Mental health services
This chapter considers the diagnosis and treatment of mental
ill-health and the adequacy of mental health support services provided to ADF
members and veterans and their families.
Diagnosis and treatment of mental illness
The committee received a number of submissions commenting on the
treatment and diagnosis of mental ill-health.
Phoenix Australia acknowledged that it is difficult to evaluate the quality and
commitment to evidence-based mental health services delivered by external
providers, but stressed the importance of evaluation of the quality of care:
If we are serious about ensuring that past and present
Defence Force members get the best possible care...the evaluation of the quality
and outcomes of contracted work across private clinical service facilities and
private practitioners is a challenge that we must continue to try to address.
This would also include the evaluation of the utilisation by practitioners and
services of available referral options and pathways to maximise the matching
levels of need to level of care.
The Returned & Services League of Australia (RSL) stated that
'there is an urgent need to learn more about PTSD and its related mental health
problems and to develop new and effective treatments'. The RSL told the
committee that 'the best treatments currently available only work for some and
only a third of PTSD patients fully recover', calling for 'systemic research'
to address the gaps in the understanding of PTSD, test innovative treatments,
and discover how to improve treatment effectiveness.
Veterans' Health Advisory Council (South Australia) acknowledged
the importance of evidence-based care, but noted that evidence-based care
guidelines developed for the civilian population may not meet the specific
needs of ADF members and veterans. The Council warned that an overreliance on
civilian evidence-based care guidelines can have the unintended consequence of
limiting service provision:
...there has been an increasing constriction of the services
that will be reimbursed through these facilities with the reasonable
justification of the application of treatment guidelines and evidence-based
care. However, it is important to realise that treatment guidelines have become
an instrument of managed care that may have the unintended consequence of
limiting service provision. Evidence-based care has significant limitations in
the field of veteran mental health because treatments, used in civilian
facilities, are often developed on clinical populations who specifically
frequently exclude those with characteristics and comorbidities typical of
veterans. To highlight this disparity, there is significant and growing
evidence that psychological treatments for PTSD in veterans have worse outcomes
than in civilian population groups. Treatment guidelines developed from
non-veteran populations therefore have significant limitations on veteran's
health care, particularly in relation to informing the care of veterans with
chronic disorders who have not responded to the mainstream first line
The Council also criticised DVA's move away from veteran-specific
hospitals and the subsequent loss of specialist staff in a range of medical and
allied health fields that 'consolidated and represented generations of
expertise in the care of veterans'.
A number of submissions commented on the importance of
recognising that mental ill-health can be caused by neurological issues
(structural, biochemical, or electrical abnormalities in the brain). Major
Stuart McCarthy told the committee that, despite advances in neurological
science in treatment and rehabilitation, insufficient emphasis is given to
neurology as a causative factor of mental ill-health and that medical
practitioners are reluctant to investigate neurological causes for what appear
to be psychiatric or psychological problems:
...there has been a growing awareness of physical injuries as
causes of neurological damage, with symptoms including cognitive impairment,
for example blast causing TBI...Advances in neurological science in treatment
and rehabilitation for physical injuries have been prominent, however
insufficient emphasis is given to neurology as a causative factor. Despite
these advances, many veterans experience problems in seeking appropriate
diagnosis, treatment and support for more complex neuro-psychiatric injuries or
illnesses due to a reluctance by medical practitioners to investigate
neurological causes for ostensibly "psychiatric" or
"psychological" problems. Neurological symptoms are often initially
dismissed as "psychological".
Traumatic Brain Injuries
A number of submitters asserted that Traumatic Brain Injuries
(TBIs), also referred to as Post-Concussion Syndrome (PCS), should be
recognised as a possible cause or contributing factor when diagnosing and
treating ADF members' and veterans' symptoms of mental ill-health.
The Alliance of Defence Service Organisations explained that the symptoms of
TBI can be very similar to the symptoms of PTSD and that incorrect diagnosis
can lead to poor outcomes:
...symptoms [of PCS] which remained largely undetected until
they had actually returned home and began to manifest themselves when veterans
started having difficulty in functioning as efficiently as they had prior to
deployment...this begs the question whether PCS is masking symptoms of PTSD or
vice versa and possibly confusing the nature of treatment regimes and
rehabilitation programmes. Such a crossover of symptoms plus the delayed effect
reported by Zeitzer et al, along with any potential masking effects
could have the potential to adversely affect and complicate the successful
condition-focussed rehabilitation of injured service personnel who have
suffered a close traumatic brain injury or PTSD.
Defence advised the committee that it has 'specific policies in
place' for the care and management of patients with PTSD and TBI. DVA assured
the committee that it is aware of emerging issues regarding TBI and its impact
on mental health, noting that 'mild traumatic brain injury has come under
increasing attention by military medicine' and that its 'symptoms may mask
The committee received evidence regarding the neuro-psychiatric
effects of mefloquine hydrochloride (mefloquine),
an anti-malarial drug used to prevent and treat certain forms of malaria. Major
McCarthy informed the committee that there is extensive research providing
evidence that quinolones, including mefloquine, can cause brain injuries that
result in neuropsychiatric symptoms.
Dr Jane Quinn explained that:
The parts of the brain that it works on are the areas of the
brain that are affected in the chronic disease state caused by mefloquine
toxicity, which can be described as a limbic encephalopathy, with
vestibulopathy—if you will pardon the long terms. That basically translates to
a disorder of the part of the brain that governs anxiety, fear and normal
cognitive processing, associated with the part of the brain that deals with
balance. A majority of symptoms that have been presented in long-term
chronically affected individuals are rage, extreme anxiety, paranoia, auditory
or visual hallucinations, vestibular disorder—balance disorders, tinnitus. In a
military setting, a lot of those kinds of neuropsychiatric side effects really
cross-reference very closely with those that present in PTSD, for example.
There has been some concern in the medical profession that there is a subset of
individuals whose clinical symptoms of PTSD are exacerbated by having taken
mefloquine or that their disease state is actually caused by the drug they have
taken and not by classic PTSD at all. It is a very complex neurological
condition. It has only been well-characterised in the medical literature in the
past eight years, I would say, but it is now well-characterised, and a diagnosis
can be made.
In 2013, the United States Food and Drug Administration gave
mefloquine its strictest warning, known as a black box warning, 'due to risk of
serious psychiatric and nerve side effects.
Major McCarthy told the committee that, following the issue of the black box
warning, the commander of US Army Special Operations Command ordered that
mefloquine no longer be used. Furthermore, Major McCarthy noted that US members
exhibiting symptoms of toxicity undergo medical assessment and that mefloquine is
listed on the US Department of Veterans' Affairs 'deployment exposures'
Major McCarthy called for the introduction of a mefloquine
veterans outreach program. The program would include identifying all ADF
members administered mefloquine during their service; funding further research
regarding mefloquine toxicity; raising awareness and education regarding
mefloquine toxicity; training health staff in the diagnosis, treatment,
rehabilitation of mefloquine toxicity; and providing social support for
veterans and their families. Major McCarthy also called for a 'full,
independent inquiry into mefloquine use in the ADF and its impact on veterans
and their families, including the conduct of clinical trials by the [Army
Malaria Institute], the involvement of the manufacturer, decisions by senior
ADF leadership and the involvement of foreign governments and organisations'.
Defence advised the committee that mefloquine is one of three
anti-malarial medications approved by the Therapeutic Goods Administration
(TGA) for malaria prevention in our region and that 'it is Defence's third line
agent, meaning it is only used when one of the other two medications is not
appropriate'. Defence assured the committee that mefloquine 'is only prescribed
in accordance with TGA approved product information and Defence health policy'.
Defence acknowledged that both short-term and long-term
side-effects can result from mefloquine use and that those suffering from these
side-effects can claim compensation:
While in the majority of cases the side-effects associated
with mefloquine disappear after ceasing the medication, Defence accepts that
some people do continue to experience on-going issues. Those who claim to have
ongoing problems linked to side-effects from the use of mefloquine are provided
with appropriate medical treatment including specialist referral, assessment
and treatment. Further to this ADF members who are diagnosed as suffering
longer term or permanent side-effects from mefloquine use can also claim compensation
through the Department of Veterans Affairs (DVA) if the mefloquine was
prescribed for service reasons.
Defence noted that the 'vast majority of ADF members have never
been prescribed mefloquine', with an average of 25 members per year 'who
demonstrated such intolerance to other anti-malarial medication as to warrant being
prescribed mefloquine'. Defence stated that 'less than one per cent of ADF
members currently deployed and receiving anti-malarials are taking mefloquine'
and that 'within Defence mefloquine is prescribed at a significantly lower rate
than in the general community'.
Some submissions highlighted the impact of 'moral injury' on ADF
members' and veterans' mental health.
Professor Thomas Frame explained that moral injury results from an 'existential
dissonance', where there is a sharp disagreement between what a person believes
to be morally right and what they, or others, have experienced or done:
There is a consensus emerging that moral injury is associated
with the disturbance, disruption or diminishment of a uniformed person's moral
outlook and the depletion, degradation or disorientation of their inner moral
compass as a consequence of operational service, be it warlike or non-warlike.
It is plainly not synonymous with PTSD.
The incidence of moral injury is not predicated on a
traumatic experience. A traumatic event may cause moral injury, but a person
can be morally injured, an injury perhaps manifest in personal guilt and shame,
whether justified or not, or indifference, perhaps, to human pain and suffering
without the causal event itself being traumatic. Moral injury does not flow
from external stress but from internal reflection. It has to do with what a
person themselves makes of what they see, hear, smell, touch and taste while on
While operational service might impose an inordinate number
of physical and mental demands and be the cause of intense stress, moral injury
arises from existential dissonance associated with comparing idealised
conceptions to concrete realities. In other words, there is a sharp
disagreement about how things should be and how they actually are. So, in
reflecting upon a morally challenging experience, a morally injured person
realises they were not the individual they had previously believed themselves
to be or hoped they were. This realisation, 'I am not the person I thought I
was', causes discomfort and even despair.
Professor Frame also described the impact of moral injury:
The morally injured person can be debilitated by their
injuries in a number of ways. He or she could abandon notions of right and
wrong, good and bad, as they inhabit a world in which only legality defines
morality. So a morally injured person could become completely hostile to all
forms of authority and suspicious of every institution exercising any kind of
power. The morally injured could be paralysed by unremitting guilt and
unrelieved shame with no creative or constructive forms of confession and
absolution, forgiveness and reconciliation.
Major McCarthy noted that moral injury wounds members' and
veterans' moral character as well as destroying their capacity for social
trust, where social trust is defined as 'the expectation that power will be
used in accordance with "what's right"'. This significantly impacts
the ADF member or veteran's treatment, as the key resource for successful
psychological treatment, trust, has been destroyed:
...the significance of moral injury should now be clear,
especially the lack of trust experienced by veterans as a result of
their ADF service. Actions by authorities that destroy trust either during or
subsequent to operational service can be a cause of psychological
injuries. Lack of trust can be a key symptom of neuro-psychiatric
illnesses, including those caused by TBI and neurotoxic drugs such as
mefloquine. And a lack of trust can be a major barrier that prevents
veterans receiving effective care.
The Veterans Care Association called for a greater emphasis to be
placed on pastoral care when addressing and maintaining the mental health of
ADF members and veterans questioning their identity to address feelings of
The current paradigm of relying primarily on pharmaceutical
medication and counselling is treating illness, but not addressing the
"soul issues" of hope, identity and future purpose. The Chaplain or
peer pastoral carer is able to assure the veteran of confidential treatment of
their insecurities, their need to address guilt and reconciliation if needed,
as well as help them to imagine new possibilities of life beyond their
distress, or how to confront death with dignity.
The Vice Chief of the Defence Force, Vice Admiral Ray Griggs AO
CSC, advised the committee that Defence is working to better understand and
address concerns regarding moral injury, with the first element of this being a
scoping study with Professor Frame.
Use of pharmaceuticals and
The committee received evidence from Dr Niall McLaren, a
psychiatrist whose long career has focused on treating veterans. Dr McLaren
advised the committee that standard psychiatric management of PTSD 'relies
heavily on large doses of powerful medication in the very long term, coupled
with extensive psychological counselling of various types' and that
electroconvulsive therapy (ECT) is viewed by many psychiatrists as 'a useful
and essential treatment option'.
Dr McLaren advised the committee that he treats veterans as
outpatients, with a minimum of drugs and never uses ECT, noting that his 'results
are at least as good as if not better than the standard results'.
Dr McLaren called for the ADF to conduct an audit of private psychologists to
determine value for money in terms of treatments used and outcomes for
The ADF does not audit private psychiatrists who manage the
great bulk of veterans. There is no comparison of outcomes, no comparison of
costs, no attempt to ask people to present their results or methods, no effort
to explore options. The ADF absorbs massive costs without demur—$100,000 at
hospital admission, which in my experience is a complete waste of money. The
actual costs are a closely held secret. Truly outrageous cost claims are
submitted and paid with no questions asked. There are a lot of private
psychiatrists making a great deal of money from ADF members and veterans, but
the prevailing attitude seems to be that as long as something is being seen to
be done everybody is off the hook. CYA—cover your arse—seems to be the
prevailing ethos: heavily sedated unemployable patients who are in and out of
hospital and rarely complain too much, but when something goes wrong, like a
suicide, everybody can stand around and say: 'Well, we did our best. Look how
much we spent.'
Dr McLaren told the committee that treatment focused on the
standard methods, involving the use of powerful medications, is expensive and
ineffective, noting that 'people who embark on the standard type of program
generally do not return to work'. Dr McLaren advised the committee that, in
his experience, ECT was also very expensive but 'neither useful nor essential'.
The committee also received submissions highlighting alternative
treatments for mental ill-health including utilising emotional freedom
techniques and Ayurvedic techniques (traditional medicine from India).
Mental health services available to ADF members
Generally, submissions agreed that, provided ADF members were
willing to seek treatment, access to mental health services were adequate.
Phoenix Australia commended the ADF for its 'considerable' and 'substantial
progress with regards to the provision of mental health services for its
members, noting that if a member voluntarily presents to Garrison Health or an
ADF health facility for help regarding mental ill-health, 'there are policies
and procedures in place which should ensure that the person is assessed and
provided with appropriate treatment by an ADF mental health professional or an
externally contracted provider'.
Phoenix Australia noted that there 'remain gaps between routine
care and best practice in parts', but commented, 'it is worth noting that range
and quality of services available to current and past members of the Defence
Force are generally better than those available for citizens and other
Phoenix Australia commended Defence for 'the commitment shown by the ADF to
evaluation of their mental health programs, with a particular focus on quality
improvement. This is not an easy area, but it is fundamental to ensuring that
the programs are of optimum quality and value, and that they are being
delivered as intended'.
Some submitters did note that the quality of service was
dependant on where ADF members were based.
One submitter commented that:
The mental health treatment services available to ADF
personnel vary according to location...there are centres where there is ready
access with providers who are experienced in treating ADF personnel and who
have experience with the ADF Medical Classification System. There are other
locations where services are piecemeal and external referral is the norm.
The Royal Australian Regiment Association commented on the
removal of medical officers from regular army battalions in 2011, noting that
this has impacted on the continuity of care received by soldiers and
consequently the quality of care:
This has meant that an infantry soldier reporting to an area
medical centre is likely to be seen by a different doctor each time he reports.
On deployment, a doctor who will not be familiar with the battalion will be
attached. All Commanding Officers were and still are opposed to this loss of
capability, but their objections appear to be falling on deaf ears.
The lack of an RMO who knows the soldiers of the Battalion is
a major impediment to identity mental health issues and early intervention for
PTSD in particular in the members of the Battalion and with early intervention
of PTSD being a key issue in the management and treating of the condition the
lack of a permanent RMO is a major mistake which must be rectified.
Aspen Medical reported that its partitioners felt that 'JHC
provides high quality Mental Health Care to ADF members including [members who
have been deployed] suffering deployment related mental health conditions', but
noted that issues tend to arise when more than one agency is involved in the
delivery of care to ADF members with mental health conditions:
For example there are coordination issues between:
- Garrison and Theatre – this particularly affects the ability of MO and
MHP to readily access records that were made in theatre. This stems from the
obvious limitations to record keeping in the middle of a battlefield where
exposure to a traumatic even often occurs;
On-base and Off-base – there was a consensus view that on-base health
professionals had a greater familiarity with relevant policy than off-base
clinicians. They also better understood the context of military medicine and
mental care better than their off-base counterparts;
Clinical and Command – the transition between clinical care and ongoing
care in the unit setting can be complex to case manage. There was a general
view amongst respondents that unit commanders don't fully appreciate or
understand the role of the MP and MHP in delivering mental health care to their
unit members; and
Defence and non-Defence – this is particularly evident in the transition
out process where a veteran transitions to become the responsibility of the
Department of Veterans' Affairs (DVA). The respondents felt that there are
opportunities to improve the transition out process.
The Veterans' Health Advisory Council (South Australia)
highlighted the importance of clinical expertise and leadership in the
provision of mental health services to military personnel, criticising Defence
for using a 'purchaser-provider model', which 'assumes that the clinical
expertise exists within the broader community' and for its lack of uniformed
In addition to the devolution of health services and
expertise in Australia, specifically in the field of mental health, Australia
is faced with the additional challenge of informing, coordinating and
delivering mental health care services without any full-time uniform
psychiatrists, which is unlike any other Defence Force of equivalent size
nations, particularly our NATO allies. It is only in the last 3 years that an
APS psychiatrist has been employed in the ADF...Instead of drawing on veteran
specific expertise in various medical disciplines, the Defence Force has
depended on the specialists reserves, who primarily treat civilians, for the
Defence told the committee that early identification of mental
ill-health and access to treatment and rehabilitation for mental health issues
are key priorities. Defence advised the committee that mental health,
psychology, and rehabilitation services are provided to ADF members 'as an
integral component of the overall Defence primary health care system' and that
Defence 'is committed to continuous improvements to health services'.
Defence advised that the delivery of mental health and psychology
services is a 'multi-tiered responsibility' with:
Garrison Health Operations providing the strategic planning and
coordination of the regional health services;
ADF Centre for Mental Health providing a national operational
level for workforce training and the management of programs;
Regional Mental Health Teams providing the regional operational
level by delivering clinical supervision to service providers and coordinating
services for the Joint Health Units, and the Mental Health and Psychology
Sections at the tactical level providing local health services to ADF
Defence informed the committee that it has strengthened its
mental health workforce, creating 91 new positions:
74 new positions for regional and local service delivery (34
Australian Public Service (APS) and 40 contracted providers);
seven new positions at the ADF Centre for Mental Health (four
ADF, two APS and one contracted psychiatrist); and
10 new positions for policy and program development (one Senior
Executive Service (SES) Level 1 and nine APS).
Defence advised that its mental health and psychology services
are delivered by a wide range of health professionals including uniformed
medical officers and mental health professionals from the Army, Navy and
Defence noted that it has access to an additional 1,846 mental health service
providers (266 psychiatrists and 1,580 psychologists) under the Medibank Health
Defence informed the committee that it delivers a range of mental
health and psychology programs and training for ADF members, including:
ADF Alcohol, Tobacco and Other Drugs Program;
ADF Suicide Prevention Program;
Keep Your Mates Safe – Peer Support Network, which is intended to
address stigma, increase awareness of support services and provide practical
mental health first aid skills; and
BattleSMART, which is a preventative program designed to enhance
an individual's ability to cope effectively with increased stress and adverse or
potentially traumatic events.
Defence advised that its delivery of mental health, psychology,
and rehabilitation support services is enhanced by a number of general
awareness and promotion resources and activities including:
topical fact sheets;
Mental Health Online: webpage containing information and links to
online mental health resources for ADF members and their families and 'At Ease'
Defence helplines (All-Hours Support Line, '1800 IM SICK', and
Defence Family Helpline);
ADF Mental Health Day;
mobile apps developed in conjunction with DVA, including:
On Track with the Right Mix, which assists individuals to monitor
and manage alcohol consumption;
PTSD Coach Australia, which assists individuals to learn about
and manage symptoms that commonly occur after trauma;
High Res App, which assists individuals to build resilience and manage
their response to stress, and High Res Website, which assists individuals to
manage stress and improve resilience, providing a Self-Management and
Resilience Training (SMART) toolbox that complements the app; and
Operation Life, which assists who are at risk of suicide, in
addition to providing a guide for clinicians;
mobile apps from third parties, including:
Tactical Breather (United States of America Department of
Defence): assists individuals to gain control over physiological and
psychological responses to stress;
Breathe2Relax (United States of America Department of Defence): provides
individuals with information on stress management and the effects of stress on
My Compass: (Black Dog Institute): provides an interactive
self-help service to promote resilience and wellbeing;
MindHealthConnect Online Apps Library: provides resources from
leading health-focused organisations in Australia;
MoodGYM (Australian National University): assists individuals
develop skills for preventing and coping with depression; and
E-couch (Australian National University): provides individuals
with interactive self-help modules for depression, anxiety, relationship breakdown,
loss, and grief.
Defence advised the committee that is has developed a Defence
Mental Health Workforce Clinical Skilling Framework to ensure that the mental
health care provided by Defence is aligned with community best practice and
suits the ADF environment. Under the Framework all Defence mental health
professionals are trained, credentialed, supervised, and supported to deliver
services to ADF members. This includes upskilling in PTSD; suicide; Alcohol,
Tobacco and Other Drug assessment and treatment; acute management of mental
health presentation in the deployed environment; and the provision of
Rehabilitation specific programs
The ADF Rehabilitation Program 'aims to return ADF personnel who
are injured or ill to work in Defence or to successfully medically transition
to the civilian environment'.
Defence advised the committee that for the period of July 2013 to June 2014 a
total of 869 referrals to the ADF Rehabilitation Program were due to a primary
diagnosis of a mental illness, which is 17.3 per cent of the total number of
rehabilitation referrals for the period.
The rehabilitation program is enhanced by the Simpson Assistance Program and
the Support to Wounded, Injured or Ill Program.
The Simpson Assistance Program comprises a series of initiatives
that 'enhance the existing rehabilitation efforts by developing tailored
recovery programs to support the individual needs of ADF personnel and their
families'. Initiatives developed and piloted under the Simpson Assistance
Program include the:
Intensive Rehabilitation Teams;
'Mate-to-Mate' Peer Visitor Program;
Meaningful Engagement Options; and the
Living with Disability 'Families Stronger Together' residential
The Support to Wounded, Injured or Ill Program is a joint Defence
and DVA program delivered under the Memorandum of Understanding (MoU) and aims
'to facilitate the effective management of ADF members engaged in
rehabilitation through a framework that considers the needs of the member and
their family'. Initiatives developed under the Support to Wounded, Injured or
Ill Program include:
Soldier Recovery Centres;
Member Support Coordinators;
Individual Welfare Boards or Case Conferences; and the
ADF Arts for Recovery, Resilience, Teamwork and Skills Program.
Defence emphasised its commitment to rehabilitation. Defence
informed the committee that of the 869 individuals with a mental illness who
completed a rehabilitation program in the period from July 2013 to June 2014 a
total of 420 (or 52 per cent) are recorded as having a successful return to
work at the end of their rehabilitation program.
Mental health support for deployed
Defence advised the committee that, in addition to the mental
health services available to all ADF members, operationally-focused mental
health promotion, prevention, and early treatment services are also available for
deployed members. The aim of ADF Operational Mental Health Support is 'to
assist ADF personnel to deploy, perform their operational duties effectively
and then return to work and private lives with minimum disruption'.
All deploying members 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'. Defence advised that the BattleSMART pre-deployment program
training is delivered 'in conjunction with a comprehensive pre-deployment
During deployment, if deployed members are exposed to potentially
traumatic events, a Critical Incident Mental Health Support (CIMHS) response is
provided. The CIMHS comprises a group psycho-education brief on expected trauma
reactions, coping skills, and methods of seeking support. This is followed by a
targeted individual screening questionnaire and screening interview. The aim of
the CIMHS is to 'identify members that require immediate intervention or
scheduled follow up and facilitate a return to pre-exposure functioning'.
Deployed members in a 'high-risk' operational role that may routinely expose
them to intense operational stressors, critical incidents, and/or potentially
traumatic events (such as military police, explosive ordinance disposal
personnel, and health personnel) are provided with a Special Psychological
Screen mid-way through their deployment.
At the end of a deployment, ideally during the week prior to
leaving the operational theatre, members are provided with the Return to
Australia Psychological Screen. This comprises a BattleSMART re-adjustment
focused group briefing and an individual screening questionnaire and screening
interview. This aims to identify members 'that may benefit from an immediate
referral or early follow-up due to the deployment's impact upon their current
level of psychological functioning' as well as identifying members 'who may
potentially experience adjustment difficulties upon return to Australia'.
Defence advised the committee that mental health services are also
customised to meet the specific requirements of the operation. For example,
Defence provides Navy crews and Transit Security Element personnel assigned to
Operation RESOLUTE with a tailored program of mental health support. The
program commenced in June 2011 and comprises a biennial group SMART resilience
brief, annual Mental Health and Wellbeing Questionnaire, and a screening
interview with a Navy psychologist.
During a member's first week back in Australia the BattleSMART
brief is reinforced and the member is provided with local mental health and
welfare support contacts. A Post-Operational Psychological Screen (POPS) is
provided within three to six months of the member's return from deployment.
This aims to 'identify ADF personnel who are having reintegration difficulties
with family, civilian community and routine military duties following their
deployment, and facilitates the member in accessing the appropriate support'.
Mental health services available to veterans
A number of submissions highlighted the quality and range of
mental health support services available to veterans.
Walking Wounded commented that, 'DVA provides a very broad range of mental
health support and it would be churlish to disparage these genuine and often
Phoenix Australia commended DVA for its provision of a 'broad range of options
for veterans with mental health problems', describing it as 'probably as good
as anywhere else in the world':
DVA has been among the world leaders for over twenty years in
the provision of high quality PTSD treatment for veterans. These programs, all
of which comply with key content and performance criteria, all of which
participate in a standardised outcome evaluation process, and all of which have
a commitment to continuous improvement, have demonstrated impressive outcomes
in terms of symptom reduction and improved quality of life. DVA has also
developed a valuable range of online and mobile mental health resources for
veterans and practitioners and continues to seek to harness e-health options to
enhance its service delivery systems.
However, some submissions noted that many veterans may not be
able to access these services.
The Australian Psychological Society (APS) noted that although its members
reported that many DVA programs are of high quality and are specifically
designed to find effective solutions to improve mental health and wellbeing of
veterans, 'current service models do not effectively reach a large number of
veterans'. The APS asserted that this is in part due to the 'limitations in the
breadth and number of services available' and identified three specific groups
of veterans who are particularly disadvantaged by an absence of services:
veterans in Tasmania, veterans in rural and remote areas, and veterans with
The Veterans' Health Advisory Council (South Australia) criticised
the DVA's divestment of veterans' health assets and its move to a
purchaser-provider model. The Council asserted that this has led to the loss of
The existence of DVA run hospitals meant that there was a
group of medical and allied health specialists to both assist veterans in
clinical matters and advocate for them in broader health delivery and community
contexts. Specialist medical and allied health professionals with knowledge of
the veteran community operated as a conduit of clinical information about the
service needs of DVA veterans. With the transfer and closure of the DVA
hospitals, Australia will be in a unique position of having a Department of
Veterans Affairs that will have divested itself of health assets.
DVA advised the committee that its focus for mental health is 'firmly
on early intervention'. DVA told the committee that funding for veterans'
mental health treatment is demand-driven, stating that 'where treatment is
required it is funded' and noted that the government is investing in the
improvement of mental health services for veterans:
The benefits of early intervention are clear, both for the
veteran and their family. Recent Government budget initiatives further
highlight the commitment to treating mental health conditions. Over recent
years, significant funding has been invested in new initiatives aimed at
improving the mental health of veterans, from improved access to treatment and
counselling, through to improvements in the Department's management of clients
with complex needs, including those with mental health conditions.
DVA's expenditure on mental health has been steadily increasing
from $160.9 million in 2009-10 to $178.6 million in 2012-13. The breakdown of
the expenditure for mental health in 2012-13 is outlined in Table 4.1.
Table 4.1–DVA mental health
Mental health budget
including At Ease website; mobile phone applications; and provider engagement
training and resources.
Provide mental health
assessment and access to treatment.
Allied Mental Health
Provide assessment and
consultations, including group and individual therapies from professionals such
as psychologists or social workers.
Counselling support and
mental health treatment by psychologists and social workers. Includes case
management services, group programmes and psycho-education programs.
assessments, diagnoses, medicine management and clinical reviews as well as
anti-depressants, psycho stimulants and dementia-related drugs.
Contracts with private
hospitals for the purchase of emergency, acute care and outpatient mental
health services for the veteran community.
Arrangements with all
state and territory governments. Public and private hospitals expenditure
also includes trauma recovery programmes for post traumatic stress disorder
provided in hospitals around the country.
(formerly Australian Centre for Posttraumatic Mental Health
Provides evidence based
expert advice to inform and underpin DVA's polices and programs.
Department of Veterans'
Affairs, Submission 35, p. 39.
DVA assured the committee that it has a 'strong focus' on
purchasing evidence-based care and that it 'puts a strong focus on research and
quality to underpin its purchasing'. DVA noted that it partners with clinical
experts such as Phoenix Australia to develop resources regarding
veteran-specific mental health issues for providers, including:
Mental Health Advice Book: which aims to update the knowledge
base of practitioners who regularly treat veterans, as well as inform those who
may be less familiar with veterans' mental health issues;
Veteran Mental Health Consultation Companion: an app that offers
practitioners evidence-based consultation checklists and interactive assessment
measures with automatic score calculations and Australian military
interpretations. It is available on both iOS and android;
Online training programs in veteran mental health: providing
training modules such as Understanding the Military Experience, Case
Formulation, and PTSD Psychological Interventions; and
Evidence Compass: a website whereby research literature is
organised, reviewed, synthesised, and disseminated on questions of high
importance to the treatment of veterans.
DVA advised the committee that veterans also have access to the
online resources available to Defence members (discussed above) including DVA's
mental health website 'At Ease' which 'focuses on promoting mental health and
wellbeing, or resilience'. The website provides a range of mobile apps as well
as videos of veterans talking about mental health recovery. DVA noted that it
also implements health and wellbeing programs, in partnership with the veteran
Schedule of fees for psychologists
The committee received evidence raising concerns regarding DVA
funding schedules for mental health services.
One submitter noted it was difficult for veterans to find a psychologist who would
accept the DVA White Card:
We do have a concern that the DVA White Card schedule of fees
for psychological treatment are well below the current fees suggested by the
Australian Psychological Society; and the rate that many psychologists usually
charge. This can cause delays when veterans seek the help of a psychologist or
psychiatrist, as you need to locate a practitioner who accepts the White Card.
In our experience it can also create additional demand on services in
particular locations where there are fewer practitioners that accept the White
Card or where there are large numbers of veterans requiring services.
This concern was also raised by Dr Kevin Kraushaar, a
psychologist who has treated and is currently treating a number of veterans for
Dr Kraushaar advised the committee that many psychologists are unwilling or
unable to treat veterans due to inadequate funding for psychological services.
Dr Kraushaar drew the committee's attention to the differences in the DVA
psychologists' schedule of fees and the Australian Psychological Society's
schedule of recommended fees, outlined in Table 4.2.
Table 4.2–Comparison of DVA
psychologists schedule of fees and Australian Psychological Society's schedule
of recommended fees
DVA Item Number
APS recommended fee**
20 – 50 minutes consultation
20 – 50 minutes consultation
(out of rooms)
in addition to travel time (between $48 - $275)
50+ minutes consultation (in rooms)
$248-$447 (up to 120 minutes)
50+ minutes consultation
(out of rooms)
$248-$447 (up to 120 minutes)
in addition to travel time (between $48 - $275)
* GST Free
** Not including GST
Department of Veterans' Affairs,
Psychologists Schedule of Fees, effective 1 November 2013, http://www.dva.gov.au/sites/default/files/files/providers/psychol.pdf,
accessed 5 February 2016; Australian Psychological Society, APS National
Schedule of Recommended Fees (not including G.S.T) and item numbers for
psychological services, effective 1 July 2015 to 30 June 2016, https://www.psychology.org.au/Assets/Files/2015-16-APS-IS-SRF.pdf,
accessed 5 February 2016.
Dr Kraushaar noted that 'multiple daily sessions are not
claimable' and explained that such a policy could ultimately result in the suicide
of veterans in crisis:
The issue of multiple sessions per day in crisis situations
needs to be addressed especially for PTSD veterans in crisis...if [I] had not
answered all four suicide intervention calls and other multiple day-sessions
[my veteran client] with severe PTSD wouldn't be alive today.
Veterans and Veterans Families Counselling Service (VVCS)
A significant number of submissions expressed support for the
work of the Veterans and Veterans Families Counselling Service (VVCS).
Walking Wounded commented that the VVCS 'has continued to grow and adapt to
changing circumstances and demographics and, while it has its challenges, we
are confident that its direction is sound'.
One submitter, who is the partner of a veteran, expressed their gratitude for
I can speak very highly of the service provided by the
Veterans and Veterans Families Counselling Service (VVCS) to me as a partner. I
was assessed over the phone by an experienced and empathetic support person and
was given access to a psychologist promptly. My psychologist is excellent, and
the work I have done with her has been invaluable. I am very grateful for the
service that VVCS offer.
DVA advised that the VVCS provides free and confidential counselling
and support for veterans, peacekeepers and families. In 2013-14, VVCS:
delivered 89,513 counselling sessions to 14,136 clients;
delivered group programs to 2,074 clients;
provided 5,526 intake services that did not lead to counselling; and
received 7,050 calls to its after-hours crisis counselling
service, Veterans Line.
The VVCS provides 'free and confidential, nation-wide counselling
and support for war and service-related mental health and wellbeing
conditions'. DVA described it as 'a family inclusive organisation' where
'support is also available for relationship and family matters that can arise
due to the unique nature of military service'.
A breakdown of the demand for VVCS services since 2009-10 is listed in Table
Table 4.3–VVCS Services
Counselling sessions delivered
Intake not leading to counselling
Department of Veterans'
Affairs, Submission 35, p. 44.
DVA advised the committee that the VVCS has a counselling centre
in every capital city as well as in a counselling centre in a range of major regional
centres with large ADF and veteran populations, such as Townsville. From 2010,
VVCS has also applied a 'satellite centre' model which enables clients to
access VVCS staff clinicians through medical supercentres or services offices
located near ADF bases. VVCS also maintains a national network of contracted
outreach counsellors comprised of both psychologists and mental
health-accredited social workers to provide services to clients for whom travel
to a VVCS centre is impractical.
DVA informed the committee that VVCS clients are 'connected to
support 24 hours a day' through the national 1800 number (1800 011 046) that
connects clients to the nearest VVCS counselling centre during business hours
and functions as the VVCS crisis telephone counselling line, Veterans Line,
A number of submissions raised concerns regarding the eligibility
requirements for VVCS.
Solider On noted that unlike veterans, ADF members cannot access VVCS directly,
instead requiring a referral from a Medical Officer or Psychologist.
Furthermore, the VVCS is required to report to the ADF on the member's mental
health. Solider On asserted that this limits the usability of the service for
ADF members, who may wish to seek help but do not want the ADF to know that
they are receiving counselling:
Recently, the MoU has been expanded to allow for Medical
Officers (MO) or Psychologists in the ADF to refer members presenting to their
Health Centres to the Veteran and Veterans Families Counselling Service (VVCS).
This is an excellent step, however access to these services is predicated on
the member first presenting to an MO or psychologist and receiving a referral.
This in itself can represent a barrier to members seeking help, due to the
realistic fear that disclosing signs of PTSD or other mental health conditions
will jeopardise or end their military career. This potentially means many do
not seek treatment whilst they are serving, even as symptoms of psychological
wounds develop or worsen. This is especially problematic as early intervention
and treatment of mental health conditions is related to improved outcomes.
The following members of the veteran and defence community
presenting with mental health and wellbeing concerns can seek help from the
veterans, whether current or former serving with the ADF;
other current and former ADF members who have:
served in domestic or international disaster relief operations;
served in border protection operations;
served in the Royal Australian Navy as a submariner;
been medically discharged; or
been involved in a training accident that resulted in serious
injury to any person;
participants in the Veterans' Vocational Rehabilitation Scheme;
certain United Nations and Australian police approved
the partners and dependent children (up to age 26) of those
members listed above;
the ex-partners of Vietnam veterans within five years of
sons and daughters (of any age) of Vietnam veterans;
those with a DVA Health Card – for All Conditions (Gold);
those with a DVA Health Card – for Specific Conditions (White)
for specified mental health conditions;
the partners, dependent children and parents of members killed in
participants in the Study of Health Outcomes in Aircraft
Maintenance Personnel scheme; and
current serving members who are referred to VVCS by the ADF under
an Agreement for Services.
DVA advised the committee that the eligibility for VVCS services
extends to a broad range of people across the veteran and ex-service community
and assured the committee that, even if not eligible, members of the veteran
and ex-service community who are in need or distress are not turned away:
...VVCS does not turn away members of the veteran and
ex-service community who are in need or distress. VVCS is able to provide
limited counselling as part of its duty of care and can refer people who need
ongoing support and are not eligible for its services to more appropriate
DVA also noted that a person seeking assistance from the VVCS may
have clinical needs outside VVCS' core business or clinical skill bases. Such
people may need to be referred to specialist mental health services such as
trauma recovery programs for PTSD, hospital psychiatric services, drug and
alcohol services, or child and adolescence mental health services.
Recognition of registered
The Australian Counselling Association advised the committee that
the VVCS only use psychologists and registered mental health social workers and
that 'Medicare only allows for rebates to psychologists, psychiatrists and some
social workers'. The Australian Counselling Association called for registered
counsellors to be recognised and utilised by the VCAA, asserting that this
would 'significantly open access to services for veterans and more importantly
Mental health services available to partners, carers, and families
Chapter 2 discussed the impact an ADF member or veteran's mental
ill-health can have on their family and the importance of assisting families as
they support a member or veteran struggling with mental ill-health. Slater
& Gordon Lawyers highlighted the strain placed on families, and partners in
particular, describing them as 'at the forefront...trying to be the treater and
the provider and keeping the family together with someone who has got major
A number of submissions commented on the support available for
partners, carers, and families of ADF members and veterans struggling with
The RSL asserted that 'enhanced outcomes for veterans with mental and/or
physical injuries were linked to the support received by the carer' and that at
present 'the support is insufficient'. The RSL identified key elements of
support for families, including:
access to information about the ADF members' or veterans' condition,
how best to manage their condition at home, and the services available to
support them and the member or veteran;
carer's ability to provide care, especially long-term;
impact on children's mental health and recognition of children's
health support for carers; and
practical help for carers.
Some submissions raised the importance of practical support for
families struggling with mental ill-health, especially with regards to
The Partners of Veterans Association of Australia noted that support services
such as childcare is essential to ensure that partners of ADF members and
veterans are able to properly access mental health services:
Effective counselling needs to be in a calm format where the
communication between client and counsellor can be relaxed, therapeutic and
where trust and confidence can be built. Most times that cannot occur if a
child is present, for obvious reasons. If a partner is looking after and
juggling home life with a person with a mental health problem and has small
children, counselling will not be effective if they have not got babysitters or
other child care.
The RSL also noted that carers and families often expressed
concerns regarding the financial impact of service-related injury or illness;
the 'often hastened departure from Defence' and subsequent sudden loss of
support networks and housing; legal issues associated with relationships,
powers of attorney, guardianship, superannuation and finances; 'inadequate
separation planning from Defence'; and transition support for medically
discharged veterans and their families.
ADF members' families
Defence advised the committee that it is committed to developing
a family-sensitive approach to the delivery of mental health, psychology, and
rehabilitation services delivered to ADF members. Defence noted that the Defence
Community Organisation (DCO) provides 'a comprehensive range of support options
for Defence families and members and can be accessed directly at regional DCO
offices or via the Defence Family Helpline', including the provision of brief
Defence Community Organisation regionally based social
workers and Defence Family Helpline staff are able to provide brief
interventions to families which can include assisting the family member or
partner with their own support system, discussing strategies to enhance help
seeking and supporting treatment, options to access treatment, exploring
strategies to deal with volatility and anger and also withdrawal and
anticipating and managing triggers.
The DCO also provides a range of family support programs to help
inform families, develop their psychological resilience, and improve family and
social connectedness. The DCO publishes the magazine 'Defence Family Matters'
three times a year for Defence families as well as providing resources through
its website regarding suicide prevention; encouraging a loved one to seek help;
supporting families of wounded, injured, or ill ADF members; ADF members
experiencing trauma; and preparing your family for the return of deployed
member. The DCO also provide support calls to the families of deployed members
'which provide the opportunity for family members to raise any concerns'.
Other support available to Defence families include:
ADF Family Health program, which provides financial support to
Defence families when accessing community health care (100 per cent coverage
for General practice treatments and a capped amount for specialist care);
access to the range of mental health promotion resources and
service guides for available rehabilitation programs at the ADF Health and
Wellbeing website and DVA 'At Ease' website;
access to the Veterans and Veterans Families Counselling Service
(VVCS), subject to eligibility; and
access to the ADF All-Hours Support Line and Defence Family
DVA told the committee it recognised that 'supportive families of
veterans can help protect veterans' mental health and encourage them to seek
treatment for mental health concerns when it is needed', but that 'at the same
time, family members and carers may need their own mental health support'.
DVA advised that families have access to the same online resources as veterans
and that counselling and support is provided to eligible family members through
Accurate diagnoses and effective evidence-based treatments are
the best way to ensure that ADF members and veterans are able to manage mental
ill-health and receive the best possible treatments. To this end, the committee
strongly supports research efforts to better understand the prevalence, contributing
factors, and treatments of mental ill-health in ADF members, veterans and their
families, such as the Transition and Wellbeing Research Programme, led by the
Centre for Traumatic Stress Studies (CTSS) at the University of Adelaide.
The committee acknowledges that the military population has its
own unique mental health requirements and is concerned by evidence suggesting
that evidence-based care guidelines developed for the civilian population may
not meet the specific needs of ADF members and veterans.
It is essential that ADF members and veterans who have incurred
neurological damage are correctly diagnosed and given appropriate treatment to
ensure that they can achieve the best possible outcomes. The committee is
concerned by evidence that insufficient consideration is being given to
neurology as a causative factor for mental ill-health in ADF members and
The committee is also concerned by the evidence it received
regarding the neuropsychiatric effects of mefloquine. The committee
acknowledges that mefloquine is used by Defence as a third line agent and that
it is administered to a small percentage of the deployed population. However,
it is essential that those ADF members and veterans who have been administered
mefloquine are made aware of the possible short-term and long-term side effects
and are given access to appropriate neurological assessment, particularly if
they have exhibited symptoms of mental ill-health. The committee notes that the
Inspector General of the Australian Defence Force is currently conducting an
investigation into matters regarding the use of mefloquine.
The committee recommends that Defence and DVA contact ADF members
and veterans who have been administered mefloquine hydrochloride (mefloquine)
during their service to advise them of the possible short-term and long-term
side effects and that all ADF members and veterans who have been administered
mefloquine during their service be given access to neurological assessment.
The committee recommends that the report for the Inspector
General of the Australian Defence Force's inquiry to determine whether any
failures in military justice have occurred regarding the Australia Defence
Force's use of mefloquine be published immediately following the completion of
The committee notes the evidence that it received regarding the
impact of moral injury on ADF members' and veterans' mental health. The
committee acknowledges that Defence is working to better understand and address
concerns regarding moral injury, with the first element of this being a scoping
study with Professor Frame. The committee looks forward to the publication of
the findings of the scoping study.
Adequacy of mental health services
available to ADF members
The committee is satisfied that the ADF members' access to mental
health services is adequate, provided the member is willing to seek treatment. The
committee commends Defence for its proactive approach to mental health
promotion, prevention and early treatment services for deployed members. The
committee also commends Defence for the range of support services it provides
to Defence families, particularly those services provided by the Defence
The committee is pleased with the range of mental health and
psychology education programs as well as the resilience and crisis services
available, many of which can be accessed by ADF members who might be reluctant
to seek assistance (through the internet, through mobile apps, and via
helplines). The committee acknowledges that stigma regarding mental ill-health
continues to be a significant barrier to accessing mental health services; this
is discussed in greater detail in Chapter 5 of this report.
The committee is content that the Critical Incident Mental Health
Support response (following members' exposure to potentially traumatic events)
together with the Special Psychological Screen (for deployed members in high
risk operational roles) align with the principles of early identification and
treatment of mental health while on deployment.
The committee notes that improvements can be made to the
coordination of the delivery of care, particularly with regards to ensuring
that medical officers and mental health professionals have ready access to
records of potentially traumatic events for deployed members after deployment.
Furthermore, communication and coordination between mental health professionals
and commanders, especially with regards to the ongoing care of members in a
unit setting should be improved.
The committee recommends that the Department of Defence ensure
that medical officers and mental health professionals have ready access to
records of potentially traumatic events for members following their deployment.
Adequacy of mental health services for
The committee commends DVA for its focus on early intervention
and is satisfied that the range of mental health services available to veterans
is adequate, provided their claim has been accepted by DVA. However, the
committee is concerned that the services offered to families, primarily access
to the VVCS, seem to be inconsistent.
The committee is concerned by the evidence that psychologists are
unwilling or unable to treat veterans due to DVA providing inadequate funding
for psychological services. The committee notes that there is a significant gap
between the DVA schedule of fees and the Australian Psychological Society's
schedule of recommended fees. The committee is concerned that inadequate
funding of psychological services will limit the already scarce mental health
services available to veterans (especially those living in regional or remote
The committee recommends that the DVA Psychologists Schedule of
Fees be revised to better reflect the Australian Psychological Societies'
National Schedule of Recommended Fees and that any restrictions regarding the
number of hours or frequency of psychologist sessions are based on achieving
the best outcome and guaranteeing the safety of the veteran.
Veterans and Veterans Families
The committee commends the work of the VVCS—the service was
widely praised by submitters and witnesses. The VVCS provides an invaluable
'first-stop' resource for ADF members, veterans and their families to seek
assistance and advice regarding mental ill-health and the support and services
available to assist them. The committee believes that access to the VVCS
appears to be unnecessarily restricted by eligibility requirements. Eligibility
should be consolidated and inconsistencies based on which conflict a veteran
served in and other service requirements should be removed. Access should be
broadened to include any current or former member of the ADF and their
immediate family (partners, children, and carers).
The committee accepts the argument that the requirement that ADF
members must be referred to the VVCS and the VVCS' responsibility to report to
the ADF regarding members' mental health is likely to deter ADF members from
accessing this valuable service. While the committee acknowledges the
importance of the ADF being made aware of the mental health of its members, this
should not outweigh the importance of ensuring that members are able to receive
the care that they require. To this end, ADF members should be eligible to
access VVCS without referral and the VVCS reporting obligations should be
limited to situations where the VVCS believes that a member's mental ill-health
will compromise their safety or the safety of others.
The committee recommends that eligibility requirements for the
Veterans and Veterans Families Counselling Service (VVCS) be consolidated and
broadened to include all current and former members of the Australian Defence
Force (ADF) and their immediate families (partners, children, and carers).
The committee recommends that currently serving ADF members be
eligible to access the Veterans and Veterans Families Counselling Service
(VVCS) without referral and that the VVCS reporting obligations to the ADF be
limited to situations where the VVCS believes that a members' mental ill-health
will compromise their safety or the safety of others.
Navigation: Previous Page | Contents | Next Page