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Research Department

Supporting the commitment to advance veteran mental health

We aim to conduct high quality robust research to ensure we are delivering the best possible services for our veterans, in line with our values. The research department is led by Professor Dominic Murphy and we are committed to publishing our research as part of our commitment to contribute to the advancement of the veteran mental health field. We work closely with Kings Centre for Military Health Research at Kings College, London to ensure our research is of the highest standards.

To celebrate the work we have achieved since the department was formed, and to reflect on future areas of research we recently published a research summary, to download the report click here.

Click here to find about our Research Partners.

Our latest research

Experiences and impact of moral injury in U.K. veterinary professional wellbeing

Piloting the feasibility of delivering cognitive behavioral conjoint therapy online to military veterans and partners

Anticipating PTSD in severe COVID survivors: the case for screen-and-treat

2022 Research

An interaction between functional and traumatic predisposing, precipitating, and perpetuating factors is suggested to explain the comparatively high prevalence of insomnia in the Veteran population. Cognitive-behavioural therapy for insomnia (CBT-I) has been recommended as a first-line treatment for insomnia in the Veteran community; however, little is known about the effectiveness of CBT-I for Veterans.

Rigley, J., Neilson, C. Murphy, D. Watson, F. How effectively does CBT-I address the traumatic and functional causes of insomnia and sleep disturbance in Veterans? Journal of Military, Veteran and Family Health, 2022. doi:10.3138/jmvfh-2021-0072a

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The idea that people can be lastingly psychologically and socially affected by their own or others’ transgressive behavior is as old as humanity. It is only recently that these age-old concepts have been considered as clinically relevant social, biological, and psychological problems.

Litz, B., et al., Defining and Assessing the Syndrome of Moral Injury: Initial Findings of the Moral Injury Outcome Scale Consortium. Frontiers in Psychiatry, 2022. 13(923928): p.1-16. https://doi.org/10.3389/fpsyt.2022.923928.

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To address this gap, we investigated the efficacy of a 28-day brief alcohol intervention delivered via a mobile app in reducing weekly self-reported alcohol consumption among UK veterans seeking help for mental health difficulties.

Leightley, D., et al., Evaluating the Efficacy of the Drinks:Ration Mobile App to Reduce Alcohol Consumption in a Help-Seeking Military Veteran Population: Randomized Controlled Trial. JMIR mHealth and uHealth, 2022. 10(6): p. e38991. 1-16.

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Smartphone-based interventions are increasingly being used to facilitate positive behavior change, including reducing alcohol consumption. However, less is known about the effects of notifications to support this change, including intervention engagement and adherence. The aim of this review was to assess the role of notifications in smartphone-based interventions designed to support, manage, or reduce alcohol consumption

Williamson, C., et al., Smartphone-based alcohol interventions: A systematic review on the role of notifications in changing behaviors toward alcohol. Substance Abuse, 2022. 43(1): p. 1231-1244.DOI: 10.1089/tmj.2021.0587.

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The use of digital technology within health care service delivery, monitoring, and research is becoming progressively popular, particularly given the ongoing COVID-19 pandemic. Mobile health (m-health) apps, one form of digital technology, are increasingly being used to promote positive health related behavior change. Therefore, it is important to conduct research to understand the efficacy of m-health apps. The process of participant recruitment is an essential component in producing strong research evidence, along with ensuring an adequately powered sample to conduct meaningful analyses and draw robust conclusions.

Williamson, C., et al., Recruiting Military Veterans into Alcohol Misuse Research: The Role of Social Media and Facebook Advertising. Telemedicine and e-Health, 2022. DOI: 10.1089/tmj.2021.0587. https://doi.org/10.1080/20008198.2022.2051351.

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Veterinary professionals (VPs) are often exposed to distressing and ethically challenging events in their line of work, yet little is known about whether they may experience moral injury and the impact potentially morally injurious events PMIEs) may have on their wellbeing. This cross-sectional study aimed to examine the association between PMIEs and the mental health outcomes of U.K. VPs

Williamson, V., D. Murphy, and N. Greenberg, Experiences and impact of moral injury in U.K. veterinary professional wellbeing. European Journal of Psychotraumatology, 2022. 13:1, 2051351, https://doi.org/10.1080/20008198.2022.2051351.

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This study provides preliminary evidence of the feasibility of delivering Cognitive-Behavior Conjoint Therapy online to military veterans and partners. Results of this study encourage further rigorous examination of the efficacy of Cognitive-Behavior Conjoint Therapy when delivered online, to support its use in treating veterans with PTSD and partners who face barriers to accessing in-person support.

Hendrikx, L., D. Phee, and D. Murphy, Piloting the feasibility of delivering cognitive behavioral conjoint therapy online to military veterans and partners. Military Psychology, 2022. https://doi.org/10.1080/08995605.2022.2054653.

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At the start of the COVID-19 pandemic, individuals with pre-existing mental health difficulties were thought to be vulnerable to mental health deterioration due to the emerging threat and the actions taken to control infection rates. Yet, there remained a paucity of research investigating changes in veteran well-being, a population facing higher rates of mental health difficulties compared with the general public. This longitudinal study aimed to investigate the mental health and well-being of UK veterans with pre-existing mental health difficulties at two time points during the COVID-19 pandemic.

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Based on research from previous pandemics, studies of critical care survivors, and emerging COVID19 data, we estimate that up to 30% of survivors of severe COVID will develop PTSD. PTSD is frequently undetected across primary and secondary care settings and the psychological needs of survivors may be overshadowed by a focus on physical recovery. Delayed PTSD diagnosis is associated with poor outcomes. There is a clear case for survivors of severe COVID to be systematically screened for PTSD, and those that develop PTSD should receive timely access to evidence based treatment for PTSD and other mental health problems by multidisciplinary team.

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2021 Research

Despite making up about 11% of the UK military, there remains limited investigation on the impact of adversity women experience during their service in the UK military. Military adversity can result in a range of well-being difficulties that may persist following transition out of military. The present study therefore examined the prevalence and correlates of different types of military adversity (defined as sexual harassment, sexual assault, emotional bullying and physical assault) within a community sample of UK women veterans.

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The rights, roles and responsibilities of servicewomen in the UK Armed Forces has changed dramatically over time. Previously, service personnel were automatically discharged from the military if they became pregnant. As the percentage of servicewomen in the UK Armed Forces increases, having children during service is becoming more common and maternity policies are now in place. Having children during military service can impact on the health and well-being of servicewomen, including a greater risk of illness when returning to work.

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Individuals with preexisting psychological difficulties are at risk of further deterioration of their mental well-being during the COVID-19 pandemic. This longitudinal study, conducted during the period between two national lockdowns, aimed to investigate the impact of the COVID-19 pandemic on veterans in the United Kingdom with preexisting mental health difficulties.

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This study aims to investigate whether the Together Webinar Programme (TTP-Webinar), a 6-week structured, remote access group intervention would reduce military partners’ experience of common mental health difficulties and secondary trauma symptoms.

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Experiences of potentially morally injurious events (PMIEs) have been found to negatively impact the mental health of US personnel/veterans, yet little is known about the efect of PMIEs on the mental health of the UK Armed Forces (AF). This cross-sectional study aimed to examine the association between PMIEs and the mental health outcomes of UK AF veterans.

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This study explored the experiences of clinicians in providing treatment in cases of military-related moral injury (MI). Qualitative interviews were carried out with 15 clinicians. Clinicians found patients experienced particular maladaptive appraisals following MI, which were considered different from the responses experienced after threat-based trauma. To address MI-related distress, clinicians utilized a range of treatment approaches. Several difficulties in providing care to patients following MI were described, including the impact of providing treatment on the clinicians own mental health.

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Moral injury is understood to be the strong cognitive and emotional response that can occur following events that violate a person’s moral or ethical code.1 Potentially morally injurious events include a person’s own or other people’s acts of omission or commission, or betrayal by a trusted person in a high-stakes situation. For example, health-care staff working during the COVID-19 pandemic might experience moral injury because they perceive that they received inadequate protective equipment, or when their workload is such that they deliver care of a standard that falls well below what they would usually consider to be good enough.

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Posttraumatic stress disorder (PTSD) and alcohol use are highly prevalent among military veteran populations. Several theories have been proposed to account for the comorbidity between PTSD and problematic alcohol use, but research examining the symptom-level associations between the two is limited. The current study used network analysis to examine the associations between PTSD and problematic alcohol use. Data were collected through a cross-sectional survey of veterans of the United Kingdom Armed Forces living in Northern Ireland.

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Evidence is growing regarding the impact of potentially morally injurious events (PMIEs) on mental health; yet how moral injury may affect an individual's occupational and familial functioning remains poorly understood.

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Emerging evidence suggests that ICD-11 CPTSD is a more common condition than PTSD in treatment seeking samples although no study has explored risk factors and comorbidities of PTSD and CPTSD in veteran populations. In this study, risk factors and comorbidity between veterans meeting criteria for PTSD or CPTSD using the ICD-11 International Trauma Questionnaire (ITQ) were explored.

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2020 Research

Research has shown that the likelihood of ex-military personnel developing mental health problems following service is around one in five. Little is known about the barriers to accessing mental health in veterans from diverse ethnic backgrounds. This study aims to explore mental health treatment experiences of veterans from commonwealth countries and therefore diverse ethnic backgrounds.

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Moral injury is known to be associated with mental health difficulties in US military populations, however its impact on wellbeing in a UK Armed Forces (AF) context is less well understood. Additionally, it is not clear whether other factors known to affect service personnel’s mental health, such as adverse childhood experiences (ACEs) or military trauma, may influence whether personnel experience moral injury.

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Data are emerging showing the adverse consequences on mental health of the general public due to the COVID-19 pandemic. Little is known about the needs of veterans with pre-existing mental health difficulties during the COVID-19 pandemic.

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The need for research to advance scientific understanding must be balanced with ensuring the rights and wellbeing of participants are safeguarded, with some research topics posing more ethical quandaries for researchers than others. Moral injury is one such topic. Exposure to potentially morally injurious experiences can lead to significant distress, including posttraumatic stress disorder (PTSD), depression, and selfinjury. In this article, we discuss how the rapid expansion of research in the field of moral injury could threaten the wellbeing, dignity and integrity of participants. We also examine key guidance for carrying out ethically responsible research with participants’ rights to self-determination, confidentiality, nonmaleficence and beneficence discussed in relation to the study of moral injury. We describe how investigations of moral injury are likely to pose several challenges for researchers including managing disclosures of potentially illegal acts, the risk of harm that repeated questioning about guilt and shame may pose to participant wellbeing in longitudinal studies, as well as the possible negative impact of exposure to vicarious trauma on researchers themselves. Finally, we offer several practical recommendations that researchers, research ethics committees and other regulatory bodies can take to protect participant rights, maximise the potential benefits of research outputs and ensure the field continues to expand in an ethically responsible way.

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Alcohol misuse is higher in the UK Armed Forces than in the general population. Previous research has shown that interventions delivered via smartphones are efficacious in promoting self-monitoring of alcohol use, have utility in reducing alcohol consumption, and have a broad reach. Objective: This single-blinded randomized controlled trial (RCT) aims to assess the efficacy of a 28-day brief alcohol intervention delivered via a smartphone app (Drinks:Ration) in reducing weekly self-reported alcohol consumption between baseline and 3-month follow-up among veterans who drink at a hazardous or harmful level and receive or have received support for mental health symptoms in a clinical setting.

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Objective: To investigate the association between reported traumatic brain injury plus loss of consciousness (TBI + LOC) and a range of demographic, military, and physical and mental health factors among a sample of UK veterans seeking support for mental health difficulties. Design: The present study was a cross-sectional study. Participants: Clinical records were used to identify a sample of treatment-seeking UK veterans (N = 3335), of which a total of 403 took part. Main Measures: Information on demographic characteristics, military experiences, and a range of physical and mental health difficulties was collected. Results: Almost half of the sample (48%) reported a TBI + LOC, which was most strongly associated with drug use and childhood adversity. More modest associations also emerged with earlier service termination, likelihood of unemployment, as well as chronic pain and poor mobility. Conclusion: The findings suggested that TBI + LOC may not specifically be associated with symptoms of posttraumatic stress in a sample of treatment-seeking veterans. The demonstrated links between TBI + LOC and adverse childhood, drug use, physical health, and employment may be useful in improving the assessment and rehabilitation of veterans with TBI + LOC.

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Electronic health care records (EHRs) are a rich source of health-related information, with potential for secondary research use. In the United Kingdom, there is no national marker for identifying those who have previously served in the Armed Forces, making analysis of the health and well-being of veterans using EHRs difficult. Objective: This study aimed to develop a tool to identify veterans from free-text clinical documents recorded in a psychiatric EHR database. Methods: Veterans were manually identified using the South London and Maudsley (SLaM) Biomedical Research Centre Clinical Record Interactive Search—a database holding secondary mental health care electronic records for the SLaM National Health Service Foundation Trust. An iterative approach was taken; first, a structured query language (SQL) method was developed, which was then refined using natural language processing and machine learning to create the Military Service Identification Tool (MSIT) to identify if a patient was a civilian or veteran. Performance, defined as correct classification of veterans compared with incorrect classification, was measured using positive predictive value, negative predictive value, sensitivity, F1 score, and accuracy (otherwise termed Youden Index). Results: A gold standard dataset of 6672 free-text clinical documents was manually annotated by human coders. Of these documents, 66.00% (4470/6672) were then used to train the SQL and MSIT approaches and 34.00% (2202/6672) were used for testing the approaches. To develop the MSIT, an iterative 2-stage approach was undertaken. In the first stage, an SQL method was developed to identify veterans using a keyword rule–based approach. This approach obtained an accuracy of 0.93 in correctly predicting civilians and veterans, a positive predictive value of 0.81, a sensitivity of 0.75, and a negative predictive value of 0.95. This method informed the second stage, which was the development of the MSIT using machine learning, which, when tested, obtained an accuracy of 0.97, a positive predictive value of 0.90, a sensitivity of 0.91, and a negative predictive value of 0.98. Conclusions: The MSIT has the potential to be used in identifying veterans in the United Kingdom from free-text clinical documents, providing new and unique insights into the health and well-being of this population and their use of mental health care services.

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Research has found that treatment programmes for veterans with Post-Traumatic Stress Disorder (PTSD) have high rates of drop-out and are often not as effective as in other populations. Previous findings suggested that group cohesion during treatment significantly predicted outcomes for the military personnel receiving treatment. This research intends to assess what facilitates a veteran with PTSD to successfully complete a residential treatment programme. This study aims to qualitatively investigate the impact, and experiences of being part of a cohort within an intensive treatment of UK veterans diagnosed with PTSD. The study recruited eight participants who successfully completed this form of treatment from a veteran’s mental health charity. Semi-structured telephone interviews were conducted. Thematic analysis (TA) was used to analyse the qualitative data. Four key themes emerged: (a) Cohort relationships; knowing each other well, motivate and support each other, communication, sharing information and advice, and the effects of a non-cohesive cohort. (b) Cohort dynamics; negative moods and attitudes, the combination of people in a cohort, motivation for change, and division between cohorts, (c) Shared experience; “in the same boat”, the unique bond shared between veterans, and having similar military experiences, and (d) Containment; living in a bub¬ble, support after 1:1 therapy, learning skills, the whole package of treatment and treatment intensity. The impact of being part of a veteran cohort whilst undergoing treatment and the ability to relate to each other through shared experiences was deemed as a positive supportive aspect of this treatment, with veterans who significantly benefitted from treatment. Dynamics that can affect this were expressed, such as the impact of negative attitudes. The containing influence of inpatient treatment was discussed as beneficial to opening up within therapy.

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Morally injurious incidents may present ethical or legal quandaries, yet how military or civilian clinicians should manage such disclosures is poorly understood. Individuals who experience moral injury may be reluctant to seek help due to concerns about the legal ramifications of disclosure. Guidance on breaching patient confidentiality differs by regulatory body but also by profession, geography and context. As moral injury continues to become recognised in clinical practice, in the military and elsewhere, clarity is needed regarding best practice in managing moral injury cases and the dilemmas they present.

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This study aimed to examine how UK military veterans with complex post-traumatic stress disorder (CPTSD) engage with psychological services. Qualitative interviews were conducted with eight veterans with CPTSD. Data were analyzed using thematic analysis. UK veterans with CPTSD were found to experience a number of barriers in accessing and engaging with mental health services. That certain CPTSD symptoms (e.g., negative self-concept) may act as a deterrent to helpseeking warrants further exploration in future help-seeking initiatives to ensure that those with CPTSD are able to access appropriate care.

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Military partners are at risk of difficulties with general psychological distress and symptoms of secondary traumatisation. Yet, many partners are unable to access appropriate support due to a range of barriers to treatment. A randomised controlled trial (RCT) was conducted to assess the effectiveness of The Together Webinar Programme (TTP-Webinar) in supporting the mental health needs of partners of veterans with PTSD and other mental health difficulties.

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Veterans diagnosed with Post Traumatic Stress Disorder (PTSD) typically report poorer treatment responses, compared to those who have not served in the Armed Forces. Veterans often present with a complex symptom of PTSD. The difference between PTSD and Complex PTSD have not previously been explored in a military sample. The study aimed to validate the current only measure of ICD-11 PTSD and CPTSD, the International Trauma Questionnaire, in a sample of treatment seeking UK veterans The study recruited in total 177 Treatment seeking veterans from Combat Stress. All participants completed measures of ICD-11 PTSD and CPTSD as well as childhood and adult traumatic life events. The study found that a majority of participants (70%) reported symptoms consistent with a diagnosis of either PTSD or CPTSD. Indicating a presence of two separate disorders, where CPTSD being more frequently (56.7%) than PTSD (14.0%). CPTSD was more strongly associated with childhood trauma than PTSD Concluding that the International Trauma Questionnaire can adequately distinguish between PTSD and CPTSD within a clinical sample of UK veterans.

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The study aimed to examine the relationships between adverse childhood experiences in a sample of UK Treatment- seeking veterans The data was collected with a self- reported survey for veterans who had sought help from Combat Stress, in total 386 male veterans completed the survey. The results showed five classes of veterans with different Adverse childhood disorders (ACE), where 97% reported to have at least one ACE There were little differences between the classes on mental and physical health outcomes The total number of ACE`s was related to aggression, common mental health problems and Post Traumatic Stress Disorder In conclusion, no combination of ACE`s could specifically predict any adverse mental and/ or physical health difficulties for our sample. The higher the number of Adverse Childhood Experiences, the more prone to developing problems with aggression, common mental health problems and PTSD. Suggesting that ACE`s should be addressed in treatment with military veterans.

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Being exposed to potentially morally injurious events may be associated with adverse mental health outcomes. However, the consequences following a potentially morally injurious event compared to a traumatic but not a moral injurious event is currently poorly understood. The aim of this study was to explore veterans’ experiences of trauma and moral injury and its impact on their psychologically wellbeing. Thirty male veterans who reported traumatic and/ or morally injurious events were recruited to a semi- structured interview. Veterans cognitions and responses were found to differ following a morally injurious event compared to a traumatic, but not morally injurious event, which could have negative implications following daily functioning. The findings illustrate the need to examine effective pathways for prevention and intervention for veterans who have experienced morally injurious events.

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Military partners appear at risk for developing psychological difficulties such as depression, generalized anxiety, and secondary trauma symptoms. Yet, evidence suggests that participants report an array of barriers that prevent them from seeking and engaging with mental health support. This includes stigma-related beliefs, work and childcare responsibilities, and distance to venue where support is offered. Introduction: The Together Webinar Programme (TTP-Webinar) was developed to increase the accessibility of mental health support for military partners. The efficacy of this program has been explored in a previous study. Materials and Methods: Data for this study were taken from 68 partners who provided qualitative feedback of the program. Thematic qualitative analysis was used to explore the views of participants about the acceptability of TTPWebinar. Results: Four main themes were identified, namely perceived benefit, modality, general barriers, and areas for improvement.

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This editorial provides an overview of the potential risk factors for moral injury, practical recommendations for clinical staff with exposure to potentially morally injurious events, and recommendations for clinicians providing psychological support during and after Covid-19 pandemic,

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2019 Research

Avoidance can be a significant barrier to engaging in trauma-focused treatment for PTSD, as well as being a mechanism that creates restrictions that impact functioning and wellbeing. The current study investigated the effect of an art therapy-focused, short-stay, inpatient admission on levels of avoidance in veterans. Participants were able to use the art therapy process to express and tolerate painful thoughts and emotions, and to consider the effects of rigid perceptions. The group dynamic between the veterans created a strong container for this process. The findings suggest that art therapy can be constructively employed in assisting veterans to overcome avoidance PTSD symptoms and as a means of opening up new ways of perceiving, interpreting, and responding to situations. It is proposed that the non-verbal operations of art therapy enable this process through the use of imagination and creativity.

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Research has demonstrated that partners living alongside veterans with mental health difficulties are at high risk of developing mental health difficulties. Research to date has relied on quantitative methodologies to evaluate the efficacy of such interventions with less emphasis on learning about the experiences of individuals on the courses. The aim of this qualitative paper was to understand the experiences of partners who engaged in a five-week structured support intervention, ‘The Together Programme’ (TTP). Eight female partners were recruited from an original sample of 57 partners who were intimate relationships with treatment seeking veterans with mental health difficulties. Semi structured interviews were completed and explored using Interpretative Phenomenological Analysis. Three key themes emerged from the data, these were self-growth, changing role in relationships and connecting with others. This study suggests these key areas had an impact on participants experiences. These were factors that helped participants to normalise their experiences and increase participants understanding and interpersonal skills that promote changes in relationship functioning with the veteran.

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The aim of this study was to explore the feasibility of offering a community support programme (The Together Programme, TTP) for military partners. TTP consisted of 10 hours of group-based support delivered over a five-week course. 57 participants engaged in TTP over a year at nine locations across the UK and 44 were followed up three months later. Significant reductions were observed for symptoms of sPTSD and CMD at follow up. 51/57 (89.1%) participants completed TTP. Significant improvements in relationship satisfaction was also observed. The majority of participants reported positive experiences. However, several individuals stated wanting more sessions and that barriers such as work, and family commitments made it difficult to attend. Whilst limitations exist, the data presented suggests cautious optimism for the efficacy of offering a structured programme of support to address the needs of military partners living alongside PTSD.

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The paper aimed to describe the current state of survivors of trauma in 15 European countries, highlighting each country`s care system for trauma survivors, interventions and challenges The report demonstrate how steps towards better care for trauma survivors has been made in Europe, and the need for further training to overcome the differences between countries

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Military service can expose some individuals to multiple traumas, and ex- military personnel are at high risk of developing mental health disorders and PTSD Veterans have been found to underuse mental health services Aim: to explore the experiences of veterans seeking treatment and how they define their experiences of recovery

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There remain a number of UK military veterans who are not able to access psychological therapies for post-traumatic stress disorder (PTSD). Some of these barriers are practical, including the need to balance work and other life commitments with attendance at residential or outpatient appointments. The aims of the present study were to explore the feasibility of using tele-therapy in this population, whilst also reporting mental health outcomes for those who accessed the intervention. The intervention consisted of 12 sessions of cognitive processing therapy delivered via Skype. Participants completed various measures of mental health, including PTSD at three time points: pre-treatment, post-treatment and at three months follow-up. A measure of therapeutic alliance was also completed by participants and the clinician. A total of 27 participants engaged in tele-therapy, with a treatment completion rate of 79% and a 'did not attend' rate of 12%, which compared well against similar outpatient services. All mental health outcomes showed maintained improvement at three months follow-up, with the highest effect size recorded for PTSD. Therapeutic alliance was also rated highly by both participants and the clinician. The findings suggest that tele-therapy could provide a viable alternative format for delivering trauma-focused psychological therapies to veterans. Limitations and recommendations for future research are also presented.

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Previous research has shown that UK Armed Forces personnel can be reluctant to seek help for mental health difficulties. This study used a sample of 1,450 UK personnel to assess help-seeking in those reporting a mental health, stress or emotional problem in the past three years. Overall, 7.2% of participants had not sought any help for their problem. Being female, having higher levels of social support and more functional difficulty was related to help-seeking. However, help-seeking was infrequent for participants who were misusing alcohol, with around 53% accessing formal medical support. In contrast to previous studies of help-seeking in serving and ex-serving personnel, and the public perception, this study found that the majority of those with perceived mental health problems sought some form of help.

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This study aimed to explore the acceptability of using tele-therapy for treating PTSD in a sample of UK veterans. A sample of veterans engaged in trauma-focused psychological therapies using online video software (Skype). 16 participants were interviewed about their experiences of using tele-therapy. Five key themes emerged from the interviews: Effect of your own environment, Importance of good therapeutic alliance, Technicalities and practicalities, Personal accountability and Measuring change. Participants reported that tele-therapy gave them more flexibility and made it easier to access treatment. Some found it challenging to 'snap back' to the real world immediately after session. Some stated they would have preferred face to face appointments whereas others preferred using the online video. Overall, tele-therapy seems to be an acceptable alternative format for delivering psychological treatments.

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The study aimed to explore the childhood adversities in treatment- seeking veterans compared with the general military population. And to explore associations between childhood adversity, mental health and demographic variables. Data for the present study were taken from a separate study investigating help- seeking veterans recruited from Combat stress All participants completed surveys relating childhood adversity, mental health, and demographic variables and compared to data from the wider military population The study found that veterans who seek help for mental health difficulties are more likely to report childhood adversity then the wider Armed forces population. The high childhood adversity was linked to mental health difficulties including PTSD Suggesting that veterans may present with more complex clinical profiles that will need effective assessment and appropriate psychological and psychiatric treatment

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The article explores the diagnosis of PTSD, prevalence and risk factors, treatment and its role to health care professionals.

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Veterans in the military armed forces have often higher prevalence of difficulties with anger and aggression The aim was to review the current research evidence into the prevalence of anger and aggression in veterans Anger and aggression has been strongly linked to co- morbid difficulties, but proposes an opportunity to apply different interventions as reduction in anger Future research should aim for a more robust longitudinal and controlled trials.

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The study aimed to explore physical health complaints and health behaviours in veterans engaged with mental health service The study used previous questionnaire data from a cross- sectional study of 384 veterans Chronic pain and poor mobility were the most prevalent conditions reported Participants with PTSD were more than twice as likely to report chronic pain Of 384 veterans 76.5% were deemed overweight or obese, and 2-4 times more likely to report physical health complaints The association between PTSD, obesity, pain, impairment and potential difficulties in recovery and treatment are important findings for how health services treat patients with mental health problems in the future.

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The aim of this study was to compare and contrast the profiles of military veterans seeking formal support for post-traumatic stress disorder (PTSD) in national treatment programmes in Australia and the UK to better understand the needs of this vulnerable population.

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Research suggests that moral injury (MI) in US veterans is associated with poor psychological outcomes and disruption in functioning. However, little is known about how MI may impact UK Armed Forces (AF) veterans. This study aimed to explore the impact of MI on veteran psychological well-being and functioning. Six veterans identified as having had exposure to MI and four clinicians who treated veterans with MI were recruited from a UK charitable organisation which provides psychological care for veterans. MI was perceived to cause substantial psychological distress in this sample. Our data suggest that some veterans held extremely negative self-appraisals which appeared to contribute towards and maintain their distress.

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This editorial aims to document the profile of treatment-seeking veterans, to help better understand their complex presentations. Responses were received from 403 veterans that had engaged in treatment at Combat Stress. On average, veterans reported taking 11 years to seek support for mental health. However, this seems to be decreasing for more recent deployments (average 2 years for Afghanistan veterans). PTSD was the more frequent mental health difficulty, and higher rates of common mental health difficulties, childhood adversity and taking longer to seek support were observed to be associated with more symptomatic profiles. The wider military appeared more likely to report binge drinking, while treatment seekers more likely to endorse patterns of drinking that suggested alcohol-related harm or alcohol dependence. Over three-quarters of veterans had a body mass index (BMI) showing they were either overweight (39%) or obese (37%). The needs of treatment-seeking veterans appear to be complex, chronic and poorly understood. Further research is needed into ComplexPTSD and moral injury.

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This article aimed to overview the concept of moral injury, what support is available and what are the next steps. Moral injury is defined as the psychological distress which results from actions, or the lack of them, which violate your moral or ethical code. Research has found that moral injury can be linked to poor mental health outcomes. Barriers for accessing treatment for moral injury related mental health issues are discussed, such as worries around social and legal consequences. Currently research is still in its infancy, and there is no established treatment programme for treating patients with moral injury. Further research is needed to begin the discussion about these challenging ethical dilemmas, and what causes moral injury, and the mental illness associated with it. We can then ensure that effective help is available for those who need it.

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Veterans with PTSD symptoms rarely experience them in isolation, more commonly they are co-morbid with a range of other difficulties. This study used latent profile analysis (LPA) to explore the variations of PTSD symptom profiles. Then, further analysis examined whether variables such as childhood adversity or mental health difficulties predicted membership of those PTSD profiles. Six different PTSD profiles were found, including Low, Moderate and Severe. The Severe symptom profile was the largest one, accounting for 37.57% of the sample. Higher rates of common mental health difficulties were associated with more severe PTSD symptom profiles. The findings suggests the importance of moving away from a 'one-size fits all' approach to treatments, towards interventions tailored to meet the specific PTSD and co-morbid symptoms profiles.

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Vestibular functions include those involving the parts of the inner ear and brain that help control balance and eye movements. This study aimed to assess the long-term impact of vestibular dysfunction in veterans who had suffered a mild traumatic brain injury (mTBI). Based on self-report measures, vestibular dysfunction was found to have affected 69% of veterans in this sample (N = 162) and was equally prevalent in those experiencing blunt (59%) or blast (47%) injuries. Vestibular dysfunction was most prevalent in those who had experienced combined blunt and blast injuries (83%). It was found to be linked with post-concussive symptoms and functional disability.

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Moral injury has been defined as defined as 'perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations'. It has been found to adversely affect US veteran mental health. The aim of this study was to examine UK AF veterans' experiences of moral injury, and the perceptions and challenges faced by clinicians in treating moral injury-related mental health difficulties. Six veterans who reported moral injury exposure and four clinicians who had treated veterans with moral injury were recruited from Combat Stress. And completed semi-structured interviews. Moral injury was perceived by clinicians to be common in UK AF veterans and, where present, had a considerable negative impact on mental health. Moreover, moral injury was thought to be poorly understood among UK AF veteran clinical care teams.

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This paper aimed to investigate the relationship between body mass index (BMI), physical health problems, mental health disorders and sociodemographic characteristics in UK veterans engaged in psychological treatment. Information regarding veteran BMI, demographic characteristics, physical health conditions and mental health problems was collected and analysed. Of the 384 veterans surveyed, 37.5% were overweight (BMI 26-30) and 35.5% were obese. Obesity in this sample was 2-4 times higher than that of the general UK population. Higher scores on measures of anger, common mental health problems, systemic functioning and mobility were significantly associated with greater BMI. The findings highlight a need for mental health services to offer treatments that effectively integrate physical and mental healthcare.

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Little is known about ex-serving personell who access secodary mental health care. Previous research suggests that between 23% and 40% of former military members who meet the criteria for a psychiatric difficulty access mental health services when needed. This narrative review aimed to identify rates of mental health care utilisation, as well as the factors associated with it.

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Partners of military veterans with PTSD can themselves develop difficulties with stress, well- being and secondary trauma. The article aimed to review the current interventions for partners of veterans with PTSD A systematic literature reviewed 25 papers A wide range of interventions for improving well- being for partners exist today The literature would benefit of more robust experimental research into the effectiveness of interventions aimed at partners.

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omantic partners living alongside veterans with Post Traumatic Stress Disorder (PTSD) appear at increased risk of secondary traumatic stress (sPTSD) and common mental health difficulties (CMD) compared to the general population. The aim of this study was to explore the feasibility of offering a community support programme (The Together Programme, TTP) for military partners. Measures of CMD, sPTSD, alcohol use and relationship satisfaction were used to assess benefits. Data were also collected on attendance and participant feedback. Significant reductions were observed for symptoms of sPTSD and CMD at follow up. 51/56 (90.1%) participants completed TTP. The majority of participants reported positive experiences. However, several individuals stated wanting more sessions and that barriers such as work, and family commitments made it difficult to attend. Whilst limitations exist, the data presented suggests cautious optimism for the efficacy of offering a structured programme of support to address the needs of military partners living alongside PTSD.

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Partners of military veterans with PTSD can themselves develop difficulties with stress, well- being and secondary trauma. The article aimed to review the current interventions for partners of veterans with PTSD A systematic literature reviewed 25 papers A wide range of interventions for improving well- being for partners exist today The literature would benefit of more robust experimental research into the effectiveness of interventions aimed at partners.

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This paper aimed to explore patterns of alcohol misuse in treatment-seeking veterans compared to the UK Armed Forces personnel population and the general public. It also investigated what factors were associated with increased or decreased severity of alcohol misuse. Results suggested that treatment-seeking veterans report different patterns of alcohol misuse compared to the UK Armed Forces and the general public. This group was more likely to report alcohol dependence and alcohol-related harm. Mental health problems, functional impairment and being single were all related to greater alcohol misuse. Being older and not in work were related to reduced alcohol misuse. Knowing more about the common alcohol-related problems in this group can help inform and improve mental health interventions.

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2018 Research

Research Summary: Veterans with mental health problems are a high-risk group for substance misuse difficulties and are over-represented in forensic settings. Yet, there are few substance misuse services available for this population.This study looked at the feasibility of piloting a Veterans Forensic Substance Misuses Service (VFSMS) within a prison setting, using a case management model. Findings from three case studies suggested that case management was a feasible approach, with a range of interventions being used by veterans, including substance misuse and mental health services, plus housing and employment services.

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Little evidence has explored ex- service personnel who access secondary care services, such as specialist mental health care The study used two electric health record case registers to explore the utility and feasibility of identifying veterans accessing secondary mental health services in the UK The study showed that it is possible to identify veterans accessing secondary mental health care by using case registers.

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Substance misuse has been found to be higher in ex- military service compared to civilians The Veterans Substance Misuse Service (VSMS) was set up in 2014 to case manage veterans into appropriate services. Following treatment veterans improved in: managing their mental and physical health, living skills, social network, addictive behaviours, responsibilities, identity and self- esteem. In total, 99% reported being satisfied with received service Highlighting staff input, accessibility of service, tailored to individual needs and seeking health improvement

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While many veterans are able to access support for mental health difficulties, many still find it difficult. There are a number of barriers that can make it harder to access support. In this project, we piloted the use of remote-access video technology to deliver evidence-based psychological therapy (tele-therapy) to veterans with PTSD. Primary aims were to assess the feasibility and acceptability of tele-therapy, as well as its effectiveness in reducing mental health difficulties. 27 veterans took part, receiving Cognitive Processing Therapy via Skype. 21 completed all 12 sessions, taking an average of 14 weeks to complete. 12 veterans were interviewed post-therapy. Qualitative analysis showed that tele-therapy was well received, with participants discussing the pros and cons of tele-therapy compared to face-to-face. Results suggested that PTSD symptoms significantly reduced following tele-therapy and the effects were maintained at 3-month follow up. The report includes a number of recommendations for delivering tele-therapy based on feedback from veterans taking part and the lead clinician.

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The study explored the heterogeneity in treatment response of 960 veterans with PTSD who had been offered residential treatment Of participants, 71.3% showed positive responses, and 27.5% were identified within a treatment resistant class showing little change in severity of presentation Having depression, anxiety, and experience with a combat role during military service increased the likelihood of being treatment resistant Findings suggests the importance of triaging individuals and offering interventions tailored to their severity of presentations.

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This editorial introduced a special issue of the Healthcare journal looking at PTSD in veterans, edited by the Combat Stress research team. The editorial outlines the current challenges facing the significant minority of veterans who have difficulties in their transition to civilian life, such as mental health difficulties, accessing and utilising support, and the potential role of Complex PTSD (C-PTSD). Original papers in this issue included a qualitative study of Nature-Based Therapy, a paper which linked PTSD to risk-taking behaviours in veterans, and a study looking at anger, aggression and PTSD. Also included were papers investigating potential for juror bias when faced with veterans with PTSD involved in the judicial system, a study linking PTSD and functional impairment, and a meta-analysis of current PTSD interventions.

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This study investigated the prevalence rates of anger and aggression in UK help-seeking veterans, as well as their associations with different sociodemographic, functioning and mental health variables. Prevalence rates for significant anger and aggression were 74% and 28% respectively. Both women and those over 55 were less likely to report difficulties. Those with high levels of PTSD and other mental health difficulties were more likely to report anger and aggression. Other factors related to anger and aggression included unemployment due to ill health, and a perceived lack of family support. Veterans who are seeking support for mental health are likely to be experiencing significant difficulties with anger and aggression, especially if they have comorbid mental health difficulties. The associations between anger, aggression, and other variables, has implications for the assessment and treatment of military veterans.

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Research suggests that both mild Traumatic Brain Injury (mTBI) and PTSD have high prevalence rates in populations of ex-service personnel. However, there are challenges in accurately defining the long-term impact of mTBI and how this relates to and overlaps with mental health difficulties, particularly PTSD. Studies of US and UK veterans have demonstrated a high degree of overlap between mTBI and symptoms of PTSD and depression. Further research has found that mTBI alone did not predict well-being or functional impairment in military veterans, unless these were comorbid with PTSD.

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The aim of this paper was to explore the risk factors associated with suicidal ideation in a sample of treatment-seeking veterans. Using a cross-sectional design, participants (N=144) completed questionnaires regarding their military experiences, pre-enlistment factors and health. Data were then linked to risk assessments extracted from clinical records. After controlling for relevant variables, suicidal ideation was significantly higher in veterans who were unemployed, were early service leavers, or had a history of childhood adversity. In addition, taking longer than 5 years to seek help was associated with a reduced risk of suicidal ideation. This type of research is crucial to inform the effort to reduce suicide in military populations and has implications for service planning and knowing how to support this client group.

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A network analysis of PTSD symptoms was conducted, focusing on associations between different symptoms and how they interact with each other. This was the first network analysis to be done with UK veterans. The analysis was used to identify core symptoms of PTSD and how they connect to different elements of day to day functioning. The core PTSD symptoms identified were recurrent thoughts, nightmares, negative emotional state, detachment, and exaggerated startle response. Slightly different core symptoms have been found in samples of US veterans, although negative emotional state is most commonly found. Some connections were found between everyday functioning, e.g. impairments in close relationships, home management, and PTSD symptoms. Identifying core PTSD symptoms could have implications for treatment, as targeting the core symptoms could speed up recovery by breaking down the network of other, interacting symptoms.

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Past research suggests that military veterans can be more likely to engage in risk-taking behaviours, such as heavy smoking, alcohol misuse, dangerous driving and fighting. We measured levels of self-reported risk-taking in a sample of veterans who were seeking help for mental health difficulties. Findings showed that, of a sample of 403 veterans, 86.8% reported engaging in at least one risk-taking behaviour in the past month, with fighting the most commonly reported (77.9%). Veterans were more likely to report risk-taking if they were younger, in a relationship, had a brain injury, or if they had mental health difficulties such as depression, anxiety and PTSD (particularly hyperarousal and negative moods). Findings will help in determining possible risk factors for risk-taking in veterans. Future research could corroborate these findings and assist in the development of effective risk assessments and interventions.

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We reviewed the key issues relating to Mild Traumatic Brain Injury (mTBI) in military veterans. Prevalence rates of mTBI in UK veterans have ranged from 4.2%-9.5% for those in combat roles. Post-Concussional Syndrome (PCS) describes some of the long-term effects of mTBI, e.g. dizziness, insomnia. However, PCS is no longer recognised as a formal diagnosis in the DSM-V and might be a product of psycological distress. In a small minority of cases, mTBIs can develop into more serious, long-lasting difficulties. There is a need for clarity regarding the diagnosis of mTBI, especially when in the context of psychological distress.

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2017 Research

This study assessed the efficacy of a two-week residential treatment programme to support anger difficulties in veterans diagnosed with PTSD.

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The aim of this study was to determine optimal cut- off values of Event Scale Revised and the PTSD checklist for DSM- 5 that can be used to assess for differential diagnosis of presumptive PTSD Data from 242 veterans with mental health difficulties were analysed. Findings suggests that the PCL- 5 and IES- R can be used as a brief measure within veteran populations presenting at secondary care to assess for PTSD. Higher cut- off point can be helpful in differentiating veterans with PTSD and those with symptoms of PTSD but sub-threshold for a diagnosis.

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The research team reviewed the current evidence on using tele-therapy for veterans. The findings from 41 studies were reviewed. Results showed that tele-therapy was as effective as regular face-to-face therapy at reducing PTSD symptoms. In some cases, veterans were found to be more likely to engage in tele-therapy compared to regular therapy. The majority were satisfied with their experience of tele-therapy. Some challenges were reported regarding the therapeutic relationship, e.g. reading body language, some technological problems, but these did not affect treatment outcomes.

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This research looked into the things that stop veterans from getting help and the things that aid them. 17 veterans were interviewed. Initial barriers included recognising that there is a problem and stigma. Initial enablers included being in crisis, social support, motivation and the media. Treatment pathway barriers included practical factors and negative beliefs about health services and professionals. Treatment pathway enablers included having a diagnosis, being seen in a veteran-specific service and establishing a good relationship with the therapist.

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Data was collected from 403 veterans who contacted Combat Stress. We found that 82% had PTSD, 74% had anger difficulties, 72% had anxiety and depression, and 43% misused alcohol. 32% of the veterans who had PTSD also had other over-lapping health problems, whereas only 5% had just PTSD on its own.

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403 veterans contacting Combat Stress completed a questionnaire. A comparison was made between veterans living in England, Wales, Scotland and Northern Ireland. Help-seeking veterans residing in Northern Ireland tended to be older, have experienced less childhood adversity, joined the military after the age of 18 and taken longer to seek help. Additionally, veterans from Northern Ireland had higher levels of obesity, sensory, mobility and systemic problems and, a greater number of physical health conditions. Scottish and Welsh veterans were more likely to smoke and misuse alcohol No differences were found for mental health presentations across nations. Exploring optimum cut-off scores to screen for probable PTSD within a sample of UK treatment-seeking veterans. We looked at the ideal scores veterans needed to get on questionnaires to classify as potentially having PTSD. 242 veterans completed 2 short questionnaires as well as an interview with a qualified clinician about their symptoms. Comparing the short questionnaires against the interview, we found that higher scores were needed to accurately screen for PTSD in veterans. Focusing on the mental health of treatment-seeking veterans. As part of our desire to promote the needs of help-seeking veterans in the UK, we published an editorial on what we know, so far, about veterans from research. This editorial highlights the problems veterans face after leaving the services, things that lead to poor mental health, the barriers veterans experience in seeking help and what treatment seeking veterans look like so we can better meet their needs.

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Veterans living in Scotland appeared to be at the greatest risk of deprivation, followed by English and Welsh veterans. Northern Ireland had the least risk. The locations veterans resided in were geographically spread across the UK, but more veterans resided in urban areas. Those not in a relationship were more likely to have higher levels of deprivation. Being an Early Service Leaver and taking longer to seek help was linked to higher levels of deprivation.

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VA study on the acceptability of art therapy with 547 veterans who had completed at least one session. The questions asked whether they found the sessions useful, if they would use the skills at home and what they thought was most interesting/helpful. The majority said they strongly agreed that the session was useful and would definitely use the skills at home. Veterans said they found the experience of sharing with others, being able to express difficult feelings and the environment the most useful parts of the therapy. The study suggests that art therapy is an acceptable treatment for UK veterans.

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This study was designed to explore the experiences and needs of female partners of veterans. Eight veteran partners participated in an interview with a researcher. Experiences and needs were common challenges faces, desired support and barriers to seeking help. Common challenges faced were feelings of inequality in the relationship, loss of congruence with own identity, volatile environments and emotional distress and isolation. Desired types of support from the partners included a practical focus on improving, sharing with fellow experts and care tailored to the partner. Barriers to seeking help were found to be: practical barriers and ambivalence about the involvement of others in treatments.

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We looked at whether art therapy could help veterans overcome avoidance symptoms of PTSD. 4 veterans completed a short stay at Combat Stress for art therapy. Participants were able to express and tolerate painful thoughts and emotions and their avoidance improved after the therapy.

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2016 Research

We assessed one-year outcomes in 268 UK veterans treated for PTSD. PTSD symptom severity, depression, anxiety, alcohol use and difficulties with social and occupational functioning remained lower than before treatment. There are long-term benefits to structured treatment programmes. Support targeted at individuals after treatment will improve longer-term outcomes.

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The study investigated a new method of therapy for PTSD with 2 veterans from Combat Stress. An adapted imaginal exposure approach was used whereby veterans relive their experience outdoors, manipulate their perspective on the imagery and restructure how they think about it. It showed that imaginal exposure therapy can help veterans who experience avoidance or dissociation.

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This study examined positive change in veterans after experiencing trauma (aka. Post-traumatic growth). 149 veterans answered questions on their mental health before treatment and 6 months after treatment at Combat Stress. An association was found between better treatment response and higher reported levels of post-traumatic growth.

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This paper explains the three different stages of treatment at Combat Stress. The first stage is known as 'stabilisation' where veterans attend a two week programme. The second stage is trauma therapy, known as the 'intensive treatment programme' which lasts six weeks. The third stage is to 'reconnect veterans with their lives'.

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Study looking into how mental illness and living in deprivation is linked in England. Neighbourhood data from the government was linked to 1,967 veterans. 41% of veterans were in the most deprived areas. 21% were in the least deprived areas. Those who took longer to seek help, were single, male, younger and had a war pension were at a higher risk

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A comparison of substance misuse between UK veterans and the general public. 2331 individuals with alcohol misuse problems were referred for specialist support. They were assessed for difficulties, dependency levels, withdrawal symptoms, other substance misuse and service utilisation. No differences in severity were found between veterans and the general public. However, it was found that veterans were referred at an older age and admitted to hospital for longer than non-veterans.

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100 veteran partners were surveyed for mental health needs and barriers to seeking help. 45% met criteria for alcohol problems, 39% for depression, 37% for generalised anxiety disorder and 17% for symptoms of probable PTSD. Partners were more likely to endorse barriers such as stigma as opposed to practical barriers as reasons for not seeking help.

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2015

246 veterans were assessed after finishing the six week treatment programme and then again at a six month follow up. There were improvements in PTSD symptoms following the treatment and also after six months. The study suggests it may be beneficial to combine individual therapy with group sessions.

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Study on 244 veterans who received the six-week residential treatment programme for PTSD at Combat Stress. It was found that PTSD symptoms including avoidance, hyper-arousal and intrusive thoughts were reduced after the programme. The study also showed that treatment outcomes were better in veterans who had lower levels of anxiety and dissociation. Therefore it is important to treat other difficulties such as anxiety and dissociation before PTSD.

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A fourfold increase in the number of referrals was found over the 20 years examined. This shows that more veterans are seeking help for mental health problems than before. It was found that the time taken to seek help reduced by half. Also, although the majority of referrals were from veterans who had served in Northern Ireland, recently there have been more referrals from veterans from Iraq and Afghanistan.

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The study aimed to examine the factors that facilitate UK veterans with PTSD to engage in help-seeking behaviour. The veterans were interviewed, outlining five key themes for accessing help: Having to reach a crisis point before accepting the need for help, overcoming feelings of shame, the importance of having an internal locus of control, finding a psychological explanation for their symptoms and having strong social support The study suggests that factors that drive help seeking behaviour is related to internal stigma

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2014

The paper explores existing literature on the impact of untreated PTSD in military personnel It also looks at barriers as to why people may not seek help and interventions to address these barriers Stigma is found to be the greatest barrier, in particular having negative beliefs about oneself.

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The study interviewed serving military personnel who were seeking help for mental health problems about what triggered them to seek help Five common reasons were found for seeking help: having reached a crisis point, overcome shame, felt in control, wanted to find a psychological explanation for their symptoms and had good social support.

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The Living Archive

The Living Archive is made up of powerful first person accounts from veterans which will be stored for future reference to help encourage understanding of military trauma.