Journal of Addiction Research & Therapy
Open Access

Addiction; Addiction research; Addiction therapy; Addiction science

Introduction

Individuals with addictions and substance use disorders are known to face a number of challenges and needs associated with social determinants of health including medical, social, emotional, financial, legal and housing. These challenges require innovative care pathways that create solutions, in addition to evidence based treatment for substance use problems. As highlighted previously by the authors psychosocial interventions are crucial in supporting the recovery of military veterans. Psychosocial interventions can also be adopted through social prescribing for effective management of addiction and related issues, and can be successfully used as independent treatment methods as well as adjuncts to pharmacological treatment plans for military veterans.

At present, in the United Kingdom (UK), there are servicepersonnel leaving the military with no physical injuries but with underlying mental health problems including addictions and substance misuse disorders. These may surface on return to the family unit, or at times of stress triggered by an overreliance and use of alcohol. Previously, the author has expressed concern that there was evidence that once military service personnel are discharged, there appears to be no communication to relevant health and social services to allow for rehabilitation and treatment of mental health conditions including, addictions and substance misuse disorders. Research by Fear et al. [1] state that the prevalence of heavy drinking is higher with serving personnel than with their civilian counterparts. Hossain et al. [2] explain that this is a concern, as following a major crisis or trauma an individual may be at an increased risk of using substances to manage stress related anxiety. Johnsen, Jones, and Rugg [3] found that for those participants identified as homeless, these participants believed that there was a link between their current alcohol abuse and the drinking culture that they had been exposed to within the Armed Forces.

The use of psychosocial interventions is not a new revelation. Indeed, suggested that the concept of non-pharmaceutical interventions arose in 1942 at Northfield military Hospital in Birmingham, where a move to improve the return of neurotic casualties to military duty was tried out as a new form of treatment. This therapeutic community was short-lived due to its operating parameters, which were outside of the normal treatment plans of that time. This seminal work along with the previous success in the Peckham experiment in the 1930s, which saw the creation of an” unintentional therapeutic community” began to establish an evidence base for a shift away from the dominant medical model. In the following review of the literature, we will discuss how the social prescribing of psychosocial interventions could enhanced selfimage and create a sense of belonging for military veterans struggling to adjust to the transition to a civilian identity [4].

Discussion

Alcohol and substance misuse within the veteran population

Within western nations, there appears to be a culture of a reliance and overuse of alcohol within their military services. This is highlighted within the research of Ames and Cunradi and Fear et al. [5] within the US and UK. This research evidences that alcohol consumption rates in military service personnel exceeding those of civilian counter-parts across all age groups. This does not appear to be a camouflaged concern in so much as to say that military leaders are aware of the negative impact that excessive drinking has on the health of their troops, their effectiveness and wider reputation of Armed Forces [6,7].

In 2015, a joint report by Help for Heroes and Kings Centre for Military Health Research (KCMHR), suggested that at least 10% of veterans who served over the last 20 years present mental health conditions that need treatment. The same report estimated that at least 61,300 out of 601,000 veterans who served as Regulars in the UK Armed Forces between 1991 and 2014 might suffer from mental health problems, and that this would require professional intervention. Amongst these mental health problems was the alcohol dependency and substance use.

Indeed, the authors own research and role within the Government Review on former members of the armed forces and the criminal justice system on behalf of the Secretary of State for Justice indicated that alcohol and substance use were common features noted within the arrest profile of veterans entering the criminal justice system. DASA explored the issue of substance misuse and found that within England and Wales, male veterans were less than 50% likely to be imprisoned for drug-related offences than that of the general population but no explanation or sample size was provided. However, Bird [8] reported that there has been a four-fold increase in the number of veterans who are being discharged due to random sampling tests. According to Gillan [9], the Ministry of Defence (MoD) explained that these results were significantly lower than the 7% of civilian workforce statistics, although it is unclear how they arrived at this conclusion as the source of the civilian statistics was unclear.

A crucial factor to consider is that once military service personnel are discharged, there appears to be no communication to relevant health and social services to allow for rehabilitation and treatment for the offending behaviour, which is often linked to alcohol consumption. Indeed, no information was given to be able to ascertain how many of the reported 7% were veterans. Johnsen, Jones, and Rugg [10] found that for those participants identified as homeless, these participants believed that there was a link between their current alcohol abuse and the drinking culture that they had been exposed to within the Armed Forces. In support of this argument, Fear et al. [11] state that the prevalence of heavy drinking is higher with serving personnel than with their civilian counterparts.

Fear et al. [11] identifies Early Service Leavers (ESLs) as experiencing an elevated risk of suicide and heavy alcohol consumption over that of longer serving veterans. Within Wales, the Health Inspectorate of Wales has expressed concerns that some ESLs had been discharged back into civilian life as the result of disciplinary issues, including substance misuse without adequate liaison with statutory services and support from the MoD. There is a consensus that this group represents the most vulnerable and ineffectual at circumnavigating their transition back into civilian life especially for those exposed to combat related trauma. Alarmingly, within 29 randomised controlled trails (RCTs) Kitchiner et al. [12] undertook 29 randomised controlled trails (RCTs) examining the efficacy of psychosocial interventions for military veterans and found psychosocial interventions to be beneficial for the treatment of depression and those at risk of alcohol consumption.

Military personnel exposed to war-zone stress are at significant risk of developing Post-traumatic stress disorder (PTSD). Post-traumatic stress disorder (PTSD) has been studied in military personnel for more than 30 years, and PTSD may develop after an individual experiences or witnesses to a traumatic event, such as natural disasters or violent personal assault, life-threatening events such as terrorist attacks, violent crime and abuse, military combat, serious accidents or extended combat, exposure to certain environmental toxin. The raises their concern in highlighting scientific evidence and empirical research that suggests that military personnel with PTSD are at greater risk for more physical health problems, poorer health status, and higher medical service usage often due to excessive alcohol consumption and substance misuse. Depression is the most common comorbidity of PTSD among military personnel and this often accompanying with alcohol abuse. A meta-analysis of 57 studies, conducted among both military and civilian samples, found a major depressive disorder and PTSD comorbidity rate of 52% with evidence of alcohol abuse. Other prevalent psychiatric comorbidities of PTSD exhibited among military veterans include anxiety and substance abuse or dependence. The author has previously called for the need for a greater understanding of the problems faced by those who have been exposed to military culture, particularly in relation to alcohol abuse, which becomes a common feature within veteran’s life stories as they struggle with transiting to a civilian identity. The social prescribing of psychosocial interventions offers a bespoke and holistic treatment pathway that can improve resilience within the mind and body, and reduce the effects of living with long-term stress, which as the literature indicates can lead to a dependency on addiction and misuse of substances.

Psychosocial interventions in the reclamation of identity and belonging

A psychosocial intervention is a broad term used to describe different ways to support people to overcome challenges within their life and maintain good mental health. Psychosocial interventions have had success to aid in the normalization of the treatment process and this has relevance with military veterans who may have issues around stigma and associated shame in seeking assistance and struggling to relate to non-veteran civilian counterparts. This can be understood through Social Identity Theory which highlighted the boundaries between ‘normals’ and ‘others’. Abrams and Hogg provide insight and explains that these theories describe a psycho-social process by which individuals categorise themselves and others into groups in order to place comparative values on themselves, thus ranking their relative position in the social hierarchy. Such ranking enables selfmonitoring and potentially facilitates the reclamation of self-image. The author explains that issues around social identity are evident from his research with veterans in relation to stigma as these individuals may strive to protect their veteran identities even if this means not mixing with non-veterans. He goes on to explain that language is important in enabling the division of individuals into categories such as veteran and non-veteran as the distinction can be made to ‘in’ groups and ‘out’ groups, which effectively categorises ‘us’ and ‘them’ who are divided by impenetrable boundaries which can inhibit a sense of belonging [13].

Rather than relying on the use of medication, psychosocial interventions can be delivered through in person face-to-face as high intensity psychological therapy or in a low-intensity format via the use of Cognitive Behavioural Therapy (CBT) self-help interventions or a combination of these support modalities. For veterans the benefits of psychosocial interventions that they allow for a process of engaging in therapy but with a therapeutic intervention designed around a proactive activity. This has the positive outcome of allowing the veteran to see an output for their engagement. Crucially, these psychosocial interventions can be group based which allows the shared veteran identity to support an establishment of belonging through the familiarity of comradeship yet empowers confidence to explore and form ownership of new identities [14].

This need to belong is also a feature found within Social Identity Theory as attested by Tajfel and Turner. They explain that social identity consists of “those aspects of an individual’s self-image that derive from the social categories to which he perceives himself as belonging”. This inherent need to belong for military veterans could be seen to be indicative of the findings of Steger and Lopez [15] who observed a continuing process to establish meaning through belonging. Indeed, Barron, Davies and Wiggins (2008) identify comradeship and associated societal support to be crucial in promoting a sense of belonging for military veterans. This is supported by Burnell [16] who cite the importance of comradeship in service personnel returning home and transitioning back to post-military identities as civilians. Indeed, the author’s research infers that the absence of a sense of belonging can lead veterans into crime and often as a result of alcohol and substance misuse. Within a more recent study Mottershead & Alonaizi [17] it was demonstrated that comradeship with fellow veterans support a reclamation of identity due to the shared life experience of a culture uniquely developed and understood by veterans within the Arabian Gulf. The results of this study have clear parallels with the UK and be understood through the use of Social Identity Theory. Additionally, this could lead to further understanding of Goffman’s mortification of self and perhaps desire to return to a pre-existing identity of veteran over other less favourable or less influential identities such as the civilian identity, which the individual may struggle to establish a sense of belonging to this transitioning identity. Consequently, the misuse of alcohol and substances become a coping mechanism within the life stories of post-military identities that fail to establish a belonging to a civilian identity.

Future considerations

It is the intention of the author that the review of this literature will inform the development of social prescribing for existing psychosocial interventions applied for the well-being and rehabilitation of military veterans, reservists, emergency service personnel and their families within Wales, UK [18].

Instead of working in confined environments, the participants will be invited to join one of the regional rural hubs of the award winning national charity - Woody’s Lodge [19]. These rural hubs are at Ty Gwalia in North Wales, Penlan Farm in West Wales Amelia Farm in South Wales, and a recent development on Flat Holme Island within the Bristol Channel. The hubs offer open countryside with gardens, greenhouses and access to range of psychosocial interventions that will aid in improving the re-integration and development of relationships through indoor and outdoor activities. For those veterans making the transition to a civilian identity, the combination of directed physical work and the need to work as a team with others, provide a route back into civilian life and improve confidence, self-esteem and personalised wellbeing. In addition, the sharing of real-life experiences of the challenges of combating alcohol and substance use will also improve outcomes in physical and mental wellbeing, and help veterans to reduce the effects of stress and physical health problems.

Woody’s Lodge network of rural hubs support and mentor veterans, emergency service personnel, reservists and their families in safe, quiet and informal surroundings [20-24]. This is achieved through the use of the shared veteran identity as an ability to create effective veteran peer-support schemes centered around the social prescription of psychosocial interventions that built on a belonging to this shared veteran identity. This process is an aid to those living with addiction and reliance on substances, whose traditional hospital admissions have not been effective. The project is carried out by the registered UK charities Woody’s Lodge and Wintergreen UK – CIC which collectively provide the psychological and social support holistically. Both organisations offer complementary psychosocial interventions, free of charge to people with lived experience of health and social care challenges. This approach uses an evidence base to create bespoke psychosocial interventions to personalize recovery without needing further access to increased medical or other interventions [25-28].

Conclusions

This review has highlighted an awareness of the benefits of psychosocial interventions, as a therapeutic treatment option for addictions, substance misuse and wider mental health. However, 21st Century practices persist to align the health needs of military veterans with predominantly pharmaceutical interventions. The author advocates for a broader, holistic framework, evident within the suggested use of socially prescribing psychosocial interventions, that acknowledges personal health needs, relationships and social conditions, using a more integrative medical model that combines medical prescribing alongside social prescribing.

This paper describes the use of holistic, non-medical interventions to improve the mental health and wellbeing of military veterans with addiction and substance related problems. A regional project has been identified that will support improved access to both psychological treatments and interventions addressing the wider determinants of mental health. The author acknowledges the strength of the military identity and how transitional challenges can create an entrenched social identity which can inhibit a sense of belonging to new roles and identities within civilian life. Through the proposed use of veteran peersupport structured around psychosocial interventions, the rural hubs of Woody’s Lodge will be an empowering lead within the suggested therapeutic framework. The use of psychosocial interventions via the rural hubs has the potential to become a fully integrated pathway for primary care and social prescribing practices in Wales for the veteran community. This has significant potential for cost-saving strategies as well as strengthening the links between healthcare providers, community, voluntary and statutory services. The project is of importance in seeking to meet what is likely to be an upsurge of mental health issues for military veterans given the degrading economic climate within the UK and post-pandemic fallout.

This review acknowledges the role that medication has within a treatment plan, but advocates the use of psychosocial interventions to provide a further opportunity to respond effectively, and at an early stage, to the impact of addiction and substance misuse on the veteran and their family. The addition of social prescribing arms the medical profession with an additional asset via a gateway to communitybased resources, improved access to psychosocial therapies, as well as to veteran-led services and interventions addressing the wider determinants of impoverished self-image and a need to create a sense of belonging and purpose to a worthwhile civilian identity and a rewarding life.

Data Availability

No data are associated with this article.

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