Special Reports

A Long Road to Recovery: Battling Operational Stress Injuries

December 2008

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.

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.

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.

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.

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.)

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.

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.

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.

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.

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.

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.

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.

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.

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.

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

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.

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.

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.

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.

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.

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.

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.

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.”

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.

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.

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.”

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.

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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.

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.

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.

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.

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 CDS’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.

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