Although it notes progress over the past six years in addressing operational stress injuries (OSIs) in the Canadian Forces, a December report from the interim ombudsman for the Department of National Defence and the Canadian Forces says some military personnel and their families are still not getting the service they need.

“It’s clear that more needs to be done,” states the report, A Long Road To Recovery: Battling Operational Stress Injuries, by Interim Ombudsman Mary McFadyen. It is the second followup review of a 2002 Ombudsman’s report which made 31 recommendations for improving assessment and treatment of OSIs in the military. Only 13 of those recommendations were fully implemented, while there was partial implementation of seven others. Most of the nine recommendations of the 2008 report reiterate unimplemented recommendations of the 2002 report.

Due to pressures such as the increase in the commitment to combat in Afghanistan, “the Canadian Forces and Canadian Forces members are strained almost to the breaking point,” the report states. It emphasizes the increasing need for a robust system to identify, prevent and treat OSIs and also identifies several “new and evolving” issues, including mental health services to military families and burnout of mental health professionals and caregivers.

Although the 2008 report notes “important progress in identifying and treating OSIs, including the addition of screening deployed troops, a commitment to social support and beefing up the number of mental health professionals, some systemic issues have not been sufficiently addressed, particularly leadership and data collection,” McFadyen said in an interview with Legion Magazine.

A key recommendation of the 2002 report was the appointment of a national OSI co-ordinator reporting to the chief of defence staff. Instead, initially a steering committee was appointed and OSI was added as a secondary duty to two special advisers. But over time, the committee met less frequently and the ranks of attendees lowered; and special advisers were “simply unable to carry out such a large and important task while, at the same time, having to fulfil their primary responsibilities,” states the report.

In 2007, the CF appointed a full-time special adviser to manage non-clinical programs and in 2008 the OSI steering committee was re-established and beefed up. But no national co-ordinator was appointed, and DND’s response is that these actions are “sufficient to achieve the overall co-ordination of issues relating to OSIs.”

“I strongly disagree with this response,” McFadyen said. Not only would a national co-ordinator ensure consistency of CF policies and programs, but without one, the cultural change necessary to eliminate the stigma of OSIs will take longer and be harder to achieve, the report warns. Consequently, people are still falling through the cracks, McFadyen said, though she cannot say how many. The report notes even one is too many, since the consequences are “often devastating and long lasting.”

The Legion is also concerned about this issue. Among the resolutions passed at the 2008 dominion convention, is one urging Veterans Affairs Canada and the CF to harmonize delivery of mental health care for CF members and veterans suffering OSI injuries.

Most military establishments in Canada were visited in researching the report and 19 air, land and naval units were targeted. Relevant policies, procedures and programs were reviewed and 360 interviews conducted. A fact-finding tour of Canadian Forces Base Petawawa in Ontario, 160 kilometres northwest of Ottawa, underlined inconsistencies in service levels to serving members and their families and stress and burnout among mental health caregivers.

The report criticizes the Canadian Forces for “lukewarm leadership” that allows the stigma to persist. “Some local leaders still do not accept the fact that mental health injuries are real,” it states. Consequently, some CF members with OSIs are still reluctant to ask for help.

But there has been “tremendous progress since 2002,” says Lieutenant-Colonel Stéphane Grenier, who was appointed in 2007 as full-time special adviser on OSIs to oversee development of an educational campaign and other programs to reduce the stigma around mental health issues. He says he was not interviewed for the 2008 report. Grenier, who has an OSI himself from service in Rwanda in 1994, points to the growth of peer support networks, development of education and training modules for all ranks. About 8,000 members have been trained on OSI issues; a speakers’ bureau has been established and used for training of all ranks; OSI issues are being considered in redrafting of policies.

In addition, a “robust” mental health team is now available on deployment and OSI is now part of the post-deployment screening process, says Lt.-Col. Rakesh Jetly, psychiatrist and mental health adviser for DND/CF. With a mind to early identification of OSIs, returning troops are screened within six months after return from deployment and have a one-on-one meeting with a mental health professional. As well, the CF has beefed up its number of psychiatrists by more than 300 and expected to add another 218 by this spring. The number of clinics available for treating the CF’s 65,000 regular forces and 25,000 reservists has been increased to 11 with the addition of six VAC OSI clinics which are available to CF personnel.

“There’s still need for a national, co-ordinated approach,” says McFadyen, “to ensure there’s effective oversight to all issues related to OSI,” including consistent care, diagnosis, treatment, education and training. Her office will continue to monitor progress and report accordingly.

A second systemic issue concerns data collection. An automated record-keeping program promised to be up and running by 2008 will now not be fully operational until 2011. “It’s unfortunate,” said McFadyen, “because you need to know the extent of the problem.” Good data “helps ensure you’re targeting your money and resources at the right places.”

Instead, investigators found “no effective performance measures in place to evaluate local and regional approaches to programs.” Lacking national co-ordination and statistics, “the quality of mental health care available to CF members is inconsistent across the country,” the report states. For example, CFB Petawawa, a base of 5,100 personnel with many deployments to Afghanistan, had one psychologist and 80 per cent of the time of one psychiatrist, compared to five psychologists and three psychiatrists to serve the 6,600 at CFB Edmonton.

But, just because the computerized records system is not fully operational does not mean no research is being done,” says Jetly. For instance, the CF has been able to track a reduction in the length of time it takes a member to ask for help for OSI. In 2002, “it was five to six years, on average.” Now, half those identified with OSIs are already in care upon return to Canada, he says.

But paper records and manual research methods continue to be a hindrance. “When we did our follow-up investigation, no one could tell us specifically how many people are suffering from OSIs,” said McFadyen. “Proper and accurate statistics will eventually help everyone deal with the issue, including Veterans Affairs down the road when people have retired.”

“Accurate statistics are important to ensuring there is enough help for injured military personnel,” says Sean Bruyea, an intelligence officer for 14 years who served in the Gulf War in 1990-91. When he subsequently developed an OSI, he suffered in silence for years. “The stigma was so powerful (back then)… I was so afraid of getting help, I would rather leave the career I dearly loved.” With little help and no job, “I was one of those who grossly fell through the cracks” in the 1990s.

In order to know the full commitment to any deployment, it’s necessary to know the full cost of physical and psychological injuries, he says.  “You can’t send the military on a mission and worry about the money afterwards. It’s fundamentally unfair to say ‘well we don’t have the money’ after the soldier has fulfilled his end of the bargain by sacrificing his health or life.”

He says planning requires good statistics. Determining how large a commitment can be made depends upon knowing how many of those deployed will develop physical or psychological injuries, including the numbers affected for life, then estimating how much it will cost to support those people and care for their families.

One new issue discussed in the 2008 report is how families are affected by OSI. Aside from the stress of caring for someone, family members may themselves develop mental health problems. Yet many living in isolated military establishments face difficulties accessing care and treatment. The report notes that although health care services for military families falls under provincial responsibility, CF has a “moral responsibility” to ensure military families have access to appropriate mental health services and support in order to deal with a military member suffering from OSI.

“The cost in human dignity (for not extending service to families) is immeasurable,” says Bruyea. “The toll on kids, the alcohol and substance abuse, anger. It causes families to break up or stay together in unhealthful ways.”

Although DND concurs with the recommendation it establish an organization to work with agencies and government at all levels to ensure families receive access to the necessary spectrum of services and care they may need, it points out it does not have the mandate to provide health care to military family members (other than in Goose Bay, Labrador). Doing so would require a change in government policy and significant additional resources.

In related news, Veterans Affairs Canada announced in January the first residential Operational Stress Injuries clinic for treatment of serving military, veterans and RCMP members will open near Montreal in the fall of 2009.

The new Residential Treatment Clinic for OSIs will be located in St. Anne’s Hospital and will allow clients with complex OSIs, including anxiety disorders, depression or addiction to concentrate full time on their treatment. Up to 10 patients can be accommodated for stays of up to eight weeks.

The new residential clinic will bring to 10 the number of OSI clinics in VAC’s national network, which is complemented by five operational trauma and stress support centres operated by the Department of National Defence.

Recommendations And Responses

The following are the recommendations from A Long Road To Recovery: Battling Operational Stress Injuries by Mary McFadyen, interim ombudsman for the Department of National Defence. The response from the Chief of Defence Staff on the Office’s Second Follow-Up Report On Operational Stress Injuries follows each recommendation in italics.

• Appoint a full-time, national OSI co-ordinator, responsible for reporting directly to the chief of defence staff.
Appointment of a full-time lieutenant-colonel to oversee non-medical OSI programs plus creation of Mental Health Advisory Committee are deemed sufficient to achieve overall co-ordination of the issues related to OSI.

• Develop a database that accurately reflects the number of regular and reserve CF personnel affected by OSIs.
Concurred.

• Conduct an independent and confidential mental health survey of current and former regular and reserve CF personnel.
Supported in part. The CF can survey regular and reserve forces; Veterans Affairs Canada is responsible for retired members.

• Change occupational transfer policy to accommodate those with OSIs who could continue in military service in a different military job.
No direct comment.

• Ensure changes to accommodation policy be applied equitably to CF members with mental health and physical injuries.
No direct comment.

• Establish a national organization to ensure military families have access to care.
Concurred. 

• Ensure funding for identification, prevention and treatment of OSIs.
Supported, and expanded to include all mental health disorders, not just OSIs.

• Monitor requirement for additional health care providers in case OSIs continue to grow.
Concurred.

• Develop a national program to prevent and treat stress and burnout among mental health care workers.
Concurred with “the spirit of the recommendation” but said it is not clear a specific national program is the best way to address the problem.