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The third part of this monograph describes areas of significant progress, both in better informed attitudes and the provision of services and support, and other areas where progress is required. The persistent issue of stigma acts as a reminder of the low starting point of knowledge and uninformed attitudes towards service-related psychological injuries. A hopeful note is struck by the 2nd Commando Regiment and its approach to dealing with the health and wellbeing of its workforce. The changing attitudes of veterans have a shaping effect on broader attitudes towards service-related non-physical injuries. These pages record some attitudes that focus on the invaluable range of services and support available to veterans. Other veterans’ attitudes appear to remain trapped in an entitlement mentality that sees DVA as the enemy with whom they must wage battles for compensation. Finally, the issue of preventative mental fitness will be introduced, investment in which is seen to have good prospects for improved outcomes. Ultimately, society has come a long way from a very low starting point. However, as this report demonstrates, the results are not yet entirely effective and without significant investment in this issue now, there is the risk that the mistakes of the Vietnam War will be replicated, creating another long legacy of psychological injury from recent and current deployments.

Stigma

The issue of a pervasive stigma surrounding mental health was raised in a number of the interviews done for this research, by politicians, psychiatrists, senior military leaders and veterans.[1] The impacts of stigma associated with the mental health of civilian populations are well-understood by these groups.[2] Much work has also been done on the stigma of mental illness in a military context and on how mental health stigma in a civilian setting relates to stigma in a military setting.[3] An influential early voice on the study of stigma, Erving Goffman, described it as a sign of disgrace setting a person apart from others, often resulting in those affected delaying seeking help or denying their symptoms altogether until the point of crisis.[4] Both a lack of factual information and strong negative emotional reactions to reduced mental fitness are at play in the original data that follows. People find symptoms of psychopathology threatening and the discomfort that other people feel fosters stigma and discriminatory attitudes towards those who admit to experiencing problems.

I used to think—’that weak cu*t, what has he seen that I haven’t seen?’ Until I got it myself and then I understood, it doesn’t mean you’re weak, it’s an injury. (veteran S)

Everyone knows that you get PTSD and your career is over. (veteran R)

Personally it was a difficult time as I didn’t really have any answers why I was depressed and I couldn’t attribute it to any one incident. It was confusing and embarrassing as I had no control of my emotions and could not trust myself to keep it all in check. Initially it was something I tried to hide, but it got to a stage where I was totally useless and couldn’t concentrate on anything except trying to hide my condition. (John—Appendix A)

Left untreated, psychological injuries and reduced mental fitness can have wide-reaching negative impacts on personal wellbeing. It touches every aspect of a person’s life, including their social and emotional wellbeing, as well as their cognitive functioning. In an interview for this research, psychiatrist and specialist in veterans’ health, Dr Andrew Khoo, stated his belief that the stigma surrounding mental health in the ADF is our biggest challenge and that the single biggest difference that could be made to mental health outcomes in military personnel would be to identify unwell individuals earlier and then maintain them in effective treatments. Dr Khoo believes that dealing with stigma is a more urgent issue than even treatment development. In a culture that lauds strength and shuns weakness, the cultural change necessary to convince serving personnel to seek help is significant (Senator Linda Reynolds).

A culture that values strength and preparedness to help others before oneself (qualities that make a good soldier) leaves Defence personnel and veterans vulnerable to a reluctance to seek treatment for symptoms of psychological injuries when they occur. Coupled with a culture that views such injuries as weakness and tantamount to malingering, the landscape of stigma and mental health in Defence, becomes, for some, a cultural norm that will never be resolved (Dr Graeme Killer, DVA Principal Medical Adviser):

I‘ve heard WO1s call blokes who are genuinely injured ‘lingers‘ [malingerers] on more than one occasion—disparaging at best and downright contemptible in light of genuine illness and injury. (Sara—Appendix A)

Further complicating the issue is that a diagnosis of a psychological injury is often thought to lead to missed deployments and promotion windows, and result in involuntary discharge on medical grounds. This, combined with the fact that such injuries can be hidden, means Defence has a negative attitudinal culture around mental health that may result in large numbers of psychologically injured personnel not receiving treatment. While no one is arguing that those with reduced mental fitness require support and/or treatment as a priority over career considerations, it is widely acknowledged by working professionals both within and outside the ADF, that the stigma of mental illness is a significant additional barrier to an ADF career than a medical issue alone. The lack of recorded evidence of mental illness can result in delays in recognition by DVA in the future (Dan Pronk, former ADF Regimental Medical Officer). This has led to Veteran D, already chronically unwell, becoming re-traumatised as he attempted to establish the basis of his claims later—‘You don’t say anything until you get out, then [you’re] accused of pension chasing’ (veteran D). Increased awareness that war can have negative psychological effects and that this constitutes an entirely normal human reaction, normalises psychological injury which is an important part of this puzzle (Peter Leahy, Chairman, Soldier On). Sometimes a formal diagnosis can be unhelpful, stigmatising and making the situation worse:

Fifty years ago Michel Foucault drew attention to the medicalising of social problems; in looking at the deployed experience of uniformed men and women, we need to avoid psychologizing what may be moral problems.[5]

Suggested solutions include the need for highly-targeted stigma reduction measures (Nicole Sadler, Defence psychologist; comments in an interview for this research) because a message that reaches one target group will be ineffective with other groups. Frank Quinlan (Mental Health Australia CEO; in an interview for this research) suggested that the issue of stigma should be turned on its head. At present, those experiencing reduced mental fitness are made to feel ashamed of their situation. Instead, there is a need to replace stigma with a narrative that is unwilling to accept discrimination of those affected by injuries of this kind—‘We should be focused on an organisational discourse of genuine care and support that can equip soldiers and their commanders to layer culturally appropriate models in their own units, coupled with expert care’ (Paul Dabovich, researcher, University of Adelaide). This kind of change is unlikely to organically occur from within Defence and will require political intervention (Melissa Parke MP, ALP Fremantle).

Dr Andrew Khoo stated in an interview for this research that one of the most important things that will convince serving Defence personnel to seek treatment for mental health-related issues is to see others do it, resolve the issue with treatment and successfully return to work. In this view, this will begin to foster a justified belief that mental injuries will be treated like physical ones. Additionally, while some mental injuries, like physical ones, will not be successfully treated and result in a return to work, if others see resources and support being made available to those affected, stigma will be further eroded. The recounting of personal experiences by credible sources who overlap with the target group and who have themselves experienced reduced mental fitness, may be one strategy to assist in the erosion of stigma. The point is that rather than proselytising, these personnel instead provide the opportunity to learn from the experiences of those who have been through a successful rehabilitation program.

Soldiers sometimes seek to disguise the truth to achieve their desired outcome. Examples range from 15-year-olds forging birth certificates to join the Australian Imperial Force (AIF) in 1915 to soldiers disguising mental and physical injuries to avoid the unpleasant social and professional consequences of acknowledging them. Creating clarity around this may encourage dialogue around harm minimisation and improved strategies when a soldier’s career comes to an end (interview with Paula Dabovich).

One interviewee, John, remarked:

When I was diagnosed as having depression and anxiety issues, I was effectively downgraded medically. The period of MEC [Medical Employment Classification] downgrade was approximately 12 months, during which time I was not eligible to participate in any courses, exercises, training, weapon handling, driving of a military vehicle, etc. At certain ranks and windows in a soldier’s career you only have limited opportunity to be considered for promotion or attendance on promotion and career advancement courses. If you are ineligible for these activities due to being MEC downgraded, you essentially miss the window and that opportunity has flow-on effects for the remainder of your career. For example, DSCMA [Directorate Soldier Career Management Agency] will compare you against your peers for such things as promotion by looking at everyone’s annual PARs [Performance Appraisal Reports] over a period of 3–5 yrs. If you have been unable to participate in all activities and exercises, then your annual PAR will reflect this and you are no longer going to be competitive with your peers for promotion, courses or certain jobs. (John—Appendix A)

While a psychological injury may mean that an individual is no longer able to perform their duties until they recover fully, much like the impact of a physical injury, it is the additional element of stigma that accompanies a psychological injury which amplifies the impact beyond a medical issue. The following comments from David (see Appendix A) illustrate the manner in which reduced mental fitness can be mistaken for a disciplinary problem (and dealt with using bastardisation):

If you went to the padre or psych, [you were seen as], for lack of a better word, [a] ‘poofter, faggot or weak cu*t’; sorry for the use of this language but to understand how demoralising it was for some soldiers, these words must be used. It started from higher ranks such as a Sergeant or Corporal and as you could imagine, it only manifested tenfold amongst the diggers. I clearly remember one soldier who was thrown into a cage, locked in there like an animal, a cold bucket of water tossed in and broomsticks poked through the gaps. This is a severe case but stands true. He was later psychologically discharged from the Army. Of course that’s not fair. This was not uncommon and rank just turned a blind eye or walked out of the room when this behaviour was developing. A friend recently told me that he believes some of the courageous men he served with, were the diggers that copped sh*t every single day of their service. They were belittled, demoralised, but yet they continued to stand by their mates and serve their duty. (David—Appendix A)

Susan’s comments below illustrate the urgent need to normalise discussion and treatment of those diagnosed with a psychological injury:

One of the biggest issues that I faced in Defence was management, particularly middle management, not knowing how to handle or deal with mental illness. The truth is it should be dealt with no differently than any other injury. Management level Corporal through to Major need to make it ‘ok’ to talk about mental health. It’s all well and good having processes in place but most of these processes make people requiring them feel like they are only to be used if you are struggling or can’t handle it. Programs and support should be a continued ‘wellbeing approach’. Like a BFA [Basic Fitness Assessment] or a peer review. It’s just something that happens. It should just become so normal that no one even thinks twice about it. Going to war is not normal—seeking support for it is!! It is for this reason that there needs to be more open communication about PTSD and mental health in my opinion, to encourage people to talk openly about it. Make it normal ‘morno’ talk, not a slide show every twelve months. It needs to be personal and it needs to be real. (Susan—Appendix A)

The comments below illustrate the shame still attached to psychological injuries, which is reflected in the attitude that it is better to hide the problem than allow others to think you are ‘nuts’:

I have kept my PTSD and Chronic Depressive Disorder very quiet, so at this stage it has had minimal effect on my work life; I do find that I have time off on occasion due to ‘not feeling quite right’, but at this stage my employer is kept very much in the dark and I deal with my issues at home. Well it’s not really fair, but I also don’t want my employer and my work mates thinking that I’m nuts. (Gary—Appendix A)

While mental fitness issues can be hidden or disguised as something else, it is also the case that other kinds of (physical) medical conditions may be kept from employers for career reasons.

Ex-Service Organisations

A key feature of the service model as it currently exists is the collection of ESOs that have grown to fill the (perceived) void between services and support provided by Defence and those provided by DVA. These pages record examples of ESOs that provide an invaluable range of services and support to veterans. There is, however, a feeling (expressed by a number of interviewees for this research who prefer not to be linked to these comments) that some advocacy and support groups appear to remain trapped in an entitlement mentality that sees DVA as the enemy with whom they must wage battles for compensation. These groups are often protective of their own organisation and wary of cooperation with others. It has been noted that failure on the part of the RSL, as the premier and iconic representative group, to keep pace with the changing needs of younger veterans has contributed to the proliferation of newer and smaller organisations.[6]

As discussed in a previous section of this paper, while many interviewees acknowledge the useful role played by ESOs in plugging gaps between Defence and DVA, and providing care and support to veterans, problems (including the above-cited entitlement mentality) do exist in the current model. While a small number of such organisations have been around for decades (RSL and Legacy are the examples most people are familiar with), many smaller organisations have sprung up during times of need, then disappear. A Queensland sub-branch of the RSL has counted 80 such organisations in Queensland alone.[7] Currently, Mates for Mates and Soldier On are seen by a number of interviewees to be more responsive to the changing needs of veterans than the older organisations.

The manner in which ESOs compete for attention, public donations and government funding; the overlap and redundancy in the services they provide; and the (at times bitter) in-fighting and disagreement that occurs between the groups themselves are some of the problems that currently exist. Among the consequences of this is a diluting effect on the power of these organisations. While one compellingly expressed coherent message may find traction, empathy fatigue can be an issue when there are a number of competing voices. Some have also been noted (by sources who chose to remain anonymous) to foster an entitlement mentality and become fixated on winning DVA compensation for their members and ‘going for gold’ (securing DVA Gold Cards for veterans).

Stories related during interviews for this research include groups that celebrate every time a member receives a Gold Card as a win against DVA, and other groups that guarantee a ‘TPI’ (Totally and Permanently Incapacitated) classification if clients use their recommended form of words in a DVA application. For some, winning a benefit has become an end in itself. The emphasis on these ‘battles’, the entitlement mentality and belief that everything is compensatable, and the extent to which the current system is open to abuse and exploited by some groups, are among the observations made during interviews about the current system of ESOs. Notwithstanding these issues, a large number of veterans and others work (often unpaid) for the welfare of Australia’s ex-service men and women. The Chief of the Defence Force (CDF) believes that the ADF can play a useful coordination role with respect to ESOs (Mark Binskin—CDF). Some form of centralised administration may alleviate some of the chaos that currently exists. A coordination role that focuses efforts where they are most needed and eliminates duplication may make a positive difference to this sector. 

Another suggestion that has been made is that such organisations should actively attempt to include all veterans in activities, not just the wounded, injured or ill (Gus Gilmore—military officer). A diverse community is much better able to help a minority of those adversely affected people than if those few who experience reduced mental fitness are forced to try and help themselves in the absence of the support of empathetic veterans.

Reported experiences of members of the 2nd Commando Regiment—a case study

An encouraging note is the work being done by the 2nd Commando Regiment and the comparatively mature approach it takes to the mental fitness of its workforce. There are elements of this that provide an example of what can be done. This Regiment has achieved much-improved outcomes for its members. It has been successful at substantially reducing the stigma around reduced mental fitness and has offered substantial support to transitioning members in a culturally appropriate way.

One feature of debates around mental fitness and the military that often goes unreported is those commanders who are well-informed on mental fitness and related issues, and who genuinely care about the individual welfare of soldiers under their command and are able to communicate that to them. Numerous examples of this became apparent while completing this research. Air Chief Marshall Mark Binskin, Lieutenant General Angus Campbell, Lieutenant Colonel Ian Langford and Major General Jeffrey Sengelman all ‘get it’, as does (Wing Commander) Joanna Elkington who described her entire remit as CO as genuinely caring about her people and personally concerning herself with their welfare. Sources of information for this section include current serving members and senior leadership including the CO (with protected identities), a former 4RAR (now the 2nd Commando Regiment) Regimental Psychologist (Clint Marlborough), independent research conducted by journalist Chris Masters, and doctoral research by Paula Dabovich.

The view in the 2nd Commando Regiment is that each individual soldier represents such a significant capability that, should that capability be reduced for any (preventable) reason (including mental fitness), it should be identified as quickly as possible, resources marshalled, and appropriate care and support given to get that individual (capability) back working as soon as possible. One of the strategies used for achieving this end is the Human Performance Wing (HPW). Extracts of the Human Performance Handbook: a Guide for Commandos by Commandos, developed within the HPW, were obtained for this report (the document as a whole is restricted to internal regimental use only). The handbook states the following:

The Human Performance Wing (HPW) was established in 2013 as a soldier led, academically informed and command supported initiative to provide culturally appropriate support to seriously wounded, injured and ill commandos. HPW is an intermediate space where soldiers are supported during times of significant change, as they work to establish and achieve their goals and update their identity.

The aim of 2nd Commando Regiment’s HPW is to provide culturally relevant, non-clinical holistic care to members who are undergoing rehabilitation. HPW also facilitates personal development using human performance optimisation principals to enhance individual wellbeing and collective capability as well as providing the opportunity for those transitioning from the regiment to do so with a strong personal foundation and dignity.[8]

From a number of accounts, this is an individually focused support network that treats mental fitness in a similar way to physical fitness. It takes a mature and considered approach, often involving support personnel who have experienced the negative impacts of psychological injury themselves, with an emphasis on recovery and returning to work as soon as and wherever possible. Part of the philosophy of the HPW is to look at a ‘state of battle readiness’ as a continuum along which all soldiers operate, and that an individual temporarily posted to the HPW is simply on another point in that continuum. A current serving member of 2nd Commando Regiment commented during an interview for this research that ‘the HPW is genuinely good; look at 2nd Commando Regiment as an example of what is working well’ (veteran S).

Clint Marlborough (former military psychologist) commented during interview that 2nd Commando Regiment treats mental health like physical health; it makes a big investment in people, understanding that they will get hurt, and wanting to treat any mental/physical injuries and get them going again. Another current serving member of 2nd Commando Regiment commented that in his 15 years in the Army he had not been given any mind-related training until being posted to 2nd Commando Regiment where the CO encouraged his workforce to engage with the Redesign My Brain TV series. Paula Dabovich made the comment that the 2nd Commando Regiment has a capacity-building framework that focuses on high-end and optimised performance, and which seeks to build upon strengths regardless of very real and often serious physical, psychological or battlespace limitations. She said it focuses on growth, rather than disability.

‘Big Army’ (the Australian Regular Army) has Soldier Recovery Centres (SRCs) which at first glance look like the 2nd Commando Regiment model of High Performance Wing. However, it was described during interviews for this research as being outside the unit’s chain of command, and while the HPW is about individual results and outcomes, the SRCs become dumping grounds for unwanted and discharging soldiers. The SRCs are often staffed by NCOs and commanders who have no experience with mental fitness issues, therefore furthering the opportunities for misunderstandings and stigma to flourish. Staff equipped with maturity, compassion and wisdom have the ability to provide the level of non-clinical support genuinely required in this area. David Dunt (professor, University of Melbourne) commented during an interview for this research that the SRCs have not been rolled out well. A senior commander of 2nd Commando Regiment stated in interview that ‘while 2nd Commando Regiment is doing mental health well, it’s an indictment on the ADF, not a positive for 2 Commando’ (protected identity).

However, translating 2nd Commando Regiment’s HPW to ‘Big Army’ is not quite so simple (Senior Commander). This commander went on to say that ‘Big Army’ first has to define the problem before they can attempt to begin dealing with issues of mental fitness. A former 4RAR psychologist related a story during interview that the day he marched into the Regiment, the CO asked him ‘why the fu*k are you here? What am I supposed to do with you?’, in genuine bewilderment at the presence of a psychologist in his regiment. By the end of his posting to 4RAR, SOCAUST (Special Operations Commander Australia) presented him with an award recognising the contribution he had made to the Regiment (Clint Marlborough). This is a powerful illustration of the change in attitude and the power of having the right person for the job.

While the Special Air Services Regiment also invests heavily in the training and support given to each of its operators and achieved similar success to that described above, it was Chris Masters’ impression that the ‘brotherhood’ model of 2nd Commando Regiment means its members enjoy better mental health support than their SASR colleagues with their ‘lone wolf’ reputation.[9]

It is noted that while the time devoted to mental fitness in the Australian Regular Army, Navy and Airforce is felt by some to be inadequate, it is one of a number of competing priorities, particularly in busy operational units. As this report demonstrates, however, it is a priority that is critical to preventing the sorts of issues discussed above from flourishing. 

Prevention

Mental health promotion is any action which maximises mental health and wellbeing. Prevention is defined as interventions that occur before the initial onset of a disorder to prevent the development of the disorder. Prevention relies on reducing the risk factors for mental disorder, as well as enhancing the protective factors that promote mental health. Universal interventions are aimed at improving the overall mental health of a population: an example would be programs aimed at building mental health literacy across all personnel in all services as part of an integrated mental health awareness-raising process (Kerry Howard).

As stated, a key challenge presented by the issue of mental health and Defence is the need to find a circuit breaker to the circular argument that sees ‘broken’ veterans doing battle with DVA. As suggested, a change in narrative to one focused on health, rather than illness, might go some way to achieving this end. This preventative approach might be underpinned by an increased focus on such things as:

• raising mental health literacy/awareness
• mental health first aid and
• increasing the evidence base for best-practice preventative models.

This may not only reduce the rates and fall-out of reduced mental fitness, but potentially result in a reduction in treatment and compensation expenditure. The change in mindset in getting everyone involved in activities of this kind, not just the ‘sick’, may also make significant headway in decreasing the stigma that surrounds reduced mental fitness.

The recently released National Review of Mental Health Programmes and Services, completed by the National Mental Health Commission under the heading ‘Future Approaches and Funding Priorities’, makes the point that the re-allocation of resources to ‘upstream services’ such as prevention, can achieve value for taxpayers’ dollars.[10] For example, the Review identifies measures to help the Commonwealth maximise value for taxpayers’ dollars by using its resources as incentives to achieve desirable and measurable results, and funding outcomes rather than activity. It also proposes re-allocating funding from downstream to upstream services, including prevention and early intervention. Evidence exists for the economic benefits of a preventative approach to mental health.[11]

The World Health Organization (WHO) report Prevention of Mental Disorders—Effective Interventions and Policy Options describes prevention as one of the most obvious ways to alleviate the burdens related to ‘mental disorders’.[12] According to the report, mental disorders are linked to human rights issues which demonstrates how pervasive the effects of stigma, discrimination and human rights violations are. It is (wrongly) believed that no effective treatment modalities exist. Preventative strategies can therefore not only impact the wellbeing of those affected, but also combat the stigma associated with ‘disorders’ of this kind.

In its submission to the recently completed Senate inquiry into the mental health of the ADF, the national branch of the RSL labelled the ‘significant lack of access to services involving both prevention and care’ as ‘unsatisfactory’.[13]

Defence has a number of programs in place that incorporate elements of preventative mental health approaches. Examples include the ‘battle smart’ program (that may include a single two hour presentation delivered to a soldier); suicide prevention presentations as part of yearly top-up training; the Veterans and Veterans’ Families Counselling Service (VVCS); and ‘Mental Health Day’ activities.[14] However, these programs represent an ad hoc approach to preventative mental health care (anonymous). Where best-practice and culturally appropriate prevention strategies do not exist, making them research priorities will help close this gap in the literature and improve service provision. The application of such knowledge to the normal operating practices of the ADF may result in significant increases to the wellbeing of the workforce, as well as financial benefits for government. DVA’s allocation of resources for health treatment is around $5.5 billion annually, of which only around $200 million is allocated for mental health services. However, investment in preventative mental health represents only a fraction of this $200 million.[15]

For a workforce that receives state-of-the-art training in so much of what it does, is highly proficient in the art of conducting warfare, and is a profession that routinely exposes its people to traumatic events, the absence of a well-defined pro-active and preventative program of mental health conditioning would seem to be a significant deficiency. There appears to be little evidence of substantial preventative mental health measures being put in place and routinely used to good effect. While some preventative services do exist, little is known about the way in which the target groups access these services or how effective the services are at combating rates of reduced mental fitness.

Resilience is a topic that Defence believes is important to its work. If Defence can train resilient and well-prepared soldiers, they will fight better and be better prepared when they come home. As a senior commander said:

Firstly, I believe the weight of resources should rest with developing individual and group resilience rather than management. I believe it is important to include group resilience in any consideration of mental health. The military, particularly the Army, relies on complex social bonds that we have not fully mapped and rarely acknowledge. In my experience the resilience of strong teams has a direct relationship with the resilience of individuals within those teams. I have a feeling that the strength of the leadership of these teams also has a strong bearing on the resilience of the individuals. For example, there is a contemporary Australian Infantry battalion that adopted some very overt branding, language and labelling relating to ‘brothers in arms’, ‘unbreakable bonds’ etc.; however, the leadership was brittle and the unit would appear to have experienced quite a large number of mental health challenges subsequent to their deployment. The group resilience was poor and lacked substance, and individuals were not well prepared as a result. This is anecdotal of course. The point is that group resilience is critically important and must have substance and depth. It needs the depth of real and genuine investment, not matching sleeve tattoos and t-shirts bearing mythological Greek iconography.

Turning to individual resilience, I believe tough, challenging and realistic training has a significant influence on the development of individual mental resilience. As a Squadron Commander I used to demand that we train to failure. Obviously we also trained to win because that promoted confidence, but that came later. For a great deal of our pre-deployment training prior to Afghanistan we threw ourselves into complex and chaotic training serials and did our best to turn ourselves inside out. The debriefs went longer than the orders and we were extremely hard on ourselves. We would regularly bring in external ‘assessors’ to evaluate us and break any ‘group think’ that was developing. We stressed the importance of excellence in everything that we did, we demanded honesty when we collectively failed and we pushed ourselves to breaking point at times. This was done carefully and deliberately, and with a specific objective in mind. The objective was to harden us individually and collectively.

Individual resilience comes from knowing that one particular ‘hard moment’ is no harder than others you might have been in before. Tough training is the best way of ensuring that the ‘hard moment’ during a deployment can be placed within a context of ‘other hard moments’.

So, in my view, individual and group resilience is key to strong mental health. (senior commander, protected identity)

…

Walk soldiers up to trauma—give them their worst day in training not in the field—this is a key to well-prepared soldiers. (senior military commander)

The above sentiments on resilience reflect the experience of highly-regarded military leaders. As the evidence-base around the idea of resilience is lacking, effort could usefully be spent in bridging this evidence gap. Care does need to be taken to ensure that individuals are not left with the impression that illness reflects a lack of resilience and is therefore their fault. It is important that we do not throw the problem back on individuals, rather than holding to account the system that routinely exposes its personnel to trauma. In addition to resilience, there is an urgent need for an increased focus on other forms of psychological preventative measures and increased mental health literacy (David Dunt).

Currently, there exists a need to go beyond the focus in the military on ‘resilience’ to other preventative approaches. Prevention and resilience are not synonymous. A focus on resilience is a double-edged sword. While it may better prepare a soldier (sailor or airman) for duty (and by extension, life after the military) it may also, inadvertently, set them up for failure. If a defence member becomes unwell, it may further entrench stigmatised attitudes if they are seen to lack resilience, or made to feel that it is something they should just be able to overcome. As well as contributing to an increase in wellbeing, a change in preventative approaches is also likely to have economic benefits for government. There exists scope to apply preventative mental health approaches from civilian to military settings. As this is a complex issue, a systematic study of it is beyond the scope of this chapter; the aim instead is to highlight this as an issue where effort could helpfully be applied in the ADF.

We need to be saying to commanders, this is what you can do to improve the mental health literacy of your workforce because they care about their men: we need to be setting up efficient return-to-work policies; spend money on IT, the Web and future education packages; and identify the best points of access … the CDF gets it, but everyone needs to ‘get it’ and that comes through education. (Dr Andrew Khoo)

A psychologist with a professional interest in veterans’ mental health commented during research for this paper:

Currently there is a huge cost of treating PTSD and this is unnecessary. Prevention and mandatory psychological training and treatment should be implemented. PTSD and other psychological injuries are curable with treatments such as EMDR therapy [eye movement desensitisation and reprocessing] and the member may become deployable again. Elements of these treatment options could be included in the existing Battle Smart training. (Kerry Howard)

Another proposed treatment model relates to an increased use of training in mental health support. ‘The military could train more military personnel in accredited mental health support’ (Frank Quinlan). Despite attempts to increase the mental health literacy amongst the general population, it remains low and this is reflected in the ADF (source chose to remain anonymous). A key observation of this monograph is that there could be considerably greater focus on prevention. This is a view echoed in the American context, as described in the report Preventing Psychological Disorders in Service Members and their Families: an Assessment of Programs:[16]

Recommendation 1: The committee recommends that the DOD employ only evidence-based resilience, prevention, and reintegration programs and policies and that it eliminate non-evidence-based programming. Where programming needs exist and the evidence base is insufficient, DOD should use rigorous methods to develop, test, monitor, and evaluate new programming.

The report highlights the lack of an evidence-base for many of the 94 identified programs that specifically address prevention on the resilience, prevention and treatment continuum. The knowledge gap in the evidence for preventative mental health approaches is one that needs to be filled so that it can become a part of ‘business as usual’ for the ADF.

International and Australian approaches to PTSD 

In 2013 the Royal Australian and New Zealand College of Psychiatrists (RANZCP) conducted a review of prominent internationally recognised clinical guidelines for the treatment of PTSD.[17] It evaluated each of the guidelines using a methodology called the Appraisal of Guidelines for Research & Evaluation II (AGREE II) instrument. The following guidelines were reviewed:

1. Australian guidelines for the treatment of adults with Acute Stress Disorder and Post-traumatic Stress Disorder; Australian Centre for Post-traumatic Mental Health (ACPMH); 2013
2. Practice guideline for the treatment of patients with acute stress disorder and post-traumatic stress disorder; Agency for Healthcare Research Quality (US Department of Health and Human Services (AHRQ); 2008
3. ‘The Last Frontier’ Practice guidelines for treatment of complex trauma and trauma informed care and service delivery; Adults Surviving Child Abuse (ASCA); 2012
4. The ISTSS Expert Consensus Treatment Guidelines For Complex PTSD In Adults; International Society for Traumatic Stress Studies (ISTSS); November 2012
5. Psychiatric Evaluation of Adults, Second Edition; American Psychiatric Association (APA) Practice Guidelines, November 2004 and a Guideline Watch; March 2009
6. VA/DoD clinical practice guideline for management of post-traumatic stress, Department of Veterans’ Affairs and Department of Defense ; October 2010
7. Effective treatments for PTSD: Second Edition; Practice guidelines from International Society for Traumatic Stress Studies (ISTSS); 2010
8. The management of PTSD in adults and children in primary and secondary care; National Institute for Clinical Excellence (NICE); March 2005
9. Management of Anxiety Disorder; Clinical practice guidelines; Canadian Journal of Psychiatry; Vol 51, Supplement 2 Chapter 8; July 2006

The RANZCP working group concluded that all guidelines reviewed were of high quality and considered useful in the treatment of PTSD. It did however note that as the Australian Centre for Post-traumatic Mental Health (ACPMH) guidelines are Australian, they are likely to be more effective in a local context. It concluded that, as the evidence reviewed in all of the above nine guidelines was broadly similar, the adoption of any one of the guidelines by practitioners was appropriate.

Two of the above guidelines include the International Society for Traumatic Stress Studies (ISTSS) Expert Consensus Treatment Guidelines for Complex PTSD in Adults, and the Australian Guidelines for the Treatment of Adults with Acute Stress Disorder and Post-traumatic Stress Disorder by the Australian Centre for Post-traumatic Mental Health (ACPMH) 2013. Reference information on both are included below:

An international approach

The International Society for Traumatic Stress Studies is dedicated to sharing information about the effects of trauma and the discovery and dissemination of knowledge about policy, program and service initiatives that seek to reduce traumatic stressors and their immediate and long-term consequences.

ISTSS provides a forum for the sharing of research, clinical strategies, public policy concerns and theoretical formulations on trauma around the world. We are the premier society for the exchange of professional knowledge and expertise in the field.

Members of ISTSS include psychiatrists, psychologists, social workers, nurses, counselors, researchers, administrators, advocates, journalists, clergy, and others with an interest in the study and treatment of traumatic stress.

ISTSS members come from a variety of clinical and non-clinical settings around the world, including public and private health facilities, private practice, universities, non-university research foundations and from many different cultural backgrounds.[18]

An Australian approach

Five to 10 per cent of people will suffer from posttraumatic stress disorder (PTSD) at some point in their lives.

The Australian Guidelines for the Treatment of Acute Stress Disorder and Posttraumatic Stress Disorder provide information about the most effective treatments for PTSD. They are the first national Guidelines that provide guidance on the treatment of children and teenagers who experience PTSD.

The Guidelines aim to support high quality treatment of people with PTSD by providing a framework of best practice around which to structure treatment. While there has been growing consensus about the treatment of acute stress disorder and PTSD in recent years, approaches are varied and there is still a gap between evidence-based practice and routine clinical care.

Approved by the National Health and Medical Research Council (NHMRC), the Guidelines were developed by Phoenix Australia (formerly Australian Centre for Posttraumatic Mental Health) and a team of Australia’s leading trauma experts, in collaboration with representatives of the professional associations for psychiatrists, psychologists, general practitioners, social workers, occupational therapists, mental health nurses, school counsellors, and service users. Recommendations were based on best practice evidence found through a systematic review of the Australian and international trauma literature.[19]