Meet the Expert – Professor Walter Busuttil
Welcome to 'Meet the Expert', our series bringing you informative interviews with Armed Forces researchers, policy makers and service providers. Read on to learn about current work, aspirations for progress and future work, and insights into expert perspectives on key issues impacting ex-Service personnel and their families.
In this issue, we interviewed Professor Walter Busuttil, consultant psychiatrist, visiting Professor at King’s College London in the King's Centre for Military Health Research (KCMHR) and Director of Research and Clinical Training at Combat Stress. Walter served as a General Duties Medical Officer in the Royal Air Force and was awarded the Soldiering On Lifetime Achievement Award for services to the Military Family in 2016. He also contributed to the founding of the Combat Stress Research Department collaboration with KCMHR, the UK Psychological Trauma Society, and the Five Eyes Mental Health Research Collaborative. He previously chaired the UK Trauma Group and sits on the Mental Health Subcommittee and Armed Forces Clinical Reference Group for NHS England.
1. Please tell us about your background and how you came to be involved in work relating to the Armed Forces Community.
My grandfather and five uncles served in the UK Armed Forces. My grandfather was a First and Second World War veteran and I spent a lot of time with him as I was growing up. I have always been interested in military life and the psychological effects of war on people. I was brought up in Malta and my parents were children during the Second World War when Malta was the most bombed place on earth for two years. So, I know what it is like to live in a family and a country that has been affected by war. In 1981, I came over to the UK to study medicine and I joined the Royal Air Force (RAF) as a medical student cadet. I served in the RAF for 16 years, retiring at the Rank of Wing Commander in 1997. I first trained as a General Duties Medical Officer (GDMO) and qualified as a Principal in General Practice. I then re-trained in psychiatry and became a Consultant Psychiatrist in Military Psychiatry in 1994.
During the first Gulf War, I helped set up rehabilitation services for combatants. I was part of the background team that helped rehabilitate the British Prisoners of War (POW) from Gulf War 1. I was also part of the team that helped rehabilitate British hostages released from Beirut in 1991, with our work published in peer-reviewed literature.[1] My specialist area has always been psychological trauma and Post-Traumatic Stress Disorder (PTSD). I left the RAF in 1997 after having been the consultant in charge of the East Anglia RAF Community Psychiatric Service. For the next 10 years, I worked with civilian and military veteran sufferers of traumatic stress in the private sector and published studies exploring treatment for Complex Post-traumatic Stress Disorder (CPTSD).
I joined Combat Stress in 2007 as the Director of Medical Services. During this time, I set up clinical services across the UK for Veterans of all conflicts, from the Second World War right up to Afghanistan. When I joined Combat Stress, we were at the height of the Afghanistan War and the aftermath of the Iraq War. I was asked to set up cutting-edge clinical services by the Charity’s Board of Trustees and transform clinical interventions. I inherited three respite care homes and fourteen community-based welfare officers who were ex-military but untrained in mental health. I was told at the time, by various senior NHS staff, that veterans did not need bespoke clinical mental health services. Nevertheless, I led the development of bespoke Combat Stress clinical services across the country. We evaluated the clinical needs of the help-seeking veteran population, developed evidence-based interventions, and measured their efficacy with findings published in peer-reviewed journals.
For many years, the NHS funded most of these services by commissioning Combat Stress. However, in 2016 the NHS began developing bespoke veteran services. I advised on the setting up of these services and I am a member of the NHS England Clinical Advisory Group, which advises commissioners of health services for UK Armed Forces Personnel and Veterans and their families including mental health. These services would not exist but for the research evidence base developed over the years by our research department and many other research studies run by other UK-based and overseas centres. Overall, NHS Veterans’ services have since improved. In England we now have Op COURAGE which has been helpful and other Devolved Nations have their own clinical services. For example, in the All-Welsh Veterans Mental Health Service, in Scotland, we have Veterans First Point and in Northern Ireland, there are veterans mental health services run by the NHS.
I held this post with Combat Stress for 13 years until 2020. During this time, I set up the Combat Stress Research Centre at Combat Stress through a collaboration with KCMHR in 2014, which is now run by Prof. Dominic Murphy as Head of Research. As of right now, I am the Director of Research and Training at Combat Stress and a visiting Professor at the King’s Centre for Military Health Research (KCMHR).
2. What research projects are you currently working on and how do they fit into the bigger picture of understanding and supporting the Armed Forces Community?
Lately, the research that I have been involved in relates to needs studies and treatment outcome studies of veterans suffering from severe treatment-resistant post-traumatic stress disorder. The main research project we are currently embarking on is the use of psychedelic-assisted therapy[2]. We are preparing a trial for the use of psilocybin-assisted therapy using cognitive processing therapy with the clinical component of the trial commencing in January 2024.
As part of my visiting professorship at KCMHR, my role is mainly to advise on clinical matters and the medical safeguarding of participants in various studies. I help support and advise researchers in their research design and implementation.
3. What other research or policy areas relating to the Armed Forces Community are you especially passionate about or feel need further attention? Please expand on this and tell us about them, as much as you can.
I am passionate about military families and their needs and clinical interventions. When I was serving in the 1980s as a GP in primary care, we were fully involved with military families, especially those who lived in the military camp and in married quarters. For example, we knew when squadrons were going to be deployed abroad and we would help to support their families, including wives and children while their loved ones were away. Nowadays living on the married patch is less common and civilian General Practice is largely unaware of military families and their unique needs. Also, we do not know enough about the mental well-being and mental health of other family members including Service personnel’s parents and siblings. Especially what happens when their loved one is deployed on exercise or to a war zone. More research in this area is badly needed.
4. What are your future aspirations for the impact and utilization of your work/research?
My future aspiration is that my research into the clinical needs of help-seeking Serving and ex-Service personnel and their families, and clinical intervention programmes and their outcomes will continue and will inform the establishment of better first-class clinical services.
5. What do you think are the key challenges impacting current veterans and their families, and how do you think research and/or policy can be best used to address them?
There is a lot of collaboration between service mental health charities such as Combat Stress and the NHS, but all these services need improvement, and there needs to be less of a ‘postcode lottery’. The function of the collaboration between services needs to be much clearer for the veteran service user and access must be improved and refined to not be confusing for users who are seeking help. Clinical interventions need to be properly evaluated and made more robust. Overall, there needs to be a better understanding of the UK Armed Forces’ mental health to avoid this cliff-edge transition issue once people leave the military.
6. What do you think will be the leading challenges for the next generation of veterans and how do you think research and/or policy can be best used to address them?
I think the key challenge for current and future generations of UK Armed Forces and their families is the increased tempo of military operations including military exercises and the effects of separation from loved ones. The fact is that the tempo continues to be very demanding and there are fewer personnel being employed by the military due to cuts to the number of Serving personnel. The risk of course is that this will produce less than ideal effects on wellbeing and mental illness. This may also result in more people leaving the military prematurely with all their expertise going with them. There is a lot of pressure on the military leadership to get the balance right. Research into well-being, sickness behaviours and into evidence-based interventions will help policymakers and treatment interventions to be more efficacious.
7. Can you tell us about the methods you tend to use in your research, and why you gravitate towards these kinds of approaches?
As far as the research methods I tend to use - I always gravitate towards translational research. I guess this is because first and foremost I'm a clinician before I am a researcher. The main aim of translational research is to develop treatments and interventions. So, one needs to know what the needs are as a first step and measure the nature of the illness, prevalence, and severity. Then one needs to look at developing treatments and interventions. Translational Research has always been the approach I have used since the 1990s with the Gulf War 1 rehabilitation programmes we set up after measuring the clinical need. The interventions for the POWs and Hostages were based on an evaluation and eventual publication of the research literature. The treatment programmes devised for CPTSD in adult survivors of sexual abuse were also evaluated and published[3]. The needs studies[4] and outcomes of the evidence-based interventions[5] for veterans and their families devised at Combat Stress were also peer-reviewed and published.
At Combat Stress, we have developed large international collaborative networks with overseas counterparts in the veteran and Armed Forces mental health field. I am part of the Five Eyes in Mental Health Research Innovative Collaborative (MHRIC). This means that we collaborate with the Five Eyes nations including Canada, Australia, New Zealand, and the USA in relation to Armed Forces and veterans and military family mental health. The MHRIC advises the relevant Five Eyes Ministers on the latest research and policy which I think is very important. The other factor of translational research is to test the efficacy and effectiveness of interventions and then to disseminate and implement it as far widely as possible, providing of course that it is successful. We have done this using large data sets including those from the Five Eye multiple nations. These larger data sets available through this collaboration speed up the work and we have also carried out comparative studies[6] into needs and treatment interventions.
8. Given unlimited funding and time, what would be your dream piece of research to undertake involving the Armed Forces community?
If I had unlimited funding and time to do the dream piece of research, I would look to prove that we can manage and treat UK Armed Forces Personnel and Veterans within the same clinical service. Not having a separation between UK Armed Forces and Veteran's clinical services prevents diluting the pool of expertise within military psychiatry and psychology. These services could be run as one, enhancing staff training and increasing and broadening clinical experience and expertise. This could improve services for patients by avoiding unnecessary transitions between clinical services which we know increases the risk of disengagement from services and worsening clinical outcomes.
Many thanks to Professor Walter Busuttil for sharing his insights.
Catch us next month for another interesting and informative interview with an expert from the Armed Forces research community.
[1] Busuttil, W., Turnbull, G. J., Neal, L. A., Rollins, J., West, A. G., Blanch, N., & Herepath, R. (1995). Incorporating Psychological Debriefing Techniques within a Brief Group Psychotherapy Programme for the Treatment of Post-Traumatic Stress Disorder. British Journal of Psychiatry, 167(4), 495–502.
[2] Exploring the Acceptability and Feasibility of Using Psilocybin Assisted Psychotherapy (PaP) for Veterans With Post-traumatic stress disorder (PTSD) - FiMT Research Centre [Internet]. www.fimt-rc.org. [cited 9th August 2023]. Available from: https://fimt-rc.org/research/ongoing-research/exploring-the-acceptability-and-feasibility-of-using-psilocybin-assisted-psychotherapy-pap-for-veterans-with-post-traumatic-stress-disorder-ptsd
[3] Busuttil, W. (2006). The Development of a 90-Day Residential Program for the Treatment of Complex Posttraumatic Stress Disorder. Journal of Aggression, Maltreatment & Trauma, 12(1–2), 29–55.
[4] Describing the profile of a population of UK veterans seeking support for mental health difficulties [Internet]. www.fimt-rc.org. [cited 9th August 2023]. Available from: https://fimt-rc.org/article/20171006-describing-the-profile-of-a-population-of-uk-veterans-seeking-support-for-mental-health-difficulties
[5] Mental health and functional impairment outcomes following a 6-week intensive treatment programme for UK military veterans with post-traumatic stress disorder (PTSD): a naturalistic study to explore dropout and health outcomes at follow-up [Internet]. www.fimt-rc.org. [cited 9th August 2023]. Available from: https://fimt-rc.org/article/20150320-mental-health-and-functional-impairment-outcomes-following-a-6-week-intensive-treatment-programme-for-uk-military-veterans-with-post-traumatic-stress-disorder-ptsd-a-naturalistic
[6] Comparing the profiles of UK and Australian military veterans supported by national treatment programmes for post-traumatic stress disorder (PTSD) [Internet]. www.fimt-rc.org. [cited 9th August 2023]. Available from: https://fimt-rc.org/article/20190718-comparing-the-profiles-of-uk-and-australian-military-veterans-supported-by-national-treatment-programmes-for-post-traumatic-stress-disorder-ptsd
