apparent once these difficult situations have passed and we are left to try to process the memory of it - with all of the emotions, thoughts and images that come with this. Key emotions in moral injury are guilt, shame and feelings of betrayal. It is common to think you will never see yourself, others or the world in the same way again, like your belief system has been fundamentally changed by a single occasion or series of occasions.
In my personal opinion (which is informed by veterans I have seen) some of the veterans who suffer the worst have moral injury and feel they can’t talk about it to anyone, due to fear of judgement and lack of understanding. Finding a compassionate therapist you can build a trusting relationship with is my recommendation. This will help you start to offload, which will almost certainly give you some relief and make you feel less alone. Please access the help available to you - don’t feel like suicide is the only way out because it isn’t.
Moral injury is not a diagnosis like PTSD is, but it has been recognised by professionals and researchers as an issue we need to know more about. As a result of this there are some research papers recommending what might help. From my reading and experience, the best remedy is talking about it, whether to other veterans, loved ones or professionals. The benefits of having someone who cares about you listen and let you know that what you experienced was awful, and they would feel the same are not to be understated. Secondly it helps to build compassion for yourself, so you can take an objective look at what happened and the context around it. Compassion is not about being meek or just forgiving and forgetting. It is about developing the wisdom and courage to face what has happened because we can’t change the past, so we have to find a way to live with it that doesn’t limit everything else we do.
Moral Injury
We all have bad days from time to time. The depression I am talking about here though is when the bad days continue for weeks, months or years. When we get depressed it is often related to the unfortunate losses that we experience in life. This may involve any of the following:
Losing physical functioning - for example due to injury or disease
Losing relationships and belonging - such as losing loved ones, no longer having contact with people who gave your life meaning and on leaving the military
Losing role, purpose, structure and status
Losing hope and meaning in life
Depression is commonly thought of as feeling a deep sense of sadness, and it certainly does include this but it is also more complex than that. Most of the veterans I see who feel depressed describe it as feeling numb, exhausted and depleted. Depression zaps all energy and motivation to do the things in life you need to do, and previously wanted to do. I have seen lots of veterans who experience anhedonia, which is being unable to gain any pleasure from doing anything - even things you used to previously love doing. All of this can make you feel or think it is not worth being alive. It is very common to feel like by being this way you are burdening those around you, and that your loved ones would be better off without you. Depression blocks hope and perspective, so you are not able to think that life could get better. Many veterans who feel depressed ruminate (i.e. play negative thoughts and scenarios over and over in your mind), withdraw from others and reduce activity to an absolute minimum. You might feel like you have nothing to add to conversations or group situations.
Getting professional help when feeling depressed can be life saving, certainly if feeling suicidal. I am not going to promise that the support you will receive within your local hospital or mental health team will be perfect - because some veterans have told me about bad experiences where they have not been understood as a veteran. However, this is the first step to accessing support (you have to be alive to be able to have therapy!). There are veteran aware mental health services which act as an add on to your local services, like Op Courage - see Services for Veterans section.
Depression
Read my Blog ‘What helps Veterans to successfully manage Post Traumatic Stress?’
Veterans’ Family Members & Loved Ones
Advice for supporting your veteran with their mental health and making sure you are still looking after yourself in the process ♡
I have had the privilege of meeting many veterans’ family members - most often their partner or spouse. I have been moved and amazed at the level of practical and emotional support veterans loved ones provide to them, and the resilience to adversity that is displayed on a daily basis - at times with no obvious or immediate reward. Being with someone who is suffering intensely and daily is hard. Being with someone who is constantly being triggered into a state of anxiety or anger can be a frightening and frustrating experience.
The following tips may be useful to keep in mind:
You don’t have to (and probably can’t) fix the problem. This is not something you ‘should’ be able to do as this would require advanced mental health training and even then it can be difficult and complex, so please don’t feel guilty about this. Just continuing to be there despite how hard it is, is huge. Listening, encouraging (psychologists have a phrase - ‘push where it moves’, i.e. if you don’t want conflict then back off if you meet resistance!) and providing practical support can be very useful. If you are unsure what is helpful ask your veteran when they are feeling calm. It may be especially vital to have a plan to help prevent harm to themselves or others - including warning signs that the situation is going this way, triggers, what is helpful and who to call.
Have your own boundaries. Just because your loved one is having a hard time or has been through awful circumstances this does not mean that your needs, preferences or wellbeing should matter any less than theirs. I totally understand that in reality, it may have to be like this some of the time because in a relationship or a unit we work together and prioritise whoever is most in need. But if a relationship doesn’t have balance on this over time, resentment is likely to build. It is also likely that you will fatigue and see your own stress levels and emotions grow into something that is harder to manage. Ways to set boundaries depend on the individual but here are some examples:
Having your own time to do something you find enjoyable and relaxing regularly scheduled in, outside of the home environment. If there are things that could get in the way of this can you work around them, e.g. can someone else who you both trust be a point of contact for your loved one to protect this time for you?
Keep up your own routine of basic things that are essential for you to feel well. This may include exercise, making sure you can have undisturbed sleep, contacts which provide social support and time to make nutritious meals.
Doing things together where the difficulties your veteran is having are not the focus. This can be easier said than done of course, especially on bad days. You may also need to experiment to find activities and places that feel neutral and safe enough for this to happen. However, even having moments may give you a sense of renewed connection and this may be something you can build together over time.
It is ok to change the subject if it gets too much - or before it gets too much. Listening is great but we have to have a limit to keep ourselves safe and well.
Be honest if you are struggling. Pick your time to do this, of course, but putting it off is likely to mean difficulties grow rather than resolve.
Manage expectations about recovery. There will be good and bad days even when you are generally heading in the right direction.
Are you your loved ones carer? If so make sure you are registered as their carer as there may be financial benefits and access to support which comes from this.
Access formal or informal support. Formally you will be entitled to psychological therapy, either through the NHS, or due to long waiting times you may prefer to look at referral to a military organisation who provides support to loved ones, such as Walking With the Wounded, PTSD Resolutions and Icarus online. Informally there are organisations which provide support groups to loved ones of someone with a mental health difficulty - this includes carer support groups and veterans organisations.