How do we treat soldiers' mental health problems?

While many people are left with physical scars or killed in conflict others have less visible wounds - such as trauma or mental health conditions. Theresa Mitchell is the head of the hidden wounds service at the Help for Heroes charity.

Theresa - I think a lot of people will resonate with the idea of shell shock from the First World War, probably since Afghanistan and Iraq and those more recent wars. This idea of a hidden wound and PTSD have become more in the public domain but, unfortunately, pretty much as a depiction in movies and literature as people being mad, bad and sad, which is very untrue.

Chris - In essence, then, it's always been there, but we haven't always talked about it?

Theresa - Exactly that. It's always been. Mainly men were coming home and were either uncommunicative or had physical sensations, because PTSD presents itself not just in the mind but also in the body, but they didn't have a name for it. They just knew that people were changed by the experiences that they had undergone.

Chris - When did we realise that we needed to do something about it and when did we transition away from the stiff upper lip mindset?

Theresa - I think they took it seriously even in the First World War because I think what they needed was people back at the front. They needed people to be battle worthy and battle ready. It was the way in which it was treated. It was quite brutal. To begin with, it was about rest and relaxation and bringing people back, but then they decided that probably it had an organic origin, and they used barbiturates or they used medication or they put people into comas or really brutal treatment like brain surgery. People have heard of lobotomies, those sorts of things. You talked about the stiff upper lip; that still exists. That motto of soldier on and get on with it and be the best soldier you can be.

Chris - Are there different gradations of exposure? If someone sees something awful and it causes PTSD, does someone get twice as bad PTSD if they see something twice as awful? Or is it very much down to the individual?

Theresa - I think both, which isn't the straightforward answer, is it? You expect somebody to have an acute stress response when they witness something, whether that's a car accident or if they're in combat. But people recover from that. What happens with PTSD is it becomes enduring. It is imminently treatable, I want people to hear that, but I think that maybe what you are talking about is something that we call moral injury whereby, if there's something that we would call an act of omission or commission, if there was something I did do or I should have done and I didn't, that can make the PTSD more difficult to treat. PTSD is very much fear-based. It's not the event that causes the difficulty, it's your belief about the event, what you thought was going to happen. It isn't a coherent timeline with PTSD.

Theresa - It's not like a memory, it's fragmented. If your belief is that you did something awful or you didn't prevent something awful happening, that makes it difficult to treat. If I give you an example, a young man who held a child who'd been mortally wounded in an attack. He held that child for a period of time and what happened was that he had a child himself of the same age at home and the reason he struggled so much was he felt that it was his duty to protect that child and he had failed in that duty. So therefore, whilst the event itself was really, really awful to witness, there was a deeper sense around it. There was a belief he had about it and it was the belief that created the difficulty for him.

Chris - Are we getting better at treating it? Because I've seen over the years a number of people with different viewpoints about how we should or shouldn't go about talking people down from the aftermath of particularly harrowing events and experiences and so on, and what's good to do, what's not good to do. This seems to sometimes be at odds with previous guidance. So do we know the best way of managing this now?

Theresa - I feel that this idea that I don't want to talk about it, events were so traumatic and so dreadful at the time and so chaotic that you didn't actually manage to process what was happening in a coherent way. Therefore, by revisiting those events, in a way that means you can tolerate it. I think that the gold standard treatments, which are EMDR, which is eye movement desensitisation and reprocessing, and trauma focused CBT which is the model I practise in, I think those models, they're evidence-based and actually have been proved to be really effective in allowing people to process the trauma that they live with. It's perfectly normal when you've been through an event that's left you with a wound like this to want to avoid thinking about it, wanting to avoid things that remind you of it, but what they do is they maintain and perpetuate the difficulty. Having the courage to look at the difficulty that you have will be the best thing that will help you through it.