PTSD. Can we better prepare so we are less likely to develop PTSD?

A few weeks ago, I noticed a headline in The Times: “Alarm over surge in suicides by veterans of Afghanistan war.” The sad news was that there’d been a spate of suicides among former soldiers who took part in the bloodiest fighting in Afghanistan. In drawing attention to the facts, Johnny Mercer, the minister for veterans, said that he would expedite government plans for a new mental health service for veterans.

The piece revealed that fourteen former and soldiers have taken their own lives in the previous two months. A high proportion were veterans of Britain’s combat mission in Afghanistan between 2002 and 2014, and were described by Mr Mercer as “a specific unit that served at a specific time in Afghanistan . . . the bloodiest time”.  To his credit, Mr Mercer confirmed that plans would be brought forward for a “high-intensity” mental health programme which will treat post-traumatic stress disorder (PTSD) and help veterans with problems such as addiction and debt.

The Times went on to report: Reflecting on the possibility that some of the veterans may have been suffering from delayed-onset post-traumatic stress disorder, which research suggests can occur about a decade or more after a traumatic event, the minister [Mr Mercer] said: “I’m scratching around looking at evidence from across the globe, including the US, Israel and Australia, to understand if there is an event at the ten-year point. I’m yet to see a conclusive basis for that.”

However, data sets are scarcer than they could have been: the Ministry of Defence has been criticised because it did not collect data on veterans – unlike the US, Canada and Australia. It is now doing so.  I fear that the British “stiff upper lip” has led to a denial of the need to capture data that could have aided our understanding.

Yet, while Britain plays catch-up, other counties have made progress by investigating the ways that such “causalities of war” may be reduced.

Before going further, I will add that PTSD is not just related to military experiences.  Many people develop PTSD as a result of significant, traumatic, horrific or highly stressful events including terrorist attacks, accidents, bereavement, bullying, childbirth and physical, mental, sexual or child abuse.  Sufferers often associate emotions such a fear, guilt, shame and distress with events, or with their own reactions and actions… even where such emotions are not logical or appropriate.  They may start to recall the event(s) and to re-experience these emotions. They may find it difficult to control their emotions or may seek to avoid situations, people or topics that may trigger recollection of the event and of the  emotions that they associated with it.  People with PTSD often develop anxiety and depression. They may become irritable or experience emotional swings.  They are prone to becoming addicted to substances or to gambling as they seek to avoid episodes of PTSD symptoms.  It is estimated that half of us are exposed to traumatic events at some point in our lives and 20% of these will develop PTSD (

So, while it is important that we understand the way that PTSD symptoms can increase over time, and how best to address such problems, we might also seek out ways to help to avoid developing PTSD in the first place… kind of “inoculating people against developing PTSD”.

Back in 2011 the US Marine Corps ran a trial to see if mindfulness could help combatants to deal with the stresses war and reduce the longer term emotional scars that can cause PTSD.

Camp Pendleton in California is the training base for the Marines known for turning out some of the military’s toughest warriors – and they studied how to make troops less prone to problems through meditative practices based on mindfulness. Facing a record suicide rate and thousands of veterans seeking treatment for post-traumatic stress, the US military sought for ways to reduce strains on service members burdened with more than a decade of fighting in Iraq and Afghanistan.

The Marine Corps experimented with a series of mental exercises called “Mindfulness-Based Mind Fitness Training” to see if they could enhance the performance of troops, and their preparation to better handle stress.  The study involved 160 Marines who were taught to focus their attention by concentrating on their body’s sensations, including breathing, in a period of silence. The Marines practiced the calming methods prior to being immersed in a mock Afghan village with screaming actors and controlled blasts to expose them to combat stress.  Another 160 other Marines went through the mock village with no mindfulness-based training, acting as the control group.

The paper was published in American Journal of Psychiatry (2014 August). The research was led by Naval Health Research Center scientist Douglas C. Johnson.

So, what did they find?  Well, in comparison with the control the group the marines prepared by the mindfulness programme:

  • Demonstrated less apprehension prior to the exercise
  • Demonstrated a more rapid recovery (breathing and heart rate) at the end of the exercise
  • Exhibited bio markers representing lower levels of stress and associated physical responses
  • MRI scans showed reduced emotional responses to stimuli after the exercise.

The research concluded that the results showed that mechanisms related to stress recovery can be modified in healthy individuals prior to stress exposure, with important implications for evidence-based mental health research and treatment. Here’s the paper:

The paper states: Our investigation yielded three main results. First, mindfulness altered heart rate and breathing rate recovery following stressful training. Second, mindfulness modulated a strongly correlated set of peripheral biomarkers before, during, and after exposure to a stressful training session. Third, the neuroimaging results support the hypothesis that mindfulness affects brain structures that are important in integrating information about the internal physiological state and the body’s response to stress. Thus, the mindfulness programme demonstrated beneficial effects across multiple domains indicating enhanced recovery from stress. …. Taken together, these findings constitute evidence for the prevention and treatment of stress-related pathology.

We ask combatants to put their “lives on the line” and to be exposed to chaotic, stressful and even horrific experiences.  It seems to me that we owe them the best possible preparation and aftercare.  This research demonstrated the insulating effect of a simple 20-hour mindfulness programme that provided some protection against longer-term stress related illness.    Mr Mercer is now, quite rightly, amping-up the aftercare for those impacted – but what about improving the preparation for combat?

Even if we British have not carried out the research, then surely, we can at least implement the programmes shown to be effective by the research trials run by others.

“Mindful Organising” – for highly reliable performance.

Some time back I read Matthew Syed’s book “Black Box Thinking: Marginal Gains and the Secrets of High Performance”.  It’s a great book.  It contrasts the attitude “to reporting and learning from errors” of the commercial aviation industry and with that found in healthcare organisations.

Any failures or errors within the aviation industry are reported openly and investigated. Recommendations are mandated… thereby ensuring that lessons are learnt and similar failures are avoided.  Unfortunately, in many healthcare settings, any unexpected outcome – like death – is often be put down to “unexpected complications” or an “inability of the patient to respond”.  Worse in many situations there is a lack of “psychological safety” to enable staff to report concerns or errors without jeopardising their careers… and there may even be a keenness to avoid blame and any subsequent claims.  Hopefully healthcare organisations are addressing these barriers to improvement.

This week I have been reading about organisations which set in place structures to detect and correct errors.  It’s called “Mindful Organising”. This 2016 report in “Industrial and Labor Relations Review” surveyed 95 hospital nursing units in 10 hospitals. They found that for each significant increase in a team’s organising according to collective mindfulness principles, 10% fewer medication errors and 33% fewer patient falls were recorded. See here.

Achieving highly reliable (nearly error-free) performance in a high-risk setting requires the rapid detection and correction of anomalous or unexpected events. Several case studies – including those focusing on naval aircraft-carrier flight decks, nuclear power-plant control rooms and air traffic control operations – qualitatively linked “mindful organising” and “nearly error-free performance”. Case studies in healthcare contexts connected “mindful organising” with reductions in errors and to “highly reliable performance”. They provided quantitative evidence that “mindful organising” is associated with improved patient safety.

So, what is “mindful organising”?

The report defines “mindful organising” as “the application of respectful interaction to detecting and correcting errors and adapting to unexpected events”. It entails a set of actions and interactions through which members of a work group anticipate, prevent, and dynamically respond to errors and unexpected events by:

1) regularly discussing the various ways in which things can go wrong and collectively analysing early indications of trouble;

2) frequently questioning the adequacy of existing procedures and discussing potentially more reliable alternatives;

3) sharing with each other the most current information about their unique skills and knowledge;

4) committing to recovering quickly from setbacks by thoroughly analysing, discussing, and learning from them;

and 5) deferring to expertise rather than authority when resolving problems.

“Respectful interaction”, including “honest reporting”, enables employees to identify where potential threats reside and to more readily notice even weak signals of impending danger by fostering “perspective taking” (…acting with awareness of how one’s actions affect others) and “shared understanding”.  Promoting a culture offering “ psychological safety” is also essential (see my previous post here).

It seems that the openness, empathy, listening skills and objectivity of mindfulness practice might be a way of equipping staff with the attitude and skills to engage in “mindful organising”.  I hope so. I remain very keen to identify an organisation – perhaps in the care sector – who may be interested in a controlled programme to explore the benefits of becoming a Mindful Organisation.