Primary/Intermediate Care - DCMH Departments of Community Mental Health UK 15, Germany 4, Cyprus 1, Gibraltar 1 Multiprofessional Psychiatrists, Clinical Psychologists, Community Mental Health Nurses (CMHN) Mental Health Social Workers Localised services to tri-Service catchment areas Managing Trauma in the Uniformed 31 July 2011 27 Services: an ESTSS task force
UK Departments of Community Mental Health Kinloss Faslane Leuchars Northern Ireland Catterick Brize Norton Cranwell Marham Donnington Colchester Woolwic h Plymouth Aldershot Tidworth Portsmouth
DCMH Aim is to provide local service enabling clients to stay in Service environment Normal social support networks maintained MES restricted if necessary Effective DCMH Treatments based on NICE guidelines: CBT, EMDR, Medication All DCMH nurses trained in psychotherapeutic interventions above Managing Trauma in the Uniformed 31 July 2011 29 Services: an ESTSS task force
DCMH DCMH aim 'to provide timely assessment and treatment to maximise operational and occupational capability within HM Forces, and, for those personnel who cannot be rehabilitated, to ensure they receive a smooth as possible transition to civilian life’ Managing Trauma in the Uniformed Services: an ESTSS task force
DCMH DASA (Defence Analysis Statistics and Advice) DASA Annual Summary 2010 5581 new attendances (c. 2.77% of AF) Of these 3932 (1.96% of AF) diagnosed Very low threshold of referral to DCMH in comparison with National Health Service i.e. an Occupational Mental Health Service Managing Trauma in the Uniformed 31 July 2011 31 Services: an ESTSS task force
General Findings Army > Royal Navy and RAF Royal Marines < Army and RAF Females 2 x Males Other Ranks > Officers Most common Dx is Adjustment Disorder 249 personnel diagnosed with PTSD in 2009 (=0.12%) Rates of adjustment disorder, neurotic disorder and PTSD higher in those who have deployed (but lower rates of mood disorder) Use of alcohol is a problem within AF (Fear et al 2010) AF personnel drink more than their civilian counterparts Managing Trauma in the Uniformed 31 July 2011 32 Services: an ESTSS task force
Inpatient Care Last MoD inpatient unit closed in 2003 Priory Group from 2003 to 2008 Now consortium of 6 English and 2 Scottish NHS Trusts since Dec 2008 315 admissions to In-Patient Service Provider (ISP) in 2010 (c. O.15% of AF strength) Only 5% of DCMH referrals referred on for inpatient care Assured admission within 4 hours normally as near as possible to normal location Managing Trauma in the Uniformed 31 July 2011 33 Services: an ESTSS task force
Inpatient Care Following admission, visit by Service Liaison Officer (SLO) within 72 hours Daily telephone contact Weekly visits throughout remainder of admission including attendances at ward rounds, case conferences and reviews Average length of admission 10 days Length of stay decreasing with new ISP Managing Trauma in the Uniformed 31 July 2011 34 Services: an ESTSS task force
Reservists Operationally and Mobilised – Same access to MH Care as Regulars Slightly higher risk of developing PTSD (5% vs. 4%) (KCMHR, 2006) Reservist Mental Health Programme (RMHP) established in November 2006 at RTMC Chilwell Eligible to all with operationally attributable injuries who have deployed since 2003 70 of 103 patients treated by DCMHs under RMHP have returned to deployable fitness Managing Trauma in the Uniformed 31 July 2011 35 Services: an ESTSS task force
Operational Population OMHNE Operational Mental Health Needs Evaluation Op Telic OMNHE (I) Feb 09 Rates of mental health problems similar to non- deployed population Op Herrick OMNHE (A) Jan 2010 Managing Trauma in the Uniformed 31 July 2011 36 Services: an ESTSS task force
FMHTs Field Mental Health Teams Consist of Community Mental Health Nurses (CMHNs) Visiting Psychiatrist Operationally focused mental health service Major role in psycho-education (pre-, intra-, post- deployment) Those unfit returned to UK by Aeromedical Evacuation (AE) for ISP admission or review in Primary Care or at DCMH Managing Trauma in the Uniformed 31 July 2011 37 Services: an ESTSS task force
Decompression Formed units return to UK via Cyprus 36-hour decompression is executive responsibility Decompression aims to facilitate adjustment process CMHNs provide MH support and deliver psychoeducational briefs Additional support provided by Padre Decompression evaluated by ACDMH for PJHQ – only 50% wished to go through process initially but over 90% found it to have been useful Managing Trauma in the Uniformed 31 July 2011 38 Services: an ESTSS task force
DMRC and RCDM Defence Medical Services Rehabilitation Centre Headley Court CMHNs and Psychologists, Psychiatric Support from DMHS Royal Centre for Defence Medicine Birmingham CMHNs, Psychiatric and Psychological Support from DMHS Managing Trauma in the Uniformed 31 July 2011 39 Services: an ESTSS task force
Training and Research OROSM recommended that all 3 Services should include psycho-educational material throughout initial training and promotion courses and on discharge – currently being audited and implemented throughout Academic Centre for Defence Mental Health (ACDMH) run Diploma in Military Mental Health and MSc Courses RCDM run Enhanced Operational Mental Health Course CMHNs all attend CBT Basics, EMDR Level 1, and Motivational Interviewing Training Commitment to funding and conducting research 31 July 2011 40 Managing Trauma in the Uniformed Services:
In Conclusion - 1 UK MoD takes psychological disorders very seriously There is a high priority attached to increasing awareness, combating stigma and providing effective diagnosis and treatment DMS wishes to increase number of MH personnel Managing Trauma in the 31 July 2011 41 Uniformed Services: an ESTSS task force
In Conclusion - 2 It is hoped that efforts to increase awareness of mental health issues and support available will reduce incidence of mental health problems in future veterans It is believed that the themes and recommendations of Dr Andrew Murrison MP’s recent report ‘Fighting Fit’ will make a vital contribution towards rebuilding the Military Covenant and providing additional support to members of the UK Armed Forces and ex-UK Armed Service personnel with MH issues Managing Trauma in the Uniformed 31 July 2011 42 Services: an ESTSS task force
Thank you Dr Jamie Hacker Hughes DCA Psychology and Head of Defence Clinical Psychology Ministry of Defence Joint Medical Command HQ Surgeon General Coltman House DMS Whittington Lichfield WS14 9PY UK SGJMCHCare-ClinPsych@mod.uk Managing Trauma in the Uniformed Services: an ESTSS task force
Echoes Online Empowerment for the police force By Jan Schaart Managing Trauma in the Uniformed Services: an ESTSS task force
Arq Psychotrauma Expert Groep Arq Psychotrauma Expert Groep consists of several expert organizations, all specialists in their own field, which have organized themselves around the issue of psychological trauma. Their partnership within Arq creates added value. Through the exchange of expertise, experience and potential for innovation, the needs of societies can be better anticipated and served. The complementary nature of their union allows greater benefits for both individuals and organizations. The partners in Arq work together on scientific research, education and training as well as international activities in the Arq Research Program, Arq Education Program and Arq International Program respectively.
Echoes Online: empowerment for the police force • Arq Psycho Trauma Expert Groep: • 9 partners, 5 working with uniformed services • Mission: to develop practical knowledge Presentation: • Services we offer the police force • Echoes Online: objects & concept of empowerment • Portal for the police force Managing Trauma in the Uniformed Services: an ESTSS task force 24 May 2011 46
Echoes Online: services we offer police force Impact Foundation: partner in Arq • National advice centre for psychosocial care after disasters, developed the military guidelines for psychosocial support for uniformed service organizations in collaboration with police and fire brigade. • Guidelines: prevent work stress & health related problems. • Organization peer support = key aspect, + organizational resilience, individual responsibility & healthy work conditions. • Guidelines accepted by all as standard psychosocial support • Pilot 2011 implement guidelines 5 regions (15.000 policemen) Managing Trauma in the Uniformed Services: 24 May 2011 an ESTSS task force 47
Echoes Online: services we offer police force IVP ( Institute for Psychotrauma ) • IVP: partner in Arq Psychotrauma Expert Groep, is a business unit working with the government and private companies. • The core business is research, crises management, consultation, treatment of psychotrauma and training. • IVP has over 25 years experience working with the police force, mostly after a crisis, training stress coping, sometimes consultation about prevention activities within the frame work of labour legislation. Managing Trauma in the Uniformed Services: 24 May 2011 an ESTSS task force 48
Echoes Online: services we offer police force P sychotrauma D iagnosis C entre: partner in Arq • Developed for veterans: to deliver a fast (takes one day) and clear diagnostic assessment and, if necessary, recommendations for treatment • Special PDC part is outpatient clinic for policemen with PTSD symptoms (180 pro year) • Trained staff, who know the police force by experience, coordinate the assessment and treatment Managing Trauma in the Uniformed Services: 24 May 2011 an ESTSS task force 49
Echoes Online: services we offer police force Foundation Centre ’45 : partner in Arq • National psychotrauma mental health institute • Foundation Centre ’45 offers outpatient clinic, day clinic and 24 hours inpatient clinic treatment services • Special day clinic groups in which policemen are treated in a multidisciplinary setting • Treatment: psychiatric care, individual psychotrauma therapy (EMDR, CBT), group therapy & nonverbal therapy • The results are very positive, 80% of the patients report being satisfied about the results
Echoes Online: services we offer police force Echoes Foundation : partner in Arq • Founded by Eric Vermetten after Tsunami 2004 • Huge need among survivors and relatives of the victims: therefore online intervention for the victims: www.tisei.org (presentations of results) • Sharing experiences, complete memories, information available help • Echoes: platform for online psychosocial developments, also developing websites for people exposed to overwhelming and traumatic events • Portals created for civilians, veterans, companies, disasters (Tripoli) and now working on a police portal: http://www.echoesonline.nl Managing Trauma in the Uniformed Services: 24 May 2011 an ESTSS task force 51
Echoes Online: objects • Promote online possibilities psychosocial support victims • Create portals as safe environment for colleagues • Concept of empowerment • Validated screening tools • Stimulate research, quality management and development in online psychosocial interventions Managing Trauma in the Uniformed Services: 24 May 2011 an ESTSS task force 52
Echoes Online: concept of empowerment Prevention • Get in contact with the whole exposed community • Get in contact with people at risk • Inform people how to get help when needed Empowerment 1 • Inform people about consequences of traumatic events • Inform people about temporary complaints • Provide tools how to deal with these complaints Managing Trauma in the Uniformed Services: 24 May 2011 an ESTSS task force 53
Echoes Online: concept of empowerment • exchanging experiences • support each other in overcoming difficulties • fill in gaps in memories with information from fellow survivors • reconstructing and reframing the disaster with each other • advising each other in legal and health care matters Managing Trauma in the Uniformed Services: 24 May 2011 an ESTSS task force 54
Echoes Online: portal police force, format Story telling and informing each other • Stories reference group: experience of several people. How to cope with ones situation and deal with problems Three tools 1. Professional information: consequences overwhelming events, PTSD symptoms, about impact and tips how to deal with symptoms etc. 2. Self-assessment: to measure the impact of the events 3. Online forum were they can contact peers Managing Trauma in the Uniformed Services: an ESTSS task force 24 May 2011 55
Echoes Online: portal police force, measure impact • DKL = impact tool known to general practitioners • Short DKL: time events, level stress, sleep and irritation Outcome 1. Green: some complaints, which don’t bother too much 2. Orange: stress related complaints, advice & repeat tip 3. Red: much stress related complaints, advice extended test • Extended test can advice to visit general practitioner • Possibility to compare tests Managing Trauma in the Uniformed Services: 24 May 2011 57 an ESTSS task force
24 May 2011 58
Echoes Online: portal for the police force • Arq Psychotrauma Expert Groep background: prevention, consultation, screening, diagnosis and treatment • Approval of the portal is important • Experts, government, regional and national police force, police trade unions & medical police services • Took 8 months to get to a mutual level of agreement Managing Trauma in the Uniformed Services: 24 May 2011 59 an ESTSS task force
Echoes Online: portal for the police force where do we stand Still two major issues 1. Privacy: environment which is not controlled by the police force 2. Possibilities for stepped care when we start • We are working on both issues • Building police care network • Working on screening tool to detect if problems are organizational focused or based on individual problems (developed by IVP for the national railroad company) Managing Trauma in the Uniformed Services: 24 May 2011 60 an ESTSS task force
Partners as from January 1st 2011: Foundation Centrum '45 IVP PDC Equator Foundation Antares Foundation Cogis War Trauma Foundation Impact Partnering projects within Arq: Arq Research Program (ARP) Arq Education Program (AEP) Arq International Program (AIP) www.arq.org
“Trust me, I’m a therapist!” Crossing the threshold – talking with fire fighters about resilience not madness Gill Moreton Rivers Centre for Traumatic Stress Edinburgh, Scotland Managing Trauma in the Uniformed Services: an ESTSS task force
Crossing the threshold…… what do we think of each other?
What do we think of each other? Us about them Them about us Brave White coats Calm Lying on couches Funny Talking about their childhoods Plain-spoken Hippies with joss sticks, whale music and beanbags Strong / big “Basket weaving coaches” Tough / robust Nut doctors Practical / resourceful Pink and fluffy Capable / reliable Pill dispensers Heroic / selfless Look like Freud Male Therapy is for those with “the madness” Handsome / tall / sexy (aka stick pencils up their noses) Resilient Cope by drinking or denial Laid back (horizontal) Avoid strong negative emotion
Rivers Centre for Traumatic Stress and the Emergency Services • Working with the Emergency Services for nearly 20 years providing: • Priority assessment and treatment to ES staff developing psychological injuries following exposure to traumatic stress at work • Screening / self-referral scheme following critical incidents • Advice and guidance to senior management and occupational health • Training for new recruits • Development of peer support initiatives within the organisation Managing Trauma in the Uniformed Services: an ESTSS task force
Overcoming stigma • In 2010 we evaluated the Critical Incident Stress Management scheme. • We got a response rate of 30% • 81% of respondents felt that there was no stigma associated with seeking help • 95% said they would make use of the Rivers Centre if they were experiencing problems • 95% said confidentiality was key to the success of the scheme Managing Trauma in the Uniformed Services: an ESTSS task force
“Never had to be in contact but colleague who went to the centre was very satisfied and full of praises for the work done there. I think the centre does a brilliant job.” “I feel this is an important service, especially when you consider the events you may be involved in. I would like to think that recent events have made this service vital to staff.” “Its good to know that if I do have any issues in the future the Centre is there for help.” “In my opinion the key to the Rivers Centre is its confidentiality and being external to the Service as unfortunately there is still a stigma about the help they offer and the impact this may have on your career.” Managing Trauma in the Uniformed Services: an ESTSS task force
Working creatively with stigma • Accepting it • Challenging it • Working with it Managing Trauma in the Uniformed Services: an ESTSS task force
Accepting it Public perceptions of mental health and therapy Helpful investment in sense of self as professional and resilient Managing Trauma in the Uniformed Services: an ESTSS task force
Challenging it Education & normalisation Personalising the service Accessibility & flexibility Managing Trauma in the Uniformed Services: an ESTSS task force
Education & normalisation Emphasis on resilience not vulnerability Equalising the possibility of both physical and psychological injuries Aim is to avoid a catastrophic reaction to developing a trauma reaction Managing Trauma in the Uniformed Services: an ESTSS task force
Education & normalisation • “Staying resilient” training with new recruits at the Scottish Fire Services College • Educating senior management & fire fighters about the interplay between organisational stress, domestic stress and resilience • Building psychological injury into Health & Safety risk assessments • Pragmatism not panic Managing Trauma in the Uniformed Services: an ESTSS task force
Personalising the service Visits to stations Articles for the Service newsletter Information on the Service intranet Participation in Occupational Health events Contributing to stress awareness days Pro-active approaches to staff Managing Trauma in the Uniformed Services: an ESTSS task force
Accessibility & flexibility Responding to major incidents, e.g. death or injury of staff members Delivering psychological first aid rather than debriefing Recognising the importance of the perception of support post-trauma Managing Trauma in the Uniformed Services: an ESTSS task force
Working with it Using peer support and testimony Building credibility Being clear about our roles
Using peer support & testimony Linking fire fighters in treatment sessions reducing shame and isolation Asking fire fighters to give messages to: new recruits colleagues starting treatment Managing Trauma in the Uniformed Services: an ESTSS task force
There were a few moments where my reaction on being told the next step caused a negative reaction – that would be a polite way of saying, I was off. However, patient reassurance and explanation convinced me to follow the advice. I cannot praise the treatment I received enough, without it I would not have been able to carry on at work. The support to recognise and learn from the incidents at times seemed too much, but explanation, encouragement and practical tasks brought me to a much happier situation. Managing Trauma in the Uniformed Services: an ESTSS task force
Building credibility Therapist or proxy fire fighter? Experts in our mutual roles 98% of the staff in our survey thought it was important we were a specialist trauma service Need to know enough to engage them and to be familiar with their role Managing Trauma in the Uniformed Services: an ESTSS task force
I don’t think I had ever felt so wound up or disheartened with myself as I approached the building. In my mind I thought my career was done, I had looked at the pension calculator and redone the family finances a dozen times in my head. I stood outside having the “will I go in or go home” argument in my head. “If I had the bottle to go in the building at the incident I surely had the bottle to go in and at least hear what was on offer”. I really didn’t think this was going to help and I wasn’t convinced I believed it worked anyway. Two hours later I had spoken more about myself and the “job” than I had to anyone in years. I was opened up like a blister desperate to be burst. “You need 5 - 6 sessions and you are fixable”. It didn’t feel like a sales pitch, it felt like they knew what they were talking about. I felt safer with “my therapist” than I had for weeks and the in my head conversation on the way home was different. Managing Trauma in the Uniformed Services: an ESTSS task force
Trust me I’m a therapist! Approachability (“no airs or graces”) Straight forwardness Confidence in our knowledge Effective treatments Humour Respect Confidentiality Managing Trauma in the Uniformed Services: an ESTSS task force
Gill Moreton Rivers Centre for Traumatic Stress Edinburgh, Scotland + 44 131 537 6743 Gillian.Moreton@nhslothian.scot.nhs.uk Managing Trauma in the Uniformed Services: an ESTSS task force
Uniformed services task force – get involved! liz.royle@krtraumasupport.co.uk www.uniformedservices.blogspot.com Managing Trauma in the Uniformed Services: an ESTSS task force
References: Adler, A.B., Bliese, P.D., McGurk, D., Hoge, C.W. & Castro, C.A. Battlemind debriefing and Battlemind training as early interventions with soldiers returning from Iraq: Randomisation by platoon. Journal of Consulting and Clinical Psychology. Vol 77(5), Oct 2009, pp. 928-940 Britt, T.W., Greene-Shortridge, T.M., Brink, S., Nguyen, Q.B., Rath, J,. Cox, A.L.. Hoge, C.W. & Castro, C.A. (2008) Perceived stigma and barriers to care for psychological treatment: implications for reactions to stressors in different contexts. Journal of Social and Clinical Psychology. Vol 27(4), Apr 2008, pp.317-335 Corrigan, P.W., River, L.P., Lundin, R.K., Penn, D.L., Uphoff-Wasowski,K., Campion, J., Mathisen, J., Gagnon, C., Bergman, M., Goldstein, H. & Kubiak, M.A. (2001) Three Strategies for Changing Attributions about Severe Mental Illness. Schizophrenia Bulletin, 27(2) pp.187-195. Corrigan, P. W. & Calabrase, J. D. (2005) Strategies for assessing and diminishing self- stigma. In P.W. Corrigan (Ed). On the stigma of mental illness. Practical strategies for research and social change. Washington D.C: American Psychiatric Association. Managing Trauma in the Uniformed Services: an ESTSS task force
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