Mental health at sea - military and civilian experience Professor Neil Greenberg 2012

Who am I? Professor of Mental Health based at Kings 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 talk What is traumatic stress What is traumatic stress How does it affect people How does it affect people Why should maritime organisations be interested Why should maritime organisations be interested What can be done What can be done

So…what is a traumatic event ?

A Potentially Traumatic Event (PTE) Is an event which leads to: Is an event which leads to: – intense helplessness – intense horror – intense fear In response to experiencing or witnessing a traumatic event In response to experiencing or witnessing a traumatic event However most do not cause illness However most do not cause illness

What is the natural history of PTSD? % distressed

So…. Not all trauma leads to psychological illness Most who get distressed recover But….most people who develop mental health problems dont get help

Stigma an attribute that is deeply discrediting (Goffman, 1963)an attribute that is deeply discrediting (Goffman, 1963) the bearer of a mark that defines him or her as deviant, flawed, limited, spoiled or generally undesirable (Jones,1984)the bearer of a mark that defines him or her as deviant, flawed, limited, spoiled or generally undesirable (Jones,1984)

WW1 - Stigma It is wholly out of place to show them compassion. People with shell shock are weaklings who should never been allowed to join the Army or tricksters who deserved to be punished Captain Dunn, Medical officer, RWF

WW 2 - A Stiff Upper Lip LMF and the RAF LMF and the RAF General Patton General Patton Not until the end of WW2 was it realised that everyone has their breaking point Not until the end of WW2 was it realised that everyone has their breaking point

Stigma and Barriers to Care Gould et al, 2010, JRSM

Internal Stigma – Naval Service Langston et al, 2010, JMH

Most people with PTSD do not get treatment Woodhead et al, 2010, Soc Sci Med

So…. Distressed people do not usually ask for help Distressed people do not usually ask for help Most worry about what their peers and immediate line managers will think of them Most worry about what their peers and immediate line managers will think of them Stigma is particularly a problem for those who have mental health problems Stigma is particularly a problem for those 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 dont 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 harms way

Economically – mental health affects business In 2008 ~ 13.5 million days were lost to work- related stress in the UKIn 2008 ~ 13.5 million days were lost to work- related stress in the UK Presenteeism accounts for 1.5 X as much working time lost as sickness absencePresenteeism accounts for 1.5 X as much working time lost as sickness absence Esp important with safety critical roles Esp important with safety critical roles Concentration Concentration Motivation Motivation Customer focus Customer 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 theres just two papers)

Feinstein et al JTS 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 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) Total PPV 18% (5-31%); NPV 97% (96-98%)

Why do people develop PTSD

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 PTSD (NICE slide edited) What isnt 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! Neil: