Lifetime trauma, mental health, alcohol and help-seeking; the phenomenological experience of veterans residing in Northern Ireland

doi:10.21203/rs.3.rs-3961899/v1

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Research Article

Lifetime trauma, mental health, alcohol and help-seeking; the phenomenological experience of veterans residing in Northern Ireland

https://doi.org/10.21203/rs.3.rs-3961899/v1

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Journal Publication

published 10 Sep, 2024

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Background

Veteran residents in Northern Ireland (NI) are an under-researched population. Little is known of their experiences of trauma and mental health management. The overall mental health of veterans living in NI may be poorer than other veteran populations, due to the challenges presented by the unique landscape. Understanding their experiences is crucial for providing appropriate, targeted support.

Method

Six male veterans, who had received a mental health diagnosis, living in NI and all aged > 40 years agreed to partake. Interpretative phenomenological analysis was used to explore their experiences. Semi-structured interviews, using open-ended questions, were conducted over the telephone.

Results

Two experiential themes were identified each containing three experiential statements. Statements for ‘an extreme lack of’ included: lack of mental health literacy/awareness; lack of expectations of official support; lack of a sense of perceived appreciation. Statements for ‘an extreme abundance of’ included: exacerbated exposure to a range of extreme environments; high levels of ruled-based living; high levels of engaging with informal/local level support.

Conclusions

Several experiential statements aligned with existing literature, including having poor mental health literacy and problem recognition, and heavily utilising social support versus formal help-seeking. Some novel findings were elicited, including bouncing between extreme positive and negative environments (e.g., rapidly between conflict trauma and extreme sports or partying). This could be as detrimental to mental health as experiencing conflict trauma. Heavy alcohol use was just another rule soldiers followed, with veterans reflecting alcohol autonomy only presented itself post-military. Positive help-seeking experiences failed to improve poor opinions of support organisations. Finally, poor self-perceptions connected to military status are pertinent in NI, which fuels self-marginalisation and distrust. Veterans living in NI likely have elevated levels of lifetime trauma exposure, due to their affiliation with the Troubles, other military-related traumas and general lifetime traumas. Moreover, NI veterans often demonstrate a reluctance to help-seek due to security concerns, resulting in potentially poorer mental health outcomes. Understanding how NI veterans interpret their experiences is key to providing adequate healthcare. Novel findings would benefit from further exploration.

Veterans

Northern Ireland

Experiences

Help-seeking

Mental Health

Alcohol

Military veterans residing in Northern Ireland (NI) are an under-researched population, mainly due to security concerns connected to the Troubles’ legacy. Generally, anyone in NI who is an ex-Crown employee is potentially vulnerable to sectarian violence^(1,2). To foster a sense of safety it is common for veterans in NI not to disclose their veteran status. Currently, NI is the only UK nation that purposely does not collect military affiliation data via the national census. Overall, NI veterans are unlikely to discuss their previous work-related experiences^(3,4). This need for non-disclosure and hypervigilance towards security applies to not only native NI veterans but also those who choose to settle in NI at a later date.

While the experiences of veterans residing in NI have been under-explored certain assumptions can be made, including being exposed to elevated levels of lifetime trauma. Those who were native to NI and of a particular age were likely ‘Children of Troubles’, and witnessed localised conflict trauma during their everyday lives⁽⁵⁾. NI, as a nation, has also historically experienced high rates of social deprivation, meaning that many who grew up in NI had more adverse childhood experiences⁽⁶⁾. As the Troubles unfolded some NI residents chose to join the local military regiment; the Ulster Defence Regiment (UDR). The UDR were members of the local community and were living in their own theatre of war. For the UDR it was not possible to escape Troubles-related trauma exposure, even during their leisure time⁽²⁾. The UDR in particular were frequently the target of sectarian attacks, which was difficult to manage as they did not live in a secure barracks. Even if an NI native chose to join the military as a method of leaving NI, particularly during those turbulent times, they were likely sent on deployment to a location or context that contained perceived or actual trauma exposure.

Research relating to elevated trauma exposure has referred to trauma being layered across a person’s life course ⁽⁷⁾, and this layering can have detrimental effects on mental health outcomes. Literature pertaining to the effect on mental health of living in NI during the Troubles, found that the fear of perceived trauma was as detrimental to mental health outcomes as experiencing actual trauma ⁽⁸⁾. If specific traumas experienced by soldiers/veterans are associated with poorer mental health^(9,10), it follows that layered trauma (actual and perceived) is likely to be especially detrimental to mental health. Evidence associated with military populations does suggest there has, historically, been a trend in using alcohol to cope with the psychological effects of (actual and perceived) traumatic experiences⁽¹¹⁾. The use of alcohol also appears to be intrinsically linked to non-help-seeking. Help-seeking, especially for poor mental health, was stigmatised by the military ⁽¹²⁾, while alcohol use was encouraged and facilitated ⁽¹¹⁾. Lower tendencies to help-seek often cascade to veteran life, which could partially account for low global help-seeking rates in veterans and higher levels of alcohol dependence ^(13,10). It is perhaps unsurprising that Combat Stress, the UK’s leading veteran mental health charity, reported that veterans tend to present with multiple, co-occurring mental health difficulties, with 95.6% screening for hazardous alcohol use. Moreover, Combat Stress found that NI veterans made up a disproportionately large number of mental health treatment attendees, and waited an average of 13 years to help-seek⁽¹⁰⁾. Veterans who delay help-seeking, and spend a protracted time managing their difficulties with alcohol, ultimately do help-seek out of heightened functional impairment⁽¹⁴⁾. Unfortunately, at this stage, veterans’ overall mental health difficulties are more complex, which makes treatment more challenging both for providers and veterans.

If veterans in NI did wish to help-seek, regardless of stigmatised attitudes and complexities surrounding comorbid mental health difficulties, resources are particularly low locally. The lack of accessible and available resources is also considered to be connected to the Troubles legacy, and may be an added barrier to help-seeking for this population⁽¹⁵⁾. If a veteran has specific healthcare needs they have to use the same healthcare pathway as the general population. Statutory, clinical support is limited for everyone in NI and waiting lists are lengthy⁽¹⁶⁾. Even if a veteran was entitled to expedited healthcare, due to their veteran status, it is unlikely they would disclose their status to access such care. Some veterans could opt for private care, but not all can meet these costs, and in the UK medical costs are frequently not covered by healthcare insurance. Regarding the charity sector, just six out of approximately 1,200 military or veteran-specific organisations are situated in NI ⁽¹⁵⁾. Veteran help-seeking literature does suggest that limited or inaccessible resources, together with poor experiences of attempting to use such resources, are key barriers to help-seeking^(17,18). Issues associated with resource availability, accessibility and user experience impact all veterans, not just those who are native.

To improve or develop services for veterans resident in NI it is essential that their experiences are understood regarding the pathway between trauma and help-seeking for poor mental health outcomes. Adequate support for mental health should be trauma-informed and relevant to address specific mental health difficulties. It is also essential to develop or enhance services where positive help-seeking experiences are a key component. Evidence relating to veterans in NI indicates that rates of mental health difficulties are equal to, or higher than, that of a clinical, help-seeking sample⁽¹⁹⁾. Moreover, there is a reported relationship between summative trauma and comorbid mental health outcomes, together with an association between PTSD symptoms and alcohol difficulties for veterans in NI^(20,21). However, currently, we are unaware of the actual experiences of veterans in NI, relating to their response to trauma and how they manage their mental health in the NI context. Understanding these types of experiences is crucial to providing and improving veterans in NI with the care they need. There are instances where veterans do engage in help-seeking, albeit out of absolute need^(22,23). However, to support veterans in NI it is important to understand their experiences, that occur amidst the unique challenges that exist in the NI landscape. This study aimed to explore the experiences of any veterans residing in NI in relation to lifetime trauma, mental health, alcohol and help-seeking.

Design

To explore the subjective experiences of veterans resident in NI the study adopted a qualitative, phenomenological approach, namely, interpretative phenomenological analysis (IPA)(14). IPA is often used as an exploratory tool to understand how people make sense of their own internal and external world⁽²⁴⁾. This study received ethical approval from XXX University (EPS 19_286).

Participants

Participants were eligible for participation if they were over 18 years of age, resident in NI (native and non-native to NI) and had sought help for mental health difficulties and/or hazardous alcohol use. Sources of help-seeking included statutory support, private care or charities. Types of support included medical, therapeutic or practical care. Excluded support was informal in nature, such as friends or family. Eligibility was restricted to being a veteran, as defined by the UK definition of having previously served at least one day in military service⁽²⁵⁾. Veteran status as per the UK definition is not associated with deployment. Seven male participants provided an interview, but one immediately withdrew their data over security concerns. See Table 1 for participant information. Six participants were deemed an acceptable sample number for this IPA study, given a fairly in-depth analysis was being conducted⁽²⁴⁾.

Table 1

Demographic Information
No of participants (n)	6*
Gender Male Female	6
Age < 40 51–60 61–70 < 80	2 3
Highest education level attained Primary school CSE/GCSE. O/A level Vocational qualifications Degree Postgraduate	1 1 3
Employment status Employed Retired Medically retired Unemployed	3 1 2
Religion Protestant Catholic Other None	5 1
Area of residence (first three digits of postcode or county)	BT1 x 1 BT8 x 1 BT23 x 3
Length of service in the military < 5yrs 5-10yrs 11-15yrs 16-20yrs > 20yrs	1 2 2
Length of service in NI < 5yrs 5-10yrs 11-15yrs 16-20yrs > 20yrs	3 2 1
Relationship status Single Married Cohabiting Divorced Widow/widowed	3 2
Have you received an official mental health diagnosis from a health professional – who (e.g., GP, Psychiatrist, Psychologist, Support worker) and what was it? (e.g., Depression, Anxiety, PTSD, Social Phobia) Yes No	6 (3 PTSD, 2 anxiety, 1 did not say)
*one participant chose not to answer all questions, so some of the table is based on responses of 5 participants

Recruitment

Participants were recruited via a range of methods. An advert was circulated on social media (Twitter; Facebook) and sent to personal network contacts within specific charities/support organisations (BLESMA veteran limbless charity; Sea, Sailor, Army & Families Association (SSAFA); Combat Stress veteran mental health; Royal British Legion (RBL); the Ulster Defence Regiment Aftercare Service; and Alcoholics Anonymous NI. Moreover, an interview was given to British Forces Posted Overseas (BFPO) UK radio to advertise the study. Snowball sampling was encouraged by any participant who agreed to take part.

Data collection

Participants were provided verbal information, followed by a participation information sheet and consent form via email. Participants were invited to ask questions before partaking. Informed consent was collected verbally over the telephone ahead of each interview.

Single-person interviews were conducted via telephone. Telephone interviews were utilised due to Covid-19 restrictions, however, it was not considered that telephone interviews would compromise the quality of data collection. Studies have found little difference in data quality outcomes between telephone and in-person interviews⁽²⁶⁾. Given the veteran population residing in NI was considered hard-to-reach/hidden some may have felt more comfortable partaking by telephone due to enhanced anonymity.

Interviews were semi-structured and loosely followed an interview guide, based on open-ended questions. The interview guide asked questions relating to participants' positive and negative experiences relating to living in NI as a veteran, the military and help-seeking. Veterans were also asked about alcohol use, mental health, NI community and culture, identity and perception changes over time.

Interviews lasted from 37 to 134 minutes and took place between the 11th of May and the 16th of September 2020. Upon interview commencement demographic information was collected; one participant provided partial information to protect their anonymity. All interviews were audio-recorded and transcribed verbatim. Any identifying features were removed entirely or replaced with pseudonyms in the transcripts, to protect anonymity. All transcripts were sent to participants to ensure they found the level of accuracy and anonymity acceptable. All participants were emailed a £20 Amazon e-voucher code immediately after their interview. Finally, each participant received a verbal and emailed debrief.

Analysis

The IPA approach was adopted to qualitatively explore people’s own real-world lived experiences. IPA draws on concepts linked to phenomenology, hermeneutics and ideography^{(27, 24)}. There is an acknowledgement within phenomenological approaches that each person’s experience is unique, thus people may converge on their experiences and describe similarities but also have experiential divergent uniqueness. Understanding such uniqueness and sharedness is useful from the perspective of improving services and future help-seeking experiences of specific populations.

Conducting IPA is a multi-stage, inductive process, which elicits experiential statements that are closely linked to the data. Experiential statements are developed during the IPA process, as opposed to being pre-defined and then looked for within the data. All transcripts were read line-by-line a few times to get an understanding of the participants’ accounts. Salient quotes were highlighted across each transcript, initial notes relating to the quotes were made, codes were assigned to pieces of text, and initial experiential statements relating to similar codes were created. The next phase involved considering a list of preliminary experiential statements to ascertain if clusters or groups of statements sharing a similarity, across all transcripts, could be identified. The list of experiential statements was refined; some statements sharing similarities were collapsed into larger, more robust experiential statements. The final list of statements was considered as to whether they were overarching, superordinate personal experiential themes or experiential statements. Experiential statements and personal experiential themes were also compared against the quotes to ensure the statements and experiential themes were elicited from the data and labelled appropriately^(28,24). See Table 2 for the final list of experiential statements and personal experiential themes.

Credibility and trustworthiness

Steps were taken to foster trustworthiness and credibility of the findings of this study. As the experiences of the participants were understood through the interpretation of the research team⁽²⁹⁾, it is essential to note that one researcher had a former affiliation with the veteran charity SSAFA. During post-interview, peer debrief sessions a discussion was had so that preconceptions and assumptions could be reflected on and considered during the overall data interpretation/analytic process⁽³⁰⁾. During the analytic process, the research team discussed the process of experiential statement and personal experiential theme formation. The research team agreed the final statement and personal experiential theme labels, to ensure they accurately reflected participants’ experiences.

Analysis identified three experiential statements embedded within two personal experiential themes. Table 2 provides a summary of the statements and personal experiential themes identified across the six transcripts.

Table 2 Summary of experiential statements and personal experiential themes

Personal experiential theme 1: Veterans living in NI experience an extreme lack of …

The first personal experiential theme related to participants’ experiencing an extreme lack of something across their life.

Mental health literacy and awareness

The participants generally thought there was nothing wrong with them mentally; they did not believe they needed help despite being prompted to help-seek by others. It was common for participants to repeat the phrase “without realising it’, which highlighted their reflection they did have unmet mental health needs. There was a tendency to use avoidance, repression and compartmentalisation, which was ultimately unhelpful. Having a lack of awareness/literacy around coping with mental health difficulties, and turning to maladaptive strategies, often culminated in reaching a rock-bottom place, such as suicide attempts. Moreover, suicide attempts were frequently multiple, therefore, the first attempt did not lead to an awareness they needed to reach out for mental health help. The lack of awareness extended to not knowing how or where to access mental health support; some did not help seek until it was thrust into their hand/face by a trusted comrade.

I didn’t realise it [I needed help]…she [my wife] suggested I get some counselling and I was always like ‘what for? But you can only deal with so much and the compartmentalising is actually hurting you…[I] just got deeper into a darker place…[after several suicide attempts] I needed to do something to avoid me acting on the urge again. (P3)

Expectations of official armed forces support

Participants had low expectations of support linked to the wider government, statutory and health services, and official veteran charities. Experiences that fuelled low expectations often spanned back to active service or occurred as soldiers left the military. One veteran described witnessing another soldier’s experience of help-seeking as “walking down an alleyway towards a clown with an axe and severed head” (P1). Alternatively, there seemed to be no support at all, which contributed to worsening mental health.

When I was discharged, they closed the door in my face; that was my support [from the MOD]. I was depressed, in pain, anxious, all sorts. I felt suicidal. I had lost everything. (P4)

When participants did help-seek, now as veterans, they often had poor experiences which led to making swift judgements regarding the usefulness of support and the competence of professionals. Within the context of accessing psychological support (via a GP), therapy sessions were either not enough (duration or amount), participants often felt misunderstood, or they did not like the therapy/therapist. Other poor experiences were connected to accessing support within NI-based charities, where veterans reported having their needs ignored.

Every single charity almost without exception has a tick sheet. They stick your name down, Mr Smith, did we see him? Tick. Was he contacted in 72 hours? Tick. Did we offer something? Tick. Anything we can do? No. Tick. Finished. (P5)

Negativity towards charities was compounded by assumptions that superior support was offered in England. The veterans were aware there were fewer resources in NI and described instances of being offered care overseas. However, travel overseas was not always possible due to mental or physical impairments. It was considered that those who offered such support to the veterans resident in NI did not fully appreciate NI veterans’ needs or that veterans are “fairly dispersed and hiding” (P1).

I’ve a friend who’s originally from NI...he’s utilising [England-based care]… it’s very good. He is definitely being looked after better across there. (P6)

Regardless of what support is offered, and who provides it, there were also those participants who described not trusting anyone (e.g., doctors; housing officers; social workers) due to the perception such workers have sectarian beliefs. Those who reported having these fears described having the lowest expectations of official support, and often made the swiftest negative pre-judgements.

It’s hard because as soon as you go in and the doctor is from the other ‘side’, you know he doesn’t give a f***. (P2)

There were two accounts of some positive help-seeking experiences. Participants reported resonating with their therapists and that the process was considered beneficial. Yet, these positive instances often followed a series of negative experiences, and the overall perceptions of support in NI remained low.

Sense of perceived appreciation

A strong theme expressed was that the NI veterans did not feel appreciated, which may have begun at the outset of military life. During military service, it did not seem to matter what you achieved, as a shadow would be cast over your achievements if you were physically or mentally impaired in some way. This mentality drove many to strive for perfection, to be respected and appreciated.

Imagine I am the battalion shooting champion; I’m the cross-country champion, I play football, I play golf and I’m always in the top tier… represent the military and flies the flag...the day I break my leg and I must go sick they don’t remember the sportsman, the representative; it’s that waster [they remember]. (P4)

This sense of being undervalued continues into veteran life. Some felt that official support organisations failed to demonstrate appreciation for the veteran community, and inappropriately took credit for their positive actions and initiatives.

The saddest thing is there’s loads of veterans who are willing to give up their time but they’re not going to give it to an organisation or on behalf of an organisation that’s going to take the credit for it. (P5)

The other source of non-appreciation experienced acutely by many participants was linked to the general NI public. In contrast to US veterans, they felt their service was not recognised nor valued as it should be, which contributed to the sense of self-marginalisation within NI.

When I joined ….my belief would have been that when I completed my service I would not be praised or acknowledged….it’s not just the government but a huge section of the British people. I feel they don’t acknowledge the sacrifice that servicemen and women have done. In comparison, the US are a pretty proud [of the military] public. Definitely makes me want to hide my status. (P5)

Personal experiential theme 2: Veterans living in NI experience an extreme abundance of …

The second personal experiential theme related to participants’ experiencing an extreme abundance of ‘something’ across their lives.

Exacerbated exposure to a range of ‘extreme’ environments

Participants described being embedded within environments containing extremes. Considering the span of a veteran’s life course, particularly within NI, the first extremes encountered were likely related to local trauma. Some participants inferred they had grown up as ‘Children of the Troubles’. Participants who chose to join the UDR, often experienced direct Troubles’ trauma on their local streets. Non-natives who were deployed to NI also experienced Troubles’ trauma. Members of the security forces situated in NI were generally the direct target of sectarian violence, with two participants describing themselves as being the ‘mark’ of violent attacks. Moreover, many participants also experienced military-related trauma outside of NI, not limited to operational exercises.

Participants who chose to settle or remain in NI after military service, were transitioning as veterans within an environment they generally perceived as traumatic. Living with the threat of trauma directed at Crown affiliates brought a sense of extreme hypervigilance and distrust of outsiders, and participants were managing a constant feeling of animosity.

Therefore, native veterans seemed to have travelled a full ‘trauma-exposure circle’; they had been born into traumatic exposure, continued to be exposed to environmental extremes through military life, and had retired into an environment with perceived or actual trauma.

I was raised and witnessed a lot; the discontent, the rioting. [From home] I watched gun battles, I used to hear gun battles, I used to see hooded men walking about the streets…[while in the UDR] a person set me up to get killed, and again in the [regular army] service (P5)

The lows that really stay with you are the tragedies, people died … the easiest one [to recall] was when a young fellow died on [foreign] exercise. It was tragic. He died in a training accident and not even on tour. (P1)

Aside from experiencing environmental trauma, some described engaging in activities at an extreme level, including playing sports and parting. Not only did veterans describe shifting between these environmental extremes (traumatic and pleasurable) regularly, but sometimes it occurred quite suddenly.

When you stop, it’s like you’re catching up on six weeks of living in a hole. Fitting six weeks life into a two-week gap before you do it again. Everyone does it…you try to live two days in one….you are trying to put the days you have lost socially into the days you have got so you go further; double up; you party harder before going off again. (P1)

[When not on tour] I decided to do a full ironman for my first triathlon and not a basic triathlon…I was encouraged to compete for the UK. I ran 115 miles in 26 hours, and placed within the top 15 of the whole UK. (P2)

Given that the veterans described transitioning between combat deployments, sometimes without decompression, and experienced periods of intense partying or ‘activities’, they seemed to regularly be in some kind of ‘extreme’ state or situation (physically and mentally).

Rule-based living

Much of military life was described as heavily ‘rule’ or procedure-based. There was unquestioning respect for the rules, which were strict and inflexible and instilled from the outset of military life. Rule-breaking was stigmatised and deviating from the rules (e.g., formally help-seeking for mental health) could be harmful to one’s career.

We weren’t even allowed to go home for the funeral … you get on with it. You get over it. It was the policy. You don’t go to counselling or anything if you want your career; you just crack on. (P3)

Instead of help-seeking via therapy to manage stress and trauma, alcohol was used excessively. Alcohol use was both encouraged and permitted as self-medication, to ultimately help soldiers get back to work.

During service there was an awful lot of alcohol and a lot of sadness… he died we came back to camp, we packed up his stuff, we had a funeral, we got drunk, I was sad, we went back to work. (P1)

Alcohol was also used to aid socialisation and celebration. It extended beyond its being a permitted substance and instead was expected and ritualistic. Drinking excessively was a cultural rule, with alienation being a consequence of non-conformity.

You go into the mess and you’re encouraged to drink before you go in and sit down around seven. You’ll not leave the table. Waiters, waitresses come and fill your glasses with wine and port. You don't get an opportunity to say, ‘I can't drink wine; could you get me a Fanta orange’... if you didn’t join in you’re were alienated. (P5)

Once some leave the military, they may change their alcohol-related attitudes and behaviours. Participants often realised that holding such rule-based attitudes/behaviours is unnecessary and maladaptive, choosing to no longer engage with the overuse (or sometimes any use) of alcohol.

A lot of guys [veterans] want to go for a coffee you know, and a chat [rather than the pub]…I would avoid places like the Legion as I was trying to be different; I just didn’t want to be around that [the drinking culture]. I wasn’t me anymore and doesn’t help me. (P4)

Similarly, the need to challenge and break the no-help-seeking rule was acknowledged and encouraged by many participants, usually due to poor quality of life and functional impairment. They reasoned that although as soldiers they did not break that rule, it no longer applied once the military ‘connection’ was severed.

While I was serving [I was] incredibly reluctant to [get] help but once I left there was no connection or..[no barrier]. (P1)

Engagement with informal and local-level support

Participants expressed having an abundance of informal support through camaraderie and veteran connection. Long-lasting camaraderie often came from sharing intense operational experiences. Veterans considered they were best placed to offer support to each other, due to the peer bond they shared.

Six weeks living in a trench, sharing experiences together means you get very close. It’s hard to replicate the social connection outside the military. (P1)

Most participants commented that they socialised within NI with ex-military or ex-security as they mutually respected each other’s privacy and opinions surrounding security concerns. Although the need to stay vigilant was stated by all participants, most described being friendly with some select community members and having a few close local friends who were non-Crown affiliates.

Despite a lack of official, publicised social events in NI, for security reasons, a few select events were well supported by local veterans. Moreover, there were non-veteran-specific membership clubs that enabled veteran interaction, such as the Freemasons or the Orange Order.

Remembrance Day’s a great occasion for it [reconnection] because we all get together. My local Orange Lodge seems to have a disproportionately high number of ex-UDRs. (P1)

Some ‘unofficial’, veteran-specific, often veteran-run, activity clubs existed across NI. The local clubs were engaged with by veterans in a variety of ways; through receiving support, getting involved in local support, or both. P5 described running such a club that facilitated fellowship; it brought people together.

Veterans were invited along, we’d go out, we’d have a bit of lunch and a bit of craic. We started to meet once a month but that went to one day a week, as people wanted to meet more often. (P5).

Another source of local, informal support came from families. Some participants opted to move nearer to their families, who provided them with support and mental health relief.

My family helps me [mentally]…seeing my kids makes my heart glow…seeing my kids is probably the biggest thing [that helps me]. (P2)

This study aimed to explore the experience of lifetime trauma, mental health and/or hazardous alcohol use and help-seeking from the perspective of veterans residing within NI. While the two personal experiential themes were presented as ‘lack of’ and ‘abundance of’ they were not polar ends of the same continuum. For example, literacy awareness was only associated with the ‘lack of’ personal experiential theme; there was no opposite experiential statement found under the ‘abundance of’ personal experiential theme.

As trauma and mental health have been extensively explored in the context of military populations, it was considered useful to compare what findings aligned with existing evidence versus the novel findings from the current study.

Experiential findings – aligning with existing literature

Experiential statements were elicited that align with existing evidence, such as having an extreme lack of mental health literacy/awareness together with low expectations of official support^(17,23). Johnson and Possemato⁽³¹⁾ reported that problem recognition was the strongest predictor of veteran help-seeking for mental health difficulties followed by treatment attitudes, within a US primary care setting. Recent years have seen an increase in interventions attempting to improve help-seeking experiences and behaviours, which include reducing stigma, improving literacy and bettering resource access. Some help-seeking interventions appear to have led to a reduction in the time taken to help-seek^(32,33). However, those appearing to have most benefited from such interventions are younger and have served in more recent conflicts⁽³³⁾. This current study’s participants were older and likely had less (if any) mental health and/or hazardous alcohol use education, which could account for the lower levels of mental health literacy described.

A further experiential statement that supports wider armed forces community literature related to being in extreme environments/experiences, which often had a traumatic connotation. Regarding the specific traumas mentioned in this study, those events that some reported as being particularly traumatic experiences were related to foreign deployments. Troubles-related traumas were acknowledged as traumas yet not necessarily as the participants’ most traumatic experiences. The degree to which the NI landscape was experienced as particularly traumatising was a matter of interpretation. Living in NI may have led to a degree of resilience towards certain traumas^(34,35).

Aside from trauma, it is customary for soldiers to partake in activities perceived as extreme, yet pleasurable (e.g., skydiving, rock climbing)⁽³⁶⁾. Even where sports are considered non-extreme (e.g., running), involvement is often encouraged and engaged in at extreme levels. This perhaps accounts for why some military personnel frequently feature at elite-level sporting competitions^(37,38).

The experiential theme ‘abundance of’ extreme activities extended to socialising and drinking alcohol as soldiers; such activities frequently align with existing literature⁽¹¹⁾. All participants in this study discussed socialising and drinking heavily, to cope with operational deployment stress and to catch up on the sense of missed recreational time. Moreover, alcohol was used communally to engage in shared coping, consolation, commemoration, celebration, or for any other reason the soldiers chose to drink. Such experiential themes have been mirrored across existing literature; the opinion that alcohol ‘lubricates the military’ is engrained historically^(39,11,14). One current shift in UK military training is intended to reduce alcohol use as a coping strategy. OpSmart aims to increase resilience ahead of pending trauma, thus reducing forms of maladaptive coping, such as drinking or other risky behaviours⁽⁴⁰⁾. However, the effectiveness of OpSmart, in the context of mental health/alcohol outcomes for soldiers and veterans, is currently unknown. Older veterans, who are more representative of this study participant group, likely never received such training.

The final experiential statement aligning with existing evidence relates to the engagement in local-level support. Participants described local support as clubs/associations with an armed forces community affiliation, as well as family, friends and peers. Social support appears as a mental health buffer and help-seeking enabler for veterans across the veteran literature⁽²³⁾. Local support may assist with psychological and practical issues, and foster a sense of belongingness and purpose which are positive for mental health and quality of life outcomes^(41–44).

Experiential findings – challenging existing literature

There were several experiential statements, or elements of experiential statements, that either challenged existing armed forces community findings or were considered novel in this study.

The first novel finding relates to the point that the participants residing in NI have likely experienced elevated levels of layered, lifetime trauma ranging from childhood to military trauma and continuing onto post-Troubles trauma. Essentially, veterans residing in NI cannot (currently) escape trauma exposure which makes them (or their environment) unique compared to other UK nations (and most global veteran populations). Despite some participants suggesting their most traumatising experiences were unrelated to the Troubles, or its legacy, the most commonly reported driver for maintaining a hidden status is the persistent threat of trauma^(3,4).

A factor negatively compounding the experience of living in an extreme environment is lacking a sense of appreciation. Generally, the lack of appreciation is not unique across extant global armed forces community literature. Vietnam, Iraq and Afghanistan veterans have had hostility directed towards them due to opinions over those military campaigns^(45–47). Yet, the sense of hostility and disfavour directed at NI veterans is connected to them being representatives of the Crown and not a particular military campaign. The negativity is perceived to feel a lot more personal, especially among those who served with the UDR. Experiencing a poor sense of self-appreciation, due to public perceptions/interactions, is concerning as it may lead to worse mental health outcomes and fuel self-marginalisation⁽⁴⁵⁾.

Where participants in this study did have mental health difficulties, or perhaps another cause to seek out support, everyone interviewed did engage in help-seeking. Help-seeking in the veteran community is not a novel finding, and existing evidence seems to suggest that as veterans engage on the help-seeking journey their perceptions of support services often improve in line with their improved health-related or help-seeking experiences^(48–50). However, the help-seeking experiences of veterans in the NI context seemed to make little difference to the negative attitudes surrounding support services and help-seeking more broadly. As such, it was the negative attitudes towards official support services that largely drove heavy engagement with local-level support. The help-seeking journey appeared to improve attitudes towards local-level support rather than official support, which is a finding not discussed in veteran literature.

One of the most pertinent findings relates to behaviours being associated with following or breaking ‘rules’. Armed forces community literature often explores behaviours or concepts in isolation, such as help-seeking or excessive drinking. Yet, when examining the experiences reported in this study it appears behaviours are often the manifestation of general rule compliance/non-compliance. The Values and Standards document, as set out by the British Army⁽⁵¹⁾, lists 43 points of compliance for soldiers, emphasising a need for courage and discipline. From one’s career outset, soldiers are conditioned to believe it is necessary to display mental strength (therefore implying they do not need help) and must comply, unquestionably with rules (presumably regardless of what the rules are). Rule-breaking has repercussions to encourage adherence, therefore, soldiers arguably have little real autonomy. While a rule-based structure may bring comfort and stability within the military, the veterans in this study reflected that the rules (e.g., no help-seeking and excessive alcohol) did not serve them as civilians. Rules could and should be broken, to meet their own health needs without fear of repercussion. Armed forces community literature does place general behaviour within the context of what is ‘expected’ as per military norms, yet this study highlighted the degree to which many are simply following rules as opposed to considering behavioural norms as optional guidelines. Behaviour, regardless of behaviour type, is more likely the result of heavy conditioning as opposed to people acting with any real autonomy. If it is the case that soldiers are not acting with real autonomy, or were not historically, questions should be asked concerning the degree to which they are accountable for their behaviour as veterans. Veterans could be thought of as victims, due to heavy upstream conditioning. While several veterans in this study did challenge the rules around non-help-seeking and alcohol reliance, there will be many veterans who continue to live by military-based rules that cascade into their veteran life.

The final novel finding concerns having a variety of ‘extreme’ experiences or being exposed to a range of extreme environments. Two points are worth highlighting: first, armed forces literature frequently discusses soldiers’ exposure to ‘extremes’ as opposed to veterans’ (e.g., combat); second, no findings exist currently that feature the constant shift between ‘extremes’ regardless of whether those extremes are positive or negative. Literature does discuss the impact of shifting between deployment and non-deployment, and the impact of transition from the military to civilian life. Yet, no literature has addressed the constant or collective swing between multiple, diverse extreme environments, or environments containing extreme experiences. This experiential theme warrants further exploration.

Limitations and Strengths

This study has some limitations, for example, in terms of the sample females and officers were unrepresented. This trend was unsurprising as the military is male, non-officer dominant. It would have been useful to have insights into female veterans’ lived experiences within the NI context. Regarding data collection, telephone interviews possibly meant that rapport building was potentially reduced, and non-verbal cues were missed. There was also a noticeable difference in interview length; whilst attempts were made to draw equally on data from all interviews there was a chance that the longer interviews informed more of the themes and overall findings. The study was conducted during Covid which could have led some veterans to reflect that their experiences of NI were negatively impacted further. However, no veteran referred to covid.

This study had several strengths; despite NI veterans being hard to reach the six participants interviewed in this study were open and candid. Perhaps because the study moved to telephone interviews the participants enjoyed the added anonymity, which led to greater transparency. It is also a strength that native and non-native NI veterans provided an account of their experiences. It was interesting to note that native and non-native experiences were similar in many respects. As this is the first study to qualitatively explore the experiences of veterans living in NI, the findings are to be considered novel with respect to this population, which is a strength of this paper.

Implications and conclusions

These findings imply that many veterans continue to stay hidden, or prefer to use local support organisations, to manage their poor mental health. While social support is a useful resource it may not be sufficient to manage the complex needs that some veterans in NI have. If adequate resources do not exist in NI this likely compounds mental health problems that exist there. Another cause for turning to social support is that grass-roots organisations create a space where veterans feel appreciated, and local veterans may perceive they have some control over their own needs. Efforts need to be made by official organisations and statutory services to engage with the grass-roots organisations, but in a manner that does not cause any veterans to fear for their safety. If official support can reach veterans via such channels, or perhaps through the NI Veterans’ Support Office⁽⁵²⁾ (VSO – the point of contact for organisations supporting NI veterans), this may help improve veterans’ opinions of wider NI official support. It may also strengthen trust between services and veteran service users. Although there is currently no obligation for any doctors’ surgery to be ‘veteran friendly’ in NI⁽⁵²⁾, local surgeries could choose to take that stance and advertise themselves accordingly (locally and via the VSO). If barriers to support cannot be entirely removed, organisations should continue to work collaboratively to increase awareness and education about veterans in the community to reduce ‘them versus us’ thinking.

As and when veterans do engage with support, and they choose to disclose their veteran status, it would be useful to reflect on the degree to which they are a product of their rule-abiding environment. Acknowledging the effect of rule-based living is important within a therapy support context. This study has demonstrated that veterans do challenge rule-based thinking, therefore they ought to be empowered and encouraged to do this (adaptively) in a supportive environment. Of course, veterans are equally unlikely to disclose their military status, therefore, if anyone presents with a specific set of experiences or complaints that may make them appear to be a veteran their privacy should be respected.

Wherever possible a Patient Public Involvement (PPI)⁽⁵³⁾ approach ought to be adopted, so that NI veterans are included as stakeholders in their own public awareness campaigns and collaborative (organisation/statutory/community) projects. It would be useful to explore through research the outcomes and impact of these sorts of approaches to improving support for veterans living in NI.

Ethics approval and consent to participate - Ethics was granted by Queen’s University Ethic research committee for this study (EPS 19_286). Every participant provided informed consent verbally and by email.

Consent for publishing – consent is given to publish.

Availability of data and materials – The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests – no competing interests to report.

Funding - The authors disclose receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Royal British Legion, United Kingdom (under grant EGR17Q4/100015).

Authors’ contributions – Generated study funding (CA), study design (CH, PT, CA), ethics application (CH, CA), recruitment (CH, CA), data collection (CH) , data analysis (CH) data interpretation (CH, PT), manuscript drafts (CH, PT, HC, CA).

Acknowledgements – The authors wish to acknowledge all the veterans who kindly described their experiences, and Dr Ben Harper who provided additional advice regarding using appropriately and correctly.

Bruce S. The Edge of the Union. The Ulster Loyalist Political Vision. New York: Oxford University Press Inc; 1994.
Potter J. A Testimony to Courage: The History of the Ulster Defence Regiment 1969–1992. Barnsley: Lee Cooper; 2001.
Armour C, Walker E, Waterhouse-Bradley B, Hall M, Ross J. Current and Future Needs of Veterans in Northern Ireland. Coleraine: Psychology Research Institute, Faculty of Life and Health Sciences, University of Ulster; 2017.
Armour C, Walker E, Matthew D, Waterhouse-Bradley B, Ross J, et al. Exploring the Need for a Veterans’ Centre in Northern Ireland. Psychology Research Institute, Faculty of Life and Health Sciences, University of Ulster; 2018.
Bunting B, Ferry F, Murphy S, O’Neill S, Bolton D. Trauma Associated with Civil Conflict and Posttraumatic Stress Disorder: Evidence From the Northern Ireland Study of Health and Stress. J Trauma Stress. 2013;26:134–41.
Tomlinson M. Risking peace in the ‘war against the poor’? Social exclusion and the legacies of the Northern Ireland conflict. Crit Soc Policy. 2016;36(1):104–23.
Trego LL, Wilson C. A Social Ecological Model for Military Women’s Health. Women’s Health Issues. 2021;31:S11–21.
Schmid K, Muldoon OT. Perceived threat, social identification, and psychological well-being: The effects of political conflict exposure. Political Psychol. 2015;36(1):75–92.
Gaska KA, Kimerling R. Patterns of Adverse Experiences and Health Outcomes Among Women Veterans. Am J Prev Med. 2018;55(6):803–11. A.
Murphy D, Ashwick R, Palmer E, Busuttil W. Describing the profile of a population of UK veterans seeking support for mental health difficulties. J Mental Health. 2017;Early on-l:1–8.
Jones E, Fear N. Alcohol use and misuse within the military: A Review. Int Rev Psychiatry. 2011;23:166–72.
Sharp ML, Fear NT, Rona RJ, Wessely S, Greenberg N, Jones N, et al. Stigma as a barrier to seeking health care among military personnel with mental health problems. Epidemiol Rev. 2015;37:144–62.
Hom MA, Stanley IH, Schneider ME, Joiner Jr. TE. A systematic review of help-seeking and mental health service utilization among military service members. Clin Psychol Rev. 2017;53:59–78.
Kiernan MD, Moran S, Hill M. Understanding why veterans are reluctant to access help for alcohol problems: Considerations for nurse education. Nurse Educ Today. 2016;47:92–8.
Armour C, Waterhouse-Bradley B, Walker E, Ross J. Supporting & Serving Military Veterans in Northern Ireland. Coleraine: Psychological Research Institute, Faculty of Life and Health Sciences, Ulster University; 2017.
Slainte A, Poustie M. Mental Health Strategy 2021–2031. Department of Health (Northern Ireland); 2021. pp. 1–94.
Hitch C, Toner P, Armour C. Enablers and barriers to military veterans seeking help for mental health and alcohol difficulties: A systematic review of the quantitative evidence. J Health Serv Res Policy. 2023;0(0):1–15.
Possemato K, Wray LO, Johnson E, Webster B, Beehler GP. Facilitators and Barriers to Seeking Mental Health Care Among Primary Care Veterans With Posttraumatic Stress Disorder. J Trauma Stress. 2018;31(5):742–52.
Armour C, McGlinchey E, Ross J. The Health and Wellbeing of Armed Forces Veterans in Northern Ireland: The Results of a Cross-sectional Psychological Wellbeing Survey. Belfast: Queens University; 2021. pp. 1–90.
McGlinchey E, Ross J, Murphy D, Shorter GW, Armour C. Disentangling the Symptom-Level Nuances in Comorbid Posttraumatic Stress Disorder and Problematic Alcohol Use in Northern Irish Military Veterans: A Network Analysis. J Trauma Stress. 2021;1–10.
Spikol E, Robinson M, Mcglinchey E, Ross J, Armour C, Spikol E, et al. Exploring complex-PTSD comorbidity in trauma- exposed Northern Ireland veterans. Eur J Psychotraumatology. 2022;31(1):1–13.
Harden L, Murphy D. Risk factors of suicidal ideation in a population of UK military veterans seeking support for mental health difficulties. J R Army Med Corps. 2018;1–5.
Hitch C, Toner P, Armour C. A Qualitative Systematic Review of Enablers and Barriers to Help Seeking for Veterans that have Completely Left the Military Within the Context of Mental Health and Alcohol. JVS. 2023;9(1):15–30.
Smith J, Flowers P, Larkin M. Interpretative Phenomenological Analysis. Theory, method and Research. 2nd Edition. London: SAGE Publications Ltd; 2021.
Gribble R, Wessely S, Klein S, Alexander DA, Dandeker C, Fear NT. Who is a ‘Veteran’? Understanding Definitions of the Term Among the British Public: A Research Note. RUSI J. 2019;164(7):10–7.
Vogl S. Telephone versus face-to-face interviews. Sociol Methodol. 2013;43:133–77.
Noon E. Interpretive Phenomenological Analysis: An Appropriate Methodology for Educational Research? Journal of Perspectives in Applied Academic Practice. 2018;|(1):75–83.
Lyons E, Coyle A, editors. Analysing Qualitative Data in Psychology. Sage; 2021.
O’Mullan C, Doherty M, Coates R, Tilley P. Using Interpretative Phenomenoligical Analysis (IPA) to privde insights into female sexual difficulties. Sex Relatsh Therapy. 2019;34(1):75–86.
Elo S, Kääriäinen M, Kanste O, Polkki T, Utriainen K, Kyngas H. Qualitative content analysis. SAGE Open. 2014;4(1).
Johnson EM, Possemato K. Problem Recognition and Treatment Beliefs Relate to Mental Health Utilization Among Veteran Primary Care Patients. Psychological Services. 2019.
Karras E, Arriola N, McCarten JM, Britton PC, Besterman-Dahan K, Stecker TA. Perceptions of Public Messaging to Facilitate Help Seeking during Crisis among U.S. Veterans at Risk for Suicide. Archives Suicide Res. 2020;0(0):1–14.
Murphy D, Weijers B, Palmer E, Busuttil W. Exploring Patterns in Referrals to Combat Stress for Uk Veterans with Mental Health Difficulties between 1994 and 2014. Int J Emerg Mental Health Hum Resil. 2015;17(3):652–8.
Mark KM, Stevelink SAM, Choi J, Fear NT. Post-traumatic growth in the military: A systematic review. Occup Environ Med. 2018;0:1–12.
Vallières F, Hyland P, Murphy J. Navigating the who, where, what, when, how and why of trauma exposure and response. Eur J Psychotraumatology. 2021;12(1):1–8.
Johnson T, Murariu G. Veterans in the UK: Issues Facing the ex-service community. The Trajectory Partnersip; 2016.
Forces Net. The British Forces Athletes Who’ll Be Competing in The Winter Olympics. 2018.
Moore R. Army boxer Karriss Artingtall: I can hold my head up high’ after olympic bronze. Forces Net. 2021.
Claridge D. Constructions of Masculinity and Men’s Experiences of Barriers to Help-Seeking from Mental Health Services. University of Hull; 2017.
Ministry of Defence. Mental Resilience. ARMY Be the Best: People. 2020.
McDermott J. ‘It’s Like Therapy But More Fun’ Armed Forces and Veterans’ Breakfast Clubs: A Study of Their Emergence as Veterans’ Self-Help Communities. Sociol Res Online. 2020;1–18.
Mellotte H, Murphy D, Rafferty L, Greenberg N. Pathways into mental health care for UK veterans: a qualitative study. Eur J Psychotraumatology. 2017;8(1):1389207.
Sayer NA, Friedemann-Sanchez G, Spoont M, Murdoch M, Parker LE, Chiros C, et al. A qualitative study of determinants of PTSD treatment initiation in veterans. Psychiatry. 2009;72(3):238–55.
Straus E, Norman SB, Tripp JC, Pitts M, Pietrzak RH. Purpose in Life and Conscientiousness Protect Against the Development of Suicidal Ideation in U. S. Military Veterans With PTSD and MDD : Results From the National Health and Resilience in Veterans Study. Chronic Stress. 2019;3:1–10.
Markowitz FE, Kintzle SM, Castro CA, Lancaster SL. Effects of Perceived Public Regard on the Well-Being of Military Veterans. Soc Mental Health. 2019;00(0):1–14.
Marshall RP, Jorm AF, Grayson DA, Dobson M, O’Toole B, RP M, et al. Help-seeking in Vietnam veterans: post-traumatic stress disorder and other predictors. Aust N Z J Public Health. 1997;21(2):211–3.
Phillips R, Connelly V. Examining myths of the mad, bad and sad British veteran in today’s media: a qualitative approach. J military Sociol. 2021.
Jakupcak M, Hoerster KD, Blais RK, Malte CA, Hunt S, Seal K. Readiness for Change Predicts VA Mental Healthcare Utilization Among Iraq and Afghanistan War Veterans. J Trauma Stress. 2013;26(1):165–8.
Iversen A, Dyson C, Smith N, Greenberg N, Walwyn R, Unwin C, et al. Goodbye and good luck’: The mental health needs and treatment experiences of British ex-service personnel. Br J Psychiatry. 2005;186(JUNE):480–6.
Rafferty L, Stevelink S. Military veterans pathways to mental health support: The need for new solutions. Occup Environ Med. 2019;76.
British Army. Values and standards of the British Army. 2018. p. 19.
Office for Veterans’ Affairs. Veterans’ Strategy Action Plan: 2022–2024. London; 2022.

No competing interests reported.

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Lifetime trauma, mental health, alcohol and help-seeking; the phenomenological experience of veterans residing in Northern Ireland

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Journal Publication

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Abstract

Background

Method

Results

Conclusions

INTRODUCTION

METHODS

Design

Participants

Recruitment

Data collection

Analysis

Credibility and trustworthiness

RESULTS

Personal experiential theme 1: Veterans living in NI experience an extreme lack of …

Mental health literacy and awareness

Expectations of official armed forces support

Sense of perceived appreciation

Personal experiential theme 2: Veterans living in NI experience an extreme abundance of …

Exacerbated exposure to a range of ‘extreme’ environments

Rule-based living

Engagement with informal and local-level support

DISCUSSION

Experiential findings – aligning with existing literature

Experiential findings – challenging existing literature

Limitations and Strengths

Implications and conclusions

Declarations

References

Additional Declarations

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