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Effectiveness of our Treatment Programmes

On an on-going basis, we consider how effective our programmes are and what makes them more effective.

Year  Title Summary
2018 Describing the feasibility of using case management in a specialist forensic substance misuse intervention for UK veterans: A case study.
  • Veterans with mental health problems are a high-risk group for substance misuse difficulties and are over-represented in forensic settings. Yet, there are few substance misuse services available for this population.
  • This study looked at the feasibility of piloting a Veterans Forensic Substance Misuses Service (VFSMS) within a prison setting, using a case management model.
  • Findings from three case studies suggested that case management was a feasible approach, with a range of interventions being used by veterans, including substance misuse and mental health services, plus housing and employment services.
  • Outcome measures suggested that alcohol and substance misuse recovery improved following the VFSMS intervention.
  • While the scope of the findings is limited, they suggested that case management is a feasible substance misuse intervention, with preliminary findings showing improvements in substance misuse outcomes for veterans.

Exploring the Efficacy of an Anger Management Programme for veterans with Post-Traumatic Stress Disorder

  • 172 veterans who attended the Anger Management programme at Combat Stress completed health measures before and after treatment
  • Significant reductions were found in levels of anger and aggression after completing the programme
  • The mean levels of anger after the programme were below the threshold
  • Reductions were also seen in symptoms of PTSD, depression and anxiety
  • Veterans who were unemployed, not in a relationship or who had left the military early had poorer treatment outcomes.
2016 Long-term responses to treatment in UK veterans with military-related PTSD: an observational study 
  • We assessed one-year outcomes in 268 UK veterans treated for PTSD
  • PTSD symptom severity, depression, anxiety, alcohol use and difficulties with social and occupational functioning remained lower than before treatment
  • There are long-term benefits to structured treatment programmes
  • Support targeted at individuals after treatment will improve longer-term outcomes.
2016 An adapted imaginal exposure approach to traditional methods used within trauma-focused Cognitive Behavioural Therapy, trialled with a veteran population 
  • The study investigated a new method of therapy for PTSD with 2 veterans from Combat Stress
  • An adapted imaginal exposure approach was used whereby veterans relive their experience outdoors, manipulate their perspective on the imagery and restructure how they think about it
  • It showed that imaginal exposure therapy can help veterans who experience avoidance or dissociation.
2016 Post-traumatic growth among the UK veterans following treatment for post-traumatic stress disorder.
  • This study examined positive change in veterans after experiencing trauma (aka. Post-traumatic growth)
  • 149 veterans answered questions on their mental health before treatment and 6 months after treatment at Combat Stress
  • An association was found between better treatment response and higher reported levels of post-traumatic growth.

Mental health and functional impairment outcomes following a 6-week intensive treatment programme for UK military veterans with post-traumatic stress disorder (PTSD)

  • 246 veterans were assessed after finishing the six week treatment programme and then again at a six month follow up
  • There were improvements in PTSD symptoms following the treatment and also after six months
  •  The study suggests it may be beneficial to combine individual therapy with group sessions.
2015 Exploring Outcome Predictors in UK Veterans Treated for PTSD 
  • Study on 244 veterans who received the six-week residential treatment programme for PTSD at Combat Stress
  • It was found that PTSD symptoms including avoidance, hyper-arousal and intrusive thoughts were reduced after the programme
  • The study also showed that treatment outcomes were better in veterans who had lower levels of anxiety and dissociation
  • Therefore it is important to treat other difficulties such as anxiety and dissociation before PTSD.


Accessibility of Treatment

Our programmes should be available to all veterans who need them so we look at who is accessing our services, how this is changing and what may influence this.

Year  Title Summary
2018 Exploring the feasibility and acceptability of using tele-therapy for UK veterans with PTSD.
  • While many veterans are able to access support for mental health difficulties, many still find it difficult. There are a number of barriers that can make it harder to access support.
  • In this project, we piloted the use of remote-access video technology to deliver evidence-based psychological therapy (tele-therapy) to veterans with PTSD.
  • Primary aims were to assess the feasibility and acceptability of tele-therapy, as well as its effectiveness in reducing mental health difficulties.
  • 27 veterans took part, receiving Cognitive Processing Therapy via Skype. 21 completed all 12 sessions, taking an average of 14 weeks to complete.
  • 12 veterans were interviewed post-therapy. Qualitative analysis showed that tele-therapy was well received, with participants discussing the pros and cons of tele-therapy compared to face-to-face.
  • Results suggested that PTSD symptoms significantly reduced following tele-therapy and the effects were maintained at 3-month follow up.
  • The report includes a number of recommendations for delivering tele-therapy based on feedback from veterans taking part and the lead clinician.
2017 Systematic review of lessons learned from delivering tele-therapy to veterans with PTSD
  • The research team reviewed the current evidence on using tele-therapy for veterans.
  • The findings from 41 studies were reviewed.
  • Results showed that tele-therapy was as effective as regular face-to-face therapy at reducing PTSD symptoms.
  • In some cases, veterans were found to be more likely to engage in tele-therapy compared to regular therapy.
  • The majority were satisfied with their experience of tele-therapy.
  • Some challenges were reported regarding the therapeutic relationship, e.g. reading body language, some technological problems, but these did not affect treatment outcomes.
2017 Pathways into mental health care for UK veterans: a qualitative study
  • This research looked into the things that stop veterans from getting help and the things that aid them.
  • 17 veterans were interviewed.
  • Initial barriers included recognising that there is a problem and 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 relationship with the therapist.

Detailing the clinical pathways at Combat Stress for UK veterans experiencing symptoms of complex post traumatic stress disorder.

  • This paper explains the three different stages of treatment at Combat Stress
  • The first stage is known as ‘stabilisation’ where veterans attend a two week programme
  • The second stage is trauma therapy, known as the ‘intensive treatment programme’ which lasts six weeks
  • The third stage is to ‘reconnect veterans with their lives’.
2015 Exploring Patterns in Referrals to Combat Stress for UK Veterans with Mental Health Difficulties between 1994 and 2014 
  • A fourfold increase in the number of referrals was found over the 20 years examined
  • This shows that more veterans are seeking help for mental health problems than before
  •  It was found that the time taken to seek help reduced by half
  • Also, although the majority of referrals were from veterans who had served in Northern Ireland, recently there have been more referrals from veterans from Iraq and Afghanistan.
2014 Exploring positive pathways to care for members of  the UK Armed Forces receiving treatment for PTSD: a qualitative study 
  • The study interviewed serving military personnel who were seeking help for mental health problems about what triggered them to seek help
  • Five common reasons were found for seeking help: having reached a crisis point, overcome shame, felt in control, wanted to find a psychological explanation for their symptoms and had good social support.
2014 PTSD, stigma and barriers to help-seeking within the UK Armed Forces 
  • The paper explores existing literature on the impact of untreated PTSD in military personnel
  •  It also looks at barriers as to why people may not seek help and interventions to address these barriers
  • Stigma is found to be the greatest barrier, in particular having negative beliefs about oneself.


Exploring the needs of the Veteran Community

To make sure our treatments are tailored to the needs of veterans, we conduct research to help us understand their specific problems and how they differ to other people who experience mental health problems

Year  Title Summary
2018 Editorial: Understanding the Needs of Veterans with PTSD
  • This editorial introduced a special issue of the Healthcare journal looking at PTSD in veterans, edited by the Combat Stress research team.
  • The editorial outlines the current challenges facing the significant minority of veterans who have difficulties in their transition to civilian life, such as mental health difficulties, accessing and utilising support, and the potential role of Complex PTSD (C-PTSD).

  • Original papers in this issue included a qualitative study of Nature-Based Therapy, a paper which linked PTSD to risk-taking behaviours in veterans, and a study looking at anger, aggression and PTSD.

  • Also included were papers investigating potential for juror bias when faced with veterans with PTSD involved in the judicial system, a study linking PTSD and functional impairment, and a meta-analysis of current PTSD interventions.


Anger and Aggression in UK Treatment-Seeking Veterans with PTSD

  • This study investigated the prevalence rates of anger and aggression in UK help-seeking veterans, as well as their associations with different sociodemographic, functioning and mental health variables.
  • Prevalence rates for significant anger and aggression were 74% and 28% respectively. Both women and those over 55 were less likely to report difficulties.
  • Those with high levels of PTSD and other mental health difficulties were more likely to report anger and aggression.
  • Other factors related to anger and aggression included unemployment due to ill health, and a perceived lack of family support. 
  • Veterans who are seeking support for mental health are likely to be experiencing significant difficulties with anger and aggression, especially if they have comorbid mental health difficulties. The associations between anger, aggression, and other variables, has implications for the assessment and treatment of military veterans


2018 Review of PTSD and Mild Traumatic Brain Injury in Ex-Service personnel.
  • Research suggests that both mild Traumatic Brain Injury (mTBI) and PTSD have high prevalence rates in populations of ex-service personnel.
  • However, there are challenges in accurately defining the long-term impact of mTBI and how this relates to and overlaps with mental health difficulties, particularly PTSD.
  • Studies of US and UK veterans have demonstrated a high degree of overlap between mTBI and symptoms of PTSD and depression.
  • Further research has found that mTBI alone did not predict well-being or functional impairment in military veterans, unless these were comorbid with PTSD.
  • Overall, there is a compelling case for the need for further research to disentangle the symptoms of mTBI and PTSD, and to investigate the longer-term consequences of these difficulties being co-morbid.

Risk factors of suicidal ideation in a population of UK military veterans seeking support for mental health difficulties.

  • The aim of this paper was to explore the risk factors associated with suicidal ideation in a sample of treatment-seeking veterans.
  • Using a cross-sectional design, participants (N=144) completed questionnaires regarding their military experiences, pre-enlistment factors and health. Data were then linked to risk assessments extracted from clinical records.
  • After controlling for relevant variables, suicidal ideation was significantly higher in veterans who were unemployed, were early service leavers, or had a history of childhood adversity.
  • In addition, taking longer than 5 years to seek help was associated with a reduced risk of suicidal ideation.
  • This type of research is crucial to inform the effort to reduce suicide in military populations and has implications for service planning and knowing how to support this client group.
2018 A network analysis of DSM-5 posttraumatic stress disorder and functional impairment in UK treatment-seeking veterans. 
  • A network analysis of PTSD symptoms was conducted, focusing on associations between different symptoms and how they interact with each other. This was the first network analysis to be done with UK veterans.
  • The analysis was used to identify core symptoms of PTSD and how they connect to different elements of day to day functioning.
  • The core PTSD symptoms identified were recurrent thoughts, nightmares, negative emotional state, detachment, and exaggerated startle response.
  • Slightly different core symptoms have been found in samples of US veterans, although negative emotional state is most commonly found.
  • Some connections were found between everyday functioning, e.g. impairments in close relationships, home management, and PTSD symptoms.
  • Identifying core PTSD symptoms could have implications for treatment, as targeting the core symptoms could speed up recovery by breaking down the network of other, interacting symptoms.
2018 Exploring demographics and health as predictors of risk-taking in UK help-seeking veterans.
  • Past research suggests that military veterans can be more likely to engage in risk-taking behaviours, such as heavy smoking, alcohol misuse, dangerous driving and fighting.
  • We measured levels of self-reported risk-taking in a sample of veterans who were seeking help for mental health difficulties.
  • Findings showed that, of a sample of 403 veterans, 86.8% reported engaging in at least one risk-taking behaviour in the past month, with fighting the most commonly reported (77.9%).
  • Veterans were more likely to report risk-taking if they were younger, in a relationship, had a brain injury, or if they had mental health difficulties such as depression, anxiety and PTSD (particularly hyperarousal and negative moods).
  • Findings will help in determining possible risk factors for risk-taking in veterans. Future research could corroborate these findings and assist in the development of effective risk assessments and interventions.
2018 A review of traumatic brain injury in military veterans: Current issues and understanding. 
  • We reviewed the key issues relating to Mild Traumatic Brain Injury (mTBI) in military veterans.
  • Prevalence rates of mTBI in UK veterans have ranged from 4.2%-9.5% for those in combat roles.
  • Post-Concussional Syndrome (PCS) describes some of the long-term effects of mTBI, e.g. dizziness, insomnia. However, PCS is no longer recognised as a formal diagnosis in the DSM-V and might be a product of psycological distress. 
  • In a small minority of cases, mTBIs can develop into more serious, long-lasting difficulties. 
  • There is a need for clarity regarding the diagnosis of mTBI, especially when in the context of psychological distress.   

Describing the profile of a population of UK veterans seeking support

for mental health difficulties
  • Data was collected from 403 veterans who contacted Combat Stress
  • We found that 82% had PTSD, 74% had anger difficulties, 72% had anxiety and depression, and 43% misused alcohol.
  • 32% of the veterans who had PTSD also had other over-lapping health problems, whereas only 5% had just PTSD on its own.

Exploring the health risks of help-seeking military veterans living in different parts of the UK 

  • 403 veterans contacting Combat Stress completed a questionnaire
  • A comparison was made between veterans living in England, Wales, Scotland and Northern Ireland
  • Help-seeking veterans residing in Northern Ireland tended to be older, have experienced less childhood adversity, joined the military after the age of 18 and taken longer to seek help
  • Additionally, veterans from Northern Ireland had higher levels of obesity, sensory, mobility and systemic problems and, a greater number of physical health conditions
  • Scottish and Welsh veterans were more likely to smoke and misuse alcohol
  • No differences were found for mental health presentations across nations.

Exploring optimum cut-off scores to screen for probable PTSD within a sample of UK treatment-seeking veterans

  • We looked at the ideal scores veterans needed to get on questionnaires to classify as potentially having PTSD.
  • 242 veterans completed 2 short questionnaires as well as an interview with a qualified clinician about their symptoms
  • Comparing the short questionnaires against the interview, we found that higher scores were needed to accurately screen for PTSD in veterans

Focusing on the mental health of treatment-seeking veterans

  • As part of our desire to promote the needs of help-seeking veterans in the UK, we published an editorial on what we know, so far, about veterans from research.
  • This editorial highlights the problems veterans face after leaving the services, things that lead to poor mental health, the barriers veterans experience in seeking help and what treatment seeking veterans look like so we can better meet their needs.

Multiple deprivation in help-seeking UK veterans - A report

  • A report on 3,120 veterans from combat stress with mental health difficulties
  • Veterans with mental health difficulties are more likely to reside in areas of higher deprivation.
  • Veterans living in Scotland appeared to be at the greatest risk of deprivation, followed by English and Welsh veterans. Northern Ireland had the least risk.
  • The locations veterans resided in were geographically spread across the UK, but more veterans resided in urban areas
  • Those not in a relationship were more likely to have higher levels of deprivation
  • Being an Early Service Leaver and taking longer to seek help was linked to higher levels of deprivation. 
2016 Exploring Indices of Multiple Deprivation within a Sample of Veterans Seeking Help for Mental Health Difficulties Residing in England 
  • Study looking into how mental illness and living in deprivation is linked in England
  • Neighbourhood data from the government was linked to 1,967 veterans
  • 41% of veterans were in the most deprived areas
  • 21% were in the least deprived areas
  • Those who took longer to seek help, were single, male, younger and had a war pension were at a higher risk
  • Help seeking veterans were found to have an increased risk of living in deprived areas
2016 Do alcohol misuse, service utilisation, and demographic characteristics differ between UK veterans and members of the general public attending an NHS general hospital? 
  • A comparison of substance misuse between UK veterans and the general public
  • 2331 individuals with alcohol misuse problems were referred for specialist support
  • They were assessed for difficulties, dependency levels, withdrawal symptoms, other substance misuse and service utilisation
  • No differences in severity were found between veterans and the general public
  • However, it was found that veterans were referred at an older age and admitted to hospital for longer than non-veterans
2016 Experience of post-traumatic growth in UK veterans with PTSD: a qualitative study 
  • Interviews were completed with 8 veterans from Combat Stress
  • Veterans were asked about their experience of positive changes since completing the treatment programme (post-traumatic growth)
  • It was found that veterans felt they their experience had allowed them to accept negative events, develop an appreciation of the world, connect with other and re-evaluated their sense of purpose
  • It was also found that veterans had positively developed in areas of understanding reactions, developing an open mindset and committing to change
  • These findings suggest that the ITP treatment programme can encourage positive growth in veterans. 
2015 Prevalence and Associations Between Traumatic Brain Injury and Mental Health Difficulties Within UK Veterans Accessing Support for Mental Health Difficulties
  • Out of 123 veterans seeking help with Combat Stress, 63% reported having a traumatic brain injury.
  • No relationship was found between having a traumatic brain injury and post-concussion symptoms.
  • However, a link was found between having a traumatic brain injury and depression or anger problems.


Partners and Carers

The needs of the families and friends are often very important in providing support to veterans on their pathway to recovery. We are interested in the experiences of those close to veterans and what can be done to help them.

Year  Title Summary

Living alongside military PTSD: a qualitative study of female partners’ experiences with UK veterans

  • This study was designed to explore the experiences and needs of female partners of veterans
  • Eight veteran partners participated in an interview with a researcher
  • Experiences and needs were common challenges faces, desired support and barriers to seeking help
  • Common challenges faced were feelings of inequality in the relationship, loss of congruence with own identity, volatile environments and emotional distress and isolation
  • Desired types of support from the partners included a practical focus on improving, sharing with fellow experts and care tailored to the partner
  • Barriers to seeking help were found to be: practical barriers and ambivalence about the involvement of others in treatments. 
2016 Mental health difficulties and help-seeking beliefs within a sample of female partners of UK Veterans diagnosed with Post-Traumatic Stress Disorder
  • 100 veteran partners were surveyed for mental health needs and barriers to seeking help
  • 45% met criteria for alcohol problems, 39% for depression, 37% for generalised anxiety disorder and 17% for symptoms of probable PTSD
  • Partners were more likely to endorse barriers such as stigma as opposed to practical barriers as reasons for not seeking help.

Art Therapy

Art therapy can help make it easier for veterans to express themselves, especially when they find it hard to talk about thoughts and feelings. Research has shown that art therapy can help reduce stress, anxiety and increase awareness and self-esteem.

Year  Title Summary
2017 Using art therapy to overcome avoidance in veterans with chronic post-traumatic stress disorder 
  • We looked at whether art therapy could help veterans overcome avoidance symptoms of PTSD
  • 4 veterans completed a short stay at Combat Stress for art therapy
  • Participants were able to express and tolerate painful thoughts and emotions and their avoidance improved after the therapy.

Veterans' perspectives on the acceptability of art therapy: a mixed-methods study 

  • A study on the acceptability of art therapy with 547 veterans who had completed at least one session
  • The questions asked whether they found the sessions useful, if they would use the skills at home and what they thought was most interesting/helpful 
  • The majority said they strongly agreed that the session was useful and would definitely use the skills at home
  • Veterans said they found the experience of sharing with others, being able to express difficult feelings and the environment the most useful parts of the therapy
  • The study suggests that art therapy is an acceptable treatment for UK veterans. 
2016 Factors that influence engagement in an inpatient art therapy group for veterans with Post Traumatic Stress Disorder
  • Two surveys were conducted on 29 veterans at Combat Stress
  • The first looked at why people did or did not attend all sessions
  • The second survey looked at the benefits of art therapy sessions
  • It was found that 100% of the 19 veterans in survey 1 preferred to do emotional work in individual sessions
  • 100% of the 10 participants in survey 2 found the sessions relaxing
  • Veterans said they were able to overcome anxiety and develop new ways of thinking
2014 The invisible wound: Veterans’ art therapy 
  • Qualitative analysis of veterans comments during an art therapy session
  • Disconnection, avoidance, control and presenting a mask were identified as problems
  • Art therapy helped them connect, share fears and anxieties, deal with feelings and drop their masks
  • Veterans bonded as a ‘band of brothers’ and felt supported and understood 


These are some of the research partners we work with: