NDDN Committee Report

THE MENTAL HEALTH NETWORK IN THE CANADIAN FORCES

Over the last ten years, the Department of National Defence and the Canadian Forces have established a range of programs and initiatives to contribute to the identification, prevention and treatment of mental health problems.

The Enhanced Post-deployment Screening Process, a survey conducted
90 to 180 days after the return of deployed troops to Canada, tracks personnel experiencing deployment-related mental health problems. The five Canadian Forces Operational Trauma Stress Support Centres in Esquimalt, Edmonton, Toronto, Ottawa and Halifax have been joined by six Veterans Affairs Canada Operational Stress Injury clinics in Montreal, Fredericton, Quebec City, London, Winnipeg, and Calgary. The Operational Stress Injury Social Support (OSISS) network provides peer support, family counselling and bereavement services across the country.

A Special Advisor to the Chief of Military Personnel (CMP) oversees the management of non-clinical matters related to OSI. An Operational Stress Injury Steering Committee, which includes key senior leadership of the Canadian Forces, studies innovative ways of dealing with OSI, while an arm’s-length joint Department of National Defence/Veterans Affairs Canada Mental Health Services Advisory Committee (MHSAC) reports to the CMP and to Veterans Affairs Canada leadership on mental health issues.

These are all admirable initiatives, but as has been covered elsewhere in this report, the real challenges are found in effectively implementing higher policies and direction. To ensure that state-of-the-art practices are available to all Canadian Forces chain of command appointments and mental health professionals the Committee thinks that more strategic advantage can be taken of Department of National Defence and Canadian Forces involvement in the FHP.

RECOMMENDATION 25

In conjunction with other Federal Healthcare Partnership stakeholders, the Department of National Defence, Veterans Affairs Canada and the Canadian Forces should hold an annual national conference on best practices and advancements in military health care overall, with special emphasis on mental health care.

THE MORAL RESPONSIBILITY

Civilian military family members are covered by provincial health care programs. The Canadian Forces has no formal or legislated mandate to treat civilian military family members. Canadian Forces resources are budgeted and allocated on military requirements alone and do not formally take into account the health requirements of military families because the Canadian Forces have no mandate to do so.

Nonetheless, the Committee heard much about the moral responsibility of the Canadian Forces to care for military families. We note however, that the Canadian Forces itself was the first to assume this responsibility many years ago. The Canadian Forces has always offered care and support to its military families in keeping with the resources available and what it could do.

Some non-military witnesses arbitrarily spoke of this moral responsibility not only as though it was something new, but in a way that exceeded the Canadian Forces mandate and resources. In recent testimony, a representative of the Department of National Defence and Canadian Forces Ombudsman said, “First, as mental health injuries are the result of military service, and the direct cause of family stress, the Canadian Forces have a moral responsibility to ensure that care and treatment are provided to families.”[55] Not only can the Canadian Forces not ensure care and treatment that is beyond their mandate, they also certainly cannot do so if it involves interfering in legislated provincial affairs.

NOT ENOUGH PEOPLE

The central issue facing the Canadian Forces is the shortage of personnel, almost everywhere, almost all the time. This is not a new phenomenon. It has been a significant impediment to all Canadian Forces activity for generations. Despite government authorization and funding that allows an increase in Canadian Forces personnel strength to nearly 100,000 Regular and Reserve personnel, the net growth has been weak.[56]
In many ways, this too is a whole-of-government issue, but it is beyond the scope of this study. What is relevant here is the fact that the extended impact of this chronic shortage is instrumental in thwarting the ability of low-level chains of command to supervise and care for their soldiers.

Personnel growth is also hindered by the steady attrition of mid-level senior officers and senior non-commissioned officers (Sr NCOs), partly as a result of a relentless tempo of operational training and deployment, particularly in Afghanistan.

One consequence of this chronic personnel shortage is the fact that, because of the ‘operations primacy’ approach in the Canadian Forces, many training establishments have less personnel than they need. To provide the necessary instructional, support or administrative staff required to conduct training activity, military personnel from other units are temporarily assigned to military schools and training activities.

Throughout every year, but mainly during the spring and summer training periods, hundreds, if not thousands of junior military leaders, particularly in the Army, are removed from their units and ‘tasked’ to instruct, support or administer a variety of training activities at other locations. The bulk of these ‘taskings’ fall on the Master Corporal, Sergeant, Warrant Officer, Lieutenant and Captain ranks—the very ranks that provide close supervision of soldiers. These ‘taskings’ usually require the tasked individual to be away from home (again) for up to two months at a time.

Concurrent with the summer ‘tasking’ period is the annual posting cycle during which many Canadian Forces personnel and their families are re-assigned to new duties elsewhere. Such moves normally come every two or three years over the course
of a career.

The case of one Army battalion is instructive. It returned from a seven month tour of duty in Afghanistan in the spring of a year. Their time in Afghanistan had been marked by some of the largest ground combat operations in the history of NATO and in the history of Canada since the Korean War. They had sustained many killed and wounded, but they had fought well and were now home for a rest.

After about three days back in garrison, where necessary administration was completed and equipment turned in, unit personnel were allowed to depart on some
well-deserved leave. Most went home to families, living either in garrison, or in other towns across Canada. Some young single soldiers remained on their own, in their quarters, on-base.

In effect, everyone became unsupervised and beyond the observation of their peers and unit chain of command who knew them best. In the nearly three weeks of leave, a few soldiers succumbed to symptoms of OSI, some disruptively and violently so. The problem was, this all happened at home, or beyond the view of the unit chain of command. Families began to suffer too.

When the period of post-deployment leave was finished and unit personnel returned to duty, those soldiers suffering to various degrees from the symptoms of OSI tended not to step forward and self-report their difficulty. Instead, many of the problems came to light in the form of disciplinary issues resulting from inappropriate behaviour. They became identified as ‘problem soldiers’

At this time, being the beginning of the summer training period, the inevitable ‘taskings’ started to come in. Unit Junior NCOs, Senior NCOs, Warrant Officers and junior officers started to depart for temporary training assignments elsewhere. Young soldiers, a few of whom now obviously suffered from a variety of OSI were increasingly supervised by a dwindling cadre of junior leaders, some of whom had their own post-deployment issues, but who could not escape the increasing workload. All this was happening during the period that the Army theoretically identifies as a post-operation ‘reconstitution’ phase.

It must be remembered too, that this is now also the ‘active posting season’ and some of the battalion’s leadership personnel are packing up and moving their families to a new location, as the military member is re-assigned to a new job.

Just when an experienced, familiar chain of command is needed to bring all unit personnel through the post-deployment phase, part of which involves mental health screening, it is dissipated by the burden of ‘taskings’ and postings. In an interview, a Commanding Officer, who arrived on posting and the Regimental Sergeant Major, who remained in the unit, lamented the circumstances of a chain of command ravaged by ‘taskings’, recalling their deep regret at not being able to do more, but also recalling their feeling of frustration and helplessness in being unable to stem the tide of ‘taskings’.

This brief vignette illustrates that, while no one argues with the pre-eminence of ‘operational primacy’ in the Canadian Forces, there is a requirement to reflect upon what might come second. From what we have seen and heard, the Committee feels that concern for the health, particularly mental health, of personnel in units returning from operational tours of duty should, to the extent and duration required, be given primacy over other considerations. Put bluntly, the continuing health of soldiers should outweigh training challenges of the moment.

RECOMMENDATION 26

The Canadian Forces should ensure that personnel in units returning from operational tours of duty are exempt any further non-operational deployment away from their unit for the defined duration of the
post-deployment reconstitution phase, unless to do so would negatively affect patient well-being according to mental health professionals.

RECOMMENDATION 27

The Canadian Forces should ensure continuity in the chain of command in units returning from operational tours of duty, particularly at lower levels, remains in place, as much as operational requirements allow, during the post-deployment reconstitution phase.

PREVENTION AND EXTENDED DOCTRINE

The Committee heard evidence from various professionals that there are few to no preventative diagnostics available at this time for mental health problems before people join the Canadian Forces. Similarly, it would present legal and human rights difficulties to implement a recruitment screening mechanism based on psychological diagnostic tools. Current Canadian Forces training is some of the best in the world and ably provides many soldiers with the tools they need to psychologically prepare them for the stresses they will encounter. Pre-mission training is also some of the best in the world (see Annex on Prevention). However, the Committee believes that more needs to be done to prepare soldiers for the battlefield stresses they could encounter. Research on how to adequately prepare soldiers and prevent OSI and PTSD needs to be a focus—i.e. an ‘ounce of prevention’ is certainly worth a ‘pound of cure’. Current and ongoing advancements in ‘Battlemind’ training in the United States may prove especially fruitful and deserves attention by Canadian Forces medical personnel and policy officers.

As mentioned earlier, the Committee heard a considerable amount of evidence to the effect that operational casualty care on the battlefield is second to none and that all involved are nothing short of courageous, professional and dedicated. Concern over the efficacy of medical care and treatment begins after injured personnel leave the battlefield. Recognizing that the Canadian Forces have proven doctrine covering Health Services Support to Operations, we suggest further effort be devoted to developing extended doctrine covering the period from battlefield evacuation to recovery or transfer to Veterans Affairs Canada support upon release. This doctrine might include such subjects as:

a)    a standardized regimen of continuing care for both physical and psychological injuries, from point of injury to recovery or release:

b)    care and administration upon assignment to the SPHL;

c)    role and responsibilities of the operational chain of command;

d)    role and responsibilities of the medical chain of command;

e)    role and responsibilities of injured personnel undergoing care; and

f)     role of the family in continuing care.

RECOMMENDATION 28

The Canadian Forces should develop health services doctrine to cover the care and treatment of Canadian Forces casualties from the point of evacuation to recovery or release and transfer to Veterans Affairs Canada support.

RECOMMENDATION 29

The Canadian Forces should ensure their extended health services doctrine includes measures addressing OSI from recruitment through to retirement, with particular emphasis on the preparation of soldiers to endure psychological traumas before they engage in combat operations. The Canadian Forces should investigate best practices in psychological preparation for OSI and PTSD.

THE CLINIC

A number of witnesses who appeared before the Committee, including
Dr. Greg Passey and Senator Romeo Dallaire, a noted psychiatrist and former Canadian Forces officer respectively, recommended that military mental health clinics should be located off-base, so that those seeking help would not be seen by friends, peers and the chain of command. The same point was made by some personnel participating in a Canadian Forces Patient Satisfaction Survey in January 2009. They wanted a more discreet location.

Another view holds that moving mental health clinics off-base would only aggravate the issue of stigmatization. Besides, going off-base in a small town like Petawawa would not necessarily provide a more discreet location, unless the clinic was placed at some distance. If psychological injuries are to be thought of and treated the same as physical injuries, it stands to reason that they would be attended to in the same facility. Having the Operational Trauma Stress Support Centres remain on base is not only economical and efficient, it is one way of mitigating any inappropriate stigma.

RECOMMENDATION 30

The Department of National Defence and the Canadian Forces should institute a program, in concert with Provincial and Territorial governments, to monitor best practices for the cooperation and integration of Canadian Forces health services with local community health and social services, and implement common high standards.

THIRD LOCATION DECOMPRESSION

Most troops returning from a tour of duty in Afghanistan are required to undergo a short period of ‘decompression’ in Cyprus, a location specifically chosen to provide a safe and ‘normal’ atmosphere for a few days, where soldiers can rest and relax after enduring the operational environment of combat in Afghanistan. This period of decompression lasts from three to five days, depending on arrival and departure times of military flights. During their stay in Cyprus, troops are provided with a few hours of briefings about the challenges of reintegration back home. They are given information on OSI and provided with social support contact information should they need it.

It is important to note that while decompression may be useful in identifying some who might display symptoms of OSI, this is not the primary aim of the decompression activity. Decompression is primarily aimed at assisting personnel to ready themselves for reintegration into their family, either as a returning spouse, or returning son or daughter. Families in Canada have managed their lives during the soldier’s absence in Afghanistan, but the returning soldier might be expecting to ‘pick up where he left off’ before his departure. There may be a period of readjustment for both parties. Decompression briefings aim to help the returning soldier understand some of the readjustment challenges he or she may face. It should also be noted that equivalent briefings are made available to spouses and families through MFRCs at home.

The Committee also notes that holistic health and spiritual care are vitally important to many Canadians, including the Canadian Forces. Military padres and/or privately contracted religious/spiritual advisors provide an important service for Canadian Forces members who request and rely on their services. The Committee heard testimony that these religious/spiritual professionals provided excellent services to Canadian Forces members during the decompression state—not to mention at bases across Canada.

RECOMMENDATION 31

The Canadian Forces should ensure that a military padre or contracted religious/spiritual advisors are available at any third location decompression centre and are included in the Canadian Forces strategy on mental health care.

OPERATIONAL TRAUMA STRESS SUPPORT CENTRES

These centres were established in 1999 and are located in Edmonton, Esquimalt, Halifax, Ottawa and Valcartier.[57] They provide assistance to serving members of the Canadian Forces and their families dealing with stresses arising from military operations. Operational Trauma Stress Support Centres holistically address a myriad of psychological, emotional, spiritual and relationship problems, with a multi-disciplinary team of medical professionals, including a psychiatrist, a psychologist, a social worker, a chaplain and a community health nurse.

Although not mandated to treat civilian family members, Operational Trauma Stress Support Centres, as part of their holistic approach, do sometimes treat families, particularly where the military members has an OSI, or when both spouses are having relationship difficulties.

The Committee notes that relationship and family stress is a further contributor to retention problems and an additional stressor for those suffering from OSIs and PTSD. We heard evidence that suggested the Canadian Forces hire registered marriage and family therapists to be included on the Operational Trauma Stress Support Centre multi-disciplinary team. We feel however, that while such relational treatment might be needed, the Canadian Forces should retain the flexibility to decide whether such professionals need to be hired permanently, or whether there services can be contracted in the local area. Nonetheless, the idea does represent the need to be open to new and alternative treatments that have not traditionally been part of the military health care system.

RECOMMENDATION 32

The Canadian Forces should regularly review the composition of the Operational Trauma Stress Support Centre multi-disciplinary teams and remain open to the addition or use of clinical professionals not traditionally found in the military health care system, such as registered marriage and family therapists and that the services thereof be added to the Dependents’ Extended Health Care schedule of covered benefits.

KEEPING TRACK OF HEALTH INFORMATION

It seems that the CFHS does not know how exactly how many Canadian Forces members suffer from OSI. Such records are not aggregated. Past reports of both the Auditor General of Canada and the Department of National Defence and the Canadian Forces Ombudsman were critical of the CFHS for its inability to collate health care information at the national level. A Canadian Forces project to field an information system that could maintain such records was expected to have been completed before now. In the second follow-up report published in December 2008, the Ombudsman remained pointedly critical of the Canadian Forces’ apparent lack of success in getting such a system up and running.

Although there are, in fact, a number of processes by which the Canadian Forces can track personnel with particular health issues, they are not precise or disciplined enough to compile and sustain up-to-date information on all patients, all the time.

However, Canadian Forces health records are being computerized, in concert with a national effort to develop electronic health records across Canada. In fact, the Canadian Forces Health Information System (CFHIS) is nearing completion. CFHIS is an electronic health record solution that will securely share information and coordinate care for Regular and Reserve force personnel, anytime, anywhere. It creates a complete health record for every Canadian Forces member by integrating a number of software applications that support a wide range of Canadian Forces health services and functions including: centralized patient registration and scheduling; computerized physician order entry and clinical notes; pharmacy information system; laboratory information system; a radiology information system; and a dental information system.[58]

CFHIS project began rolling out electronic patient registration, scheduling and immunization tracking capabilities to medical and dental clinics across the country in
April 2005 and by September it reached the half way point, with 21 sites and 438 trained users accessing new applications. There seems to be no further, current information available on the project and when presented with the opportunity when she appeared before the Committee, the Surgeon General offered no details on the project, leaving Committee members under the impression that little, if anything was being done to address the recommendations of both the Auditor General and Ombudsman. We continue to wonder why the Canadian Forces remains so reticent about what seems to be positive news.

RECOMMENDATION 33

The Canadian Forces should provide this Committee, the Auditor General of Canada and the Department of National Defence and Canadian Forces Ombudsman with a full, unclassified update of the status of the Canadian Forces Health Information System, along with a meaningful explanation of when it will reach full operational capacity.

RECOMMENDATION 34

The federal government should move immediately to provide the necessary resources to reach full operational capability of the Canadian Forces Health Information Systems project, with the assistance of a database.