Full Report in PDF English http://www.ombudsman.forces.gc.ca/rep-rap/sr-rs/fuf-csf/doc/fuf-csf-eng.pdf
Full Report in PDF FRENCH http://www.ombudsman.forces.gc.ca/rep-rap/sr-rs/fuf-csf/doc/fuf-csf-fra.pdf
Fortitude Under Fatigue: Assessing the Delivery of Care for Operational Stress Injuries that Canadian Forces Members Need and Deserve is the third follow-up by the Ombudsman for the Department of National Defence (DND) and the Canadian Forces (CF), evaluating the CF's ability to respond to the challenge of post-traumatic stress disorder (PTSD) and other operational stress injuries (OSIs). This report was based on the initial evaluation conducted in early 2002, and two follow-up reports in late 2002 and 2008. It also incorporated the Ombudsman's case study of the mental health situation in Petawawa carried out in 2008.
The study focused exclusively on Regular Force members of the CF and their families because a companion study specifically targeting the Reserve Force and OSIs will be conducted as a follow up to this investigation. It is expected to be completed by the end of 2013. While families were covered in this report, they will equally be the subject of a more focused analysis which is underway and will be completed in mid 2013.
A review of DND/CF action in response to the nine recommendations of the previous 2008 follow-up Ombudsman's report A Long Road to Recovery found that six of these were met, partially met or were being met, while two were considered inconclusive. One recommendation, the requirement for a national database accurately reflecting the magnitude of the CF's evolving OSI imperative, was not met. A summary of these recommendations is provided at annex A – Progress Report Summary.
Several observations and concerns were identified as part of this evaluation of the 2008 recommendations. The most significant is the considerable gap which remains between the capability to deliver the care CF members with OSIs need and deserve, and the actual capacity to deliver it. This gap is primarily the result of a chronic inability to achieve, or come close to achieving, the established manning level of the mental health function. The impact this has had on the frontline delivery of care, treatment and support to CF members with PTSD and other OSIs and their families has been profound.
Another concern is the extent to which enhanced support to military families coping with CF members with OSIs is coherent and effective in meeting their needs. The report also underscores the inability to assess the appropriateness of DND/CF funding allocated to the OSI imperative, along with the difficulty in evaluating whether the current mental health structure is sufficiently robust to meet the requirement. Finally, it highlights the reality that while operations in Afghanistan have wound down after more than a decade, the OSI burden remains at peak intensity, and will continue at this level for several years yet. This is the result of the latent nature of the affliction, combined with the mounting cumulative burden resulting from 20 years of almost continuous CF operations.
Fortitude Under Fatigue's over-arching observation is that while the CF's capacity to meet the PTSD/OSI challenge is functioning, it is doing so largely due to the determination and commitment of the mental health providers who continue to deliver quality frontline care despite being severely overburdened and operating in difficult professional environments. The function is clearly strained.
Implementation of the recommendations made in the 2008 case study Assessing the State of Mental Health Services in Petawawa was also examined in detail. Of the seven recommendations in the case study, three were considered fully met and three partially met. One recommendation was no longer applicable. This assessment is also included in annex A.
Major observations and concerns regarding Petawawa include the dramatic increase in mental health provider manning, though a chronic shortfall persists. The continuing challenge of military families coping with members with operational stress injuries was observed despite important enhancements to family care and support. Overall, while Petawawa's mental health capacity has improved appreciably, it remains strained, reflective of the CF-wide situation.
In addition to the recommendations, Fortitude Under Fatigue flagged a number of key findings observed over the course of the study. These are captured at annex B – Summary of Findings. The favourable findings included: the progression from an ad hoc system into a comprehensive OSI care capability, though one that is still transitioning into a single coherent system; the commitment to the OSI issue of DND/CF strategic leadership, resulting in the inculcation of PTSD/OSIs across the CF as an accepted reality of modern military service; the professionalism, passion and dedication of DND/CF mental health providers, which has kept the capability functioning despite serious impediments; reduced barriers to care including an important reduction in the stigma surrounding OSIs, allowing CF members to come forward and seek the care they require more readily; and improved support to military families coping with CF members suffering from OSIs, predicated on the inextricable link between OSI-related care and stable family environments.
The less favourable findings include the previously mentioned chronic manning shortfall in spite of ongoing recruiting efforts and mitigation measures, representing a frontline caregiver deficit of 15-22% for the CF's steady state mental health requirement; extensive outsourcing of treatment for CF members suffering from OSIs with the limitations inherent in such outsourcing; poor situational awareness of strategic and functional leadership of the magnitude of the OSI imperative as it evolves over time; and an ad hoc approach to systemic qualitative performance measurement which has hindered the CF's ability to assess the effectiveness of its OSI capability.
Fortitude Under Fatigue concludes with six specific recommendations, summarized at annex C – Summary of Recommendations. The first is that the CF must maintain the current institutional focus on the provision of appropriate care, treatment and support for CF members suffering from PTSD and other OSIs in spite of the natural deceleration resulting from the close of major operations in Afghanistan along with various corporate pressures, including renewed fiscal restraint.
The second recommendation is that the CF develop and implement a more assertive and innovative recruiting campaign aimed at reducing the persistent caregiver manning shortfall.
Recommendation three urges the CF to undertake systemic qualitative performance measurement aimed at assessing the effectiveness of its response to the PTSD/OSI imperative.
Recommendation four calls for a holistic evaluation of the CF's current mental health capacity a decade after it was first implemented.
The fifth recommendation encourages the CF's strategic leadership to examine the palpable and growing tensions between commander and clinician and commander and administrator relative to the medical care and administrative support for CF members suffering from OSIs.
Finally, recommendation six calls for the CF's strategic leadership to consider the viability of a more modern application of the principle of universality of service amidst concerns about the institution's continued moral commitment to its members.
Section 1: Background
"I believe we have one of the best military health-care systems amongst our allies and are leaders in health care in this country. But we are far from perfect."2
– Chief of the Defence Staff General Walter Natynczyk,
Initial PTSD Report. On February 5th, 2002 the Ombudsman for the Department of National Defence and the Canadian Forces (DND/CF) published a special report entitled Systemic Treatment of CF Members with PTSD.3 It evaluated the CF's ability to respond effectively to the modern mental health challenge driven largely by post-traumatic stress disorder (PTSD).
The report rendered two major conclusions: (1) PTSD was a serious and growing problem for the CF and (2) the CF's approach to mental health injuries generally, and PTSD specifically, was inadequate.
These conclusions were reinforced by 31 specific recommendations designed to improve DND/CF's ability to diagnose, treat and care for members suffering from PTSD. These recommendations spanned the mental health care continuum, addressing institutional leadership and coordination; national tracking; awareness, education and training; standardized treatment; and caregiver stress and burnout.
First Follow-up Report. In December 2002, ten months after the initial report, the Ombudsman released an initial follow-up examining DND/CF action in response to the 31 recommendations.4 This report determined that clear progress had been made despite the short interval, especially the heightened awareness of senior leadership of the importance of mental health injuries. The lack of progress in key areas such as organizational stigma, training, data collection, and national coordination was equally noted. The report concluded with a commitment by the Ombudsman to continue monitoring DND/CF progress in addressing the escalating PTSD challenge.
Second Follow-up Report. A second follow-up report on PTSD and other operational stress injuries (OSIs) entitled A Long Road to Recovery was released by the Ombudsman in December 2008 – six years after Systemic Treatment of CF Members with PTSD.5 Its objective was to track the organization's progress during this decisive interval, dominated by operations in Afghanistan. In assessing the forward movement, the study posed the fundamental question: Are CF members suffering from PTSD and other OSIs being diagnosed and getting the care and treatment they need to continue contributing to Canadian society, either as members of the CF or as civilians?
The report concluded that while there had been considerable progress across the care spectrum from 2002 to 2008 due to new OSI-specific policies, structural improvements and methodological adjustments, some members were still slipping through the cracks and not receiving the attention and care they needed.
The report also identified the prevailing organizational barriers to care: proximity to urban centers, the availability of mental health care professionals, and persistently negative attitudes of both superiors and peers towards those suffering from mental health injuries. In addition, the report lamented the absence of coordinated national support for the families of military members who were suffering from operational stress injuries. It found that accessing care and support was especially difficult for families living in isolated military locations. The lack of a national database allowing the CF to track the scope of the PTSD/OSI issue as it evolved was underlined as well.
Positive developments were also recognized. The report highlighted an improvement in identifying, preventing and treating mental health injuries; a more robust mental health capability at the local level; better pre- and post-deployment screening; and the addition of a post-deployment decompression phase to operational deployments. DND/CF's continued commitment to peer support through the Operational Stress Injury Social Support program was recognized as another positive step.
Finally, the announcement (coincidental to the release of A Long Road to Recovery) that the CF's mental health capacity would grow by 218 care providers and managers by end-March 2009 was praised. This increase would almost double the CF's existing mental health establishment. It was hoped that such a dramatic increase would alleviate the strain the Canadian Forces Health System was under in dealing with both the latent mental health care requirements of various CF missions of the 1990s in the Balkans, Africa, Southeast Asia and the Americas, and the new demand generated from ongoing operations in Afghanistan.
A Long Road to Recovery concluded with nine recommendations which required further DND/CF action, several of which were reprised from 2002's Systemic Treatment of CF Members with PTSD report. The Interim Ombudsman reaffirmed her commitment to tracking DND/CF's continued progress on this issue.
Canadian Forces Base Petawawa Case Study. Concurrent to A Long Road to Recovery, a companion case study was produced by the Office of the Ombudsman in December 2008 examining the situation at Canadian Forces Base Petawawa.6 The study, Assessing the State of Mental Health Services in Petawawa, was considered necessary due to a combination of factors: the exceptionally high operational tempo the base experienced from 2002 onward, the volatile nature of the operations its members were engaged in during that period, the base's geographic isolation, the considerable volume of complaints from Petawawa to the Office of the Ombudsman between 2002 and 2008, and a request from the Base Commander to the Ombudsman to look into the situation at Petawawa.
The case study yielded three conclusions. First, it determined that a critical lack of mental health care capability existed in Petawawa and the outlying area, often making it difficult and at times impossible for members suffering from PTSD or other OSIs to receive timely and appropriate care. The second was a palpable professional fatigue, and in numerous cases burnout, among Petawawa mental health providers as a result of excessive demand and insufficient resources. And the third was a negative, sometimes toxic, operating environment in which the relationships between primary health providers, mental health caregivers, and the chain of command were generally very poor, adversely impacting the care provided to those suffering from PTSD and other OSIs.
Seven recommendations deemed necessary to stabilize the PTSD/OSI situation at Canadian Forces Base Petawawa closed out the report. The recommendations addressed the deficit in mental health caregivers, the base's muddled health services governance structure, the deterioration of relationships between providers, the need for interim approaches pending long-term solutions, and the importance of helping the families of service members suffering from OSIs access available care and support.
Standing Committee Report. In June 2009, the Parliamentary Standing Committee on National Defence released Doing Well and Doing Better; Health Services Provided to Canadian Forces Personnel with an Emphasis on Post Traumatic Stress Disorder.7 The study assessed the care provided to Canadian Forces members suffering from operational stress injuries from a whole-of-government perspective. It included testimony from the DND/CF Interim Ombudsman on the findings of A Long Road to Recovery.
The Standing Committee concluded that three over-arching issues were at the root of much of the challenge facing the CF in caring for members with PTSD. First, stigma towards those suffering from PTSD/OSIs remained prevalent. Second, a discrepancy between what was stated at the strategic level and what was happening at the unit and clinic level was detrimental. Third, the continued shortage of mental health professionals was impeding the delivery and sustainability of care.
Doing Well and Doing Better called for revitalized leadership involvement, as well as improved programming and services. It identified 36 recommendations on themes such as caregiver shortages, care for families, casualty tracking, and stigma reduction. Many of these were very similar to recommendations in A Long Road to Recovery.
Third Follow-up Report. This sequence of events is the prelude to Fortitude under Fatigue; Assessing the Delivery of Care for Operational Stress Injuries that Canadian Forces Members Need and Deserve, the third follow-up report by the Ombudsman of the Department of National Defence and the Canadian Forces examining DND/CF's response to post-traumatic stress disorder and other operational stress injuries.
Format. This report consists of four distinct sections. This first section outlines the background leading to this report. The second section delivers a progress report on the nine recommendations from A Long Road to Recovery and the seven recommendations from Assessing the State of Mental Health Services in Petawawa. The third section contains the findings beyond these 16 specific recommendations, while the fourth identifies the key recommendations necessary for the CF to meet the OSI challenge moving forward.
Additionally, synopses of the progress report (section 2), findings (section 3) and recommendations (section 4) are presented in annexes A, B and C.
Limitations. This report is based upon extensive research. Over a ten-month period of study, eight bases were visited, 216 formal interviews were conducted and over 480 individuals interviewed or consulted, many more than once.8 These included DND/CF strategic leaders, commanders and supervisors at all levels of the chain of command, senior staff officers and planners, medical professionals and managers, administrative support staff, researchers, external experts, and other stakeholders of note.
Military members themselves were interviewed as well, both those suffering from PTSD/OSIs and those not. Family members of CF service personnel suffering from PTSD or other OSIs were also consulted. The information obtained from all of these interactions, reinforced by over 650 references and documents, form the backbone of this report.9 Almost without exception, those engaged were respectful, forthright and gracious, including those who were suffering. The Office of the Ombudsman extends its heartfelt appreciation to every individual who contributed to this endeavour.
As with its precursors, this report was developed with a single objective; to deliver an accurate and fair representation of DND/CF's ability to identify, prevent and treat post-traumatic stress disorder and other operational stress injuries. While the Office of the Ombudsman is confident that the portrait presented in this report is precise and balanced, the challenges often involved in large, complex studies came to bear in this project. The sheer volume of information, combined with the number of players, perspectives and jurisdictions, resulted in contradictions and inconsistencies that were not always easily reconciled. Moreover, several key information gaps had to be contended with despite the mountain of evidence.
Each conclusion which follows is rooted in verifiable fact. Potential conclusions which could not be fully proven were discarded, no matter how compelling. Where conclusion cedes to observation or concern, the transition is explicitly indicated.
Time and space is an inevitable challenge in such a large analysis. The DND/CF mental health capability continues to evolve, as it should. Some information gleaned in the summer of 2011 had changed by spring 2012, and may well be different again in winter 2012 or summer 2013. As such, this report is a snapshot in time – it cannot be otherwise. However, the continuum of this series of reports, beginning with 2002's Systemic Treatment of CF Members with PTSD through to this concluding follow-up, presents a clear and revealing trajectory of the DND/CF mental health capability over time. As a result, the value of the findings and conclusions contained herein extend beyond the timeframe of publishing.
Terminology is important in an analysis as complex as this. In the interests of clarity, the term capability refers to the intended ability to achieve a desired effect under specific standards and conditions, while the subset term capacity refers to the actual ability to achieve a desired effect under specific standards and conditions.10 More simply stated, the capability is that which is planned for, structured and intended, while the capacity is that which is tangibly in place and actually delivering results. This distinction is crucial to the analysis which follows.
This study focuses exclusively on Regular Force members with OSIs and their families. The omission of Reserve Force members is intentional – the scope of the Reserve care dimension of the OSI issue is sufficiently important to warrant its own examination. Consequently, care for Reservists suffering from OSIs is the sole focus of the forthcoming Office of the Ombudsman Reserve OSI Report, which will be completed by the end of 2013.
As this report will outline, there are few straight lines in assessing DND/CF's capability to meet the PTSD/OSI challenge. An issue as complex as operational stress injuries, tackled by an organization as diverse as the Canadian Forces, all but eliminates the possibility of simple, over-arching solutions. Recent history in this country and abroad has proven that there are few quick fixes related to OSIs.
While much improved, the CF's mental health capability is not perfect, as the institution's strategic leadership has admitted, and there is still important work to be done. There have been many hits and some misses since 2002, and forward progress has at times required some lateral movement.
The one unwavering straight line, though, has been the passion and commitment of those on the frontlines of this effort. The ceaseless devotion of the medical professionals, care providers, managers, clerical staff, and peers both enabling and delivering care has been the single constant throughout this analysis.
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Section 2: Progress Report
Assessing the Recommendations of A Long Road to Recovery and Petawawa Case Study (2008)
"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".11
– Excerpt from A Long Road to Recovery, December 2008.
Recommendations – A Long Road to Recovery
Recommendation 1: National Operational Stress Injury (OSI) coordinator
In December 2008 A Long Road to Recovery recommended:
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.
This follow-up review has determined that this recommendation has been met.
As outlined in both the Minister of National Defence and Chief of the Defence Staff formal responses to A Long Road to Recovery, the Chief of Military Personnel was confirmed as the Canadian Forces' (CF) national lead on operational stress injuries, reporting directly to the Chief of the Defence Staff on all related matters.12,13 As the functional authority for health services, casualty support, and family support, among other portfolios, it was the position of both the Minister of National Defence and the Chief of the Defence Staff that creating an OSI entity or office independent of the Chief of Military Personnel structure would separate responsibility from accountability.
To increase the Chief of Military Personnel's ability to focus directly on the OSI imperative amidst his spectrum of responsibilities, the position of OSI Special Advisor was established in May 2008.14 A Lieutenant Colonel position, the OSI Special Advisor was mandated to oversee the management of non-clinical matters related to OSIs, including the creation of an education campaign to raise awareness of operational stress injuries. The OSI Special Advisor provided input on budget, business planning and hiring imperatives, and contributed to the development and delivery of OSI awareness curriculum. He also supported and advocated for continued social and peer support.
In January 2009, the Directorate of Mental Health was created.15 Its mission was to provide a single focus for mental health-related activities and programs within the CF. Such a focal point was considered essential due to the scale and intensity of the mental health function in its brisk evolution during the post-Rx2000 period of 2002 to 2008. Launched in January 2000, Rx2000 was the Canadian Forces Health Services' comprehensive reform project. It focused on the four pillars of continuity of care, accountability, health protection and sustainability of health services human resources.
The responsibilities of the new Director of Mental Health, a clinician at the rank of colonel reporting directly to the Deputy Surgeon General, included:
* ensuring adequacy of clinical resources to meet mental health treatment needs;
* ensuring coherence between clinical, occupational, peer support, educational, preventive, and family support aspects of mental health care;
* monitoring performance of CF initiatives pertaining to mental health including reporting on status, and benchmarking against our major allies;
* maintaining awareness of best practices and clinical research relevant to mental health problems of interest to the CF;
* ensuring ongoing coordination with Veterans Affairs Canada, select bodies such as the Canadian Mental Health Commission and other stakeholders; and
* acting as a preferred CF spokesman on matters related to mental health.
Additionally, the role of Mental Health and Psychiatry Advisor reporting to the Surgeon General was established in January 2010. Serving in tandem with the Director of Mental Health as the senior advisor on all mental health matters, the Mental Health and Psychiatry Advisor supports the mental health professional technical network, executes national mental health outreach activities, and serves as a senior spokesperson on mental health issues.
The stand-up of both the Director of Mental Health and the Mental Health and Psychiatry Advisor positions in rapid succession (2009-2010), twinned with the progress achieved in the period of the mid to late-2000s in institutionalizing the pertinence of the mental health imperative within the CF, led the Chief of Military Personnel to decide in 2011 that the OSI Special Advisor role was no longer required.16 The levels of mental health inculcation and engagement at all levels of CF leadership were considered irreversible, and thus no longer dependent upon a single active champion – a function the OSI Special Advisor had ably performed since the position's inception. Moreover, the overlap in responsibilities between the OSI Special Advisor and Director of Mental Health/ Mental Health and Psychiatry Advisor was considered an opportunity to rationalize the structure without any drop-off in performance. Consequently, as of 2012's active posting season the position will no longer be filled.
It is clear that the senior OSI advisory function has been effective in supporting Department of National Defence (DND) and CF leadership, and bringing coherence and coordination to the mental health effort. While the route taken to achieve this was not that proposed in the recommendation from A Long Road to Recovery, the capacity sought has been achieved. The Chief of Military Personnel, supported by various permutations of OSI Special Advisor, Director of Mental Health and Mental Health and Psychiatry Advisor (directly and via the Surgeon General), has consistently provided the situational awareness, advice and guidance necessary for strategic leadership to exercise decisive direction on the OSI imperative. Moreover, the senior OSI advisory function has played a central role in enabling DND/CF's sustained institutional focus on operational stress injuries.17,18 Accordingly, the recommendation is deemed met.
The evolution of the senior OSI advisory role has brought forward one concern pertaining to the balance of perspectives. The interim construct in which the Chief of Military Personnel was advised by both the OSI Special Advisor and the Director of Mental Health/Mental Health Advisor ensured a combination of clinical and non-clinical perspectives to DND/CF strategic leadership.
While the pertinence of mental health has become firmly entrenched within DND/CF on an institutional scale over the period of the early 2000s to 2012, the role of OSI Special Advisor went beyond this promotional function. He was central to education, partnerships, and non-clinical approaches to treatment including social peer support. The decision not to renew the OSI Special Advisor could limit the extent of non-clinical 'operator' input the Chief of Military Personnel receives as both the Director of Mental Health and Mental Health and Psychiatry Advisor view the OSI imperative through the clinician's prism.19
If the CF continues to adhere to the mixed approach of leveraging both clinical and non-clinical means in addressing the OSI imperative, as it has committed to since 2001 with the inception of the OSI Social Support program and reaffirmed repeatedly since then, reducing the senior advisory function to a single perspective may not be optimal. The inherent interplay between clinicians and non-clinicians has served the CF well in recent years in maintaining a balanced approach to addressing PTSD/OSIs based on both professional medical care and social peer-based support. The continued application of this mixed approach may become vulnerable with the removal of the OSI Special Advisor from the senior advisory equation.20
The Director Casualty Support Management has been designated to assume most of the OSI Special Advisor's duties, though it is not known whether he will be able to focus on the requirement to the extent his predecessor did due to the considerable breadth of his responsibilities. Moreover, much of the OSI Special Advisor role appears to have been formally and informally rolled into the functions of the Director of Mental Health and Mental Health Advisor, potentially limiting the Director Casualty Support Management's involvement. While the latter has provided, and will continue to provide, the Chief of Military Personnel with input and situational awareness obtained through his role as commanding officer of the Joint Personnel Support Unit, it is uncertain whether he will have the capacity to focus on the other aspects of the OSI Special Advisory function.
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Recommendation 2: National OSI database
In December 2008 A Long Road to Recovery recommended:
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.
This follow-up review has determined that this recommendation has not been met.
The closest the CF has come to implementing a national PTSD/OSI database is the Canadian Forces Health Information System, a CF-wide electronic medical information database designed to manage health information efficiently in support of decision-making and enhanced operational effectiveness. It is intended to deliver integrated, automated health information for every serving member of the Regular and Reserve Force, based both in garrison and deployed around the globe. The Canadian Forces Health Information System is a relatively new tool having only been completed in spring 2012, though it has been used for some time in its iterative form.
There are important limitations with the Canadian Forces Health Information System as a generator of a national OSI database. The first is its role. At present it can provide only basic reporting information on resource utilization, relating type of resource with location of patient, appointment type and availability. Obtaining a national portrait of any specific illness or injury, OSIs or otherwise, requires the extraction of large volumes of raw data based on specifically inputted parameters, followed by a detailed, labour-intensive interpretation of that data by the Canadian Forces Health Services epidemiological team. Without these steps the data is largely incoherent. A full week is generally necessary for this interpretation, subject to the availability of an epidemiologist.21
The second limitation is that the inclusion of mental health notes into the Canadian Forces Health Information System was not foreseen when the project was originally designed. As a result, notes from mental health caregivers cannot be inputted into the system as presently configured, and there is currently no firm direction regarding if or when this might change. Technically, the Canadian Forces Health Information System has the capacity to incorporate these mental health notes if the project parameters are adjusted, much as it has the potential to be used as a more responsive reporting tool if this is deemed a priority. However, such decisions have not yet been made. In the estimate of a senior CF medical authority intimately familiar with the Canadian Forces Health Information System, if the system was to be modified to regularly report on the OSI issue CF-wide (and there is as yet no indication that it will be) this would be unlikely before 2014-2015 at the earliest.22
Since 2000, the Canadian Forces has conducted considerable research on the impacts of mental health conditions, and continues to study this. The fall 2011 report entitled Cumulative Incidence of PTSD and Other Mental Disorders in Canadian Forces Personnel Deployed in Support of the Mission in Afghanistan 2001-2008, executed by the Deployment Health team within the Directorate of Mental Health, is one such research initiative.23 Measuring the incidence rate of CF personnel deploying to Afghanistan between 2001 and 2008, the study provides detailed estimates of the fraction of deployed personnel diagnosed with an OSI over a prolonged period following their return. The report equips the CF with a strong indication of the scope of the OSI imperative specific to Afghanistan, and is especially valuable as a predictive tool for projecting future care requirements. It is consistent with the CF Health Services' research approach of informing the future rather than pinpointing the present or comparing with the past.
Though this research will assist the Canadian Forces to anticipate the impacts of OSIs in contemplating and planning future deployments, it does not consider the OSI incidence for missions other than Afghanistan, nor does it account for the cumulative aspect of operational stress injuries amongst CF members. As such, it is unable to provide institution-wide, single-stop tracking of the OSI issue at regular, specific intervals as it evolves over time.
The CF has placed considerable emphasis on the Enhanced Post-Deployment Screening process as a means of better assessing the health status of members upon their return from operational missions, including their mental health. By extension, this provides additional insight into the scope of the OSI issue.24 The screening, undertaken as of 2007, is designed for all members deploying to an operational theatre for a minimum of 60 days, and is administered within three to six months following their return. Regrettably, the results of this enhanced screening are adversely affected by a response rate of only 76%.25 A full quarter of those returning from deployment are not evaluated, offering the possibility of skewed results. Moreover, a number of recently deployed members indicated that the questionnaire was 'easy to beat' – that is they were convinced they could hide or withhold information pertaining to their mental health state they did not wish to share. This claim was corroborated by several senior medical professionals.26
The Canadian Forces Health and Lifestyle Survey, conducted every four years (despite a formal commitment by DND following the publication of A Long Road to Recovery to double the frequency to every two years as of 2008), examines the mental health status of a large sampling of CF members.27 It provides another slice of the OSI imperative, but is unable to present a fully comprehensive mapping of the condition at any selected point in time.
Within both the Chief of Military Personnel organization generally, and the Directorate of Mental Health specifically, there is little inclination for developing a more complete tracking of OSIs. Exact case counts are not considered especially useful. The approach is that 'if you're sick, you're sick' and all that matters is delivering the right care.28 The precise prevalence of individual illnesses or injuries is not seen as particularly relevant.
Moreover, both the Canadian Forces medical and personnel communities claim to be experiencing what they had generally anticipated with regard to PTSD and other OSIs because operational stress injuries are not epidemic in nature and therefore follow a fairly predictable trajectory.29
In addition to the science of these various studies and surveys, the Canadian Forces Health Services also integrate a practical element in assessing the scope of the OSI requirement. Wait times required for patients to consult with mental health care providers are closely observed on a clinic-by-clinic basis by the Director of Mental Health and the Mental Health and Psychiatry Advisor. This allows them to monitor not only the effectiveness of individual clinics, but through extrapolation the efficiency of the mental health system as a whole. Short wait times are generally indicative of sufficient capacity, while long wait times point towards demand outstripping capacity. Consistently long wait times can lead to detailed consultation with the concerned clinic, Staff Assistance Visits, the deployment of temporary augmented resources, or even an adjustment to the structure.
Once again, execution appears to have impeded effectiveness. Until only very recently the key metric that the Director of Mental Health and the Mental Health and Psychiatry Advisor monitored most closely was the wait time for the first available appointment to the mental health care provider: psychiatrist, psychologist, social worker, addictions counsellor or mental health nurse. It was acknowledged in 2012 that tracking this metric did not in fact accurately reflect patient access to care and often portrayed an overly positive representation.30 As a result, in May 2012 mental health clinics were instructed by the Director of Mental Health to switch to the wait time for the third next available appointment, which the general health community considers a much more reliable standard for measuring patient access to care.31
Additionally, many mental health clinics have been unable to consistently generate the monthly statistics requested by the Director of Mental Health (which according to a number of mental health caregivers include several metrics of dubious value).32 The effort required of clinics already facing excessive workloads to compile current accurate statistics has been onerous, especially since most clinics do not possess common information management or caseload tracking systems. This is largely a holdover from the pre-Rx2000 era when mental health clinics were very small, making caseload tracking and other data management requirements much simpler. As clinics ballooned to three to five times their pre-Rx2000 size in recent years, clinic managers and team leaders generally resorted to local, often improvised, information management solutions. The evidence indicates that these makeshift solutions have had varying degrees of success.
As an example, one clinic manager outlined that the only way to stay on top of his clinic's caseload was to cease all of his management and clinical activities for several days once every month, physically connect with every provider within the clinic, and put together a detailed compilation of all individual caseloads.33 This appeared to be the practice for other clinics as well.
As a result of this difficulty in managing data and tracking key statistics at the clinic level, the monthly reports published by the Directorate of Mental Health have often featured outdated information. During much of 2011, as many as a third of the mental health clinics did not report their current wait times and other statistics regularly. For the month of March 2012, the Director of Mental Health received only 7 statistical returns from the CF's 26 mental health clinics.34
When clinics have been unable to supply current statistics for a given month, the practice has been to plug in the last input received from that clinic, no matter how dated. In the 2010-2012 period, this last known value as it is termed was often as much as six-plus months out of date, distorting the overall precision of the national report.
In summary, while DND/CF possesses an array of research, informational and data inputs on PTSD and other OSIs, it is unable to generate a precise, punctual institution-wide portrait of the issue. The national representation generated by the Canadian Forces Health System is an amalgam of various inputs, which are all individually hindered by significant limitations. The Directorate of Mental Health CF-wide statistical report is based on patchy, often dated, inputs. The net result is institutional reporting on the scope of the OSI imperative that is neither sufficiently consistent nor adequately reliable to calibrate DND/CF priorities and resources effectively.
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Recommendation 3: CF-wide mental health survey
In December 2008 A Long Road to Recovery recommended:
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 follow-up review has determined that this recommendation is being met.
The CF has partnered with Statistics Canada to execute a follow-up Canadian Forces Mental Health Supplement to the Canadian Community Health Survey in 2012, the results of which will be published in 2013. This will be the second such independent national CF mental health survey, bookending the 2002 Canadian Forces Mental Health Supplement to the Canadian Community Health Survey.35
This is a very important endeavour. The 2002 survey was the driver for much of the mental health structure's reconfiguration as part of the Rx2000 Mental Health Initiative. It was the major catalyst in establishing the CF's current mental health structure, establishment and footprint.
This 2012 follow-up will provide the opportunity to validate the CF's mental health capability. While a decade of sustained operations and other contemporary factors have contributed to a number of punctual adjustments to the capability, the underpinnings of the Rx2000 2002 mental health construct remain largely intact. The pending survey is a crucial opportunity for the CF to validate its decade-old construct by measuring how effectively it is delivering the services and programs that CF members suffering from PTSD and other OSIs need and deserve.
As in 2002, this national survey will also allow the CF to compare its mental health capability with that delivered to the Canadian civilian population.
The CF demographic being surveyed will include a random representative sampling of all Regular and Reserve Force members serving as of mid-2012 (consistent with the recommendation). It will not include former CF members as this is beyond the purview of the DND/CF mandate and is the responsibility of Veterans Affairs Canada.
The 10-year interval between serials of this cornerstone national independent mental health survey is of concern, especially during a period of significant organizational strain punctuated by sustained operations in Afghanistan. The CF conducted considerable related research during this interval such as the Enhanced Post-Deployment Screenings, the cyclical Health and Lifestyle Survey, the Cumulative Incidence of PTSD 2001 – 2008 Report, the Canadian Forces Base Gagetown 2010-2011 OSI Incidence Study and others. And the research results contributed to positive changes to mental health configurations, methodologies and protocols. However, these individual inputs were not independent, nor did they systematically assess the CF's holistic mental health capability, which the 2012 Statistics Canada survey will.
A decade is a long interval between comprehensive benchmarks, especially during one of the most turbulent periods in Canadian military history. Waiting a full ten years before validating a capability identified as a top institutional priority appears disproportionately long. This delay may have limited the CF's ability to make key adjustments to its mental health capability during this crucial phase.
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Recommendation 4: Accommodation policy
In December 2008 A Long Road to Recovery recommended:
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.
This follow-up review has determined that this recommendation has been met to the extent that it could be.
The CF has put in place or enhanced a number of measures designed to assist ill and injured members return to military service or civilian life.
The formalization in 2011 of the Caring For Our Own comprehensive approach for the care of ill and injured members and their families is one enhancement. It provides a coherent mapping of the CF's focus on recovery from illness or injury, rehabilitation to an optimal level of health, and reintegration, preferably to military service.36 Caring For Our Own articulates a commitment by the CF to provide all necessary care and support for serving members and their families in the event of illness or injury.
This is achieved by providing the most current, evidence-based treatment designed to return the member to full health and normal military duty. If this is not medically possible, the objective shifts to achieving an optimal level of recovery and returning to normal military duty. And in situations where this remains unattainable, the goal becomes maximizing recovery and preparing the member for transition to civilian life.
In terms of timeframe, the 2011 directive on Complex Cases provides ill and injured members who have permanent Medical Employment Limitations an extended period of retention in the CF for up to three years if they are deemed to have complex transitional needs, which appears to be the case for a preponderance of OSI sufferers.37 This extended period of retention allows members to benefit from prolonged treatment and rehabilitation, and increased preparation for transition to civilian life.
The CF's recent decision to make both the Cadet Organizations Administrative and Training Service and the Canadian Rangers organization available to ill and injured members unable to reintegrate into the Regular Force and Primary Reserve provides an additional employment option.38
Though designed as a transitional measure, the Return To Work program, the CF's vocational rehabilitation program, assists ill and injured members restore their health through reintegration into an appropriate workplace and progressive resumption of duties. The program incorporates an array of private sector organizations and companies in order to provide a broad spectrum of rehabilitative opportunities. Empirical data surrounding the program is limited, precluding any viable evaluation.
Finally, the leadership/management of ill and injured CF personnel is appreciably more coordinated than in the past. Effective case management is a major reason for this. Medical case management integrated into the primary care capability plays a more prominent role in assuring the continuity of care for patients. Administrative case coordination embedded within the Integrated Personnel Support Centres as part of the Joint Personnel Support Unit organization connects ill and injured members to all relevant medical, vocational, financial and social resources. Whereas in the recent past ill and injured members had to seek out these various resources, often during periods in which their capacity to do so was limited, these resources now interface directly with the member through the Integrated Personnel Support Centre staff.
The gradual acceptance of the Integrated Personnel Support Centres/Joint Personnel Support Unit as enablers in the recovery, rehabilitation and reintegration of ill and injured members by a growing proportion of the chain of command appears to be serving ill and injured members effectively, though perspectives still vary drastically.39 Some elements of the chain of command were convinced that the Joint Personnel Support Unit structure provides the ill and injured with the qualified, focused attention and resources they require. Others felt strongly that removing ill and injured members from the 'family structure' that is the unit and peers during a period of increased vulnerability and need was an abdication of the fundamental leadership principle of caring for one's own.
Another irritant undermining the Joint Personnel Support Unit structure is the loss of allowances tied to active status within a unit.40 Losing one's Land Duty Allowance, flight or sea pay, or similar allowance as a consequence of coming forward to seek mental health care and eventually being posted to the Joint Personnel Support Unit, however temporarily, removes money from a military family's income and as such is a major disincentive.
Overall, the CF has demonstrated a concerted effort to enable ill and injured members by putting in place a number of measures which potentially favour them without encroaching upon foundational institutional principles and policies, beginning with the universality of service.41
These measures are not ideal however. Opening up the Cadet Organizations Administrative and Training Service/Canadian Rangers option to members no longer able to meet universality of service requirements is not a game-changer, either quantitatively or qualitatively. And the three-year transitional period (for those who qualify) is certainly helpful to members no longer able to be retained in the Regular Force or Primary Reserve, but in most cases it simply delays what is invariably an unwanted and unwelcomed result – release from the Canadian Forces as a result of injury or illness, and with it the loss of career and potentially of livelihood.
Repeated evidence from multiple sources suggests a fundamental and growing institutional tension between the requirement to respect the principle of the universality of service, and the CF's long-standing moral obligation to take care of those it sends in harm's way.42 (This tension is examined in greater detail in section 4). The measures outlined above appear to have exploited all of the available space around the margins of universality of service. Further forward movement seems impossible without coming into direct conflict with it.
The dichotomy of views on the Joint Personnel Support Unit concept is understandable as it is a new and innovative construct inserted within an already large and complex structure. In many locations it is still in its infancy and cultural acceptance has yet to consistently take root.
A second observation is the prevailing perception at the grassroots level that members suffering from mental health injuries are released from the CF more swiftly than those with physical injuries.43 This perception was noted on numerous occasions from a variety of sources. An analysis of available information indicates that this is inaccurate, and in fact the opposite scenario is more prevalent. OSI sufferers facing release are regularly deemed 'complex cases' and as such are eligible for part or all of the three year transitional period. Moreover, the administrative review which determines suitability for continued service and triggers release cannot be initiated until a reliable prognosis of health and functional capacity has been made by the relevant medical authority. Due to the complexity of OSIs, this stabilization period necessary before a definitive prognosis can be made is generally longer than that for physical injuries. Accordingly, the overall period leading to medical release from the CF appears to be generally longer for members suffering from mental health injuries, though the CF has yet to formally measure this.44
As for the possibility that the CF is more disposed to releasing members suffering from permanent mental health injuries over those with permanent physical injuries, no concrete evidence of this was discovered. The philosophy that 'an injury is an injury' seems to govern the personnel management process, starting with Director Casualty Support Management who as the Joint Personnel Support Unit Commanding Officer is theoretically responsible for the management of all ill and injured with a second temporary or a permanent medical category.
Additionally, there is a palpable frustration amongst some members suffering from OSIs toward the verbal commitment of the former Chief of the Defence Staff with regard to permanently retaining those ill and injured whose conditions were caused as a result of deployed operations.45 Without debating the merits of the declaration, the fact is that there is a sense on the part of some that an organizational promise was made and then reneged upon.
Finally, the term 'return to civilian life' is sometimes employed by CF leaders and administrators. It completely misrepresents the reality facing most members afflicted with OSIs and no longer fit to serve. Though demographics are shifting, a preponderance of CF members still joined the military in early adulthood and know only what it is to be a sailor, soldier or airman/woman. Not only has their military career been the only one they have ever had, but it is a major part of their identity. As a result, the notion of 'returning to civilian life' is invariably more complex and cathartic than the term suggests.46 More often than not it is an arrival to adult civilian life rather than a return, with all the uncertainty and trepidation that such entails.
Moreover, the stripping away of an important part of one's identity inherent in release from the CF can be as difficult to deal with as the long-term effects of the injury or illness which provoked it. It seems that this is especially the case when the decision to leave is imposed upon a member as a result of injuries or illness incurred in the conduct of duty. The resultant sense of loss, coupled with permanent injuries which often limit post-military career opportunities and overall quality of life, can be devastating to OSI sufferers released from the CF.
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Recommendation 5: Occupational Transfer policy
In December 2008 A Long Road to Recovery recommended:
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.
This follow-up review has determined that this recommendation has been met to the extent that it could be.
There have been no substantive changes to the Occupational Transfer policy or methodology concerning CF members deemed unemployable or non-deployable as a result of OSIs. The obstacle is the immutability of the universality of service principle. In the existing military employment structure, there are no viable options to move ill/injured members who no longer satisfy the terms of the universality of service from one occupation to another.
There is also little evidence that CF members suffering from OSIs do not receive equitable consideration for occupational transfer compared to personnel suffering from physical injuries, as was suggested on multiple occasions. Some members subject to medical employment limitations or temporary medical categories because of PTSD and other OSIs have responded to treatment and progressed sufficiently to have their limitations removed and categories restored, enabling full return to normal duty.47
Structurally and procedurally, the CF has instituted, formalized or enhanced a number of measures designed to assist injured or ill members recover, rehabilitate and reintegrate. The result is better stewardship of the ill and injured from both the medical and administrative perspectives. This impact of enhanced stewardship is twofold. One, it offers increased opportunity for optimal recovery, rehabilitation and reintegration to normal military duty, in an original occupation or a new one. Two, it provides a more deliberate approach throughout which the member has greater opportunity to demonstrate an acceptable level of recovery and/or rehabilitation, augmenting the probability of reintegration.
Medically, these structural and procedural enhancements include the stand-up of the seven Operational Trauma and Stress Support Centres across Canada in response to increases in mental health demand fuelled primarily by OSIs. The clinical treatment; resilience training and education; and psychological, emotional and spiritual support they deliver provide a more coherent, comprehensive care package for patients, increasing the possibility of optimal recovery, rehabilitation and reintegration.
The establishment and refinement of a standardized diagnostic protocol for OSIs in 2008-2009 has equally contributed to recovery, rehabilitation and reintegration by establishing a CF-wide common grid within which members with OSIs can be more effectively treated and cared for. More professional medical case management also contributes to recovery, rehabilitation and reintegration.
Administratively, the establishment and gradual acceptance of the Joint Personnel Support Unit / Integrated Personnel Support Centre structure appears to be providing improved management of ill and injured, though as outlined earlier there is still considerable debate around the Joint Personnel Support Unit structure.
As the majority of these measures are relatively recent it is impossible to definitively determine that they are contributing, or will contribute to, higher rates of reintegration and retention for members with OSIs. However, isolated and anecdotal evidence suggests this could be the case.
There exists a perception amongst an element of the grassroots CF demographic that once a member is posted to the Joint Personnel Support Unit and assigned to an Integrated Personnel Support Centre upon issuance of a second temporary medical category as per recent policy, he/she is unlikely to return to the unit and normal military duty.48 Articulated otherwise, some view the Integrated Personnel Support Centre as the 'kiss of death' from a career perspective. As long as this perception persists, it constitutes a veritable barrier to care.
A second concern is the reticence of those elements of the chain of command who are either opposed to the Joint Personnel Support Unit approach to managing the significantly ill and injured, or have yet to embrace it.49 If this friction is not promptly reconciled by CF strategic leadership, it is questionable whether the current approach will succeed on an institutional level.
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Recommendation 6: National family support resource
In December 2008 A Long Road to Recovery recommended:
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.
This follow-up review has determined that this recommendation has been partially met.
In 2010 the Directorate of Quality of Life was re-established after having been disbanded the previous year. The Directorate's renewed mandate is to contribute to a mission ready force by providing for the unique needs of military families and mitigating the disadvantages inherent in military service.50 A key element of this mandate is addressing the challenges and stresses associated with frequent relocations and prolonged absences including operational deployments.
One of the Directorate of Quality of Life's major responsibilities is facilitating family access to external care, support and opportunities, especially in the key areas of health care, child and increasingly elder care, education, and employment/career. This entails creating and fostering relationships with appropriate entities and leveraging these to improve access for military families, wholly consistent with the recommendation.51
The complexity involved in caring for military families cannot be understated, particularly concerning jurisdictions. DND/CF acknowledges both its policy responsibilities and moral obligation to provide support and services to military families to address the stresses unique to military life, and appears committed to delivering. However most of the key areas involved: (i.e., medical care, education, family care (child and elder), and employment continuity including professional equivalencies, certification and seniority), are largely the purview of public or private entities falling beyond the federal sphere of responsibility. Accordingly, the solutions to military family imperatives are rarely simple and usually involve extensive effort.
The Directorate of Quality of Life enjoys a symbiotic relationship with the Directorate of Military Family Support, which is focused primarily on service delivery of programs and initiatives serving military families.
The effectiveness of this renewed Directorate of Quality of Life construct is inconclusive at this juncture. The period since its regeneration (mid-2010) is very short, especially in light of the complex nature of the mandate.
A major preoccupation regarding national support to military families is the Directorate of Quality of Life's current capacity. At the moment of disbandment in 2009 it had 25 personnel to execute its former mandate. At present the Directorate has just 10 positions to achieve its new mission (which is different but does not seem appreciably less challenging than the former), only four of which are baseline funded.52 This is almost certainly inadequate to execute the mission it has been accorded.
A second concern is timeframe. The reality is that DND/CF's national coordinating structures responsible for serving military families are still in considerable flux in 2012, more than a decade after the commitment to sustained operations in Afghanistan. As outlined, the Directorate of Quality of Life was disbanded in 2009 and re-established in 2010. This reversal has resulted in confusion and dislocation. Moreover, the present Directorate of Quality of Life / Directorate of Military Family Support configuration appears to be in transition, with each directorate technically operating independe
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