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The second part of this monograph maps changing attitudes towards mental health and the ADF from a range of stakeholders. These include the Federal Parliament and the departments (the ADF, Defence and DVA). A growing awareness and increasingly sophisticated understanding of this issue is evident in the parliament, the military and the broader community. This has corresponded with an increased level of services and support available to those who require it. Nevertheless, while the senior leadership of the ADF, Defence and DVA recognise the serious nature of the issue and are focused on positive change in helping those affected, these attitudes have not sufficiently permeated the low and mid-levels of these organisations. A disconnect has been noted between the attitudes and support of senior leadership and the services available, with better outcomes for those affected. Encouragingly, there exists a tangible appreciation amongst the Defence hierarchy that attitudinal and cultural change is not a found object, and there is commitment to continuous improvement and learning by doing evident within this group. Another limitation is the incomplete evidence on what constitutes best-practice in terms of education, prevention and treatment.

The Parliament of Australia

The parliament, as a key national institution, plays a significant role in shaping attitudes on the treatment of military personnel and veterans, and their mental health care. However, there is no formal reporting mechanism between the bureaucracy and the parliament devoted solely to ADF mental health. 

As seen following previous wars in which Australia fought, there is currently no shortage of attention and resources allocated to this issue. History has taught us, however, that this initial interest will wane. While popular attention given to the issue in recent months and years has been quite substantial, there has not been as much interest in it on the floor of parliament as media attention might suggest. However, this may not be the best indicator of parliamentary interest as the issue does come up in other ways within parliamentary processes. These include:

• on the floor of both houses of parliament (including statements from the minister, questions with/without notice, second reading speeches/debate)
• committee examination of legislation, referred inquiries, annual reports, budgets and white papers [Defence and Veterans’ Affairs] (including by the Joint Standing Committee on Foreign Affairs, Defence and Trade, and the Senate Standing Committees on Foreign Affairs, Defence and Trade)
• legislation (although in the Veterans’ Affairs portfolio the introduction of new legislation is rare)
• Parliamentary Friendship Groups (Parliamentary Friends of Defence, and Parliamentary Friends of Mental Illness)
• the Prime Ministerial Advisory Council on Veterans’ Mental Health and
• dialogue between MPs and the media.

The intention of this chapter is not to review all the above in a detailed systematic way, but instead to draw attention to some of the key forms debate on mental health and Defence takes within the Federal Parliament.

Influencing the attitude of the current parliament are those 21 senators and members whose biographical entry in the Parliamentary Handbook records military service.[1] While this service spans war and peacetime service from the 1970s to 2012 in both the full and part-time military, only a small number could be described as ‘career soldiers’, and fewer still have seen active war service.

In the Parliamentary Library publication Commonwealth Members of Parliament who have Served in War (2007) Lumb, Bennett and Moremon state:

Of those Commonwealth MPs who were elected before 1970, a remarkably high percentage experienced war service—some before entering Parliament, some while they were members, and some after they had left the Parliament. Although the total number is uncertain, at least 265 (30.2 per cent) of the total membership of the Parliament between 1901 and 1970 gave war service at some stage of their lives. Of the total membership since Federation, at least 286 (19 per cent) did so. Since 1970, twenty-one, or 3.4 per cent of the total membership, have done so. [2]

…

MPs who were servicemen prior to their entry into the Parliament have tended to be very involved in policy debates in relation to such areas as repatriation, conditions for returned servicemen, defence and foreign affairs.[3]

While on a much smaller scale, the latter observation holds true of the current parliamentarians who made their careers in the military before joining parliament. However, as noted in the Parliamentary Library research paper, the influence of those who served in war is much reduced, reflecting the comparatively small percentage of Australian society who has seen war. As the number of war veterans in the current parliament is limited, so is their influence.

Floor of parliament

The observations below are based on textual analysis of parliamentary debates from both the House of Representatives and the Senate during the current 44th Parliament. The search terms used in compiling this data were ‘mental health’ and ‘defence’ and related combinations on the Parliament of Australia website and in the ‘ParlInfo’ database.

The data has been grouped into like categories and includes:

• statements by the minister announcing the government’s position and new policy initiatives
• the continuing influence of Vietnam War veterans
• the sometimes anecdotal accounts given in parliament
• lauding of the previous government’s achievements
• the position taken by minor parties
• the theatre project The Long Way Home
• the perhaps self-fulfilling prophecies of some positions
• deeply felt personal views and
• the aspirational quality of some of the sentiments expressed.

Ministerial statements

During 2014, the Minister for Veterans’ Affairs regularly addressed the parliament on the issue of mental health and Defence. Issues covered included the government’s agenda; the launch of a promotional video on services available; a smart phone app with information on PTSD; and an initiative to write to all transitioning members with departmental information.

I am pleased to inform the chamber that today I am launching a video that will remind serving members that, while they may not need help or access to services now, they may need assistance in the future, and there are many avenues available to them to pursue. This video stresses that DVA and Defence have a shared responsibility to look after serving and ex-serving personnel and their families now and into the future. The video is just one of many activities being rolled out as part of a campaign to fully engage the Defence and veteran communities and their families by providing them with information on the support and services available to them.

In particular, the video provides details of nonliability health care, whereby many ex-serving men and women can get treatment for depression, anxiety, PTSD, and substance or alcohol misuse without having to lodge a claim or link their condition to service. This launch will take place at the second meeting of the Prime Minister’s Advisory Council on Veterans’ Mental Health, otherwise known as PMAC, which is taking place today. This video was one of the recommendations of the military compensation review with further engagement and awareness of what benefits are available. The aim of the video is to reinforce to current serving members that, no matter what stage of your career you are at, it is DVA and Defence’s job to look after your family now and into the future, and is a reminder also that Defence looks after your health treatment when you are serving and, when you are discharged, DVA provides early access to health and support services. Both DVA and Defence have shared responsibilities, which both the assistant minister and myself take very seriously.

I am pleased to inform the chamber that the VVCS [the Veterans and Veterans’ Families Counselling Service]has been exploring ways to improve awareness of the services it provides to veterans and their families. The VVCS has a prominent online presence, including a modern website and Facebook page. Today, it also announced the Support When You Need It campaign, which is targeted at those who have recently separated from the ADF to encourage them to contact the VVCS in tough times and to utilise the counselling and support services available to them. VVCS counsellors have an understanding of military culture and can help to address concerns such as relationship and family issues, anxiety, depression, anger, sleep difficulties, PTSD, and alcohol or substance misuse, with the aim of finding effective solutions for improved mental health and wellbeing.[4]

…

This weekend, right across Australia, all Australians will have the opportunity to welcome home those who served in Operation Slipper. There will be troop marches throughout the nation. I encourage all Australians to attend and support those men and women who were engaged in Operation Slipper. Many of those men and women may require now, or sometime in the future, assistance to deal with anxiety, stress or other mental health conditions. I have said to this chamber before that veterans’ mental health is a matter of great personal importance to me and also to the government. I am therefore delighted today to launch a new smartphone app, called High Res, which continues the government’s commitment.[5]

…

In relation to Senator Reynolds’ question, it seems remarkable to me that those who were transitioning out of Defence could not be contacted by my department unless they actually lodged a claim. Ridiculous! Privacy laws precluded that. So I worked with the department, and the secretary will now write to every transitioning member telling them exactly what the department offers and, just as importantly, telling their families what the department offers. It has filled a massive gap, and ex-service personnel or those transitioning deserve to know what is available.[6]

Vietnam veteran influence

The Vietnam experience, powerful lobby groups, and a desire not to repeat the mistakes of the past continue to influence policy and service provision, including in the area of mental health:

I will take this opportunity to place on the public record, the Vietnam veteran community is really still in a state of shock following the passing of Tim McCombe. He was a fearless advocate for the Vietnam veterans. As long as they are not listening, I said at his funeral that the four people who scare me most are my mother, my wife and my two daughters and after that it was Tim McCombe. You knew you had had a good clip around the ears from Tim if you deserved it. He had no fear and no favour. He was a fantastic advocate and he will be very sadly missed. I know I speak for everyone at the table here in relation to that.[7]

…

Since becoming the Minister for Veterans’ Affairs, and in the three years prior as the shadow minister, I made it clear that I was not prepared to see the mistakes of the past repeated when it came to the nation’s treatment of its veterans, ex-service personnel and their families. The treatment of Vietnam veterans on their return remains a dark stain on this nation’s history. It is something that must never be repeated. This philosophy underpins everything the government seeks to achieve.[8]

…

We view veterans’ mental health as absolutely fundamental to where this nation is heading. We believe that early intervention is the key to helping these young men and women and their families. The Australian government is currently spending $166 million per annum, uncapped, on the mental health needs of our serving men and women and ex-serving men and women. Quite frankly, this nation cannot afford to repeat the mistakes of the past. What was done to those men returning from Vietnam so long ago now this nation simply cannot do to the young men and women returning from recent conflicts. We are determined to address their needs.[9]

As a senior bureaucrat commented (anonymously) during the research for this paper, the Vietnam veteran cohort needs to be treated very carefully in terms of service provision, but also to ensure that lingering resentments and suspicion of the government and bureaucracy do not poison the next generation of veterans.

Anecdotal

There are a number of backbenchers on both sides of politics who have taken a personal interest in the issue of mental health and Defence. Some draw on anecdotal evidence of conversations they have had within their own electorate and things they have heard in the media, while others take a broader view of the issues:

However—and I had a detailed conversation with one veteran in particular—a number in our veteran community experience PTSD. We know that with the new cohort coming out of Afghanistan and Iraq—Afghanistan in particular—accessing a specific VAN [Veterans’ Access Network] network shopfront is much easier for them than going into a DHS service. My view is that these people have sacrificed, or have been prepared to sacrifice, their life in defending of our country. I think that we owe it to them, notwithstanding that we understand the Australian government’s decision, as I said, to consolidate its service, to provide accessible shopfront services so members of our veterans community who have served our country so well in conflicts feel comfortable accessing these services. If I could, on behalf of the Casey Regional Veterans Welfare Centre, I respectfully ask the government to reconsider its decision. It is in the best interest of our veterans that it does so.[10]

…

I want to talk about this very serious issue of mental health, which I was reminded of in recent days with the tragedy of the partner of Mick Jagger from the Rolling Stones and what he would be going through now. What a terrible outcome it is when people seem to have lost hope. I have been told—and make no mistake about it, I am no mental health expert, a doctor or whatever—from good source that mental health is actually an illness. It is like catching a cold or the flu. The pressures get you down and you become ill—and it can be cured.

Just in the past week there has been a significant announcement by my colleague the Minister for Veterans’ Affairs, Senator Michael Ronaldson. The minister has announced the establishment of a new prime ministerial advisory council with a renewed focus on mental health. …because life is a partnership and mental health is not a stigma.[11]

References to the previous Labor Government

There are some members of the Opposition who choose to engage the issue by rehearsing the achievements of the previous Labor Government. Both sides of politics are guilty of this tactic. While this is an accepted part of the functioning of parliament, it might be seen as subverting genuine bipartisan goodwill towards achieving outcomes:

So while those opposite will continually seek to denigrate Labor’s record, Labor’s accomplishments, Labor’s passion and Labor’s commitment to our veterans and to our ex-service men and women, let that denigration be known for the furphy that it is. And let it be understood that Labor can point to an extraordinary record of accomplishment in this very important area of public policy, because those opposite—try as they might—do not have the single claim to be the custodians and defenders of our former service men and women, our veterans community. As we have seen over 11 long years, the Howard government did precisely nothing. And under the zealotry of people like Senator Minchin they made sure that doing nothing in this space was a matter of high principle for them. Labor has in fact delivered a whole series of reforms in this important space—reforms that mean investment, mean stronger commemoration of our military history, and mean that there are practical solutions delivering real benefits for our veterans every single day of the year.[12]

Minor party positions

There are some thoughtful voices which attempt to situate the issue of mental health and serving personnel and veterans in the wider context of the decision to send them to war in the first place. Echoing the question posed by journalist Kerry O’Brien, quoted at the front of this paper, is the following statement:

The Australian Greens believe that we have, essentially, a twofold obligation to our serving personnel. The first is that we should never deploy them unless it is absolutely necessary. We are well aware that in the past 15 years the ADF have been deployed into three wars of choice. I do not propose to get into arguments about where that decision should lie, or even the merits of those particular deployments. But we owe it to them—in fact, I think it is our highest responsibility—not to throw them into harm’s way unless there is the very best possible reason for doing so. Obviously, we strongly disagree with some of the decisions that have been made in the recent past.

The second obligation we owe them is to look after them, both while they are on deployment and particularly when they come back. For anybody who is not aware of what I am talking about, view a Four Corners program that ran not long ago, or read Major General John Cantwell’s book Exit Wounds, to get a vivid insight into what happens to some of these people who have been exposed to horrific violence—and these are some of the most highly-trained and disciplined people the ADF has—who, when they return, are basically unable to decompress and assimilate the things that they have seen and done, having been at very close quarters to people being killed or injured, or having suffering horrific injuries themselves.

But nonetheless it is amazing TV fodder for politicians to wrap themselves up in the flag and stand in front of the troops before sending them off into harm’s way. But it is much harder to find politicians who will stand up for people who are suffering inordinately once they return home.[13]

The Long Way Home

One idea that appears to have captured the imagination of a number of politicians was the ADF’s theatre project, The Long Way Home:

I also want to take this opportunity to mention The Long Way Home, a play that was showing around Australia earlier this year. Just as media has an important role in raising awareness, so too do the arts—and this was achieved through this wonderful production, The Long Way Home. The play was written by Daniel Keene in collaboration with the Australian Defence Force, and it takes the words and experiences of soldiers and builds them into a work that acknowledges the damage of conflict alongside the mundanity and sometimes thrill of soldiering. It highlights the unique challenges faced by our service men and women in their return to everyday life after operations around the world.[14]

…

On Saturday night I had the opportunity to join with the Governor-General, Quentin Bryce, the Chief of the Defence Force, David Hurley, the War Memorial Director, Brendan Nelson, the Chief of Navy, Ray Griggs, and several other people of significance within the defence industry at a presentation of what can only be described as a unique and inspiring theatre production called The Long Way Home. The Long Way Home is part of a performing arts program to assist the rehabilitation and recovery of men and women in the ADF who have been wounded or injured or have become ill in service. This is an extraordinary production and I would urge those listening to the broadcast tonight to look out for opportunities to see it in their own city when The Long Way Home tours throughout Australia.[15]

Self-fulfilling prophecy

While a number of politicians appear genuinely committed to improving the mental health care available to military personnel and veterans, to talk of ‘constant mental and physiological impairments’ and looking after this group ‘until they are dead’ potentially risks the issue becoming a self-fulfilling prophecy. There is a danger of unnecessarily encouraging a belief that military service damages some people for life and that they can only survive with the assistance of ongoing government support:

In Labor’s last budget, we committed a record $12.5 billion to veterans, including an additional $26.4 million over the forward estimates to expand access to mental health services for current and former members of the ADF and their families. Labor hopes that the Abbott government is able to work in a sensible and bipartisan approach in aiding in the proper repatriation and suitable care of our returning soldiers. I believe the project for 310 St Kilda Road to turn this building back to a safe place, a constructive space, for returned soldiers will help our heroes battle the constant mental and physiological impairments they face each day due to the sacrifices they made to protect our country.[16]

…

I have long taken the view—and I think it is acknowledged—that once someone goes through the recruitment gates, goes out to Kapooka and does their recruitment training they are potentially a client of the Department of Veterans’ Affairs for the rest of their life. What we have to acknowledge is that once we accept someone into the Defence Force we see them as part of the family that we need to look after, ultimately until they are dead. That means ongoing care not only of them but also, in particular circumstances, their families.[17]

In what sounds like another self-fulfilling prophecy from a passionate supporter of veterans, this is obviously an attempt to foster a sense of ‘the real cost’ of war on the (mental) health of those who fight them, but there is something fatalistic and ultimately depressing about this conclusion. This is also sometimes the case when similar sentiments are expressed by veterans groups. 

Independent voices

The following excerpts from Senate Hansard demonstrate the depth of feeling felt for the issue, reflecting a mixture of deeply-felt personal anger and a strategic attempt to draw attention to it:

Shame, Binskin! Shame, Griggs! Shame, Morrison! Your years of service will be rightly tainted and stained by your compliance with a despicable government wage offer to people you are supposed to support and protect at all times.

The reason all political parties, senior military and government bureaucrats want to cover up veteran suicide rate is that it is damming proof of their incompetence and failure to stand up for our diggers. Today, the Minister for Veterans’ Affairs, Senator Ronaldson, rose in this place and talked about mental health, trying to give the impression he cares about veterans living with mental health illnesses.

I almost bought what he was selling—the deep voice, the measured delivery. I have to admire the minister: he has almost mastered the art of faking sincerity.

Mr President, I will not accept any more of the Prime Minister’s or the Minister for Veterans’ Affairs spiteful, illegal and discriminatory attitude towards people with mental illness or other disabilities.[18]

…

The Prime Minister must act now and sack Senator Ronaldson—I have asked for it in the past and I will continue to ask for it—and put someone in the position who at least actually give a shit about veterans more and does not worry about overseas junkets.[19]

…

Mr President, I ask a further supplementary question. Would the Minister for Defence agree that the transition period between defence and into veterans’ affairs is an absolute failure?[20]

Aspirational

Some mentions in parliament are aspirational such as the ‘passion’ described below to make access to mental health services in remote locations as accessible as it is in urban areas. Likewise, the second quote outlines a proposal to fund veterans’ pensions and improved mental health services using revenue from the (now repealed) mining tax.

One of my passions is to make sure that access to good mental health services in regional areas of New South Wales like Gilmore are just as accessible for someone living in Ulladulla or Jamberoo as they are for a city resident and that young people, veterans and victims of domestic violence all get the very essential mental health care and guidance they need so their families never see the image that I spoke of earlier.[21]

…

Let me turn now to mental health. We could invest revenue from a decent mining tax—a tax over the mining of our shared resources—in proper reform of mental health services.

Let me now turn to veterans’ affairs. Revenue from an adequate mining tax could be used to introduce a fair and equitable system for veterans’ pensions.[22]

The quote below is an example of the need for greater dissemination of information on this complex issue. While some MPs have informed themselves of the details, availed themselves of briefings, and have a working knowledge of the research around the issue of mental health and Defence, others are less familiar with this material. As a senior public servant (on the condition of anonymity) remarked in an interview for this paper:

If an MP or Senator doesn’t know how to ask for a briefing then what are they doing there? What more can I do for them? If they want to run a second rate institution then that’s up to them. There are no excuses for politicians not to be informed, there are enough opportunities for them to inform themselves on this issue, as evidenced by those that choose to.

Psychologists recognise that PTSD is about exposure to trauma—which may or may not come from operational service overseas—although as demonstrated by these comments, this is not widely understood:

It has been of interest to me in terms of post-traumatic stress disorder, PTSD. Some information that was made available to our committee recently was that more than 50 per cent of serving and retired military personnel who record the fact that they are suffering post-traumatic stress disorder have never deployed outside our country. I do not know the reasons for this, but what I do applaud is the funding that has been expended in trying to come to an understanding of why that might be the case.[23]

Previous committee inquiry

During the 43rd Parliament, the Defence Sub-Committee of the Joint Standing Committee on Foreign Affairs, Defence and Trade conducted an inquiry entitled Care of ADF Personnel Wounded and Injured on Operations, the report of which was released in June 2013.[24] The report included a chapter on ‘mental health concerns’ (pp. 49–74) and made four recommendations, namely:

• DVA accept complementary therapies (where an evidence base exists)
• Defence publish regular updates on research outcomes and program implementation
• Defence and DVA undertake a study of psychological support offered to partners and family and
• psychological first aid be made a research priority.

The government response of December 2013 either ‘supported’ or ‘supported in principle’ all four recommendations, but the government has been slow to act on them. Various groups remain frustrated that repeated inquiries do not appear to have led to substantial change.

Recent Senate committee inquiry

The Senate Foreign Affairs, Defence and Trade References Committee recently examined ‘the mental health of Australian Defence Force (ADF) personnel who have returned from combat, peacekeeping or other deployment’. Submissions closed on 26 June 2015 and the inquiry reported in March 2016.

The inquiry homepage states:

In terms of setting expectations, the committee emphasises that it is not in a position to address individual cases of mental ill-health and post-traumatic stress disorder (PTSD) among ADF personnel who have returned from combat, peacekeeping or other overseas deployment.

As the terms of reference of the inquiry indicate, the committee’s focus is on the mental health support, evaluation and counselling services provided by Defence and DVA, and the identification and disclosure policies of the ADF in relation to mental ill-health and PTSD.[25]

…

Terms of Reference

The mental health of Australian Defence Force (ADF) personnel who have returned from combat, peacekeeping or other deployment, with particular reference to:

a. the extent and significance of mental ill-health and post-traumatic stress disorder (PTSD) among returned service personnel;

b. identification and disclosure policies of the ADF in relation to mental ill-health and PTSD;

c. recordkeeping for mental ill-health and PTSD, including hospitalisations and deaths;

d. mental health evaluation and counselling services available to returned service personnel;

e. the adequacy of mental health support services, including housing support services, provided by the Department of Veterans’ Affairs (DVA);

f. the support available for partners, carers and families of returned service personnel who experience mental ill-health and PTSD;

g. the growing number of returned service personnel experiencing homelessness due to mental ill-health, PTSD and other issues related to their service;

h. the effectiveness of the Memorandum of Understanding between the ADF and DVA for the Cooperative Delivery of Care;

i. the effectiveness of training and education offerings to returned service personnel upon their discharge from the ADF; and

j. any other related matters.[26]

The inquiry received 76 submissions, held four days of hearings, and took additional evidence in camera.

Parliamentary inquiries allow for a more open discourse around the issue than may otherwise be possible.     While the bureaucracy is sometimes seen to resist these opportunities, the range and number of submissions demonstrates that individuals and organisations want to engage with this process. Like every parliamentary process, it is not immune to political posturing, but as the instigator of this inquiry, Senator Whish-Wilson, commented in an interview for this monograph, a strong set of bipartisan recommendations will have the best chance of making a real and positive impact on this issue for veterans.

In responding to the inquiry and the interest it may generate, the minister is presented with an excellent opportunity to engage with many groups that can potentially counter the obfuscation of the departments (source chose to remain anonymous). This requires a willingness to openly engage in dialogue and not become defensive of existing practices. Another comment made during interviews for this paper by a senior member of the academic medical community (on the condition of anonymity) is that many experts chose not to participate because they fear recrimination from the bureaucracy that could affect future government-funded research. An extension of the same criticism is that there is a distinct lack of an information-sharing forum, independent from the bureaucracy, where expert advice can be provided in an honest and fearless manner. Parliamentary inquiries, as they are currently operated and run, do not solve this problem.

Parliamentary Friendship Groups

Another opportunity for debate and information-sharing on issues related to mental health and Defence are the Parliamentary Friendship Groups.[27] Although these groups do not routinely keep minutes of meetings or other records, and while they do not constitute a decision-making forum, they do provide a useful starting point where issues can be raised and agendas coalesced. The two groups most relevant to this issue are:

Parliamentary Friends of Defence

The objective of this group is to foster informed debate on defence issues and the strategic environment and to increase understanding of the challenges that face many current and former members of the Australian Defence force.

Parliamentary Friends of Mental Illness

The primary objective of the Parliamentary Friends of Mental Illness is to improve Parliamentarian’s awareness and understanding of mental health issues that affect constituents in their electorates. This includes connecting Members and Senators with those living with a mental illness, their families and carers, as well as those working in the area of mental health including researchers, advocates and clinicians. In addition the group works to assist parliamentarians and their staff to be effective in supporting their constituents who are affected by mental illness.

Defence—policy background on mental health

A foundation for the development of ADF policy on mental health is the National Mental Health Strategy 1992.[28] It was a comprehensive framework to guide mental health reform. Its aims included the promotion of mental health in the Australian community, the prevention of mental disorders, the reduction of negative impacts where mental disorders do occur and the assurance of the rights of people with mental illnesses. In 1998 the second mental health plan was released, with subsequent versions released in 2003 and 2009. Most recently, the Mental Health Statement of Rights and Responsibilities was revised in 2012.[29]

In 2000, eight years after the release of the national plan, the Department of Defence released the inaugural edition of its Australian Defence Force Health Status Report.[30] This report aimed to present a summary of the health status of ADF personnel. It sought to provide a baseline against which future workforce health summaries could be measured, to identify health policy needs and recommend preventative health strategies. Its major findings with regard to mental health identified that available data was insufficient to provide a proper assessment of mental health status across the ADF. The most notable of the specific recommendations to come from the report was for an integrated program to prevent, detect and treat mental illness. It also signalled that a comprehensive ADF-wide strategy and suicide prevention policy was being developed at that time.

This recommendation came to fruition in 2002 when the Joint Health Command Vice Chief of the Defence Force released Mental Health Strategy—Live Well, Work Well, Be Well.[31] This document recognised that mental health is a key element in the delivery of the personnel component to capability. It stated, for the first time, that the traditional medical model the ADF had previously been using as a basis for the delivery of mental health services, without a specific and targeted focus on mental health in its own right, was lacking and needed to be improved. While mental health care services had previously been provided to full and part-time ADF members, the strategy acknowledged that these services had been lacking in several key areas, including the coordination of service development and delivery, as well as the lack of standardisation in mental health policy.[32]

A key milestone in the evolution of mental health and Defence came with the 2009 Review of Mental Health Care in the ADF and Transition to Discharge by Professor David Dunt.[33] In his wide-ranging examination of mental health among serving and ex-serving members of the Defence Force, Dunt found that the arrangements in place compared favourably to other Australian workplaces as well as foreign military forces. He did go on to highlight 52 gaps in the delivery of mental health services and recommend reforms to rectify them. Broadly, the report highlighted a lack of funding for both the Directorate of Mental Health and Regional Mental Health Teams, and the need to further develop the overall strategy with regard to mental health. In his review, Dunt made the observation that these reforms would need to be marketed properly to ensure they had the maximum impact on members.[34]

Among other key themes identified by Dunt was the need to improve:

• privacy arrangements, disclosure and the sharing of mental health information
• the Medical Employment Classification (MEC) system as it relates to mental health
• the ADF rehabilitation program for mental health-related issues
• the transition from serving to non-serving Defence member
• communication with families of Defence members, particularly with regard to deployments and posting issues and
• the conduct of further mental health research and surveillance.[35]

The Department of Defence agreed to 49 of the 52 recommendations and partially agreed to the remaining three.[36] It promised a ‘comprehensive plan to address the Dunt review recommendations’ in May of the same year. It is interesting to note that while many key issues were identified by Dunt and his recommendations were agreed to by Defence, many of the same issues were identified by veterans as continuing problems in the six years since the release of the report in 2009. Among the outcomes of the reform agenda initiated by Dunt was the 2010 ADF Mental Health Prevalence and Wellbeing Study (MHPWS or ‘the Study’).[37] The Study claimed to have captured around half of all serving Defence personnel between April 2010 and January 2011 for the purpose of examining the prevalence rates of common mental disorders, optimal cut-offs for relevant measures and the impacts of occupational stressors. The Study compared results of Defence members with a community sample and found that overall rates of mental disorders were similar between the two groups.

The Study found that lifetime prevalence rates were higher in the ADF, but that experiences of mental disorders in the previous twelve months were similar in both samples. One in five ADF members reported experiencing a mental disorder in the previous 12 months. Approximately seven per cent of this number experienced more than one mental disorder at the same time. Women experienced the highest rates of anxiety disorders while men experienced the highest rates of PTSD.

Interestingly, the Study found that rates of alcohol disorders (dependence and harmful use) was ‘significantly’ lower in the ADF than the Australian community sample, with the majority of reported ADF alcohol disorders occurring in males in the 18–27 age bracket. It also found that there was no significant difference between Officers and ORs (Other Ranks) in the prevalence of alcohol use disorders.

The Study also looked at suicidality (ideation, planning, attempting) and found that while the rates of thinking of committing suicide and making suicide plans was higher in the ADF than the Australian community, rates of actual suicides were not markedly different between the two groups (p. 38). Additionally, the number of reported deaths in the ADF was lower than in the community. This does not, however, take account of the ‘healthy soldier effect’—that only relatively young and healthy people are recruited and given better access to health services. It also does not account for those who may have become unwell or not coped with military life and were discharged. Therefore, the above statistics represent those who remain in the Defence Force, rather than the cohort who joined. The figures may therefore not represent the true burden of suicide that results from military service (Dr Alexander McFarlane).

Issues associated with stigma were also highlighted by the report. Over 27 per cent felt they would be treated differently as a result of a mental health-related issue. Approximately the same percentage reported fear of harm to their career because of perceived stigma. Perhaps the most telling statistic reported in the Study related to stigma was that approximately 37 per cent felt that the stigma associated with mental illness would reduce their deployability.

While mental or physical injury may inevitably interrupt an individual’s career, the stigma associated with mental injury carries an additional burden. This stigma, combined with the fact that non-physical injuries can be hidden, motivates many to disguise a suspected psychological injury.  

We know from the MHPWS that the prevalence of mental health disorders, such as PTSD, between deployed and non-deployed personnel did not differ. Because it is counter-intuitive and contradicts a substantial body of research that associates deployments with increased risk of poor mental health, a follow-up study was commissioned in 2013 by the Centre for Traumatic Stress Studies at the University of Adelaide entitled Detailed associations between operational deployment and mental disorder in the Australian Defence Force: results from the 2010 ADF Mental Health Prevalence and Wellbeing dataset. This study found that there were a number of factors that may explain this result. These include significant demographic differences that exist between deployed and non-deployed groups suggesting a ‘healthy soldier effect’; as lifetime trauma history is strongly associated with mental disorder (particularly PTSD) regardless of deployment status, both deployed and non-deployed may be at a similar level of risk; that deployment may be a risk factor for specific subgroups, but not the entire deployed population.

The next phase in mental health for Defence was the production of the 2011 ADF Mental Health and Wellbeing Strategy (‘the Strategy’).[38] This was a result of both the Dunt Review and the Prevalence and Wellbeing Study. The Strategy claims to represent a whole-of-government approach as it draws on the Government’s National Mental Health Policy (2008) as well as the Fourth National Mental Health Plan (2009–2014).[39] The Strategy claims to be based on a ‘military occupational mental health approach’ and states:

Good mental health within the ADF operates on a continuum, starting with a person’s entry into the ADF, their selection, assessment and suitability to the right job, through to preparing them to operate in risky environments. Furthermore, it provides the most effective treatment and rehabilitation if they become ill or injured so they can return to work as soon as possible. If the person cannot return to work in the ADF, as a last resort we will enable the individual and their family to make the transition to civilian life with the appropriate support in place to maximise their mental health and wellbeing. (D.J Hurley, General, Chief of the Defence Force, p. iv)

Treatment and support is reaching the majority, but as Major General Gus Gilmore quoted above stated, it is the five per cent of veterans who are not receiving proper health care on whom we need to focus our efforts. The Strategy does address the issue of stigma in a realistic way, acknowledging it as a major issue and expressing the need to overcome its effects, as well as break down the barriers that prevent individuals from seeking care. The Strategy states:

Due to the unique demands of military service, the ADF Mental Health and Wellbeing Strategy is underpinned by a military occupational mental health and wellbeing approach based on the Military Occupational Mental Health and Wellbeing Model. (p. 7, emphasis added)

While these strategies, approaches and models sound impressive and speak (broadly) to the key issues in these debates, the (perceived) disconnect between the attitudes of senior members of the ADF and the experiences of soldiers on the ground remains an area of concern. The Strategy outlines the following seven priority areas:

• addressing stigma and barriers to care
• enhancing service delivery
• developing e-mental health approaches
• upskilling health providers
• improving pathways to care
• strengthening the mental screening continuum and
• developing a comprehensive peer support network (2011 ADF Mental Health and Wellbeing Strategy).[40]

A senior doctor working in veterans’ health (who chose to remain anonymous) has noted a lack of systematic auditing of clinical service delivery, particularly since it was outsourced to Medibank Solutions, an organisation that he considers lacks the occupational expertise needed to deal with traumatic stress. A senior mental health clinician interviewed for this research stated that there are comparatively few mental health clinicians within Australia’s armed forces compared to our allies, and an assumption that these services can be purchased (anonymous).

The next piece of the puzzle regarding Defence and mental health policy is the Mental Health and Wellbeing Action Plan 2012–2015 (‘the Plan’).[41] This plan came about as a result of the Dunt Review and the 2011 ADF Mental Health and Wellbeing Strategy. The objectives of the Plan were to finalise the implementation of the Dunt Review recommendations and achieve the strategic objectives of the Strategy. The Plan, prepared by the Mental Health, Psychology and Rehabilitation (MHP&R) Branch of Joint Health Command, provides more detail for the seven priority areas listed in the above Strategy. It listed individual goals under each of the seven sections and promised the delivery of an implementation schedule.

In 2014, a joint funding venture by both the Department of Defence and the Department of Veterans’ Affairs saw the rollout of the Transition and Wellbeing Research Program, which was delivered by the Centre for Traumatic Stress Studies (CTSS).[42] This program claims to be the largest and most comprehensive study undertaken in Australia to date which examines the impact of military service on the wellbeing of Defence members and their families. The program promises to deliver three studies:

• Mental Health and Wellbeing Transition Study—the scope of this study is to survey 25,000 ex-serving ADF members who transitioned from serving between 2010 and 2014, 5,000 reservists and 18,000 currently serving ADF members.[43]
• Impact of Combat Study—looks at the wellbeing of 2,000 participants in the Middle East Area of Operations (MEAO) Prospective Health Study.[44]
• Family Wellbeing Study—conducted by the Australian Institute of Family Studies and focuses on the wellbeing of families of serving and ex-serving Defence members.[45]

The Australian Centre for Post-traumatic Mental Health (ACPMH) (now Phoenix Australia) was commissioned by the ADF to develop a mental health screening framework that could be used in both operational and non-operational settings across the three services to achieve improved screening outcomes across the ADF.[46] ACPMH determined that four health problems or disorders would be specifically targeted in the program: PTSD, depression, problematic alcohol consumption and suicide ideation. The framework concluded that all ADF members should be regularly screened, that new processes should be added to existing ones to achieve optimal screening levels, and that identifiable and anonymous screens should both form a part of the health care system. The framework utilised three instruments: the Posttraumatic Checklist (PCL), the Kessler Psychological Distress Scale (K10) and the Alcohol Use Disorders Identification Test (AUDIT). For individuals who scored above the thresholds on any of these, an individual face-to-face interview was then administered. This included a standardised protocol which involved an assessment of suicidality and lifetime trauma exposure. All the above would operate on a 12 month cycle and have a tri-service focus.

In 2014 the Department of Defence released its Alcohol Management Strategy and Plan 2014–2017 in which it provides a new strategy for alcohol management—reducing the harmful effects of misuse, enhancing capability, and reducing costs.[47] Among its stated objectives is ‘systemic cultural change’ around attitudes to the use of alcohol. The Strategy and Plan draws on evidence from the National Drug Strategy 2010–2015 and the World Health Organization regarding harm minimisation with alcohol use.[48] Defence is currently working on an updated ADF Mental Health and Wellbeing Strategy 2016–2020.[49] Led by Joint Health Command (JHC), this will involve wide consultation with stakeholders inside and outside Defence. Defence also communicates with the parliament and the public on issues around the mental health of its workforce through the Defence and Joint Health Command annual reports and Defence white papers, as well as through submissions to former and current inquiries.

The Department of Defence submission to the recent Senate inquiry states:[50]

Mental Health, Psychology and Rehabilitation Programs

The delivery of mental health, psychology and rehabilitation services is enhanced by a number of specific programs and initiatives. These programs are described below.

General awareness and promotion resources and activities. To aid in the mental health literacy and awareness for ADF members and their families, a range of promotion resources and activities are provided. These include topical fact sheets, Internet access to mental health information via the ADF Health and Wellbeing portal, provision of Defence help lines (All-Hours Support Line, ‘1800 IM SICK’ and Defence Family Helpline) and, in partnership with DVA, a number of mobile applications. Aligned with annual international and national mental health awareness initiatives in October, the ADF Mental Health Day is a significant opportunity to further the understanding of mental health issues in Defence. (p. 12)

…

Pre-deployment phase. All deploying ADF personnel receive a BattleSMART mental health brief that is designed to enhance their ability to operate effectively in the deployment environment and is tailored to meet the specific demands of the deployment. The BattleSMART pre-deployment training is delivered in conjunction with a comprehensive pre-deployment training package.

Deployment phase. For deployed members that are exposed to potentially traumatic events a Critical Incident Mental Health Support response is provided, consisting of a group psycho-education brief on expected trauma reactions, coping skills and methods on seeking support, followed by targeted individual screening questionnaire and screening interview. This aims to identify members that require immediate intervention or scheduled follow up and facilitate a return to pre-exposure functioning. Deployed high risk groups, those whose operational role may routinely expose them to intense operational stressors, critical incidents, and/or potentially traumatic events, such as military police, explosive ordnance disposal personnel and health personnel are provided a Special Psychological Screen approximately mid-way through the deployment regardless of their actual exposure to potentially traumatic events. (p. 14)

…

Joint Health Command has developed the LifeSMART presentation which aims to increase member’s individual psychological resilience and develop awareness of better ways of coping with the challenges of transition to civilian life. This presentation is delivered as part of a two-day ADF Transition Seminar which aims to ensure members and their families are well-informed, and which encourages them ‘to access educational, financial, rehabilitation, compensation and other government services to facilitate sound transition planning. Regional ADF Transition Centres provide administrative management and support to members who are required to finalise their arrangements well before their date of separation from the ADF. (p. 18)

…

Services provided by the Directorate of National Programs in the Defence Community Organisation ‘ensure that ADF personnel and their families remain well-informed, and are encouraged to access educational, financial, rehabilitation, compensation and other government services to facilitate sound transition planning’, including the ‘Veterans and Veterans Families Counselling Service’s Stepping Out program’, which ‘is available prior to separation’, although attendance is also supported by DVA for up to 12 months post-separation. (p. 19)

Defence continues to improve the ways in which it supports its workforce, including in the key areas of stigma reduction strategies, preventative mental health and transition support. While there remains a group that continues to experience substantial negative effects of military-related reduced mental fitness, there remains a question as to whether the above solutions are the right ones, sufficient, and/or being delivered in a culturally appropriate way. Defence is proactively attempting to respond to these challenges. In a subsequent section of this paper there are some more detailed observations on the level of preventative mental health care currently available. In an interview for this paper, a senior bureaucrat commented:

While Defence has downsized its workforce by over 4,000 jobs over the last three years, none of the losses have been in the areas of social work or medical staff. It should be evident from a resource allocation point of view how seriously we take this issue.

Nevertheless, most acknowledge this is not an issue that can be wholly solved by resource allocation. The following quote from a PTSD-diagnosed veteran illustrates some perceived shortfalls in the mental health care currently available to serving Defence personnel. He describes the Post-Operational Psychological Screen (POPS) process that he underwent. The perceived absence of a sufficiently trained clinician (and particularly the description of ‘young female’ clinicians who soldiers wanted to impress), is not unusual and felt to be ineffective in achieving a therapeutic outcome. The description also highlights the ‘tick and flick’ approach to psychological support in the military and the way it serves organisational ends rather than providing actual psychological support for individuals:

I do not believe they [issues described] were [addressed fairly]. All members, including myself, were given the green light upon returning to Australia after our tour to Afghanistan. I clearly remember all three of my screenings, two of which were with young females under the age of 25 with no history of deployment and after a few quick general questions I walked out the door after 10 minutes. I do not understand how I was so easily assessed and given back to the battalion. I had only just turned 19, shot through both thighs, nightmares each evening and total confusion from chronic nerve damage. I do not understand why critical questions aiming to discover depth within my mind were not drawn to the surface and assessed professionally. (David—Appendix A)

As noted, mental health in the ADF is a priority for the organisation as it is for government. It does however compete with mental health services to the broader community. While there are deficiencies in the policies and provision of mental health services to the ADF, an anonymous source interviewed for this research stated that they are significantly better developed compared with those available to the respective workforces of first responder organisations.

The following chapter will consider the background to research, planning and reviews in the recent history of the Department of Veterans’ Affairs.

Department of Veterans’ Affairs—policy background on mental health

Established in 1976 following the end of hostilities in Vietnam, the Department of Veterans’ Affairs (DVA) has had to adapt to the changing profile of veterans—from a client base of First and Second World War veterans and their families, to veterans of Vietnam and the current generation of ‘younger veterans’ from the more recent conflicts in the Middle East and our own region, as well as a host of smaller groups. The client base now also includes another non-traditional client group—active service Australian Defence Force members who access DVA services through On Base Advisory Services (OBAS).

DVA is responsible for providing medical care, income support and compensation to serving Defence members, veterans and related communities, as well as their families. The Veterans’ Affairs portfolio is administered by the Minister for Veterans’ Affairs, currently a Victorian Liberal Party MP, Dan Tehan. The four key entities of the portfolio are:

• Department of Veterans’ Affairs
• Military Rehabilitation and Compensation Commission
• Repatriation Commission
• Australian War Memorial

Supporting the work of the Commissions is the following list of additional entities:

• Office of Australian War Graves
• Repatriation Medical Authority
• Specialist Medical Review Council
• Defence Service Homes Insurance Scheme
• Veterans’ Review Board

The Department of Veterans’ Affairs is responsible for the administration of several key Commonwealth Acts which include:

• Veterans Entitlements Act 1986 (VEA)
• Military Rehabilitation and Compensation Act 2004 (MRCA)
• Safety, Rehabilitation and Compensation Act 1988 (SRCA)
• War Graves Act 1980
• Defence Service Homes Act 1918

The National Mental Health Strategy 1992 (and subsequent iterations) was used as a foundation stone for DVA’s mental health policy, as it was for the equivalent Defence mental health policy. As such, DVA sought to align its mental health policies and practices with those of the National Mental Health Strategy. This was reflected in the DVA publication Towards Better Mental Health for the Veteran Community—Mental Health Policy and Strategic Directions 2001.[51] As with the Defence equivalent, there was a lag of nine years between the national and departmental strategies. This document was designed as a guide for future planning and the provision of all mental health-related services to clients of DVA, and it emphasised the Department’s stated commitment to ‘integrated and community orientated mental health care’. The document contained four strategic directions:

• enabling a comprehensive approach to health care
• responding to specific mental health needs
• planning and purchasing effective services and
• strengthening partnerships and participation in mental health care (Towards Better Mental Health for the Veteran Community—Mental Health Policy and Strategic Directions 2001).[52]

This document drew upon published and available statistics on mental health that existed at the time. It acknowledged the detrimental effect that a mental illness has on the quality of life for veterans and that veterans experience prevalence rates for such illnesses at twice that of the general population. At the time, the DVA treatment population was 350,000, of whom 22 per cent (or 73,000) would receive some form of mental health treatment within any given year. The document also reported that psychiatric medication use was high amongst this population, with 20 per cent being prescribed one or more drugs. The number of accepted compensation claims for mental health-related reasons was also increasing and was averaging 25 per cent of the treatment population per annum (equivalent to 3,400 new cases every year). PTSD, and to a lesser extent, alcohol dependence, accounted for most of the increase. One in five veterans of the Vietnam War has been accepted as experiencing war-related PTSD.

At the time this document was published (2001), DVA was spending $190 million annually on compensation, treatment and support for veterans and their families affected by a mental health disorder. The document predicted that this was likely to increase in coming years for several reasons, including that mental health-related disabilities tended to be of a long-term nature and that there was a greater understanding of mental disorders and a greater willingness of those affected to seek recognition and treatment.[53] Finally, the document refers to DVA’s Strategic Direction for Health 1999–2007 which developed a ‘more inclusive’ understanding of health. Its emphasis included a ‘more integrated’ approach to health care, the provision of a greater range of choices, increased emphasis on ‘preventative health’, and partnerships with the veteran community to promote ‘enhanced health’. Its broader aims included: a ‘holistic approach to veteran care’; addressing identified issues in residential and community care; creating nationally consistent health services; and better integrating DVA’s health arrangements with the Department of Defence.[54]

Pathways to Care in Veterans Recently Compensated for a Mental Health Condition (ACPMH—now Phoenix Australia)[55]

A report commissioned by DVA conducted by the Australian Centre for Post-traumatic Mental Health (now Phoenix Australia) entitled Pathways to Care in Veterans Recently Compensated for a Mental Health Condition was released in 2004. The study investigated how veterans recently compensated for a mental health condition accessed mental health care. The study concluded that compensated veterans have poorer health/quality of life than age-adjusted norms, despite the fact that around 90 per cent reported that their treatment had helped them. It stated that 43 per cent of participants in the study were not receiving treatment for the condition for which they had been compensated and 23 per cent had stopped their treatment altogether. The study recommended more research be done to explore the reasons for many of these issues.[56]

Independent Study into Suicide in the Ex-Service Community 2009[57] (DVA, conducted by Professor David Dunt)

This study points to the value of interventions such as clinician education (including in the detection and treatment of depression) and restrictions on access to firearms. It also highlights the importance of alerting general practitioners and other mental health workers to the increased risk of suicide amongst the veteran population.

This study picks up on the fact that while suicide rates are lower amongst serving military personnel than the general population, this is due to a ‘healthy worker’ selection effects and that this may fade over time. The study highlights the importance of transitioning members feeling as if their service has been properly recognised by Defence and the problems that result when this does not occur.[58] This was a theme that arose in conversation with veterans during research for this paper.

One of the recommendations the study makes is to simplify the claims process and reduce the three military compensation schemes to one (p. 12—a proposal echoed by Senator Jacqui Lambie in an interview for this research). The study also recommended that DVA improve the communication process between its staff and clients who should rightly expect to be treated with respect and empathy; that there should continue to be a place for Ex-Service Organisations (ESOs) and that existing volunteer pension officers continue to play a role.[59] Furthermore, it was recommended that DVA should continue to improve the way in which it approaches ‘hard-to-engage’ clients (p. 15). The study also makes the observation that while DVA has been very active in supporting funding for research, it has been less active in supporting the evaluation of its programs.

Australian National Audit Office Audit Report: Administration of Mental Health Initiatives to Support Younger Veterans (DVA)[60]

The purpose of this 2011–12 audit report was to examine the effectiveness of DVA’s administration of mental health programs and services in support of veterans of contemporary conflicts. In particular, it focused on the available programs of care and support in the context of mental health policy objectives to gauge if these programs met their objectives with regard to younger veterans.

The report noted that many younger veterans had served in numerous ADF deployments over the preceding decade and form a group which is particularly at risk of discharging from the military with an undiagnosed and untreated mental health condition. Further complicating the provision of health care to this group is that unlike previous generations of veterans, younger veterans do not necessarily maintain links with the ADF post-discharge or engage with DVA, nor are they easily contacted through Ex-Service Organisations.[61]

The review noted numerous studies commissioned by DVA into the scale of the problem and how best to meet the needs of younger veterans with mental health issues.[62] It noted that while attempts had been made to consolidate mental and social health efforts, the policy, programs, services and data systems continued to be managed across separate business areas. It highlighted the limited effectiveness of mental health initiatives, and gave examples of programs with a very poor take-up rate (examples cited included the Transition Management Service (TMS) and the Stepping Out program). Further examples are given where DVA has recognised problems and developed solutions, but failed to fully implement them. One such example relates to the problem of tracking mental health care in transitioning members—a whole-of-life framework was developed, yet the report notes that the first steps of this framework were yet to be implemented five years after its launch.[63]

Strategy

A key planning document for the Department of Veterans’ Affairs is its 2013 Veteran Mental Health Strategy.[64] This high-level planning document maps the department’s intentions with regard to the mental health care of current and future veterans and their families. It is designed to provide a blueprint to guide the development of an action plan for the department’s intended mental health services. The Strategy claims to provide the framework for a coordinated approach to the implementation and evaluation of existing programs, as well as planned new initiatives.[65] The Strategy balances the need to cater for veterans of previous conflicts as well as veterans from the more recent military campaigns in our region and the Middle East.

Australian Public Service Commission Review of DVA 2013[66]

Completed in December 2013, the Australian Public Service Commission (APSC) undertook a review of the organisational capability of the Department of Veterans’ Affairs. The report states:

It is evident to the review team that DVA staff are strongly committed to supporting the Australian veteran community. There is a palpable, sincere and passionate sense of mission among client-facing, administrative and policy staff within DVA; namely, to support those who serve, or have served, and to commemorate their sacrifice.

The review team identified three key focus areas needing urgent attention for DVA to transform. They were:

1. operating structure, governance arrangements and information and communications technology (ICT);
2. approach to clients, culture and staffing;
3. efforts to formulate effective strategy, establish priorities and use feedback.

The report noted that whole-department improvements had been modest in preceding years and that major transformation was required. Organisation-wide cultural impediments also made sustaining motivation among DVA staff to support veterans, problematic. It noted that client service and acquiescence to every demand were distinctly separate issues. Also noted was that consistency and clarity around decision-making was just as important as a commitment to client service; that priorities need to be set, particularly in the claims area where it quoted a staff member as saying that a claim ‘is not seen as a person but an exercise in processing paper’.[67]

Samuel, quoted in Appendix A of this paper, echoed this point saying: ‘[DVA is] always busy and stretched. You are a number as more defence personnel are diagnosed’.

The report also noted that challenges persist for DVA in engaging with contemporary veterans who are not accessible in the way that previous generations of veterans were, and that this engagement was a key element in securing ‘buy-in’ from this new generation.[68] Anecdotally, many of the challenges highlighted above would appear to continue to inhibit the effective functioning of DVA, to the frustration of some clients. A senior member of the academic medical community commented in an interview that ‘[since this review], little has changed’.

In December 2013, the Minister for Veterans’ Affairs, Michael Ronaldson, announced the release of the planning document Towards 2020: a Blueprint for Veterans’ Affairs:

‘The Secretary and I share a determination to ensure that the core strategy of the Department going forward is one that is fully client focussed, responsive and connected’, Senator Ronaldson said.[69]

He went on to say:

The main component of the plan is the Key Strategic matrix. This centres on the use of three key strategies—client-focused, responsive and connected—to describe the type of services we provide, and behaviours we need to embed across all areas of our business. These strategies should span across our work with clients, in developing and maintaining our culture and in shaping our organisation, and in doing so will help DVA to achieve our vision.

This is an example of the kind of rhetoric employed by DVA to counter some of the above criticisms. Another was the often repeated ‘four pillar approach’, as described here in a statement by Minister Ronaldson:

At the last election, the Government announced a comprehensive policy agenda to meeting the needs of veterans and their families. We announced our four-pillar approach to veterans’ affairs:

• Recognising the unique nature of military service;
• Retaining a stand-alone Department of Veterans’ Affairs;
• Tackling the mental health challenges for veterans and their families; and
• Supporting veterans through adequate advocacy and welfare services.[70] (emphasis added)

Mental health features prominently in various research projects undertaken by DVA and is a particular focus of the current project Transition and Wellbeing Research Program. Launched in July 2014, the focus of this research is the mental and physical health of service personnel after discharge, and how symptoms change over time.

Department of Veterans’ Affairs Annual Report 2013–14[71]

The 2013–14 annual report affirms the department’s stated commitment to mental health as a priority area of attention for the coming year. The report cites the Veteran Mental Health Strategy—a Ten Year Framework 2013–2023 as the source document for much of the department’s thinking around mental health issues. It includes reference to a new ‘strategic model’ which aims to generate ‘best practice research’ in support of mental health care. It also discusses its collaborative research efforts with the Department of Defence as well as research institutions.[72]

The Prime Ministerial Advisory Council on Veterans’ Mental Health (PMAC) is a new initiative launched in 2014 by the current government and administered by DVA.[73] It forms another part of the way in which the department approaches the issue of mental health and its client base. A senior health professional who agreed to be cited in this report on the condition of anonymity criticised the PMAC for the lack of representation on its board of independent health professionals. This deficiency is broader than the PMAC and has been noted (same source) as applying to the field more generally. Some health professionals working in veterans medical research and practice feel (none agreed to be identified) that the opportunities to contribute in a meaningful sense are limited, and that consultative and advisory forums dominated by bureaucrats do not make best use of specialist medical expertise.

A key feature of the mental health-related activities during 2013–14 on which the department reported was the range of online education and self-assessment tools. Issues targeted included veteran suicide; alcohol consumption; access to research findings; and tools to assist practitioners in managing complex cases. Communication tools utilised as part of these initiatives included website development, smart phone apps and YouTube. The report also contains reference to the $26.4 million allocated in the Budget to strengthen its commitment to veterans’ mental health and corresponding initiatives.

Department of Veterans’ Affairs Annual Report 2014–15[74]

Under the heading of ‘mental health’ DVA’s 2014–15 annual report states the following:

During 2014–15, the Department’s efforts in mental health were focused on early intervention, to improve the longer term prospects of veterans’ recovery from mental illness. Activities included:

• promoting mental health and wellbeing through DVA’s mental health online portal, At Ease;
• implementing ways to make it easier to access mental health treatment through DVA’s Non-Liability Health Care arrangements;
• expanding eligibility under the VVCS; and
• reducing the time taken to process compensation claims.

It also appears to be placing more emphasis on homeless veterans and the provision of services and support to this group. Suicide prevention is another area of focus for the department identified in this document.

DVA submission to the recent Senate inquiry

In June 2015 DVA made a 54-page submission to the recently completed Senate inquiry entitled The Mental Health of Australian Defence Force (ADF) Personnel who have Returned from Combat, Peacekeeping or other Deployment.[75] The document provides some comprehensive information about DVA’s contemporary approach to mental health.

Despite the comprehensive information available in this submission and the numerous programs offered by DVA, a persistent criticism of the department raised during interviews for this paper was the apparent lack of strategy to develop and sustain expertise in the area of veterans’ mental health (the source chose to remain anonymous). DVA makes the assumption that this expertise will exist within the broader health system and be available for purchase. While there have been some moves towards sustaining this resource through Phoenix Australia, the department has, to some extent, divested itself of the responsibility for fostering future clinical research expertise (same source). A further observation made by this source was that the number of experts within the ranks of the department has decreased with its downsizing. This has led to an increased reliance on bureaucratic solutions to complex problems rather than being guided by professionally-led change. The theme emerged during conversations with professionals working in this space that a disconnect exists between Defence and DVA.  This will be explored further in the following sections of this report.  

The following two excerpts from veterans interviewed for this research illustrate the frustrations felt by some veterans with the apparent inconsistency between the recognition of issues by one bureaucratic organisation and not another. Harry said:

Since my discharge from Defence I have had a lot of frustration with my transition to DVA. What was allowed and proved to be a need in Defence, needed to be proven again and reasons for it [provided] to DVA. There is no link between the two, creating stress to families and individuals. (Harry—Appendix A)

Gary expressed similar sentiments:

As for my compensation claim, I was medical 401 discharged due to an injury I sustained while on SAS selection in Perth; the compensation board denied liability for five long years. How can you deny liability for an injury that was sustained on a course for work which the Army then sacked me for? (Gary—Appendix A)

Care needs to be taken not to confuse a DVA client not getting what they want, with larger systemic problems. The focus here is on the ways in which the provision of services and support can be strengthened. Part of identifying where problems exist is listening to the experiences of those who have been through the system. Once again, care needs to be exercised in generalising from the experience of the very small number of veterans who participated in this research. What is being suggested is that experiences such as those cited above, combined with the testimony of working professionals, can point to areas where sustained research might usefully be focused. There is also a shared feeling that complaints are not listened to and are therefore not worth making:

Since discharge I have had no ongoing relationship with Defence. Contact with DVA is extremely frustrating. You ring up for help and get told to refer to their website. The whole process is very complicated and without the hard work done by advocates the claim process would have no chance of success as you do not have access to the relevant legislation and DVA’s statement of principles regarding different types of injuries. DVA often sends out the wrong paperwork. I have been accused by DVA of not attending medical appointments and/or not sending paperwork back in. I have been spoken to like I am a complete moron, with utter disregard and contempt. You are made to feel like you are another whinging serviceman out to defraud the system, or a complete bludger who has just suddenly decided to quit work and live off the system.

Several of my veteran friends have even gone as far as to lodge official complaints against the person from DVA who they were speaking to because of the accusations and degrading and insulting manner in which they are being spoken to. You get the feeling that DVA makes the whole process so complicated and drawn out that you will give up out of sheer frustration. In regards to being treated fairly, it is my opinion that DVA looks for the easy option that will save the department money. No regard for the veteran’s personal and family life is taken into account. The stress of the whole process from start to finish is extremely taxing on both the veteran and their family. Often, the easy option taken by DVA results in the veteran and their advocate having to take DVA’s findings and decisions to the Veterans Review Board for appeals, and the veteran being admitted to a psych hospital for further review and also to prove to DVA that your PTSD is real. The cost of this to DVA must be substantial and it seems the only party to benefit from this is the private hospital. During the veteran’s stay in hospital he may be heavily sedated to alleviate the symptoms of PTSD brought on by the bureaucratic red tape.

I understand the need for checks to ensure that people are not defrauding the system, but … you spend countless hours in psychiatrists’ offices reliving the events on operations that lead to PTSD, and with your wife/partner telling the psych the effect of PTSD on the family and in social interactions, and [there is] the physical pain that you live with daily due to soft tissue injuries you sustained during your service, the hearing loss and tinnitus from small arms rifles, the news that one of your mates that you served with has taken his life as he felt that was the last option because a person in DVA decides that he isn’t worth a full pension and only receives $900 per month despite the medical reports saying he will require ongoing medical treatment. (Walter—Appendix A)

For more information on the relationship between DVA and Defence, including arrangements for the transfer of responsibility between departments when an ADF member is discharged, see the explanation of the Memorandum of Understanding on the DVA website.[76]

2014–15 Department of Veterans’ Affairs Budget Fact Sheet[77]

According to its 2014–15 Budget Fact Sheet, DVA received $12.3 billion for veterans, and supports around 310,000 veterans and dependents. ‘This funding includes $6.7 billion for income support and compensation pensions and $5.5 billion for health services’, including mental health services.

Image problem

While much good work is recorded in the above chronology of the department’s evolving approach to the (mental) wellbeing of its client pool, it is common to hear veterans (both of Vietnam and more recent conflicts) talk of their extreme frustration with the department. This sentiment is echoed by working professionals and acknowledged during interviews for this research by a number of senior DVA officers. While there is strong criticism of available programs, the lack of evidence around what constitutes best-practice is limited, leaving the department in a very difficult position. Should an evidence base for best practice service provision not exist, DVA can hardly be criticised for not implementing it. The (negative) image of DVA is a significant and perennial problem for the department. While numerous DVA publications communicate the department’s efforts to address the root causes of its image problem (see, for example, the DVA submission to the Senate Committee, The Mental Health of Australian Defence Force members and veterans), as long as there are military personnel negatively affected by their service, DVA’s image problem may be unsolvable.[78] as long as there are military personnel negatively affected by their service, DVA’s image problem may be unsolvable.