My friend Tug and the scandal of our shell-shocked soldiers

As the former commander of 3 Para, Colonel Stuart Tootal has watched troops succumb to the misery of PTSD. So why, he asks, is the Government doing so little about it?
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It was 6 September 2006; we called it the "day of days". Three Para had had many like it during the battle group's first tour of duty in Afghanistan but none quite so bad: a patrol trapped in a mine-strewn gully combined with Taliban mortar attacks against my men in Musa Qaleh and Sangin had left three dead and 18 wounded.

I remember listening with dread as reports came over the radio when members of the rescue party were struck down by mines one after the other as they attempted to rescue a fallen comrade. A winch helicopter we had requested to lift them to safety took too long to arrive. Three men lost their legs and Corporal Mark Wright (who was to be posthumously awarded the George Cross) selflessly went to their rescue and lost his life.

Another man who would be decorated for his gallantry that day also suffered an injury – but his was invisible.

In a desperate bid to get to Mark Wright, Cpl Tug Hartley had thrown his medical pack in front of him as an improvised mine-clearing device. Amazingly the only physical wounds he suffered were from shrapnel but, as it later became apparent, he suffered a wound to his mind in the form of post-traumatic stress disorder (PTSD).

I initially shared a general scepticism about PTSD until I saw what happened to brave men like Tug and some other servicemen and women returning from Afghanistan.

Once described as shell shock, PTSD is a complex subject. In simple terms it is a psychological injury where traumatic experiences remain trapped in a person's memory. Recurring flashbacks, vivid dreams, aggression and dysfunctional behaviour – at work and within relationships – are some of the symptoms. It is the brain's natural reaction to having witnessed life-threatening incidents or intense fear and horror. While few are untouched by their experiences of serving in places like Helmand, for some the traumatic events they have witnessed continue to haunt them long after the fighting is over.

In Tug's case, returning to his own regiment at the end of the tour, he was moved to an administrative part of the unit. He felt isolated from those with whom he had served in Helmand, and the ghosts of the "day of days" never left him.

An uncharacteristic and near violent altercation with his wife finally convinced him that he needed to seek help. This led to him being sent on sick leave and ultimately being medically discharged from the Army in February 2008.

The drugs he had been prescribed stopped on the termination of his service. Tug signed on with his GP who had no idea what PTSD was and she broke down in tears when he described what he had witnessed in the Kajaki minefield.

Tug was referred to a specialist. The following October he was still waiting for an appointment when he attended the inquest into the death of Mark Wright, whose parents had set up a charity to help soldiers suffering from their experiences of combat.

The Mark Wright Project paid Tug to see a counsellor, which in his words "worked wonders" and helped him deal with the trauma he was suffering.

Sadly his case is not atypical. The Ministry of Defence has been surprisingly unprepared to deal with the psychological implications of sending soldiers to serve in Afghanistan, given the experiences of Northern Ireland, the Falklands and Iraq.

Officials claim the incidence of PTSD is small. In 2008, 3,181 new cases of general "mental disorder" were identified, representing a rate of 16.1 per 1,000 personnel. Of these, 136 were given an initial assessment of PTSD, which amounts to a diagnosis of less than 0.5 per cent.

But anecdotal evidence suggests that these figures are too low, especially when compared to the higher rate of PTSD sufferers in the US military. The inaccuracy in measuring rates of PTSD is compounded by the fact that many soldiers are reluctant to admit that they are suffering, either due to stigma or concern over the impact on their careers.

The problem is further exacerbated by the fact that many cases of PTSD can take years to develop, often long after veterans have completed their service.

When left untreated, the classic symptoms often develop into alcoholism, drug abuse, crime, homelessness and suicide. The fact that a high percentage of homeless people are ex-service personnel, and more veterans of the Falklands have committed suicide than were killed in the conflict, is indicative of the extent of the problem of PTSD that is still not grasped fully by the state.

The burden has been carried by a number of charities such as the Mark Wright Project, or others like Resolution, Combat Stress or the Braveheart Programme, which are seeking to address the issue. Each differs in their approach to providing private treatment, but their proliferation reflects a significant gap in MoD and NHS capability.

The MoD has commissioned an independent study into PTSD at King's College London, but it has come late in the day and the data regarding the scope of the problem remains too imprecise. There is also still too much emphasis on relying on charities to provide treatment at a time when our armed forces are facing an unprecedented level of operational commitments.

Successful prosecution of the conflict in Afghanistan will take years. Traumatic experiences of combat will continue to remain trapped in the minds of some, and the incidence of PTSD is likely to increase, especially as our troops complete the necessary cycle of repetitive tours of duty.

Since 2003 more than 150,000 troops will have served in either Iraq or Afghanistan. Some will have made repeated tours in both theatres.

Even if the diagnosis rates remain small, several hundred soldiers can be expected to suffer from PTSD in the short term and many more when they leave the service. This opens the prospect of a bow wave of cases building up over the next decade.

Some things have improved. Since January 2009, the contract for military healthcare has been won by a partnership of NHS trusts, led by the South Staffordshire and Shropshire Healthcare NHS Foundation Trust. Six other trusts in the partnership are spread across the country. Service personnel now receive training to increase awareness of PTSD and greater use is made of trauma-risk management – a peer-group mentoring system developed by the Royal Marines for use in the aftermath of traumatic events. The families of personnel returning from operations also receive briefings to alert them to the possible after-effects of a deployment.

But, despite this, too few veterans are aware of the new NHS trust system and how to get help. Too many GPs lack a proper understanding of PTSD and what our soldiers have been through. When I spoke to Tug he had no idea of what support was available from the state.

If the system is to cater for the growing problem of PTSD, the NHS and MoD must reach out to all armed forces veterans and their GPs to inform them about how to access it. They must also work with PTSD charities, like the Mark Wright Project, to help co-ordinate their efforts to fill the gaps in the treatment system. Six years on from the invasion of Iraq, and over three years after the UK's entry into the unforgiving desert plains of Helmand, soldiers who have risked life and limb for this country deserve better.

Colonel Stuart Tootal commanded the first UK battle group to be sent to Helmand in 2006. He touches on the problem of PTSD in his book Danger Close published by John Murray

Explainer: Post-traumatic stress disorder

*Post-traumatic stress disorder (PTSD) is a complex and debilitating condition that can affect every aspect of a person's life. It is a psychological response to the experience of events of an intensely traumatic nature. These type of events often involve a risk to life – one's own or that of one's colleagues. It is a condition that can affect anyone, regardless of age, gender or culture.

During the First World War it was referred to as "shell shock"; it became "war neurosis" during the Second World War; and "combat stress reaction" during the Vietnam War. In the 1980s, the term Post-traumatic stress disorder was introduced.

Although PTSD was first brought to public attention by war veterans, it can result from any number of traumatic incidents. The common denominator is exposure to a threatening event that has provoked intense fear, horror or a sense of helplessness in the individual concerned.

The sort of traumatic events that might be experienced by members of the general public include physical assault, rape, accidents or witnessing the death or injury of others – as well as natural disasters, such as earthquakes, hurricanes, tsunamis and fires.

In the case of serving personnel, traumatic events mostly relate to the direct experience of combat, to operating in a dangerous warzone, or to taking part in difficult and distressing peace-keeping operations.

Veterans can also suffer from a variety of other mental health problems such as clinical depression, anxiety, adjustment disorders, phobias, anger problems, obsessive compulsive disorder, bi-polar illness (manic depression), substance abuse or dependence.

..................... Source: Combat Stress