What mental health support is available to veterans?

A few months ago the Government announced that for the first time, they would gather data on veteran deaths by suicide and launch a review into veteran deaths by suicide over the last 10 years. Before now, we have not recorded these data, despite the fact that veterans face almost double the risk of PTSD compared with non-veteran members of the public (7.4% versus 4% according to 2018 data).

Michelle, 49, is a veteran in the UK, and says she found transitioning back into civilian life very challenging.

"I completed three tours of Afghanistan before my world changed," she says. "If I am honest I never really had the chance to transition through the normal route. Once I was medically discharged I moved back up north but unfortunately I was still in such a dark place that nothing really registered for a couple of years at least. I was struggling so much with the PTSD that this consumed me and I never really had the opportunity or headspace to process my leaving of my dream career.

"I feel like I have still not come to terms with leaving as there was no real closure for me. (Because I was medically discharged) I never really had the opportunity to say goodbye to my comrades and friends, nor did I go through the standard resettlement process to prepare me for civilian life."

For Michelle, the most important thing is transition support for veterans who left on medical grounds, and to offer veterans therapy from specialists: "I would like to see a rehabilitation facility much like that for those with physical or medical illnesses or injuries. There should also be an opportunity for those injured mentally to be able to rehabilitate fully and be able to stay in.

"It would also be good for those veterans struggling mentally, to receive therapy from someone who has been in the military, or at least understands military life," she adds. "I once had a young therapist straight out of training try to go through some trauma training with me. It was evident immediately that it was way above her head and she admitted she would have to refer me on. When you have been waiting to see a therapist for a long time, it is not helpful to have to be re-referred."

A life interrupted

Michael, 32, was made redundant from the RAF in 2011 when he was 21. "In my case, although I had only officially spent three years in the RAF," he says, "I'd basically committed my adolescent life from about the age of 12 to achieving that entry into that career path.

"I officially left the service in 2012, by which point I had completed the first year of my undergraduate studies. During that year I never really processed my loss or grief and do not believe that steps were put in place to help me manage this.

"Later that year," he explains, "my first adult relationship broke down after I left the service, which I attributed to changes in my behaviour and mood. I wasn't the person I used to be. I realised that something wasn't right and I was diagnosed with depression. In my darkest periods I had no self-esteem, no self-worth and did not see a future that had any purpose or any joy in it."

He notes that there was a huge amount of shame associated with how much he was struggling, particularly in light of the fact he was young, attending university and didn't have work or family responsibilities to worry about at the time.

He says Samaritans provided a valuable service that was easy for him to access when he needed it: "I first reached out to them during the winter of 2012. I found them a wonderful service - without being dramatic, it was lifesaving. This, combined with counselling, helped me through the toughest period, and it is a service I have continued to access in subsequent years." He and Michelle now both volunteer for Samaritans by sharing their experience with journalists covering veteran mental health stories.

The medical director of UK charity Combat Stress, Dr Walter Busuttil, warned recently that in the last decade, the number of veterans seeking their help has increased by 97%. (They help more than 2,000 new veterans a year.) Those who served in Afghanistan and Iraq show a particular need for support, he noted.

Risks for female veterans

Dr Lauren Godier-McBard is a senior research fellow at Anglia Ruskin's Veterans and Families Institute for Military Social Research. Last summer she published We Also Served, a report into women's well-being after service. She found evidence that women are less likely than men to access mental health services - something already well demonstrated amongst US veterans.

"Despite the fact that women are a minority in the veteran community - just 11% - only 6% of those accessing NHS veteran mental health services are women: half of what you would expect," she says.

A combination of factors inhibits female veterans, she explains: "Women may see those services as a mirror of military culture. For those who've undergone experiences like bullying, harassment and violence - particularly from male colleagues - they don't necessarily then feel comfortable going back into those environments again. Women may also worry that mental healthcare professionals in those services - which are set up predominantly around men - don't understand the different needs women in those services might have."

Female factors

Dr Godier-McBard's work also showed that amongst veterans, women run the same risk of dying by suicide as men. This is a clear difference compared with the civilian population, where men have a higher risk. She also nods to research by Prof Beverley Bergman, and from the King's Centre For Military Health Research. This found women who'd served in the military decades ago had faced much shorter careers (for example, being retired when they married or started a family) and greater exposure to what's known broadly as 'military adversity' - harassment, abuse or bullying.

Gathering more data on experience of service might not shine more light on the relationship it has with mental health problems and suicide, she warns: "There is a tendency, or there has been historically, to perpetuate the idea that veterans are more likely to die by suicide, or that there's an epidemic of veteran suicide, which isn't necessarily supported by data. My concern would be an over-interpretation of the findings, which for me are just a starting point."

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The role of therapy

Dr Justin Havers is a psychotherapist who has worked with veterans, and specialises in a form of therapy called Eye Movement Desensitisation and Reprocessing (EMDR). He has recently co-written a study of 93 patients that found online EMDR was an effective treatment for people who can't or prefer not to access in-person therapy.

Like Dr Godier-McBard, he feels that reports of a 'tsunami of need' overstate the mental health problems of service leavers and veterans. For him, the biggest issue for service leavers and veterans is getting them to seek help in the first place.

"That's been one that's always traditionally been one of the big issues. You've got two factors of this: Is help available? And if so, is it the right help?” he says. "Over the last 20 years with the operations in Iraq and Afghanistan, obviously that's created another kind of 'bow wave' of requirement. But it's not the 'tsunami of need' that the media portrays ... Maybe five or six years ago, there was a narrative that said: "We've abandoned our veterans, we don't provide any support, they're hopelessly let down." That’s not the case.

"But," he admits, "it is not as joined-up as it could be. When people leave the military, they lose a family, and that kind of transition can be really hard. That's often when problems manifest."

Hundreds of charities

In October 2021, Samaritans launched an app specifically to provide support for veterans to help them self-manage mental health symptoms. The app had been developed with support from the Ministry of Defence and veterans with experience of mental health problems after the Royal British Legion supported Samaritans to run focus groups with veterans about their needs for mental health support.

Although he hasn't used Samaritans' app himself, Michael feels that if it had been available 10 years ago he would have done. "There's a degree of trust and professionalism and authority around that organisation pairing with the military," he says.

There are thought to be over 1,800 UK charities which specialise in helping veterans, and for some service leavers and veterans (and their clinicians), having so much choice can make it hard to know where to start.

Bringing it all together

One of the app's functions is to signpost users on to eight charities that specialise in mental health support: Samaritans, All Call Signs, Togetherall, the Soldiers, Sailors, Airmen and Families Association (SSAFA), the Royal British Legion, Help for Heroes, Combat Stress, and PTSD Resolution. All the charities are members of one or both official service charity federations, Cobseo and Contact Armed Forces, which scrutinise and legitimise the work of charities.

Joseph Walcott is the military programme lead at Samaritans. He was in the Royal Artillery for seven years and left in 2017.

"No one really joins the military to potentially go and fight," he says. "It's about travelling, camaraderie, adventure, helping others and the opportunity perhaps, to give something and have a vocation and enjoy it. We wanted to be able to translate that as much as we could and incorporate that.

"We used focus groups to focus in on the content we would include. That means themes that we explored in the app are purely based from focus group feedback, subsequent focus groups and a literature review by the King's Centre. We really wanted to cover the key wants and needs service leavers might have during their transitional period."

Users have so far said the app was "useful" and easy to use - "what they've been waiting for": they found the podcasts and videos "inspiring", and called the tips and exercises "invaluable" on difficult days. The charity estimates that the app has been downloaded over 500 times to date, which, tracked against the estimated 4% of leavers with mental or emotional challenges, appears to be registering the right level of engagement.

Helplines for veterans

Like anyone else, veterans can access help from the NHS. Because veterans run higher risks of some mental health diagnoses (such as PTSD), they also get access to a new veteran-specific mental health service called Op Courage. It merges three former services: the Transition, Intervention and Liaison Service (TILS), the Complex Treatment Service (CTS) and the Health High Intensity Service (HIS).

Veterans can self-refer to Op Courage for assessment, or ask their GP for a referral.

For those looking for helplines where listeners specialise in supporting veterans, Combat Stress runs a 24-hour helpline (0800 138 1619) as well as text and email services. They also offer self-help guides for those who prefer not to contact anyone: guides cover PTSD, substance and alcohol misuse and physical health problems, and they also have a guide for partners or relatives of veterans with PTSD.

As ever, Samaritans' 24-hour line (116 123) is open to anyone (including veterans) in distress or despair.