Psychological Therapies for the Armed Forces Community

Rebecca Oliver

There can be many challenges faced after a career in the military has ended, including physical injuries, mental health challenges, difficulties with transition, financial strain, and isolation. At Help for Heroes, our vision is to create a society where everyone in the Armed Forces Community (AFC) lives well after service, and we strive to ensure that members of the AFC are valued, supported and recognised. The support we provide aims to help individuals to manage their physical and mental health, as well as addressing welfare needs and social isolation, to equip them for a successful life after service. Our support is offered to all members of the AFC including veterans, serving personnel, those who worked alongside the UK Armed Forces, and the families of each of these groups.

The Hidden Wounds Service is the psychological therapies service within Help for Heroes.We provide a range of talking therapies to veterans and their families and can support with difficulties including depression, anxiety, anger, grief and PTSD.We frequently support individuals with mental health needs linked to their military service, and we can also support those with difficulties that may have begun before or after their service that may not have been identified or diagnosed whilst they were serving. Our provision of therapy includes counselling, high-intensity CBT and low-intensity CBT, with treatment offered in line with the model of stepped care.

The low-intensity branch of our service is aligned with the Step 2 pathways within NHS Talking Therapies services, with interventions delivered by our Psychological Wellbeing Practitioners (PWPs) mirroring those offered by our PWP colleagues in the NHS. We offer the core Step 2 guided self-help interventions, including Behavioural Activation, Cognitive Restructuring, Graded Exposure and Dealing with Worry over 6-8 sessions, using veteran-specific resources and adapting delivery of these interventions to ensure it is tailored to our target population.

There are some difficulties more prevalent amongst veterans compared to the general population, such as anger and problematic drinking. For this reason,we utilise several bespoke evidence-based low-intensity interventions that have been developed in response to these AFC-specific needs. For example, our ‘Breaking the Anger Habit’ intervention is offered to those for whom anger has become a problem, either because it has become excessive, too frequent, too easily triggered or has become hard to stop.This protocol uses principles of CBT to support individuals with understanding how anger can become a habit and helping them to build awareness of their own triggers and warning signs for anger, so that over time and with regular practice they can break this habit by responding differently to their warning cues.

For others, anger will be less of an instant reaction to an external trigger and more linked to periods of rumination, which may take the form of thinking over losses and frustrations, dwelling on negatives, or thinking about things that could have been done differently.Those reporting a cycle of being stuck in feelings of anger and repetitive negative thinking about losses or setbacks often benefit from our ‘Stopping Angry Overthinking’ intervention, which focuses on understanding and identifying rumination, before taking steps to break the vicious cycle by shifting thinking from abstract (“why did this happen?”) to concrete (“what happened/how did this happen?”).

Research has shown that excessive alcohol use has been more common in the UK Armed Forces compared to the general population (Fear et al., 2007), and often forms part of military culture, with links to social cohesion (Du Preez, Sundin & Fear, 2012). As part of the low-intensity provision within the Hidden Wounds Service,we offer a veteran-specific guided self-help programme for those wishing to reduce their alcohol use. This is a multi-phased approach involving psychoeducation and selfmonitoring of alcohol use, setting goals around drinking behaviour, and maintaining progress. A thorough assessment of drinking behaviour is completed before offering this intervention due to the risks associated with reducing alcohol use in cases of dependence, where we may signpost to more specialist substance misuse services.

It is well documented that the impact of mental health problems amongst veterans can be far reaching for family members (Senior, Clarke & Wilson-Menzfeld, 2023). For this reason, our therapeutic interventions can be offered to family members where appropriate. Additionally,we offer a bespoke CBT-based intervention called CRAFT (Community Reinforcement and Family Training) for the loved ones of veterans who may be experiencing mental health difficulties.The aim of CRAFT is to help the loved one to support and encourage the veteran to seek support for their difficulties, as well as providing them with skills to improve their own wellbeing and their relationship with the veteran. CRAFT is underpinned by the understanding that behaviour change happens through positive interactions and that loved ones can play a crucial role in supporting the veteran with their recovery. CRAFT is typically completed over 8-10 sessions and covers a range of skills-based topics including communication, increasing positive behaviours and self-care.

Within Help for Heroes, several other teams sit alongside the Hidden Wounds Service, together forming a holistic and integrated recovery service. Our Case Management team can support with a range of welfare issues including financial management, employment support and housing difficulties, while our Grants team offers financial support towards things like travel costs for medical appointments and home adaptations. We have a Clinical Services team made up of nurses and occupational therapists who provide high quality clinical support to those with physical injury or illness, and our Recovery College offers free courses on a range of topics, providing skills to help individuals to manage their physical and mental wellbeing. Finally, our Sports, Activity and Fellowship team runs a range of sporting and social events across the UK for veterans and their families, bringing people together where they live.

To access the support available within Help for Heroes, individuals can refer themselves via the website: https://www.helpforheroes.org.uk/get-help/ask-for-help/ or can contact the Supporter Care Team on 0300 303 9888.

External services are welcome to refer consenting individuals by emailing getsupport@helpforheroes.org.uk

You can find out more about Help for Heroes at https://www.helpforheroes.org.uk/

If you have an interest in low intensity working with the Armed Forces Community, you can join the national forum with Future NHS: https://future.nhs.uk/connect.ti/NationalLowIntensityVeterans/grouphome

Rebecca Oliver is a Senior Psychological Wellbeing Practitioner at the Hidden Wounds Service, provided by Help for Heroes

References

Du Preez, J., Sundin, J.,Wessely, S., & Fear, N.T. (2012). Unit cohesion and mental health in the UK armed forces. Occupational Medicine, 62(1), 47-53.

Fear, N.T., Iversen, A.,Meltzer, H.,Workman, L., Hull, L., Greenberg, N., ... & Wessely, S. (2007). Patterns of drinking in the UK Armed Forces. Addiction, 102(11), 1749-1759.

Senior, E., Clarke, A., & Wilson-Menzfeld, G. (2023).The military spouse experience of living alongside their serving/veteran partner with a mental health issue: A systematic review and narrative synthesis. PLOS One, 18(5), e0285714.

This article was originally published in CBT Today magazine December 2023.

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