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03: Improving mental health in the UK Armed Forces and other “at risk” organisations

Submitting Institution

King's College London

Unit of Assessment

Psychology, Psychiatry and Neuroscience

Summary Impact Type

Health

Research Subject Area(s)

Medical and Health Sciences: Public Health and Health Services
Psychology and Cognitive Sciences: Psychology

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Summary of the impact

Individuals exposed to trauma are at risk of poor mental health. Researchers at King's College London (KCL) in collaboration with the Royal Marines and Royal Navy, developed a traumatic incident peer support programme — Trauma Risk Management (TRiM) — aimed at mitigating the psychological impact of traumatic events. KCL research demonstrating the effectiveness of TRiM led to the adoption of the programme by the entire UK Armed Forces (~180,000 personnel) and by a range of other organisations that place personnel in harm's way, such as the police, the Foreign and Commonwealth Office and security firms. TRiM is also recommended by NATO and the NHS for post incident psychological support.

Underpinning research

There is considerable evidence that personnel who work in challenging environments can be adversely affected by their work. Historically, people exposed to traumatic events were treated with a single session of psychological debriefing. However, a 2002 Cochrane Review, whose authorship included KCL researchers firmly debunked the benefits that such treatments could bring to people exposed to traumatic events, and highlighted that these interventions are both ineffective and have the potential to harm. Research at King's College London (KCL) led by Prof Sir Simon Wessely (1991-present, Chair of Psychological Medicine), Prof Neil Greenberg (2002-present, Professor of Defence Mental Health) and Major Norman Jones (2007-present, Senior Lecturer in Military Mental Health) has concentrated on developing, testing and refining a more holistic programme to aid those exposed to traumatic events.

KCL research shows service personnel need a support mechanism
A 2010 KCL-led survey of 1,599 naval personnel revealed that concerns about seeking help for mental health problems are very common, especially among more junior personnel. Other KCL research has shown that the stigma associated with mental health problems prevents distressed individuals from seeking help including social support and, in some cases, evidence-based treatment, both of which are known to help return such individuals to a good state of health (1). KCL led, in collaboration with the British Military, a survey of UK peacekeepers on their return from deployment confirmed the benefits of support. Two-thirds of the 1,202 participants who did speak about their experiences did so informally to their colleagues and family and the study identified that this informal support mechanism promoted good mental health (2).

The Royal Navy and KCL develop TRiM
Previous models of immediate post-trauma support (e.g. critical incident stress debriefing) have been shown to be both ineffective and have the potential to harm. Because UK military personnel are at high risk of traumatic exposure, KCL researchers worked with the British Military to develop and test an evidence-based peer support programme that could encourage possibly reticent personnel to seek help when appropriate. The result of this work was Trauma Risk Management (TRiM), a traumatic incident peer support programme. TRiM training enables non mental health professionals to carry out evidence-based psychological risk assessments after traumatic events. The results of these assessments are used to foster recovery by encouraging individuals to access informal social support from colleagues while being assisted by proactive, informed leaders or to access professional support where this is indicated (3).

KCL help show the validity of TRiM and it is expanded to other Armed Forces
Subsequently, KCL worked with the Royal Navy to design and implement a randomised controlled trial (RCT) of TRiM. Such studies were essential for TRiM to be accepted throughout the military. This RCT was carried out in 12 warships, half of which were randomised to receive TRiM training after baseline data collection was completed. At follow up, 12-18 months later, Naval personnel were interviewed and completed quantitative surveys to ascertain TRiM's impact. The results showed that unlike previous interventions, TRiM did not cause harm and its use was linked to an improvement in organisational functioning in the TRiM trained ships (4). The qualitative arm of the study also identified that TRiM was a highly acceptable method of post-incident peer support and that personnel considered that TRiM supplemented existing systems of support rather than replaced them (5). A further study examined the use of TRiM for Royal Marines and Army personnel deployed to Afghanistan. Participants were surveyed prior to (n = 180), during (n = 105) and upon return (n = 137) from an operational deployment. The effects of TRiM seemed to operate via facilitating social support since TRiM-experienced military units reported more access to social support during deployment and less psychological distress (6) than TRiM-naive units.

TRiM is adapted for non-military personnel
The TRiM protocol has also been used in non-military situations, for instance, following the attacks on the World Trade Centre in New York on September 11th 2001, the UK Foreign and Commonwealth Office (FCO) deployed TRiM-trained personnel to work with the FCO in New York. KCL research running alongside this deployment not only showed that TRiM was a well-received process but that changes in post-incident mental health could be measured by the 10-item TRiM Risk Assessment Tool (7).

Overall, these studies demonstrated that TRiM is not harmful, appears to link to better organisational functioning, is highly acceptable to military personnel who might benefit from it, has an impact on post-incident psychological health and appears to work through helping mobilise social support.

References to the research

1. Langston V, Greenberg N, Fear NT, Iversen AC, French C, Wessely S. Stigma and mental health in the Royal Navy. J Ment Health 2010;19(1):8-16. Doi: 10.3109/09638230802522999 (14 Scopus citations)

2. Greenberg N, Thomas S, Iversen A, Unwin C, Hull L, Wessely S. Do military peacekeepers want to talk about their experiences? Perceived psychological support of UK military peacekeepers on return from deployment. J Ment Health 2003;12;6:561-69. Doi: 10.1080/09638230310001627928 (40 Scopus citations)

3. Jones N, Roberts P, Greenberg N. Peer-group risk assessment: a post-traumatic management strategy for hierarchical organizations. Occup Med 2003;53,469-47. Doi: 10.1093/occmed/kqg093 (29 Scopus citations)

4. Greenberg N, Langston V, Everitt B, Iversen A, Fear NT, Jones N, Wessely S. A cluster randomized controlled trial to determine the efficacy of Trauma Risk Management (TRiM) in a military population. J Trauma Stress 2010;23(4):430-6. Doi: 10.1002/jts.20538 (11 Scopus citations)

5. Greenberg N, Langston V, Iversen AC, Wessely S. The acceptability of Trauma Risk Management within the UK Armed Forces. Occup Med (Lond) 2011;61(3):184-9. Doi: 10.1093/occmed/kqr022 (4 Scopus citations)

6. Frappell-Cooke W, Gulina M, Green K, Hacker Hughes J, Greenberg N. Does trauma risk management reduce psychological distress in deployed troops? Occup Med (Lond) 2010;60(8):645-50. Doi: 10.1093/occmed/kqq149 (6 Scopus citations)

7. Greenberg N, Dow C, Bland D. Psychological risk assessment following the terrorist attacks in New York in 2001. J Ment Health 2009:18(3):216-23. Doi: 10.1080/09638230802053391 (1 Scopus citation)

Grants

• 1998-2000 (£84,855) PI: Wessely S. Medical Research Council. Gulf War illness epidemiological study III

• 2004 (£250,000) PI: Greenberg N. Ministry of Defence. Randomised Controlled Trial of TRiM

• 2005-2010 (£1.2M) PI: Greenberg N, Fear N, Wessely S. Ministry of Defence. Military academic department funding for TRiM research

Details of the impact

Following research at King's College London (KCL) highlighting the failures of single session post-incident psychological debriefing, there was a capability gap for organisations that predictably place their people in harm's way. There was little evidence on the effective response to staff's psychological health needs after traumatic events so KCL researchers developed TRiM. The accumulated evidence demonstrates that TRiM allows `at risk' organisations to support their staff through the use of evidence-based interventions, thereby ensuring that such organisations are able to meet their legal and moral duties.

Military use of TRiM: While TRiM began in the Royal Marines, following the results of high quality KCL research (later published in Greenberg et al. 2010) it was adopted by all the UK Armed Forces from 2008. Across the military, TRiM is now available to approximately 180,000 regular personnel and for many thousands of reservists whilst deployed. The Royal Navy has a webpage dedicated to `Emotional Support' which discusses its use of TRiM. Their Operational Stress Management Policy describes the background and delivery of TRiM in detail and acknowledges the contribution of KCL by citing both background research (Greenberg et al. 2003) and detailing how the programme was developed based upon research findings (1a). The Army also highlights its use of TRiM on its website and testifies that TRiM "is a process that has already been used on operations in Iraq and Afghanistan for the last two years" and "has developed credibility among those it is intended for and increased awareness of operational stress and detection of its effects" (1b).

Over the last ten years, the UK military have operated in highly testing environments in Iraq and Afghanistan. Recent UK military health research has shown that, in spite of the challenges UK troops have faced, military personnel's mental health status has been relatively unaffected. While it is not possible to confirm what part the use of TRiM has had in generating this level of resilience in UK troops, there are plenty of examples of TRiM being mentioned in Hansard by politicians who deem it an important part of the Armed Forces mental health support processes. For instance, in a 2012 debate on the mental health of former service personnel, the Minister of State for the Ministry of Defence discussed how TRiM "is helping to identify those at risk and provide support to them" (1c). TRiM is now widely accepted as part of military mental health and it, and KCL researchers, are featured on Government pages (1d) and the NHS Choices website discussing this topic (1e).

Non-military use of TRiM: KCL TRiM research underpins the decision of other organisations, such as the Foreign and Commonwealth Office, to use TRiM to demonstrate their commitment to deliver the best evidence based support for their personnel (2a). Over time its use has spread to emergency services, security firms and media companies. For instance, Kent Police use TRiM to "assess the response of a member of staff exposed to a potentially traumatic incident" (2b) and in 2011, Essex police issued formal TRiM guidance as part of their established procedures (2c). The security company Centurion Safety also use TRiM and train their Human Resources and Occupational Health workers to use it "to risk assess the needs of those who have been involved in a traumatic event and determine what follow-up practical support is required" (2d). Much of this training, or similar, is provided by March On Stress, a company set up by Prof Greenberg in 2001 and now the UK's leading commercial TRiM training provider (2e). Their clients include the BBC, where one journalist said of TRiM that it "creates a safe, impartial and non-judgmental framework that won't influence your salary or your next deployment" (2f).

Support for the use of TRiM in national and international guidelines: As both the popularity and scientific evidence supporting the use of TRiM has grown, so has the number of recommendations that it be used more widely. TRiM is recommended by the Department of Health for supporting staff after they have dealt with disasters (3a, which cites a TRiM review article by Prof Greenberg) and similarly, in 2008, NATO recommended the use of TRiM for its personnel (3b). Numerous emergency services, including the NHS South Central Ambulance Service (3c) and the London Ambulance (3d), use TRiM and have established supportive networks so their TRiM trained staff can link up with each other to improve their service.

KCL researchers have met with and briefed military representatives from several foreign nations about TRiM and the scientific evidence supporting its use. As a result, several nations have begun consideration of the use of TRiM. For example, the Dutch military now use TRiM (3e) and TRiM has also influenced the US approach to traumatic stress management. The US Army Medical Department use Traumatic Event Management (TEM), a modified version of TRiM which was developed with the input of Prof Greenberg (3f).

Discussions with KCL researchers about TRiM also led to the UK Centre for Social Justice to recommend that the "benefits of military Trauma Risk Management (TRiM) should be more widely distributed to civilian organisations where there is an increased risk of exposure to trauma" (3g).