Examination of Witnesses (Questions 440-459)
7 JULY 2004
PROFESSOR KEITH
HAWTON AND
PROFESSOR SIMON
WESSELY
Q440 Mr Hancock: What is the significance
there? You talked about the state of the mental health of people
on deployment improving, they are better off; with people not
on deployment it goes down. This is a critical time for these
young people, is it not?
Professor Wessely: Yes. We do
not have specific evidence on that, except to say that what you
say sounds highly plausible from the psychological point of view
and fits in with what are the benefits of military service, why
it helps you. Therefore the point you have just made would say
that is a risky period. It is when they hang around bases and
really have not much to do. I cannot give you any figures on that
except to say that seems very plausible.
Q441 Mr Jones: Can I turn to training?
Professor Hawton already mentioned that 16- to 18-year-olds face
certain issues or problems in their lives which make them more
prone to self-harm than suicide and I should be interested if
you could just run through some of those. On a general point,
what should the Army be doing in terms of support once people
are into training, monitoring people's mental health but also
reacting to issues, particularly in this group of 16- to 18-year-olds
which you have already identified as a vulnerable group in society
and in the Army?
Professor Hawton: The first thing
is that I do not have first-hand knowledge of what attitudes towards
mental health are generally in the armed forces in the UK. Going
back to this notion of a population approach to trying to do something
about this problem rather than trying to screen out people, one
of the crucial things is whether mental health problems can be
less stigmatised—and I am talking about emotional problems
in general and not just major mental illness—whether there
can be a sense that helping people who are getting into such difficulties
is everybody's business within the Army, not just that of psychiatrists
or medics. Just taking the example of the US Air Force suicide
prevention programme, which I assume the Committee has been made
aware of, the key elements in that seem to be the whole attitude
change which comes through the programme starting from the top,
from the highest in command, saying they had to do something about
mental health, mental health had to be their concern, saying we
know people at this age develop mental health problems, we cannot
pretend it is an unfortunate occurrence which we would rather
did not happen because it does happen, making it everyone's concern,
particularly trainers and supervisors of young people. That then
leads on to ensuring that they are getting good training, recognising
the point which was made earlier about the rapid turnover, which
is of course an issue, which means that in any case such training
would have to be repeated to ensure that people kept their skills
level up, generally getting over to people that we do care what
happens about emotional issues and so on, getting help early,
making it less stigmatising to get help. Again I realise there
are issues here, because if you are going to take help-seeking
away from the line of command of an individual, which is desirable,
you also have the conflict with what we talked about earlier,
of people who may be at risk to themselves also being risky in
other ways. There is that issue about confidentiality and yet
maintaining safety within the force. I think the approach to it
has to be a really general one in terms of how you approach mental
health issues and concerns for people's mental health, repeating
what we have said several times, not the idea that you screen
people out, but that you recognise that it is a dynamic situation.
People can develop problems at any stage, so the idea of cross-sectional
screening, even later on during people's training or forces career,
is not a particularly good one. I think it is all about vigilance,
awareness, knowledge, compassion and making people feel safer
about seeking help when they are getting into difficulties.
Professor Wessely: I would certainly
agree with that. First of all you have to say stigma of mental
disorder, emotional matters, is a very general problem. In my
career I have looked after two of your colleagues who were extremely
insistent that nobody knew that was the case. So this is not just
a thing for the military, it is a thing for everyone. Secondly,
it is true though, if you spend time with the military, that their
particular culture is more stigmatising of emotional weakness
and vulnerability and unfortunately, unlike Keith, I do see problems
there, because I do think that is the nature of their job. They
are not like middle-aged academics or Maudsley social workers.
They are somewhat tough people and they are to do a different
job of fighting, not emoting. Part of that is that they learn
to repress emotions and fear. It is a subtle thing that we want
to do here. We definitely do want to increase people's willingness
to admit to emotional distress and come forward, but in a way
which is compatible with their overall purpose and culture. It
is not an easy thing to do. It is not a simple thing which putting
up posters around the barracks is going to achieve. It is a difficult
one.
Professor Hawton: Although I do
think there is a difference between resilience in the face of
the stresses of military combat and dealing with emotional problems,
I do feel you can have separation between those two objectives.
Professor Wessely: There are specific
things. Our research has shown that people are very reluctant
indeed to come and talk to RMOs, who are officers. There are only
five psychiatrists in the Army anyway, so most people are not
ever going to see a psychiatrist. Community psychiatric nurses
(CPNs) have a somewhat different reputation and the Army do have
quite a few CPNs. I cannot see any reason why CPNs should not
be attached to training units and I do not think they are at the
moment. They are much closer and less stigmatising and they are
not officers. I think if you were going to present, you would
be more likely to go to see a CPN than you would a medical officer.
Professor Hawton: They are likely
to be closer in age as well.
Professor Wessely: Yes, they are
likely to be closer in age. The other thing is that the Army do
have quite a few of them, whereas the situation with doctors is
more problematic.
Q442 Mr Cran: Could we get back to the
question you have both spoken to us about and that is the question
of a strategy that an organisation should have for the prevention
of suicide, for identifying it and all the rest of it. As far
as I can see, and we have gone around the armed forces fairly
exhaustively, there is a strategy, but it is quite a loose strategy.
It depends upon the corporal noticing if the behaviour of the
individual, the recruit, is rather different, if performance is
falling off and all of that. Then there is encouragement to go
to see the padre and then sometimes, as far as I can see quite
often it, stops there because of the confidentiality. Only in
extremis does it happen to be the case that the individual in
question is signposted to the doctor, not a psychiatrist but a
doctor, who then, as far as I can see, might be able to push the
individual in one direction or another, perhaps to a psychiatrist.
It all seems to me to be quite loose. Do either of you have any
knowledge to confirm or deny that?
Professor Wessely: You are right.
First of all, if you just took away the word "Army"
that is a description of how mental health services work anyway.
They are very loose things, people have to present, they have
to be spotted by the GP and they have to be referred on. In many
respects the Army, in a somewhat closed environment, knows people
better than an average GP would. If you want a strategic approach,
what the evidence says is very much what Professor Hawton has
just been saying, then favour the population based strategy of
doing things which addresses everyone. For example, increase the
training ratios, increase the education in spotting emotional
disorders in the NCOs, which would then apply across the board
to everyone, as opposed to targeting individuals. That would be
a general strategy. It is sometimes called the population approach
as opposed to the high risk approach. I am sorry, I have gone
completely incoherent and forgotten what your question was.
Q443 Mr Cran: I was saying that I thought
the strategy the armed forces have was quite loose. Whether loose
or not, it may actually be effective. I do not know. The question
is: should they have a tighter strategy.
Professor Wessely: There is nothing
wrong with a loose strategy, so long as they do have regular checks
to make sure that it has been working. Personally I should like
to see them as strong on these issues and as robust as they are
on issues such as racism or bullying, which have a much higher
priority and which I know, from personal experience, commanding
officers' careers can end on. It is not just the strategy, it
is, as you have just said, that there is nothing particularly
wrong with their strategy. It is a question of how much importance
is put on it and how much effort is put into actually changing
attitudes which are difficult. The US Air Force has done a good
job on that, but it is a difficult process. We are both against
simple, glib solutions to this problem. It is a problem which
requires years and absolutely, unquestionably, requires leadership
from the top in the way that the military does show that kind
of leadership on issues which desperately matter to them.
Professor Hawton: There has to
be a commitment to a clear philosophy about mental health and
putting this as a priority, not the priority, recognising that
mental health problems will occur in young people, that there
are particular factors which in some ways may make it more difficult
for people with mental health problems, because of fear of stigma,
fear of being discharged from the force and so on, which may make
it particularly difficult for them to seek help. One can draw
an analogy with what happens in the general population, but there
are particular issues within the forces situation which also need
to be addressed. The underlying one is having this as a priority.
Q444 Mr Cran: May I put the question
the other way? Is it the professional view of both of you that
we should adopt what the US Army has, the US Army suicide prevention
programme? It is pretty comprehensive, is it not? All officers
to identify mental illness and all the rest. Pretty comprehensive.
Should we do this?
Professor Wessely: It is. No,
I do not think we should because there are other elements of it
which I do not think are effective and I do not think are suitable
for the British culture and the British military culture. I would
say that it should be reviewed and there are elements of that
programme which are very good and there are other elements, for
example the use of critical incident stress debriefing which we
are completely opposed to and we think makes you worse. Flooding
the Army with trained counsellors every time they have an accident
would be complete anathema. That is the American policy. Bits
of it certainly; the whole thing, no.
Professor Hawton: The common theme
of it is right, which is very much along the lines of what we
have been talking about. I do feel that lessons can be learned
from it and one can select out those things which seem most appropriate
for the British situation.
Q445 Mr Cran: I do not know about you,
Chairman, but I think it would benefit the Committee if you could
possibly take the time to tell us what the US Army does that would
benefit us; not all of it, but tell us the things you think would
really benefit the UK's armed forces.
Professor Wessely: We will both
need to read that documentation.
Professor Hawton: I know at the
present time they are following up the initial study to try to
look at which bases implemented the programme, to what degrees,
and components of the programme, and where they appeared to get
greater effectiveness. There are going to be problems about numbers,
even though obviously it is a huge organisation. I know they are
trying to evaluate which might be the most effective components
of that programme. We could have a look and say what we think
would be most useful, but there may be some more information coming.
Q446 Mr Cran: It would be immensely useful
for us if you could do that.
Professor Wessely: Certainly.
Just two caveats. The general answer to your point is that the
bits which I think are most effective are the bits which involve
education and training. The bits which are least effective are
the responsive counselling interventions. Secondly, just to say,
and it is the US Air Force rather than the US Army which has published
most on this, that you still have to set this in the context of
suicide rates falling anyway in America when they implemented
their programme. Even though much of it sounds very plausible,
we still do not know that it made a difference. We simply do not
know that. The fall in the US Air Force suicide rate was pretty
much the same as what was happening outside in the population
anyway.
Q447 Mr Cran: Just so I am clear, even
with those caveats, you might have a look at it and give us the
benefit of your advice.
Professor Wessely: Certainly;
yes.
Professor Hawton: It is worth
also highlighting the fact that other outcomes were found to change
with the programme, including domestic violence and indeed accidents.
Maybe again that was a general trend which was happening. The
more outcomes you see a change in, the more likely it was to have
been effective, particularly that it was a general approach rather
than a specifically targeted approach to one problem.
Q448 Mr Cran: I just want to be clear
about two other things. I was very interested in what you said
about the fact that the incidence of suicide is lower in the armed
forces than in the general population. I know one death by suicide
is one too many, we just have to accept that is too many and whatever
we can do has to be done but it is a question of what can be done.
I am unclear what an organisation can actually do, apart from
the things you both mentioned, to prevent suicide, that is people
getting through the net. That is what seems to happen. I too have
the view that the armed forces seem to be quite good at spotting
somebody who is going off the rails, for all the reasons you have
given, and I am unclear what more they could do to prevent the
few suicides that there are.
Professor Wessely: In a way I
would feel more comfortable talking about what they could do to
reduce deliberate self-harm, because suicide is such a rare event.
It is like murder in that it is difficult to do.
Q449 Mr Cran: Self-harm then.
Professor Wessely: My own general
view, having dealt with them for some years, is that with most
of the incidents I have heard about or dealt with where there
has been a really bad outcome there is nothing wrong with the
policies; it has been local factors on the ground which have gone
wrong, usually to do with supervision or simply having too many
people and not enough trainers.
Q450 Mr Cran: And differences I see of
practice; very different as between establishments.
Professor Wessely: Yes. They are
different between services as of necessity, but there is also
tremendous variation within the services as well. I should have
thought that it was more about knowing the right things and them
not actually happening on the ground. I am just talking anecdotally
now. Where I have been asked to comment on adverse incidents,
I usually find that it is just local factors which have happened,
as it is in most organisations really.
Q451 Mr Cran: What are you recommending
in terms of self-harm?
Professor Wessely: I am very supportive
of Keith's approach on the population base. I think that better
training of trainers, increased supervision ratios, better access
to CPNs and continuing support of morale and faith in the Army
medical services, and particularly the issues of trust and confidentiality.
One of the papers we have given you identifies that as a major
problem. Whether fair or not, it does not really matter: it is
the perception that the system is leaky which does not help people
to come forward.
Q452 Mr Cran: That leads me to my last
question. So far as I can see and we have been told, there has
to be a management plan set out for vulnerable people, wherever
they are, in this cases in the armed forces, for what is going
to happen. How do we get the individual in question better? As
I can see it, because of confidentiality, there is a great reluctance
to put anything down on paper, a plan seems to me quite often
to be very, very informal indeed and not formal and I just worry
about all of that. I am not an expert, you two are. Is this a
worry to you?
Professor Wessely: I come back
to the point that it is very hard to come up with glib solutions.
I should be worried, for example, about a system which was more
formal. I should be very, very worried about a system in which
individuals are identified because they are from a broken home,
they are at risk, they are given a different uniform. I am exaggerating,
but if in some way they were targeted and being seen differently
I could see that backfiring in an horrendous way and it could
well make things worse. I am less against informal measures of
care, so long as they are effective, whereas I can see that formal
measures of care, in which it is known that Private Smith has
these problems, could quite easily lead to Private Smith having
a worse deal rather than a better deal, as opposed to general
issues across the whole of that unit.
Professor Hawton: On the other
hand there does need to be a clearly planned response to self-harm
episodes. Okay, we lack sufficient evidence about the best way
of managing self-harm in the general population, but there are
general principles about how self-harm should be managed and those
principles should be used within the Army as well. If I am answering
your question correctly, there should be attempts to use the approaches
for which there is best evidence. Incidentally, it is of interest
that NICE, the National Institute for Clinical Excellence, is
about to publish an evidence-based guideline on self-harm. It
is coming out at the end of this month. It may be that there will
be approaches within that which can be adopted within the Army,
if they are not being used currently.
Mr Cran: We will look for the NICE report,
but in the interim, and because we are passing on to another question,
it would be rather useful for the Committee to know what these
principles are. If you could possibly tell us, I for one should
be very interested and I should like to be able to test whether
the armed forces are using these[1]
Q453 Mr Jones: In terms of self-harm,
suicide is pretty self-evident, somebody kills themselves. However,
with self-harm, there must be a whole range of different things.
How easy is it for someone who is supervising youngsters to spot
that? Can you give some examples of what the range is for self-harm?
Professor Hawton: It can range
from suicide at one extreme to someone—you may well disagree
or not whether this should be called self-harm—battering
themselves in a fit of anger and expressing anger through bashing
a wall, perhaps even fracturing a finger or whatever. We recognise
that the motivation or intention behind self-harm can vary greatly
from tension relief, which may be served by self-battery or whatever,
some people do this through cutting themselves, which seems to
relieve tension, to communicating distress to others, to wanting
to block things out temporarily, which is getting closer to suicide,
where you are actually trying to escape from a situation in terms
of becoming unconscious. There is a whole range of motivations.
One of the crucial things does seem to be about the availability
of method, which is terribly important. Just taking the situation
in the USA in general, where firearms are very available in many
households, we know that the availability of a firearm in a household
increases the risk of suicide in young people in particular. One
has to think about that component of it as well as the person's
intention. We also know that people who survive very serious attempts
quite often say that they did not really want to die. Studies
have been done of people who have survived self-inflicted firearm
wounds where, when they say what went on, it appears to have been
very impulsive, often a reaction to an interpersonal event combined
with alcohol consumption and the fact that the firearm was available
led to a near fatal outcome.
Q454 Mr Hancock: Could I take you back
to what you said about the ability of the military to come to
terms with mental illness and the possibility that someone could
recover from mental illness and still be able to serve in the
armed forces? Do you think it is a serious possibility that the
military could cope with that? They might in certain trades, but
in enlisted personnel?
Professor Hawton: It depends what
mental illness one is talking about. Taking an extreme case, severe
schizophrenia, I would personally not feel very comfortable about
someone proceeding in the forces if they developed a disorder
like that. Less severe or of a similar severity is manic depressive
illness. We know that can be very well controlled and treated.
We know that most people recover from depressive illness with
treatment, although it is an illness which we increasingly recognise
recurs and there are now strategies to prevent recurrence; not
entirely effective, but pretty effective. I should be very disappointed
if people were being excluded if they developed a depressive illness,
for example, because it is so common. The proportion of the population
of this sort of age which develops depressive illness, particularly
females, is extremely high and you are going to be losing a lot
of people, many of whom may be very talented.
Professor Wessely: They do not
exclude people just because they have had an episode of depression.
The prevalence of depression in the armed forces is somewhere
between eight and 12%, depending how you measure it. Clearly they
are not excluding them. I have been involved in numerous cases
of people who have been treated and returned to full duty.
Q455 Mr Hancock: If that is the case,
why is it such a problem for young people who have a problem to
seek help in the armed forces? The evidence I read was that if
you had been in the forces for some time you were certainly more
confident that you could cope with that. Certainly my own personal
experience of a serving member of the armed forces who went through
very traumatic problems and had a serious drink problem is that
was tolerated. It was as though it was tolerated because of what
he had gone through, but they did not recognise the other problems
he had, which manifested themselves much more when he left the
military.
Professor Wessely: There are two
answers to that. The first one is that anyone who deals with adolescents
anyway knows that it is very difficult for adolescents to seek
help. This is a general problem in the whole of mental illness.
Professor Hawton: Particularly
males.
Professor Wessely: Particularly
males. Again it is not a specifically military problem. The reasons
would be a) thinking it is not a mental health problem anyway
and about one third of people we have seen just do not accept
that this is a mental health problem; b) the next big one is clearly
stigma, quite obviously, and shame; c) believing this will impact
on their career. It is all of those three factors.
Q456 Mr Hancock: What advice would you
two give us in the way of helping the armed forces come to terms
with the problems young people are facing? What advice would you
give us?
Professor Wessely: To continue
to develop their community-based services, which they have been
doing. As you know, 16 new community mental health centres have
been created, which is a very, very welcome development, but there
are still staffing problems across the whole of the defence medical
services. I think that is in keeping with what has happened in
the rest of society: to try to bring as many services as you can
down onto the level where they are needed and to continue that
trend. It is happening, but probably not as much as one would
like.
Professor Hawton: While the history
of mental health promotion and educational activities is not awfully
good, particularly based on school programmes, nonetheless one
can think about imparting certain very simple information to trainees
as part of their induction about how to recognise when they might
be getting into difficulties and, more importantly, when to recognise
that your peers may be in difficulties. That is probably important,
although the evidence from school-based programmes is that these
sorts of approaches only work when there is an institutional change
as well, in other words the whole atmosphere and attitude towards
mental health problems shows some sort of shift, such that it
is worthwhile recognising these things, because people recognise
that there are people out there taking an interest and want to
help them.
Q457 Mr Hancock: My last question relates
to the older serviceman who might be the instructor or the trainer,
who develops an interest in the elements of bullying or trying
to take advantage of a female recruit. We were told last week
that in one unit there were 15 incidents where trainers were suspended
for having some sort of relationship with recruits; 15 in one
unit at one time. This is a phenomenal figure. Is that something
which you would say was part of a mental illness which the NCO
has, the trainer who goes down that road of trying to manipulate
young recruits for their sexual pleasure or just bullying them?
Professor Hawton: It may or may
not be. It could be.
Professor Wessely: Sometimes;
it could be. It sounds more like an organisational failure, but
yes, it could be. I would not say in general that is a symptom
of mental illness, no.
Q458 Mr Hancock: Would you say that all
instructors of young personnel in the armed forces ought to be
subjected to proper psychological examination before they are
given control and command of young people?
Professor Wessely: No, I definitely
would not say that. That is coming back to a general view and
that suggests again that psychiatrists or psychologists know what
makes a good trainer and we do not.
Professor Hawton: Having a situation
of zero tolerance in that sort of situation is probably the crucial
thing.
Professor Wessely: That is not
a matter for psychiatrists; I agree completely that that is not
a matter for psychiatrists.
Q459 Mr Jones: Could I ask about training
in terms of supervising? You have already stated that trainers
should not be psychologically assessed, but how easy is it for
someone, whose job it is to train somebody in PT or other subjects
which do not involve mental health, to spot things which you as
professionals or psychiatric nurses can spot? How easy is it for
the untrained eye to spot some of these things?
Professor Wessely: I would like
to say that it is not that easy, or that would do us out of a
job. Actually in general to know that something is wrong is the
Clapham Omnibus test and that is very easy. I should like to think
we have a bit more knowledge and expertise to know exactly why,
what and where. There is nothing clever about psychiatry when
spotting that something is wrong, that somebody is drinking too
much, is crying all the time, has become more violent, is socially
withdrawn; if you know about it, because it might be happening
at home. I really do not think it requires massive expertise to
spot that.
Professor Hawton: No, it is not
rocket science.
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