This chapter considers:
Stigma still attached to mental health issues;
Mental health care available while in ADF service and during transition;
The need for veteran-specific training and networks;
The importance of research into PTSD and the improvement of treatment outcomes;
The responsiveness of Defence and DVA to emerging international knowledge in the care of veterans; and
Ways that a national network of clinics could work, were a different approach adopted.
Military personnel are usually expected to be significantly healthier than the general population, and military recruitment policies exclude people with a range of existing illnesses. As stated in the ADF Mental Health Prevalence and Wellbeing Study 2010:
Mental health and wellbeing in a military environment is unique. The military is an occupation where personnel are selected, trained and prepared to face adverse, stressful and potentially traumatising situations. To meet these demands, an approach that focuses on strengthening resilience and enabling recovery is essential (ADF, 2010).
The 2010 ADF Mental Health Prevalence and Wellbeing Study, which interviewed up to 49 per cent of ADF members, found that one in five met criteria for a 12 month mental disorder (ADF, 2010). Personnel in lower ranks, and those in the Army service, were identified as at-risk sub-groups of ADF personnel. The level of exposure to trauma was found to be associated with levels of post-traumatic stress disorder (PTSD) and depression, regardless of whether those were deployment-related.
Stigma of Mental Illness
The 2010 ADF Mental Health Prevalence Study found that while the prevalence of mental disorders in the ADF was similar to those in the general Australian population, anxiety disorders rated highly, particularly among females, and affective mood disorders such as depression rated highly among males. While the study found that 17.9 per cent of ADF members sought help for stress, emotional, mental health or family problems, barriers to ADF personnel disclosing a mental health concern included:
Fear that they would be treated differently (27.6 per cent);
Concern that their career would be adversely affected (26.9 per cent);
Deployment capacity would be reduced (36.9 per cent).
It is common for mental health issues to be unacknowledged, or concealed by an individual for a number of reasons related to the stigma still attached to the need for assistance in dealing with an issue affecting psychological health. Within the services, an individual may not want to let their team-mates down, may not want to risk losing their job or even their career, and may even avoid seeking professional assistance by relying on their friends for support:
It is also important to recognise the military environment which attracts a certain type of person; those who are willing to be exposed to the harsh realities of military life. These experiences (training and operational deployment) create strong bonds of mateship and trust between individuals which creates several complications. Firstly, no-one wants to let their mates down and will hide their struggles; secondly, admitting to physical or psychological conditions can mean removal from the team and end of careers; thirdly, well-meaning mates providing inappropriate assistance cause further withdrawal from needed professional treatment; finally, the word of peers carries a lot of weight, which leads to a few trusted providers being overwhelmed with work.
Legacy referred to the strong continuing stigma attached to reporting mental health issues:
There are cultural issues that creates a barrier for Defence personnel to report any injury or disease. They fear discharge, being thought less of, or being vilified if they report anything. There is a huge barrier in reporting mental health issues where there is a fear that Defence will no longer think they are capable of fulfilling their duties. The mental health stigma is still very much alive and well.
Dr Romaniuk, Veteran Mental Health Initiative Lead at the Gallipoli Medical Research Foundation, gave evidence that there is a ‘stigma of injury’ attached to both physical and psychological injury, a sense that ‘now you’re not really part of the team’, and that people ‘become inadvertently stigmatised and ostracised from the group because of the stigma of injury and mental health’. Her research established that the stigma of physical injury comes about because when a person goes on medical leave they are not replaced, so other members of the team have to ‘chip in’ and do the work of the injured person, which ‘builds a bit of resentment of the person who is unwell’. This makes the injured person’s rehabilitation more difficult:
So that culture of being ostracised then has a greater impact on that person’s ability to rehabilitate, because not only are they dealing with a psychological or physical injury but they’re dealing with their own team sort of turning on them as well.
While there is psychological support available in the military, ‘there’s always a stigma attached’ to accessing it:
… I think there is a kind of harden-up, toughen-up attitude which in many respects they take on themselves and they choose to take on sometimes because they want to keep deploying because they actually like their job. There are supports available, but to take that extra step, put your hand up and go through that is potentially an internal barrier.
How well an officer understands, notices and responds to an emerging mental health condition is important:
… Some people were looked after brilliantly and had a positive experience… the upper levels of rank and command get it – they understand – but there are people in the middle section who don’t get it. Maybe they have their own prejudice against mental health or whatever and so it will depend on who that person’s direct line manager is. That makes a big difference to how they’re going to be looked after.
Most transitioning ADF members will leave a highly structured environment in the military where they are surrounded by like-minded people with similar experiences, and with a sense of purpose, achievement, and camaraderie. ADF service may also involve survival in threatening environments, enduring physical, psychological and emotional trauma, and complex encounters with ‘moral injury’.
Moral injury is the damage done to one’s conscience or moral compass when that person perpetrates, witnesses, or fails to prevent acts that transgress their own moral and ethical values or codes of conduct.
Within the context of military service, particularly regarding the experience of war, “moral injury” refers to the emotional and spiritual impact of participating in, witnessing, and/or being victimized by actions and behaviours which violate a service member’s core moral values and behavioural expectations of self or others. Moral injury almost always pivots with the dimension of time: moral codes evolve alongside identities, and transitions inform perspectives that form new conclusions about old events.
Moral injury may be indicated in the following examples in war:
Using deadly force in combat and causing harm or death to civilians, either knowingly but without alternatives, or accidentally;
Giving orders in combat that result in the injury or death of a fellow service member;
Failing to provide medical aid to an injured civilian or service member;
Returning home from deployment and hearing of the executions of cooperating local nationals;
Failing to report knowledge of a sexual assault or rape committed against oneself, a fellow service member, or civilians;
Following orders that were illegal, immoral, and/or against the Rules of Engagement (ROE) or Geneva Convention;
A change in belief about the necessity or justification for war, during or after one’s service.
The consequences of moral injury can be serious distress, depression and suicidality.
Moral injury ‘complicates’ both the development and the treatment of PTSD:
… These nuances of the type of trauma you’re exposed to and how you respond to that trauma in the moment make a big difference in terms of people who go on to develop PTSD and who will respond best to treatment. A lot of the difficulties we’re now seeing with veterans is that, along with transition issues, there’s a mixture of what we’re calling ‘moral injury’ as well as PTSD. That moral injury really complicates the development and treatment of PTSD – and it’s based on those fundamental issues of taking life, not taking life and that sort of thing.
Mental Health Care during Transition
The first twelve months after separation are critical for mental health, and there is a need for the departments of Defence and Veterans’ Affairs to work closely together, as well as for an ‘holistic and tailored approach’ to transition:
While the Department of Defence and the Department of Veterans’ Affairs (DVA) both indicated greater levels of collaboration between the two agencies in their latest Annual Reports, there is an ongoing need to work more collaboratively with external agencies as when individuals, and family, transition from the ADF, they do so into the community. Recent findings in the Mental Health and Wellbeing Transition Study: Mental Health Prevalence report indicates that the first 12 months after separation from the ADF are a critical time for one’s mental health, particularly young men aged between 18-24. The transition process however is a much longer journey, and this was also reflected in the report. It also showed that not all that separate from ADF get or seek support from DVA, with only one in 10 individuals seeking, or are able to access, veteran healthcare services. This highlights the need for a holistic and tailored approach that can adapt to the diverse needs of all veterans.
The Committee heard that there are four key limitations on the current model of mental health care after transition from the ADF:
There is no clear determination as to which government body is responsible for managing the health and wellbeing of transitioned personnel, and consequently there is a gap in the care, and no handover process from the military health system to the civilian or Veterans’ Affairs health system;
There is currently a focus on the practical and occupational facets of transition, but a lack of weight given to the psychological adjustment required during transition;
There is a lack of mental health care providers in the community who have an understanding of the unique military system and culture and adequate training in gold-standard therapies; and
Service personnel reportedly have no control during a medical discharge process, which can be extremely detrimental.
The same research resulted in the following observations:
Early screening and assessment to detect those most at risk of poor transition is vital to prevent mental health deterioration;
A case management approach could facilitate the handover process and ensure coordination of health care, and navigation of the services offered by ESOs in the community
‘The difference between military and civilian culture and adjusting to this forms a vital component of the transition process’;
‘…the experience of leaving the military and reintegrating back to civilian life can be characterised by significant loss’;
‘Transitioning personnel appear particularly vulnerable to the loss of important facets prominent in military culture, which include structure, support, camaraderie and community. In addition, many experience identity loss, which is further compounded by the difficulty reconstructing their self-concept as a civilian.’;
‘…a substantial proportion will also experience a significant loss of purpose and meaning upon returning to civilian life. This perceived void of not contributing to an important collective cause appears to subsequently impact motivation to fully engage in civilian activities after service.’;
‘It’s vital that future models of mental health care acknowledge and address this experience of loss and facilitate methods to adjust to such loss for the transitioning personnel.’; and
‘The lack of military cultural competence and appropriate training by mental health providers can be really detrimental to transitioning personnel and lead to increased dropout rates, unreliable and inconsistent attendance in therapy, and worsening of mental health symptoms.’
The central outcomes and findings of this research include:
A reliable and valid psychometric assessment tool to determine psychological and cultural readiness for civilian life by identifying key areas of need for personnel prior to discharge;
Tracking progress following discharge is necessary;
A reintegration training program is necessary; and
Military cultural competency education and training for clinicians, case managers and public servants and civilian employers (already being implemented through an RSL program) is necessary.
The DVA Transition and Wellbeing Research Program found that one in five ADF personnel who have transitioned have suicidal ideation, plans or attempts in the previous 12 months, which is consistent with the research performed by the Gallipoli Medical Research Foundation, and their experience in clinical practice, that ‘those first five years out of transition, is a really risky, crucial period for people’.
One form of assistance which is proving effective is a platform called Doctors on Demand, which allows healthcare providers to join the platform and communicate with patients online through teleconferencing. This can be helpful for transitioning military personnel who are moving location, as it is accessible regardless of geographic location. It is also especially applicable for younger veterans, who are accustomed to using online platforms to access a variety of services.
Dr Paula Dabovich noted the evidence in the Mental Health Prevalence and Pathways to Care studies, mentioned in a number of submissions to this inquiry, which highlight rates of mental health disorder that occur during transition, and low rates of engagement with evidence-based care. Dr Dabovich stated that transition is ‘an extremely complex, challenging and often distressing time for service personnel, especially those who are young and discharged on medical grounds’. Issues of distress around transition are not unique to Australia, and this is a problem ‘particularly acknowledged in the USA and Canada’. A literature review found that ‘much of the transition research today is uncoordinated and descriptive’, which ‘makes it difficult to synthesise and develop practical systems of care that may otherwise help better support veterans through transition’.
The current medical discharge process is identified as one of the four key limitations on the current model of mental health care [See Chapter 2, ‘The Transition Process’]: ‘[S]ervice personnel reportedly have no control during a medical discharge process’ which can be ‘extremely detrimental’ leading to transitioning personnel becoming ‘despondent’ and losing ‘any sense of self-efficacy or belief that they can shape their own health or future’:
In order to help those medically discharged take ownership of their future and life outside of the military, a sense of control is vital in the protection of self-efficacy and a healthier adjustment to civilian life.
Legacy Australia noted that those at higher risk of self harm can include people involuntarily discharged or given a medical discharge for either a mental health issue or a serious physical illness or injury.
The RSL Queensland noted that suicide rates, which are lower for serving ADF personnel than for the general Australian population, ‘spike’ among a particular group of people transitioning from the ADF – those being discharged for a medical reason. There is a ‘really significant increase’ in this group, and the reason is that this group have not made the decision to leave the ADF, the decision has been made for them. Mr Denner said that we need a ‘laser-like focus’ on this group to better understand them and provide them with the support they need. Mr Denner also acknowledged that ‘society more broadly needs to talk about mental health; it’s not an ADF-only issue’.
Recent Improvements to Medical Treatment Outcomes
There are signs that things are improving:
I think DVA have come a long way. They reach in before people are transitioning out of Defence. They definitely do a wonderful job of picking up the people that are medically separating.
Mates4Mates has attributed the apparent reduction in the suicide rate of former ADF personnel to the work that ESOs are doing, and to the ‘improvements in DVA claims processing that have come into play over the last 12 months – Non-Liability Health Care, the immediate access that was brought in earlier this year ’.
Medical Transition Fora
Access to Medical Transition Fora is something which a number of submitters have stated that they would have liked to have had during their transition in recent years. The ADF has conducted a trial of specialised Medical Transition Fora in Brisbane and Townsville, which was to be completed at the end of 2018. It intended to implement the specialised Medical Transition Fora generally if the trial is successful.
Access to Soldier Recovery Centres
Access to Soldier Recovery Centres run by the Army was mentioned by more than one submitter as an element which would have made a positive difference to their transition experiences. While technically access to Soldier Recovery Centres is currently available to members of all three services, and the Joint Defence and DVA submission to this inquiry has confirmed this, there can be practical difficulties in gaining access for ADF members not located on Army bases. The ADF has been attending to this issue and has stated that access is now available across the services, and the Committee endorses this development.
Obtaining Medical Records
A number of submitters mentioned the difficulties that they experienced obtaining their medical records on leaving the service. During service, notes made by medical practitioners may be sparse, including for members who may have suffered injuries, illness or wounds while on active duty overseas. While adequate for military purposes, sparse medical records can lead to difficulties for individuals when seeking to obtain support from DVA for injuries received in the line of duty while on active service. Several submitters have suggested that an individual’s complete medical records should be provided to them on transitioning out of the ADF.
The ADF has indicated that the presentation of an individual’s complete medical records, is now part of the Transition process, and the Committee endorses this practice.
Non-Liability Mental Health Care
Access to non-liability mental health care for both serving and former ADF personnel recognises the dangerous nature of the work that members of the ADF are called upon to do, and the real risks to them of sustaining a significant psychological injury in the course of that work. The recent provision of non-liability mental health care for both serving and former ADF members enables individuals to seek medical care for psychological issues, no matter how much time has passed since they left their service. It also recognises and is a response to the fact that service related mental health issues may not manifest until much later and may be triggered or exacerbated by the extremes of treatment. No other country has put in place non-liability healthcare for mental health for veterans.
One submission highlighted the impact that an unsympathetic manager can have on the experience for a member exiting with a medical discharge:
The level of assistance to the medically discharging and/or transitioning members at the Defence workplace is solely reliant on the calibre of the Command. If they are unsupportive and endeavouring to find the swiftest exit for their wounded injured and ill member, it can be a distressing time for the member and family. Many of the officers and middle management lack empathy and understanding and are ignorant towards the discharging member’s conditions. The officers are not qualified to know, or care, how to provide support to a wounded, injured and ill colleague in the workplace, often times reacting negatively to their mental health state or reactions to triggers and stresses being experienced in the workplace. The term ‘Welfare Officer’ is misleading when the person in that role is not qualified, with limited ‘welfare’ experience or understanding.
Evidence from the Departments of Defence and Veterans’ Affairs
For those leaving the ADF due to medical reasons, retirement or other reasons, Defence ‘assists’ with planning to ensure a smooth reintegration into civilian life through connection to relevant government and community support and exploring opportunities for maintaining wellness and obtaining meaningful engagement’. Since July 2018 Defence has been running the specialised Transition for Employment program which provides medically transitioning ADF members who have complex circumstances, with an enhanced level of support in finding and maintaining meaningful employment, and in building up skillsets to use beyond their transition.
About 900 or 950 people per annum are medically discharged from the ADF. The veterans’ compensation and veterans’ support system is integrated into the whole of the Australian community and health sector. It consists of Australia’s universal healthcare system plus what the Department of Veterans’ Affairs provides to veterans.
In 1918 the Repatriation Department – now the Department of Veterans’ Affairs – was formed, and military hospitals were built around the country to provide lifetime healthcare for military veterans. Citizens who did not have military service had to pay for their own healthcare, and so veterans were in a relatively privileged position within Australian society, having their healthcare provided free of charge for the rest of their lives. With the establishment of Medicare, the Australian healthcare system changed, and Australia now has a universal healthcare system. With the reducing number of veterans accessing repatriation hospitals, the expense of maintaining a separate healthcare system for veterans became too high, and by 1995 the Department of Veterans’ Affairs had transferred the repatriation hospitals to the state and private healthcare systems. DVA has agreements with all Australian State and Territory Governments to provide treatment and care to eligible members of the veteran community in the public hospitals. Veterans now can access healthcare in their local area, through their local General Practitioner, accessing local services and local specialists. DVA claims that access to healthcare for veterans is actually stronger in the decentralised public/private system that the DVA funds, for the 288 000 clients of the department.
The Committee acknowledges the recent initiatives by both the Department of Defence and the Department of Veterans’ Affairs, which have made significant improvements in the elements of the transition experience for personnel. A number of witnesses to the inquiry, and submissions received, identified issues such as difficulties in getting copies of their medical records after leaving Defence, which no longer ought to be the case. These initiatives include service personnel being handed their medical documents on leaving the service; already being linked into DVA when they transition out; receiving a DVA number on recruitment; having access to non-liability mental healthcare; and the provision of a DVA White Card to all personnel.
However, it is apparent that the integration of the Repatriation Hospitals to the general hospital system has meant that veterans no longer have access to a service that is focused specifically on their needs, and that because of that focus, had developed particular expertise in the treatment of veterans. The establishment of networked centres of excellence would address this deficiency.
Continuity of Care
Continuity of care has been cited by academics/experts as important to the successful treatment of mental health issues. It has been suggested that continuity of care could be achieved by merging of the health care systems of the ADF and DVA. A number of practical considerations prevent this from taking place. One is that while the ADF has medical practitioners who are employed or recognised for treating ADF personnel, the DVA has quite a different system in which it pays service providers for treatment. In their joint submission to this inquiry, the departments of Defence and Veterans’ Affairs commented on their collaborative work, and continuity of care:
The Departments will also continue to collaborate on research, programs and initiatives to strengthen mental health resilience, increase awareness and early recognition of mental health problems, improve access to care and strengthen continuity of health care arrangements where these are required. This particularly applies to the crucial period during which ADF members transition from military service into civilian life. Defence is committed to providing flexible health support to transitioning military members, including those who need to transition at short notice for medical or compassionate reasons.
Defence and DVA also noted that Recommendation 5 of the Senate Inquiry into Suicide by Veterans and Ex-service Personnel recommended ‘the Department of Defence and the Department of Veterans’ Affairs align arrangements for the provision of professional health care’. This issue is being addressed by both departments:
DVA is a key stakeholder in the Next Generation Health Services project, in which Defence is establishing new supply arrangements for health services. This will include a network of health providers that are Defence aware and that support continuity of care for serving and transitioning members.
Soldier On told the Committee that it has recent examples where continuity of care worked well. In those cases, a complex case coordinator in DVA ensured that those individuals received the continuity of care that they needed on leaving the ADF, and that this care continued to be accessible to them when they transferred to DVA. There was the potential for these cases to ‘slip through the gaps’ if the additional support needed had not been provided, or if the individual transitioning did not think they needed that support and would not agree to accept it, or if the need was not identified early enough.
It is the Committee’s view that assigning Defence clear responsibility for managing these issues, and the adoption of a case management approach to transition, would help to address continuity of care comprehensively and permanently.
The Committee recommends that the Government ensure that in cases where personnel are being medically discharged:
Related claims are assessed by the Department of Veterans’ Affairs prior to the person’s medical discharge from Defence;
Access to Medical Transition Fora be made available to all members of the ADF subject to a medical discharge;
Access to Soldier Recovery Centres be available to all ADF members regardless of their location in Australia;
Complete individual medical records are made available to all transitioning personnel.
Veteran-specific Training and Networks
Evidence from a number of Ex-Service Organisations, and others, pointed out the importance of service providers, including medical professionals, but mental health professionals in particular, having knowledge of Defence culture and the veteran experience. The risk, if health care providers do not possess an adequate understanding of the environment from which former members of the ADF are transitioning, is that veterans are less likely to either seek out, or remain in treatment. The high drop-out rates of veterans in psychological treatment for PTSD bears out this hypothesis.
An understanding of ‘the unique relationships (and the personal impact of them) forged in service … which relate to identity, are critical for those working with veterans during the sensitive period of transition’. A focus on the primary mission, ‘maintaining the security of the nation’, dominates the highly structured and focused work environment of the ADF, and the culture tends to be counter-productive to early intervention when personnel are struggling with physical or psychological health issues. It is important to understand that some military personnel will conceal health conditions, physical and psychological, because they do not want their peers to know and judge them as weaker, and to protect their careers. Such behaviour can continue after transition to protect their new career or career prospects, which can further complicate health issues in the unfamiliar environments and different stresses of civilian life.
The ‘rules’ of Defence culture need to be well understood by clinicians in order to maintain effective therapeutic relationships with patients with ADF experience:
The deeply imbedded and persistent training which military personnel receive to become effective soldiers, sailors and airmen and airwomen, creates sets of behavioural, social & moral ‘rules’ which are strictly adhered to, often long after they have transitioned … Unless clinicians know that these rules exist and understand the context from which many veterans operate, they will have little hope of developing positive therapeutic relationships with veterans…
The superficial coverage of PTSD in some clinical psychology programs and in the training of psychiatric registrars means that the next generation of therapists are not well prepared for the challenges of practice with clients who have ADF experience. In South Australia, recognition of the value of health care professionals with knowledge of the particular issues inherent in injuries arising from military service has lead to the development of an education module for all employees of South Australian Health, to help them better understand the needs of service personnel and veterans. A South Australian group of private psychiatrists has also formed the Closing the Gap Trauma Group, who have decided to inform themselves on issues specific to veterans and military personnel. There is some concern that an insufficient number of mental health specialists within the Joint Health Command means that it is not well placed to lead clinical development in this area.
While there have been major improvements in the quality of mental health care available to ADF personnel in the last twenty years, the same could not be said of mental health care available for veterans. The closure of the Repatriation General Hospitals has led to the outsourcing of mental health care for veterans, which has generated problems for two reasons:
The significant decline in public mental health care quality and standards of care in Australia in recent years, with many clinicians expressing concerns about the lack of availability of resources and their inequitable distribution; and
The risk that care will be provided by practitioners who lack the knowledge of military-specific issues and problems. The emphasis on outsourcing assumes that the required expertise and standards of care exist in the community, which may not be the case.
The DVA is reviewing the incentives and compliance requirements for professionals to undertake veteran-specific online training (July 2018), however it is difficult for veterans to discover whether a provider has undertaken such training. Developing a register which veterans can access to find out which providers have completed the DVA training modules, or making it mandatory for DVA funded providers to complete the modules, would provide veterans with the confidence that these service providers understand their unique situation, and would assist with the development of a strong therapeutic relationship which can result in the veteran continuing to engage with the health care.
The Committee is in favour of the creation of a cohort of psychological healthcare professionals who have completed training in veteran-specific issues. Making this information available to veterans, through a register of professionals with veteran-specific qualifications, would benefit veterans and enhance their prospects of a successful transition. The establishment of networked treatment centres of excellence, appropriately located near concentrations of ADF personnel and veteran populations, would also support the development of professional knowledge and expertise.
Research into PTSD and the Improvement of Treatment Outcomes
Effects of military service
The Transition and Wellbeing Research program studied the entire Defence Force in 2010, including all of the Middle East veterans, and looked at a cohort before and after deployment. In 2015 it followed up all the people who had left the Defence Force since 2010. It also revisited those who had participated in the 2010 study who remained in the Defence Force, a cohort for whom they had pre- and post-deployment measures. One of the findings in relation to transition has been that the maximal rates of disorder are not at the point that a person leaves the ADF, but that disorders progressively emerge in the years after leaving the ADF. The effects of exposure to combat don’t manifest immediately, but may emerge over a very long time.
Another finding from the research was that of the cohort of people transitioning out of the ADF, about 20 per cent of the cohort measured between 2010 and 2014 were medically discharged, and 33 per cent of the cohort were ‘expressing significant psychological distress’. Of that transitioning cohort, approximately 6 000 persons per year, 75 per cent ‘have a lifetime prevalence of some kind of mental health disorder’. Just less than 50 per cent – over 46 per cent – have a 12 month prevalence of a mental health disorder. Both of those figures ‘are much higher than the general population’.
Why those figures are so high might be explained by the fact that this cohort of people, former members of the ADF, ‘have greater exposure to trauma and human suffering’. That exposure ‘directly correlates to the amount of mental illness that’s going to eventuate’. While the ADF has measures in place to psychologically screen people prior to going overseas (RtAPS) and on their return (POPS), the tools can only assess the information that is provided by the service member:
… Even if they’ve got problems, there are many reasons for them to not disclose them‑so that they’re deployable with their mates or so that they can get the extra benefits that they get from deploying, not just financial but status-wise.
The 33 per cent of the transitioning cohort who were experiencing psychological distress were experiencing issues such as anger, anxiety, poor sleep, relationship problems, using more alcohol and drugs. Of the 75 per cent of the transitioning cohort who have a lifetime prevalence of a psychological or psychiatric disorder, most will have either an anxiety disorder, of which one is PTSD; a depressive disorder; or substance abuse – alcohol or drugs. Lifetime prevalence rates in the general community are about 49 per cent as opposed to 75 among those who have transitioned from the ADF. The prevalence study had found that there was no difference in rates of psychiatric illness between non-deployed and deployed populations – so no difference in the prevalence of psychiatric disorder among people who were in the military, whether or not they had deployed. Dr Khoo noted that ‘it is now irrefutable in international literature and understanding in military and trauma populations that the greater the exposure to trauma, the greater the mental health outcomes, the mental health disorder that results’.
Sources of trauma
Professor McFarlane told the Committee that the 2010 study examined the source of trauma within the ADF, and the study showed that ‘a multiplicity of issues’ was at the source of the trauma suffered by ADF veterans. The first element Professor McFarlane identified, was that ‘childhood trauma is overly represented in people who join the Australian Defence Force’, although he did not support screening for childhood trauma at recruitment. The second element is accidents, such as motor vehicle accidents and training accidents, which also place peoples’ lives and health at risk. There is also that group of people who are at risk of trauma due to their combat exposure.
Professor McFarlane noted that the 2010 data did not show that those within the Defence Force who had been deployed had worse trauma than those who had not been deployed, but noted that the effects of deployments were showing among those who had left the defence force – ie those who returned from deployment and had difficulties tended to leave the Defence Force, and that’s when they are at risk of being affected by the trauma.
An extremely high proportion of the deployed force ‘have been exposed to one or other of those stressors or multiple stressors’ and that another aspect of military trauma which is different from civilian trauma is that ‘it’s very rarely a one-off; it’s usually multiple and cumulative’. There is a difference between being deployed as a commando or as a cook for example, and that special forces are more highly trained, more psychologically ready and are seen as a more resilient population. However the risk factors around trauma come down to two main factors, which are issues around the trauma, and issues around the individual. Special forces soldiers could be expected to have a higher prevalence of mental health issues because there is greater cumulative exposure, notwithstanding that they are a more highly trained and resilient workforce.
In considering the question ‘how do we produce soldiers who are resilient enough to deploy into war zones and still live in our society at the end of it?’, Dr Khoo proposed the following:
Research into personality types that would predispose people to trauma, a genetic predisposition;
Screening - talking to recruits about their childhood more, because a difficult childhood can lead to greater rates of PTSD as an adult;
Preparing serving ADF members better and trying to be preventative rather than reactive;
Improved support services at the time members are traumatised;
Encourage people to self-identify trauma related psychological problems earlier.
The effects of trauma, regardless of whether it is acquired in military service or otherwise, are cumulative and need to be managed. The Australian military is now placing people on shorter deployments of six to seven months in Afghanistan because this length of time is more protective of the mental health of those serving, even though from a military perspective, it would be optimal to deploy people for longer periods of time to build relationships to achieve certain aims. Professor MacFarlane said that limited duration of deployment is an important issue, and that NATO mandates it by law. He also observed that US troops have longer deployments, which is probably one of the reasons why they have poorer mental health.
Experience of loss
A review conducted of 18 qualitative and mixed methods studies of the experience of transition, found that the experience of transition is ‘characterised by extensive and multiple losses’ for individuals. Impacts on veterans included ‘the loss of military culture and community, identity and purpose’ and were consistent across countries and contexts. The findings underline the importance of addressing the experience of loss for transitioning ADF personnel.
There is a complex range of experiences which can lead to service personnel acquiring Post Traumatic Stress Disorder (PTSD) and suicidal ideation during their service. The effects can be exacerbated by the ‘profound loss’ that may occur during transition when ADF members leave and many aspects of their life are changing at the same time:
… you have a group of people who are affected by their service because of their service. They’ve been deployed and they’ve been exposed to traumas, and that might leave them with PTSD, depressive disorders, anxiety disorders, suicidal ideation, moral injury et cetera. So there’s that group that then will go on to discharge because of that injury. Those people may have had suicidal ideation before they left and may have it after. Then you have another group of people who may not have had any mental health conditions before they left. And then I believe that, because this period of profound loss occurs, where they’re losing everything that we’ve already talked about, in addition to having problems with their DVA compensation or getting appropriate health care et cetera… financial, family stress… it’s a major adjustment process. For some people I think that feeling of being overwhelmed and that feeling of hopelessness then can lead to suicidal ideation.
Mental health services
Issues with treatment of veterans are that the services needed are not necessarily readily available in the community, and there needs to be more oversight of, and strategy and planning for the specialist medical services needed by veterans. It doesn’t help that the mental health system is grossly underfunded and, as a consequence over the last forty years or so, standards of care in the Australian mental health system have decreased.
Two reports released in 2018 by the departments of Defence and Veterans’ Affairs indicate that almost 50 per cent of those in transition ‘become psychologically symptomatic of disorder’ yet only 25 per cent of those who are unwell ‘were engaged in evidence-based care that might otherwise improve their long-term health and occupational outcomes’. Dr Dabovich found that the lack of an overarching framework for an understanding of the process of transition has contributed to a lack of understanding of the loss of selfhood experienced by those transitioning, in particular those leaving on medical grounds, and reduces the ability of the system to shape services to meet the needs of veterans. Further research into the transition from military to civilian life would inform the provision of the most effective support to ADF personnel as they transition from ADF service, and help to ensure that mental health services in the community are able to provide for clients with previous military experience.
Another factor is that the devolution of the repatriation hospitals from the DVA has led to a loss of clinical expertise and personnel as well as researchers and epidemiologists within the department. This is not the case in other veterans’ health systems. For example, medically qualified personnel are employed in the administration of veterans’ affairs in Canada, the US and the UK. Canada and the US also employ a number of health professionals within their defence forces, and develop programs in their defence forces which are then replicated in the veterans’ community. The DVA is not as responsive as it could be to developments in international knowledge, because the organisation does not include people who are part of these international networks.
Despite several attempts, the DVA has not shown interest in receiving briefings by Professor McFarlane on the findings of the Transition and Wellbeing Research Program and their significance, and he believes this is in part due to the lack of medically qualified personnel in the department.
There are difficulties with ensuring that the quality of care that people are currently receiving is commensurate with evidence-based guidelines, because the care is dispersed, and people are making their own arrangements in an unstructured manner. A disincentive for specialists, including psychiatrists, is that DVA has frozen the remuneration to psychiatrists, and so some will not see veterans because they know they will be paid less, and there are onerous reporting and administrative requirements. Specialists who do see veterans are: those who will continue to see them regardless because they have a special interest in them; young inexperienced psychiatrists who are trying to build a practice but do not have the appropriate skills or experience to meet veterans’ needs; or psychiatrists who cannot keep a client load for whatever reason.
The RANZCP indicated in their submission to the inquiry that they see the following areas as priority areas in relation to mental health treatment of serving and formerly serving personnel:
DVA engagement with certain sub-groups of veterans, in particular younger, contemporary veterans;
Persistent problems with the structure and delivery of health care for veterans in Australia;
A lack of clinical knowledge within DVA and the ADF; and
Limited funding and coordination for research on veteran mental health.
Centres for Treatment Excellence
The establishment of a network of Centres for Treatment Excellence, which were also specialised research clinics, would allow for the development of a knowledge base or approach to the treatment of veterans with mental health issues, particularly for those patients who have not responded well to established therapies. An additional benefit of centrally located services would be the capacity to train doctors in military and veteran issues, and conduct longitudinal research.
The RANZCP submitted that one of the reasons for having Centres of Excellence was to make sure that there is a high standard of quality of care. It made the following suggestions to improve the quality of care to veterans:
A strategy to support and encourage ongoing clinical services for veterans;
Review by DVA of their engagement with contemporary veterans in various groups, especially with younger client groups in transition;
Greater roles and responsibilities for psychiatrists and clinical experts in both ADF and DVA; and
Funding for research, especially for the Transition and Wellbeing Research Program which published two pieces of research in 2018.
The Committee considers that the Government should move to establish such a network as a matter of priority.
The RANZCP recommended that specialist centres be placed where there are concentrations of veterans, so in the capital cities and near major bases such as in Townsville. The RANZCP is advocating that more specialists, particularly psychiatrists, are employed, as well as specially trained clinicians embedded in the DVA, either working there or in advisory capacities.
Evidence-based government policy
The RANZCP recommended that the Government continue to fund the Transition and Wellbeing Research Programme and support further longitudinal research on veteran mental health through a national research program. This should include a commitment to acting on the findings of the funded research. The Committee supports the need for such research to inform government planning in providing for the current and future needs of former members of the ADF.
It was suggested to the Committee that the DVA should be more flexible in considering emerging interventions in the treatment of PTSD and other military-related psychological issues. Some newer and emerging treatments do not yet have an extensive evidence base, but Veterans’ Affairs agencies in the United States, Canada, and the United Kingdom have been open to funding pilot programs to explore these types of initiatives, such as Equine Assisted Learning or Adventure Based Therapy.
Peer-to-peer support can also be a very important part of achieving good health during transition. The RANZCP said that peer support – using people who have had the life experience and a journey that’s similar – ‘is key in moving forward’ Dr Romaniuk described peer support as ‘a vital and important component’ in transition, but also indicated the importance of ensuring that those veterans who wish to be peer supporters are robust enough to handle the challenges. Mates4Mates also recommended more investment in formalised training for veterans so that they may provide meaningful peer support.
Productivity Commission Report
The Productivity Commission noted that ADF members are recruited and trained to be physically and mentally resilient, and that although they are exposed to particular mental health risks, including trauma, separation from family and frequent relocations, they also benefit from the protective factors of a strong sense of purpose, camaraderie, and easy access to health care while in service. These protective factors fall away during transition, and recent research has indicated that transition itself is a risk to health and wellbeing, with changes in employment, finances and other adjustment issues potentially leading to relationship conflict, mental health and substance abuse problems. Rates of mental illness among veterans is high, and the suicide rate for male veterans under the age of 30 years is 2.2 times that of Australian men of the same age, with those transitioning out of the ADF in the previous five years reporting high to very high levels of psychological distress.
The Commission observed that ‘DVA’s current mental health strategy is not adequate … and needs urgent updating’, saying that DVA needs to focus more on demonstrable outcomes, promote access to high-quality mental health care, and facilitate coordinated care for veterans with complex needs. In addition, DVA ought to identify the needs of family members and develop appropriate responses. The Commission recommended that the current (2013-2023) Veteran Mental Health Strategy be updated due to recent policy changes (such as non-liability access) and research findings on emerging needs.
The Productivity Commission’s draft recommendation that the Australian Government recognise that Defence has primary responsibility for the wellbeing of discharging Australian Defence Force members, and that this responsibility may extend beyond the date of discharge, resonates with the Committee and the evidence it has received. The ADF is in continual contact with all ADF personnel while they prepare for and make their transition from the ADF. DVA will have immediate contact and some responsibility only for those ADF personnel transitioning from the ADF with DVA recognised conditions. The Productivity Commissions has proposed a ‘Joint Transition Command’ within Defence to consolidate existing transition services in one organisation and take responsibility both for preparing members for, and assisting them with, their transition to civilian life. It is the Committee’s view that the administrative arrangements for managing transition should be left to Defence to determine.
The Repatriation Hospitals provided veterans’ health services in an environment that understood and was responsive to veterans’ needs. To veterans, the Repatriation Hospitals were, and were seen to be, theirs. While it is not practicable to re-establish that system, the importance to veterans of places where they could expect to receive treatment in an environment that understood them and the nature of their condition cannot be overstated. However, the establishment of networked Centres of Treatment Excellence for veterans’ mental health is achievable and would address the need to: develop the body of knowledge and new therapies in veterans’ mental health; increase the number of appropriately trained and experienced mental health practitioners; and provide veterans with the assurance that the treatment offered would be focussed on their needs and an understanding of their backgrounds and circumstances.
The Committee recommends that the Government provide for:
Case management of all individuals transitioning out of the ADF;
Where personnel are medically discharging, claims recognition by DVA prior to the individual’s medical discharge from the ADF;
Access to Medical Transition Fora to all members receiving medical discharges based on the fora trialled in Brisbane and Townsville in 2018.
The Committee recommends that the Government provide the following to better support veterans’ mental health outcomes:
A sustained funding model for veterans health research and education;
Networked Centres of Treatment Excellence for veterans’ mental health, including treatment for PTSD;
A coordinated strategy to improve treatment outcomes for PTSD;
Post-graduate education in Veteran Health and Mental Health for healthcare practitioners registered with Defence and DVA; and
Mandatory online veteran-specific training and professional development for clinicians and a register of clinicians for client information.