The Combat Stress Training Programme

UNDERSTANDING &
RESPONDING TO VETERANS
WHO MAY BE STRUGGLING
WITH POOR
MENTAL HEALTH
Module 3 of 4
WELCOME &
INTRODUCTIONS
• Your facilitators are Dr Jen Bateman, Lead Clinical Psychologist and Jolandi du Preez,
Lead Occupational Therapist.

• The webinar will be recorded and the recording shared on our ‘on-demand’ training
webpage: https://www.combatstress.org.uk/CombatStressTrainingForOrganisations

• We will be taking questions, please do submit these in the Q&A box and we will have a
Q&A session at the end of the webinar.
THE COMBAT
STRESS TRAINING Module 4:
PROGRAMME FOR Building trauma informed organisations

VETERANS’ Module 3:
WELLBEING Understanding & responding to veterans
who may be struggling with poor mental
health

Module 2:
Understanding why veterans
may be vulnerable to
poor mental health

Module 1:
Understanding wellbeing & resilience
and how to foster it
OUTLINE OF TODAY’S
TRAINING
Module 3: Understanding and responding to veterans who may be struggling with poor mental health

1. Recognise the common types of emotional distress

following service

2. Feel confident to sensitively raise the topic of emotional

wellbeing

3. Providing appropriate support and signposting to services

PART 1:
RECOGNISING THE
COMMON TYPES OF
EMOTIONAL DISTRESS
FOLLOWING SERVICE
MENTAL HEALTH WITHIN THE MILITARY
CULTURE
• How is the military addressing mental health?

• TRIM (Trauma RIsk Management) trauma

focussed peer support system

• Mental health awareness raising and

dedicated support pathways e.g. Royal Navy -
Project Regain to assist Marines to access help
easily

• Campaigns featuring role-models who are

speaking up about mental health difficulties
DEAN SHARES HIS STORY…
“I joined the Army when I came to a crossroads in my life at 24.”

“Just months after I came out of training I was deployed to

Afghanistan. During a firefight with the Taliban one of our
sections got hit badly and we lost three guys from our
platoon.
"I was so affected by what happened that I couldn't function,
even after the tour. So in late 2008 I left the Army.
“I really struggled adapting to civilian life. I lived turbulently,
gambled and neglected my family.
“I started having nightmares so I never got a proper night’s
sleep.
“One day, it all became too much. I walked aimlessly for 40
miles until I reached a bridge. I was ready to jump, but then I
thought about my family."
Dean was picked up by the police and taken to hospital. After
some time in hospital Dean's local mental health team
referred him to Combat Stress.
 Difficulties
relating Anger
(e.g. partner, Low mood,
family, depression
colleagues
Struggling etc)
to manage
physical Anxiety
health
conditions
Types of
Emotional
Distress
Post-
Alcohol and Traumatic
substance Stress
use Disorder
Complex (PTSD)
Post-
Sleep Traumatic
difficulties Grief and Stress
loss Disorder
(C-PTSD)
DEALING WITH EMOTIONS
WITHIN THE MILITARY• Compartmentalising
memories and
• Support from experiences
comrades, unit
• Humour &
camaradarie

Veterans integrate
their emotions • Staying focussed on
using a range of the next goal/action
ways of coping
• Avoidance:
triggers /
thoughts
• Distraction
• Alcohol or substance use
• Psychological decompression
UNDERSTANDING ANXIETY
• Anxiety is a word we use to describe the body’s fear response.
• This is a series of physical processes in the brain and body that
happen in response to a threat.

• These processes are often described as the fight/flight/freeze response and it is this response that
we experience in feelings of being on edge or high alert.

• This response was intended to be triggered by an external and mostly immediate threat. However
due to our sophisticated brains, it can also be triggered by memories of historical threats or
imagined scenarios, predictions and worries about future threats (real or imagined), thoughts,
feelings and relationships.

• For some veterans, it is difficult to recognise feelings of fear or anxiety as they are trained to
override them.
• Through training, they may learn to channel their fears into controlled aggression and so may
experience anger rather than anxiety when under threat
KNOWING THE SIGNS OF ANXIETY

Physical Signs: Mental Signs:

Quick, shallow breathing Tension in the Racing thoughts Feeling unreal or detached
jaw, grinding from reality
teeth

Tightness in chest Blurred or tunnel Losing sense of time Expecting the worst
vision and space

Loss of appetite Increased Feeling constantly Fearing the safety or

sensitivity to worried, restless self/others
sounds

Sweaty palms, shaking Feeling weak / Unable to concentrate Difficulty remembering things
unsteady

Increased heart rate Nausea Difficulty ‘switching Not sleeping well

off’

For more information, visit our Anxiety Self-Help Guide online: https://selfhelp.combatstress.org.uk/anxiety/page1.php
BE AWARE OF WELLBEING FLAGS

You are delivering an activity project. In the instruction phase, a

veteran seems nervous and is struggling to keep up with following
the guidance provided. She appears to be a bit flushed and shaky
and she’s struggling to concentrate on the activity. You can see she
is struggling to stay in the situation and may be a looking for a way
to exit the activity.
STRATEGIES TO SUPPORT COPING

https://selfhelp.combatstress.org.uk/depression/page1.php
DEEP BREATHING
Exhale first, count to five as you inhale and exhale, pause between breaths
UNDERSTANDING LOW MOOD
Everyone can experience changes in their mood and we can all feel low at times, it’s
natural. However, this can become a problem when:

• Low mood is persistent

Visit the Combat Stress
• It impacts on how you behave
Self Help Guide:
• You are increasingly irritable
• You have low motivation, feel lethargic and have no energy combatstress.org.uk/
• You lack enjoyment in things that you used to enjoy coping-low-mood
• You feel hopeless
• You have a poor appetite or are over-eating
• You're experiencing poor sleep
• You're taking less care of yourself
 Physical Signs: Psychological Signs:
Tearful Continuous low mood/sadness
Moving /speaking more slowly Feeling hopeless/helpless
Changes in appetite or weight Feeling more irritable than usual
Sleep difficulties
SIGNS OF
DEPRESSIO
N
Social Signs: Behavioural Signs:
Avoiding contact with friends Lack of energy
Neglecting hobbies and interests Loss of sex drive
Having difficulties in home / Little interest in activities
work life
BE AWARE OF WELLBEING FLAGS

You are co-ordinating a walking group.

You are at the rear of the group and walking alongside a veteran
who seems quite tired. You notice his appearance is more
dishevelled than previously. He seems less engaged than usual
and says he doesn’t seem to enjoy anything at the moment and
feels flat and down.
COPING WITH LOW MOOD: LETHARGY
CYCLE
COPING WITH LOW MOOD
Being more active can help to break this cycle because activity:

• Makes us feel less tired - normally when we feel tired, we need rest. When we feel low, the opposite
is true. We need to do more. Doing nothing means we feel more fatigue.
• Distracts us – being active gives our minds something else to think about. This means we are less
likely to dwell on worrying or negative thoughts.
• Improves our confidence – being active gives you a sense that you are taking control of your life
again. Small steps help rebuild shattered confidence. There is a chain reaction where you feel
motivated to try to achieve something else.
• Improves our thinking – when we are more active we start using our brains in a more positive way.
This can help us to get perspective on some problems and find new ways to manage them.
• Involves others – being more involved with others means we can improve our connections and feel
supported.

For more coping strategies, visit our Depression Self-Help Guide online:
https://selfhelp.combatstress.org.uk/depression/
UNDERSTANDING PTSD
• Post-traumatic stress disorder (PTSD) is an anxiety disorder caused by very
stressful, frightening or distressing events.

• Flashbacks (feeling as if the event is happening again) are perhaps the most well-
known symptom of PTSD.

• However other re-experiencing symptoms, such as trauma-related nightmares,

intrusive upsetting memories of the event, and strong physical and emotional
reactions when reminded of the event are just as common.

• Although it often feels like PTSD symptoms come like a bolt from the blue, it is
much more likely that they have been ‘triggered’ by a thought, feeling, or
something in our environment.
What are the symptoms of PTSD?
To struggle after a trauma is a normal part of recovery. For some, however,
the difficulties will go on to develop into PTSD. ​

Re-experiencing Hyperarousal

Avoidance Altered mood/beliefs

Thanks to the CS DVMHS Working Group for this image

What are the symptoms of PTSD?
To struggle after a trauma is a normal part of recovery. For some, however,
the difficulties will go on to develop into PTSD. ​
Re-experiencing
Hyperarousal
Recurrent, involuntary,
intrusive memories Difficulty falling or staying
asleep
Re-living the traumatic
experience(s) in the here and Irritability or outbursts of
now (flashbacks) anger

Distressing dreams Difficulty concentrating

(nightmares) Hyper-vigilance
Experiencing distress when Exaggerated startle response
confronted with reminders of
the trauma Self-destructive or reckless
behaviour
Physiological reactivity after
exposure to a reminder of the
trauma

Altered mood/beliefs
Fragmented memory
Avoidance Negative beliefs and
Of circumstances resembling expectations about oneself
or associated with the and the world
stressor Self-blame, fear, guilt,
Of trauma-related thoughts shame
and feelings Emotionally numb

Thanks to the CS DVMHS Working Group for this image

AN EXAMPLE OF HOW PTSD MAY
PRESENT
Symptom cluster Example symptom Impact on life

Avoidance I hide all my medals and military I don’t feel as close to my

memorabilia in the loft kids as they know nothing
about my military service

Re-experiencing I have nightmares that wake me up I now sleep on the sofa as

feeling anxious and startled it was waking my wife
BE AWARE OF WELLBEING FLAGS

You are co-ordinating an activity in a local wood. There is

suddenly the sound of gunfire; you know there are
occasionally pheasant shoots in the area. One member of
the group is obviously startled and freezes.
COPING WITH PTSD SYMPTOMS
Do’s and Don’ts for Providing Support:

• Do:
• Try to stay calm
• Gently remind the person of where they are, encourage them to describe their
surroundings, what do they see/hear/feel? (more ideas on next slides)
• Encourage the person to breathe slowly and deeply

• Avoid:
• Avoid crowding the person
• Don't touch the person without permission
• Avoid making any sudden movements, try not to startle or surprise the person
GROUNDING STRATEGIES TO HELP WITH
COPING
• Describe an everyday object
• Categories game – name a city, animal, fruit/veg etc. for
each letter of the alphabet
MENTAL • Make an inventory of everything around you
• Use a safety statement – “I am safe, it’s 2020, I am at …”
(involving the • Name out loud 10 things in the room that are
mind) square/rectangle, brown, white…
• Say the alphabet v..e..r..y... s..l..o..w..l..y... or say it
backwards
GROUNDING STRATEGIES TO HELP WITH
COPING
• Focus on your breathing – inhale, exhale
• Touch an object. Notice texture, temperature, colour, shape
• Hum or sing
PHYSICAL •
•
Smell – spices, flowers, herbs, scented oils
Count the trees, cars, birds
• Juggle with balls, keys, apples
(involving the • Taste something strong – lemon, mints, menthol sweets
senses) • Use a stress ball
• Run your hands under cold water
• Take a brisk walk
• Stamp feet hard, jump, snap your fingers
PART 2:
FEELING CONFIDENT TO TALK
ABOUT EMOTIONAL WELLBEING
CONVERSATION STARTERS…
“May I ask about
how you’re
“Would you feeling?”
like to talk?”

“I notice you seem

“Can I check in
[e.g. more frustrated
with you, are you ok?
than usual], how are
How are things going
you doing? ”
for you? ”

“The power of a brew…”

FEELING CONFIDENT FOR THE CONVERSATION
A 4-Step Approach

Maintain eye contact, nod, use verbal fillers to show you are listening (Examples are:
Listen: yes / sure / uh-huh…)

Agree, empathise and reflect back what’s been shared:

Agree:
• “What you’re going through sounds really tough.”
• “I can see how that would be stressful”
• “It’s ok to feel this way, it’s usual to struggle sometimes”

Curiosity: • “How can I / we best support you?”

• “What needs to happen for you to feel more at ease?”
• “What has helped in the past?”

Encourage: Provide encouragement that it’s ok to seek support to promote mental fitness.
Seek help yourself if you are unsure what to advise.
PART 3:
PROVIDING APPROPRIATE
SUPPORT AND SIGNPOSTING
TO SERVICES
SPOTTING THE SIGNS OF EMOTIONAL DISTRESS:

Irritability/
Anger

Anxiety/
Self criticism/
Seems ‘On
Hopelessness
Edge’

Alcohol/ Withdrawn/
Substance use Less interest

Trouble Low/sad
concentrating mood

Tiredness/
Fatigue
HOW TO OFFER SUPPORT
Starting the conversation is an important first step

“Is there anything I / Show empathy and

we can do to reduce understanding:
“What support can
the pressure “This is a really
we put in place?”
on you right now?” tough time”

“Are there any

stressors “It’s a difficult time ‘Tell me about how
at home that I/we right now. How are the current situation
can support you coping?” is affecting you?”
you with?”
BE AWARE OF ISSUES OF RISK (A.C.E):
If a veteran shares they are having thoughts of hurting themselves/others

ASK: Ask directly, “Are you thinking about harming yourself?

CARE: Actively listen, calmly share you are concerned and have a duty of
care to keep him/her safe. Remove means of injury if safe to do so.

ESCORT: To their GP / A&E department of local hospital. Wait with them

until assessed by a health professional. Accessing help via NHS 111 or via
phone is also a safe option. Call 999 if immediate risk to self or others.
Wait with them until they are assessed by a health professional
FURTHER SUPPORT FROM COMBAT
STRESS

24/7 Helpline: Interdisciplinary support

Online Self Help Guides:
Free help and advice for Online/Phone:
https://selfhelp.
veterans and their Occupational Therapy,
combatstress.org.uk Nursing, Psychology
families
0800 138 1619 Psychiatry

Visit our website for COVID-19 self-help guides:

combatstress.org.uk/mental-health-support-during-covid-19
CONSIDER…
Consider confidentiality
of information shared, organisational processes regarding
documenting/record keeping

Consider organisational needs regarding wellbeing and

reflecting on your approach,
putting the topic of emotional wellbeing
on the agenda

Facilitating the sharing of ideas of things that are

helping/hindering wellbeing

Routinely discussing the advantages of seeking extra support to

promote emotional wellbeing at this time
DEAN SHARES HIS STORY…

“I was diagnosed with PTSD in 2018. Talking about

everything had such an impact on me - I’m more open about
my feelings now. And the support from the other guys …was
amazing; being with other veterans who understood helped
me have a different perspective.
“Things are going well for me at the moment. I still have my
ups and downs, but I feel like I can cope.
“Now my life is about spending as much time with my family
as I can. I still use what I learnt in occupational therapy to
keep a good balance of everything and I still meet up with
the guys from ITP: they’re part of my journey now.
“Since I got in contact with Combat Stress, I haven’t looked
back.”

Thank you to Dean for sharing his story with us.

A MOMENT TO
REFLECT…

What is your top take-away

for yourself / your
organisation?

What are your

1-3 actions/next steps for
yourself / your organisation?
 SUMMARY, QUESTIONS &
NEXT STEPS
1 Question & Answer time

2 What’s one takeaway or action step for yourself / your project?

3 This is module 3 of 4, the final module is ‘Building Trauma Informed Organisations’

4 Self-assessment quiz and certificate of attendance

5 Evaluation and Feedback: https://www.surveymonkey.co.uk/r/CSTrainingCS

Thank you for your time, attention & commitment to support veterans in your organisation
ACKNOWLEDGEMENTS
Special thanks to our co-authors: Jolandi du Preez (Lead Occupational Therapist),
*
Naomi Wilson (Consultant Clinical Psychologist and Head of Psychological Therapies),
Jen Bateman (Clinical Psychologist) and all contributors from the Combat Stress National
Veterans’ Voice.

* Thank you to Combat Stress colleagues who contributed to the development /

slides within this training, including all colleagues in the DVMHS Working Group.

Sincere thanks to the Armed Forces Covenant Fund Trust for their generous
*
funding of this programme and to the Strategic Partners for all their support
REFERENCES

Stevelink, S.A et al (2018). Mental health outcomes at the end of the British involvement in the
1 Iraq and Afghanistan conflicts: a cohort study. The British Journal of Psychiatry, 213, 690-697.

Combat Stress (2020). Managing Anxiety Self Help Guide, retrieved online November 2020 at
2 https://www.combatstress.org.uk/managing-anxiety

Combat Stress (2020). Coping With Low Mood Self Help Guide, retrieved online November 2020
3 at https://www.combatstress.org.uk/coping-low-mood