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The first part of this monograph places the issue of mental
fitness and the military within a wider context of (mental) health and
Australian society. It notes, however, aspects of this issue that are
particular to military service. These include a growing appreciation of the
fact that the military exposes its personnel to trauma and therefore
experiences corresponding incidences of psychological injury; and that service
in the ADF can lead to significant life disruption when that service comes to
an end.
Defining the problem
The public don’t like how our vets are treated; don’t send
them to war and then refuse to look after them. (Senator Jacqui Lambie)
…
I have watched these issues chew people apart. (Dan
Pronk—army medical doctor, retired)
…
There is stigma involved with sharing with strangers. They
say there is no stigma but there is still. It is still a mindset amongst
soldiers and officers generally of a person who can’t sort out his own stuff. I
have witnessed negative stigma from PTSD. People still whisper and spread
stories. There is still not enough education in the public and so not as much
empathy for people’s situations. There are not enough services and support
available for sufferers of PTSD. A lot of it is about mindset. Think of the
soldier’s welfare and what is best for them and their loved ones. You sent them
there and when they return their lives are never the same.
As a soldier, you are trained from recruit training to kill
or subdue your enemy. To be the best and uphold the traditions of the Anzacs.
As men, we are too scared to say we are not good enough or that we need help at
times. We would die for each other but we will not talk about our fears to each
other because the vulnerability and embarrassment is too much at times. This
leads to disempowerment, isolation, confusion and despair where we are
helpless. Many choose suicide to end it or live lives of quiet desperation. It
affects the community at large. It needs community help. It needs mates helping
each other and looking out for each other. It needs education and listening to
the veterans. It needs funds for rehabilitation. (Samuel—Appendix A)
In addition to the contemporary popular narrative recorded
on these pages, it is useful to consider the scale of this issue and briefly
rehearse changing attitudes and from where we have come. The effects of
military service on mental fitness are poorly understood. It is known that a
career spent in the military has a significant shaping effect on the lives of
the men and women who choose this profession. An age-old tension exists between
capability and individual welfare—that is, between a commander’s desire to
maintain a fighting force and the desire to look after the welfare of
individual members of that workforce. Another historical facet of the military
and mental health has been the way in which those experiencing the negative
psychological effects of war and military service have often been branded as
cowardly and malingerers and dealt with as a disciplinary matter. Physical
wounds were often revered; however, mental scars often brought with them
humiliation and the taint of failure.
Elaborate propaganda and coercion strategies have been
employed by governments and militaries to ensure the ranks of their fighting
forces remained stocked. Examples include white feather campaigns and
instilling shame around being labelled with the administrative term ‘lack of
moral fibre’.[1]
Public attitudes and prejudices towards military-related psychological injuries
have fluctuated. While in the US during World War II there was a growing
appreciation that all military personnel were vulnerable, in Australia
following the Vietnam War, the public appeared to have reverted to World War I
thinking when military-related psychological injuries were thought to be due to
a pre-existing condition rather than war trauma.[2]
Prevalence rates of mental ill-health in service personnel
and veterans
While there are significant gaps in available statistics,
what we do know comes from Defence and DVA-funded research, in particular the
ADF Mental Health and Wellbeing Study 2010 and the Middle East Area of
Operations (MEAO) Census and Prospective Health Studies 2013.[3]
Lifetime rates for mental disorders in the ADF are
considerably higher than the Australian community with over 54 per cent of ADF
personnel experiencing a ‘disorder’ in their lifetime.[4]
ADF males report higher rates of PTSD (8.1 per cent) than males
in the general community (4.6 per cent). There is no statistical difference in
the rate of PTSD between males and females. Trauma histories between ADF males
and females do differ however, with ADF males more likely to report accidents
and other unexpected traumas, while ADF females were more likely to report
interpersonal traumas.[5]
The Mental Health Prevalence and Wellbeing Study highlighted that in addition
to exposure to traumas from civilian life, ADF personnel are additionally
exposed to job-specific trauma. The study also reports that 90 per cent of ADF
personnel have experienced at least one traumatic event in their lives,
compared with 73 per cent of an age and employment matched Australian community
sample.[6]
Contemporary Australia
Mental health and the ADF is part of a much larger context
of (mental) health and Australian society. This is a highly complex issue that
has proven to be susceptible to hijacking in the past by special interest
groups and certain professions. The Defence leadership is taking the issue
seriously and understand that it is broader than simply a health issue. As a
society-wide issue, prevailing attitudes remain dotted with significant stigma
towards those affected. Additionally, the military is a culture that does not acknowledge
weakness or inadequacy. The cultural change around destigmatising
service-related reduced mental fitness has been slow.
For example, PTSD affects a much wider population than
veterans of combat or Defence. First responders are routinely exposed to
traumatic circumstances and Indigenous children are thought to have high rates
of psychological injury as a result of exposure to trauma.[7] The state
and federal police, Department of Foreign Affairs and Trade (DFAT) and aid
agency workers are other groups thought to experience abnormally high rates of
psychological trauma.[8]
A unique feature of military service is that the military is the only
organisation that requires its workforce to kill people and destroy property as
part of their core business. Because of this, the training for and conduct of
military service can result in moral injury, a condition to which other
professions are not susceptible (Tom Frame—UNSW professor).
The fallout from unrecognised psychological injuries
includes increased incidents of self-harm, alcohol and drug abuse, domestic
violence, incarceration, homelessness, early death and suicide (Alan
Behm—FearLess CEO). One observation is that ‘homeless, displaced veterans have
replaced swagmen of a bygone era and are self-treating with suicide’ (Behm). A
feature of debates around the above issues, however, is that little data exists
to support claims being made about the prevalence of these kinds of
consequences of military service. Defence and DVA are currently attempting to
address this shortfall with several joint-funded research projects. A key
informant raised doubt about the methodologies employed by some of the research
currently underway and the extent to which it can provide an accurate read on
these complex problems (source chose to remain anonymous). Another criticism of
existing research programs is that they do not adequately account for the
so-called ‘healthy soldier effect’ (Behm). Comparisons with the general
population do not allow for the fact that defence members are a healthy group
of people at recruitment. The accurate interpretation of epidemiological data
is critically important and this has not always been done well. Such data has
in the past been skewed to shore up existing bureaucratic positions (Behm). For
example, the ADF Mental Health and Wellbeing Study 2010 states that the
‘prevalence of mental disorders was similar to the Australian community
sample…’, an interpretation of which may be that urgent action on ADF mental
health is not required.[9]
While part of a much larger picture of (mental) health and
the community, the mental health of current serving Defence personnel and
veterans has some unique aspects. Young men, and an increasing number of women,
are recruited and taught to see themselves as contributing to something
greater, where their own health and ultimately their own lives become a tool of
the government of the day. It is rarely explained in this way; it is assumed in
the role these men and women take on. Once defence personnel are taught to put
the system before themselves, they are exposed to a work environment that
doctors know will make some of them unwell. The training and qualities that
make good soldiers can be the very things that put these men and women at
greater risk of harm, and leave them less able to seek help when it is needed.
This monograph sets about framing this problem and its consequences before
presenting some of the views of the experts who set the agendas around these
issues.
While serving in a professionally satisfying and high-functioning
environment, soldiers (particularly among the Special Forces community) are
supported by their peers and feel a strong duty to project an image of strength
and not let the team down. Anecdotally, ADF members believe that a diagnosis of
mental illness will result in missed promotion windows, missed deployment
opportunities and most likely, medical discharge. The stigma of ‘mental
illness’, combined with the fact that it can be hidden, means that people are
continuing on with untreated psychological injuries and other manifestations of
reduced mental fitness. Upon leaving the military, individuals may find
themselves in comparatively low-status unsatisfying jobs, and, feeling isolated
from support, may then experience the psychological fallout of a career spent
witnessing trauma. There is often a delayed onset of symptoms associated with
PTSD and co-morbidities.[10]
This creates a set of challenges that can include difficulties in linking
exposure to trauma with (a delayed onset of) symptoms, both from the veteran’s
perspective and in official bureaucratic processes.
With low rates of mental health literacy and an inability to
identify when help may be required, the situation may become chronic, with the
individual feeling increasingly helpless before the case comes to the attention
of the medical community or DVA. Records may be patchy and an already unwell
veteran may find themselves having to retell their story numerous times in an
adversarial setting where the onus of proof is on them to demonstrate they are
deserving. The more tragic of these stories find their way into the media, and
their compelling nature and compatibility with sensational but easily
digestible media agendas mean the story becomes one of ‘this government sent
these men and women to war, they have come back broken and it is now refusing
to look after them’. Second order effects of this include industries of
Ex-Service Organisations that have sprung up in large numbers to fill a
(perceived) gap in care. While these groups are most often started by
well-intentioned people motivated by helping other veterans, numerous problems
have been identified with the current status of these groups (see section on
ESOs).
Other features of this system include traumatised veterans
appearing before Senate committees where committee members who are veterans
themselves are repeatedly exposed to harrowing stories which may trigger the
reliving of their own experiences of trauma. Such inquires pit generalist
politicians against bureaucrats well-practised at deflecting attention and
criticism with strategies such as ruling lines of inquiry outside of their
respective administrative remits.[11]
Most senior bureaucrats are not subject matter experts in mental health,
meaning the responses they give often do not clarify anything or accurately
inform the politicians regarding their concerns. Constant attacks and
accusations (both by the media and politicians) have had the effect of making
inherently insular cultures of the bureaucracy more defensive. The adversarial
nature of the hearings only increases the defensive, ‘bunker down’/‘we’re
already doing that’ responses. Linda Reynolds (Government Senator) commented:
‘the behaviour of the popular media makes Defence even more reactive and
defensive in the area of veterans’ health’.
An independently planned research strategy, informed by
subject matter experts (both academics and clinicians), is vital to properly
understanding the situation, and needs to be made a priority. It should include
both qualitative and quantitative research designed to assess the needs of
veterans in a way that genuinely engages the unique aspects of the culture of
this population and informs the design of strategies for prevention, early
intervention and treatment. At present, an independent research agenda does not
exist separate from bureaucratic control. The only reason for denying the
publication or distribution of research should be security concerns. Academic
research in the US, Canada and the UK is not subject to the same level of
bureaucratic control as it is in Australia (Dr Alexander ‘Sandy’
McFarlane—psychiatrist). When politicians and journalists sense something is
amiss, but cannot get straight answers, progress is stifled and the same
circularity is perpetuated. A program of independent and best-practice research
may be one key element in breaking the circular manner in which this issue is
played out at present.
Anyone experiencing reduced mental fitness, including
Defence members and veterans, is relatively powerless and while stories of
wounded veterans are picked up by the media, it remains the case that Defence
and DVA do not really know what to do with serving members and veterans whose
health has been adversely affected in this way. While Defence is focused on
capability, injured veterans become an issue of secondary concern. While the
leadership group of Defence is interested in this issue and has a genuine
interest in better outcomes for members of these groups, a top-down approach is
not the whole answer. Paula Dabovich (researcher—University of Adelaide) noted
that you can have the best policies, but if they are not well-understood or
accepted by the target populations, they are essentially a waste of time. A gap
in the research exists regarding how soldiers feel about the treatment and
services available, and what they actually want. ‘We [the research community]
need to listen to what soldiers actually want’ (Dabovich). The claim being made
here is not that policymakers should be dictated to by a small disgruntled group,
but that research into culturally appropriate service provision is an important
but missing component of a well-informed approach to improving the experiences
of those who feel that existing services have not been designed with their
needs in mind.
As Peter Leahy (Chairman, Soldier On) remarked ‘we’ve got to
keep talking about this issue’. Major General Gus Gilmore commented that it is
the five per cent of veterans who are not receiving proper health care on whom
we need to focus our efforts. Retired Army psychologist, Clint Marlborough,
said ‘there is a strong feeling among a number of quarters of these debates
that the issue has not been dealt with properly and it is now time to do so’.
Part of this puzzle is the relationship between the federal
government’s coordination and state-based service provision. Mirrored in the
organisation of the Returned and Services League (RSL), state-based health
systems can be fragmented (source chose to remain anonymous) due to the nature
of the systems that support them. Some, likewise, regard the federal system as
fragmented in that Defence and DVA are separate and not always successful in
working seamlessly together (ESOs have arisen to fill the gaps occurring
between these organisations). From a political perspective, although the
consolidation and coordination of these systems appears to offer efficiency
dividends, this would require political will. A key informant in this research
believes that part of DVA’s role is to be a de facto health insurer in a system
lacking systematic oversight and auditing (anonymous). A lack of coordination
between federal, state and private sector health services was noted by the same
informant.
First-hand accounts of
personal impacts
In the following quote, the wife of an Afghanistan veteran
describes the relationship between the (un)availability of physical
rehabilitation services and mental fitness impacts:
I think the ADF medical system needs considerable change
overall. It’s backward at best and risk-averse in the extreme. Some of the PTSD
issues stem from service personnel being medically downgraded and considered
unfit for their role, when the reality is with correct physio and support
services there is no reason they can’t continue in their role. I know a
considerable number of ADF members who use outside services, and pay for them
out of their own pocket, because the services provided by the army medically
are inadequate and antiquated. Further overhaul of PT practices within the army
and rehabilitation programs need genuine improvement. Having worked on an army
base and seen the rehab for physical injuries it is hopelessly inadequate; with
people not getting better physically, this is only going to add to mental
health issues. (Sara—Appendix A)
The following is a first-hand account of the suicide of
colleagues where PTSD is highlighted as a potential contributing factor:
Yes, I have a lot of mates who suffered from PTSD. Some
committed suicide but I’m unsure whether it was totally PTSD or that started
the downwards spiral and drugs/alcohol, or something else, contributed to, or
sped up, the process. I have mates at the moment who are suffering in some form
or another and others I suspect, but haven’t spoken to about it. (Charlie—Appendix
A)
Here, the effects of poor mental health literacy and the
resulting stigma are illustrated, as is an unwillingness to offer support to
those who may really need it:
Yes, and I was one of these people who looked upon it
negatively as a younger soldier. Having gone through some of the experiences
myself I could not see why people who signed up to do just that, could break
easily. I never said anything and tended to move away from people who were
suffering. These days I don’t believe that, possibly because of some of the
guys I used to look up to as a younger soldier who now suffer or/and because of
the scale of it within Defence/ex-Defence. (Charlie—Appendix A)
The following is another example of the impacts that
war-related trauma can have on the lives of those who experience it:
My boss (Lieutenant) shot and killed a Taliban suicide
bomber. [He] now suffers severe PTSD and struggles to live days without seeing
him in his life. (David—Appendix A)
After having set the scene with these pages on the scope and
unique features of the potential psychological effects of working in the
military, the background to the research, planning and reviews in Defence, DVA
and the Federal Parliament will now be considered in turn. These institutions
have done impressive work around the issue of mental fitness and the military
workforce. Care needs to be taken interpreting the above quotes taken from the
very small group of veterans who agreed to contribute to this research.
Although, as noted, many of the sentiments expressed are reflected in the
considered views of the working professionals with whom the researcher spoke.
Transition
A recurrent theme raised during interviews was that of
transition back to being a civilian following a career in the military—often
referred to as separation. This phase of a military career appears to
have significance for debates around mental fitness and the military.
A significant feature of a military career is the reported
effect it has on people when it ends. This relates to members from across the
ADF, not only combat soldiers. Part of the trauma of military service and war
appears to be the loss of the closeness and cooperation that it engenders.[12] It has
also been theorised that after living an intense and interdependent lifestyle,
the process of returning to the individual modern Western lifestyle can be
brutalising to the spirit—feelings of alienation and loneliness are often seen
to be associated with leaving a military environment:[13]
The very nature of excellence as a combat soldier requires
extremes of commitment and fusion of identity with the collective, yet
simultaneously puts them [soldiers] at risk of injury and thereby involuntary
discharge. This in turn can precipitate a sudden and unexpected shift in
identity, embodied by a change of medical employment category within their
units, followed by movement to a rehabilitation environment, change of
employment and medical discharge. Research with soldiers who are discharged on
medical grounds, confirms the high emotional impact…[14]
Discharge from the ADF is often a significant milestone in
the lives of these ‘transitioning’ members. After a career spent inside an
all-consuming institution, the process of becoming a civilian again can be
traumatic for some. Part of this process of transition is leaving a highly
satisfying and professional environment and beginning work in a low status and
comparatively low-paid job. Sara, the wife of an Afghanistan veteran said:
…helping ex-ADF members find work (particularly work that
makes them feel valued). I have a friend who is a highly-qualified Combat
Engineer, who did three trips to Afghanistan, left the army and went back to
working at the freezer in Coles where he was before he joined—hardly a
recognition of his skills and it hugely devalued him. (Sara—Appendix A)
A number of the veterans’ stories included as case studies
in this research raised the issue of employment post-discharge. A senior
Defence officer remarked that he had been meeting with a NSW minister to devise
a way to give veterans priority pathways into state emergency services
employment. Such a strategy was intended to act as a positive for both
organisations, as veterans have already self-selected into the army and would
have attributes valued in the emergency services, making it beneficial to both
individuals and first responder organisations. A note of caution, however, is
that the potential for exposure to trauma is actually greater in the emergency
service sector than the military, and compared to Defence, the first responder
organisations do not have comprehensive health systems for members. Stigma
surrounding mental health is also a major problem. Perhaps a transition into
other leadership roles would be a better outcome. Defence should prepare
Special Operations Command [SOCOMD] operators (and by extension all ADF
personnel) for careers after discharge (Dan Pronk). While the emotional distress
of alienation and loneliness that may accompany transition can be deeply
unsettling for some, the issue of employment was an immediate problem raised by
numerous contributors to this research.
Many people interviewed for this paper felt strongly that
Defence should play a more active role in the employment futures of members who
are no longer ‘fit’ for active duty. In these cases, Defence could consider
options for retaining the significant skills and expertise of its highly
developed workforce and implement policies to support members being retained
within the workforce in some capacity. Members may be better utilised within
another area of the organisation, or allocated to a specialised ‘arm’ of the
organisation. Alternatively, consideration may be given to the development of a
program that sees the ‘redistribution’ of affected personnel into other
supportive work environments, in which personnel feel that they are able to
make a valuable contribution with their existing skill set in an effective and
well-supported capacity (Kerry Howard—psychologist). (See the following section
on the 2nd Commando Regiment for an example of how this approach has been
successfully implemented).
A different approach might helpfully be taken to models of
career progression and transition where workforce flexibility is achieved
through the adoption of a range of solutions that assist in the transition
process and leave veterans with the thoroughgoing impression that their futures
and a high quality of life will be better served by a productive and functional
engagement with the community, rather than a fight for pensions and a life of
welfare dependency. For those experiencing chronic debilitating conditions,
however, there may be little choice. Others may require their need for social
inclusion to be supported in meaningful but less permanent ways.[15]
Soldier On has called for a ‘universal transition program’
for all separating ADF members to ensure that this group has effective access
to study and meaningful employment post-discharge.[16]
[1]. See for example “Can It Be True?” editorial by “W.M.” from the 3 April 1940 issue of
the Daily Mirror:
‘Is it possible that nitwit girls are reviving the infamous “white feather”
campaign of the last war? Rumours reach us from Doncaster to the effect that
certain female louts are thus insulting male workers in or out of reserved
occupations’; Wilkins, T. (2015) ‘Lacking moral fibre’. [online] Available at: www.defenceofthereal.wordpres.com [Accessed: 1 September 2015].
[2]. Magee, D. (2006), in ‘History of PTSD’. [online] Available at:
www.historyofptsd.wordpress.com [Accessed 12 September 2015]; McFarlane, A. and
Forbes, D. (2015) ‘The journey from moral inferiority to post-traumatic stress
disorder’, The Medical Journal of Australia; 202(7), pp. 348–349.
[4]. Defence submission (34) to APH Senate Standing
Committee on Foreign Affairs, Defence and Trade—Inquiry into the mental health
of Australian Defence Force (ADF) personnel who have returned from combat,
peacekeeping or other deployment, op. cit.
[5]. Australian Defence Force, 2010, ADF mental
health prevalence and wellbeing study, op. cit.
[7]. Nadew, G. (2012) ‘Exposure to traumatic
events, prevalence of post-traumatic stress disorder and alcohol abuse in
Aboriginal communities’, Rural and Remote Health 12, p. 1667. [Online]
Available at: http://www.rrh.org.au [Accessed 12 September 2015].
[9]. Australian Defence Force, 2010, ADF mental
health prevalence and wellbeing study, op. cit.
[10]. Frueh, B., Grubaugh, A., Yeager, D., Magruder,
D. (2009) ‘Delayed-onset post-traumatic stress disorder among war veterans in
primary care clinics’, The British Journal of Psychiatry, May 2009,
194(6), pp. 515–520.
[11]. APH Joint Standing Committee on Foreign Affairs,
Defence and Trade—Inquiry of the Defence Sub-Committee, 2013. Care of ADF
personnel wounded and injured on operations, op. cit.
[13]. Demers, A. (2011), ‘When veterans return: the
role of community in reintegration’, Journal of Loss and Trauma, 16(2),
pp. 160–179.
[14]. Dabovich, P. (2015) Identity and veteran
health behaviours: considerations of context, culture and change, culture,
medicine, and psychiatry, forthcoming.
[15]. For a comprehensive list of the resources DVA
devotes to transitioning members, see its submission (35) to the Senate
Inquiry.
[16]. Soldier On submission (29) to APH Senate
Standing Committee on Foreign Affairs, Defence and Trade—Inquiry into the mental
health of Australian Defence Force (ADF) personnel who have returned from
combat, peacekeeping or other deployment, op. cit.