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Mental well-being interventions in the military: The ten key principles
  1. Erin G Lawrence1,
  2. N Jones1,
  3. N Greenberg2,
  4. N T Fear1,
  5. S Wessely1,2,
  6. G Michael1,
  7. S Taylor-Beirne1 and
  8. A Simms1
  1. 1 Academic Department of Military Mental Health, King's College London, London, UK
  2. 2 King's Centre for Military Health Research, King's College London, London, UK
  1. Correspondence to Erin G Lawrence, Academic Department of Military Mental Health, Weston Education Centre, King's College London, London SE5 9RJ, UK; erin.g.lawrence{at}kcl.ac.uk

Abstract

Organisations including the United Kingdom Armed Forces should seek to implement mental health interventions to increase the psychological well-being of their workforce. This editorial briefly presents ten key principles that military forces should consider before implementing such interventions. These include job-focused training; evaluating interventions; the use of internal versus external training providers; the role of leaders; unit cohesion, single versus multiple session psychological interventions; not overgeneralising the applicability of interventions; the need for repeated skills practice; raising awareness and the fallibility of screening.

  • mental health
  • psychiatry
  • adult psychiatry

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Introduction

Given that military personnel are more often exposed to physical and psychological danger, the prevalence of mental health disorders in the UK military community is higher than the general population.1 2 It is therefore vital that the United Kingdom Armed Forces (UKAF) does what it can to minimise psychological harm where possible. In this editorial, we offer ten basic principles to help in this task.

Principle 1: Job-focused training

The most powerful intervention to improve and sustain good mental health in the face of adversity is the training you receive to do your job.3 Ensuring that personnel feel competent in carrying out their role is a mental health intervention.

Principle 2: Evaluating interventions

In mental health, interventions are often implemented because they are appealing, easy to use or have been promoted by an interested party. However, just because an intervention sounds good, it does not always follow that it works. For example, robust studies in non-military settings suggest that mental health first aid training has minimal or no effect on behaviour.4 Any new intervention should be rigorously evaluated at an early stage to save money, time, effort and resources should it prove to be ineffective,5 noting that anecdotal testimonials are not evidence of widespread positive impact. Instead, robust quantitative and qualitative research methods are needed to evaluate treatment impact.

Principle 3:Internal versus external training providers

Where possible, mental health interventions should be provided internally within the organisation. Peer or leader-delivered support appears to be as effective as external provision6 and often more acceptable,7 likely due to the internal workplace culture and cohesion within the UKAF. Internally delivered interventions are also likely to be more relevant, effective (as observed in non-military organisations),8 generalisable and sustainable.

Principle 4: The role of leaders

As seen in both the UK and US military, the best mental health support is provided by high quality ‘shop-floor’ supervisors/leaders.9 10 Arguably, most important to the mental health of the individual or small group are visibly supportive leaders.11 Positive effects for leader support on sickness absence have also been reported within other public sector organisations.12

Principle 5: Unit cohesion

Higher unit cohesion is associated with better mental health outcomes within the UKAF.13 To improve team members’ mental health, military planners should aim to maximise unit cohesion through training, sport, socialising and other ‘team building’ activities.

Principle 6: Single versus multiple session interventions

Clinical research has found that brief, one-off interventions are ineffective.14 Stand-alone sessions should therefore be avoided, and follow-up sessions should be provided as much as possible to increase interventional efficacy.

Principle 7: Overgeneralising from clinical interventions

Mental ill-health prevention strategies, which aim to stop people becoming mentally ill, are not the same as mental ill-health treatments, which aim to help people who are unwell, get better. Understanding this difference is vital, as prevention strategies often borrow aspects of mental health interventions, incorrectly assuming that they will work on people who are already psychologically well.15 The UKAF should avoid overgeneralising from mental ill-health treatments when implementing prevention strategies.

Principle 8: Repeated skills practice

Simply giving people information or education on its own either in person or by written/electronic means rarely, if ever, brings about useful change. Research in both military and non-military settings has found that it is far more useful to provide information in conjunction with repeated skills practice, rehearsal, modelling and role play.16 17

Principle 9: Raising awareness—is it always needed?

Raising awareness of mental well-being is an intervention. However, there is always the risk of unintended consequences when raising awareness.18 Potentially pathologising normal emotions may lead people to seek unnecessary treatments and place strain on resources, which in turn may cause a sense of disillusionment and cynicism among personnel. If military organisations choose to raise mental health awareness, they must evaluate both the benefits and the consequences, while ensuring they have the capacity to meet the demand for well-being services.

Principle 10: Screening

Psychological health screening is frequently suggested as a way of preventing mental disorders. Repeated studies within the UKAF suggest that it is ineffective as a preventative intervention19 20 and may cause harm by providing false reassurance that staff who have been screened are psychologically well. Furthermore, potential false positives which classify someone as being unwell when they are psychologically healthy can increase fear and worry among personnel.

Conclusion

While it is imperative that the UKAF fully support the mental well-being of their personnel, caution should be exercised over the implementation of new interventions. We urge that the ten key principles presented in this paper are considered by the UKAF prior to implementing mental health interventions. A review of the evidence base and robust evaluation strategies are vital to ensure that an intervention is effective and is a valuable allocation of time, money and resources.

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References

Footnotes

  • Contributors The idea for this manuscript arose following discussions between AS, NJ, NG and SW, who then planned the ten key principles outlined in this editorial. AS and NJ wrote the first draft of the paper. NG, SW, GM, STB, NTF and EGL provided comments and redrafted as required. EGL wrote the abstract and made the major revision of the paper, which was amended into an editorial piece. All authors have seen and approved the final version of this manuscript for submission.

  • Funding This editorial was funded by Ministry of Defence (JFC/7A/00005).

  • Competing interests AS, NJ, GM and STB work for the MoD. EGL and NTF are funded on grants from the UK MoD. SW has also received grant funding from the MoD. NG and NTF are trustees of veterans’ charities. NG is the lead for military and veterans’ health at the Royal College of Psychiatrists.

  • Provenance and peer review Not commissioned; externally peer reviewed.