Evaluation of Community Reinforcement and Family Therapy in the UK military community.

Background: Partners and family can play a key role in encouraging military service and ex-service personnel to seek help for their mental health. Community Reinforcement Approach and Family Training (CRAFT) was developed to equip concerned significant others (CSOs) of those experiencing substance use disorders with skills to encourage their loved one to enter treatment and improve their own well-being. It was adapted in the US for CSOs of ex-service personnel with post-traumatic stress disorder (PTSD) (VA-CRAFT).Objective: This study aimed to evaluate an adaptation of VA-CRAFT for use with CSOs of serving and ex-service personnel experiencing PTSD and Common Mental Disorders in the UK (UKV-CRAFT).Method: Acceptability of UKV-CRAFT was assessed with interviews with experts, namely key stakeholders (n = 15) working in support provision for serving and ex-service personnel. In addition, individuals who took part in a small-scale demonstrative trial of UKV-CRAFT (three CSOs and three facilitators who delivered UKV-CRAFT) provided feedback.Results: UKV-CRAFT was viewed positively, with interviewees highlighting that programmes like UKV-CRAFT filled a gap in provision for UK Armed Forces families as most services were only available to the serving or ex-service personnel. Interviewees praised how UKV-CRAFT enhanced CSO well-being and communication with their loved one. Concerns over the confidentiality of taking part in UKV-CRAFT were raised due to the perceived negative effects of highlighting a loved one's mental ill health, especially for CSOs of serving personnel. Ideas for improvement included broadening access to all CSOs regardless of whether their loved one was seeking treatment.Conclusion: Interviewees regarded UKV-CRAFT as a potentially useful intervention suggesting it could be proactively offered universally to support timely help-seeking if required. We recommend further evaluation of UKV-CRAFT on a wider scale, incorporating our recommendations, to assess its effectiveness accurately.

Community Reinforcement And Family Therapy (CRAFT), a programme for the concerned significant others (CSOs) of people experiencing Substance Abuse Disorders (SUDs), was adapted for the CSOs of UK Armed Forces serving and ex-service personnel (UKV-CRAFT).UKV-CRAFT aimed to equip CSOs with the skills to encourage their Armed Forces loved ones to seek mental health treatment; it was evaluated by post-trial interviews with UKV-CRAFT facilitators, recipients, and Armed Forces stakeholders.UKV-CRAFT was found to be a useful intervention for CSOs but would benefit from further evaluation on a wider scale.Evaluation of Community Reinforcement And Family Therapy in the UK military community.

Gender differences in structural and attitudinal barriers to mental healthcare in UK Armed Forces personnel and veterans with self-reported mental health problems.

PURPOSE: Structural and attitudinal barriers often hinder treatment-seeking for mental health problems among members of the Armed Forces. However, little is known about potential gender differences in structural and attitudinal barriers among members of the UK Armed Forces. The current study aimed to explore how men and women differ in terms of these barriers to care among a sample of UK Armed Forces personnel and veterans with self-reported mental health problems. METHODS: Currently serving and ex-serving members of the UK Armed Forces who self-reported a mental health problem were invited to participate in a semi-structured phone interview on mental health and treatment-seeking. The final sample included 1448 participants (1229 men and 219 women). All participants reported on their current mental health, public stigma, self-stigma, and barriers to mental healthcare. RESULTS: Overall, men and women reported similar levels of both structural and attitudinal barriers, with no significant differences detected. The highest scores for both men and women were observed in attitudinal barriers relating to self-stigma domains, which encapsulate internalised attitudes and beliefs about mental illness and treatment. CONCLUSIONS: Findings suggest that anti-stigma campaigns can be targeted simultaneously at both men and women within the Armed Forces. In particular, targeting self-stigma may be beneficial for health promotion campaigns.

Evaluating a Smartphone App (MeT4VeT) to Support the Mental Health of UK Armed Forces Veterans: Feasibility Randomized Controlled Trial.

BACKGROUND: Previous research demonstrates that less than 50% of military veterans experiencing mental health difficulties seek formal support. Veterans often struggle to identify problems as mental health difficulties. In addition, they may fail to recognize the need for support before reaching a crisis point and face difficulties navigating care pathways to access support. OBJECTIVE: A feasibility trial was conducted to assess a novel digital smartphone app (Mental Health Toolkit for Veterans Project [MeT4VeT]) for UK Armed Forces (UKAF) veterans experiencing mental health difficulties. The trial aimed to explore the feasibility and acceptability of trial procedures for a later randomized controlled trial (RCT) and to assess the acceptability of the MeT4VeT app. METHODS: Participants were recruited at UK military medical centers, by advertising on social media, and through veteran third-sector organizations between February and November 2021, and assessed for eligibility (male, owned a smartphone, served at least 2 years in the UKAF, left the UKAF within the last 2 years, not undertaking formal mental health treatment). Eligible participants were assigned, on a 1:1 ratio, to either the intervention group (full app) or a control group (noninteractive app with signposting information). Three key objectives were determined a priori to assess the practicality of running an RCT including an assessment of recruitment and retention, evaluation of the technical app delivery and measurement processes, and acceptability and usability of the intervention. RESULTS: In total, 791 individuals completed the participant information sheet, of which 261 (33%) were ineligible, 377 (48%) declined or were unable to be contacted for consent, and 103 (13%) did not download the app or complete the baseline measures. Of this, 50 participants completed baseline measures and were randomly assigned to the intervention group (n=24) or the control group (n=26). The trial was effective at enabling both the technical delivery of the intervention and collection of outcome measures, with improvements in mental health demonstrated for the intervention group from baseline to the 3-month follow-up. Recruitment and retention challenges were highlighted with only 50 out of the 530 eligible participants enrolled in the trial. The acceptability and usability of the MeT4VeT app were generally supported, and it was reported to be a useful, accessible way for veterans to monitor and manage their mental health. CONCLUSIONS: The results highlighted that further work is needed to refine recruitment processes and maintain engagement with the app. Following this, an RCT can be considered to robustly assess the ability of the app to positively affect mental health outcomes indicated within this trial. TRIAL REGISTRATION: ClinicalTrials.gov NCT05993676; https://clinicaltrials.gov/ct2/show/NCT05993676.

Adjustment disorder in the Armed Forces: a systematic review.

BACKGROUND: In the UK military, adjustment disorder (AjD) is reported as one of the most diagnosed mental disorders, alongside depression, in personnel presenting to mental health services. Despite this, little is understood about what may predict AjD, common treatment or outcomes for this population. AIM: The systematic review aimed to summarise existing research for AjD in Armed Forces (AF) populations, including prevalence and risk factors, and to outline clinical and occupational outcomes. METHOD: A literature search was conducted in December 2020 to identify research that investigated AjD within an AF population (serving or veteran) following the PRISMA guidelines. RESULTS: Eighty-three studies were included in the review. The AjD prevalence estimates in AF populations with a mental disorder was considerably higher for serving AF personnel (34.9%) compared to veterans (12.8%). Childhood adversities were identified as a risk factor for AjD. AjD was found to increase the risk of suicidal ideation, with one study reporting a risk ratio of 4.70 (95% Confidence Interval: 3.50-6.20). Talking therapies were the most common treatment for AjD, however none reported on treatment effectiveness. CONCLUSION: This review found that AjD was commonly reported across international AF. Despite heterogeneity in the results, the review identifies several literature gaps.

A Service Evaluation of the Military HeadFIT Initiative: An Implementation Study.

(1) Background: UK Armed Forces personnel provide first response, support and protection during national and international disasters and conflicts. They thus have a psychologically challenging role which requires them to maintain a good state of mental health and wellbeing. HeadFIT is a preventative initiative developed to help foster mental fitness through various self-help tools and resources online including techniques to de-stress and increase drive. This paper reports on an independent service evaluation of HeadFIT to examine feasibility and acceptability among Ministry of Defence (MOD) personnel. (2) Methods: Qualitative interviews were held with the HeadFIT beneficiaries, including military personnel and civil servants. The beneficiaries provided feedback on HeadFIT through questionnaires and interviews, and website traffic data were also collected. Qualitative data were analysed using framework analysis. (3) Results: Beneficiaries generally reported positive views on the HeadFIT initiative, with most agreeing that the tools could support them to foster their mental fitness. However, concerns were raised around the uptake of HeadFIT and participants suggested methods to improve usability. (4) Conclusions: Several recommendations were made to improve the resources, usability, uptake, and implementation and communication of HeadFIT.

The journey to professional mental health support: a qualitative exploration of the barriers and facilitators impacting military veterans' engagement with mental health treatment.

Background: It is often claimed that military veterans are reticent to seek help for mental disorders, even though delayed treatment may impair recovery and impact the wellbeing of those close to the veteran. Objective: This paper aims to explore the barriers and facilitators to accessing professional mental health support for three groups of veterans who met criteria for a probable mental health disorder and: (1) do not recognize a probable mental disorder; (2) recognize they are affected by a mental disorder but are not seeking professional support; or (3) are currently seeking professional mental health support. Method: Qualitative telephone interviews were conducted with 62 UK military veterans. Thematic analysis identified core themes along an illustrative journey towards professional mental health support. Results: Distinct barriers and facilitators to care were discussed by each group of veterans depicting changes as veterans moved towards accessing professional mental health support. In contrast to much of the literature, stigma was not a commonly reported barrier to care; instead care-seeking decisions centred on a perceived need for treatment, waiting until a crisis event occurred. Whilst the recognition of treatment need represented a pivotal moment, our data identified numerous key steps which had to be surmounted prior to care-seeking. Conclusion: As care-seeking decisions within this sample appeared to centre on a perceived need for treatment future efforts designed to encourage help-seeking in UK military veterans may be best spent targeting the early identification and management of mental health disorders to encourage veterans to seek support before reaching a crisis event.

Antecedentes: Generalmente se sostiene que los veteranos militares son reticentes a buscar ayuda para trastornos mentales, incluso aunque el retraso del tratamiento puede afectar a la recuperación e impactar en el bienestar de las personas cercanas al veterano.Objetivo: Este trabajo busca explorar las barreras y facilitadores al acceso a apoyo profesional de salud mental para tres grupos de veteranos que cumplen criterios para un probable trastorno de salud mental y: 1) No reconocen un probable trastorno mental; 2) Reconocen que están afectados por un trastorno mental pero no están buscando apoyo profesional; o 3) están actualmente buscando apoyo profesional de salud mental.Método: Se realizaron entrevistas telefónicas cualitativas a 62 veteranos militares de Reino Unido. El análisis temático identificó temas nucleares a lo largo de un viaje ilustrativo hacia el apoyo profesional de salud mental.Resultados: Se discutieron distintas barreras y facilitadores a la atención por cada grupo de veteranos, describiendo cambios a medida que los veteranos se movían hacia el acceso al apoyo profesional de salud mental. En contraste a mucha literatura, el estigma no fue una barrera a la atención comunmente reportada; en su lugar las decisiones de búsqueda de atención se centraron en la necesidad percibida de tratamiento, esperando hasta que ocurría un evento de crisis. A pesar de que el reconocimiento de la necesidad de tratamiento representó un momento decisivo, nuestros datos identificaron numerosos pasos clave que debían ser superados antes de la búsqueda de atención.Conclusión: Dado que las decisiones de búsqueda de atención dentro de esta muestra parecían centrarse en una percepción de necesidad de tratamiento, los esfuerzos futuros diseñados para promover la búsqueda de ayuda en veteranos militares del Reino Unido podrían ser mejor invertidos apuntando a la identificación temprana y manejo de trastornos de salud mental para alentar a los veteranos a buscar apoyo antes de alcanzar un evento de crisis.

Community reinforcement and family training and rates of treatment entry: a systematic review.

BACKGROUND AND AIMS: Adaptations with different modes of delivery and target addictions have found highly divergent rates of success for Community Reinforcement Approach and Family Training (CRAFT). This study aims to clarify which (1) treatment components and (2) participant characteristics contribute to rates of identified patient (IP) treatment entry. METHOD: Systematic review of CRAFT evaluation studies of all designs (controlled and uncontrolled) with data synthesis and narrative analysis of addiction treatment services and university research departments in North America and Europe. RESULTS: A total of 691 concerned significant others (CSOs), predominately female spouses/parents, participating in 20 distinct treatment conditions from 14 studies. The main outcome of IP treatment entry rate reported by CSOs up to 12 months after starting CRAFT with key predictors/correlates including IP addiction, IP-CSO relationship, CRAFT modality and integration of treatment for IP. Meta-analysis found CRAFT to be twice as effective as controls/comparison groups. Multi-modality treatment, including both individual and group sessions, yielded the highest IP treatment entry rates (77 and 86%), with progressively lower rates for individual (12.5-71%), group (60%) and self-directed workbook (13.3-40%) modalities. While all five studies targeting gambling addiction had consistently low rates (12.5-23%), other treatment components, including therapist training, treatment fidelity and integrating treatment for the IP, were implicated. CONCLUSIONS: Adaptations of Community Reinforcement Approach and Family Training for different delivery modalities and addictions have yielded widely varying rates of treatment engagement for the identified patient, with those offering the most comprehensive support to the concerned significant other, including individual and group sessions, having highest levels of engagement success.

Pathways into mental health care for UK veterans: a qualitative study.

Background: It is well established that veterans suffering from mental health difficulties under use mental health services. Objective: This study aimed to understand more about the barriers that prevent veterans from seeking professional help and the enablers that assist veterans in seeking professional help. It also aimed to explore potential mechanisms to improve veterans' help-seeking and pathways to care. Method: The study employed a qualitative design whereby 17 veterans who had recently attended specialist veteran mental health services took part in semi-structured interviews. The resultant data were analysed using grounded theory. Results: Participants described two distinct stages to their help-seeking: initial help-seeking and pathways through treatment. Specific barriers and enablers to help-seeking were identified at each stage. Initial barriers included recognizing that there is a problem, self-stigma and anticipated public stigma. Initial enablers included being in crisis, social support, motivation and the media. Treatment pathway barriers included practical factors and negative beliefs about health services and professionals. Treatment pathway enablers included having a diagnosis, being seen in a veteran-specific service and establishing a good therapeutic relationship. Participants provided some suggestions for interventions to improve veterans' help-seeking in future; these focussed on enhancing both veterans and health professionals' knowledge regarding mental health difficulties. Conclusions: This study identified a number of barriers and enablers that may impact a veteran's journey in seeking help from professional services for mental health difficulties. Enablers such as reaching a crisis point, social support, the media, having a diagnosis of PTSD and veteran-specific mental health services appeared to be important in opposing stigma-related beliefs and in supporting veterans to engage in help-seeking behaviours.

Planteamiento: Está bien establecido que los veteranos que sufren de problemas de salud mental infrautilizan los servicios de salud mental. Objetivo: Este estudio estaba dirigido a comprender más sobre las barreras que impiden que los veteranos busquen ayuda profesional y aquello que les facilita su búsqueda de ayuda profesional. También tenía como objetivo explorar posibles mecanismos para mejorar la búsqueda de ayuda y las vías que llevan a dicha atención de los veteranos. Método: El estudio empleó un diseño cualitativo mediante el cual 17 veteranos, que habían asistido recientemente a servicios especializados de salud mental para veteranos, participaron en entrevistas semiestructuradas. Los datos resultantes se analizaron utilizando una teoría fundamentada. Resultados: Los participantes describieron dos etapas distintas en su búsqueda de ayuda: búsqueda inicial de ayuda; y vías del tratamiento. En cada etapa se identificaron las barreras específicas y los facilitadores para dicha búsqueda de ayuda. Las barreras iniciales incluyeron el reconocimiento de que existe un problema, el autoestigma y el estigma público anticipado. Los facilitadores iniciales incluyeron estar en crisis, apoyo social, motivación y los medios de comunicación. Las barreras a recibir tratamiento incluían factores prácticos y creencias negativas sobre los servicios de salud y los profesionales. Lo que facilitaba el recibir tratamiento incluía tener un diagnóstico, ser vistos en un servicio específico para veteranos y establecer una buena relación terapéutica. Los participantes proporcionaron algunas sugerencias de intervenciones para mejorar la búsqueda de ayuda de los veteranos en el futuro; estos se enfocaron en mejorar el conocimiento sobre las dificultades de salud mental. tanto de los veteranos como el de los profesionales de la salud. Conclusiones: Este estudio identificó una serie de barreras y facilitadores que pueden influir en que los veteranos busquen ayuda de servicios profesionales para las dificultades de salud mental. Facilitadores como llegar a un punto de crisis, el apoyo social, los medios de comunicación, tener un diagnóstico de TEPT y servicios de salud mental específicos para veteranos parecían ser importantes a la hora de enfrentarse a creencias estigmatizadas y de apoyar a los veteranos a implicarse en conductas de búsqueda de ayuda.

What could they have been thinking? How sociotechnical system design influences cognition: a case study of the Stockwell shooting.

Understanding why an individual acted in a certain way is of fundamental importance to the human factors community, especially when the choice of action results in an undesirable outcome. This challenge is typically tackled by applying retrospective interview techniques to generate models of what happened, recording deviations from a 'correct procedure'. While such approaches may have great utility in tightly constrained procedural environments, they are less applicable in complex sociotechnical systems that require individuals to modify procedures in real time to respond to a changing environment. For complex sociotechnical systems, a formative approach is required that maps the information available to the individual and considers its impact on performance and action. A context-specific, activity-independent, constraint-based model forms the basis of this approach. To illustrate, an example of the Stockwell shooting is used, where an innocent man, mistaken for a suicide bomber, was shot dead. Transferable findings are then presented. STATEMENT OF RELEVANCE: This paper presents a new approach that can be applied proactively to consider how sociotechnical system design, and the information available to an individual, can affect their performance. The approach is proposed to be complementary to the existing tools in the mental models phase of the cognitive work analysis framework.

Translating concepts of complexity to the field of ergonomics.

Since 1958 more than 80 journal papers from the mainstream ergonomics literature have used either the words 'complex' or 'complexity' in their titles. Of those, more than 90% have been published in only the past 20 years. This observation communicates something interesting about the way in which contemporary ergonomics problems are being understood. The study of complexity itself derives from non-linear mathematics but many of its core concepts have found analogies in numerous non-mathematical domains. Set against this cross-disciplinary background, the current paper aims to provide a similar initial mapping to the field of ergonomics. In it, the ergonomics problem space, complexity metrics and powerful concepts such as emergence raise complexity to the status of an important contingency factor in achieving a match between ergonomics problems and ergonomics methods. The concept of relative predictive efficiency is used to illustrate how this match could be achieved in practice. What is clear overall is that a major source of, and solution to, complexity are the humans in systems. Understanding complexity on its own terms offers the potential to leverage disproportionate effects from ergonomics interventions and to tighten up the often loose usage of the term in the titles of ergonomics papers. STATEMENT OF RELEVANCE: This paper reviews and discusses concepts from the study of complexity and maps them to ergonomics problems and methods. It concludes that humans are a major source of and solution to complexity in systems and that complexity is a powerful contingency factor, which should be considered to ensure that ergonomics approaches match the true nature of ergonomics problems.

The famous five factors in teamwork: a case study of fratricide.

The purpose of this paper is to propose foundations for a theory of errors in teamwork based upon analysis of a case study of fratricide alongside a review of the existing literature. This approach may help to promote a better understanding of interactions within complex systems and help in the formulation of hypotheses and predictions concerning errors in teamwork, particularly incidents of fratricide. It is proposed that a fusion of concepts drawn from error models, with common causal categories taken from teamwork models, could allow for an in-depth exploration of incidents of fratricide. It is argued that such a model has the potential to explore the core causal categories identified as present in an incident of fratricide. This view marks fratricide as a process of errors occurring throughout the military system as a whole, particularly due to problems in teamwork within this complex system. Implications of this viewpoint for the development of a new theory of fratricide are offered. STATEMENT OF RELEVANCE: This article provides an insight into the fusion of existing error and teamwork models for the analysis of an incident of fratricide. Within this paper, a number of commonalities among models of teamwork have been identified allowing for the development of a model.