Mental health at sea - military Mental health at sea - military and civilian experienceand civilian experience

Professor Neil GreenbergProfessor Neil Greenberg

20122012

Who am I?Who am I?• Professor of Mental Health based at King’s College London

• Occupational Psychiatrist and Director of March on Stress

• Military background in the Royal Navy for 23 years

• Supported and provided psychological advice and assessments– UK Government (e.g. FCO, DFID)– Media (e.g. BBC)– Emergency Services (e.g. Fire, Ambulance, Police)– Security Companies (e.g. Maritime, Land)– Military (e.g. UK AF, US, CAN)

Plan for my talkPlan for my talk

• What is traumatic stressWhat is traumatic stress

• How does it affect peopleHow does it affect people

• Why should maritime organisations be Why should maritime organisations be interestedinterested

• What can be doneWhat can be done

So…what is a traumatic So…what is a traumatic eventevent

??

A Potentially Traumatic Event A Potentially Traumatic Event (PTE)(PTE)

• Is an event which leads to: Is an event which leads to: – intense helplessnessintense helplessness– intense horrorintense horror– intense fear intense fear

• In response to experiencing or In response to experiencing or witnessing a traumatic eventwitnessing a traumatic event

• However most do not cause illnessHowever most do not cause illness

WhatWhat is the natural history of PTSD? is the natural history of PTSD?

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0 10 20 30 40 50 60

Time elapsed since trauma (weeks)

PT

SD

ca

se

ne

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(%

)

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dis

tres

sed

So….

• Not all trauma leads to psychological illness

• Most who get distressed recover

• But….most people who develop mental health problems don’t get help

StigmaStigma

• ““an attribute that is deeply discrediting” (Goffman, an attribute that is deeply discrediting” (Goffman, 1963)1963)

• ““the bearer of a mark that defines him or her as the bearer of a mark that defines him or her as deviant, flawed, limited, spoiled or generally deviant, flawed, limited, spoiled or generally undesirable”undesirable” (Jones,1984)(Jones,1984)

WW1 - StigmaWW1 - Stigma

““It is wholly out of place to show themIt is wholly out of place to show themcompassion. People with shell shock arecompassion. People with shell shock are

weaklings who should never been weaklings who should never been allowed to join the Army or tricksters whoallowed to join the Army or tricksters who

deserved to be punished”deserved to be punished”

Captain Dunn, Medical officer, RWFCaptain Dunn, Medical officer, RWF

WW 2 - A Stiff Upper LipWW 2 - A Stiff Upper Lip

• LMF and the RAFLMF and the RAF

• General PattonGeneral Patton

• Not until the end of WW2 was it realised that Not until the end of WW2 was it realised that “everyone has their breaking point”“everyone has their breaking point”

Stigma and Barriers to CareStigma and Barriers to Care

Stigma and Barriers to Care

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Don't knowwhere toget help

Difficultygettingtime offwork

Wouldharm my

career

My unitleadershipmight treat

medifferently

Would beseen as

weak

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USA

UK

AUS

CAN

Gould et al, 2010, JRSM

Perceived Stigma

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Would be seen as weak by CoC***

Would affect my promotion ***

Would not be given responsibility***

Would not be trusted by peers***

Would be embarassed asking for help***

My peers would tease me***

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PsychCase

Non Case

Internal Stigma – Naval ServiceInternal Stigma – Naval Service

Langston et al, 2010, JMH

0%10%20%30%40%50%60%70%80%

No treatment Medication only Counselling ortherapy only

Non Veterans

Military Veterans

Most people with PTSD do not get Most people with PTSD do not get treatmenttreatment

Woodhead et al, 2010, Soc Sci Med

So….

• Distressed people do not usually ask for helpDistressed people do not usually ask for help

• Most worry about what their peers and Most worry about what their peers and immediate line managers will think of themimmediate line managers will think of them

• Stigma is particularly a problem for those Stigma is particularly a problem for those who have mental health problems who have mental health problems

Why should shipping companies be interested in traumatic stress?

Morally – shipping is a ‘high’ threat profession

Lives lost on cargo ships – Shipping facts website

Legally – it could be expensive if they don’t

• MoD high court case – 2002/2003: 1000 ex service personnel– Case lasted over a year; £20M legal costs– MoD not found to be negligent since they had

invested heavily in supporting personnel– Those not treated well won up to £650K damages– Lessons to be learned apply to other organisations

that “predictably place their staff in harm’s way”

Economically – mental health affects business

• In 2008 ~In 2008 ~ 13.5 million days were lost to work- 13.5 million days were lost to work-related stress in the UKrelated stress in the UK

• Presenteeism accounts for 1.5 X as much Presenteeism accounts for 1.5 X as much working time lost as sickness absence working time lost as sickness absence Esp important with safety critical rolesEsp important with safety critical roles

ConcentrationConcentrationMotivationMotivationCustomer focusCustomer focus

For organisations that respond well - crises are golden opportunities

Share-price post major incident

“Risks That Matter”, Dr. Deborah Pretty, Oxford Metrica, 2002

Other important ‘maritime’ mental health risks

• The psychological impact of hostage taking– On the individual– Colleagues– Family– Reputation

• The health of private security contractors– Ex-military therefore ‘trauma exposed’– High degrees of vigilance required for long periods– Unclear what motivates them to do the work

What about the PSCs who ‘protect’ at risk vessels?

?(well there’s just two papers)

Feinstein et al JTS 2009

• 79 War-Zone contractors completed an Internet-based psychiatric assessment.

• Males, average age of 43

– depression 20% (CES-D)– psychological distress 28% (GHQ-28)– excessive weekly alcohol consumption 17% (units)

• 1/3 had PTSD symptoms in the moderate to severe range

• 12% had any organisational psychological preparation before deployment

• 10% had employer-organized access to psychological help following deployment

Messenger et al JOEM 2012

• In depth interviews with small (n=7) group of UK PSCs

• No clinically significant levels of distress were reported

• Examined the main ‘themes’ of why people work in the PSC field

Messenger et al JOEM 2012

• the appeal of the job• The lure of money• Autonomy• A desire to be challenged/the buzz• A military identity

• vulnerability• The scale and nature of the danger• Mistrust (esp ‘unknown’ colleagues (inc locals))• The risk of unemployment (see last point on holding back)

• keeping going• Not thinking about the danger and a sense of personal strength• The importance of leave• A safe place to talk

• seeking help for stress in the workplace• Reaching out v holding back

Possible PSC media interest

Operational Stress Management

• Prevent

• Detect

• Treat

Prevent

• Robust operational stress policy– Philosophy– Duties of individuals and managers

• Mental Health awareness training especially for managers/leaders

The impact of leaders on mental health

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Prevalence of probable PTSD*

Overall

Good Leadership

Poor Leadership

Jones et al, Psychiatry, 2011

Prevent

• Robust operational stress policy

• Mental Health awareness training especially for managers

• Having appropriate enlistment standards– The seduction of screening

Selection Screening UK military

Before and After Iraq War 2003

Iraq War 2003

Follow Up Study 2004

Pre Iraq Data Collection 2002

n=3000

Pre Deployment Selection/Screening: PTSD Cases

After Iraq Invasion (04)

+ - Total

Before Iraq Invasion (02)

+ 6 27 33

- 41 1540 1581

Total 47 1567 1614

PPV 18% (5-31%); NPV 97% (96-98%)

Why do people develop PTSD

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Detect

• Peer led ‘trauma awareness’ training– Psychological first aid– Available wherever incidents happen– Non medical therefore less stigma

TRiM – Trauma Risk Management

• Peer group support and risk assessment strategy

• Set up within the Royal Marines in late ’90s – now – all Services (since 2007). FCO, BBC, Em Serv, PSC etc.

• ‘Human resource’ initiative

• TRiM is not a cure - assesses psychological risk & suggests management and signposts

• Trained practitioners at all levels/grades

Trauma Risk Management (TRiM)- What is it?

What Peer Practitioners are not!

– Counsellors– Therapists– Pseudo-psychologists– Group Huggers– Scented Candle users

TRiM

publications

Detect

• Psychological health monitoring/support– Proactive surveillance– Advice, support and signposting as needed– Ongoing, independent, avenue for seeking mental

health support– Demonstrates ‘due diligence’

• Based upon best evidence

Treat

• National Guidelines– Evidence based– Delivered by trained, experienced mental health

professionals

Not what we are after - Psychological Debriefing

How to deal with PTSDHow to deal with PTSD (NICE slide (NICE slide edited)edited)

What isn’t recommended…

•“Psychological Debriefing”•Ineffective psychological treatments•For PTSD, drug treatments NOT a first line treatment (different for depression)

What is recommended…

•“Watchful Waiting”•Checking in after a month•Trauma-focused treatments (CBT and EMDR) for adults and children if unwell (NICE, 2005)

And sellers of Bad Science often will say they have ‘the answer’

Summary

• Most people exposed to traumatic events will cope

• However, some will become ill• Those that do are unlikely to seek help• Moral, legal and economic reasons to manage

traumatic stress effectively exist• Evidence based prevent, detect and treat

solutions are available

Any Questions?- Fire Away!Any Questions?- Fire Away!

Neil: sososanta@aol.com

www.marchonstress.com