working creatively to promote resilience in the uniformed ...€¦ · •currently considering a...

Working creatively to promote resilience in the uniformed

services

Liz Royle

Dr Jamie Hacker Hughes

Dr Walter Busuttil

Jan Schaart

Gill Moreton

Managing Trauma in the Uniformed Services: an ESTSS task force

Aims of the Uniformed Services Task Force

Promoting the understanding and treatment of trauma in the police, fire and military services

Providing a forum for expert exchange to develop best practice in proactive support and intervention

Encouraging research


• Over 40 members representing 10 different countries and working with fire, police, military, veterans, paramedics

• Website with resources, blog, book reviews

• Email list with training and research news

• Currently considering a Delphi study into best practice guidelines for running family support groups for the military services


Addressing issues of stigma and creating accessible services

by Liz Royle


If you build it, they will come … not necessarily!

55 – 62% of soldiers and Marines meeting screening criteria for major depression, generalised anxiety or PTSD were “uninterested in receiving help” (Dickstein et

al, 2010)

Research has consistently shown that those who are more functionally impaired are less likely to be

receiving mental health services and that stigma, shame and attitudes towards treatment are

important factors in this.


Barriers to CareLack of trust in mental health professionals

Not knowing where to get help from

Inadequate transportation to get there

Difficulty in scheduling appointments / get time off

Financial constraints

Concerns about impact on career

Lack of confidence in effectiveness of treatment(Hoge et al, 2004; Wright et al, 2009)

Stigma is a different construct (Britt et al, 2008)


Stigma arises because of

• Labelling

• Stereotyping

• Cognitive separation into “them and us”

• Status loss

• Discrimination(Link & Phelan, 2001; Corrigan, 2005)

Societal / public stigma v self-stigma


Onset responsibility

• biological / medical

• heredity / weakness

• events based

• malingerers

Offset responsibility

• why aren’t you better yet?

• take care with psycho-education!(Weiner, Perry & Magnusson, 1988; Gibbs et al, 2011)


Effects of stigma

Inhibiting help-seeking behaviour with those most in need perceiving

the greatest stigma (Hoge et al, 2004)

Impacting on therapy with increased rates of drop-out and treatment non-

compliance (Royle, Keenan & Farrell, 2009)


Stigma in the military

A necessary evil?

Historically, mental disorders were seen as representing personality weakness – a notion nurtured by the military service in wartime as a deterrent to stress-casualty epidemics


Stigma in the military

Combat requires toughness, mission focus, group and individual self-sufficiency creating a belief system that

“help-seeking is a sign of weakness”(Dickstein, 2010)


Stigma in the police: an added dimension

The interface with people who have mental health problems can reinforce stereotypes – mad, bad or dangerous (Royle, 2003; Watson et al, 2004; Lamb, 2002)

Detracting from the “real job”

Perception of mental health services and treatments as poor or ineffective

Compassion and sympathy but not empathy


Are issues of stigma magnified for the ex-services police officer?

Preliminary findings from PhD research: What are the attitudes of ex-military personnel,

who have joined the police service, towards seeking help with mental health problems?


The nature of policing may create a skewed perspective

“People see them as a nuisance. We lock them up 136 Mental Health Act,

bring them in and they’re urinating on the floor, banging on the cell and we

obviously have to take them to whichever institution is deemed fit and

it’s just a pain in the a*** because they’re difficult to deal with”


Ex-military police officers – a discrete population? A cognitive separation into “us and them”

Us: “without a shadow of a doubt, we’re different,” “tougher,” “disciplined,”

Them: “They can’t cope with the nasty side of policing,” “Bobbies now just can’t cope with that whereas all the ex-service lads sit there and it’s not a problem”


Taking “us and them” a step further

Police officers with mental health issues: “Weak. Mentally weak and unable to cope with life’s ups and

downs.”

“There are people in the job today that shouldn’t be”


Self-stigma: how it can feel to stop being like “us” and become like“ them”

“A waste of a uniform … damaged goods”

“The fear of losing my job … non-acceptance of having a problem”

“Completely worthless”

“People like me don’t get mentally ill”

“Why am I here? I’m not mad … I flipped and trashed (the psychiatrist’s) office … kicked his

table over, kicked the drinks over…”


Addressing stigma: lessons learned from the general population (Corrigan et al, 2001)

Contact - direct contact with people with mental health issues

Education – correcting misconceptions

Protest – openly rejecting negative stereotypes and language


Applying this to the uniformed services

Contact - May not be as helpful for the police, (Pinfold 2005)

Education – A normal response to an abnormal event

Battlemind training large group training participants report lower levels of stigma (Adler 2009)

Caveat: Normalising reactions may increase stigma of PTSD (Nash et al 2009)

Protest - May drive beliefs underground

Positive leadership and unit cohesion help (Wright et al 2009)

We need to tackle both self-stigma and societal stigma in order to make effective treatments accessible


Managing Trauma in the Uniformed Services:an ESTSS task force

Dr Jamie Hacker Hughes CPsychol CSci FBPsS

31 July 2011

Managing Trauma in the

Uniformed Services:

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Background

Generally fit, young healthy population

c. 80% below cut-offs using GHQ-12

King’s Centre for Military Health Research

Broadly in accordance with civilian population

20% above cut-off on self-rated scales

Below many comparable occupations exposed to similar stressors

31 July 2011Managing Trauma in the Uniformed

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Non-Deployed Population

Single Service (sS) Stress Management Policies

Routine role of Commanders, Welfare and Families Officers, Generic Social Workers and Chain of Command

Overarching Review of Operational Stress Management (OROSM) 2005

Migration from inpatient and outpatient model to focus on role of Chain of Command supported by community-based mental health care


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an ESTSS task force

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PTSD

KCMHR

Cohort study

4% PTSD rates (7% in Combat Arms)

Based on self-report

Using 4-item PC-PTSD

Number of diagnosed cases much lower

249 in 2010 (1.2 per 1000 strength DASA)


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an ESTSS task force

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Primary Care

Single Service (sS) General Medical Practitioners (GMPs)

Additional support from Welfare (Navy Personnel and Family Service, Army Welfare Service, RAF Welfare Service), Padres and TRiM (peer-support) practitioners

First level MH support with DCMH liaison

In NHS approx 30% of presentations are MH related

Similar in British Armed Forces


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an ESTSS task force

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Trauma Risk Incident Management TRiM

Peer-delivered risk assessment system

Developed to fill void left after withdrawal of CISD in 2000 (Cochrane review etc)

Developed by 2 Army Mental Health Nurses; Pioneered by Royal Marines (RM); Researched in an RCT within RN by ACDMH and KCMHR

Now used in all three Services

TRiM practitioners undertake immediate support and signpost on to formal MH care

Defence Mental Health ServicesWhat can a Referred

Soldier / Sailor / Aviator expect?Speed of Access – both Inpatient and Community

servicesNurse-led assessment MDT functioning – filter to psychiatrist / psychologist /

nurse for: medication / diagnostic complexities / specific treatments / prognostic and occupational advice / direct liaison with unit etc)

Fitness – Return Fit or Partially Fit or Discharge (Those personnel discharged on MH grounds are supported throughout by Defence Mental Health Social Workers)


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Primary/Intermediate Care - DCMH

Departments of Community Mental Health

UK 15, Germany 4, Cyprus 1, Gibraltar 1

Multiprofessional

Psychiatrists, Clinical Psychologists, Community Mental Health Nurses (CMHN) Mental Health Social Workers

Localised services to tri-Service catchment areas

UK Departments of Community Mental Health

Kinloss

Catterick

Cranwell

Marham

Colchester

Woolwic

hAldershot

Brize Norton

Plymouth

Tidworth

Northern Ireland

Portsmouth

Leuchars

Donnington

Faslane


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DCMH

Aim is to provide local service enabling clients to stay in Service environment

Normal social support networks maintained

MES restricted if necessary

Effective DCMH Treatments based on NICE guidelines: CBT, EMDR, Medication

All DCMH nurses trained in psychotherapeutic interventions above

DCMH

DCMH aim

'to provide timely assessment and treatment to maximise operational and occupational capability within HM Forces,

and, for those personnel who cannot be rehabilitated, to ensure they receive a smooth as possible transition to civilian life’

Managing Trauma in the Uniformed Services:

an ESTSS task force

31 July 2011

Managing Trauma in the Uniformed

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DCMH

DASA (Defence Analysis Statistics and Advice)

DASA Annual Summary 2010

5581 new attendances (c. 2.77% of AF)

Of these 3932 (1.96% of AF) diagnosed

Very low threshold of referral to DCMH in comparison with National Health Service

i.e. an Occupational Mental Health Service


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General Findings

Army > Royal Navy and RAF

Royal Marines < Army and RAF

Females 2 x Males

Other Ranks > Officers

Most common Dx is Adjustment Disorder

249 personnel diagnosed with PTSD in 2009 (=0.12%)

Rates of adjustment disorder, neurotic disorder and PTSD higher in those who have deployed (but lower rates of mood disorder)

Use of alcohol is a problem within AF (Fear et al 2010)

AF personnel drink more than their civilian counterparts


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Inpatient Care

Last MoD inpatient unit closed in 2003

Priory Group from 2003 to 2008

Now consortium of 6 English and 2 Scottish NHS Trusts since Dec 2008

315 admissions to In-Patient Service Provider (ISP) in 2010 (c. O.15% of AF strength)

Only 5% of DCMH referrals referred on for inpatient care

Assured admission within 4 hours normally as near as possible to normal location


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Inpatient Care

Following admission, visit by Service Liaison Officer (SLO) within 72 hours

Daily telephone contact

Weekly visits throughout remainder of admission including attendances at ward rounds, case conferences and reviews

Average length of admission 10 days

Length of stay decreasing with new ISP


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an ESTSS task force

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Reservists

Operationally and Mobilised – Same access to MH Care as Regulars

Slightly higher risk of developing PTSD (5% vs. 4%) (KCMHR, 2006)

Reservist Mental Health Programme (RMHP) established in November 2006 at RTMC Chilwell

Eligible to all with operationally attributable injuries who have deployed since 2003

70 of 103 patients treated by DCMHs under RMHP have returned to deployable fitness


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Operational Population

OMHNE

Operational Mental Health Needs Evaluation

Op Telic OMNHE (I) Feb 09

Rates of mental health problems similar to non-deployed population

Op Herrick OMNHE (A) Jan 2010


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FMHTs

Field Mental Health Teams Consist of Community Mental Health Nurses (CMHNs)

Visiting PsychiatristOperationally focused mental health serviceMajor role in psycho-education (pre-, intra-, post-

deployment)Those unfit returned to UK by Aeromedical Evacuation

(AE) for ISP admission or review in Primary Care or at DCMH


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Decompression

Formed units return to UK via Cyprus36-hour decompression is executive responsibilityDecompression aims to facilitate adjustment processCMHNs provide MH support and deliver

psychoeducational briefsAdditional support provided by PadreDecompression evaluated by ACDMH for PJHQ – only

50% wished to go through process initially but over 90% found it to have been useful


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DMRC and RCDM

Defence Medical Services Rehabilitation Centre Headley Court

CMHNs and Psychologists, Psychiatric Support from DMHS

Royal Centre for Defence Medicine Birmingham

CMHNs, Psychiatric and Psychological Support from DMHS

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Training and ResearchOROSM recommended that all 3 Services should

include psycho-educational material throughout initial training and promotion courses and on discharge – currently being audited and implemented throughout

Academic Centre for Defence Mental Health (ACDMH) run Diploma in Military Mental Health and MSc Courses

RCDM run Enhanced Operational Mental Health CourseCMHNs all attend CBT Basics, EMDR Level 1, and

Motivational Interviewing TrainingCommitment to funding and conducting research


Services:

31 July 2011 41

In Conclusion - 1

UK MoD takes psychological disorders very seriously

There is a high priority attached to increasing awareness, combating stigma and providing effective diagnosis and treatment

DMS wishes to increase number of MH personnel

Managing Trauma in the

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In Conclusion - 2

It is hoped that efforts to increase awareness of mental health issues and support available will reduce incidence of mental health problems in future veterans

It is believed that the themes and recommendations of Dr Andrew Murrison MP’s recent report ‘Fighting Fit’ will make a vital contribution towards rebuilding the Military Covenant and providing additional support to members of the UK Armed Forces and ex-UK Armed Service personnel with MH issues


Services:

an ESTSS task force

Thank you

Dr Jamie Hacker Hughes

DCA Psychology and

Head of Defence Clinical Psychology

Ministry of Defence Joint Medical Command

HQ Surgeon General

Coltman House DMS Whittington

Lichfield WS14 9PY UK

[email protected]

Managing Trauma in the Uniformed Services:an ESTSS task force

Echoes Online

Empowerment for the police force

By Jan Schaart


Arq Psychotrauma Expert Groep

Arq Psychotrauma Expert Groep consists of several expert organizations, all

specialists in their own field, which have organized themselves around the issue of

psychological trauma.

Their partnership within Arq creates added value. Through the exchange of

expertise, experience and potential for innovation, the needs of societies can be

better anticipated and served. The complementary nature of their union allows

greater benefits for both individuals and organizations.

The partners in Arq work together on scientific research, education and

training as well as international activities in the Arq Research Program, Arq

Education Program and Arq International Program respectively.

24 May 2011


an ESTSS task force 46

Echoes Online: empowerment for the police force

• Arq Psycho Trauma Expert Groep:

• 9 partners, 5 working with uniformed services

• Mission: to develop practical knowledge

Presentation:

• Services we offer the police force

• Echoes Online: objects & concept of empowerment

• Portal for the police force

24 May 2011



Echoes Online: services we offer police force Impact Foundation: partner in Arq

• National advice centre for psychosocial care after disasters, developed the military guidelines for psychosocial support for uniformed service organizations in collaboration with police and fire brigade.

• Guidelines: prevent work stress & health related problems.

• Organization peer support = key aspect, + organizational resilience, individual responsibility & healthy work conditions.

• Guidelines accepted by all as standard psychosocial support

• Pilot 2011 implement guidelines 5 regions (15.000 policemen)

24 May 2011



Echoes Online: services we offer police force IVP (Institute for Psychotrauma)

• IVP: partner in Arq Psychotrauma Expert Groep, is a business unit working with the government and private companies.

• The core business is research, crises management, consultation, treatment of psychotrauma and training.

• IVP has over 25 years experience working with the police force, mostly after a crisis, training stress coping, sometimes consultation about prevention activities within the frame work of labour legislation.

24 May 2011



Echoes Online: services we offer police forcePsychotrauma Diagnosis Centre: partner in Arq

• Developed for veterans: to deliver a fast (takes one day) and clear diagnostic assessment and, if necessary, recommendations for treatment

• Special PDC part is outpatient clinic for policemen with PTSD symptoms (180 pro year)

• Trained staff, who know the police force by experience,

coordinate the assessment and treatment

Echoes Online: services we offer police force Foundation Centre ’45: partner in Arq

• National psychotrauma mental health institute

• Foundation Centre ’45 offers outpatient clinic, day clinic and 24 hours inpatient clinic treatment services

• Special day clinic groups in which policemen are treated in a multidisciplinary setting

• Treatment: psychiatric care, individual psychotrauma therapy (EMDR, CBT), group therapy & nonverbal therapy

• The results are very positive, 80% of the patients report being satisfied about the results

24 May 2011



Echoes Online: services we offer police forceEchoes Foundation: partner in Arq

• Founded by Eric Vermetten after Tsunami 2004

• Huge need among survivors and relatives of the victims: therefore online intervention for the victims: www.tisei.org (presentations of results)

• Sharing experiences, complete memories, information available help

• Echoes: platform for online psychosocial developments, also developing websites for people exposed to overwhelming and traumatic events

• Portals created for civilians, veterans, companies, disasters (Tripoli) and now working on a police portal: http://www.echoesonline.nl

http://www.tisei.org/

http://www.tisei.org/

http://www.echoesonline.nl/

http://www.echoesonline.nl/

24 May 2011



Echoes Online: objects

• Promote online possibilities psychosocial support victims

• Create portals as safe environment for colleagues

• Concept of empowerment

• Validated screening tools

• Stimulate research, quality management and development in online psychosocial interventions

24 May 2011



Echoes Online: concept of empowerment

Prevention

• Get in contact with the whole exposed community

• Get in contact with people at risk

• Inform people how to get help when needed

Empowerment 1

• Inform people about consequences of traumatic events

• Inform people about temporary complaints

• Provide tools how to deal with these complaints

24 May 2011



Echoes Online: concept of empowerment

• exchanging experiences

• support each other in overcoming difficulties

• fill in gaps in memories with information from fellow survivors

• reconstructing and reframing the disaster with each other

• advising each other in legal and health care matters

24 May 2011



Echoes Online: portal police force, format

Story telling and informing each other• Stories reference group: experience of several people.

How to cope with ones situation and deal with problems

Three tools1. Professional information: consequences overwhelming

events, PTSD symptoms, about impact and tips how to deal with symptoms etc.

2. Self-assessment: to measure the impact of the events

3. Online forum were they can contact peers

24 May 2011Managing Trauma in the Uniformed Services:


Echoes Online: portal police force, measure impact

• DKL = impact tool known to general practitioners

• Short DKL: time events, level stress, sleep and irritation

Outcome

1. Green: some complaints, which don’t bother too much

2. Orange: stress related complaints, advice & repeat tip

3. Red: much stress related complaints, advice extended test

• Extended test can advice to visit general practitioner

• Possibility to compare tests

24 May 2011 58



Echoes Online: portal for the police force

• Arq Psychotrauma Expert Groep background: prevention, consultation, screening, diagnosis and treatment

• Approval of the portal is important

• Experts, government, regional and national police force, police trade unions & medical police services

• Took 8 months to get to a mutual level of agreement



Echoes Online: portal for the police forcewhere do we stand

Still two major issues 1. Privacy: environment which is not controlled by the police

force2. Possibilities for stepped care when we start

• We are working on both issues• Building police care network • Working on screening tool to detect if problems are

organizational focused or based on individual problems (developed by IVP for the national railroad company)

www.arq.org

Partners as from January 1st 2011:

Foundation Centrum '45

IVP

PDC

Equator Foundation

Antares Foundation

Cogis

War Trauma Foundation

Impact

Partnering projects within Arq:

Arq Research Program (ARP)

Arq Education Program (AEP)

Arq International Program (AIP)

“Trust me, I’m a therapist!”

Crossing the threshold – talking with fire fighters about

resilience not madness

Gill Moreton

Rivers Centre for Traumatic Stress

Edinburgh, Scotland


Crossing the threshold……

what do we think of each other?

What do we think of each other?Us about them

Brave

Calm

Funny

Plain-spoken

Strong / big

Tough / robust

Practical / resourceful

Capable / reliable

Heroic / selfless

Male

Handsome / tall / sexy

Resilient

Cope by drinking or denial

Laid back (horizontal)

Avoid strong negative emotion

Them about us

White coats

Lying on couches

Talking about their childhoods

Hippies with joss sticks, whale music and beanbags

“Basket weaving coaches”

Nut doctors

Pink and fluffy

Pill dispensers

Look like Freud

Therapy is for those with “the madness” (aka stick pencils up their noses)

Rivers Centre for Traumatic Stress and the

Emergency Services

• Working with the Emergency Services for nearly 20 years providing:

• Priority assessment and treatment to ES staff developing psychological injuries following exposure to traumatic stress at work

• Screening / self-referral scheme following critical incidents

• Advice and guidance to senior management and occupational health

• Training for new recruits

• Development of peer support initiatives within the organisation


Overcoming stigma

• In 2010 we evaluated the Critical Incident Stress Management

scheme.

• We got a response rate of 30%

• 81% of respondents felt that there was no stigma associated

with seeking help

• 95% said they would make use of the Rivers Centre if they were

experiencing problems

• 95% said confidentiality was key to the success of the scheme


“Never had to be in contact but colleague who went to the centre was very satisfied and full of praises for the work done there. I think the

centre does a brilliant job.”

“I feel this is an important service, especially when you consider the events you may be involved in. I would like to think that recent

events have made this service vital to staff.”

“Its good to know that if I do have any issues in the future the Centre is there for help.”

“In my opinion the key to the Rivers Centre is its confidentiality and being external to the Service as unfortunately there is still a stigma

about the help they offer and the impact this may have on your career.”


Working creatively with stigma

•Accepting it

•Challenging it

• Working with it


Accepting it

Public perceptions of mental health and therapy

Helpful investment in sense of self as professional and resilient


Challenging it

Education & normalisation

Personalising the service

Accessibility & flexibility



Emphasis on resilience not vulnerability

Equalising the possibility of both physical and

psychological injuries

Aim is to avoid a catastrophic reaction to developing

a trauma reaction



• “Staying resilient” training with new recruits at the

Scottish Fire Services College

• Educating senior management & fire fighters about the

interplay between organisational stress, domestic

stress and resilience

• Building psychological injury into Health & Safety risk

assessments

• Pragmatism not panic


Personalising the service

Visits to stations

Articles for the Service newsletter

Information on the Service intranet

Participation in Occupational Health events

Contributing to stress awareness days

Pro-active approaches to staff


Accessibility & flexibility

Responding to major incidents, e.g. death or injury

of staff members

Delivering psychological first aid rather than

debriefing

Recognising the importance of the perception of

support post-trauma


Working with it

Using peer support and testimony

Building credibility

Being clear about our roles

Using peer support & testimony

Linking fire fighters in treatment sessions

reducing shame and isolation

Asking fire fighters to give messages to:

new recruits

colleagues starting treatment


There were a few moments where my reaction on being told

the next step caused a negative reaction – that would be a

polite way of saying, I was off. However, patient reassurance

and explanation convinced me to follow the advice.

I cannot praise the treatment I received enough, without it I

would not have been able to carry on at work. The support to

recognise and learn from the incidents at times seemed too

much, but explanation, encouragement and practical tasks

brought me to a much happier situation.


Building credibility

Therapist or proxy fire fighter?

Experts in our mutual roles

98% of the staff in our survey thought it was important we

were a specialist trauma service

Need to know enough to engage them and to be familiar

with their role


I don’t think I had ever felt so wound up or disheartened with myself as

I approached the building. In my mind I thought my career was done, I

had looked at the pension calculator and redone the family finances a

dozen times in my head. I stood outside having the “will I go in or go

home” argument in my head. “If I had the bottle to go in the building at

the incident I surely had the bottle to go in and at least hear what was

on offer”. I really didn’t think this was going to help and I wasn’t

convinced I believed it worked anyway.

Two hours later I had spoken more about myself and the “job” than I

had to anyone in years. I was opened up like a blister desperate to be

burst. “You need 5-6 sessions and you are fixable”. It didn’t feel like a

sales pitch, it felt like they knew what they were talking about. I felt

safer with “my therapist” than I had for weeks and the in my head

conversation on the way home was different.


Trust me I’m a therapist!

Approachability (“no airs or graces”)

Straight forwardness

Confidence in our knowledge

Effective treatments

Humour

Respect

Confidentiality


Gill Moreton

Rivers Centre for Traumatic Stress

Edinburgh, Scotland

+ 44 131 537 6743

[email protected]


mailto:[email protected]

Uniformed services task force –get involved!

[email protected]

www.uniformedservices.blogspot.com


References:


Adler, A.B., Bliese, P.D., McGurk, D., Hoge, C.W. & Castro, C.A. Battlemind debriefing and Battlemind training as early interventions with soldiers returning from Iraq: Randomisation by platoon. Journal of Consulting and Clinical Psychology. Vol 77(5), Oct 2009, pp. 928-940

Britt, T.W., Greene-Shortridge, T.M., Brink, S., Nguyen, Q.B., Rath, J,. Cox, A.L.. Hoge, C.W. & Castro, C.A. (2008) Perceived stigma and barriers to care for psychological treatment: implications for reactions to stressors in different contexts. Journal of Social and Clinical Psychology. Vol 27(4), Apr 2008, pp.317-335

Corrigan, P.W., River, L.P., Lundin, R.K., Penn, D.L., Uphoff-Wasowski,K., Campion, J., Mathisen, J., Gagnon, C., Bergman, M., Goldstein, H. & Kubiak, M.A. (2001) Three Strategies for Changing Attributions about Severe Mental Illness. Schizophrenia Bulletin, 27(2) pp.187-195.

Corrigan, P. W. & Calabrase, J. D. (2005) Strategies for assessing and diminishing self-stigma. In P.W. Corrigan (Ed). On the stigma of mental illness. Practical strategies for research and social change. Washington D.C: American Psychiatric Association.

References continued:


Dickstein, B.D., Vogt, D.S., Handa, S. & Litz, B.T. (2010) Targeting self-stigma in returning military personnel and veterans: a review of intervention strategies. Military Psychology. Vol 22, pp.224-236

Hoge, C.W., Castro, C.A., Messer, S.C., McGurk, D., Cotting, D.I. & Koffman, R.L. (2004) Combat duty in Iraq and Afghanistan, mental health problems and barriers to care. The New England Journal of Medicine. Vol 351(1), Jul 2004, pp.13-22

Gibbs, D.A., Rae Olmsted, K.L., Brown, J.M., & Clinton-Sherrod, A.M. (2011) Dynamics of stigma for alcohol and mental health treatment among army soldiers. Military Psychology, 23. 36-51

Lamb, H. R., L. E. Weinberger, et al. (2002). The police and mental health. Psychiatric Services 55(10): 1266-1271.

Link, B.G. & Phelan, J.C. (2001) Conceptualising Stigma. Annual Review of Sociology, 27, pp.363-385



Royle, L. (2003) An exploration of the perceptions of police firearms officers to traumatic work-related incidents and the relevance, in their opinion, of different support interventions offered. Counselling and Psychotherapy 3(2) p.173

Royle, L., Keenan, P. & Farrell, D. (2009) Issues of stigma for first responders accessing support for post traumatic stress. International Journal of Emergency Mental Health. Vol 11(2), Spring 2009, pp. 79-86

Nash, W.P., Silva, C. & Litz, B. (2009) The historic origins of military and veteran mental health stigma and the stress injury model as a means to reduce it. Psychiatric Annals. Vol 39(8), Aug 2009, pp.789-794

Pinfold, V., Thornicroft, G., Huxley, P. & Farmer, P. (2005) Active ingredients in anti-stigma programmes in mental health. International Review of Psychiatry. Vol 17(2), Apr 2005, pp. 123-131



Watson, A. C., P. W. Corrigan, et al. (2004). Police officers' attitudes toward and decisions about persons with mental illness. Psychiatric Services 55(1): 49-53.

Weiner, B., Perry, R.P., & Magnusson, J. (1988) An attributional analysis of reactions to stigmas. Journal of Personality and Social Psychology. 55(5), 738-748

Watson, A. C., P. W. Corrigan, et al. (2004). Police officers' attitudes toward and decisions about persons with mental illness. Psychiatric Services 55(1): 49-53.

Wright, K.M., Cabrera, O.A., Bliese, P.D., Adler, A.B., Hoge, C.W & Castro, C.A. (2009) Stigma and barriers to care in soldiers post-combat. Psychological Services. Vol 6(2), pp.108-116

working creatively to promote resilience in the uniformed ...€¦ · •currently considering a...

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