PTSD - The hidden wounds are hardest to heal

This year, Prince Harry (who served two tours of duty in Afghanistan) has been spearheading an awareness campaign for PTSD, anxiety and depression among servicemen and women as part of Heads Together – the joint initiative he has launched with the Duke and Duchess of Cambridge. ‘Mental health is a sensitive subject among a lot of people, but it doesn’t need to be,’ he said in a recent TV interview. ‘We need to talk about it more, get rid of the stigma.’

Ministry of Defence figures show that more than 220,000 British personnel served in the Iraq and Afghan campaigns and Help for Heroes has estimated that almost 60,000 of them could develop a mental health problem. Combat Stress, the leading mental health charity for veterans, says it has experienced a 71 per cent rise in referrals in five years, and it anticipates an ongoing increase because, on average, traumatised ex-soldiers wait 13 years before seeking help. ‘When they do finally reach out, they often say it is their families that have made them come forward,’ says CEO Sue Freeth. ‘Behind every veteran suffering in silence, there are loved ones having to do the same.’

Many soldiers suffering from post-traumatic stress disorder feel unable to acknowledge their plight because of the stigma. Catherine O’Brien meets families who found themselves on the front line struggling to care for their loved ones

A month into his first tour of Helmand Province during the height of the conflict in May 2007, Alex, a Grenadier Guardsman, had been shot at point blank range by a Taliban fighter. The bullet had gone under his helmet, through his temple and into his eye socket, causing horrific head trauma. Twice during the emergency flight back to the UK his heart stopped and he had to be revived by defibrillator.

The Queen Elizabeth Hospital in Birmingham is the specialist centre for UK military personnel injured in conflict zones and a welfare officer was on hand for Alex’s mother when she arrived there to see her son. But once she brought her son back to the family home in Lincoln, they were on their own. ‘There was no back-up and I was thrown in at the deep end,’ she says. She and Alex talked, ‘but he didn’t want to tell me everything that had happened – I think he was trying to spare my feelings’. Soon afterwards, what Marion describes as ‘the hell’ kicked in. While still recovering, Alex learned that three of his best friends had been killed in Afghanistan. ‘He kept saying, “Why should I live if they’ve died?”’ Marion recalls. Then, on top of his survivor’s guilt, came the hammer blow of being told that surgeons were not going to be able to save the sight in his right eye. ‘That meant his Army career was over – and as far as he was concerned, he had nothing left to live for.’

To block out flashbacks and nightmares, Alex began drinking heavily. He admits: ‘I was drunk most of the time. I’d go out till the early hours, collapse, wake up, and open another bottle of beer.’ He picked fights because ‘everyone was the enemy’, and Marion recalls countless times being called by strangers who had grabbed his phone and looked up ‘Mum’ in his contacts. ‘I’d turn up in pubs and nightclubs in my dressing gown and drag him out screaming. At home I’d lock him in his room, only for him to climb out of the window.’ One morning she went upstairs to find him, still drunk from the night before, tying his bedsheets together in order to hang himself from the loft hatch. On another occasion, after insisting he walked with her to the local shops ‘to get some fresh air’, she became aware that he was veering off the pavement directly into the path of an oncoming bus. ‘He had this blank look on his face and I had two seconds to stop him so I hit him, knocking him to the ground – it was either that or watch him die.’

Finally they contacted Alex’s sergeant, who set the wheels in motion for him to have treatment at Headley Court, the specialist Ministry of Defence rehabilitation centre in Surrey for wounded soldiers. Through his GP, he was also referred to a counsellor, who told him: ‘I’m not going to be able to take away what happened to you, but I will teach you how to cope with it.’ Nine years on, Alex has rebuilt his life. He lives with

If mental health remains a largely taboo subject on civvy street, a deeply embedded macho culture makes it even more difficult to talk about within military circles. According to the MoD website: ‘In many ways, the stigma associated with mental health problems is more disabling than the condition itself.’ Sue Freeth of Combat Stress says: ‘Younger soldiers experiencing problems, particularly those who served in Iraq and Afghanistan, are coming forward for treatment sooner – within four years – which is encouraging. But we are dealing with a massive embarrassment factor – the expectation that you should be able to cope, and fear that if you speak up, you will be putting your career, and the respect of those you value, on the line.’

Patrick Rea, of PTSD Resolution, a charity that provides counselling for veterans and families, adds: ‘Soldiers soldier on. They are immensely proud, which means we often become involved only when matters have reached crisis point. The end-of-tether moment frequently involves wives or girlfriends who may have felt helpless for years before finally being able to persuade their partners to make the call.’

Sue Freeth at Combat Stress says: ‘To be candid, the Army has always had difficulties in managing people on sick leave, and mental health is something that is only just becoming OK to talk about.’ She praises veterans and their families who are prepared to speak out, ‘because getting individuals to tell their stories helps reduce stigma and enables others to feel they can come forward’.

She also welcomes extra government funding – three years ago, £7.4 million was set aside to improve mental health services for veterans and service personnel, and this February NHS England announced plans to invest a further £1 billion a year in mental health services generally for the next five years. But NHS care remains patchy. Combat Stress surveyed GPs last year and found too many are unfamiliar with guidelines for treatment of military psychological traumas.

‘This lack of knowledge can lead to veterans experiencing delays in accessing specialist help or being placed on less effective treatment programmes,’ says Freeth. Combat Stress runs a 24-hour helpline which is available to veterans, serving personnel and their families. The charity also incorporates family sessions into its recovery programmes. ‘We would like to do more for families but we need more funding to make it happen.’

The term post-traumatic stress disorder (PTSD) was first used by veterans of the Vietnam War, but the problem has existed a lot longer and been known as shell shock, battle fatigue and soldier’s heart. According to Dr Manveer Kaur, senior clinical psychologist with Combat Stress, the condition is often based on an ‘I could have died – that could have been it for me’ memory.

In civilian life, a traumatic event such as being involved in an accident or assault can lead to PTSD. A key difference with war veterans is that they usually present with multiple traumatic experiences. ‘Many also have a feeling of guilt or shame based on survivors’ guilt – they have seen colleagues maimed and killed and there is a sense of ‘I should have done more – I’ve let the side down,’ says Dr Kaur.

● Veterans present with cluster symptoms. The first involves re-experiencing. They have one or more memories in which they feared for their life and those memories haven’t been processed and stored properly. Consequently random triggers can make them pop out unpredictably. Examples of common triggers are fireworks – a reminder of explosions and gunfire – and barbecues, the smell of burning flesh. ‘When a veteran has a trigger moment, he or she may suddenly zone out, glaze over, stop talking mid-sentence or lose track of a conversation,’ says Dr Kaur. ‘They may also start breathing rapidly and even adopt a body position, such as crouching down, that is part of the re-experiencing process.’

● The second set of symptoms is connected to mood swings – veterans with PTSD may be more irritable, snappy or critical. Disturbed sleep caused by nightmares and flashbacks can exacerbate black moods. They may be hyper-vigilant and unable to cope with crowds, confined spaces and loud noises.

● The third set of symptoms is connected to avoidance. ‘If you are having flashbacks triggered by random experiences it makes sense that you will withdraw to avoid the triggers,’ Dr Kaur explains. ‘Veterans may become reclusive, avoiding shopping trips or meals out for fear of something unpredictable happening. If they do go to a restaurant, they may want to sit close to the door in case they need to get out in a hurry.’

● As well as physical avoidance, veterans with PTSD may become emotionally withdrawn. Their minds and bodies go into a state of numbness. They appear to be cold and cut off, which can be particularly hard for partners and children to understand.

● Veterans can be highly self-critical. They may feel that PTSD is a sign of weakness, that they should be coping, working, caring for their families – and that makes them harder on themselves.

● Self-medication is common, particularly with alcohol. Drinking is socially acceptable and encouraged in military circles – it is perceived as a reward after a hard day’s work or a long tour. Veterans with PTSD may use alcohol to shut off emotionally and numb painful memories.

● Less common, but also used as avoidance tools, are drugs such as cannabis and cocaine, eating disorders and self-harm.

● Seeking prompt treatment is key to maximising the chances of recovery from PTSD. ‘If the sufferer receives the right treatment in the right environment, rates of recovery are very positive. Veterans can live normal, fulfilling lives, are able to work with the condition and generally become symptom-free for long periods,’ says Dr Kaur.