Speeches

Post-Traumatic Stress Disorder: A Canadian Perspective

By
Pierre Daigle, Ombudsman
for the Department of National Defence and Canadian Forces

April 27, 2010

Second International Conference of Ombudsman Institutions
for the Armed Forces

Vienna, Austria

Introduction

The Office of the Ombudsman was created in 1998 to increase openness and transparency in the Department of National Defence and the Canadian Forces, as well as to ensure the fair treatment of concerns raised by Canadian Forces members, departmental employees, and their families.

The office acts as a direct source of information, referral and education. It is also responsible for reviewing and investigating individual concerns and complaints from current and former Canadian Forces members, departmental employees, military family members and other constituents who believe that they have been treated improperly or unfairly by the Department of National Defence or the Canadian Forces.

More broadly, the Ombudsman has a mandate to investigate and make recommendations to improve the overall well-being and quality of life of the members of the Defence community. Investigations from the office have produced substantial and long-lasting improvements in the Canadian Forces, most notably in the area of post-traumatic stress disorder and other operational stress injuries. Indeed, since 2002, the Ombudsman’s office has done a significant amount of work regarding the care and treatment of Canadian Forces members who are suffering from mental health injuries.

This paper provides information on the investigations undertaken, and reports produced, by the Ombudsman’s office on the issue of post-traumatic stress disorder and other operational stress injuries. It also details some of the actions that have been taken following the Ombudsman’s work in 2008, as well as the Ombudsman’s future plans regarding mental health injuries in the Canadian.

Part 1: Original Investigation (and follow up) into Post-Traumatic Stress Disorder in the Canadian Forces

In 2002, the military Ombudsman investigated an individual complaint by a Canadian Forces member who was diagnosed with post-traumatic stress disorder related to his deployment to Croatia in 1994. The complainant alleged that, following his diagnosis, he was stigmatized and unjustly treated by the Canadian military.

The Ombudsman’s investigation determined that the complainant had, in fact, been stigmatized by his unit and been left with virtually no support system. At the same time, the investigation found that this was a widespread problem in the Canadian Forces. In releasing his special report, entitled Systemic Treatment of CF Members with PTSD¹, the Ombudsman 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 the illness 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 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 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 report², which indicated that a number of new initiatives 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 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 follow up report, the Ombudsman made a commitment to continue to monitor this issue.

Part 2: Follow up Investigation into Post-Traumatic Stress Disorder and other Operational Stress Injuries

In December 2008, the Ombudsman’s office published a second follow up report, entitled A Long Road to Recovery: Battling Operational Stress Injuries³, intended to track the progress made by the Department of National Defence and the Canadian Forces in implementing its 2002 recommendations. The report also highlighted some new and evolving issues and problems. The overriding aim of the office, however, was to establish whether Canadian Forces members who suffered from post-traumatic stress disorder or other operational stress injuries were being diagnosed and getting the care and treatment they needed in order to continue to be contributing members of Canadian society – either within the Canadian Forces or as civilians.

After an extensive investigation, the office found that the Department of National Defence and the Canadian Forces had made progress in addressing many of the issues and challenges related to mental health injuries. However, investigators also determined that there continued to be cases where injured soldiers, sailors, airmen and airwomen, who had served their country with courage and dedication, were slipping through the cracks of an ad hoc system.

The report outlined a number of areas in the military’s approach to operational stress injuries where confusion and discrepancy remained, and where progress continued to be slow. Investigators found that high-level direction and national coordination was still sporadic; efforts to standardize care and treatment across the Canadian Forces were inconsistent; the collection of national data and statistics was insufficient; performance measures to evaluate local and regional approaches and programs were lacking; and the strong commitment from senior leadership regarding operational stress injuries had not reached everyone.

The report also recognized the dramatic impact operational stress injuries can have on military families. Investigators found a number of individual cases where military members and/or their families were not treated fairly by the Canadian Forces or did not get access to the care and treatment that they needed. It was clear that access to quality care depended on a number of arbitrary factors, including: where the military member lived, 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.

In addition to inconsistent care for military members and their families, investigators also discovered a shortage of caregivers including chaplains, social workers, physicians, psychologists, psychiatrists and mental health nurses. This shortage, coupled with an increasing demand for their services, had 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.

In releasing A Long Road to Recovery: Battling Operational Stress Injuries, the Ombudsman made nine recommendations to the Minister of National Defence which were intended to ensure that mental health sufferers in the Defence community received consistent, quality and timely care. These recommendations were as follows:

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.

In the report, the Ombudsman also stated that these recommendations would form the basis of all future monitoring and reporting by the office.

A Case Study: Assessing the State of Mental Health Services at CFB Petawawa

As part of the office’s investigation into the issue of post-traumatic stress disorder and other operational stress injuries, the Ombudsman’s office travelled to Canadian Forces Base (CFB) Petawawa to assess the mental health services that were available to military members and their families at the base and in the local area⁴.

Since 2002, more than 8,500 Petawawa-based personnel had deployed to Afghanistan. Given this intense operational tempo, and taking into account the hazardous nature of the Afghanistan operation and the isolated geographical location of CFB Petawawa, the Ombudsman believed that this base would be a valuable case study in the office’s broader investigation regarding the issue of post-traumatic stress disorder and other operational stress injuries in the Canadian Forces.

The Ombudsman’s office had also received complaints indicating that there was a lack of appropriate mental health care for soldiers and their families who were desperately trying to cope with significant stresses related to deployment and, in particular, Afghanistan.

During the fact-finding visit, the Ombudsman was informed of two problems, in particular, that were having a real and negative impact on Canadian Forces members and their families at the base, namely: the overall lack of health care at the base, and in the immediate area, to identify and care for individuals with mental health injuries; and the noticeable burnout of military caregivers at all levels.

There was a general consensus among those interviewed by the Ombudsman that it was extremely difficult and time-consuming for a Canadian Forces member to get a diagnosis of, and rehabilitative care for, a mental health injury or illness at CFB Petawawa. Furthermore, the Ombudsman was told that the type of rehabilitative care generally recommended by doctors in Ottawa was not available at CFB Petawawa.

At the same time, the availability of services aimed specifically at the overall health and well-being of the family unit was not only found to be insufficient, but was being reduced. Access to base social work counselling sessions by military families were limited to those sessions in which the military member participated, which served to drastically limit the availability of care since military members are often away from base on training or deployment. It also served to limit the effectiveness of the care available, as family members are often reluctant to fully express their concerns in the presence of their military loved one who may be experiencing severe difficulties.

It was also clear that the caregivers at CFB Petawawa were struggling to meet the increasing demand for their services with the limited resources available to them.

As part of this case study, released in December 2008, the Ombudsman made seven recommendations aimed at improving the quality and timeliness of mental health services and treatment available to Canadian Forces members and their families at CFB Petawawa.

Part 3: Actions Undertaken Following the Ombudsman's Work

Following the publication of the Ombudsman’s special report in 2008, the Department of National Defence and the Canadian Forces announced two initiatives to address some of the Ombudsman’s concerns and recommendations.

In May 2009, the Minister of National Defence announced the expansion of the Joint Personnel Support Unit to an additional eleven locations dedicated to the care of ill and injured Canadian Forces personnel, former personnel, their families and the families of the deceased. The Joint Personnel Support Unit and its integrated support centres, totaling 19 locations across the country, provide ill and injured Canadian Forces members, veterans and their families access to an integrated ‘one-stop service’ that brings together a number of Veterans Affairs Canada and Canadian Forces programs and services.

In June 2009, the Chief of the Defence Staff launched the Canadian Forces Mental Health Awareness Campaign with the objective of educating Canadian Forces personnel on mental health issues and building a culture of understanding. The campaign’s theme of “Be the Difference” encouraged all Canadian Forces personnel – from Sergeants to Generals/Admirals – to make a difference to those affected by mental health issues.

Also in June 2009, the House of Commons Standing Committee on National Defence finalized its long-term study on military health care and released a report, Doing Well and Doing Better: Health Services Provided to Canadian Forces Personnel with an Emphasis on Post-Traumatic Stress Disorder⁵. As part of the committee’s examination of the root causes of difficulties facing military health care, the Ombudsman was asked to discuss the key findings and recommendations in our December 2008 special report on operational stress injuries. This testimony was referenced throughout the parliamentary committee’s final report.

In terms of its findings, the House of Commons Standing Committee on National Defence verified many of the Ombudsman’s conclusions including the fact that post-traumatic stress disorder and other operational stress injuries are a significant problem for the Canadian Forces and the Government of Canada. Using statistics generated from screening questionnaires of military personnel, the committee estimated that, of the 27,000 Canadian Forces members who had served in Afghanistan between 2002 and 2008, approximately 1,120 could exhibit symptoms of post-traumatic stress disorder and 3,640 could exhibit some sort of mental health concern. These statistics do not take into account those Canadian Forces members who have served in Afghanistan after 2008, nor do they consider the military personnel who served in dangerous and demanding military operations before the Afghanistan mission (including the Balkans, Rwanda, and others).

The parliamentary committee also echoed a number of the Ombudsman’s most serious concerns related to post-traumatic stress disorder and other operational stress injuries, including:

• the negative attitudes toward mental health issues in the Canadian Forces;
• inconsistent care that left many Canadian Forces members ‘falling through the cracks’;
• the shortage of professional health care providers;
• the requirement for better tracking mechanisms for mental health sufferers; and
• the need to do more for the families of Canadian Forces members suffering from post-traumatic stress disorder or other operational stress injuries.

In releasing its report, the parliamentary committee made 36 recommendations to address the problems in the health services available to Canadian Forces members suffering from post-traumatic stress disorder, many of which reinforce the work of the Ombudsman’s office. Of particular note was recommendation 11, which stated, “The Canadian Forces should formally recognize the requirement to include, where appropriate, selected family members in the treatment regime of psychologically injured personnel and take measures to ensure they are consulted and included in treatment plans, to the extent it is helpful to do so.”⁶

In addition, recommendation 33 called on the Canadian Forces to provide the “Committee, the Auditor General of Canada and the Department of National Defence and Canadian Forces Ombudsman with a full, unclassified update of the status of the Canadian Forces Health Information System, along with a meaningful explanation of when it will reach full operational capacity.”⁷

The Government of Canada agreed with all of the proposed recommendations in the report from the House of Commons Standing Committee on National Defence; although, in some cases, it proposed alternative means of implementation.

Part 4: Ombudsman's Plans Regarding Post-Traumatic Stress Disorder and Operational Stress Injuries

The Ombudsman and the Ombudsman’s office have announced publicly in the past six months that the office will be launching a third follow-up investigation into the issue of post-traumatic stress disorder and other operational stress injuries in the Canadian Forces. While recognizing that progress has been made by the Canadian Forces to prevent, identify and treat military personnel suffering from mental health injuries, the large number of current military sufferers – and even larger number of anticipated sufferers – has led the Ombudsman to the conclusion that this issue demands additional review and evaluation by the office. The Ombudsman has also made it clear that he remains concerned about a number of problems related to mental health injuries that have yet to be addressed – or adequately addressed – by the Canadian Forces.

For example, the Canadian Forces still does not track information and statistics that adequately reflect the number of military personnel who are affected by stress-related injuries. As a result, it is impossible to say exactly how many people are affected by operational stress injuries. One of the original 31 recommendations made by the Ombudsman’s office in 2002 was that the Canadian Forces should create a database that would allow them to track the number of people who are affected by stress-related injuries. Unfortunately, this has not yet been completed. Without reliable data, it is very difficult to understand the extent and seriousness of the problem – and design and implement effective national programs to help those suffering from an operational stress injury. This data could also be used to target education and training initiatives where they are most needed.

Another issue that the Ombudsman will be tracking more closely in the months to come is the care and treatment available to the families of military members suffering from operational stress injuries. The Ombudsman’s 2008 investigation was 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. Yet, when a Canadian Forces member has an operational stress injury, it is a significant challenge for the whole family, not just the member. So this will be a priority the office in the upcoming follow-up investigation.

Planning for the third follow-up investigation on the issue of post-traumatic stress disorder and other operational stress injuries will begin in the summer of 2010. As a starting point, the office will evaluate the status of the nine recommendations made in its 2008 special report, A Long Road to Recovery: Battling Operational Stress Injuries.

Conclusion

Since 2002, the issue of post-traumatic stress disorder and other operational stress injuries as been a – if not the most – significant priority for the Ombudsman’s office. The office has conducted a special investigation and two follow-up reviews/investigations resulting in the publication of three reports and more than forty recommendations aimed at ensuring that Canadian Forces members suffering from post-traumatic stress disorder or other operational stress injuries are properly diagnosed and receive the care and treatment they require so that they can continue to be contributing members of Canadian society. 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 of National Defence, the Canadian Forces and the Government of Canada as a whole. And it will remain a priority for the Ombudsman’s office.

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