ARCHIVED - A Long Road to Recovery: Battling Operational Stress Injuries - Second Review of the Department of National Defence and Canadian Forces' Action on Operational Stress Injuries

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December 2008

Letter to the Minister

November 12, 2008

The Honourable Peter G. MacKay, P.C., Q.C., M.P.
Minister of National Defence
Major-General George R. Pearkes Building
13th Floor, North Tower
101 Colonel By Drive
Ottawa, Ontario K1A 0K2
 

Dear Minister MacKay:
 

Please find enclosed six copies of our special report entitled A Long Road to Recovery: Battling Operational Stress Injuries: Second Review of the Department of National Defence and Canadian Forces’ Action on Operational Stress Injuries. This report was previously submitted to you on September 2, 2008. This report is submitted to you pursuant to paragraph 38(1)(b) of the Ministerial Directives respecting the Office of the Ombudsman.
 

With the re-submission of this Report to you, we will be publishing the report no sooner than 28 days from the date of this letter. As in the past, we will advise your Office of the exact date that we intend to publish.
 

We look forward to receiving your response to our recommendations.
 

Yours truly,

Mary McFadyen
Interim Ombudsman

 

c.c.:Mr. Robert Fonberg, Deputy Minister
General Walter Natynczyk, Chief of the Defence Staff

 

Enclosures (6)

  

Introduction

…the data we have so far from these four- to six-month detailed screening follow-ups suggest that about 27% of people coming back [from Afghanistan] have some difficulties. The vast majority, about 16%, have hazardous drinking behaviour. So more than half of that 27% – 16% of the total deployed – show hazardous drinking behaviour. But an important number of people are struggling with more serious mental health issues, depression and post-traumatic stress disorder being the two most notable.

 Brigadier-General H.F. Jaeger, Surgeon General, Canadian Forces
Appearance before the Standing Committee on Public Accounts, January 31, 2008.
 

On February 5, 2002, the Ombudsman for National Defence and the Canadian Forces published his findings related to post-traumatic stress disorder (PTSD) in Canada’s military. In his special report, entitled Systemic Treatment of CF Members with PTSD, he concluded that post-traumatic stress disorder was a very serious problem for hundreds – if not thousands – of members of the Canadian Forces. He also found that the military’s approach to mental health injuries was inadequate and that the organization was not treating individual members who suffered from it appropriately.
 

When the Ombudsman released his report, he provided 31 recommendations to the Department of National Defence and the Canadian Forces aimed at helping them to identify and treat post-traumatic stress disorder in the military. These recommendations addressed a wide range of issues, including the need to: track, on a national basis, members affected by these serious injuries; establish awareness, education and training programs across the Canadian Forces; determine the most effective ways of helping members returning from deployment reintegrate into family life; accelerate efforts at standardizing treatment for affected members; deal with the stress and burnout amongst caregivers; improve support programs for the families of members diagnosed with post-traumatic stress disorder; and create a senior position, reporting to the Chief of the Defence Staff, and responsible for coordinating mental health initiatives across the Canadian Forces. The Ombudsman also made a commitment to assess the implementation of these recommendations with an investigation to conclude nine months after the release of this initial report.
 

In December 2002, the Ombudsman released a follow-up report, which indicated that a number of new programs had been put in place to deal with post-traumatic stress disorder and other operational stress injuries. The report also highlighted a significant increase in the level of awareness of these mental health injuries. Unfortunately, the Ombudsman also found that little progress had been made in the areas of outreach and training, the collection of data, and the overall level and effectiveness of leadership and coordination at the national level regarding post-traumatic stress disorder and other operational stress injuries. He also found that negative attitudes towards these injuries remained widespread and that the required change in culture was slow to non-existent. In releasing this report, the Ombudsman made a commitment to continue to monitor this issue.
 

This second follow-up report is intended track the progress made by the Department and the Canadian Forces in implementing the office’s previous recommendations related to post-traumatic stress disorder and other operational stress injuries. In some cases, where the organization did not implement a recommendation exactly as presented, Ombudsman investigators assessed the degree to which National Defence and the Canadian Forces have addressed the intent or spirit of that recommendation.
 

This follow up also highlights some new and evolving problems that have been uncovered by Ombudsman investigators during their review of the status of previous recommendations – most notably, the lack of services and support available to military families – and provides several recommendations for improvement.
 

As part of their second follow up, Ombudsman investigators conducted more than 360 individual interviews with current and former Canadian Forces members suffering from post-traumatic stress disorder or other operational stress injuries, as well as a number of military families, staff of Military Family Resource Centres, management and staff of Operational Trauma and Stress Support Centres, professional caregivers, all levels of the military chain of command, staff of key programs and groups such as ‘Return to Work’ coordinators, Service Personnel Holding List coordinators and the Directorate of Casualty Support and Administration. Investigators also met with staff at Veterans Affairs Canada and conducted an extensive review of all relevant documentation, policies, procedures and programs within Canada’s military.
 

As a result of this work, Ombudsman investigators found that the Department of National Defence and the Canadian Forces have made progress over the past six years in addressing many of the issues and challenges related to post-traumatic stress disorder and other operational stress injuries. The office was pleased to learn, for example, of the organization’s intention to hire an additional 218 mental health professionals by the end of March 2009. In general, the findings made by Ombudsman investigators during this second follow up confirm the Chief of the Defence Staff’s testimony in June 2008 at the Standing Committee on National Defence that the military  “healthcare system is meeting the vast majority of patient needs.” 
 

However, investigators also found evidence to substantiate the Chief of the Defence Staff’s assessment that the system is not perfect. Indeed, investigators found – and the office is aware of – a number of individual cases where military members and/or their families were not treated fairly by the Canadian Forces or, for a variety of reasons, did not get access to the care and treatment that they so desperately needed. The consequences for individuals who fall through the cracks are often devastating and long lasting. Although the Department and the Canadian Forces have made progress in identifying, preventing and treating post-traumatic stress disorder and other operational stress injuries within Canada’s Defence community, it is clear that more needs to be done.
 

Most notably, Ombudsman investigators found that 18 (out of 31) recommendations from 2002 – particularly those dealing with broader issues of leadership, governance, data collection and monitoring – have not been fully implemented to the satisfaction of the Ombudsman’s office. The office believes that this has hampered the overall coordination of efforts and consistency of care received by military members across the country suffering from post-traumatic stress disorder or other operational stress injuries. This must change.
 

At the same time, Ombudsman investigators found that the negative stigma associated with post-traumatic stress disorder and other operational stress injuries remains a real problem at a number of military establishments across the country. Indeed, mental health caregivers from every region in Canada raised this as one of the biggest challenges still facing the Canadian Forces. Although a number of training and education programs have been created to help bring about culture change associated with these serious mental health injuries, it is clear that more is required. It is also clear that stronger leadership at the local level is needed at certain military establishments.At the same time, Ombudsman investigators found that the negative stigma associated with post-traumatic stress disorder and other operational stress injuries remains a real problem at a number of military establishments across the country. Indeed, mental health caregivers from every region in Canada raised this as one of the biggest challenges still facing the Canadian Forces. Although a number of training and education programs have been created to help bring about culture change associated with these serious mental health injuries, it is clear that more is required. It is also clear that stronger leadership at the local level is needed at certain military establishments.
 

One of the 2002 recommendations addressed the inflexibility and delay in the bureaucratic processes by which a Canadian Forces member can move from one occupational group to another. It was evident in the original investigation that the Canadian Forces was losing dedicated, trained and operationally experienced members who were capable of continued service if allowed to transfer to another occupation. During this second follow up, Ombudsman investigators found that, although the Canadian Forces had accepted the original recommendation, no real progress has been made in making the process of occupational transfers less complicated and more responsive to the needs of members suffering from post-traumatic stress disorder or other occupational stress injuries.
 

A lack of resources (including an insufficient number of caregivers) and caregiver burnout were also major concerns for the Ombudsman in 2002. The anticipated addition of 218 mental health professionals by the end of March 2009 may finally begin to address these significant shortcomings.
 

In assessing the overall status of recommendations made in 2002, Ombudsman investigators also found new and evolving areas of concern. Clearly, the environment in which Canada’s military has been operating in recent years has changed dramatically. With the mission in Afghanistan, the level and intensity of combat operations have increased substantially. And, as noted by the Surgeon General in January 2008, a significant number of soldiers are returning from overseas deployments suffering with mental health issues. In addition, with the high operational tempo, the transformation initiative, the emphasis on recruitment and retention, and the introduction of a number of other priorities in recent years, it has also become evident that the Canadian Forces and Canadian Forces members are strained almost to the breaking point. Given these factors, the Ombudsman’s office believes that the need for a robust system focused on identifying, preventing and treating post-traumatic stress disorder and other operational stress injuries is even higher today than it was in 2002. Furthermore, knowing as we do that post-traumatic stress disorder and other operational stress injuries can, and often do, manifest over a number of years, the need to have a knowledgeable and supportive military culture in place will only grow over time.
 

It is also apparent now – in a way that was not necessarily evident in 2002 – that the challenges and difficulties associated with post-traumatic stress disorder and other operational stress injuries are not restricted to military personnel alone. Through their work, Ombudsman investigators found that family members of an individual who sustains a mental health injury on deployment also suffer with a variety of problems. They may suffer indirectly as a result of having to care for the military member. They may develop stress-related mental health problems themselves. Or the dynamics within families may be adversely affected. Family members may also suffer from the stress of having a Canadian Forces member on a dangerous deployment, whether or not that military member himself or herself suffers an operational stress injury. Regardless of the problem, the Ombudsman’s office believes that the Department and the Canadian Forces must do more to assist and support military families.
 

The overriding aim of this second follow-up report is to answer the basic question: Are Canadian Forces members who suffer from post-traumatic stress disorder or other operational stress injuries being diagnosed and getting the care and treatment they need so that they can continue to be contributing members of Canadian society – either within the Canadian Forces or as civilians? Unfortunately, the answer is that some members are not. In some cases, injured soldiers, sailors, airmen and airwomen who have served their country with courage and dedication are slipping through the cracks of an ad hoc system.
 

Given the very dangerous and demanding nature of the current mission in Afghanistan, it is clear that post-traumatic stress disorder and other operational stress injuries will become an even greater challenge for the Canadian Forces – and a real hardship for Canada’s soldiers, sailors, airmen and airwomen – for many years to come. In many respects, this will be a generational challenge for the Department, the Canadian Forces and the Government of Canada as a whole.

 

Table of Contents

 

Reviewing the Progress 

…the mission in Afghanistan may potentially have a significant long-term mental health impact, but the Canadian Forces strives to improve, and has improved, a robust program to deploy forces that are mentally ready, to support them well in-theatre, with mental health resources, and to maximize the early identification and treatment of
conditions that manifest after deployment.

Lieutenant-General Michel Gauthier, Commander Canadian Expeditionary Force Command
Standing Committee on National Defence, April 3, 2008
 

Attached at Annex A is a detailed summary of findings regarding the status of the recommendations made by the military Ombudsman in his 2002 special report, entitled Systemic Treatment of CF Members with PTSD. In this annex, Ombudsman investigators have assessed which recommendations have been implemented, which recommendations have been partially implemented and which recommendations have not been implemented at all – either in practice or intent. Overall, it is not an impressive record. Indeed, only 13 of the original 31 recommendations in the 2002 report have been fully implemented to the satisfaction of the Ombudsman’s office.
 

In general, Ombudsman investigators found that the Department of National Defence and the Canadian Forces have made important progress in identifying, preventing and treating post-traumatic stress disorder and other operational stress injuries. In recent years, a number of positive initiatives have been implemented by the Canadian Forces Health Services organization. Local mental health care initiatives have sprung up across the country. The Canadian Forces has improved its pre-deployment screening process and made a serious commitment to the Operational Stress Injury Social Support program. A decompression phase has been introduced for troops redeploying from Afghanistan. And the Department and the Canadian Forces have committed to hiring an additional 218 mental health professionals by the end of March 2009. All of these are positive initiatives.
 

However, there is still much work to be done. Given that the consequences for individuals who fall through the cracks are often devastating and long lasting, the Department and the Canadian Forces cannot accept that even one member of the Defence community may fall through the cracks. Sadly, and for a variety of reasons, this is happening today. Ombudsman investigators found – and the office is aware of – a number of individual cases where military members and/or their families did not get access to the care and treatment that they so desperately needed.
 

Following 360 interviews and a thorough review of all relevant policies, procedures and programs, Ombudsman investigators found a number of areas in the military’s approach to post-traumatic stress disorder and other operational stress injuries where confusion and discrepancy remains, and where progress is slow. For example, high-level direction and coordination is still sporadic. Efforts to standardize care and treatment across the Canadian Forces have been – and remain – inconsistent. The collection of national data and statistics is insufficient. Ombudsman investigators found no effective performance measures in place to evaluate local and regional approaches and programs. And, it is clear that a strong commitment from senior leadership regarding post-traumatic stress disorder and other operational stress injuries has not reached everyone.
 

Ombudsman investigators found that education and training efforts related to post-traumatic stress disorder and other operational stress injuries are improving. However, more needs to be done to address cultural problems that still exist at a number of Canadian Forces establishments. For example, not enough is being done at the local level to overcome the continued reluctance of injured members to come forward and seek assistance. Initiatives undertaken by the Operational Stress Injury Social Support program and the Canadian Defence Academy have led to noticeable improvements; however, a stronger, more determined effort by senior leadership at the local level is needed to end the negative myths and stereotypes and bring about a positive and lasting change in culture. Unfortunately, the office is aware that some local leaders still do not accept the fact that mental health injuries are real – and often devastating – injuries. This must change.
 

Ombudsman investigators were also unable to find any evidence of a coordinated, national approach to ensuring timely access to care and treatment for the families of military members suffering from post-traumatic stress disorder or other operational stress injuries. Indeed, the availability, quality and timeliness of care vary greatly from military establishment to military establishment. Where military establishments are located in or by large urban centres, there seems to be an adequate standard of care for military families. However, Ombudsman investigators found that military families living on or near more isolated military establishments often face tremendous difficulties in accessing the care and treatment that they may require to deal with the mental health injuries of their military loved ones.
 

In releasing this second follow-up report on the issue of post-traumatic stress disorder and other operational stress injuries, the office intends to highlight these issues, and many others, that need to be addressed. Dealing effectively with mental health injuries while, at the same time, creating an environment where members are comfortable in seeking care is essential in maintaining the operational capability of the Canadian Forces. More fundamentally, Canada’s men and women in uniform deserve to be treated with care and dignity for the service they have provided and the sacrifices they have made. To that end, the overriding aim of this second follow-up report is to answer the fundamental question:
 

Are Canadian Forces members who suffer from post-traumatic stress disorder or other operational stress injuries being diagnosed and getting the care and treatment they need so that they can continue to be contributing members of Canadian society – either within the Canadian Forces or as civilians?

  

Need for National Leadership and Coordination

The Ombudsman’s 2002 special report noted that there was no one person or agency responsible for managing or coordinating issues related to post-traumatic stress disorder or other operational stress injuries across the Department of National Defence and the Canadian Forces. In order to bring national leadership and direction to the problem, the report called for the creation of a “PTSD coordinator reporting directly to the CDS and responsible for coordinating issues related to PTSD across the Canadian Forces.”     
  

In response, the Department and the Canadian Forces indicated that the Assistant Deputy Minister – Human Resources Military (now the Chief of Military Personnel) was, de facto, the national coordinator for the issue of post-traumatic stress disorder and other operational stress injuries. In addition, an Operational Stress Injuries Steering Committee was created in May 2002, consisting of representatives of each major group in the Department and the Canadian Forces. The committee had the mandate to increase awareness and acceptance of these serious mental health injuries across the organization and to harmonize military policies and procedures to support these initiatives.
 

Following the release of the Ombudsman’s 2002 report, the Chief of the Defence Staff also appointed two Special Advisors on the issue of operational stress injuries. The Director of Training Education and Policy and the Canadian Forces Chief Warrant Officer were originally appointed to these positions and terms of reference were issued in July 2002. Although given the responsibility to “take the lead in representing the Chief of the Defence Staff's interests in implemening solutions, working closely with the Committee and Environmental Chiefs of Staff,” the terms of reference specified that the positions were a “secondary duty” with access to the Chief of the Defence Staff on a regular basis but reporting to the Assistant Deputy Minister – Human Resources Military. It should be noted that both Special Advisors had extremely demanding primary duties.
 

During their investigation, Ombudsman investigators specifically looked for indications that these initiatives were having an effect. For example, they asked three senior members of one Service Personnel Holding List1 office if any of them had ever heard of the Operational Stress Injury Steering Committee or of the Special Advisors. They were unanimous in answering that they had never heard of these initiatives. At another military establishment, the senior officer responsible for overseeing the Service Personnel Holding List stated that she had no knowledge of the Steering Committee or Special Advisors. She also claimed that when she needed information on the issue of post-traumatic stress disorder or other operational stress injuries, she turned to local authorities. This seemed to be common across the country.Service Personnel Holding List Coordinators are routinely involved in assisting operational stress injury sufferers. That many of them are unaware of the Operational Stress Injury Steering Committee or of the Special Advisors is of concern.
 

Ombudsman investigators found that the Operational Stress Injuries Steering Committee, which was stood up in July 2002, quickly lost momentum and direction. Although the committee was supposed to meet twice a year, meetings were sporadic at best, and the level (i.e., rank) and authority of those attending dropped off dramatically at each successive meeting.
 

At the same time, the Special Advisors informed Ombudsman investigators that they were rarely contacted for information or advice from military establishments outside of Ottawa. Investigators were also unable to find any indication that the Special Advisors had influenced or assisted in the development of training and/or education on the issue of post-traumatic stress disorder or other operational stress injuries in any concrete way. The Special Advisors were unable to provide documentation demonstrating an attempt to measure the amount of training that is occurring, to identify any gaps or inconsistencies or to improve coordination. Personnel who were directly involved in the development of education and training material reported that they were unaware of the Special Advisor positions. This should not be construed as an adverse comment against the Special Advisors, both of whom seemed dedicated to improving awareness of post-traumatic stress disorder and other operational stress injuries. Ombudsman investigators found that they were simply unable to carry out such a large and important task while, at the same time, having to fulfill their primary responsibilities. These duties have now fallen to a Special Assistant to the Chief of Military Personnel at the Canadian Forces Mental Health Support Coordinator.

 


 1. The Service Personnel Holding List (SPHL) is an administrative tool to help support a Regular Force member who has become medically unfit - that is, with significant employment limitations - for six months or more. The intent of the SPHL is to provide the injured member with the best opportunity to recover in order to permit a return to normal duties, or the best opportunity to adequately prepare for a compulsory reassignment or release. The list also allows the unit to backfill the member’s position until he/she is released, returns to duty or is transferred.

 

The first step in addressing any significant challenge or problem is a clear and determined commitment to do so from the senior leadership of an organization. The original intent of the Ombudsman’s 2002 recommendation to create a “PTSD coordinator” was to put in place a senior military officer who could, on behalf and at the direction of the Chief of the Defence Staff, ensure national leadership and coordination of the Canadian Forces’ approach to post-traumatic stress disorder and other operational stress injuries. Overall, Ombudsman investigators found the measures taken in this regard have been inadequate.
 

It is clear that significant culture change takes time in a large organization like the Canadian Forces. However, without strong and committed leadership, culture change is much more difficult to bring about and takes even longer. In the case of mental health injuries, lukewarm leadership has real – and sometimes devastating – consequences for those affected. The Canadian Forces is fortunate to have dedicated mental health professionals at military establishments across Canada delivering support and doing as much as they possibly can to help military members suffering from post-traumatic stress disorder and other operational stress injuries. Certainly, this demanding mission has not been made any easier by an overall lack of leadership and coordination at the national level.
 

In a May 2008 Canadian Forces General Message (CANFORGEN 093/08), the Canadian Forces announced that it is now taking “decisive steps” to support Canadian Forces Mental Health Services. One of these steps is the re-establishment of the Operational Stress Injuries Steering Committee. Funding is also being increased to the Operational Stress Injury Social Support program. Finally, a Special Advisor to the Chief of Military Personnel will oversee the management of non-clinical matters related to operational stress injuries, including the creation of an education campaign to raise awareness and understanding of these mental health injuries.
 

It has yet to be seen whether these initiatives will be any more effective than the ones announced after the Ombudsman’s first report on post-traumatic stress disorder. However, it should be noted that the Department and the Canadian Forces continue to refuse to appoint a senior officer of significant rank (and reporting directly to the Chief of the Defence Staff) whose sole, primary duty would be to act as national coordinator – and effective oversight – for issues related to post-traumatic stress disorder and other operational stress injuries. This position currently rests with the Chief of Military Personnel as one of his many duties and responsibilities.
 

Given the ineffectiveness of previous piecemeal oversight initiatives, the Chief of the Defence Staff should appoint a senior officer whose primary duty and responsibility is to provide national leadership and coordination of all issues related to post-traumatic stress disorder and other operational stress injuries. Moreover, given the expected importance of this issue across the Canadian Forces for decades to come, this individual must have the requisite authority to contribute to, or intervene at, any level, and should report directly to the Chief of the Defence Staff.

 

Table of Contents

 

Need for Statistical Information

In the 2002 special report on post-traumatic stress disorder, the Ombudsman found that there was “no centralized Canadian Forces-wide process to collect up-to-date statistics on the number of current and former Canadian Forces members who have been diagnosed with post-traumatic stress disorder or other stress-related injuries.”     
 

A national database is critical in understanding the extent of the problem, including the number of Canadian Forces personnel affected by mental health injuries. With a national database, the Canadian Forces would be much better able to evaluate the impact of various clinical interventions and provide guidance to improve the numbers of treatment successes. In addition, national data could be used to target education and training initiatives where they are most needed and could be most effective.
 

Although a national database has not yet been established, Ombudsman investigators have learned that the Canadian Forces Health Services group is planning a fully automated medical record keeping system. Once up and running, the system would provide the capability to track those Canadian Forces members who have been diagnosed with post-traumatic stress disorder or another operational stress injury. Ombudsman investigators were assured that every effort was being made to move this system forward as quickly as possible, and that it should be operational in 2008. However, according to an October 2007 report from the Auditor General of Canada on military health care, the electronic system has been delayed and will not be completed before the end of 2011. This is unfortunate.
 

In order to put in place a more coordinated and holistic approach to post-traumatic stress disorder and other operational stress injuries, health care providers in the Department and the Canadian Forces must have the tools available to properly understand the extent and seriousness of the problem. Without these tools, it is more difficult to design and implement effective programs across the country while ensuring that scarce resources are allocated properly.
 

Given that nearly a decade will have passed before this recommendation is (potentially) finally implemented, one is again left to question the lukewarm leadership and commitment at the national level to addressing post-traumatic stress disorder and other operational stress injuries.

 

Updated Data Required

The Department and the Canadian Forces should also conduct an independent and confidential mental health survey that includes current and former members of the Regular Force and Reserves in order to gauge the success of existing programs and determine where more, or different types of, services are required.
 

A mental health survey was undertaken by Statistics Canada in 2002 as part of the Canadian Community Health Survey and the results were released in September 2003. In 2004, the Canadian Forces conducted a Health and Lifestyle survey concerning their level of satisfaction with the health care services that members were receiving. However, it is clear that more (and more up-to-date) information is needed regarding mental health services.

 

Unequal Treatment Across Canada

Given an overall lack of national leadership, coordination, statistics and data, it is not surprising that Ombudsman investigators found that the quality of mental health care available to Canadian Forces members is inconsistent across the country. At some military establishments, investigators found robust programs in place and few problems. At other places, it was clear that individuals were not getting the care and treatment they needed. In nearly every instance, investigators determined that the quality of mental health care depended on the location of the military establishment and the number and types of health care professionals on hand for diagnoses and treatment.
 

For example, although Canadian Forces Base (CFB) Petawawa has been the home base for many of the recent deployments to Afghanistan, Ombudsman investigators found that Canadian Forces members were having difficulty accessing timely mental health care services. Indeed, according to figures provided by the Base Surgeon at CFB Petawawa, it has significantly fewer resources to treat mental health injuries than other bases of comparable size that are closer to large populated areas. For example:

 

BaseMilitary PersonnelPsychologistsPsychiatrists
Petawawa 5,100 1.1 0.8
Valcartier 4,500 8.5 4.0
Edmonton 6,600 5.0 3.0

 

Given the lack of mental health services at CFB Petawawa, many in that military community are forced to travel more than 160 kilometres to Ottawa, the closest metropolitan centre, for help. In February 2008, the Canadian Forces Surgeon General recognized at the Standing Committee on National Defence that the military was experiencing a “serious challenge” in attracting mental health care providers to CFB Petawawa. However, after more than six years since the original report on post-traumatic stress disorder was published, the Ombudsman’s office is only now beginning to see a national effort to dealing with this problem and other localized problems across the country.
 

In the course of their work, Ombudsman investigators did observe a number of local initiatives that had been undertaken to address concerns about the availability of mental health services on base. For example, at the Maritime Forces Pacific Formation Health Services, the issue of access to treatment for those reluctant to attend the local Operational Trauma and Stress Support Centre has been partly addressed by authorizing one of their civilian staff doctors to see patients at a clinic away from the base. This positive solution ensures that treatment is still under the Canadian Forces umbrella but also allows individuals who are reluctant to seek treatment the opportunity to get the assistance they need.
 

Veterans Affairs Canada is also developing an initiative aimed at providing Canadian Forces members with care and treatment away from their military bases. Five operational stress injury clinics have been opened by Veterans Affairs Canada (at Ste-Anne de Bellevue in Montreal, Quebec, the Paul Priquet Centre in Ste-Foy, Quebec, the Parkwood Centre in London, Ontario, the Deer Lodge Centre in Winnipeg, Manitoba, and a clinic in Calgary, Alberta) to provide out-patient care to members and former members suffering from an operational stress injury. Another clinic is also being established in Fredericton, New Brunswick.
 

Although critically important, these local initiatives do not ensure fair and consistent treatment across the country for military members suffering from post-traumatic stress disorder or other operational stress injuries. For example, Ombudsman investigators found that a number of Canadian Forces members with mental health injuries lost contact with their home units after being placed on the Service Personnel Holding List. This is contrary to direction from the Chief of the Defence Staff (in 2003), and the resulting sense of abandonment has had a negative impact on the soldiers, sailors, airmen and airwomen suffering from post-traumatic stress disorder or other operational stress injuries.
 

Overall, a lack of national leadership and coordination and insufficient health care providers at certain military establishments across Canada has had – and is continuing to have – a real and negative impact on those suffering from post-traumatic stress disorder or other operational stress injuries. It has also helped to create unequal care and treatment from military establishment to military establishment.
 

The Need for More Resources

During their investigation, Ombudsman investigators found that the Department of National Defence and the Canadian Forces were having difficulty in implementing (fully or even partially) a number of original recommendations as a result of resource constraints, most notably insufficient numbers of mental health care providers. The Canadian Forces spends approximately $500 million a year on health care for military members. From 2004-2009, the military will have invested nearly $100 million specifically in the area of mental health care. However, the Canadian Forces has simply not had enough mental health care providers in recent years to ensure proper care and treatment for all military members suffering from post-traumatic stress disorder or other operational stress injuries.
 

Nationally, funding for Operational Trauma and Stress Support Centres, as well as mental health training and education, has increased over the past few years. However, in many cases, it has been extremely difficult or impossible to find sufficient numbers of qualified people to provide these services. Although Canadian society as a whole is suffering from a shortage of mental health care providers, the problem is exacerbated for the Canadian Forces as many military communities are located in smaller centres and the operational tempo continues to be extremely demanding. Given the current strain that they are under, operational units are unable to retain individuals who are not fully deployable, including those suffering from operational stress injuries. Medical units across the country report being understaffed for the level of activity they have to support. And Military Family Resource Centres told investigators that they lack the resources required to provide the full range of services to everyone that needs their help.
 

A significant shortage of qualified mental health care providers at military establishments across the country has contributed to inconsistent and incomplete care and treatment for the men and women of the Canadian Forces. The Ombudsman’s office was, therefore, pleased to learn of the military’s intention to hire an additional 218 mental health professionals by the end of March 2009. This should help fill some of the serious gaps that exist in the current military mental health care system. The addition of mental health care providers also serves to underscore the need for a national coordinator who would ensure that new resources would be allocated to those areas where they are needed the most.

 

Table of Contents

 

Culture Change Still Needed

After completing the original 2002 investigation, the Ombudsman found that military members who were diagnosed with post-traumatic stress disorder were often stigmatized as being fakers, malingerers or as being weak and incapable. This was due, in very large part, to ignorance and a fundamental misunderstanding of the nature and severity of the injury. At the same time, the stigma associated with mental health injuries did not exist to the same degree with physical injuries, particularly obvious physical injuries. The consequence of this distinction was usually a different type of treatment and administration for those Canadian Forces members with mental health, as opposed to physical, injuries.
 

As a result of this widespread stigma, military members suffering from post-traumatic stress disorder or other operational stress injuries were often reluctant to seek help. Moreover, when Canadian Forces members were diagnosed with these mental health injuries, they frequently felt shunned and sidelined. As well, military families had little, if any, support available to help them understand and cope with these injuries. All of this had an extremely negative impact on the prospects for successful treatment and recovery.
 

The Ombudsman’s 2002 report contained a number of recommendations aimed at addressing this harmful stigma by changing the culture and mentality in the Canadian Forces related to post-traumatic stress disorder and other operational stress injuries. In fact, nearly one quarter of the original 31 recommendations touched on the need to develop and sustain a more supportive military culture through significantly improved awareness, education and training initiatives.
 

Unfortunately, during the course of this second follow up, Ombudsman investigators found that the stigma associated with post-traumatic stress disorder and other operational stress injuries still exists throughout the Canadian Forces. Indeed, mental health care providers from virtually every military establishment across the country informed investigators that there is still a “stigma attached with coming forward for assistance.” It was also clear that the severity of the stigma differed at each military establishment depending on the commitment of the local leadership and the quality of programs in place.
 

Ombudsman investigators also found that many of the education and training initiatives resulting from the Ombudsman’s previous recommendations have not progressed very quickly, and some even appear to have stalled altogether. Investigators visited almost every military establishment in Canada, specifically targeting 19 air, land and naval units. With the exception of mandated training by Land Forces Western Area, they were unable to find any evidence of direction (or even guidance) being issued to units by their chain of command to carry out training related to post-traumatic stress disorder or other operational stress injuries, nor were they able to find any evidence that actual training was taking place at regular intervals.
 

Although the Department of National Defence and the Canadian Forces have issued policies aimed at changing, through education and training, a harmful culture that stigmatizes post-traumatic stress disorder and other operational stress injuries, they are not making their way down to the unit level with any consistency or in any type of coordinated fashion. Indeed, it was evident that most field units were still not requesting any type of education or training. Investigators were also unable to locate any performance measures designed to assess the effectiveness of unit training that was in place in some locations.
 

National leadership, coordination and direction are required in the areas of awareness, education and training in order to effect lasting culture change in the Canadian Forces. Unfortunately, there is no comprehensive and integrated regime currently in place, nor is there any way to measure the effectiveness of the ad hoc programs operating across the country. This means that the harmful stigma associated with post-traumatic stress disorder and other operational stress injuries will very likely continue in the Canadian Forces well into the future, with the severity of the stigma – and the accompanying consequences – continuing to differ from military establishment to military establishment.

 

 I just want to work” – The Need to Reduce Bureaucracy

In his 2002 report, the Ombudsman made a recommendation to address the lengthy and inflexible bureaucratic processes by which a Canadian Forces member – including one suffering from post-traumatic stress disorder or another operational stress injury – could move from one military occupation to another. It was evident during the original investigation that the Canadian Forces was losing dedicated, trained and operationally experienced military members who were capable of continued service if only they were allowed to transfer to another occupation.
 

The military responded to this recommendation by undertaking an examination focused on how occupational transfer regulations and procedures could be implemented in a more expeditious manner. The study was to be completed by June 30, 2002. However, there has been no change in the actual process, despite the fact that senior leadership recognized the need to significantly improve the occupational transfer process and directed, in 2003, the then Assistant Deputy Minister – Human Resources Military (now Chief of Military Personnel) to build flexibility into the process. The Operational Stress Injuries Steering Committee also reviewed this issue; however, no progress was made.
 

The occupational transfer process is a lengthy, bureaucratic and inflexible system. Very often a person suffering from post-traumatic stress disorder or another operational stress injury may still be capable of making a positive contribution to the Canadian Forces in another job. But the complexity of the occupational transfer process results in many of these members being released from the military. Where an individual can still contribute to the Canadian Forces in some capacity, and wishes to remain, this opportunity should be facilitated.
 

One of the main shortcomings in the occupational transfer process for Canadian Forces members suffering from post-traumatic stress disorder or other operational stress injuries is that, in order to be granted a transfer, they must be fit in their original occupation prior to being allowed to transfer to a new one. For many sufferers, going back into the occupation where their mental health injury occurred could inflame their trauma. As a result, they are often considered medically unfit for that occupation and, therefore, cannot be granted a transfer to another, even though they may be fit in all other ways to continue their career in the Canadian Forces.
 

Neither the Canadian Forces Accommodation Policy nor the Service Personnel Holding List procedures allow a member diagnosed with post-traumatic stress disorder or another operational stress injury to continue his or her career. Instead, when members are “accommodated” under the Accommodation Policy, their careers can be prolonged for up to a maximum of three years, while those placed on the Service Personnel Holding List can be extended up to a maximum of two years. Nevertheless, the end result for these members – many of whom desperately want to stay in the military – is a release from the Canadian Forces.
 

It is the understanding of the Ombudsman’s office that the Canadian Forces is currently reviewing the Accommodation Policy, with the intention of allowing for seriously (physically) wounded soldiers, sailors, airmen and airwomen to continue their military careers. Any changes to this effect must also include fair and consistent treatment for members suffering from post-traumatic stress disorder and other operational stress injuries.
 

During this second follow up, a number of mental health professionals, administrators, Service Personnel Holding List coordinators and representatives of the chain of command also advised Ombudsman investigators that the time it takes to process the paperwork and receive a decision regarding an occupational transfer is just too long. For example, the Ombudsman’s office received a complaint from a Canadian Forces member who was on the verge of being released from the military, even though he was deployable in his occupation, because the paperwork that re-established his medical category had not been processed expeditiously through the system. Fortunately, as a result of an intervention by the Ombudsman’s office, the release was cancelled. However, it is unknown if others have been lost in similar bureaucratic circumstances.
 

The overly complex and bureaucratic processes surrounding occupational transfers continue to exact a real human cost through the loss of valuable personnel who have a strong desire for, and are capable of, continued service to their country. In the six years since the original recommendation was made to improve the occupational transfer process, the Canadian Forces is no further ahead on this issue. This is unfortunate and must be addressed immediately.

 

The Need to Help Military Families

One of the original recommendations in the 2002 special report called on the Canadian Forces to “take steps to improve support programs designed for the families of members diagnosed with PTSD, at all elements and locations.” During the course of this follow-up investigation, Ombudsman investigators found that the treatment of military families, including the services and support available to them, was an area of major concern for Canadian Forces members, including those suffering from post-traumatic stress disorder and other operational stress injuries. Indeed, most felt very strongly that the Canadian Forces has a responsibility to assist the families of those military members suffering from mental health injuries as a result of their service to Canada. For their part, family members were clear and nearly unanimous in pointing out that, when a Canadian Forces member has post-traumatic stress disorder or another operational stress injury, it is a significant challenge for the whole family, often requiring support and assistance from and for each family member.
 

Families require education about the nature of mental health injuries, and assistance in understanding the challenges that someone with this type of serious injury is facing. It is also clear that post-traumatic stress disorder and other operational stress injuries can affect families and family members differently than physical injuries. Families often require information about how to deal with the new and often disturbing behaviour of the person suffering from a mental health injury, and assistance in re-establishing family relationships given this new reality. At times, they may also require individual therapy to assist them in working through their emotional reaction to the sufferer of the mental health injury. They often feel anger at the situation and/or the family member with the mental health injury, grief at the loss of the person they once knew, fear for the future of the sufferer and the family as a whole, or despair at their inability to cope. As a result, a number of family members described the need for anger management courses for their children, couples counseling and caregiver support. Unfortunately, family members often did not know how to access these services.
 

Directors and staff at Military Family Resource Centres across the country spoke to investigators about the tremendous need to support the families of Canadian Forces members with post-traumatic stress disorder or other operational stress injuries. Indeed, a number of centres have dedicated resources to provide short-term interventions and referral for families in crisis as a result of a member’s mental health injury. However, many staff members called for a more integrated approach, or as one individual put it,  “a structured, funded family therapy group.”   
  

Although the Department and the Canadian Forces do not have a legal responsibility to provide health care to family members, there are two compelling reasons for them to ensure that military families have access to timely and appropriate services and support. First, as the mental health injuries are often the result of military service required by Canada and the Canadian Forces, and the direct cause of family stress and dysfunction, the organization has a moral responsibility to ensure that care and treatment is provided. A second, more practical, reason for the Department and the Canadian Forces to ensure that military families are looked after is that this reduces the stress on the mental health injury sufferer and can speed up recovery time.
 

There are also situations where families of Canadian Forces members, who do not have mental health injuries, are deeply affected by stress and anxiety while the member is preparing to deploy to Afghanistan, is on deployment, or is returning from the mission. Even in these circumstances, it makes practical sense for the Department and the Canadian Forces to ensure that the family has the appropriate care and support. If a Canadian Forces member is confident that his or her family is receiving the assistance they need, that member will be better able to focus on the military mission.
 

During this second follow up, Ombudsman investigators found a number of quality programs offered by provincial and municipal governments, local Military Family Resource Centres and local base chaplains to support military families, and individual family members, across the country. In addition, several Operational Stress Injury Social Support program locations now have family peer support coordinators (e.g., Victoria, Edmonton, Shilo, Winnipeg, Hamilton, Trenton, Petawawa, Montreal, Quebec City, Gagetown and Halifax). These programs provide invaluable assistance and support to hundreds of military families every year.
 

However, investigators did not find any evidence of a coordinated, national approach to ensuring that military families are able to access, in a timely manner, the mental health care and support that they may need. Unfortunately, as with military members themselves, the quality and timeliness of mental health care available to family members varies greatly from military establishment to military establishment. Where bases are located in or by large urban centers (e.g., Edmonton and Valcartier), there is generally an appropriate level of care available to family members. However, not all military establishments are located near large urban areas, and when a Canadian Forces member is posted to one of the more isolated bases, his or her family often finds it extremely difficult to access the type of care and support they need in the surrounding community.
 

Given the sacrifices that military families make for their loved ones and their country, the Government of Canada and the Canadian Forces have a moral responsibility to ensure that they have access to appropriate mental health care in order to deal with a military loved one suffering from post-traumatic stress disorder or another operational stress injury, or the stress associated with the deployment of their loved one to Afghanistan or other combat zones throughout the world. At a human level, it is unacceptable to focus on jurisdictional or legal obstacles (i.e., federal/provincial responsibilities vis-à-vis health care) as an argument for ignoring the mental health needs of military spouses and children at some military establishments.

 

Caregiver Issues

In his 2002 report, the Ombudsman recommended that the Canadian Forces “take steps to deal with the issues of stress and burnout created by lack of resources and high caseloads among Canadian Forces caregivers.” As part of this second follow up, Ombudsman investigators found that some progress has been made in this regard but that much more needs to be done.
 

Caregivers – chaplains, social workers, physicians, psychologists, psychiatrists, and mental health nurses – are invaluable members of the Defence community, particularly in the battle against post-traumatic stress disorder and other operational stress injuries. Unfortunately, there simply has not been enough of them hired since 2002 to ensure an effective and consistent mental health care program across the Canadian Forces. At the same time, this shortage of caregivers, coupled with an increasing demand for their services, has led to even greater instances of stress and burnout in the caregiver community, as well as increasing challenges associated with the hiring and retention of mental health specialists.
 

Caregivers, particularly case managers, indicated to Ombudsman investigators that their caseloads are daunting. The majority of caregivers interviewed stated that stress and burnout was a pressing concern, to the point that it was leading some to quit the military and the Defence community. During one interview, a mental health professional commented that, “...as a group, we worry about ourselves.” Similar sentiments were voiced by many, with some actually identifying by name the co-workers about whom they were most concerned: “[She] is feeling the heat - her voice sounds beat.” One Canadian Forces chaplain described the situation as, “...you have nothing to give but everybody asks for something.”    
 

For their part, military mental health injury sufferers were nearly unanimous in telling Ombudsman investigators that there was an insufficient number of caregivers to provide the level of assistance and support that was required by those suffering from post-traumatic stress disorder or other operational stress injuries.
 

Given the current shortage of mental health care professionals in the Defence community, and with the instances of mental health injuries on the rise as a result of the mission in Afghanistan, the Ombudsman’ office was pleased to learn of the intention of the Department and the Canadian Forces to hire an additional 218 mental health professionals by the end of March 2009. It should be noted, however, that the Canadian Forces are one of many employers across the country vying for health care professionals and it may be difficult to fulfill this commitment. This makes it even more essential for the military to retain the mental health care professionals already working in the Defence community.
 

In order to recruit and retain sufficient numbers of mental health care professionals, the Department and the Canadian Forces must ensure that an appropriate level of funding is available across the country for the identification, prevention and treatment of post-traumatic stress disorder and other operational stress injuries. The military must also monitor and assess the requirement for additional mental health care professionals should the challenge associated with mental health injuries continue to grow. Finally, the Canadian Forces should consider developing and implementing a national program or initiative aimed specifically at assisting and preventing stress and burnout among the mental health care community.
 

Table of Contents

 

The Way Forward

The overriding aim of this second follow up on post-traumatic stress disorder and other operational stress injuries is to answer the following basic question: 
 

Are Canadian Forces members who suffer from post-traumatic stress disorder or other operational stress injuries being diagnosed and getting the care and treatment they need so that they can continue to be contributing members of Canadian society – either within the Canadian Forces or as civilians?

 

Unfortunately, the answer is that some are not. Ombudsman investigators found cases of Canadian Forces members who have slipped through the cracks of an ad hoc system after having served their country with courage and dedication.
 

It is clear that the Department of National Defence and the Canadian Forces have made progress over the past six years in addressing many of the issues and challenges related to mental health injuries. It is also clear, however, that access to quality care for a military member suffering from a mental health injury still depends on a number of arbitrary factors, including: where the member lives; the distance of the member’s base from the nearest large city; the availability of mental health care professionals; and the attitude of the member’s superiors and peers. These factors should not affect the standard of care that Canada’s soldiers, sailors, airmen and airwomen receive when they are suffering from post-traumatic stress disorder or other operational stress injuries. Regardless of where they are located, what their duties are, or who they work and train with, all Canadian Forces members are entitled to quality, consistent and timely care when they are injured.
 

Some of the individual problems found by Ombudsman investigators likely could have been prevented – or, potentially, alleviated in the future – with the full implementation of the Ombudsman’s original recommendations. As a result of their work, investigators found that a number of important recommendations from 2002 – particularly those dealing with broader issues of leadership, governance, data collection and monitoring – have not been implemented, either in practice or intent. This has hampered the overall coordination of efforts and consistency of care received by military members across the country suffering from post-traumatic stress disorder or other operational stress injuries.
 

At the same time, in assessing the overall status of recommendations made in 2002, Ombudsman investigators found new and evolving areas of concern. The environment in which Canada’s military has been operating in recent years has changed dramatically. With the mission in Afghanistan, the level and intensity of combat operations have increased substantially. And, as noted by the Surgeon General, a large number of soldiers are returning from overseas deployments suffering from mental health injuries. In addition, with the high operational tempo, the transformation initiative, the emphasis on recruitment and retention, and the introduction of a number of other priorities in recent years, it has become evident that the Canadian Forces and Canadian Forces members are strained almost to the breaking point. Given these factors, the need for a robust system focused on identifying, preventing and treating post-traumatic stress disorder and other operational stress injuries is even higher today than it was in 2002. Furthermore, knowing as we do that post-traumatic stress disorder can, and often does, manifest over a number of years, the need to have a knowledgeable and supportive military culture in place across the country will only grow over time.
 

Given these new and evolving realities, this second follow-up report also focuses on three issues that Ombudsman investigators consider to be critical in ensuring quality and timely care for military members suffering from post-traumatic stress disorder or other operational stress injuries, specifically: 
 

  1. National governance and leadership;
     
  2. The treatment of military families; and
     
  3. Emerging caregiver issues.
     

These issues form the basis of the office’s recommendations in this second follow up, as well as its future monitoring activity.

 

Table of Contents

 

National Governance and Leadership

As a result of this second follow-up investigation, the Ombudsman’s office believes that the Department of National Defence and the Canadian Forces need to strengthen national governance related to the identification, prevention and treatment of post-traumatic stress disorder and other operational stress injuries in order to ensure that military members suffering from these serious injuries do not slip through the cracks.
 

In the original 2002 report, the Ombudsman recommended that a position of Post-Traumatic Stress Disorder Coordinator be created, reporting directly to the Chief of the Defence Staff, with the responsibility for coordinating all issues related to post-traumatic stress disorder across the Canadian Forces. This was not done. And all informal attempts to name someone responsible for the issue (i.e., as a “secondary duty”) within the Canadian Forces have not accomplished the intended results.
 

There remains a real and pressing need within the Canadian Forces to create a high-ranking position of national coordinator for mental health injuries, reporting directly to the Chief of the Defence Staff, and whose primary responsibility is to coordinate, at the national level, the Canadian Forces’ response to post-traumatic stress disorder and other operational stress injuries. This senior position will also help ensure that mental health injuries are an ongoing priority at the highest levels, and that all matters associated with these injuries are fully considered when allocating resources within Canada’s military. Finally, this position would have an important practical and symbolic role to play in helping to bring about culture change across the country. This change is desperately needed in the Canadian Forces in order to finally attack and defeat the stigma associated with mental health injuries, as well as to ensure more widespread acceptance at all military establishments that these injuries are both legitimate and serious.
 

In addition to the creation of a national coordinator position, a more concentrated effort at the national level must be made to coordinate the multitude of initiatives now in place to deal with post-traumatic stress disorder and other operational stress injuries. Current training and education programs regarding these injuries need to be strengthened considerably and made more consistent across the country. Indeed, these programs should be targeted at all levels of the Canadian Forces – from recruit and specialist training to all promotion-oriented education and training. A national coordinator could lead the design, development and implementation of a new standardized national education and training program taking into account the latest data, statistics and analysis regarding the new and evolving environment facing the Canadian Forces.
 

In going forward, it is recommended that:
 

  • 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.
     

In going forward, there also continues to be a significant need for the creation of a national database that can accurately reflect the number of Canadian Forces personnel affected by post-traumatic stress disorder and other operational stress injuries. Such a database would allow the Canadian Forces and, in particular, a National Operational Stress Injury Coordinator to assess the situation as it stands today, and gauge what changes are required to strengthen the ad hoc regime now in place for the identification, prevention and treatment of mental health injuries. The Ombudsman’s office stands by the first recommendation in the 2002 report that:
 

  • 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.
     

In addition to a national database, there is also a real and pressing need for updated national statistics related to post-traumatic stress disorder and other operational stress injuries. The third recommendation in the Ombudsman’s original report called for an independent and impartial mental health survey to be conducted. This was done in 2002. Given that six years have now passed, and the Canadian Forces finds itself in a new and constantly evolving operational environment, it is time to update these statistics. Therefore, it is recommended that:
 

  • 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.
     

It is the understanding of the Ombudsman’s office that the Canadian Forces is currently reviewing the Accommodation Policy, with the intention of allowing for seriously (physically) wounded soldiers, sailors, airmen and airwomen to continue their military careers. Any changes to this effect must also include fair and consistent treatment for members suffering from post-traumatic stress disorder and other operational stress injuries. Therefore, it is recommended that:
 

  • Any changes – formal or informal – to the Accommodation Policy (or the approach taken by the Canadian Forces to wounded members who want to continue their military careers) be applied equitably to Canadian Forces members with both mental health and physical injuries.
     

In his 2002 report, the Ombudsman made a recommendation to address the lengthy and inflexible bureaucratic processes by which a Canadian Forces member – including one suffering from post-traumatic stress disorder or another operational stress injury – could move from one military occupation to another. It was evident during the original investigation that the Canadian Forces was losing dedicated, trained and operationally experienced military members who were capable of continued service if only they were allowed to transfer to another occupation. Unfortunately, this remains a significant problem. Therefore, it is recommended that:
 

  • The rules regarding occupational transfer be changed to accommodate, in an efficient manner, members diagnosed with post-traumatic stress disorder or other operational stress injuries who could continue their military service if they transferred to another military occupation.
     

The overly complex and bureaucratic processes surrounding occupational transfers continue to exact a real human cost through the loss of valuable personnel who have a strong desire for, and are capable of, continued service to their country. This must change.
 

Family Issues

During this second follow up, a large number of Canadian Forces members expressed legitimate concerns regarding the quality and timeliness of mental health care available to their families across the country. The Ombudsman’s office acknowledges that health care services for military families falls under the jurisdictional responsibility of the province in which the families live and is not the direct responsibility of the Canadian Forces. However, the Government of Canada and the Canadian Forces have a moral responsibility to ensure that military families have access to appropriate mental health services and support in order to deal with a military loved one suffering from post-traumatic stress disorder or another operational stress injury, or the stress associated with the deployment of their loved ones to Afghanistan or other combat zones throughout the world.
 

Canadian Forces members see their care and treatment as being intrinsically linked to the care and treatment of their families. At the same time, and at a human level, it is unacceptable to focus on jurisdictional or legal obstacles (i.e., interpretation of federal/provincial responsibilities vis-à-vis health care) as an argument for ignoring the mental health needs of military spouses and children at some military establishments. It is recommended, therefore, that:
 

  • 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.
     

The National Operational Stress Injury Coordinator should be given the responsibility for coordinating this organization and ensuring that military families and military family members do not fall through the cracks in the future.

 

Caregiver Issues

Canadian Forces members suffering from post-traumatic stress disorder or other operational stress injuries obtain care and assistance from a number of sources, including: chaplains, social workers, physicians, psychologists, psychiatrists, and mental health nurses. As a result of this second follow up, Ombudsman investigators found that there is a significant shortage of qualified mental health caregivers. They also found that today’s caregivers are carrying heavy caseloads, and many are in danger of burning out.
 

Given the current shortage of mental health care professionals in the Defence community, and with the instances of mental health injuries on the rise as a result of the mission in Afghanistan, the Ombudsman’s office was pleased to learn of the intention of the Department and the Canadian Forces to hire an additional 218 mental health professionals by the end of March 2009. It should be noted, however, that the Canadian Forces are one of many employers across the country vying for health care professionals and it may be difficult to fulfill this commitment. This makes it even more essential for the military to retain the mental health care professionals already working in the Defence community.
 

In order to ensure that sufficient numbers of mental health care professionals are available to provide care and treatment to military members suffering from mental health injuries, it is recommended that:
 

  • 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.
     
  • 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.
     

The Canadian Forces must also address in the short- and longer-term the issue of burnout in the caregiver community. Therefore, it is recommended that:
 

  • 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.
     

The National Operational Stress Injury Coordinator should be given the responsibility for ensuring the well-being and overall effectiveness of the mental health care community.

 

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Conclusion

The Ombudsman’s office has been closely associated with the issue of post-traumatic stress disorder and other operational stress injuries in the Canadian Forces since 2002. Annex A shows that, while progress has been made by the Department and the Canadian Forces, only 13 of the original 31 recommendations in the 2002 report have been fully implemented to the satisfaction of the Ombudsman’s office. There are a number of important issues that remain unresolved, which are resulting in some military mental health sufferers slipping through the cracks of an ad hoc system.
 

In going forward, the Ombudsman’s office calls on the Department and the Canadian Forces to implement the intent of all 31 recommendations. The office is also focused on nine recommendations to address current realities and current problems regarding post-traumatic stress disorder and other operational stress injuries.
 

The following recommendations will form the basis of all future monitoring and reporting by the office:
 

  1. 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.
     
  2. 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.
     
  3. 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.
     
  4. Any changes – formal or informal – to the Accommodation Policy (or the approach taken by the Canadian Forces to wounded members who want to continue their military careers) be applied equitably to Canadian Forces members with both mental health and physical injuries.
     
  5. The rules regarding occupational transfer be changed to accommodate, in an efficient manner, members diagnosed with post-traumatic stress disorder or other operational stress injuries who could continue their military service if they transferred to another military occupation.
     
  6. 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.
     
  7. 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.
     
  8. 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.
     
  9. 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.

 

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Annex A: Overview of the Original 31 Recommendations

The Department of National Defence and the Canadian Forces have made significant progress in the treatment and care of members suffering from operational stress injuries. In summary, we consider that of the 31 original recommendations, 13 have been implemented, 7 have been partially implemented, and 11 have not been implemented to a level that satisfies the full intent of our initial recommendations.
 

Based on the evidence gathered during our investigation, the following is a status report of the implementation of the 31 initial recommendations.

 

Recommendation 1

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.
 

Status: Not Implemented

  

The lack of accurate statistics makes it more difficult to increase the level of awareness and understanding of the seriousness of this problem within the Canadian Forces, and allows inaccurate and harmful speculation about the validity of the injury to proliferate. It has also impedes the Canadian Forces’ ability to gauge the effect of operational stress injuries on its members and their families.
 

The manual collection of data at the national level ceased in the fall of 2003. According to the senior Canadian Forces psychiatrist, the manual collection of confidential statistics from the Operational Trauma and Stress Support Centres (OTSSCs) and other mental health organizations was too labour-intensive to continue.
 

On the other hand, Canadian Forces Health Services is planning an electronic information system (the Canadian Forces Health Information System), but it is not yet operational. It will, when implemented, provide medical record keeping for Canadian Forces members, and provide the capability to track those who have been diagnosed with an operational stress injury. It is expected to be up and running sometime in 2008. In the meantime, OTSSCs have developed their own database and information systems to meet their local needs. Unfortunately, this does not provide means of capturing the magnitude of the problem at the national level.

 

Recommendation 2

The Canadian Forces develop a database on suicides among members and former members.
 

Status: Implemented

  

To understand the extent of psychological injuries, it was recommended that the Canadian Forces begin to collect statistics about suicides in order to provide important insight into how many Canadian Forces members and former members are affected by post-traumatic stress disorder. Currently, the collection of statistics of all reported suicides of serving Canadian Forces members is the responsibility of the Directorate of Casualty Support and Administration. However, if a suicide or suicide attempt takes place outside of a military environment, a civilian investigation takes place and the Department and the Canadian Forces may not be informed of the exact cause of death. Consequently, while the database may not be 100 percent accurate, it is as complete as the Department and Canadian Forces can make it.

 

Recommendation 3

The Canadian Forces conduct an independent and confidential mental health survey that includes former members, as well as Regular and Reserve components.
 

Status: Implemented

  

The Canadian Forces needs statistical information on the state of the mental health of its members. A mental health survey was conducted as part of the Canadian Community Health Survey in 2002 and completed by the Canadian Forces in collaboration with Statistics Canada.
 

The Canadian Community Health Service measured the frequency of occurrence of certain mental disorders, utilization of mental health services, perceived health needs, and links among mental health and social demographic, geographic and economic variables. According to the results, illnesses that are common in the civilian sector are also common in the Canadian Forces. The survey concluded that the most common illness that Canadian Forces members face is depression, followed by alcohol dependency, social phobia and post-traumatic stress disorder.
 

This data is dated and it is time to conduct another survey. This office strongly urges the Department and the Canadian Forces to do so.
 

 Recommendation 4

The Canadian Forces examine the issue of work therapy while on the Service Personnel Holding List (SPHL) in more detail, with a view to creating policies and procedures to deal equitably with issues that arise from members on the SPHL earning secondary income from employment as part of a therapy program.
 

Status: Implemented

  

This office encouraged the Canadian Forces to provide meaningful employment to members suffering from an operational stress injury when they were no longer able to function in their primary role. It was recognized that ongoing employment is extremely beneficial to some people suffering from an operational stress injury, but it was not readily available within the Canadian Forces. As a result, patients were encouraged to seek employment in the civilian sector for the therapeutic benefit. However, monetary compensation for such work while the member continued to draw a military salary created both significant resentment amongst peers and a legal issue.
 

Both concerns were addressed through the implementation of the Canadian Forces Return to Work Program introduced with the release of CANFORGEN 090/03 in July 2003. Specific guidance for the program is provided by the Assistant Deputy Minister (Human Resources – Military) Instruction 05/03 and includes direction on how and when a member may be referred to a civilian work therapy program. Simply put, it states that if the requirement exists for a Canadian Forces member to be employed in a government workplace outside of the Canadian Forces it is to be done through a secondment or attachment as authorized by Queens Regulations and Orders, Chapter 10. (Members on SPHL who are not part of the Return to Work Program can still earn money from other sources in the civilian market.)

 

Recommendation 5

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

Status: Not Implemented

  

Accurate and timely information about operational stress injuries is required for all Canadian Forces units. The initial investigation revealed that the level of awareness of operational stress injuries at the unit level was quite low. Having the latest information delivered directly to units, at least in part by qualified mental health professionals, would increase the individual member’s level of awareness of the subject with an eventual view to reducing the cultural barriers that prevent many of those afflicted from coming forward and seeking help.
 

The OTSSC mandate includes assessment, treatment and research as well as a specific requirement for outreach. However, OTSSCs are overtasked and do not have sufficient resources to carry out outreach activities that have proven quite effective. The staff at one OTSSC noted that the numbers of new assessments increased dramatically (in the range of 50 percent) after an outreach activity. They also noted that they are now seeing members much sooner after the triggering event than previously.
 

The second part of the equation is that in order for an outreach program to be provided, units must request it. This investigation found that the frequency of outreach requests from units varied considerably but has generally been very low. My investigators visited most of the military bases in Canada and surveyed operational units on each of those bases. With the exception of one Reserve unit, none of the 25 operational units surveyed had requested outreach training from an OTSSC.
 

Although progress has been made within the OTSSCs and outreach training is improving at local levels, significant work remains to be done to ensure that it is being effectively targeted to all units, and that operational units integrate it into their local training programs.

As with other aspects of education and training, although appropriate direction was issued, outreach training is largely uncoordinated at the national level. There are significant regional variations in the quantity and quality of the training that actually reaches the units, with no apparent oversight from any central authority, and no evident feedback of the effectiveness of the program to higher authority. There was no direction that we could find down the operational chain of command for units to request outreach training on a regular basis. Until a degree of central coordination is established to ensure all units are receiving the training, and a feedback mechanism is developed to assess its effectiveness, the intent of this recommendation will not be met.
 

Recommendation 6

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

Status: Partially Implemented

  

Regrettably, while funding to Mental Health Clinics to operate OTSSCs has increased significantly, outreach remains an incremental activity due to high workloads and the lack of consistent requests from units.
 

While most OTSSCs reported that they had adequate funds to carry out necessary outreach activities, there is still a serious shortage of time available for most mental health professionals to fully meet the requirement, as treatment of post-traumatic stress disorder must come first. A staff member at one OTSSC clearly stated that outreach is not being done due to a lack of time and staff. In the words of a professional staff member at another OTSSC: “We have sufficient financial resources to carry out necessary outreach activities - for example, to cover staff travel - however, it is having the time freed up from treatment and assessment activities to be able to provide the necessary outreach.”  
 
 
The full intent of this recommendation will not be met until OTSSC resources allow for a consistent level of outreach to be offered and units regularly request the training.

  

Recommendation 7

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

  

The most effective way to reduce the stigma associated with operational stress injuries and tackle culture change is by injecting appropriate education and training into the curricula of all Canadian Forces training courses, from recruit training through to specialist- and promotion-oriented training.
 

Within the Canadian Forces the responsibility for training and education is distributed across several areas. In the case of specific operational stress injury education and training, the Directorate of Training and Education Policy is responsible for developing policy; the Canadian Defence Academy has overall responsibility for delivery; and the Operational Stress Injury Social Support (OSISS) Speakers Bureau, amongst other agencies, is responsible for actually delivering content. Operational and continuation training, on the other hand, is the responsibility of the environmental commands.
 

The Canadian Defence Academy is planning to introduce specific information into leadership curricula of Canadian Forces common professional development courses.
 

In July 2006, the Canadian Forces indicated that progress in this area had effectively stalled due to a lack of available and credible subject matter experts from both the clinical and OSISS side to deliver training. The best estimate that Canadian Defence Academy had at the time of this report for full implementation of the training was September 2007. The Canadian Forces further reported that the Canadian Defence Academy met with the Canadian Forces Manager of OSISS in July 2006 to discuss innovative ways to allow the requisite support from the Speakers Bureau to be made available. Ideas being considered include videotaping some of the presentations to allow wider dissemination of the information (including to Reserve units), adding more participants to the Speakers Bureau, and treating speakers as subject matter experts, thus eliminating some of the technical requirements for lessons plans and so on.
 

Virtually everyone involved in this investigation and in previous investigations dealing with operational stress injuries has agreed that only through education and training will the military culture eventually evolve to the point that operational stress injuries are treated as just another injury. A comment made by a senior officer at the Canadian Defence Academy who continues to work on the implementation of this recommendation illustrates the understanding of this reality: The acceptance of stress casualties in the 'warrior' culture will require time and education.” 
 

This recommendation has not progressed satisfactorily and, as a result, effective culture change is not taking place within the Canadian Forces at the rate that it ought to be. High-level intervention in direct support of the Canadian Defence Academy for this activity is needed. Until senior levels of the Canadian Forces intervene in direct support to provide enough qualified and credible personnel to develop and deliver this training, little advancement can be expected.
  

Recommendation 8

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

  

In the Canadian Forces, basic qualification training, such as centralized professional development training, is normally the responsibility of the Chief of Military Personnel. Operational and continuation training designed to develop and enhance the operational effectiveness of the member, which occurs after basic qualification training is completed, is the responsibility of the force generators – in traditional terms: the army, navy and air force. It is imperative to continue to promote and provide knowledge development about operational stress injuries in those environmental commands.
 

The coordination of appropriate continuation training to deal with operational stress injury issues across each environment is problematic, and no indication was found during this investigation of any performance measures designed to assess the effectiveness of unit training. Indeed, it was evident that most field units are still not requesting outreach training on operational stress injuries from available resources such as OTSSCs.
 

The need for continuation training with respect to operational stress injuries must be addressed by high-level direction from the chain of command. The split in responsibility between the central organization and the force generators is very effective for most military training activities; however, for training that is focused on changing the culture of the Canadian Forces, much stronger central direction and coordination is essential.

  

Recommendation 9

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
 

The original report concluded that the overall quantity and quality of post-traumatic stress disorder training and education was insufficient to meet the needs of the Canadian Forces. It also noted that the training regime most Canadian Forces members are subjected to is already filled to capacity and well beyond in many cases. This recommendation was designed to create a priority for post-traumatic stress disorder training and education and provide a centralized means to ensure it was being observed.
 

Ombudsman investigators found that there had been very little improvement in training given to units with respect to operational stress injuries. Similarly, the absence of coordination from the national level remains an issue. This is surprising given that the Chief of the Defence Staff issued a dispatch to the chain of command on December 10, 2002, calling anything less than giving the utmost care and understanding to those who suffer from operational stress injuries an unacceptable failure of leadership.  
 

The benefit of training and education is still not reliably making its way down to the unit level in a consistent and coordinated fashion. Significantly more coordination and direction is required in the area of education and training before the Canadian Forces can be described as making a serious effort to effect lasting culture change. Despite the significant effort being put forward by organizations like the OTSSCs, OSISS and the Canadian Defence Academy, there is little overall coordination of these initiatives and high-level support has not translated into prioritized resource allocations.
   

Recommendation 10

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

  

Training and education activities within the Canadian Forces are split amongst several organisations functioning at different levels, i.e., strategic, operational and tactical. While this division is workable for operational issues, it is problematic for educational initiatives designed to facilitate culture change. A centralized approach is necessary to ensure operational stress injury training and education was being delivered according to policy. Recommendation 31 suggested the creation of a Post-Traumatic Stress Disorder Coordinator to play a central role in strategic level operational stress injury initiatives. Training and education would have been part of his/her recommended responsibilities. Unfortunately, the recommendation was never implemented.

  

Recommendation 11

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

  

The OSISS program, its Peer Coordinators and their Speakers Bureau all include members with post-traumatic stress disorder. It has been very successful in providing meaningful education about operational stress injury issues to Canadian Forces members since its inception in 2003. Work, however, still remains to be done to ensure sufficient numbers of credible and qualified speakers are available to meet the demand.
 

We strongly encourage the Canadian Forces to nurture the considerable capability that resides in this relatively small and inexpensive program. In order to see it reach its full potential, the Speakers Bureau must receive high-level support, as well as coordination of its efforts to both ensure that all units in the Canadian Forces are aware of the capability, and that its coordinated use with other aspects of education and training are fully exploited.
  

Recommendation 12

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

  

The OSISS approach to achieving the multidisciplinary objective has been to include a mental health professional as part of their presentation package whenever possible. Unfortunately, due to the high workload and limited availability of these professionals, that does not always happen. To compensate, OSISS speakers have been including a slide package that has been pre-approved by mental health professionals to ensure the information provided is consistent and accurate. In a further effort to both standardize and improve the consistency of the message, OSISS has produced a video to present the bulk of the information, allowing the OSISS speaker to focus on introducing the message, adding personal observations and, most importantly, interacting with the audience.
 

All of the OTSSCs indicated that they believed multidisciplinary teams were the most effective approach to outreach, and felt the inclusion of experienced military members was a good idea. As one clinician stated, ...[you] hear from others who say they are not therapists, etc... but there is a place in the continuum of care for them.Another realistic-minded individual noted, “People will be talking to their peers anyway so let's bring them in  because they're training and its safe.”    
 

Outreach training that includes the full spectrum of medical and mental health skills, as well as experienced soldiers, continues to be the most successful way of effecting attitude change in the Canadian Forces. According to both OSISS leadership and OTSSC staff who have participated, the impact of the combined approach is tremendously effective.
 

This is an important area, which will require continued leadership and active coordination to ensure that outreach training is provided to all units across the organization in a consistent and standardized fashion, and its effectiveness must be constantly monitored. This is currently not happening and until it does this recommendation must be considered to be in the process of being implemented but should not yet be designated as closed.

  

Recommendation 13

The Canadian Forces allot additional resources to accelerate the implementation of the proposed mental health education initiatives developed by the Rx2000 Mental Health Team.
 

Status: Implemented
 

The Canadian Forces has allotted significant resources to support the package of mental health initiatives developed by the Rx2000 mental health team. Under this initiative there are a variety of detailed plans being implemented to address the previous lack of resources in the field of mental health care.
 

The full implementation of the mental health aspects of this project is scheduled for completion in 2009-2010. As part of the Rx2000 plan, the headquarters cell will have a unit of 15 people working on the administration and coordination of mental health services. Of those 15 positions, three will be dedicated to mental health education and training.
  

Recommendation 14

The Canadian Forces develop a standardized screening process that involves all of the pertinent specialists and that is under the control of a single point of contact.
 

Status: Implemented

  

There is a need to ensure a standard approach to the screening of Canadian Forces members, both Regular and Reserve, prior to any major deployment. The original and follow-up investigation concluded that pre-deployment screening was inconsistent, depending largely on where it was conducted.
 

On August 10, 2004, Canadian Forces General Message (CANFORGEN) 112/04 ‘Screening and Reintegration for Canadian Forces Deployments’ supplemented by a Deputy Chief of the Defence Staff Direction on International Operations (Chapter 12) put in place new policies and procedures that standardized the screening and reintegration processes for international operations. It established standardized pre- and post-deployment screening and reintegration procedures for international operations and introduced a two-tier screening process for both Regular and Reserve Force members effective November 1, 2004. This policy states that, commanding officers are to ensure that unit readiness levels are reviewed annually.  Subsequently, Canadian Forces General Message CANFORGEN 118/05 ‘Screening and Reintegration for Canadian Forces’ was issued on July 4, 2005, reinforcing the procedures already in place. It also further standardized the annual screening process for all Canadian Forces members, both Regular and Reserve Force.
 

The treatment for Reservists and Regular Force augmentees is clearly stated, making commanders responsible for ensuring that both of these groups undergo the exact same screening and reintegration standard as members of formed units. It also states that returning Reserve and augmentee members are to be met on arrival in Canada and upon return to their home unit, and that they are to be provided with the same number of partial work days at their home unit as the Formed Unit with which they deployed.
 

This new policy includes the use of Departure Assistance Group and Arrival Assistance Group procedures to ensure all personnel are prepared to deploy in support of operations and that appropriate post-deployment follow-up is conducted to ensure their continued operational fitness for future operational deployments.
 

As well, the Director General Health Services has been providing standardized training on pre- and post-deployment screening procedures to all mental health staff associated with deployments.

 

Table of Contents

  

Recommendation 15

The Canadian Forces set up a pilot project to determine the most effective ways of allowing members returning from deployment to be reintegrated into family and garrison life.

Status: Implemented
 

The original investigation found that the limited adjustment time between a member’s departure from a theatre of operations and his/her return to their family could be an exacerbating stress factor. The Canadian Forces was encouraged to develop a standardized approach to the reintegration of members returning from major deployments. It was suggested that reintegration could include a number of approaches to dealing with the post-deployment period, including a decompression phase prior to returning home and the use of a gradual reintegration to normal routine.
 

In December 2002, the Chief of the Defence Staff issued Staff Order 119 assigning the authority to implement a separate Third Location Decompression period at the end of a deployment, if required, to each Task Force Commander, after consultation with the Deputy Chief of the Defence Staff. This option was used in January 2002 when the soldiers returning from Operation Apollo were sent to Guam for three to five days of decompression.
 

During that time, members had an opportunity to rest and de-stress in a safe environment, while also receiving information and training sessions on subjects such as family and work reintegration, anger management and operational stress injury warning signs and suicide awareness. Upon their return home, they worked up to five full days and seven half days, allowing them time to gradually reintegrate back into their family lives before going on a period of block leave.
 

On May 27, 2004, the Chief of the Defence Staff was provided with this office’s special report “From Tents to Sheets: An Analysis of the CF Experience with Third Location Decompression after Deployment,” which contained 14 recommended principles to help guide commanders when determining if decompression at a third location is warranted. In response to this report, on August 10, 2004, the Canadian Forces introduced CANFORGEN 112/04 – a new policy and procedure with respect to pre-deployment screening and post-deployment reintegration.
 

The current Canadian Forces deployment to Afghanistan, Operation Archer, has been a challenging one for Canadian Forces members. Accordingly, a Third Location Decompression in Cyprus was approved for the troops returning from that theatre of operations between July 30 and September 14, 2006, and for the subsequent redeployment in February and March 2007. In both of these Third Location Decompression activities, educational sessions provided by a group of mental health professionals and peer support coordinators from the OSISS group, interspersed with ample time for individual rest and recreation activities, were provided.
 

Anecdotal information from a number of soldiers who have experienced Third Location Decompression indicates that this procedure has been very effective; however, post-deployment Health Research and Education personnel of the Canadian Forces Health Services group, as well as Defence Research and Development Canada, are presently conducting an evaluation of this process and, once completed, these evaluations should provide the Canadian Forces an objective means to determine the value of the overall procedure.

   

Recommendation 16

The Canadian Forces provide sufficient incremental resources to permit all mental health caregivers, including padres and social workers, to access training required to deal with mental health issues.
 

Status: Partially Implemented

  

Caregivers need to keep up with ongoing research on the full range of mental health issues, including post-traumatic stress disorder and other operational stress injuries.
 

We heard from several Canadian Forces chaplains that they do not have access to sufficient training. The Chaplain General’s position, however, was that the current level of training is proving to be successful. Aside from basic training, all chaplains in the Canadian Forces now receive a specialized course on peacekeeping operations and pastoral counselling and are eligible to attend a range of career development courses. Before they deploy, all chaplains receive the theatre specific training. Chaplains in the Canadian Forces are supported primarily by the Canadian Forces Chaplain School and Centre and the Branch also has a formal liaison with St. Paul University in Ottawa for staff resources and academic courses.
 

For the majority of social workers in the Canadian Forces, time is the one resource that there is certainly not enough of, although they do have training opportunities available to them. Aside from the annual social workers conference, a national mental health meeting is held every year where a number of social workers, mental health nurses, case managers, psychologists and psychiatrists are invited to attend.
 

The Canadian Forces continues to rely heavily on civilian contractors to provide mental health support. In March 2001, a civilian company was awarded a three-year contract valued at $92 million to provide third-party health care services to the Canadian Forces, and by September 2004 the Canadian Forces had 800 health care contractors provided by this company. A new five-year contract, valued at more than $400 million, “for the provision and management of Health Service Providers,” was awarded to a new company and became effective on April 1, 2005.
 

The Rx2000 Project Coordinator provided an explanation of the contracting process and the training conditions for contractors. Each contractor is responsible for negotiating their own terms with the contract service provider, including expenses for professional development or training. For example, if a contractor negotiates a per annum rate of $70,000, he or she may also negotiate an additional $30,000 allotment to cover training expenses and holiday time off. The time required for training is recognized in the financial compensation portion of the contract. If the contractor does not feel that the Department and Canadian Forces-mandated training is necessary or they don’t have time, there is usually no requirement under the contract for them to attend. We were further advised that the Canadian Forces has established specific qualifications and skill sets for new contractors, which must be met before they can be retained. The Department and the Canadian Forces have also agreed to pay for contractors to attend any training that is required by their organizations once they have been retained, in order to acquire skills that are over and above the basic qualifications established by the contract.
 

Contractors are required to have the necessary professional qualifications before they are eligible to provide services to the Department and the Canadian Forces. These contractors, many of whom work side by side with Departmental employees and Canadian Forces members providing support to members suffering from operational stress injuries, have not, in the past, had the same access to ongoing education and training related to operational stress injuries and the unique challenges of dealing with operational stress injuries in the military. Contractors do not have the same rights and entitlements as employees. However, there is great mutual benefit to be derived from providing these contractors with access to existing training and education programs with respect to the treatment of operational stress injury issues in the military and in facilitating best practices exchanges with departmental and Canadian Forces personnel.
 

We were informed that the Canadian Forces is striving to hire public servants to fill most of these positions, which could ultimately alleviate the training problem; however, there are other benefits of a mixed work force that may be adversely impacted by a move in that direction. The Canadian Forces needs to creatively explore ways to achieve the training goals while avoiding the unintended consequences inherent in removing contractors from the mix.
 

The need for adequate training and education for those providing treatment and support in the mental health field, including social workers and chaplains, is an urgent one that requires immediate attention. The earmarking of funds is a good first step but is only one part of the required response.
 

This recommendation is still outstanding. The Canadian Forces has taken the decision that this item is closed because resources have been allocated to Rx2000, but this program will not be fully implemented until 2009.

 

Recommendation 17

The Canadian Forces provide sufficient incremental resources for the social work branch to hold an annual retreat.
 

Status: Implemented

  

Social workers are effectively the gatekeepers for Canadian Forces members seeking care for mental health issues, and as such are the linchpin of the entire mental health system. The tremendous workload imposed on them is constantly increasing, resulting in people who are often near physical and mental exhaustion, yet they continue to devote themselves to the care of the members. Support is needed for social workers so that they may continue to provide a high level of service to Canadian Forces members and their families. All social workers, regardless of their status, employment or contractual relationship with the Canadian Forces, should receive the same support.
 

The first conference for social workers was held in September 2002. Subsequent conferences were held in October 2003, September 2004 and 2005, and the fifth annual conference was held in January 2007.
 

During this follow-up investigation, all social workers interviewed agreed that the conference was extremely beneficial and that there should be an opportunity to attend such conferences on a regular basis.

 

Recommendation 18

The rules regarding occupational transfer be changed to quickly accommodate members diagnosed with post-traumatic stress disorder who would benefit therapeutically from working in another military occupation.
 

Status: Not Implemented

  

The original investigation revealed concerns about the inflexibility and delay inherent in the Canadian Forces’ occupational transfer process. It was evident that the Canadian Forces was losing valuable personnel resources by releasing dedicated, trained and operationally experienced military members who were qualified and capable of continued service if transferred into another occupation.
 

This investigation revealed that complaints about the occupational transfer process were still widespread, including that the process is too slow and unresponsive.  The lengthy, bureaucratic and seemingly inflexible system in place to respond to requests for occupational transfers is frustrating the very people who must deal with the issue. Personnel associated with the process, including mental health professionals, administrators and Service Personnel Holding List Coordinators as well as the chain of command, reported that the time it takes to process paperwork and receive a decision is just too long.

  

Recommendation 19

The Canadian Forces audit and assess the effectiveness of policies and procedures designed to assist Reserve Force members and augmentees pre- and post-deployment.
 

Status: Implemented

  

CANFORGEN 112/04, issued on August 10, 2004, introduced procedures to standardize both the pre- and post-deployment screening processes and reintegration procedures for Reserve Members. This new policy specifically provided that, Commanders are to ensure that augmentees and individuals undergo screening and reintegration to the same standards as members of formed units. It emphasized the requirement for Commanding Officers to ensure that both Reserve members and augmentees are fully included in all of the screening and reintegration processes.
 

Subsequently, CANFORGEN 118/05, ’Screening and Reintegration for Canadian Forces’ was released in July 2005. It reinforced the previous message and standardized annual as well as pre- and post-deployment screening procedures for all members of the Regular and Primary Reserve. All are required to follow the exact same procedures.
 

The Deputy Chief of the Defence Staff Direction, Direction for International Operations (DDIO) (Chapter 12 - Personnel Support), which is now the responsibility of the Canadian Forces Expeditionary Force Command, contains a useful checklist dealing directly with pre- and post-deployment screening requirements for both Reserve members and augmentees.
 

These new policies and procedures have resulted in a much-needed improvement in the quality of pre- and post-deployment screening and follow up for both Regular Force augmentees and Reserve members.

 

Recommendation 20

The Canadian Forces review policies and procedures with a view to making them as flexible as possible to accommodate the needs of members who have been diagnosed with post-traumatic stress disorder and wish to remain with their units for as long as is possible.
 

Status: Partially Implemented
 

The Canadian Forces needs to find ways to provide Commanding Officers with sufficient flexibility to retain members suffering from operational stress injuries in their units, even when the member is not deployable in his/her primary occupation.
 

Previously, the Canadian Forces had sufficient numbers to allow units to retain injured members beyond their established strength (referred to as Military Manning Overhead Billets), thus giving them the ability to retain injured members while still allowing the unit to field its full deployable establishment. Today, every non-essential position has been pared from unit establishments and every established position is required to permit a unit to carry out operational taskings.
 

However, the Canadian Forces Accommodation Policy, introduced in 2000, is now being used to assist members who suffer from operational stress injuries to continue to work in the Canadian Forces. This policy permits members to be retained for up to three years even though they do not meet the Universality of Service criteria. However, the unit must have a vacant position against which to hold the individual, and both a recommendation from the member’s Medical Officer and approval from Director Military Careers Administration and Resource Management is required.
 

The major obstacle is the lack of available vacant positions at the unit level that can be used for this purpose. Unit Commanding Officers are reluctant to fill positions with members that are not fully deployable, especially for an extended period due to their ongoing operational requirements.
 

While the implementation of the Canadian Forces Accommodation Policy appears to address some of the concerns that led to the original recommendation, clear direction is still needed at the national level.

  

Recommendation 21

The Canadian Forces review procedures for placing members on the SPHL to ensure a greater role for input from Medical Officers and Commanding Officers.
 

Status: Implemented
 

The SPHL is an administrative tool intended to facilitate support to Regular Force members who have been diagnosed with a long-term illness or injury. Its intent is two fold: to provide a Canadian Forces member the best opportunity to recover from an injury in order to permit a return to normal duties, or the best opportunity to adequately prepare for release; and also to enable a replacement to be posted into the member’s unit. Members may eventually be directly released from the military from the SPHL or they may be transferred back to normal duties once their medical condition improves.
 

The most consistent complaint heard from the people responsible for administering the SPHL was the lack of a detailed national policy. This lack of definitive direction continues to produce inconsistencies in how people are treated once placed on the SPHL.
 

The Ombudsman’s office was provided a copy of a draft of Department Administrative Order and Directive (DAOD) 500x – Service Personnel Holding List for comment in March 2002, by the Directorate of Casualty Support Administration. It covered a variety of issues dealing with the administration and support of members placed on the SPHL, including operating principles for the SPHL, process for personnel on the SPHL, and responsibilities. As of February 2008, this DAOD still has not been issued. The continuing delay in issuing this directive has resulted in inconsistencies in how members are being treated.
 

Several Commanding Officers expressed concern that their input was not being considered when this key decision was made by National Defence Headquarters. By involving a member’s Medical Officer and chain of command, the SPHL posting decision is made at a level as close as possible to the member, and not by a centralized bureaucracy at a higher headquarter’s level.
 

Canadian Forces General Message 100/00 assigns the authority to approve a posting to the SPHL to the member’s career manager. This decision is to be made in consultation with the member’s Commanding Officer and the appropriate Health Care Coordinator, who make the original application and recommendation for such a posting.

  

Recommendation 22

Units maintain contact with members on the SPHL bi-weekly, subject to any restrictions imposed by the member’s treating caregiver, or any desire expressed by the member.
 

Status: Partially Implemented

  

During the original investigation, many injured members expressed strong feelings of rejection when their units failed to maintain contact with them once they were placed on the SPHL.
 

Management of the SPHL varies across the Canadian Forces, reflecting local priorities. In some areas, a centralized SPHL approach is used, while in others a decentralized or unit-focused method is in place. In the centralized approach, the unit is no longer responsible for the individual; rather, the central agency staff administers, employs and is responsible for the day-to-day care of the individual. In the decentralized or unit approach, the member’ unit retains responsibility for all of these details.
 

During the course of this recent investigation, a number of unit adjutants reported that their unit did have a mechanism in place to maintain regular contact with members on the SPHL. The majority of these ‘mechanisms’ called for contact on an average of once every two weeks and in their opinion it was working all right.   

  

Recommendation 23

The Canadian Forces address resource issues that are preventing units from properly looking after members diagnosed with post-traumatic stress disorder within their units.
 

Status: Partially Implemented

  

This recommendation came about as a result of the feeling of abandonment that many members felt after they had been posted from their unit to the SPHL. The intention of this recommendation was to bring to the attention of all units their responsibility to maintain regular contact with all of their injured members.
 

The impact of the current operational tempo is certainly significant. Units are focused on meeting the requirement to be deployable and often the consequence of that is that maintaining contact with the members who are not 100 percent healthy becomes secondary. There is little administrative capability left at the unit level to monitor this activity, and the lack of detailed instructions on how members on unit SPHL are to be treated continues to produce inconsistencies amongst units.
 

As discussed under Recommendation 21 above, the requirement to get the DAOD on the SPHL published and in place needs to become a priority. This ongoing lack of definitive direction for the SPHL continues to affect how some members are being treated when placed on it. There needs to be a national policy for the SPHL.

  

Recommendation 24

The Canadian Forces prioritize and accelerate the efforts toward standardizing treatment of members diagnosed with post-traumatic stress disorder among OTSSCs.
 

Status: Not Implemented
 

During the original investigation and the subsequent follow up in 2002, significant concern was expressed about the lack of standardization in treatment and consistency in approach among the OTSSCs.
 

Standardization of treatment across OTSSCs was improved by the introduction of the OTSSC Treatment Standardization Committee. This Committee was created “to develop and maintain a treatment guideline registry of accepted treatments and therapies for the purpose of ensuring optimal evidence based treatment of 'deployment' related mental health illnesses and injuries and provide constant revision. ” The Committee held its first meeting on January 16, 2002, and was meeting regularly until February 2005. According to the Canadian Forces Chief Psychiatrist, meetings have not been held since as there have been  “no significant changes in the treatment literature to address” and the primary focus has been on “unifying the approach to assessment across the CF as it had become apparent that there were significant differences amongst our clinics.”   
  

These concerns about assessments became apparent during recently publicized events identifying disagreements amongst departmental and Canadian Forces caregivers concerning the application of standard psychometric testing techniques. An unintended and distressing consequence of this public discussion was the identification of significant friction within the Canadian Forces mental health community, and the resulting media conflict between National Defence Headquarters and several Canadian Forces caregivers.

  

Recommendation 25

OTSSCs be resourced on a priority basis, and to a level sufficient to perform all of their designated functions.
 

Status: Implemented
 

Subsequent to the first follow-up report, the Department and the Canadian Forces indicated that a significant increase in funding was forthcoming. The Canadian Forces has met their commitment in increasing the funding to mental health services through Rx2000, in the order of $98 million over five years, with an annual baseline adjustment of $23 million after that. Although personnel shortages are an issue and continue to affect service delivery at each OTSSC, these are related to the broader problem of a lack of qualified mental health professionals in many parts of Canada. An officer in the Canadian Forces health services group headquarters informed my office that, there is a requirement to increase MH [mental health] resources in all clinics. As each serves a different population, the requirements vary. From coast to coast, however, this personnel increase includes: psychiatrists, psychologists, social workers and administrative support staff. When the project is complete, the goal is to have every MH clinic capable of providing a wide range of MH services, delivered by the preceding disciplines.   

  

Recommendation 26

The Director General Health Services initiate a pilot project that locates one OTSSC off base, to ascertain whether such an arrangement is better suited to the objectives of the OTSSC.
 

Status: Implemented
 

The intent of this recommendation was to remove what was to many members an obstacle to seeking mental health care at the earliest possible juncture. Moving an OTSSC to more anonymous premises off base was one way to achieve that goal. During this follow-up investigation, my office asked numerous mental health professionals and treatment and support providers from both military and private practices, as well as members of OSISS, to provide their input on the issue of establishing a pilot project for an off-base OTSSC. Although some working in the mental health field commented that to send a member off base to seek treatment is to re-stigmatize them (a concern shared by OSISS), most commented that many injured members still hesitate to seek treatment because they have to go to the OTSSC on the base. Most could identify at least one case where the member sought help off base rather than risk the perceived consequences of coming to the OTSSC.
 

In a letter dated September 10, 2003, a previous Assistant Deputy Minister (Human Resources – Military) noted that the Canadian Forces was exploring the possibility of extending service hours at the OTSSCs, and that this would allow CF members who are apprehensive about going to the OTSSC during normal working hours to access the services after hours when there are few people around. This may remove some of the fear of being seen by their colleagues.” The Canadian Forces senior psychiatrist indicated in an interview his support for this, noting that “you get patients to come in after hours so it doesn't impact on their work. By going off base, people automatically guess that something's going on.  
 

An initiative that has the potential to contribute positively to off-base access for Canadian Forces members has been developed by Veterans Affairs Canada. As of the writing of this report, six operational stress injury clinics have been opened by Veterans Affairs Canada across the country to provide out-patient care to members, former members and Royal Canadian Mounted Police members suffering from a stress injury. These are located in Ste-Anne de Bellevue (Ste-Anne’s National Operational Stress Injury Centre) in Montreal; La Maison Paul-Triquet Operational Stress Injury Clinic in Ste Foy, Quebec; the Parkwood Operational Stress Injury Clinic in London, Ontario; the Deer Lodge Operational Stress Injury Clinic in Winnipeg, Manitoba; the Calgary Operational Stress Injury Clinic, located in a shopping centre in Calgary, Alberta; and the sixth clinic, which recently opened in Fredericton, New Brunswick. Two more are scheduled to open in Ottawa, Ontario, and Edmonton, Alberta, in the near future. Eventually, it is envisioned that a total of 11 of these clinics will be in operation across the country. Referral by a military Medical Officer is required for Canadian Forces members to access such clinics.

 

Table of Contents

  

Recommendation 27

The Canadian Forces take steps to deal with the issues of stress and burn-out created by lack of resources and high caseloads among Canadian Forces caregivers.
 

Status: Partially Implemented
 

There is a shortage of professional health caregivers in the Canadian Forces and more resources need to be allocated to alleviate the burn-out and stress being experienced by many of these dedicated professionals. The Canadian Forces also must compete with the demands for more health caregivers in the public sector and private sector.
 

To meet today’s demands, the extremely dedicated Canadian Forces mental health professionals are operating at or near burn-out levels. During one interview, one mental health professional commented that, ... as a group, we worry about ourselves.  Similar sentiments were voiced by many, with some going so far as to identify by name to my investigators the co-workers who they were concerned about or who they knew were exhausted, [She] is feeling the heat - her voice sounds beat. One Canadian Forces chaplain described the situation as, You have nothing to give but everybody asks for something.   
 

The intent of Rx2000 to address the shortage of Canadian Forces Mental Health Professionals through a phased approach of hiring additional staff would appear to meet the original intent of this recommendation. That said, however, this plan will only be successful if those resources are available, and the plan is fully implemented.

  

Recommendation 28

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
 

There is a need to address the lack of support available to the families of members diagnosed with post-traumatic stress disorder. There is still no mandated Canadian Forces-wide policy or other guidance available to ensure a consistent approach to support and outreach programs for families.
 

In general, family members reported to my investigators that they are still not being provided with adequate information, help or support they believe they need. There are no specific dedicated programs to support the children of Canadian Forces members suffering from an operational stress injury.
 

Although some successful programs and initiatives exist, the majority of these are the fruits of individual efforts and not the result of a Canadian Forces-mandated standard or policy for the support and treatment of families. A good example of such initiative is the co-funding between the Department/Canadian Forces and the province of Ontario provided to the Phoenix centre in Petawawa to provide counselling for dependants affected by member’s deployments.
 

It remains, however, that the only Canadian Forces-mandated family support program we were made of aware of (other than the OSISS Family Peer Support Program), is a six-week information session for partners run by the OTSSCs. Other support programs or groups in place are there because the people who see the need for them have taken it upon themselves to implement them.
 

The Canadian Forces medical services group, through the Rx2000 mental health team, has also started to move ahead on the issue as part of its five-year implementation plan, which was scheduled to commence in 2005. Of the 200 new mental health positions within the Canadian Forces, 48 are designated to provide member orientated family focused care.  
 

The Canadian Forces response to this recommendation stated that Military Family Resource Centres are part of the solution to providing improved services and support to families of Canadian Forces members suffering from operational stress injuries. Military Family Resource Centres, however, report that they are not mandated, funded or staffed to provide long-term, ongoing support programs for families. Their mandate is limited to short-term individual counselling to family members, not group support. The mandated “Family Separation and Reunion”  program, referred to in the Canadian Forces’ response, provides information about how to deal with long separations and family reunion. We were informed by Military Family Resource Centre staff that the program does not provide information or support programs in the area of operational stress injuries for families.
 

Much work remains to be done in this area. Although initiatives are currently in progress, the Canadian Forces needs a national policy and standard to ensure consistent and coordinated support and outreach for families of Canadian Forces members suffering from operational stress injuries.

 

Recommendation 29

The Canadian Forces continue support for the Operational Stress Injury Social Support initiative and provide resources as required to extend this or similar programs across the Canadian Forces.
 

Status: Implemented
 

The OSISS group continues to be incredibly successful in dealing with the continuum of operational stress injury issues. The Canadian Forces needs to continue to support this initiative. Canadian Forces members who are suffering from an operational stress injury are not only effective, credible educators, but more importantly, are the people that, in many cases, members will initially approach for help and support.
 

There appears to be a high degree of support across the Canadian Forces for OSISS and its cadre of Peer Support Coordinators. However, both care providers and the chain of command have expressed concerns about individual workload and the capacity of the group to absorb the ever-growing burden.
 

The long-term welfare of the individual Coordinators is a serious concern to many. As future demands grow on OSISS (including the expansion into providing services to family members), careful oversight will be required to ensure that the OSISS group’s continued success does not come at the expense of the health and well-being of its individual members. This office fully supports the initiative by the OSISS Management Team to find and put in place assistance for individual Peer Support Coordinators.
 

As for the OSISS program, the Department and the Canadian Forces must continue to assess its growing needs on an ongoing basis, and continue to provide the appropriate levels of support.

  

Recommendation 30

The Canadian Forces initiate an end-to-end review of the rules dealing with confidentiality of medical information. In the short term, breaches of confidentiality must be dealt with quickly and visibly to re-establish confidence in the Canadian Force's commitment to protect personal information.
 

Status: Implemented

  

During the course of the initial investigation, instances were reported where it was common knowledge in a member’s unit that they were suffering from an operational stress injury, and they were being ostracized by superiors and peers as a result. This contributed to reluctance on the part of other sufferers to come forward to seek treatment.
 

However, considerable efforts have since been made to deal with this issue, and strict guidelines have now been put in place to ensure that a Canadian Forces member’s medical information is only accessible to those deemed to have a “need to know.”  
 

Although concerns were raised about the lack of communication between the medical profession and the chain of command at virtually every location my investigators visited, during the course of this latest review the intent of the original recommendation has been met, and requires no further action. However, the issue of effective communication in providing a balance between professional confidentiality and operational “need to know” will remain a challenge for the medical community and the chain of command.

  

Recommendation 31

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

  

There is a need to create a single point of contact for those operational stress injury issues that need to be coordinated across the Canadian Forces and the position should be at a high level, reporting directly to the Chief of the Defence Staff.
 

Instead of adopting this recommendation, the Canadian Forces chose to adopt two different strategies to coordinate operational stress injury-related activities and foster awareness and education. The Operational Stress Injury Steering Committee was created in May 2002 and is now chaired by the Chief of Military Personnel. The committee, made up of representatives of each major management group in the Department and the Canadian Forces, has a mandate to advance the awareness and acceptance of operational stress injury issues by all Canadian Forces members and to harmonize Canadian Forces policies to support these initiatives. The committee is programmed to meet twice a year, but has regrettably not met this schedule.
 

The Operational Stress Injury Steering Committee initiated a sub-group entitled the Mental Health Culture Change Task Force to clarify ongoing activities and provide coordination of existing educational initiatives. The task force was mandated to present a brief to the full committee on the state of operational stress injury initiatives; however, after its first meeting, the Steering Committee did not meet for over a year and the task force efforts were effectively abandoned.
 

The other mechanism for coordination of operational stress injury initiatives and to facilitate culture change was the appointment of two Operational Stress Injury Special Advisors to the Chief of the Defence Staff. Initially, the Director Training Education and Policy in the Director General Military Human Resources Policy and Planning section and the Canadian Forces Chief Warrant Officer were appointed to these positions with terms of reference issued in July 2002. The terms of reference specify that the positions are a “secondary duty” with access to the Chief of the Defence Staff on a regular basis but reporting to the Assistant Deputy Minister (Human Resources – Military), now the Chief of Military Personnel. Although tasked with responsibility to take the lead in representing the CD's interests in implementing solutions, working closely with the Committee and Environmental Chiefs of Staff, the Director Training Education and Policy was also a full-time director in the personnel organization with an exceedingly heavy workload. The responsibility now appears to have been passed to a Special Assistant to the Chief of Military Personnel as the Canadian Forces Mental Health Support Coordinator. During this investigation, Ombudsman investigators specifically looked for indications that this dual approach was having an effect. They were unable to find any indication that the Operational Stress Injury Special Advisors to the Chief of the Defence Staff had influenced or assisted the development of training or education in the Canadian Forces in any concrete way. The Special Advisors were unable to provide any reports or plans showing an attempt to measure the amount of training that is occurring, or to identify any gaps or inconsistencies, or to improve coordination. Both Advisors indicated that they had seldom been contacted for information or advice from the field. Personnel who are directly involved in the development of material in the education and training process eported that they were unaware of the Operational Stress Injury Advisor positions or what assistance they might be able to provide. This should not be construed as an adverse comment against either of the Advisors, both of whom our investigators found to be very dedicated and committed to improving awareness of operational stress injury-related issues. They are simply not positioned to carry out such a large and important task in addition to their other full-time duties. The coordination of operational stress injury initiatives in the Canadian Forces at the national level, across all environments, is a full-time job, deserving of the requisite resources.
 

The Steering Committee and the Advisor position created to advance the awareness and acceptance of operational stress injury issues by all Canadian Forces members and to harmonize Canadian Forces policies to support these initiatives, have failed to achieve any measurable degree of success.
 

The Steering Committee, although scheduled to meet bi-annually, went for 18 months between meetings, and much like the Special Advisors, the body was virtually unknown in the field.
 

The Operational Stress Injury Coordinators had all but disappeared. This responsibility has moved around within the Chief of Military Personnel organization and has now fallen to the Special Assistant to the Chief of Military Personnel. Due to the overlapping responsibilities within the Canadian Forces and the scarcity of resources, this coordination remains critical for both effectiveness and efficiency. It is clear that coordination of efforts has not yet been successful.
 

The formal response to this recommendation from the Canadian Forces stated that the item was closed. This is clearly not an issue that can be dismissed so easily. This investigation revealed that while much progress has been made with respect to the way in which members with an operational stress injury are treated in the Canadian Forces, there remains a persistent lack of awareness and acceptance of operational stress injury issues by some Canadian Forces members. This is exacerbated by the obvious lack of coordination of Canadian Forces policies to support the evolution of the necessary culture change within the military. I strongly disagree with this response. The Canadian Forces must develop the ability to provide effective, strategic coordination and oversight to their activities in dealing with operational stress injuries, especially in the areas of training and education.
 

Until this coordination and leadership at the national level is effectively implemented, this recommendation cannot be considered closed.
 

Table of Contents

 

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

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 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.

 


 

Annex B to
CDS 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)
 

  1. In collaboration with DGHS and VAC, coordinating the drafting of an over-arching OSI Campaign Plan.
     
  2. In collaboration with DGHS Occupational Health physicians, developing a non-clinical OSI disability management framework.
     
  3. Liaising with internal and external organizations on non-clinical approaches to dealing with OSIs.
     
  4. Proposing strategic concepts for non-clinical approaches to dealing with OSIs.
     
  5. 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.
     
  6. 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)
     
  7. 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.
     
  8. Developing, implementing, and monitoring the effectiveness of an internal OSI-education program and related information activities.
     
  9. Performing spokesperson role on non-clinical aspects of OSIs.
     
  10. Managing the OSI Speakers Bureau.
     
  11. Supporting CDA in the development of OSI training and education modules for all ranks.
     
  12. Developing pre- and post-deployment OSI modules.
     
  13. 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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