Standing together against combat trauma

There is probably no more hostile environment to mental health treatment than the military. Recently, a new treatment method has been widely adopted by the UK Armed Forces and, perhaps for the first time in history, officers are requesting it in droves.

In major wars since the 20th century more fighters have been lost to psychiatric casualties than bodily injuries but psychiatrists and psychologists are still mistrusted by the corps.

It was explained to me rather tactfully that “soldiers are not necessarily the most psychologically minded of individuals” and it is likely a combination of the macho culture and conditioning to deal with discomfort by sheer grit that casts mental strain as weakness in the military.

This has made both mental health problems and their treatment a source of significant stigma in one of the professions most likely to cause trauma and breakdown in its employees.

Trauma Risk Management or TRiM was first developed by the Royal Marines, one of the UK’s most hardened battle corps, and trains key members to recognise signs of mental strain in their comrades and provides support at the level of the unit.

It’s a wonderfully conceived approach as it takes advantage of the esprit de corps, the intense group bond that forms between fellow soldiers, but which also makes them wary of accepting help from ‘outsiders’.

But it also avoids the practice of sending in outsiders to provide ‘debriefings’ after traumatic incidents which have been found, in many cases, to make the trauma worse.

A recent paper [pdf] published in Journal of the Royal Army Medical Corps outlines the TRiM approach. Non-medical mid-level soldiers are trained to assess their colleagues after a potentially traumatic event and look for risk factors for poor-coping, provide information on which psychological reactions to expect, give informal support and know when to refer to specialist medical staff.

More widely the approach aims to change attitudes to mental distress by making it both an acceptable topic and another form of operational training.

And it is clear that there is a currently a need for a different approach, particularly it seems, in the US military.

A recent review of post-traumatic stress disorder (PTSD) in soldiers deployed to Iraq found that, seemingly uniquely, US soldiers show increased levels of the disorder one year after returning from the war zone. This is exactly the opposite pattern to that which is typically seen in other soldiers and civilians.

Science writer David Dobbs has received a lot of flak for suggesting that the system that provides mental health treatment to US veterans is unintentionally encouraging long-term disability but the figures suggest he may be right.

TRiM could be an effective counter-measure to mental illness in the military and it is certainly popular. It is also being adopted widely in the civilian emergency services, but it remains under-researched.

The recent paper on TRiM notes that a trial is currently being run by the UK Ministry of Defence and preliminary results suggest cautious optimism although we still await the first published study its effectiveness when deployed on the ground.

In light of the lack of evidence, it’s perhaps a little worrying that TRiM is being increasingly flashed around as a PR-friendly talisman of good practice whenever the military’s mental health credentials are questioned and it has also now become the basis of a minor training industry.

Nevertheless, the simple fact that it has been accepted and requested by the armed forces themselves is a significant advance for military psychiatry.

pdf of ‘Trauma risk management (TRiM) in the UK Armed Forces’

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