27. Armed forces
Source: gov.uk (2025-11-28)

How to treat problem alcohol use in UK armed forces personnel and veterans. It covers evidence-based interventions adapted for armed forces settings, the transition to civilian life and tailored support for veterans in community alcohol treatment services.

27.1 Main points

Armed forces community

The Armed Forces Covenant is a promise by the nation ensuring that those who serve or have served in the armed forces, and their families, are treated fairly. For more information, see Armed Forces Covenant: guidance and support (https://www.gov.uk/government/collections/armed-forces-covenant-supporting-information).

Alcohol treatment for armed forces serving personnel

UK armed forces personnel have a higher prevalence of harmful (higher risk) drinking and alcohol dependence compared to a similar demographic in the general population. This includes people serving in the:
- Royal Navy
- Royal Air Force
- British Army
In line with the principles of the Armed Forces Covenant, serving personnel should have access to evidence-based alcohol treatment equivalent to that available to the general population.

Defence primary healthcare and mental healthcare staff should use every opportunity to identify serving armed forces personnel with increasing risk, higher risk or dependent drinking and offer brief interventions or evidence-based alcohol treatment. Line managers, welfare support staff and peer support recovery champions can also help people to access treatment.

Alcohol treatment provided by the Ministry of Defence (MOD) Defence Medical Services for armed forces serving personnel should meet recognised standards of good practice. These are set out in the National Institute for Health and Care Excellence (NICE) clinical guideline Alcohol-use disorders: diagnosis, assessment and management of harmful drinking (high-risk drinking) and alcohol dependence (https://www.nice.org.uk/guidance/CG115) (CG115) and these alcohol treatment clinical guidelines. Clinicians should deliver interventions that are tailored to the armed forces setting.

Clinicians should promote continuity and consistency of care between Defence Medical Services and external specialist alcohol treatment services. Defence and external alcohol treatment services should work together and set up partnership agreements to provide risk-managed and evidence-based treatment for people with alcohol dependence who require specialist treatment.

All clinicians responsible for treating serving armed forces personnel should:
- be trained and competent in alcohol identification and delivering brief advice
- have the necessary specialist treatment competencies
- receive ongoing support and clinical supervision
There should be a framework in place to enable clinicians to provide good quality care suitable for deployed armed forces, using of remote consultations based on defence clinical guidance which meets the guidelines set out in NICE CG115.

Important concerns for clinicians treating serving armed forces personnel are supporting occupational fitness and managing occupational risk. The latter should reflect the access to weapons that exists for most personnel and the potential that they may undertake safety critical duties as part of their role.

Defence primary healthcare commissions and provides safe and effective healthcare to meet the needs of patients and manage occupational risk. It should continue to implement the alcohol treatment pathway in line with NICE CG115 and adapt it for the armed forces.

Transition from the armed forces to civilian life

Continuity of care and a smooth transition between services is vital for serving personnel in need of alcohol treatment and support who are transferring from the armed forces to civilian life. Defence healthcare and local alcohol treatment services need to agree referral pathways and processes to support this.

Alcohol treatment for veterans

Veterans have a higher prevalence of harmful (higher risk) drinking including alcohol dependence than the general population. The Office for Veterans’ Affairs report Health and wellbeing study of serving and ex-serving UK armed forces personnel (PDF, 11.2MB) (https://kcmhr.org/pdf/Phase_4_Health_and_Wellbeing_Cohort_Study_Report.pdf) also looked at post-traumatic stress disorder (PTSD). It found that veterans who were exposed to combat during deployment in Afghanistan or Iraq have a higher prevalence of probable PTSD than the general population and serving personnel.

While most veterans make the transition to civilian life without difficulty, a minority experience difficulties and require additional or specialist support.

Veterans access alcohol treatment through services provided for the general population. To meet the needs of veterans, it is vital that alcohol treatment services:
- reduce barriers to accessing alcohol treatment for veterans
- tailor alcohol treatment interventions to meet the needs of veterans
- provide information and support for veterans to access other relevant services, including specialist organisations for veterans
Veterans’ families have specific needs. Alcohol treatment practitioners should ask about the needs of family members, and where appropriate involve them in the person’s treatment. They should also offer family members support or refer them to services for carers or veterans’ charities that offer some support to families (see resources in section 27.10).

27.2 Harmful (higher risk) drinking and alcohol dependence among serving armed forces personnel

The guidance in section 27.2 is for clinicians in the Defence Medical Services and clinicians in other services who provide alcohol treatment to serving personnel.

27.2.1 Overview

There is strong evidence that heavy alcohol consumption in the UK armed forces is more common than in the general population. Research has suggested that harmful drinking and alcohol dependence (or alcohol misuse) is one of the most often reported conditions in the armed forces.

The Office for Veterans’ Affairs report Health and wellbeing study of serving and ex-serving UK armed forces personnel (PDF, 11.2MB) (https://kcmhr.org/pdf/Phase_4_Health_and_Wellbeing_Cohort_Study_Report.pdf) found that 8.4% had problems with alcohol misuse. This is substantially higher than the general population. Previous studies had found alcohol misuse declining but this has levelled off (Stevelink and others, 2018).

The health harms associated with harmful (higher risk) alcohol use are not always recognised. One research report (Jones and Fear, 2011) observed that:

“Some doctors viewed it as wholly harmful to both social and occupational function and to health, while others argued that alcohol had a specific role in lifting morale, aiding unit cohesion and protecting soldiers from adjustment disorders. Although alcoholism has always been identified as incompatible with military service, the effects of habitual heavy drinking among military personnel are less well understood.”

27.2.2 Summary of relevant research

Drinking at increasing or higher risk levels

Increased alcohol use in the military has been linked to perceived social pressure (Irizar and others, 2020) and a social network that includes heavy drinking associates (Anderson and others, 2020).

Alcohol screening has recently been included as part of dental inspections for serving UK armed forces personnel. MOD statistics on alcohol use in the armed forces (https://www.gov.uk/government/statistics/alcohol-usage-in-the-uk-armed-forces-1-june-2016-to-31-may-2017) (from 1 June 2016 to 31 May 2017) shows that 61% of personnel reported drinking at increasing or higher risk levels. This may underrepresent the true rates, since people in the military can under-report their levels of drinking due to the perceived consequences of disclosing that information (Sheppard and others, 2013).

A large-scale study found that half of UK serving and ex-serving military personnel experiencing problem drinking do not self-report their drinking behaviour as problematic (Spanakis and others, 2023). The study found that people with “greater problem drinking severity, poorer mental or physical health, and negative life experiences” are more likely to recognise their harmful alcohol use as a problem.

Alcohol use and specific issues faced by armed forces personnel

Harmful drinking and alcohol dependence have been linked to work strain and functional impairment (Jones and Coetzee, 2018; Rona and others, 2010). People who have undergone particularly stressful military experiences are at greatest risk of harmful drinking, including alcohol dependence (Jones and Fear, 2011). Reservists may be particularly vulnerable (Harvey and others, 2011).

The Office for Veterans’ Affairs report ‘Health and wellbeing study of serving and ex-serving UK armed forces personnel’ found that a substantial minority of currently serving personnel experienced mental health conditions. This included:
- 27.9% with common mental health disorders, such as anxiety and depression
- 7.4% with probable PTSD
- 7.6% with alcohol misuse
Effectively treating armed forces personnel

Research points to complex environmental, cultural and individual factors connected with armed forces personnel having increased drinking harms. However, there is a lack of work focusing on potential treatment approaches and effectiveness in serving military populations (Doherty and others, 2017).

Recent work in the UK and USA has highlighted the promising role of digital or remote interventions. These emphasise self-management of hazardous and harmful alcohol use, for serving and ex-serving armed forces personnel, where they do not need specialist pharmacological interventions. These include delivering interventions by phone and through websites and smartphone apps (Brief and others, 2013; Puddephatt and others, 2019; Walker and others, 2017).

Family and partners

There is some research on the family situation of armed forces personnel who are managing problem alcohol use, although the majority of work is based in the USA. This includes research that found encouragement from partners was important to service personnel seeking care (Trail and others, 2017). This is consistent with findings on partner or family encouragement and involvement in care for people with problem alcohol use in the civilian population (Copello and others, 2009).

27.3 Alcohol treatment for serving UK armed forces personnel

The guidance in section 27.3 is for clinicians in the Defence Medical Services and clinicians in other services who provide alcohol treatment to serving personnel.

Chapters 1 to 12 of these guidelines contain guidance on the core elements of alcohol treatment. Most of these core elements are relevant for clinicians providing alcohol treatment or referring patients to specialist alcohol treatment provision. However, there are some specific considerations for delivering these interventions in an armed forces setting.

27.3.1 The Armed Forces Covenant

The Armed Forces Covenant sets out the nation’s commitment to ensuring that those who serve or have served in the Armed Forces, and their families, are treated fairly.

It sets out that members of the armed forces community “should face no disadvantage compared to other citizens in the provision of public and commercial services” and that “special consideration is appropriate in some cases, especially for those who have given most such as the injured and the bereaved”.

For more information, see Armed Forces Covenant: guidance and support (https://www.gov.uk/government/collections/armed-forces-covenant-supporting-information).

27.3.2 Defence primary care and mental health services

Armed forces personnel and members of the military reserve force who are actively mobilised are entitled to care provided by Defence Medical Services (https://www.gov.uk/government/groups/defence-medical-services). Alcohol identification, brief interventions, assessment and treatment are carried out by defence primary care and mental health clinicians. Mental health services are staffed by uniformed and civilian mental health professionals including psychiatrists, clinical psychologists and mental health nurses. For remote locations, including overseas, satellite support is provided by mental health teams.

Professionals with alcohol and drug expertise are embedded in defence medical teams. There are various pathways to receiving alcohol assessment and treatment in defence primary care and mental health service settings, including:
- medical referral
- self-referral
- following direction to attend from line managers
- signposting from peer support initiatives
There is ongoing work to implement a more integrated defence alcohol treatment pathway led by good practice evidence. This includes defence primary healthcare developing detailed clinical guidance for treatment, based on NICE CG115 with interventions adapted for an armed forces population.

27.3.3 Medically assisted withdrawal

Assessment for patients requiring medically assisted withdrawal is provided by defence mental health teams working alongside defence primary care clinicians. Inpatient medically assisted withdrawal is provided through defence contracted inpatient service providers (a consortium of NHS trusts) for serving personnel who need this level of care.

27.3.4 Local and overseas arrangements

To optimise patient care, some defence medical teams have agreements with local specialist alcohol treatment services available to the general population. These services provide alcohol treatment interventions for serving personnel.

For overseas locations, patients with acute mental health conditions who need treatment in the UK can be medically evacuated. On-site or ‘field’ mental health teams provide support to personnel directly involved in military operations, including those of a combat nature.

Additional arrangements cover medical care of dependants of armed forces personnel and UK civil servants living on overseas bases.

27.3.5 Approach to alcohol and drug use in the armed forces

The MOD’s Joint Service Publication (https://www.gov.uk/government/collections/joint-service-publication-jsp) (JSP) documents provide overall rules, policy and guidelines that apply across the armed forces. Some JSP documents are relevant to managing problems with alcohol and other substances. There are different policies for managing problem alcohol use compared to drug use in the UK armed forces.

JSP policy and guidance is based on a view that harmful alcohol use and alcohol dependence are preventable and recoverable. This provides an approach involving education, awareness and regulation alongside medical support. In some circumstances, disclosure of medical information by medical officers to the chain of command will be justifiable in the public interest. In such cases, MOD guidance is that medical officers work with patients to obtain consent for disclosure where possible and help them to engage with treatment.

Harmful alcohol use including alcohol dependence may lead to administrative action, and this can include discharge from the armed forces.

The MOD sees illicit drug use (not including alcohol) as inconsistent with military service and has a zero-tolerance policy. This means personnel who use illicit drugs can expect to be removed from the armed forces.

The Armed Forces Act 2011 allows testing for drugs and alcohol to be carried out in specified circumstances. So, there is routine random compulsory testing for controlled drugs.

JSP 835: alcohol and substance misuse testing (PDF, 575KB) (https://assets.publishing.service.gov.uk/media/5a800906ed915d74e33f80f1/20131101-JSP_835-V2_0-U_3.pdf) sets out that exceeding the alcohol limit for prescribed safety-critical duties is an offence under section 20A of the Armed Forces Act 2006. It sets a limit on the amount of alcohol a person subject to service law can have in their breath, blood or urine for prescribed safety-critical duties. A commanding officer can require a person to be tested if they are suspected of being over the limit (there is no minimum accepted limit for illegal drugs).

27.4 Principles for providing alcohol treatment and recovery support under Defence Medical Services

The guidance in section 27.4 is for clinicians in the Defence Medical Services and clinicians in other services who provide alcohol treatment to serving personnel.

27.4.1 General principles

Principles of care for armed forces personnel should ensure that they are able to freely access evidence-based alcohol treatment equivalent to that available to the general population. Personnel are entitled to safe and effective treatment across the range of armed forces environments where they are required to work and live. Alcohol treatment interventions can be provided by:
- Defence Medical Services, in some cases in partnership with local alcohol treatment services used by the general population, or by
- defence-commissioned NHS services for inpatient medically assisted withdrawal
27.4.2 Maintaining operational effectiveness and managing risk

Defence medical teams have a principal role in maintaining the operational effectiveness of the armed forces and managing risk, including performing safety critical duties. This includes:
- strengthening communication between different healthcare providers
- providing clear protocols for risk assessment and management
- involving other relevant people, including line managers, when necessary
Assessment and treatment of harmful (higher risk) drinking and alcohol dependence should be guided by evidence on effective intervention approaches as described in chapters 1 to 12 of these guidelines.

27.4.3 Optimising engagement and recovery

Armed forces personnel might not disclose harmful alcohol and drug use to avoid potentially negative consequences for their employment.

To increase the chance of successful treatment, clinicians should carry out thorough assessment using a motivational approach, including building readiness for treatment and commitment to it. Interventions should emphasise general health and wellbeing and create opportunities to encourage people to disclose problem alcohol and drug use. Defence primary care and mental health teams are well placed to identify and treat co-occurring physical health and mental health conditions.

Interventions should take account of social factors linked with maintaining harmful drinking and alcohol dependence and should include peer support options. Clinicians should signpost personnel to peer support where necessary. This includes putting them in touch with armed forces recovery champions with lived experience of recovery from alcohol dependence, and external mutual aid organisations.

See chapter 4 for guidance on assessment and treatment and recovery planning.

27.4.4 Addressing the needs of the mobile armed forces population

Armed forces personnel are a mobile population subject to changes in geographical base, sometimes at short notice. Regulations restrict alcohol consumption in certain locations or during certain operational circumstances. For example, no alcohol during some periods of training or active assignment (including when off duty).

Care pathways should provide comprehensive alcohol support and treatment across different locations and when changes occur to a patient’s geographical base. Assessment of alcohol use should take account of the effects of occupational requirements and implications for treatment.

On-site or ‘field’ mental health teams provide support to personnel directly involved in military operations, including those of a combat nature.

Remote or digital consultations (phone, video link, online) may be particularly useful in addressing the needs of deployed armed forces, and clinicians should make use of this capability. For example, to enable continued care following a change of geographical location, or when sites overseas lack facilities for in-person appointments. Where appropriate, as well as delivering interventions, clinicians should promote evidence-based digital tools and apps to help provide information, self-monitoring and for using self-help strategies.

27.4.5 Medically assisted withdrawal

The inpatient pathway for armed forces personnel who need medically assisted withdrawal includes treatment from a contracted inpatient service provider. If assessed as appropriate for the person, Defence Medical Services can provide community-based medically assisted withdrawal (also called ambulatory medically assisted withdrawal). In some areas this might involve working in partnership with local community alcohol treatment services.

When providing medically assisted withdrawal, clinicians should:
- follow clear risk assessment and management protocols
- prepare the patient for medically assisted withdrawal
- provide follow-up support with a long-term recovery focus
There is guidance on medically assisted withdrawal in:
- chapter 10 on pharmacological interventions
- chapter 11 on community medically assisted withdrawal
- chapter 12 on specialist inpatient medically assisted withdrawal
27.4.6 Sociocultural influences

The drinking culture in the armed forces is heavily influenced by social factors such as peer pressure and perceived approval of drinking by others. Defence public health initiatives (including alcohol pricing and availability on bases) should be developed as part of a broader strategy that includes promoting health and wellbeing initiatives within the organisation.

27.4.7 Future developments

Defence primary healthcare provides and commissions healthcare to meet the needs of patients and to manage organisational risk. It should continue to implement the defence primary care alcohol pathway to support the provision of alcohol prevention and treatment in the armed forces. Senior defence clinicians have endorsed the pathway.

Implementing and adopting the pathway in a sustained way will include:
- using organisational links between the medical, public health and people support groups in defence headquarters, enabling a comprehensive approach to address the drinking culture in the armed forces
- using a combined approach that involves defence medical teams delivering treatment alongside defence public health initiatives that include price and availability controls, awareness raising, screening and referral to treatment
- strengthening governance processes for the alcohol treatment pathway
- integrating initiatives to promote healthy lifestyles and encourage a recovery ethos
- developing care and treatment pathways that take account of a person’s family situation, including affected family members (who might also be higher risk drinkers) and addressing the risk of domestic abuse and intimate partner violence
- working towards greater consistency in arrangements for how defence regional mental health networks partner with locally commissioned alcohol treatment services for the general population
- working with peer support groups and having links to outside mutual aid organisations which include online groups
- the Defence Medical Services gambling treatment pathway that links to alcohol care and connects people with specialist external treatment if required, including NHS gambling treatment clinics
27.5 Continuity of care during transition from serving in the armed forces to civilian life

The guidance in 27.5 is for clinicians within Defence Medical Services and for clinicians and practitioners in community alcohol treatment services.

Defence mental health teams treat higher risk alcohol use including dependence, and co-occurring alcohol use and mental health conditions.

JSP 950 on defence mental health services covers continuity of care (which is available for internal use in the armed forces only). It outlines that any service personnel identified with a mental healthcare need can continue to access local mental healthcare for up to 6 months after leaving the armed forces. This applies to service personnel:
- already receiving treatment through a department of community mental health (DCMH), which offer specialist outpatient mental healthcare for serving armed forces in the UK
- identified by primary care and referred to DCMH before their last day in service
Continuity of care and a smooth transition between services is vital for serving personnel with problem alcohol use who are transferring from the armed forces to civilian life. Defence healthcare and local community alcohol treatment services need to agree referral pathways and processes to support this. There should be individual plans in place so there is no gap in care, and the person is prepared for the transition.

Arrangements should be based on individual needs and circumstances. Some people may continue to receive care from Defence Medical Services during the 6 months following their last day of service, or they could move to alcohol treatment services for the general population before that.

27.6 Alcohol treatment and recovery support for veterans

The guidance in section 27.6 is for practitioners in specialist alcohol treatment services and practitioners in other settings who provide alcohol treatment.

A veteran is defined as anyone who has served for at least one day in the UK armed forces (regular or reserve) or merchant mariners who have seen duty on legally defined military operations.

These guidelines use the term ‘veteran’. Some people may prefer to use the term ‘ex-serving military personnel’ or ‘ex-armed forces’, so it is helpful to ask the person you are working with which term they prefer to use to describe themselves.

27.6.1 Summary of evidence on veterans and alcohol use

The Office for Veterans’ Affairs report Health and wellbeing study of serving and ex-serving UK armed forces personnel (PDF, 11.2MB) (https://kcmhr.org/pdf/Phase_4_Health_and_Wellbeing_Cohort_Study_Report.pdf) found the following.

Veterans had substantially higher levels of alcohol misuse (harmful drinking including alcohol dependence) than the general population.

Veterans reported higher levels of probable PTSD and complex PTSD (C-PTSD) than the general population and serving personnel. Veterans who were deployed to Iraq and Afghanistan and exposed to combat reported higher levels of PTSD and C-PTSD than those who were not deployed.

Loneliness was associated with alcohol misuse in veterans. It is not clear whether loneliness causes harmful drinking or harmful drinking causes loneliness. Research on the general population shows that loneliness and common mental health problems can each influence the other.

In other research (Irizar and others, 2020), alcohol misuse (harmful drinking including alcohol dependence) has been found to be more common in serving and ex-serving armed forces personnel who said they drank:
- to cope with stress, mental health conditions or social pressure
- alone and at home
There is evidence that PTSD is associated with higher levels of alcohol use in veterans (Osborne and others, 2022).

Other work has pointed out factors linked to problem alcohol use for veterans including:
- using other substances (Gunn and others, 2019)
- depression and suicide risk (Mrnak-Meyer and others, 2011)
- gambling (Davis and others, 2017)
27.6.2 Armed Forces Covenant commitments to veterans

The Armed Forces Covenant Legal Duty is a legal obligation on certain public bodies to have due regard to the covenant principles when carrying out certain functions in healthcare, education and housing. The public bodies subject to this legal duty include local authorities and various NHS bodies.

For more information, see Armed Forces Covenant: guidance and support (https://www.gov.uk/government/collections/armed-forces-covenant-supporting-information).

Organisations that do not have any legal obligation can still sign up to or work to the principles of the Armed Forces Covenant. Organisations providing alcohol treatment are eligible to sign up to the Armed Forces Covenant and several large service provider organisations in Great Britain have done so.

The Armed Forces Covenant sets out that armed forces veterans should receive priority treatment for a condition which relates to their service, compared to the general population with the same level of clinical need.

27.6.3 General healthcare and alcohol treatment for UK veterans

When veterans leave the armed forces, their general healthcare needs are the responsibility of the NHS and the vast majority use services in the same way as any other citizen. Veterans with problem alcohol use will use specialist alcohol treatment services in the same way as any other citizen. Specialist alcohol treatment services are available in every local area across the UK. Commissioning arrangements for specialist alcohol treatment services vary between England, Scotland, Wales and Northern Ireland.

A minority of veterans will require additional support from specialist services for veterans that can help with a range of needs relating to their time in the armed forces and their transition into civilian life. The NHS offers some specialist mental health and physical health services for veterans. Several armed forces charities provide information and services across the UK. MOD also provides services, including welfare support for some veterans.

You can find more information about services and support for veterans across the UK in section 27.7.

27.6.4 Considerations when working with veterans

While most veterans make the transition to civilian life without difficulty, a minority find it difficult and require appropriate support. It is vital to:
- reduce barriers to accessing alcohol treatment
- tailor treatment to meet their needs
- help them to access other relevant services
Some veterans find it difficult to make social connections in the civilian community and so experience isolation and loneliness. They may miss the camaraderie, shared culture and structure of the armed forces but may not feel comfortable approaching civilian support organisations.

Issues that deter many people from accessing alcohol treatment such as stigma or lack of trust in services can be particularly relevant for veterans. Armed forces culture places high value on fitness, self-sufficiency and overcoming challenges, and some veterans can perceive seeking help for alcohol or mental health problems as a weakness.

Veterans who have been exposed to combat may have experienced trauma and like many people with problem alcohol use, they may also have experienced childhood trauma.

Some veterans who have been exposed to combat may have witnessed or done things that went against their moral values. This can lead to feelings of guilt and shame and a wish to avoid talking about their personal experience and emotions.

Veterans can also be concerned that staff in civilian organisations will not understand their experience in the armed forces and may have found a lack of understanding in the past when approaching civilian support services.

There are of course differences between veterans. Some prefer to approach specialist services or support from the armed forces community including specialist charities, but some may prefer to seek help from civilian services and separate themselves from specialist armed forces organisations.

As there is a culture of heavy drinking in the armed forces, veterans may not recognise their alcohol use is a problem until a late stage.

Veterans may also be unaware of services that are available and how to navigate these.

While most veterans find employment on leaving the armed forces, a minority do not. They can find it difficult to negotiate civilian recruitment procedures or lack confidence in transferring their skills. They can experience a loss of sense of purpose after leaving the armed forces and unemployment can contribute to this.

Managing finances, including housing costs, in civilian society differs from managing finances in the armed forces, as some day-to-day costs are taken directly from the salary in the armed forces. Veterans who are unprepared for the difference can find financial management challenging, especially when living on a low income. Loss of housing and financial problems can lead to social exclusion.

27.6.5 Increasing access to alcohol treatment services for veterans

There are several actions commissioners and providers of alcohol treatment services can take to increase access to alcohol treatment for veterans.

Commissioners and providers of community alcohol treatment services should be aware of the approximate numbers of veterans living in their local area. They should work with any local armed forces charities and veterans with lived experience to include the needs of veterans in their local needs assessment. Commissioners can find statistics on the veteran population at constituency level in Constituency data: UK armed forces veterans (https://commonslibrary.parliament.uk/constituency-data-uk-armed-forces-veterans-2021-census/). Commissioners can also create a custom data set using the 2021 census (https://www.ons.gov.uk/datasets/create) on the Office for National Statistics website to access data for other local footprints. Regional or local veterans’ charities may also be able to provide information on the local veteran population.

Alcohol treatment services should make sure their staff have a basic understanding of armed forces culture and some of the specific needs that veterans can have, including veterans who have been exposed to combat. Armed forces charities can provide information on armed forces culture and specific needs of veterans (see resources section 27.7).

Anonymity can help to reduce concerns about stigma and services should consider offering appointments for veterans at a satellite site that is not publicly identifiable as an alcohol treatment service.

Community alcohol treatment services and local defence healthcare services need to agree referral pathways and processes to support transition for people at the end of their time in service. See section 27.5 for more guidance on supporting people making this transition.

Alcohol treatment services should have pathways with NHS veterans’ healthcare services and national and local veterans’ charities that provide individual support. Effective pathways should enable two-way referrals, specialist advice and information sharing.

Alcohol treatment services should work to the 2 main principles of care for people with co-occurring problem alcohol use and mental health conditions. These principles are ‘everyone’s job’ and ‘no wrong door’.

You can read more about these principles in section 2.3.4 of chapter 2 on principles of care.

Alcohol treatment service literature and information displayed in alcohol treatment services should be inclusive of veterans. Armed forces charities and people with lived experience can advise on how service literature could be designed to attract veterans. Using only images of veterans with physical disabilities is not helpful, because veterans may interpret this as meaning that only veterans with physical disabilities need support.

If there are veterans with lived experience among peer support organisations, it can be helpful for them to be involved in welcoming the person to the service or answering their questions at an early stage.

27.6.6 Tailoring treatment to meet the needs of veterans

Identifying veterans during assessment

Services should consider adding a standard question as part of their assessment that asks people whether they have ever served in the armed forces in a regular or a reserve role and record this. This is so the service is aware of that person’s experience and can also inform them of specific services for veterans if the person might benefit from these. If there is referral information that the person has been in the armed forces, the assessor should ask about their experience and its possible relationship to their alcohol use.

The assessor should also ask if their GP knows they have served in the armed forces and encourage them to let their GP know if they have not. This is so their GP can refer or signpost them to specialist services if the person might benefit from them. Some GPs are accredited as ‘veteran friendly GPs’ (see resources in section 27.7 for more information).

Understanding armed forces culture

Staff who work with veterans need a basic understanding of armed forces culture and the kind of experiences veterans may have had. A practitioner should be able to communicate to the person that they are interested in their experience in the armed forces and though there may be things they do not yet know about, they are interested to learn so they can better understand and work with the person.

See resources in section 27.8 for information on free training on healthcare for veterans.

The person’s role and rank and which service they were in while serving in the armed forces is likely to be important to them, so asking about this will show interest in their armed forces experience.

Using a trauma informed approach and identifying PTSD

Veterans may have experienced trauma through exposure to combat. Like other people accessing alcohol treatment, they may also have experienced childhood trauma. A trauma informed approach is important for helping the person to engage and to build a therapeutic relationship. You can read more about a trauma-informed approach in the guidance Working definition of trauma-informed practice (https://www.gov.uk/government/publications/working-definition-of-trauma-informed-practice).

Practitioners should not assume a veteran has PTSD. But they should be able to identify possible signs of PTSD (including complex PTSD) and offer a referral for specialist assessment through one of the following:
- a suitably qualified clinician within the service
- a local mental health service that can assess and treat PTSD
- specialist mental health service for veterans (see resources in section 27.7)
Therapeutic relationship

Good practice in building a therapeutic relationship that applies to everyone accessing services can be particularly important for working with veterans. The ability to communicate honesty, transparency, respect and reliability is essential.

Choice and continuity of care

There is a wide range of services and support available to veterans. Practitioners should be able to inform people of these and support them to access any services that are relevant for them. Specialist support and activities can help people feel connected to the veterans’ community. However, the person may choose not to be involved with specialist services or support and it is important that they have the choice. You can find information on relevant organisations in the resources section.

Good practice in continuity of care can be particularly important for veterans. Practitioners should make sure that:
- transitions from one service or one practitioner to another are smooth
- the veteran has been involved in planning the transition
- all arrangements are clear to the veteran before the transition takes place
Multi-agency working

As with other people in treatment, where a veteran is accessing more than one service at the same time, effective multi-agency working and care co-ordination is vital, so there is a holistic approach to their needs.

See chapter 4 for guidance on:
- multi-agency assessment (in section 4.4.5)
- multidisciplinary and multi-agency treatment and recovery planning (in section 4.10.4 and 4.10.5)
Veterans accessing alcohol treatment services often experience co-occurring problem alcohol use and mental health conditions. Chapter 18 provides guidance on working with people with co-occurring problem alcohol use and mental health conditions.

Social connections and employment

If a veteran experiences social isolation and loneliness after leaving the armed forces, this should be addressed in the treatment and recovery plan. Local recovery-oriented peer support and activities can be helpful in building social connections and identifying purposeful activities they enjoy. There is an online SMART (self-management recovery training) veterans programme (see resources in section 27.7).

Specialist veteran organisations can also help veterans make social connections and feel a sense of belonging if they wish to continue their involvement with the armed forces community.

For guidance on helping people to access recovery-oriented peer support including mutual aid groups, see section 5.5.4 of chapter 5, and chapter 6.

Veterans who are unemployed should be offered personalised employment support. Where a veteran needs support with financial planning, benefits, debt or housing problems, support for these needs can be offered through:
- the alcohol treatment service
- local partner organisations
- specialist veterans organisations
Access to this support will depend on availability and the person’s preferences.

Diversity among veterans

Treatment should always be based on individual need and take into account diverse aspects of the person’s identity and experience. Although the majority of veterans are White men, veterans are diverse in terms of age, gender, race and ethnicity, religion, sexual orientation, gender identity and disability. These aspects of identity will have played a part in how they experienced life in the armed forces. As in wider society, they may have experienced prejudice, harassment or discrimination on the basis of these characteristics. There is guidance on tailoring treatment to diverse needs in chapter 25 on developing inclusive services.

LGBT veterans: support and next steps (https://www.gov.uk/government/collections/lgbt-veterans-support-and-next-steps) provides guidance on restorative measures, support and services for those impacted by the pre-2000 law banning same-sex sexual activity or the policy banning LGBT people from serving in the armed forces.

Lead practitioner for veterans

It can be helpful for alcohol treatment services to have a lead practitioner or champion for veterans who can share expertise and promote good practice specific to veterans.

27.6.7 Veterans’ families

Families and carers of veterans including bereaved families are part of the armed forces community and the Armed Forces Covenant sets out commitments to them. Families of veterans may need support and practitioners should ask veterans about the support needs of their families. There is relevant guidance for alcohol treatment services on working with families in section 5.8 of chapter 5 on psychosocial interventions.

Families of veterans can experience specific stresses. While the veteran was serving in the armed forces, their families may have had to move home many times, and they may have been absent for long periods of time. This could result in:
- a disjointed CV for spouses affecting their employment opportunities
- mixed schooling for children
- complex family dynamics
Family life changes for all veterans after transition to civilian life. Veterans’ families can benefit from information and advice on how to support their family member who is experiencing problem alcohol use and may also be experiencing co-occurring mental health or physical health conditions. They may also need psychological or practical support for themselves. There are veterans’ organisations that provide specialist information and support for families, including bereaved families. The resources section in 27.7 includes information on veterans’ charities that provide support for families.

27.7 Resources

Healthcare resources

Healthcare for the armed forces community (https://www.nhs.uk/nhs-services/armed-forces-community/) provides information and links to services provided by the NHS for the armed forces including reservists, veterans and family members of someone who is serving or who has served. This includes a step-by-step guide for service leavers.

The Royal College of GPs and NHS England Veterans’ health hub (https://elearning.rcgp.org.uk/course/view.php?id=803) is a free support programme for GPs and their teams in England. This can help to identify, understand and support veterans and, where appropriate, refer them to specialist healthcare services designed especially for them.

Support for veterans

Veterans UK (https://www.gov.uk/government/organisations/veterans-uk) is part of the MOD. It provides free support for veterans and their families, including a helpline, veterans welfare service, defence transition services and injury and bereavement compensation scheme payments.

Royal British Legion (https://www.britishlegion.org.uk/) is the largest armed forces charity and is at the centre of a wide network of services and organisations supporting the armed forces community. It provides lifelong support to serving and ex-serving personnel and their families, from expert advice and guidance to recovery and rehabilitation, through transitioning to civilian life. It can help people access other armed forces support organisations.

Soldiers’, Sailors’ and Airmen’s Families Association (SSAFA) (https://www.ssafa.org.uk/) provides welfare, health and support services for serving military personnel, veterans and their families.

Mental health support for veterans

Combat Stress (https://combatstress.org.uk/) is a charity that provides clinical treatment and support for veterans, focusing on those with complex mental health issues resulting from their experiences during military service.

Forces in Mind Trust (https://www.fim-trust.org/) works to support the armed forces community by funding research on the mental health needs of veterans.

Mutual aid

SMART Recovery’s veterans programme (https://smartrecovery.org.uk/smart_veterans/) provides a national network of mutual aid groups and online training and tools for veterans affected by alcohol problems and other addictive behaviours.

Resources for Scotland, Wales and Northern Ireland

The Scottish Government’s armed forces and veterans community (https://www.gov.scot/policies/veterans-and-armed-forces/) provides a range of measures to support the veterans and armed forces community across healthcare, housing, education, justice, skills and employability.

NHS Wales’ veterans page (https://www.veteranswales.co.uk/) provides information on a specialised priority services for veterans in Wales who are experiencing mental health difficulties related specifically to their military service.

Support for veterans and their families in Northern Ireland (https://www.gov.uk/guidance/support-for-veterans-and-their-families-in-northern-ireland) provides information on welfare, specialist healthcare and advocacy support available to veterans and their families in Northern Ireland.

27.8 References

Anderson Goodell EM, Johnson RM, Latkin CA, Homish DL and Homish GG. Risk and protective effects of social networks on alcohol use problems among army reserve and national guard soldiers (https://www.sciencedirect.com/science/article/abs/pii/S0306460319306999?via%3Dihub). Addictive Behaviors 2020: volume 103, article 106244 (registration and subscription required for full article).

Bell NS, Harford T, McCarroll JE and Senier L. Drinking and spouse abuse among U.S. Army soldiers (https://onlinelibrary.wiley.com/doi/abs/10.1097/01.ALC.0000148102.89841.9B). Alcohol Clinical and Experimental Research 2004: volume 28, issue 12, pages 1,890 to 1,897 (registration and subscription required for full article).

Brief DJ, Rubin A, Keane TM, Enggasser JL, Roy M, Helmuth E, Hermos J, Lachowicz M, Rybin D and Rosenbloom D. Web intervention for OEF/OIF veterans with problem drinking and PTSD symptoms: a randomized clinical trial (https://psycnet.apa.org/doiLanding?doi=10.1037%2Fa0033697). Journal of Consulting and Clinical Psychology 2013: volume 81, issue 5, pages 890 to 900 (registration and subscription required for full article).

Chui Z, Fear N, Greenberg N, Jones N, Jones E and Goodwin L. Combat exposure and co-occurring mental health problems in UK armed forces personnel (https://www.tandfonline.com/doi/full/10.1080/09638237.2020.1766666). Journal of Mental Health 2020: volume 31, issue 5, pages 624 to 633 (registration and subscription required for full article).

Copello AG, Velleman RDB and Templeton LJ. Family interventions in the treatment of alcohol and drug problems (https://onlinelibrary.wiley.com/doi/abs/10.1080/09595230500302356). Drug and Alcohol Review 2009: volume 24, issue 4, pages 369 to 385 (registration and subscription required for full article).

Davis AK, Bonar EE, Goldstick J, Walton MA, Winters J and Chermack ST. Binge drinking and non-partner aggression are associated with gambling among veterans with recent substance use in outpatient treatment (https://www.sciencedirect.com/science/article/abs/pii/S0306460317301995?via%3Dihub). Addictive Behaviors 2017: volume 74, pages 27 to 32 (registration and subscription required for full article).

Doherty AM, Mason C, Fear NT, Rona RJ, Greenberg N and Goodwin L. Are brief alcohol interventions targeting alcohol use efficacious in military and veteran populations? A meta-analysis (https://www.sciencedirect.com/science/article/abs/pii/S0376871617303034?via%3Dihub). Drug and Alcohol Dependence 2017: volume 178, pages 571 to 578 (registration and subscription required for full article).

Fear NT, Iversen A, Meltzer H, Workman L, Hull L, Greenberg N, Barker C, Browne T, Earnshaw M, Horn O, Jones M, Murphy D, Rona RJ, Hotopf M and Wessely S. Patterns of drinking in the UK Armed Forces (https://onlinelibrary.wiley.com/doi/10.1111/j.1360-0443.2007.01978.x). Addiction 2007: volume 102, issue 11, pages 1,749 to 1,759 (registration and subscription required for full article).

Fear NT, Jones M, Murphy D, Hull L, Iversen AC, Coker B, Machell l, Sundin J, Woodhead C, Jones N, Greenberg N, Landau S, Dandeker C, Rona RJ, Hotopf M and Wessely S. What are the consequences of deployment to Iraq and Afghanistan on the mental health of the UK armed forces? A cohort study (https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60672-1/fulltext). Lancet 2010: volume 375, issue 9728, pages 1,783 to 1,797 (registration and subscription required for full article).

Gunn R, Jackson K, Borsari B and Metrik J. A longitudinal examination of daily patterns of cannabis and alcohol co-use among medicinal and recreational veteran cannabis users (https://www.sciencedirect.com/science/article/abs/pii/S0376871619304387?via%3Dihub). Drug and Alcohol Dependence 2019: volume 205, article 107661.

Harvey SB, Hatch SL, Jones M, Hull L, Jones N, Greenberg N, Dandeker C, Fear NT and Wessely S. Coming home: social functioning and the mental health of UK reservists on return from deployment to Iraq or Afghanistan (https://www.sciencedirect.com/science/article/abs/pii/S1047279711001517?via%3Dihub). Annals of Epidemiology 2011: volume 21, issue 9, pages 666 to 672 (registration and subscription required for full article).

Irizar P, Leightley D, Stevelink S, Rona R, Jones N, Gouni K, Puddephatt JA, Fear N, Wessely S and Goodwin L. Drinking motivations in UK serving and ex-serving military personnel (https://academic.oup.com/occmed/article/70/4/259/5713396). Occupational Medicine 2020: volume 70, issue 4, pages 259 to 267.

Jones N and Coetzee R. What drives UK military personnel to seek mental healthcare, work strain or something else? (https://militaryhealth.bmj.com/content/164/4/248). Journal of the Royal Army Medical Corps 2018: volume 164, issue 4, pages 248 to 252 (registration and subscription required for full article).

Jones E and Fear NT. Alcohol use and misuse within the military: a review (https://www.tandfonline.com/doi/full/10.3109/09540261.2010.550868). International Review of Psychiatry 2011: volume 23, issue 2, pages 166 to 172 (registration and subscription required for full article).

King K, Leightley D, Greenberg N and Fear N. The DrinksRation smartphone app for modifying alcohol use behaviors in UK military service personnel at risk of alcohol-related harm: protocol for a randomized controlled trial (https://www.researchprotocols.org/2023/1/e49918/). JMIR Research Protocols 2023: volume 12, article e4991.

Knight T, Jones M, Jones N, Fertout M, Greenberg N, Wessely S and Fear NT. Alcohol misuse in the UK armed forces (https://oem.bmj.com/content/68/Suppl_1/A100.1). Occupational and Environmental Medicine 2011: volume 68, issue s1.

LeardMann CA, Powell TM, Smith TC, Bell MR, Smith B, Boyko EJ, Hooper TI, Gackstetter GD, Ghamsary M and Hoge C. Risk factors associated with suicide in current and former US military personnel (https://jamanetwork.com/journals/jama/fullarticle/1724276). JAMA 2013: volume 310, issue 5, pages 496 to 506.

Murphy D, Palmer E, Westwood G, Busuttil W and Greenberg N. Do alcohol misuse, service utilisation, and demographic characteristics differ between UK veterans and members of the general public attending an NHS general hospital? (https://www.mdpi.com/2077-0383/5/11/95). Journal of Clinical Medicine 2016: volume 5, issue 11, article 95.

Mrnak-Meyer J, Tate SR, Tripp JC, Worley MJ, Jajodia A and Mcquaid JR. Predictors of suicide-related hospitalization among U.S. veterans receiving treatment for comorbid depression and substance dependence (https://onlinelibrary.wiley.com/doi/10.1111/j.1943-278X.2011.00051.x). Suicide and Life Threatening Behavior 2011: volume 41, issue 5, pages 532 to 542 (registration and subscription required for full article).

Osbourne A, Wilson-Menzfeld G, McGill G and Kiernan MD. Military service and alcohol use: a systematic narrative review (https://academic.oup.com/occmed/article/72/5/313/6604127). Occupational Medicine 2022: volume 72, issue 5, pages 313 to 323.

Puddephatt JA, Leightley D, Palmer L, Jones N, Mahmoodi T, Drummond C, Rona RJ, Fear NT, Field M and Goodwin L. A qualitative evaluation of the acceptability of a tailored smartphone alcohol intervention for a military population: information about drinking for ex-serving personnel (InDEx) app (https://mhealth.jmir.org/2019/5/e12267). JMIR mHealth and uHealth 2019: volume 7, issue 5, article e12267.

Rhead R, MacManus D, Jones M, Greenberg N, Fear NT and Goodwin L. Mental health disorders and alcohol misuse among UK military veterans and the general population: a comparison study (https://www.cambridge.org/core/journals/psychological-medicine/article/abs/mental-health-disorders-and-alcohol-misuse-among-uk-military-veterans-and-the-general-population-a-comparison-study/A7A8AAF182C7AA8B228A340666A1DDE6). Psychological Medicine 2022: volume 52, issue 2, pages 292 to 302 (registration and subscription required for full article).

Rona RJ, Jones M, Fear NT, Hull L, Hotopf M and Wessely S. Alcohol misuse and functional impairment in the UK armed forces: a population-based study (https://www.sciencedirect.com/science/article/abs/pii/S0376871609004232?via%3Dihub). Drug and Alcohol Dependence 2010: volume 108, issue 1 to 2, pages 37 to 42 (registration and subscription required for full article).

Sheppard SC, Forsyth JP, Earleywine M, Hickling EJ and Lehrbach MP. Improving base rate estimation of alcohol misuse in the military: a preliminary report (https://www.jsad.com/doi/10.15288/jsad.2013.74.917). Journal of Studies on Alcohol and Drugs 2013: volume 74, issue 6, pages 917 to 922 (registration and subscription required for full article).

Spanakis P, Gribble R, Stevelink S, Rona R, Fear N and Goodwin L. Problem drinking recognition among UK military personnel: prevalence and associations (https://link.springer.com/article/10.1007/s00127-022-02306-x). Social Psychiatry and Psychiatric Epidemiology 2023: volume 58, pages193 to 203.

Stevelink S, Jones M, Hull L, Pernet D, MacCrimmon S, Goodwin L, MacManus D, Murphy D, Jones N and Greenberg N. Mental health outcomes at the end of the British involvement in the Iraq and Afghanistan conflicts: a cohort study. British Journal of Psychiatry (https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/mental-health-outcomes-at-the-end-of-the-british-involvement-in-the-iraq-and-afghanistan-conflicts-a-cohort-study/E77CCC4B6D0B2A3B6A481C0980D29E93) 2018: volume 213, issue 6, pages 690 to 697.

Thandi G, Sundin J, Ng-Knight T, Jones M, Hull L, Jones N, Greenberg N, Rona RJ, Wessely S and Fear NT. Alcohol misuse in the United Kingdom Armed Forces: a longitudinal study (https://www.sciencedirect.com/science/article/abs/pii/S0376871615016282?via%3Dihub). Drug and Alcohol Dependence 2015: volume 156, pages 78 to 83 (registration and subscription required for full article).

Trail TE, Osilla KC, Pedersen ER, Gore KL, Tolpadi A and Rodriguez LM. Results from a randomized controlled trial of a web-based intervention for those concerned with their military partner’s drinking (https://onlinelibrary.wiley.com/doi/10.1111/acer.13392). Alcoholism: Clinical and Experimental Research 2017: volume 41, issue s1, article 306A.

Walker DD, Walton TO, Neighbors C, Kaysen D, Mbilinyi L, Darnell J, Rodriguez L and Roffman RA. Randomized trial of motivational interviewing plus feedback for soldiers with untreated alcohol abuse (https://psycnet.apa.org/doiLanding?doi=10.1037%2Fccp0000148). Journal of Consulting and Clinical psychology 2017: volume 85, issue 2, pages 99 to 110 (registration and subscription required for full article).