Many ex-servicemen suffering from combat stress are damaged not by a traumatic event, but by the shock of returning from war. When they fall prey to insomnia, guilt, anxiety and isolation, the military, it seems, does not have all the answers

The faces of the two young Afghan policemen would never leave him. They had both been shot while defending their position and bled to death in the back of a trailer as AJ and a medic tried to staunch their wounds. They could not have been more than 17 years old. AJ, as the former Royal Marine asked me to call him, was on his second deployment to Afghanistan. The first tour, in 2001, had been quiet. Five years later, his unit, 45 Commando, was engaged in fierce fighting with the Taliban outside the town of Gereshk. As a sniper, AJ acted as lookout for the other marines, carefully spotting enemy positions and either calling in mortar fire or counting down from three, according to his training, and pulling the trigger.

After the battle at Gereshk, AJ’s unit was deployed to Sangin, a small town on the Helmand river. It was a Taliban stronghold, and soldiers from the Parachute Regiment had narrowly managed to hold the town centre after intense fighting a few months before. AJ’s unit was based 4km away in an outpost known as FOB (Forward Operating Base) Robinson, where an outer ring of earth-filled wire cages formed the first line of defence. The marines bedded down in buildings in an inner circle nicknamed the Dust Bowl. A tower made of mud bricks stood in the centre and AJ took turns with the other snipers to man a makeshift bunker on the top, cradling their rifles and scanning the dun-coloured landscape for any sign of Taliban fighters.

Nowhere in Sangin was safe, but the tower was particularly exposed. FOB Robinson had been set up on a slope, giving the Taliban concealed in the town a clear aim into its interior. They exploited the site’s weakness to the full, hammering the base with 120mm mortars that made the ground shake. Sometimes as many as 30 rounds would slam into the ground in a single attack.

While other marines took cover, AJ and his sniper team would remain on the tower – searching the surrounding patchwork of terrain for any sign of the enemy. Each time he heard the crump of a mortar being fired, AJ flinched, suspended for 30 seconds, waiting. It was only when he heard an ear-splitting blast as the shell struck home that he knew he was still alive.

“Anything happened, any ‘bang’ – you had to be involved,” AJ said. “People were relying on your optics, especially at night – you could see more than they could.”

One freezing January night, just before 11pm, AJ was about to climb down from the tower to hand over the watch when he felt an unusual pang. It was if a silent voice was urging him to take one last look. His thermal scope took a while to reboot. When it flickered back to life, something stirred on the North Fort, a sinister-looking ruin almost 1km away. He watched a heat spot bob up and down. Then there were two. He picked up a field telephone and called the duty room.

“Stand the men to,” he said. “We’re about to get attacked.”

He had shot at targets on the North Fort before and knew the precise range – 728 metres. As yawning marines stumbled out of their quarters, pulling on combat helmets and quickly taking up their positions, AJ saw two men on the fort. A flash of light flooded his eyepiece. The man in his sights had lit the propellant on a rocket. The glow of the fuse illuminated his target like a halo. He fired. The man fell, and his rocket arced into the night’s sky. The blast signalled the start of a carefully planned attack. AJ’s warning had meant the marines were ready and the night lit up with the laser-like streaks of tracers. He remained on the tower, counting down from three and squeezing his trigger, over and over.

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The strain of combat left a physical imprint. Each time AJ fired his sniper rifle, the recoil rippled through his body. His head began to feel numb and his ears rang with a maddening high-pitched sound that lasted for days. Combat also took a toll on his nerves. He had always been self-reliant, content with his own company and often happier sharing a quiet drink than in a rowdy bar. But he watched the marines preparing for patrols with a stab of envy – their camaraderie left him feeling even more isolated in his nest. When the others were resting, he would be hard at work reinforcing the makeshift fortifications on the tower. Someone nicknamed him Rommel after the German general known for his preoccupation with defence. “Let’s say five or six mortars come in an hour,” AJ said. “Goes quiet. They say: ‘Stand down. It’s over.’ I couldn’t switch off. You’re just left feeling on edge – look around, see some people making drinks, taking body armour off, getting a shower. How do you know a bomb’s not going to land any minute? If we got 10 minutes spare, I’d be filling sandbags.”

I couldn’t switch off. You’re just left feeling on edge. How do you know a bomb’s not going to land any minute? AJ

One day, a shell exploded just outside the base walls, then one hit inside the perimeter. The next struck close to their building. AJ agreed with his partner that they were too exposed: the next time they heard a mortar being fired they would scramble down from the tower during the 30-second lull before impact. There was another dull thud as a mortar was launched, and he threw himself off the tower. Laden with body armour and ammunition, he slammed into the ground on his backside, pain lancing up his spine. He struggled on for another week, but he could barely walk and eventually his commander had no choice but to transfer him to safety for medical attention.

AJ did not want to leave but he knew he had no choice: the Chinooks only landed every two weeks and would be on the ground for no more than 10 seconds. As the helicopter raced across the hard-packed desert, he could not know that his hardest battle lay ahead.

* * *

Up to 20,000 servicemen are leaving the forces each year, many returning to a civilian world they last knew as teenagers. The military, which has supervised their every waking hour in the field of battle, faces very different challenges with young men returning from war. When, after months of watchful duty, AJ was transferred home because of injury, his depression and anxiety became unmanageable. And it became clear that the military did not have the answers.

When I went to meet AJ at his home in the south-west of England in January last year, he came to pick me up in his white four-wheel drive. No obvious signs marked him as a former Royal Marine: the regulation haircut and shaggy moustache he had sported on tour were long gone, and, with blond hair down to his collar, he could have passed for a surfer. AJ lived with his wife and two teenage sons. At home, he settled back on the sofa and swung his legs onto a foot rest. He had a palpable air of calm.

AJ came from a family of Yorkshire trawlermen, but with the fishing industry in decline, his father had encouraged him to visit the army careers office in Hull. AJ had applied to join the marines at 19, and was later selected for the arduous training in marksmanship, concealment and stalking to qualify as a sniper. In Afghanistan his role had been to kill enemy soldiers in a cool and methodical fashion – unlike infantrymen, who often found themselves firing through dense undergrowth in the adrenalin-fuelled heat of close-quarter battles. In Helmand he had discovered there was no remorse attached to shooting somebody who was intent on killing him or his comrades. “Shooting somebody seemed easy,” he explained. “The biggest fear was us getting hurt.”

Facebook Twitter Pinterest Royal Marines mount an assault in Helmand province, Afghanistan Photograph: Hamish Burke/MoD/Crown/PA

After he arrived back in Britain, he knew something was wrong. He was unable to sleep, and constantly on edge. Though the Royal Marines had pioneered a system called Trauma Risk Management, or TRiM (now used throughout the military), where troops are trained to recognise colleagues in distress, he kept his problems to himself. By the time he returned to the Royal Marine Commando Training Centre at Lympstone, AJ felt worse. At one point he lost his memory for several days. He was taking a course to qualify for a promotion to sergeant. One of the training exercises precisely replicated an incident from Afghanistan and though he seemed to perform well, he vomited as soon as he was alone. He began to skip sessions and wander aimlessly around the base or spend long periods staring across the river Exe.

Despite his growing anxiety, AJ earned his promotion to sergeant. He was assigned a role as an instructor, but as he lectured classes on preparing orders for battle, he would suddenly find himself back on the tower in Robinson, braced for a fresh barrage of mortar rounds. He only realised he had trailed off in mid-sentence when his audience began to murmur. He felt as if he was encased in a glass dome – the world beyond seemed remote and unreal. “It was all about me, it was all about Afghan – you live in a bubble,” he said, touching his fingertips together to form a globe. “The only things that matter are actually right here and within arm’s reach – anything else, you can’t take it in,” he said. “You’re emotionally numb. You don’t really care about anyone else’s emotions – they don’t matter.”

AJ’s superiors were sufficiently concerned about his state of mind to assign him sessions of a therapy known as EMDR – eye movement desensitisation and reprocessing, one of the standard treatments for PTSD used by the military and NHS. In an EMDR session, the therapist asks the client to recall an image of a traumatic memory, the accompanying emotion and where it is felt in the body. The therapy can sometimes achieve remarkable results, but in AJ’s case, it made him feel worse – the seemingly endless sessions brought the terror of war flooding back.

“They actually said to me: ‘You’ve persisted to a point where it won’t work,’” AJ said. “‘You’ve topped out with EMDR – don’t do any more.’”

Though his voice never wavered, our conversation was marked by long moments of silence. Several times, when speaking of the worst incidents, I noticed that, while his face betrayed no hint of emotion, he would slowly clench his toes. Therapists embarking on trauma treatment sometimes ask clients to spend some minutes visualising a “safe place” that they can visit if they feel overwhelmed. Ever since he was a boy, setting out with his father on the family trawler, AJ had drawn comfort from the ocean. When the darkness returned, he would imagine a summer’s day on the shoreline – hear the cry of seagulls and the crash of waves, and feel the gritty softness of his toes digging into the sand.

AJ was medically discharged from the marines five years after he came back from Afghanistan. As his last day approached, he spent much of his time alone at home. Looking back, he could see that his chain of command, while sympathetic, had been uncertain how best to handle him. Many serving soldiers find it difficult to access meaningful care. Sometimes they have to make long trips from their base to the nearest military mental health centre, and in many cases there is no out-of-hours crisis service.

“It’s a funny one: you want help and don’t want help, so they didn’t know what to do,” AJ said. “I’d be angry at them. They’d be worried that they’re causing you stress. They didn’t know where the line was, whether to intervene or step back. I knew I needed to be away from the military. Because I’m a sergeant they assumed I’ve got the level-headedness to organise it and sort it out myself.”

On his last day as a marine, AJ’s wife went to work. He got up from the kitchen table and found himself walking towards the garage door intent on ending it all. A silent voice was calling: “Everything will be easy if you come with me.”

He preferred not to speak in detail about the following moments apart from to say that the thought of his two sons finding him dead prompted him to step back from the brink. He knew he owed it to himself and his family to get well again. But he was haunted by the loss of a member of his company who had been killed by a buried Taliban bomb. The device had been planted in ground AJ had kept safe from his nest on the watchtower. He could not shake the feeling that when he was sent home injured, he left his fellow soldiers unguarded.

Because AJ was back in the UK when his fellow marine had died, he was able to attend the funeral. “The hardest thing I have ever done: I felt responsible for the device being laid in my territory while I was ‘off watch’. This funeral felt like it was my creation. Guilt – even innocent guilt – is an evil thing.”

AJ became fixated on helmet-camera footage shot in Afghanistan and uploaded onto YouTube. “It was a first sign, I think, of depression and a macabre interest in death,” he said. One day, he was out with his wife and his children in Exeter when another driver barged past him as he was reversing out of a parking space. He threw his car into gear and pursued the man until they were both forced to stop at a roundabout. AJ jumped out and began running towards the driver, who managed to accelerate away. AJ stood in the road bellowing obscenities until he gradually realised that a queue of people were staring at him from a bus stop.

“I would have just kept beating him until he was dead, I know I would,” AJ said quietly. “I had no control. And that’s when I knew I needed some help.”

I would have just kept beating him until he was dead. I had no control. And that’s when I knew I needed some help

* * *

There have always been a number of returning servicemen who, having survived combat, become casualties of peace – unable to withstand the sense of futureless isolation that engulfs them when they leave behind friendships forged under fire. Such problems can be particularly pronounced for young men from inner cities or small-town estates who looked to the military to provide them with a way out but then find themselves back home after a few years of service. In the course of my research I deliberately sought out those who had struggled the hardest on leaving the military, but it was still striking how many spoke about their suicide attempts or about former comrades who had taken their own lives. There was a special poignancy attached to the fate of men who had survived encounters with enemies of flesh and blood, only to fall in a battle with their own minds.

This spring, a report by Combat Stress, the veterans’ mental health charity, said the number of ex-forces members seeking help had risen by 26% in a year. A report published by the King’s Centre for Military Health Research in early 2015 suggested that service personnel may be twice as likely to suffer from depression and anxiety as the general working population. Unlike in the United States, where an epidemic of military suicides has gained widespread coverage, the relationship between suicide and service has received limited attention in Britain. As part of an investigation for the BBC’s Panorama programme in 2013, journalist Toby Harnden wrote to coroners around the country and found that there had been a steady increase in the number of suicides among those who had served in Afghanistan and Iraq. There were seven likely suicides of serving personnel in 2010, compared with 15 in 2011 and 21 in 2012. Of those 21, 16 had served in Afghanistan or Iraq.

In response to the Panorama programme, the MoD issued a statement, saying that suicide rates among personnel who were still serving in the military were significantly lower than in the rest of the population. This was not entirely surprising: during service they were employed, generally in good health and looked after – problems tended to arise with much greater intensity when they left. Some former servicemen I spoke to stressed that it was not necessarily traumatic memories that proved intolerable, but often the reverse culture shock of adjusting to civilian life – and the lost sense of purpose, the broken relationships and the hopelessness that could follow.

It has been a century since the first world war physician and psychologist Charles S Myers first introduced the term “shell shock” into the medical literature with an article in the Lancet. Yet the system that has developed to support soldiers struggling with invisible wounds has grown up in an ad hoc fashion, with responsibility divided today between the MoD, NHS and charities. While the range of services on offer is growing, a trickier problem has yet to be solved: the stigma that deters many from seeking help.

* * *

As the battle of Trafalgar commenced in 1805, Admiral Nelson sent a semaphore signal to the rest of the fleet: “England expects that every man will do his duty.” The words captured the spirit of self-sacrifice that has long shaped Britain’s martial culture, and prescribed a studied silence as the standard remedy for distress.

Portsmouth remains the home of a major Royal Navy base, where Nelson’s Victory is dwarfed by the grey silhouettes of modern-day warships looming above centuries-old docks. The complex is also home to one of a network of 16 mental health centres located at military bases across Britain, known as Departments of Community Mental Health, or DCMHs, which treat outpatients. Since the closure of Britain’s military hospitals in the 1990s, the MoD has contracted out all in-patient psychiatry. For some years the private Priory Group held the contract, but the NHS has taken responsibility for all residential psychiatry of serving military personnel since 2008.

Surgeon Captain John Sharpley, defence consultant adviser in psychiatry, has served for 28 years in the Royal Navy, and bears ultimate responsibility for the care of the forces’ unseen wounds. Antique maritime charts decorate the walls of his office and a ship in a bottle rests on a shelf of psychology texts. As the military’s chief psychiatrist, one of Sharpley’s main tasks is to oversee the network of DCMHs, designed to allow personnel rapid access to psychological assessments. The military provides twice as many mental health staff per capita as the NHS does for the civilian population, primarily because it needs to be able to ascertain rapidly whether somebody is fit for duty – a priority task when jobs might involve operating weapons or leading troops in battle. Personnel are also trained, to varying standards, to offer treatment – medications for depression or anxiety, for example, and some psychotherapy – but the core function is a military version of occupational health. In that sense, the words of Lord Moran, writing in 1945, still have a ring of truth today: “My job as a medical officer was to value the assets of the battalion – to take stock – to guard against depreciation.”

For PTSD, the military employs the same two treatments recommended by the National Institute for Health and Care Excellence for use in the NHS. The first of these is a trauma-focused version of cognitive behavioural therapy (CBT), a form of talk therapy in which a therapist aims to help a client improve their mood by learning to identify and change negative patterns of thought and behaviour. CBT has occupied pride of place in a government drive to expand access to psychotherapy for common problems such as depression and anxiety in recent years. The trauma-specific variant involves repeatedly revisiting a painful memory in order to gradually weaken its grip on the present.

There is, however, growing concern in the psychotherapy community over CBT’s effectiveness for the most severe cases of PTSD. Though research suggests that the technique may work for otherwise healthy people who may have experienced a one-off traumatic event, far fewer studies have tested its results for people with ingrained PTSD symptoms stemming from multiple shocks suffered over many years – the kind often presented by soldiers.

The other recommended PTSD treatment is eye movement desensitisation and reprocessing, or EMDR, which AJ had tried. The approach has not enjoyed the same level of state support as CBT, though many trauma specialists argue that it can sometimes prove extremely effective. But EMDR has risks attached, particularly if it is started too early in the therapy process, when it can reopen wounds instead of healing them.

Sharpley’s staff had no shortage of opportunities to put both approaches into practice. In the year to 31 March 2014, 396 service personnel were diagnosed with PTSD, an increase of almost 20% on the previous year. There had also been a 12% increase in the rate of mental disorders diagnosed as a whole, including depression and anxiety. The picture was complicated by the fact that these official statistics might capture only a fraction of the overall burden of illness, since many personnel feared that asking for help might damage their careers.

“10% of what we see comes to the DCMHs,” said Sharpley. “90% we don’t see.”

As the fighting in Afghanistan intensified, the army launched a publicity campaign called “Don’t Bottle It Up” to encourage more troops to come forward. Though attitudes are changing, Sharpley said, there was still a view in the military that some stigma around mental health is essential to bind the organisation together.

“The military operation is dependent on small groups, not individuals,” he said. “And stigma is bad for the individual, but good for the group.”

He gave the example of a unit of 10 soldiers ordered to assault a hill and destroy a machine-gun nest. Since they would all be risking their lives, they would ostracise anybody showing signs of weakness. “If they’ve got a person in that group who’s not functioning properly, what are they are going to do?” Sharpley said. “Get rid of them and get another one who’s OK. That’s why stigma’s good for the group. In the second world war, it was OK to shun someone with a mental health problem – it’s not OK now,” he said. “That creates a lot of conflict in the military. It’s an interesting conflict we have difficulty managing.”

It was notable that neither Sharpley nor anybody else I spoke to in the military could point to a single senior serving officer who was speaking out publicly about overcoming their own mental health problems. The official message to troops was to seek help, but the hierarchy seemed reluctant to demonstrate that suffering from PTSD, or a bout of depression or alcohol misuse, did not have to wreck your career.

* * *

Since traumatic reaction was first identified, it has caused controversy amongst physicians, who have argued over its origins. In the US, the Pentagon has spent large sums on neuropsychological testing programmes to investigate whether shockwaves from roadside bombs in Iraq and Afghanistan may have caused thousands of hard-to-detect cases of what is known as mild traumatic brain injury, or MTBI, whose sufferers can exhibit some of the symptoms found in PTSD. Though British troops have been subjected to many similar blasts, the MoD has taken a more passive approach, encouraging people to come forward if they think they may have symptoms of MTBI, fearing that actively screening for cases might inadvertently lead to the creation of a new “signature injury” from the recent conflicts – just as Gulf war syndrome emerged as a catalyst for controversy in the 1990s.

Facebook Twitter Pinterest American troops in Afghanistan. The US has spent large sums on research into the effects of shockwaves from roadside bombs on soldiers’ brains. Photograph: Johannes Eisele/AFP/Getty Images

Like many others in military mental health, Sharpley was keen to dispel what he saw as a widespread misperception that the mere fact of witnessing a horrific incident or experiencing a life-threatening event would inevitably cause chronic symptoms. In his experience, the active ingredient in many apparent cases of trauma was a sense of broken trust. Though this sense of betrayal was by no means universal, Sharpley’s point echoed what I had been told by a number of ex-forces personnel, whose pain stemmed in large part from the way relationships had ruptured in the aftermath of tours, rather than solely from their experiences in the war zone.

Sharpley gave the theoretical case of an Apache helicopter gunship crew who might have fired at some figures highlighted on their screens. “They kill them. They see this splat. They have to play their video to their commanding officer. Then, say, command decides they hit the wrong target and killed civilians – and the pilot receives a reprimand. For two months, he is known as the idiot who made the mistake and his marriage starts to crumble when he returns.” A year later, the pilot may present to a mental health nurse, saying he was haunted by images of the targets turning to “red mist”, though as Sharpley says: “It isn’t the case at all – the trauma was possibly being ticked off by his commanding officer for doing the wrong thing. His loyalty to the CO or the system has been shattered.”

Some of the men I met certainly felt betrayed by an individual, perhaps a superior whom they felt had not taken their personal struggles seriously enough. Others were burdened with a conviction that they had betrayed themselves, perhaps because of something they had done – or, more commonly, had failed to do. Bonds forged in training and under fire were so profound that it was not uncommon for soldiers to suffer lacerating feelings of guilt for surviving when others had not, or to punish themselves over deaths they felt they could have prevented, even when it was clear there was nothing they could have done.

AJ was a case in point. He felt burdened by the death of the marine who had stepped on a buried bomb in ground he had kept safe until he was forced to return to Britain. The fact he had not been in Afghanistan at the time of the man’s death was of no comfort. While on duty, he had felt responsible for keeping the men safe – and the feeling stayed with him. The guilt of leaving them unprotected tormented him.

The military could not help AJ. When he left the marines, he was advised to prepare for a lifelong struggle with his anxiety and flashes of rage. But in the years after discharge, he discovered a quiet determination to find his own path to healing. Increasingly, soldiers suffering combat stress, and their partners and families, are seeking their own solutions. After leaving the marines, AJ made an appointment with a charity in Bath called Save Our Soldier, which offers emotional coaching to ex-forces. As he navigated winding country roads with his wife, he felt a growing sense of apprehension, which deepened as they drove through a seemingly deserted village. The satnav kept urging AJ onwards but roadworks blocked his path, and he felt the same mortal fear that had gripped him when mortar shells rained down in Sangin. His tension proved contagious and soon his wife was also close to panic. AJ yanked the car around, fighting a wild urge to ram into an approaching tractor.

When AJ talked through the journey with Lee Hayward, Save our Soldier’s founder and lead coach, he had a flash of insight – the drive had triggered suppressed memories of the day he had driven into an ambush in Afghanistan. He was led through an exercise to release the trapped feelings and felt a surge of relief.

“It worked – I had a total emotional outburst,” AJ said. “No problems driving since.”

The case presented a dilemma familiar to many other smaller military charities offering psychological support to former service personnel. Hayward had no formal clinical training and some medical professionals might regard his techniques with a high degree of scepticism, even concern. But until the reach and effectiveness of treatment for servicemen and women affected by symptoms of anxiety and depression improve, people will continue to seek out whatever solutions are on offer.

In an email that AJ wrote to me, he said: “It is a long and exhausting journey of self-discovery. The stress from combat is something I did not expect to suffer with. However, when I was told at discharge that there is no cure and it will last for life, I refused to accept this as a married man and father of two. There is a way.”

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