Reaching out to those suffering in silence

Canadian Military Mental Health

The statistics are chilling, and they tell a grim story of an invisible illness that, according to both the Canadian Mental Health Association and the Centre for Addiction and Mental Health Foundation, affects one in five Canadians at some time in their lives. Its consequences can be devastating for the individuals suffering from mental illness and their family and friends. As the second leading cause of death in the 15-34 age range; and it is no different among members of Canada’s armed forces.

DND’s 2015 Report on Suicide Mortality in the CAF (1995-2014) shows that during the 20-year study period, 225 regular force males died by suicide or 20.2 per 100,000. By comparison, Statistics Canada reports that the suicide rate in Canadian males between the ages of 20-60 ranged between 17 and 26.7 per 100,000 in 2012, the most recent year of data available.

The small statistical number of those who die by their own hands belies its tragic significance. Each life lost to suicide has a major impact on family, friends and colleagues, not to mention that, to an organization like the Canadian Armed Forces, each suicide represents a loss of a valued member of the military family. Both the Canadian Armed Forces and the Defence Department have invested heavily in improving mental health services to its members and in encouraging people to simply ask for help when needed.

The organization has created and – more importantly – diligently reinforced a culture that is supportive of those who suffer mental health problems.

Although realistically impossible to achieve, the military organization endeavours to reduce the suicide rate to zero.

“We have a very good mental health system that addresses the complete spectrum of mental health issues,” says Colonel Andrew Downes, the Director of Mental Health at CF Medical Services. “We understand that no system is perfect, and so we are trying to improve and enhance the work we do for our current and future patients. We are concerned about the confidence of our patients in our system and how this affects their decisions to come forward for care. The more they trust us, the more likely they are to come forward for care or less likely to drop out of care. We encourage informed, constructive criticism that can lead to improvements.”

Factors and Stressors
DND’s 2015 suicide report lays out some of the aspects of the suicide problem in the CAF. This dispassionate exploration of the statistics and the grim realities behind it make it a difficult document to read.

There has been a slight increase in suicides in the Canadian Forces in the past several years, and not surprisingly, it is more frequently seen among army personnel, who have a two to three times greater rate of suicide than their navy or air force counterparts.

During the mission in Afghanistan it was primarily army personnel who were involved in the most dangerous and intense aspects of the mission. So, within the Canadian Armed Forces, their rate of mental illness is higher, and their suicide rate is higher as well.

Suicide is a multi-factorial, multi-faceted event. Contributing factors include biological, psychological, personal, social, cultural influences, and others, that all come into play – and no two people are alike. For example, some with severe depression are not suicidal at all, and others with relatively mild mental illness become suicidal. There are myriad factors to consider.

Statistically, males are three to five times more at risk of suicide than females, despite the fact that females have a higher risk of mental illness than males.

When an individual with a mental illness faces some kind of stressor, the interplay between the illness and the stressor may “cloud” the mind and reduce the person’s ability to manage the situation or even to consider other options.

“For example,” Col Downes explains, “if a person’s spouse leaves, the person with mental illness may not have the capacity to see that things will get better, or it is too painful an event to endure. So they may see suicide as the only option, whereas that is a less likely response for somebody without mental illness.”

There could be other stressors, such as administrative, financial, legal or disciplinary issues, which can create a watershed moment. “These particular kinds of stressors may also contribute to the final motivation of the suicidal behaviour,” agrees the Director.

Complicating factors that affect mental illness are numerous and varied, and mostly beyond the control of the Canadian Armed Forces. Factors like adverse childhood experiences and personality type are clear examples. Also, not all life-partner / family relationships can withstand the stresses of military life or mental illness. Individuals may make financial decisions that lead to significant debt, which can negatively impact their mental health. The CAF does provide support programs like financial and marital counselling, which can help to mitigate the impact of these situations, but often people ask for help only when the problem has become critical.

However, the CAF mental health specialists can exercise some influence on opening and conducting the dialogue about suicide and mental illness in the Canadian Forces. The leadership of the Canadian Forces and the families of service personnel can provide educated support to people in ways that can help them.

Education is provided to give personnel the insight to understand when they may need help for mental illness; treatment is always available when the individual seeks care; and support is offered when military members are going through stressful periods in their lives.

Suicide is not a unique military problem. It is a human problem within society. The CAF monitors what other agencies are doing and looks for opportunities to identify lessons learned and adopt best practices. The CAF Health Services Group has partnered with a number of academic institutions to conduct and share research to better understand mental illness and to develop, integrate and employ new treatments for mental illness within the military family. Further, the Health Services Group is conducting continuous epidemical research on mental health and suicide.

Every suicide in the Canadian Forces is subjected to two investigations. First is an administrative board of inquiry. The second, a two-member Medical Professional Technical Suicide Review  (MPTSR) looks at the clinical aspects of the suicide. They interview the clinicians, and usually the family. They speak with the person’s chain of command and others (friends for example) to better understand the person’s state of mental health and the kind of care the person received, as they endeavour to discover areas for improvement of mental health services, and what lessons could be learned to improve care and reduce future suicides.

“One of the important findings is that about half the people who die by suicide were not in any kind of medical care and had no known diagnosis, and the other half were in medical care of some sort,” Colonel Downes observed. “This highlights the importance of our efforts to encourage people to get into care, and as well to improve the quality of care and support available.

“While depression is the most common diagnosis found in people who die by suicide in the Canadian Armed Forces, it is not the only mental health concern being addressed by the CAF’s medical community. There are many other diagnoses like PTSD, anxiety disorders, substance use disorders,” he added.

Military members are frequently concerned about the impact of any medical diagnosis, including a mental illness, on their careers, and that they may be judged and treated differently by their colleagues and supervisors. This stigma of mental illness is not specific to the military, but is a common problem throughout Canada, one which all levels of leadership and command within the Canadian Armed Forces has worked to reduce the impact of this barrier to care.

Recent research shows that military members are more likely seek care for mental health problems than the general Canadian population, and that their needs are more likely to have been met. They are also much more likely to speak with colleagues and supervisors about their mental health problems than civilians.

“As the mission in Afghanistan started, we were very concerned about the mental health impact of combat operations on the individuals we sent there and, as a result of that, we deployed psychiatrists as part of the mental health team to Kandahar. The Afghanistan mission was the first time we did that.”

An initiative called the Third Location Decompression Program was also instituted in response to that perceived need. Everyone returning from Afghanistan would take a little time-out at a location where they would have an opportunity to relax before coming home (most went to Cyprus). While decompressing, they would be given some mental health education to help them recognize behaviours in themselves that might suggest they needed to come for care.

Over the period of the mission in Afghanistan, the number of staff working in mental health clinics roughly doubled, and a program called the Road to Mental Readiness (R2MR) was launched.

“Our Road to Mental Readiness program is quite simple, but ground-breaking,” the colonel explains. “It aims to improve knowledge about mental health and improve mental resilience. Its components are based on sports psychology, and comprise what we call be big four: goal-setting, visualization, self-talk; and tactical breathing. This allows people to set realistic goals for themselves, to visualize them succeeding in those goals, as well as managing stressful situations.”

Colonel Downes further explains that “self-talk is a manner of telling yourself that you can succeed, that you can do this, as opposed to ‘I am going to fail.’ Sometimes people may be predisposed to think negatively of themselves rather than positively. This is a way of replacing a negative self-image and negative ideas with more positive thoughts and words. It’s about creating a positive mindset when facing stress. It’s about emphasizing optimism rather than pessimism.”

The R2MR’s acceptance across a spectrum of organizations is testimony to its success. The Mental Health Commission of Canada has adapted the R2MR program for use in the civilian workplace and by a number of police forces, including the RCMP, and other agencies.

The mental health clinic for CAF members in Ottawa, is located at the Monfort Hospital. (Photo: MCpl Paul MacGregor Canadian Forces Combat Camera)

The Mental Health Commission of Canada (MHCC) is funded by Health Canada to be a catalyst in the effort to enhance the mental health system in Canada and improve Canadians’ attitudes and reactions to mental health issues.

The R2MR program has been integrated into many stages of a service member’s career. Recruits undergoing basic training receive an initial R2MR package, and there is evidence that it helps them to succeed on basic training and reduces drop-outs. CAF members receive further modules of R2MR at different points in their careers, such as prior to and returning from mission deployments. There is a leadership module for the various leadership programs.

And the work continues. The program is being adapted and tailored for different occupations, because each has unique stressors. An example is Search and Rescue Technicians, whose work requirements to rescue victims of accidents, disasters and misadventure, frequently put them in mortal danger.

RX 2000
With the advent of the new millennium, the CF Surgeon General launched a project called RX2000 that was a reinvestment in the overall Canadian Forces’ health care system. One of its components was a plan to fortify military mental health services.

The planned improvements to the mental health system allowed the mental health principals to be better prepared to meet the needs of CAF members returning from Afghanistan.

Stigma Reduction
The R2MR program is a resiliency program that it gives people the knowledge and tools to help manage their stress. It also provides them with further mental health education to enable them to better recognize when they need to seek care.

As Col Downes tells FrontLine, the stigma that has been historically attached to issues of mental health is a huge barrier to care; it may prevent or limit someone’s willingness to ask for care. “This is why we have been putting a lot of emphasis on mental health education, so that we can get these people into care, so people will come forward for care when they need it. We’ve put a lot of effort into stigma reduction through our training programs over the past few years. We have events like brigade mental health days where brigades or units will take some time to talk about mental health issues. We’ve also participated in the Bell Canada Let’s Talk program over the last three years. This is all in an effort to increase communication about mental health and reduce stigma. And we do have data to suggest that stigma in the military may be at a lower level than in the general Canadian society.

“We opened the first five Operational Trauma and Stress Support Centres (OTSSC) before the year 2000,” Downes continues. “They specialize in operationally-related mental health injuries, and in 2011 we added two more, creating a network of seven regional clinics across the country.

Enhanced post-deployment screening has also been added to the process. “About three to six months after people come back from deployments they undergo an extensive mental health screen, which allows us to identify people with mental health difficulties and get them into care, if they are not already in care. But we know that sometimes people’s symptoms haven’t manifested at that time. That’s why we’ve also increased our education program. We’re not relying only on screening to get people into care, but thankfully people are coming into care on their own accord.”

Early Care Key to Recovery
The Surgeon General’s mental health strategy was put in place in 2013 to guide improvements to the CAF Mental health program over the following five years. It has seven major thrusts including measuring and improving mental health outcomes, expanding mental health education and training, and better using technology for communication, diagnosis and treatment.

There is also a series of standardized treatments for people so clinicians have a list of consistent psychotherapy options that are based on evidence of their effectiveness. The Canadian Forces also recently introduced direct entry mental health notes to the electronic health record, allowing clinicians to more readily access a patient’s health information. This improves communication within the health team, which should lead to better care.

A service member must meet the standard required by the principle of universality of service, which requires all Canadian military personnel to be mentally and physically able to complete the tasks required. People are concerned that they will be released from the CAF if they come forward for help with their problems – and this becomes a barrier to recovery.

“In fact,” Col Downes underscores, “we find that people are more likely to be retained in the military if they come forward early because it gives us a better change to cure them. If people delay, if they wait too long, the condition is more likely to progress and it will be much harder to achieve a full recovery. We encourage people to come forward for care and to come forward as early as possible so we can maximize their chances to return to duty.”

Health services practitioners are convinced that early detection and early care are the key to success. “You wouldn’t hesitate to see a specialist about a broken limb,” says Colonel Downes, “nor should you hesitate to see a specialist about a mental problem.”

Ottawa Hospital Virtual Reality Lab for Mental Health
Mental illness among the general Canadian population is more than tragic, and more than crippling, it is also incredibly expensive. The Mental Health Commission of Canada estimates the cost to the Canadian economy of $50 billion in treatment, care and support services, which represents 2.8% of Canada’s gross domestic product. Over the next 30 years, it is expected to cost Canadians more than $2.5 trillion which, coincidentally, is the annual global cost of mental illness.

Canada’s Department of National Defence and Armed Forces are more concerned with the personal impact of mental illness rather than its fiduciary effect. Military mental health authorities have focused their attentions on discovering and implementing the most up-to-date, evidence-based and clinically effective treatments available for service personnel suffering from operational stress injuries, such as post-traumatic stress disorder. They have seized on some technological initiatives to provide high quality care to traumatized military patients.

Virtual Reality Therapy (VRT) is one option showing significant promise. These technologies first emerged from the Sensorama Simulator – Morton L. Heilig’s 1962 effort to introduce simulation into training and instruction. From that humble beginning, the University of Southern California’s Institute for Creative Technologies developed the Bravemind virtual reality exposure therapy application specifically designed for treatment of mental health disorders linked to the Afghanistan and IRAQ conflict. It is the only known virtual reality system with documented clinical evidence of improved health outcomes in military populations.

Bravemind was developed to treat post-traumatic stress by having the patient, assisted by a trained therapist, encounter and process his or her traumatic memories through reliving the experience in a virtual environment under carefully controlled circumstances. The application consists of a series of virtual scenarios that are relevant to the particular military patient’s context, and can replicate experiences in Afghanistan, including urban situations and desert road environments. Canada purchased two copies of the Bravemind VRT application in 2014.

The Canadian Armed Forces use virtual reality headsets and computer systems that run Bravemind software. Forty-two Canadian military clinicians are now trained, and 25 Canadian soldiers are being treated using the US-developed virtual Iraq and Afghanistan environments. The software is being Canadianized by using Canadian uniforms and vehicles.

The Canadian application, CAREN, for Computer Assisted Rehabilitation Environment, expands on traditional virtual reality therapy by incorporating motion. Called military motion memory desensitization and reprocessing (3MDR) therapy, it was initially developed by the Netherlands military. It combines eye movement desensitization and reprocessing (EMDR) therapy with a brisk walking pace and sensations associated with explosions and gunfire.

The CAREN system provides a safe and controlled therapeutic learning environment for Canadian military personnel to confront their traumatic experiences, challenge their abilities in physical rehabilitation and experience exposure therapy as part of their treatment for psychiatric disorders. It also allows therapists and researchers to accurately measure and conduct very technical analysis to provide the best opportunities for patient care.

Tim Dunne is FrontLine’s Atlantic Canada correspondent. In his 37 years as a member of the Canadian Armed Forces, he served in Albania, Bosnia Herzegovina, Croatia, Egypt, Israel, Italy, Kosovo, former Yugoslav republic of Macedonia, North Africa, and Turkey.