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Veteran Transition September 2013 Veterans and Transition to Civilian Society: an historical perspective Edgar Jones Institute of Psychiatry and Kings.

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Presentation on theme: "Veteran Transition September 2013 Veterans and Transition to Civilian Society: an historical perspective Edgar Jones Institute of Psychiatry and Kings."— Presentation transcript:

1 Veteran Transition September 2013 Veterans and Transition to Civilian Society: an historical perspective Edgar Jones Institute of Psychiatry and Kings Centre for Military Health Research

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3 Veteran Transition Why study transition in the past? The veteran population has inherent research challenges. Subjects are often difficult to identify and self-report data also presents problems.

4 Veteran Transition Understatement of psychiatric morbidity Because of stigma, veterans often suffer in silence, creating a culture of hidden morbidity. Psychological disorders are often accompanied by cognitive and memory deficits which impair the accurate recall of events.

5 Veteran Transition Overstatement of trauma Studies of 1991 Gulf War veterans showed that those with poor health perception emphasised traumatic experiences and adverse consequences. Recall of exposures was not stable over time. Research conducted by Veterans First Point (funded by NHS Lothian and MoD) in Scotland showed discrepancies between self report and military records in 50% of those attending the service. Wessely et al (2003), Stability of recall of military hazards, BJPsych, 183:

6 Veteran Transition Detection of veterans Despite the issue of a badge, veterans themselves are not readily identifiable once they have moved into the civilian community. Those that stand out are not always what they seem to be.

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8 Veteran Transition The value of h istorical data Evidence gathered from the aftermath of World War Two is high quality in terms of sample size and the detailed and verified nature of the case notes. The Ministry of Pensions went to great care to verify service records, medical files and the veterans state of health through annual medical boards and specialist reports.

9 Veteran Transition What was the core principle driving UK veteran policy in 1945? Work, or paid employment, was considered crucial because: 1. In itself, work was therapeutic, a natural extension of occupational therapy, generating self- esteem and confidence. The ability to work consistently was interpreted as a sign of health. 2. Employment was of material benefit to the veteran, his family and society as a whole.

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11 Veteran Transition The importance attached to work had been developed into policies during the war itself: 1. The Annexure Scheme 2. Demobilisation plans that emphasised employment opportunities 3. Civil Resettlement Units 4. War pension policy in relation to psychiatric injury

12 Veteran Transition Mill Hill Hospital follow-up study of veterans Between March 1941 and June 1942, Aubrey Lewis led a team of psychiatric social workers who visited 120 discharged servicemen living in London. He described the results as disturbing as the men had gone downhill as a group: they were less usefully employed than before, earning less, less contented, less tolerable to live with, less healthy. He discovered that 15 were unemployed and 44 were doing light or desultory work only. Only 50% could be classed as socially satisfactory in respect of work and otherwise. Aubrey Lewis, Social effects of neurosis, Lancet, 1943, 1, ,

13 Veteran Transition Discharged servicemen A 1943 study by Eric Guttmann and E.L. Thomas of British servicemen discharged from the forces for at least 15 months following mental illness, found: A large proportion of them find it difficult to return to civilian occupation as shown both in delay in taking up work and in the frequency of job changes. There is a high rate of absenteeism due to sickness... Moreover the men feel unhappy in their private lives; they feel self-conscious, and they are liable to social frictions... Though it is impossible to assess the exact degree of their deterioration, it is certain that a considerable proportion of men show more marked symptoms and a poorer adjustment than before they served in the Army. E. Guttman and E.L. Thomas (1946), A Report on Re-adjustment in Civil Life of Soldiers discharged from the Army on account of neurosis, London: HMSO, p. 161.

14 Veteran Transition Annexure Scheme Introduced in summer 1941, the Annexure Scheme involved a multi-disciplinary assessment of a soldiers skills and aptitude so that they could be offered vocational training to enhance their employability within the armed forces thereby avoiding premature discharge. In addition, such service personnel would be better prepared for the time when they returned to civilian life. Ahrenfeldt, R.H. (1958), Psychiatry in the British Army in the Second World War, London: Routledge, pp

15 Veteran Transition Annexure Scheme A follow-up investigation conducted in 1943 by Aubrey Lewis found that the additional training not only raised the percentage of treated servicemen who returned to military service (58% compared with 36% before its introduction) but also improved outcomes (46% performing satisfactorily after twelve months compared with 23% before the annexure system). Around 10,000 servicemen were retained in the armed forces under the scheme, which ended in August A. Lewis and K. Goodyear (1944), Vocational aspects of neurosis in soldiers, Lancet, 2:

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17 Veteran Transition Demobilisation policy Ernest Bevins demobilisation plan, announced in September 1944, gave priority based on age, length of service and value to the community. Two months of military service were equivalent to a year of age. Tables were issued so that servicemen could calculate when they would leave the armed forces.

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19 Veteran Transition Demobilisation Scheme By the end of 1946, 4.5 million men and women had been demobilised from the forces. Priority was given to servicemen needed to rebuild the economy. 10% of servicemen were category B, those with special skills vital to reconstruction (coal miners, builders, teachers, policemen etc).

20 Veteran Transition Psychiatric illness and transition In 1944, Major P.H. Newman, a surgeon and himself a repatriated prisoner-of-war, argued that returning POWs suffered from a psychological form of caisson disease. Having too little time to adjust to normal service or civilian life from the confines of captivity, their abnormal behaviour was characterised as a form of adjustment disorder. P.H. Newman, The prisoner-of-war mentality, Its effect after repatriation, BMJ, 1 (1944), 8-10.

21 Veteran Transition Problems of adjustment Lt Colonel A.T.M. Wilson, RAMC psychiatrist, also believed that the transition from captive to fully functioning citizen could not be rushed and argued that men who return to civil employment too soon tend to break down in three to four weeks. Meeting on 17 February 1945 to discuss certain medical aspects of the rehabilitation of repatriated prisoners of war, TNA, WO32/11125, 2.

22 Veteran Transition Crookham Experiment (1944) Wilson concluded: repatriation after more than two years as a POW is not accompanied by automatic recovery. Further, all the evidence we have suggests that with slight changes of emphasis, exactly similar difficulties are encountered by men who have served overseas for more than two years. Poor social re- adaptation was considered likely in at least 20% of cases.

23 Veteran Transition Civil Resettlement Units ( ) Twenty CRUs were opened in summer 1945 for returning POWs. They offered re- education, training and resocialisation programmes under light military discipline. Attendance was voluntary for Army personnel, and 53,000 veterans attended the six-week residential courses.

24 Veteran Transition Civil Resettlement Units ( ) Curle and Trist found that 26% of a sample of 50 who had attended CRUs exhibited unsettlement (apathy, restlessness, hostility and extreme dependency) compared with 64% of 100 veterans who had not attended. However, they acknowledged that theses results were probably influenced by selection bias. A. Curle and E. Trist, Transitional communities and social reconnection, part II, Human Relations, 1 (1947),

25 Veteran Transition Family briefing Families were briefed on what to expect from their returning fathers, sons and husbands. Pamphlets containing practical advice on how to behave were prepared. The Prisoner of War Comes Home, Directorate of Army Psychiatry Technical Memorandum, No. 13, May 1944.

26 Veteran Transition Advice to families 1. Try to imagine the feelings of a returned POW. He s bound to take time to get back to his old ways. 2. Limit his first meeting to members of his own family circle and not even that if he doesn t want to meet people. 3. You must realise that he is very anxious … Wait for him to tell you about it and in his own time. 4. Remember that he may be irritable and moody. He may want to be alone … Show understanding but avoid sympathy or pity. 5. Be as patient as you can. 6. He may be full of grouses. Don t join in his grouses; but also don t contradict. Just listen.

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28 Veteran Transition How successful was government policy? Because of the trade cycle and the colossal demand for goods and services, this was a period of full employment. Jobs were readily available in all grades of employment. During the 1930s, UK unemployment was never less than 9.3% and rose to 22.1%. Between 1945 and 1951 it was as low as 1.3% and never higher than 3.1%. Veterans were given preference under the 1944 Reinstatement of Civil Employment Act, which required employers to re-engage ex-workers who had served in the armed forces for at least six to 12 months, depending on the length of their pre-war employment record.

29 Veteran Transition Vocational training and grants for education Government training centres offered free training for about 30 industries with the assistance of employers and trade unions. Grants were offered for professional qualifications and university places. Resettlement grants of £ 150 were offered to those who wished to set up their own business, together with a three-month course in business methods.

30 Veteran Transition War Pensioners Because of full employment, even those awarded a war pension for psychiatric disorder readily found work. From a random sample of 367 servicemen awarded a pension for a psychosomatic or psychological disorder, 295 (80%) were in full-time employment in the post-1945 period.

31 UK Veterans of World War Two awarded a War Pension War Pension Diagnosis In employmentNot workingNot known Effort syndrome 56 (83.6%)3 (4.5%)8 (11.9%) Psychoneurosis154 (77%)11 (5.5%)35 (17.7%) Non-ulcer dyspepsia 85 (85%)2 (2%)13 (13%) Total295 (80%)16 (4%)56 (15%)

32 Veteran Transition Commonwealth Nations: post-war policy Policy makers believed that those capable of working should be actively employed. Education and vocational training was offered by all Commonwealth nations. UK servicemen were entitled to only six months of vocational training through the Ministry of Labour but Canadians could spend as many months in training as they had spent in the armed forces and were eligible for some government funding to attend a university.

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34 Veteran Transition Commonwealth Nations: post-war policy Australia and New Zealand had the most generous policies. New Zealand veterans were offered three-years vocational training and under the Commonwealth Rehabilitation Scheme Australian veterans were offered university education or technical apprenticeship training with scholarships and allowances for a maximum of two years.

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37 Veteran Transition The GI Bill of Rights The greatest accomplishment of the American Legion was the passage of the GI Bill of Rights in Returning US veterans were entitled to claim tuition fees for college education, home loans and other benefits. Some economists have argued that it created a vast and prosperous middle class that returned in taxes far more than the original investment in education and home ownership.

38 Veteran Transition The Best Years of Our Lives (1946) Directed by William Wyler, this film explored the problems faced by three veterans: mental trauma, excessive use of alcohol and the effects of physical disability (loss of both hands), in an infantry sergeant, sailor and airforce captain.

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40 Veteran Transition The Best Years of Our Lives won seven Oscars in 1946, including Best Picture, Best Director (William Wyler), Best Actor (Frederic March) and Best Supporting Actor (Harold Russell). It was the highest grossing film in both the United States and UK since the release of Gone with the Wind. It remains the sixth most attended film of all time in the UK, with over 20 million tickets sold. The film had one of the highest viewing figures of all time, with ticket sales exceeding $20.4 million.

41 Veteran Transition Importance of community The role of East Grinstead in helping burned aircrew rehabilitate reveals the power of the informal therapeutic community and the importance of self- help groups.

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43 Veteran Transition Queen Victoria Hospital, East Grinstead Archie McIndoe ran the RAF burns unit at East Grinstead. A relative of Harold Gillies who had pioneered plastic surgery at Sidcup during the First World War, he radically changed physical and psychological treatment. Local people were enlisted to assist with informal rehabilitation in cafes, cinemas, dance halls and pubs. Patients supported themselves through the Guinea Pig Club.

44 Veteran Transition Civilians and veterans Because of the Blitz, air-raids on major towns, many UK civilians had first-hand experience of war. This gave them an understanding of veterans problems. Soldiers returned to a nation schooled in the psychological impact of war.

45 Veteran Transition Civilians and veterans Today a distance has been created between the military and the civilian population that inhibits understanding by civilians and integration by veterans. Elevated to special status by the media, service personnel have almost become a group apart from the society from which they were originally recruited.

46 Veteran Transition Veterans and popular culture Today the general public believe that service personnel routinely suffer long-term, serious psychological harm as a result of service in Afghanistan: Disturbingly, more than nine out of ten of the public thought it was common for personnel leaving the Forces to have some kind of physical, emotional or mental health problem, though personnel themselves did not share this view. Some personnel were concerned that sympathy should not come to play to great a part in the public attitude to the Forces – the last thing they wanted was for people to feel sorry for them (Lord Ashcroft poll, May 2012).

47 Veteran Transition Veterans and culture post-1945 Many soldiers left the armed forces in with a new sense of self confidence. Not only had they acquired skills and knowledge of the world, some had advanced themselves up the social ladder. Military service did much to end a tradition of class deference by giving veterans independence of mind.

48 Veteran Transition Brian Thompson, observed that his father, Bert, a telephone linesman before the war, was transformed by his military service into a forcefully upwardly mobile figure. Wearing a RAF Association scarf, he gave the civilian world his burly truculence, signed off papers with a beautifully assertive signature, blanked the weak and venal.

49 Veteran Transition Veterans experience: a transformative event Reflecting on his experience as a sergeant in the 51 st Royal Tank Regiment, Donald Featherstone thought that his combatant service in Italy during was the greatest moulding of my life. After forty years, he believed that all the good and bad qualities I possess emanate from the six and a half years I spent in the Army. I shudder to think what I would have been like without it – yet shudder at the realization of what it has made me! In retrospect – and again I say that with slight doubts – I think if I had my life over again I would do it all again as it happened.

50 Veteran Transition Prospective study of US World War Two veterans A sample of 107 Harvard University students were followed- up over 50 years. Although the intensity of combat exposure was shown to predict the symptoms of PTSD in 1946 and 1988, the surprising finding was that men with high-combat exposure were more likely to be in Whos Who in America and have good psycho-social outcomes. They had successful careers and mature relationships. Distress from PTSD symptoms may be mediated by a productive work environment. Lee, K.A., Vaillant, G.E., Torrey, W.C. and Elder, G.H. (1995), A 50-year prospective study of the psychological sequelae of World War Two combat, American Journal of Psychiatry, 152(4):

51 Veteran Transition Work, veterans and mental illness: modern studies A number of studies have demonstrated that veterans who are unable to work are at greater risk of mental illness.

52 Veteran Transition Piper Alpha survivors In July 1988, the North Sea oil platform exploded, killing 167 men. The 61 survivors were more likely to report symptoms of PTSD if they had struggled to find work due to a disability following the incident. Hull, A.M. et al. (2002), Survivors of the Piper Alpha oil platform disaster: long- term follow-up study, Br J Psychiatry, 181:

53 Veteran Transition Service personnel with chronic physical disabilities from wartime injuries that formally restrict their employment and ability to deploy have higher rates of PTSD. Those who have been downgraded in this way are up to three times more likely to report psychological distress and symptoms of mental illness, regardless of whether the downgrading was for psychiatric reasons. Friedman, M.J et al (1994), Post-traumatic stress disorder in the military veteran, Psychiatr Clin North Am, 17(2): Rona, RJ et al (2006), Medical downgrading, self perception of health and psychological symptoms in the British armed forces, Occup Environ Med, 63:

54 Veteran Transition Combat Stress I n 1927 the Ex-Services Welfare Society bought the Thermega electric blanket factory in Leatherhead to provide employment and retraining veterans of World War One who suffered from shell shock and other psychological disorders. Housing for families was also provided.

55 Veteran Transition Veterans Aid Founded in 1933 as the Embankment Fellowship Centre (EFC) to provide temporary accommodation and food for destitute ex-servicemen. In 1969 renamed Ex-Service Fellowship Centres, it continued to provide welfare support for unemployed veterans.

56 Veteran Transition Personal empowerment plan (PEP) Veterans Aid supports people until they are independent by providing access to all kinds of education, vocational training and personal empowerment courses. Their policy is to buttress confidence, employability and independence.

57 Veterans: summary Greater emphasis on the skills and resilience of veterans to counteract popular perceptions of the military as inherently vulnerable. Programmes to enhance employability and to assist with work opportunities. Initiatives to reduce the gap in popular perception between civilians and the military not only to inform about veteran issues but also establish common ground and facilitate integration after discharge.


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