A lot of the veterans I see have been suffering for years so they have chronic problems with depression, anxiety, alcohol abuse and post-traumatic stress disorder (PTSD).
They suffer from night sweats and suddenly wake up, terrified or anxious, having had nightmares. Some have invasive memories where things keep popping into their minds, a bomb going off, a friend's death or being shot at. Worse still, they can get flashbacks where they actually see a snapshot or replay a film. Sometimes they are looking at the film and sometimes they are actually in it, it is happening to them again.
They get irritated, anxious, suffer from palpitations and feel on edge. They can be hyper-vigilant, constantly looking out for signs of danger. They will be walking down the street looking for hiding places in case there is a sniper in the window, or will sit in the pub with their backs against the wall so they can see anyone coming in. They say things they don't want to say and, very rarely, they can get violent. They cannot stand loud noises. The 5 November [Bonfire night] is a particularly difficult time.
Often they have social problems; a history of multiple employers, relationships and house moves. Some will have been homeless.
We spend five days assessing them and then put forward a treatment plan to their GP, outlining what Combat Stress [Ex-Services Mental Welfare Society] will do for them and what the NHS should do. They are then put on a programme of six one-week or three two-week sessions. This will include ensuring they are on the proper prescribed medication, which can be a combination of antidepressants, mood stabilisers or anti-psychotic drugs.
They are then treated with trauma focused cognitive behaviour therapy (TFCBT) and eye movement desensitisation and reprocessing (EMDR). With the former you talk to the person, expose them to the trauma in a safe environment rather than let them simply avoid it. With the latter you help the person visualise something that bothers them and then couple it with something fairly safe. By moving between the two, the one that bothers them becomes less stressful. Some people are sceptical about this treatment but it gets results.
TFCBT and EMDR are very efficacious in someone with one trauma but with veterans you may be talking about young men who have served in Iraq, Northern Ireland, Sierra Leone and Kosovo, so they have multiple traumas. These guys need a lot longer.
We also do group treatment. Combat Stress is a quasi-military environment and veterans feel more comfortable talking among themselves.
Some people who have suffered from chronic problems have done extremely well and been taken back into mainstream work.
I met one chap years ago who was on the wrong medication, drinking a lot and had depression, PTSD and flashbacks almost to the point of being psychotic. He still comes here. It has taken years, there were layers of trauma but he is much better now. He is in a good marriage and has work.
One young man came back from Iraq and they tried to section him under the Mental Health Act, commit him to a psychiatric unit. He was having flashbacks and nightmares so bad that they wrongly thought he was psychotic. He came to us. He has a wife and children and they are still together and doing much better.
In America research conducted after the Vietnam war found that 30.9 per cent of veterans had lifelong PTSD, 26.4 per cent lifelong depression and a massive 43.5 per cent lifelong anxiety. It is rewarding to help these people but it is frustrating that there is not more assistance for them out there. There is a massive lack of understanding and a massive lack of knowledge in relation to this problem.
Dr Walter Busuttil is medical director at Combat Stress
Under pressure Combat stress
How many British service personnel are suffering from combat stress?
Government research says just under five in every 1,000 members of the Armed Forces (including non-operational) present with mental disorders, though it warns many may choose not to come forward. A study by The King's Centre for Military Health found that less than 1 per cent of those deployed to Iraq suffered from post-traumatic stress disorder, though the figures rose dramatically for the Territorial Army and reservists.
Has the problem increased since the conflicts in Iraq and Afghanistan?
Combat Stress, the charity which helps thousands of veterans, has seen a 53 per cent increase in three years. In 2008 alone, 3,700 new cases came forward. The charity can only help former – not serving – personnel, and those coming forward include soldiers who served in previous wars for whom the current conflicts have proved a telling reminder. The average time it takes a serviceman or woman to admit to combat stress is 14 years.
What are the concerns?
Experts fear there is a "time bomb" of mental health problems for which existing treatment facilities may prove insufficient. There are also concerns that treating soldiers alongside the general population may be inappropriate as many soldiers feel uncomfortable talking to civilians about the horrors of battle.
What is the Ministry of Defence doing?
There are 15 military Departments of Community Mental Health around the country, providing access to clinical psychologists and mental health social workers. A contract has been awarded to provide in-patient care by a partnership of NHS trusts. The military also deploys psychiatrists and mental health nurses on operations, and has started a trauma risk management programme.
For Valour: The other living holders of the Victoria Cross
John Alexander Cruickshank
Born: 20 May 1920
Rank: Flight Lieutenant
Force: 210 Sqdn, Royal Air Force Volunteer Reserve
Won the VC in 1944 during the Second World War and is the oldest surviving recipient. Was attacking a U-boat in a hail of flak shells when one burst inside the aircraft. One member of the crew was killed and two wounded, and although he had been hit, Cruickshank went in again, releasing his depth charges, which straddled the U-boat perfectly, and it sank.
LATER: He left the RAF in September 1946 to return to a career in banking.
Force: 10th Gurkha Rifles
Limbu was in an advance party of 16 Gurkhas in 1965 during the Indonesian Confrontation when they encountered 30 Indonesians holding a position on top of a hill. He went forward with two men, but when they were 10 yards from the machine-gun position, the sentry opened fire. Limbu rushed forward and killed him with a grenade. The remaining enemy combatants opened fire wounding the two men with Limbu, who made three journeys to rescue his comrades.
LATER: No information.
Born: 6 July 1919
Force: 2/4th Australian Infantry Battalion
On 15 May 1945 in New Guinea, Private Kenna stood up in full view of a Japanese bunker less than 50 yards away – firing his Bren gun from the hip. As a result of his gallantry the bunker was taken without further loss. Three weeks later he was shot in the mouth and spent more than a year in hospital before being discharged in December 1946.
LATER: After the war he worked with the local council and played Australian rules football for his local team.
Born: 21 September 1927
Force: The Black Watch att'd 1st Bn, King's Own Scottish Borderers
In November 1951, Private Speakman's section was holding the left flank of his company's position. On his own initiative he collected grenades and led six others as they carried out a series of charges. They broke up several enemy attacks, causing heavy casualties. Even after he was wounded by shrapnel, he continued to lead charge after charge.
LATER: Served in Malaya as an SAS sergeant.
Born: 30 December 1917
Rank: Havildar (sergeant)
Force: 4th Bn, 8th Gurkha Rifles, Indian Army
He successfully picked up and threw two grenades thrown into his trench in Burma in 1945. When he threw a third it exploded, blowing off his fingers and causing serious injuries to his face and body.
LATER: Returned to Nepal.
Born: 30 August 1933.
Rank: Warrant Officer Class II
Force: Australian Army Training Team, Vietnam
He is an Australian hero of the Vietnam War; the last Australian recipient of the original Victoria Cross; and one of only two living Australian recipients of the original VC, the other being Edward Kenna.
LATER: Payne retired from the army in 1975.
Bill Henry 'Willie' Apiata
Born: 28 June 1972
Force: 1st New Zealand Special Air Service Group
The first recipient of the Victoria Cross for New Zealand, he received the award on 2 July 2007 for bravery under fire during the Afghanistan conflict in 2004, after carrying a badly wounded comrade across a battlefield to safety.
Mark Gregor Strang Donaldson
Born: 2 April 1979
Force: Australian SAS
Exposed himself to enemy fire to protect injured troops and then rescued an interpreter under fire in Oruzgan province during Operation Slipper, the Australian contribution to the war in Afghanistan.
Tul Bahadur Pun
Born 23 March 1923
Rank: Warrant Officer Class I
Force: 3rd Bn, 6th Gurkha Rifles, Indian Army
As a 21-year-old rifleman he was taking part in an attack on a railway bridge in Burma. Armed with a Bren gun he continued the charge alone in the face of heavy fire and reached the position, killed three of the occupants and put five more to flight, capturing two light machine-guns and much ammunition.
LATER: He was refused entrance to the UK by British officials in Nepal as it was claimed he "doesn't have strong enough ties with the UK". On 1 June 2007 this decision was overturned.