resilience in the uniformed services Liz Royle Dr Jamie Hacker - - PowerPoint PPT Presentation

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

Managing Trauma in the Uniformed Services: an ESTSS task force

• 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

Managing Trauma in the Uniformed Services: an ESTSS task force

Addressing issues of stigma and creating accessible services by Liz Royle

Managing Trauma in the Uniformed Services: an ESTSS task force

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.

Managing Trauma in the Uniformed Services: an ESTSS task force

Barriers to Care

Lack 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)

Managing Trauma in the Uniformed Services: an ESTSS task force

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

Managing Trauma in the Uniformed Services: an ESTSS task force

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)

Managing Trauma in the Uniformed Services: an ESTSS task force

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)

Managing Trauma in the Uniformed Services: an ESTSS task force

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

Managing Trauma in the Uniformed Services: an ESTSS task force

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)

Managing Trauma in the Uniformed Services: an ESTSS task force

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

Managing Trauma in the Uniformed Services: an ESTSS task force

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?

Managing Trauma in the Uniformed Services: an ESTSS task force

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

• bviously 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”

Managing Trauma in the Uniformed Services: an ESTSS task force

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”

Managing Trauma in the Uniformed Services: an ESTSS task force

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”

Managing Trauma in the Uniformed Services: an ESTSS task force

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…”

Managing Trauma in the Uniformed Services: an ESTSS task force

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

Managing Trauma in the Uniformed Services: an ESTSS task force

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

Managing Trauma in the Uniformed Services: an ESTSS task force

Dr Jamie Hacker Hughes CPsychol CSci FBPsS

31 July 2011

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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

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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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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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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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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 Services What can a Referred Soldier / Sailor / Aviator expect?

Speed of Access – both Inpatient and Community services Nurse-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 h Aldershot 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

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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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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 Psychiatrist Operationally focused mental health service Major 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 Cyprus 36-hour decompression is executive responsibility Decompression aims to facilitate adjustment process CMHNs provide MH support and deliver psychoeducational briefs Additional support provided by Padre Decompression 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 Research

OROSM 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 Course CMHNs all attend CBT Basics, EMDR Level 1, and Motivational Interviewing Training Commitment to funding and conducting research

Managing Trauma in the Uniformed Services:

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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

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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

Managing Trauma in the Uniformed 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 SGJMCHCare-ClinPsych@mod.uk

Managing Trauma in the Uniformed Services: an ESTSS task force

Echoes Online

Empowerment for the police force

By Jan Schaart Managing Trauma in the Uniformed Services: an ESTSS task force

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.

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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

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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)

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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.

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Echoes Online: services we offer police force Psychotrauma 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

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Echoes Online: services we offer police force Echoes 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

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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

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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

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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

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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 tools 1. 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

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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

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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

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Echoes Online: portal for the police force where do we stand

Still two major issues 1. Privacy: environment which is not controlled by the police force 2. 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
• rganizational 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

Managing Trauma in the Uniformed Services: an ESTSS task force

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
• rganisation

Managing Trauma in the Uniformed Services: an ESTSS task force

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

Managing Trauma in the Uniformed Services: an ESTSS task force

“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.” Managing Trauma in the Uniformed Services: an ESTSS task force

Working creatively with stigma

• Accepting it
• Challenging it
• Working with it

Managing Trauma in the Uniformed Services: an ESTSS task force

Accepting it

Public perceptions of mental health and therapy Helpful investment in sense of self as professional and resilient

Managing Trauma in the Uniformed Services: an ESTSS task force

Challenging it

Education & normalisation Personalising the service

Accessibility & flexibility

Managing Trauma in the Uniformed Services: an ESTSS task force

Education & normalisation

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

Managing Trauma in the Uniformed Services: an ESTSS task force

Education & normalisation

• “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

Managing Trauma in the Uniformed Services: an ESTSS task force

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

Managing Trauma in the Uniformed Services: an ESTSS task force

Accessibility & flexibility

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

• f staff members

Delivering psychological first aid rather than debriefing Recognising the importance of the perception of support post-trauma

Managing Trauma in the Uniformed Services: an ESTSS task force

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

Managing Trauma in the Uniformed Services: an ESTSS task force

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.

Managing Trauma in the Uniformed Services: an ESTSS task force

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

Managing Trauma in the Uniformed Services: an ESTSS task force

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

• n 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. Managing Trauma in the Uniformed Services: an ESTSS task force

Trust me I’m a therapist!

Approachability (“no airs or graces”) Straight forwardness Confidence in our knowledge Effective treatments Humour Respect Confidentiality

Managing Trauma in the Uniformed Services: an ESTSS task force

Gill Moreton Rivers Centre for Traumatic Stress Edinburgh, Scotland + 44 131 537 6743

Gillian.Moreton@nhslothian.scot.nhs.uk Managing Trauma in the Uniformed Services: an ESTSS task force

Uniformed services task force – get involved!

liz.royle@krtraumasupport.co.uk www.uniformedservices.blogspot.com

Managing Trauma in the Uniformed Services: an ESTSS task force

References:

Managing Trauma in the Uniformed Services: an ESTSS task force

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:

Managing Trauma in the Uniformed Services: an ESTSS task force

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

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Managing Trauma in the Uniformed Services: an ESTSS task force

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