ARCHIVED - Response from the Chief of the Defence Staff on the Office's Second Follow-up Report on Operational Stress Injuries

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27 October 2008

Mrs. Margaret Brandon
DG Operations
Office of the DND/CF Ombudsman
100 Metcalfe Street, 12th floor
Ottawa ON K1P 5M1
 

Dear Mrs. Brandon,

Thank you for the copy of the Interim Report: Second Review of the Department of National Defence and Canadian Forces’ Action on Operational Stress Injuries. It is appreciated to be given the opportunity to provide comments with regard to the advances and changes we have made in this very important area.

The report was reviewed and our comments with additional information are provided at Annexes A and B.

I look forward to continuing our joint efforts in addressing any matter that comes to your attention.

Sincerely,
 

General W.J. Natynczyk

Annexes

Annex A – Comments provided by DCSM and DGHS
Annex B – Roles and responsibilities – OSI Senior Advisor


Annex A to CDS Letter to DG Operations, Office of the DND/CF Ombudsman
Dated October 2008

Comments Provided by DCSM and DGHS

A full-time position of National Operational Stress Injury Coordinator be created, reporting directly to the Chief of the Defence Staff and responsible for all issues related to operational stress injuries, including: the quality and consistency of care, diagnosis and treatment; and training and education across the Canadian Forces.

While the report acknowledges that a series of decisive steps (section 39) have been undertaken over the last year and announced in May 2008, a full analysis of the intent of these various initiatives and how they complement each other to create a full spectrum of interventions would be required in the report. The report focuses much of its attention on the CF not appointing a post-traumatic stress disorder (PTSD) Special Advisor who reports directly to the CDS.

From a CF point of view, the creation of a Mental Health Services Advisory Committee and the appointment of an OSI Special Advisor at the rank of Lieutenant-Colonel who reports directly to the CMP are deemed sufficient to achieve the overall coordination of issues relating to Operational Stress Injuries (OSIs). While it is agreed that OSIs continue to need our full attention, appointing someone who reports directly to the CDS may be seen as an effective measure in the short term, when in fact it would bypass important staff procedures and the various chains of commands and stakeholders within the CMP chain of command. This approach may not address adequately the long term issues and it may not allow new processes and policies to become fully integrated CF wide.

The creation of the Mental Health Services Advisory Committee will look at services and programs from a DND and VAC perspective. By reporting directly to CMP and Senior VAC ADM, it will tackle systemic and strategic shortfalls by putting forth cogent recommendations that are sound. Most importantly, it will take into account transition issues following the release of a CF member and will provide, in the long term, a seamless hand over of case files to VAC.

On the other hand, the OSI Special Advisor will provide CMP with reliable advice in the realm of non-clinical issues relevant to the full recovery of CF personnel. The OSI Special Advisor has also been tasked to take the lead in the development of a national education strategy to increase the mental health literacy within the CF. Drawing on day to day experiences and lessons from cases managed on behalf of the CMP and the CDS, this national strategy will aim at reducing the OSI stigma. Work in this field started on 8 November 2007 with the creation of a National Mental Health & OSI Joint Speakers Bureau (JSB). The JSB is jointly managed between the office of the OSI Special Advisor and Rx 2000 Mental Health Training. An innovative approach to education was developed in cooperation with the University of Ottawa and a curriculum was implemented on 1st May 2008 following the endorsement from the OSI Steering Committee held on 22nd April 2008.

The OSI Special Advisor continues to build bridges and partnerships, both at home and abroad with organizations such as our own Health Services organization, the Round Table on Mental Health and Addictions, the Canadian Mental Health Association and organizations such as the Combat Operational Stress Control group from the US Marine Corps. Working in this manner allows for the creation of innovative approaches to address the non-clinical needs of individuals suffering from mental health illness and OSIs by leveraging best practices from other outside agencies. The CMP also accepted an invitation by the Mental Health Commission to appoint the OSI Special Advisor to the Mental Health Commission of Canada. While the OSI Special Advisor reports to the CMP rather then to the CDS, this command relationship is deemed effective and there are no plans at this stage to create a National OSI Coordinator who reports directly to the CDS (section 115). It is therefore felt that the intent of the Ombudsman’s recommendation is achieved here through these two distinct mechanisms and that no further action is required on this issue.

The major observation that we would like to draw to your attention is the focus of the report on OSIs. Health Services would like the emphasis to be more broadly on Mental Health and not focus on specific disorders such as PTSD. All Mental Health disorders deserve the same care, attention and support. To single out specific conditions can lead to an inherent double standard of care and can inadvertently worsen stigma for patients whose mental health problem is not an OSI.

This is not supported as written. The Surgeon General has responsibility for the quality and consistency of all clinical medical services, including the care, diagnosis and treatment of mental health problems, including Operational Stress Injuries. We do, however, agree with the spirit of this recommendation and are supportive of a position being created to support CMP and enhance understanding and collaboration between the health care system and other parts of the CF.

The Canadian Forces establish and properly resource an organization – at the national level – responsible for working with external agencies and all levels of government, as required, to ensure that military families and individual members of the families of military personnel have access to the broad spectrum of services and care they need.

We concur with this recommendation, but feel ‘ensure’ may be too strong a word to use and ‘help ensure’ may be better. As your report notes, there is very substantial regional variation in availability of resources across the country, and presently the CF does not have the mandate to provide health care to families of CF members in Canada (other than at Goose Bay, Labrador). There would be very significant resource and political implications to changing this reality.

The Canadian Forces provide an appropriate level of funding across the country for the identification, prevention and treatment of post-traumatic stress disorder and other operational stress injuries.

This is supported and it is suggested that it be expanded to include all mental health disorders, not just PTSD and OSIs.

The Canadian Forces monitor and assess the requirement for additional mental health care professionals should the challenge associated with mental health injuries continue to grow.

We concur with this recommendation.

The Canadian Forces develop and implement a national program or initiative aimed specifically at assisting and preventing stress and burnout among the mental health care community.

We concur with the spirit of this recommendation. Addressing mental health provider shortfalls will in and of itself be of considerable help. However, it is far from clear that a specific national program is the best way to address caregiver stress; which has many causes, including a strong sense that whatever a provider does, it won’t be perceived as good enough. The quote from a Chaplain to the effect that  “You have nothing to give but everybody asks for something” is very telling. We need more providers, yes – but we (both the CF and those offering comment) also need to ensure our providers know that they are doing a great job and that they are appreciated. Perhaps the recommendation might be better phrased as  “The Canadian Forces take steps to regularly monitor mental health provider well-being, and make available resources to allow early intervention when stress and burnout threaten the future effectiveness of individuals, teams or the community as a whole.” 

Recommendation 1 In Annex A: Overview of the Original 31 Recommendations

The Canadian Forces develop a database that accurately reflects the number of Canadian Forces personnel, including members of both the Regular and Reserve forces, who are affected by stress-related injuries.

We concur with this recommendation.

Recommendation 3 In Annex A: Overview of the Original 31 Recommendations

The Canadian Forces conduct an independent and confidential mental health survey, which should include current and former Canadian Forces members from both the Regular and Reserve forces.

This recommendation is supported in part. The CF can conduct a survey of Regular and Reserve Force members; however it is not responsible for former CF members. Veterans Affairs may be able to gather information on retired members of the Canadian Forces.

Recommendation 5 In Annex A: Overview of the Original 31 Recommendations

The Canadian Forces initiate a program whereby all units receive outreach training about post-traumatic stress disorder via the OTSSCs.

Status: Not Implemented (2)

The CF has aggressively pursued outreach and education via a non clinical path by appointing an OSI Special Advisor whose role includes the development of a coherent educational campaign to increase mental health literacy within the CF audience.

In accordance with CANFORGEN 093/08 CDS 011/08, the OSI Special Advisor and the Rx2000 Mental Health Training team jointly launched the Mental Health & Operational Stress Injury Joint Working Group (WG) in December 2007. The WG is composed of mental health professionals, staff from Director Casualty Support Management (DCSM), Veterans of operations, and family members who have personally experienced the effects of OSIs. The overarching goal of this WG is to be the single point of contact and coordination for the review and development of non-clinical interventions regarding mental health in the Canadian Forces (CF) and provide strategic guidance to the Mental Health & OSI Joint Speakers Bureau (MH & OSI JSB).

The WG also includes external partners and collaborators such as the Ottawa University and the US Marine Corps Combat Stress Control Group.

The WG is developing an educational campaign supported by a robust and culture-changing curriculum that is/will be delivered through Canadian Defence Academy (CDA) at venues such as Basic Military Qualification (BMQ), Primary Leadership Qualification (PLQ), Intermediate Leadership Qualification (ILQ), and Advance Leadership Qualification (ALQ), supported by additional training modules that can be delivered at the unit level during professional development sessions. The primary means of delivery of the curriculum will be the DCSM 5 Mental Health & OSI Joint Speakers Bureau. The Speakers Bureau was originally created in 2002 to deliver this education in the form of professional briefings to soldiers new to the CF as part of the BMQ training. This instruction implements a 3.5 hour workshop format which includes lecture modules, case studies, group discussions and personal accounts delivered by trained and respected peer mentors. Additionally, two to three hour professional development sessions intended for delivery at the unit level are also available.


Recommendation 6 In Annex A: Overview of the Original 31 Recommendations

OTSSCs be funded to a level that ensure they have sufficient resources to deliver quality outreach training to units on request.

Status: Partially Implemented (1)

See response for Recommendation #5. Funding has been identified for FY 08/09 for the Joint Speakers Bureau and BP for subsequent years is currently in development.

Recommendation 7 In Annex A: Overview of the Original 31 Recommendations

Specific and detailed education and training objectives dealing with post-traumatic stress disorder be included in the curricula of all Canadian Forces educational and training establishments, and that the performance measurement criteria for these organizations reflect these objectives.

Status: Not Implemented (3)

See response for Recommendation #5. In addition the Mental Health & Operational Stress Injury Joint Working Group (WG) is currently developing an evaluation tool to validate the success of the education campaign. This evaluation tool is currently in development.

Recommendation 8 In Annex A: Overview of the Original 31 Recommendations

Canadian Forces units be mandated to provide ongoing continuation training about post-traumatic stress disorder to all members at regular intervals, in addition to any deployment-related training.

Status: Not Implemented (4)

See response for Recommendation #5. In addition, while the newly created educational curriculum is being delivered through CDA and the various career courses, an overall CF Strategy is being developed that will ensure that the educational strategy is linked to the unit annual training agenda. While it is too early to provide details of implementation, the CF approach regarding mental literacy as a whole does include continuous opportunity for refreshed knowledge to be it during Professional Development sessions and pre/post deployment sessions.

Recommendation 9 In Annex A: Overview of the Original 31 Recommendations

The Canadian Forces make post-traumatic stress disorder a mandatory part of education and training at all ranks and that educating Canadian Forces members about post-traumatic stress disorder be made a priority.

Status: Not Implemented (5)

See response for Recommendation #5. CANFORGEN 093/08 CDS 011/08 is a tangible example of the CF commitment toward Mental Health.

Recommendation 10 In Annex A: Overview of the Original 31 Recommendations

The Office of the Post-Traumatic Stress Disorder Coordinator play a central role in the education and training process by acting as a resource and advisor for bases, formations and commands.

Status: Not Implemented (6)

The Office of the OSI Special Advisor was created in November 2008 and announced by the CDS in CANFORGEN 093/08 CDS 011/08 and part of the role is education (see Annex B for detailed roles and responsibilities).

Recommendation 11 In Annex A: Overview of the Original 31 Recommendations

The Canadian Forces include members or former members who have experience of post-traumatic stress disorder in all education and training initiatives relating to post-traumatic stress disorder.

Status: Partially Implemented (2)

See response for Recommendation #5.

Recommendation 12 In Annex A: Overview of the Original 31 Recommendations

Multidisciplinary teams that include all of the professional specialties with an interest in post-traumatic stress disorder diagnosis and treatment, including experienced soldiers, be used to deliver outreach training. To enhance training effectiveness and ensure standardization, such training should fall under the control of the Office of the Post-Traumatic Stress Disorder Coordinator.

Status: Not Implemented (7)

This is a clinical matter and as such the CF does not intend to delegate this responsibility to the OSI SA. However the creation of a Mental Health Director, who will work closely with the OSI SA will be overall responsible for this area.

Recommendation 28 In Annex A: Overview of the Original 31 Recommendations

The Canadian Forces take steps to improve support programs designed for families of members diagnosed with post-traumatic stress disorder, at all elements and locations.

Status: Not Implemented (10)

From a non clinical point of view, DND has continued to expand the OSISS Family Peer Support Network by hiring new staff, expanding the geographical disposition of staff, solidifying its partnership with VAC who this year announced and addition of $1M of funding to hire close to ten new Family Peer Support Coordinators and finally by launching a bereavement peer support network from coast to coast.

Recommendation 31 In Annex A: Overview of the Original 31 Recommendations

The Canadian Forces create the position of Post-Traumatic Stress Disorder Coordinator, reporting directly to the Chief of the Defence Staff, and responsible for coordinating issues related to post-traumatic stress disorder across the Canadian Forces.

Status: Not Implemented

While the report acknowledges that a series of decisive steps (section 39) have been undertaken over the last year and announced in May 2008, a full analysis of the intent of these various initiatives and how they complement each other to create a full spectrum of interventions would be required in the report. The report focuses much of its attention on the CF not appointing a PTSD Special Advisor who reports directly to the CDS.

From a CF point of view, the creation of a Mental Health Services Advisory Committee and the appointment of an OSI Special Advisor at the rank of Lieutenant-Colonel who reports directly to the CMP are deemed sufficient to achieve the overall coordination of issues relating to OSIs. While it is agreed that OSIs continue to need our full attention, appointing someone who reports directly to the CDS may be seen as an effective measure in the short term, when in fact it would bypass important staff procedures and the various chains of commands and stakeholders within the CMP chain of command. This approach may not address adequately the long term issues and it may not allow new processes and policies to become fully integrated CF wide.

The creation of the Mental Health Services Advisory Committee will look at services and programs from a DND and VAC perspective. By reporting directly to CMP and Senior VAC ADM, it will tackle systemic and strategic shortfalls by putting forth cogent recommendations that are sound. Most importantly, it will take into account transition issues following the release of a CF member and will provide, in the long term, a seamless hand over of case files to VAC.

On the other hand, the OSI Special Advisor will provide CMP with reliable advice in the realm of non-clinical issues relevant to the full recovery CF personnel. The OSI Special Advisor has also been tasked to take the lead in the development of a national education strategy to increase the mental health literacy within the Canadian Forces. Drawing on day to day experiences and lessons from cases managed on behalf of the CMP and the CDS, this national strategy will aim at reducing the OSI stigma, increase support for those who are affected by mental health, promote early intervention ultimately impacting treatment outcomes in a positive way. Work in this field started on 8 November 2007 with the creation/renewal of a National Mental Health & OSI Joint Speakers Bureau (JSB). The JSB is jointly managed between the office of the OSI Special Advisor and Rx 2000 Mental Health Training. An innovative approach to education was developed in cooperation on 1 May 2008 following it’s endorsement by the OSI Steering Committee held on 22 April 2008.

The OSI Special Advisor continues to build bridges and partnerships, both at home and abroad with organization such as our own Health Services organization, the Round Table on Mental Health and Addictions, the Canadian Mental Health Association and organizations such as the Combat Operational Stress Control group from the US Marine Corps. Working in this manner allows for the creation of innovative approaches to address the non-clinical needs of individuals suffering from mental health illness and Operational Stress Injuries by leveraging best practices from outside agencies. The CMP also accepted an invitation by the Mental Health Commission to appoint the OSI Special Advisor to the Mental Health Commission of Canada. While the OSI Special Advisor reports to CMP rather then CDS, this command relationship is deemed effective and there are no plans at this stage to create a National OSI Coordinator who reports directly to the CDS. It is however felt that the intent of the Ombudsman’s recommendation is achieved through these two distinct mechanisms and that no further action is required on this issue.

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Annex B to DS Letter to DG Operations, Office of the DND/CF Ombudsman
Dated October 2008 

Roles and Responsibilities

Position Title: Operational Stress Injury Special Advisor (OSI SA)

Specific Accountabilities

The OSI SA is directly accountable to CMP for:

1. Providing PA advice and coordinating public communications on OSIs. (Note 1)

2. Performing assigned duties in support of the OSI (Mental Health) Steering Committee.

The OSI SA is directly accountable to DCSA for: (Note 2)

3. In collaboration with DGHS and VAC, coordinating the drafting of an over-arching OSI Campaign Plan.

4. In collaboration with DGHS Occupational Health physicians, developing a non-clinical OSI disability management framework.

5. Liaising with internal and external organizations on non-clinical approaches to dealing with OSIs.

6. Proposing strategic concepts for non-clinical approaches to dealing with OSIs.

7. Identifying and proposing additional non-clinical mental health services, which could assist in addressing the needs of the wider military population affected by mental health issues.

8. Sponsoring research proposals in the field of non-clinical interventions for OSI disability management; establishing and maintaining a database of scientifically recognized research findings and effective practices. (Note 3) 

9. Initiating and maintaining partnerships with key stakeholders, agencies, civilian organizations and allies to ensure that the CF can contribute to and benefit from a wide body of lessons learned and demonstrably effective practices in all areas relating to OSIs.

10. Developing, implementing, and monitoring the effectiveness of an internal OSI-education program and related information activities.

11. Performing spokesperson role on non-clinical aspects of OSIs.

12. Managing the OSI Speakers Bureau.

13. Supporting CDA in the development of OSI training and education modules for all ranks.

14. Developing pre- and post-deployment OSI modules.

15. Drafting OSI materials for the deployment handbook under development by DQOL.

Notes:

The Surg Gen or designated rep remains the CF authority on all clinical aspects of member care, including incidence, prevalence, and severity of any MH disorder in the CF.Specialist assistance will be necessary to assess the scientific validity and generalizability of OSI and related research studies.

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