NDDN Committee Report

Almost all injured military personnel who appeared before the Committee highlighted three principal concerns—their sense of abandonment by their unit; the long, frustrating wait for diagnosis and treatment; and, the uneven quality of treatment provided by medical professionals and case managers.

LACK OF UNIT SUPPORT

Soldiers with injuries or OSI who appeared before us all felt a clear and disappointing sense of abandonment by their unit, that began when they were evacuated from the battlefield, returned from post-deployment leave after returning from Afghanistan, or were transferred to the Service Personnel Holding List (SPHL).[41]Indeed, in 2002, the Ombudsman found there was inadequate contact between Canadian Forces members with PTSD and their units, particularly once the soldier had been placed on the SPHL.

In much of the evidence heard by the Committee, little mention was made of any attention being received from non-commissioned officers (NCOs) and junior officers. Few of the soldiers mentioned anything about the chain of command below Commanding Officers. They felt they had been left to navigate the medical system on their own. One reservist felt he was purposely being shunned by his unit. Another soldier, who had served with valour in Afghanistan and sustained both physical and psychological injuries, was so upset at the lack of attention from his unit he ended up moving home with his parents while undergoing treatment that he felt was too long in coming. He wanted nothing further to do with the Canadian Forces.

There are two aspects here. First, based on the cases before the Committee, once a soldier leaves ‘unit lines’ and is waiting for medical treatment, they seem to be forgotten by their sub-unit and unit level chain of command. This is explained, in part, because those organizations remain focussed on operations, with attention necessarily devoted to tasks at hand. Second, a problem arises when soldiers are moved back to Base locations to await treatment, beyond their immediate chain of command. It appears that no other group steps in to take over. This is where the feeling of abandonment starts, particularly for a young Private or Corporal who cannot find their way around or, if they are already exhibiting symptoms of OSI, are in no state to be wandering around unsupervised anyway.

The Committee heard of injured soldiers being left on their own for days in Kandahar Airfield, before being able to fly home to Canada, having food and drink brought to them in their accommodation trailers because they could not walk to the dining facility. This type of story was not unique. It was all the more troubling because all these young soldiers came from established regiments that pride themselves on being able ‘to take care of the troops’. Clearly, they must do better.

One witness suggested that some sort of ‘holding unit’ for injured personnel, other than the purely administrative SPHL, should be established on major Canadian Forces Bases and other locations where there are significant number of injured troops undergoing treatment. This unit would provide trained staff to exercise daily supervision of recovering soldiers and shepherd them through the maze of appointments and treatments associated with their recovery programme. However, the Committee thinks the recent announcement of the Joint Personnel Support Unit (JPSU) addresses the issue of providing adequate supervision and help to recovering soldiers.

The Committee heard ample evidence that OSIs and PTSD are often found in co-morbidity with addiction to drugs and/or alcohol. Addiction co-morbidity can further complicate OSIs and PTSD and present other problems, including legal, for Canadian Forces members.

RECOMMENDATION 8

The Canadian Forces should include treatment for substance abuse and addictions as part of the services offered to sufferers of OSI and PTSD.

RECOMMENDATION 9

The Canadian Forces should ensure that members and their families are provided with information about the risk of domestic violence that is associated with OSI and PTSD, and should provide services to family members who are at risk of or suffering from domestic violence as a result of OSI or PTSD.

QUALITY OF CARE

While the Committee was made aware of a number of examples of excellent care being provided to Canadian Forces members suffering OSI, we also heard from many Canadian Forces personnel and military family members who were critical of the lack of empathy and understanding shown by civilian health care professionals. The most common complaint was that civilian mental health professionals simply did not understand the nature of activity or traumas experienced by Canadian Forces personnel in Afghanistan, particularly those who engaged regularly in combat operations.

In one in-camera session, the Committee heard from an experienced soldier with PTSD that all he wanted was the chance to sit and talk over his experiences with fellow soldiers. Wounded soldiers with symptoms of OSI need to talk over their experiences with a person who understands what they went through, has an evident degree of empathy and is willing just to listen. Apparently some civilian contract medical health professionals are not. On the other hand, some civilian mental health professionals informed us of their concerns about inappropriate military practices and impediments to quality care for Canadian Forces members with OSI.[42]

RECOMMENDATION 10

The Canadian Forces should develop a formal outreach program to educate contracted health care professionals about the unique nature of military experiences encountered on international missions, particularly those involving any degree of combat.

The mother of a Canadian Forces soldier suffering from PTSD told the Committee that she thought many overworked military medical and mental health professionals were burdened by ‘compassion fatigue’ and therefore found it difficult to summon up the strength to be caring and empathetic in every case.

Throughout all this, there was clear consensus from all parties that personnel suffering OSI would benefit from some degree of contact with, or participation of, selected family members in their treatment program.

The Committee was told by both families of Canadian Forces members and medical professionals, such as Dr. Greg Passey that family members are susceptible to both care-givers stress and secondary PTSD.[43] This makes navigating an administratively complex program of treatment and care difficult for them.

RECOMMENDATION 11

The Canadian Forces should formally recognize the requirement to include, where appropriate, selected family members in the treatment regime of psychologically injured personnel and take measures to ensure they are consulted and included in treatment plans, to the extent it is helpful to do so.

RECOMMENDATION 12

Where injured Canadian Forces members require continuing assistance in navigating an administratively complex programme of treatment and care, the Canadian Forces should facilitate the use of a designated advocate chosen by the member and provide an appropriate level of cooperation with such advocate. Canadian Forces members should be advised of their right to an advocate. Given the concerns of additional stresses on family members, potential advocates could include retired members of the Canadian Forces and other professionals (e.g. medical doctors, psychologists, spiritual/religious advisors).

CONTINUITY OF CARE

When recovering soldiers are posted from one unit to another, their continuing care is sometimes interrupted or adversely affected in some other way. The Committee heard from a number of witnesses who had experienced a problem with continuity of care after a move, particularly if that move sends them to an area with a shortage of professional medical specialists.

We recognize the inherent challenges of balancing the operational requirements of the Canadian Forces, the treatment regimen of a recovering soldier and the preferred employment of that soldier. In recalling that the aim is to allow injured soldiers to recover and heal, in order to return to full duty, the Committee suggests that, in the absence of overriding reasons to do otherwise, continuity of care and quality treatment considerations should take priority over career development considerations.

RECOMMENDATION 13

The Canadian Forces should give primary consideration to the continuity of quality care for recovering soldiers, over career development options.

RECOMMENDATION 14

The Canadian Forces should monitor the mental health of its members for five years after deployment on operational missions, to ensure effective treatment and tracking of mental health issues.

THE STIGMA

The issue of a ‘stigma’ came up frequently. Mental health disorders are viewed pejoratively in the public at large. For many years, it was widely noted that within the military environment psychological injuries were viewed as a sign of weakness. Those who suffered a mental disorder were, sometimes harshly, judged as being ‘not tough enough’ to be a soldier. The 2002 Ombudsman’s report found that those with PTSD are often “stigmatized, ostracized and shunned by their peers and the chain of command.” Six years later, the Ombudsman’s second follow-up report in 2008 found that the “negative stigma” associated with PTSD and other OSI remained a problem. However, it noted that a number of education initiatives had been launched in the intervening years, but that stronger leadership was needed at the local level.

The Committee heard anecdotal testimony from a number of witnesses, usually of junior rank, that described how, in the military culture, physical wounds that could be seen were more readily accepted, even respected, than psychological wounds that could not be seen and were often thought to be somehow less deserving of respect and might even be considered a sign of weakness, or even more devastating, a lack of courage (‘guts’). To be fair, we also heard considerable testimony, mainly from senior ranks, that such views are changing and that all wounds, whether they be physical or psychological, are coming to be seen, and accepted as ‘injuries’.

The Canadian Forces has recognized for some time that the stigma surrounding mental illness is a leadership issue. There is evidence that significant improvement is being made. Conducted between 2006 and 2008, a recent survey of Canadian Forces personnel returning from Afghanistan, who had completed their decompression period, clearly shows that over 80% of respondents disagreed with stereotypical stigmatization. They rejected views that people with mental health disorders are weak, that their careers would be adversely impacted and that there would be difficulty getting time off work for treatment. An overwhelming 93.5% said they would not think less of anyone receiving mental health counselling.[44]

Moreover, at a US-Canada Forum on Mental Health and Productivity meeting in November 2008, the Canadian Forces was praised for its success in reducing the stigma associated with mental illness, which has become a significant workforce and productivity issue throughout North America in general.

The Canadian Forces Mental Health and Operational Stress Injury Joint Speakers Bureau has developed a national education campaign to increase general mental health literacy among all ranks of the Canadian Forces and to remove social barriers to care. To date, over 8,000 military members have received training and education through the campaign.[45]

The Committee believes that remnants of this stigma thrive largely because of the absence of an appropriate, over-arching attitude towards mental health issues in the Canadian Forces, which, as discussed at the beginning of this report, is one of the root causes of many difficulties facing the military health care system.

RECOMMENDATION 15

The Canadian Forces must recognize there still exists a certain culture, perhaps even a prejudice, regarding how mental illness is perceived among its rank and file.

RECOMMENDATION 16

The Canadian Forces should continue its efforts to educate all military personnel on the nature, processing and treatment of OSI, with a particular effort to eliminate any stigma associated with the condition.

RECOMMENDATION 17

The Canadian Forces should embed in all leadership training courses, at all levels, material on identifying and processing personnel with OSI. Enhanced material, for commanders at all levels, should be included in all pre-deployment training too.

But, there are also other, more subtle things that sustain the stigma.

Well-meaning concern over the fact that Operational Trauma Stress Support Centres, located on major Canadian Forces Bases, apparently fail to provide enough privacy is one example. We heard from a number of witnesses who said those seeking mental health help at an Operational Trauma Stress Support Centre cannot do so anonymously because others, including perhaps peers and supervisors, can see a Canadian Forces member going in and out of the building. They fear being ostracized, talked about, or worse, enduring adverse career action. The answer, according to some witnesses, is to move mental health clinics off-base, where confidentiality and privacy can be achieved.

Apart from the fact that no evidence exists to support the idea that off-base clinics provide improved confidentiality, this type of move might simply ignore or reinforce the real problem. There are medical professionals who think moving mental health facilities off-base only reinforces the perception of stigma. If psychological injuries are to be treated the same as physical injuries, perhaps Operational Trauma Stress Support Centres should be co-located with other medical services on the base to encourage the equivalency. This issue is discussed further in a later section.

RECOMMENDATION 18

The Department of National Defence and the Canadian Forces should move to co-locate all medical facilities on military bases, in a manner that supports the concept that all injuries and ailments will be treated with equal respect and that works to eliminate any lingering stigma associated with mental health issues.

The physical separation of those who suffer OSI from their unit and peers is another issue that feeds the stigma. Often such patients are left idle at home, with their family, only to venture out when treatment demands it. As comforting as being at home with family might be, it is not ‘normal’ for a soldier, who usually fills a day on duty within the unit, among peers, where daily routine is largely managed. The Committee thinks that any stigma would be further reduced if, like those with a physical injury, OSI sufferers were engaged in at least a near-normal, supervised daily routine among peers. The establishment of the JPSU will help in this regard.

JOINT PERSONNEL SUPPORT UNIT

On March 2, 2009, the Canadian Forces announced that, over the coming months, a network of eight support centres will open (Vancouver, Edmonton, Shilo, Toronto, Petawawa, Valcartier, Gagetown and Halifax), known as Integrated Personnel Support Centres (IPSCs), which are all to be subordinate to the JPSU, located in Ottawa.[46] The JPSU and its satellite IPSCs, are to respond to requests for support and report, through the chain of command, on issues of concern raised by ill and injured CF personnel. They aim to improve the quality of health care and services, to ensure military personnel have access to a consistently high standard of care and support across the country, and reduce gaps, overlaps and confusion, so no one ‘falls through the cracks’.

The JPSU will coordinate Canadian Forces and Veterans Affairs Canada health care services for military personnel and their families; support serving and releasing Canadian Forces personnel, both Regular and Reserve Force; cater to both referrals and walk-in clients, to long-term injured personnel and to members considering retirement. It responds to queries from family members regarding support services and programs for ill and injured personnel, and provides referrals as appropriate.

RECOMMENDATION 19

The Department of National Defence should ensure that adequate resources are allocated to the establishment of a sufficient number of the Joint Personnel Support Units and Integrated Personnel Support Centres to provide this level of support and service nation-wide.

RESERVISTS

The Department of National Defence and Canadian Forces Ombudsman’s report on the inequities of Reserve Force benefits as a result of injury confirms the administrative challenges that have long been facing the Reserve Force. During our study, the Committee acquired evidence that Reserve units are unable to complete necessary administration relating to mental health post-deployment screening. One witness described how he received no contact or support from his small city-based regiment.

In another area of the country, post-deployment screening of 57 soldiers in a strong Reserve regiment was not completed in the six-month time frame defined for the activity. During that period:

a)    35 of 57 had completed the required medical follow-up;

b)    14 of 57 had completed the tuberculosis skin test; and

c)    36 of 57 had completed the Enhanced Post-Deployment Screening survey.[47]

In practice, most returning Reservists are simply given instructions to fill out certain forms at specific times and that they must contact, on their own, a local contracted social worker, to arrange an appointment for and interview. Some of these contracted civilian social workers have been described as having no idea what Reservists did in Afghanistan, no empathy and little interest in digging too deeply into the psychological state of soldiers.

When Reservists come home from an overseas operation, they can be effectively supervised for the duration of their full-time service contract, which may (usually) expire between 60 to 90 days after their return. During that time, injuries or ailments that become apparent can be addressed. In cases where those injuries and ailments are not remedied during the period of the full-time service contract, the contract can be extended until the military member has recovered, or until the soldier wishes to terminate the contract. In either case, Canadian Forces supervision of care and treatment continues.

Difficulties arise in two ways. First, some injuries, particularly OSI, may not become apparent during the life of the full-time service contract. So after about 90 days the Reservist returns to civilian life and at some later point, when they start to have difficulty, they may or may not seek help on their own. The Reserve unit may never know about the problem.

Second, it is a fact that some Reservists, even upon being instructed to complete forms and make appointments, simply do not. Off duty, they cannot be compelled to do so. Reserve unit efforts to organize and complete such administration can face frustrating delays. In some Reserve units, a more proactive approach seems to work, whereby contract civilian social workers are brought to the armouries on a parade night and all returning personnel (usually not a large number in any one Reserve unit) are interviewed individually and the necessary forms completed. Reserve units that take a more passive approach and leave it up to individual Reservists to complete the forms and make interview appointments themselves tend to get less satisfactory results.

RECOMMENDATION 20

Reserve unit chains of command must be intimately and proactively involved in ensuring their returning personnel complete the post-deployment process on time, including all necessary administration, interviews and medical appointments. Where individual Reservists are undergoing continuing care and treatment after full-time service, Reserve unit chains of command must remain in regular contact with CFHS case managers and take an active interest in the soldier’s treatment program.

RECOMMENDATION 21

The Canadian Forces must continue their efforts to inform and educate military members and their families about the nature and treatment of OSI, but with an enhanced focus on Reserve Force commanders, personnel and their families, particularly those who reside at some distance from a military installation.

CONTINUING SERVICE

One of the more emotional points that came before the Committee was the issue of whether and how an injured soldier might be allowed to continue serving in the Canadian Forces. It was sometimes amazing to hear from wounded servicemen and women who, no matter what their malady, wanted desperately to remain in uniform, in some capacity. Emotion aside, in the profession of arms in Canada, no one is owed a long military career and no one has a right to promotion. Nonetheless, the issue deserves sober discussion.

Department of National Defence Departmental Administrative Order and Directive (DAOD) 5023-0 spells out the policy on Universality of Service in the Canadian Forces.[48] The principle of universality of service or ‘soldier first’ principle holds that Canadian Forces members are liable to perform general military duties and common defence and security duties, not just the duties of their military occupation or occupational specification. This may include, but is not limited to, the requirement to be physically fit, employable and deployable for general operational duties. All Canadian Forces personnel must meet the Minimum Operational Standards.[49]

To execute its mission the Canadian Forces must be given broad authority and latitude in utilizing Canadian Forces members and their skills. The statutory basis for this authority is Section 33 of the NDA, the essence of which is recognized in the Canadian Human Rights Act which provides that the duty to accommodate is subject to the principle of universality of service.[50] Under this principle, Canadian Forces members must at all times and under any circumstances perform any functions that they may be required to perform. This open-ended nature of military service is one of the features that distinguish it from the civilian notion of employment governed by a contract.

Injured personnel whose prognosis leads to eventual full employability again are retained in the Canadian Forces while they recover. Some however, whether they suffer from a physical or psychological wound, may still meet Minimum Operational Standards, but will not regain full employability in their former trade because they cannot meet the medical standards for that particular trade. Rather than being released from the Canadian Forces, they may be offered an occupational transfer (OT) to another, less demanding trade.

During testimony, the Committee heard that OT bureaucracy needed to be streamlined to allow transfers to happen quickly, particularly in the cases of OSI sufferers who were eager to get back into familiar, but less demanding surroundings. While we did not pursue this issue in detail, we do wish to note that OT is not entirely the panacea some make it out to be. Recalling the mission orientation of the Canadian Forces, it must be remembered that only personnel who can fully meet employability standards can be retained for their full period of service. All Canadian Forces trades ultimately have an operational role. Postal clerks, cooks and infantrymen find themselves side by side in Afghanistan.

The OT process is not merely a trade reassignment activity. There is more to it than that. Complex considerations are involved related to medical status, qualifications, operational requirements, training schedules etc. Without explicit evidence to the contrary, the Committee cannot find any fault with the existing system. We are confident that the Canadian Forces will continue to take necessary steps to achieve any further efficiency that may be required to allow the timely transfer of injured soldiers to another military trade, in keeping with operational requirements.

Some Canadian Forces personnel are injured so badly and suffer so grievously from physical injury or OSI/PTSD that they will not recover to a level of employability, even in a less strenuous trade. In accordance with universality of service regulations they will usually be released from the Canadian Forces and responsibility for their continuing care will be taken up by Veterans Affairs Canada. Today however, the Chief of Defence Staff applies a good deal of compassion and common sense to the application of existing regulations in order to allow injured soldiers the time and support they need to heal and come to their own decisions about continuing service.

RECOMMENDATION 22

The Committee encourages the Minister of National Defence and the Canadian Forces to continue to strive for the compassionate application of existing regulations regarding universality of service and minimum operational standards, to allow the continued employment of recovering soldiers, as long as such employment contributes to Canadian Forces operational requirements.