Surgeon General's Mental Health Strategy: CAF Mental Health Programs and Services

The CAF was sensitized to the psychological impact of operations as members returned from missions such as those in the former Yugoslavia, Somalia, Rwanda and Afghanistan. While the CAF is now internationally recognized for its operational excellence, the cost has included an increased prevalence of chronic psychological injuries that has required a strong commitment from the CAF to manage.

The CF H Svcs Gp has been in a constant state of evolutionary and revolutionary change, starting with the major resource reductions of Operation PHOENIX in the mid-90s, followed by the reform and reinvestment of the Rx2000 project, and finally, the many new initiatives and resources since the beginning of combat operations in Afghanistan in 2006. All changes were directed by CAF leadership and the final result is our current health system, which delivers a relatively outstanding standard of comprehensive, high-quality care.

In the CAF Ombudsman’s 2012 review entitled Fortitude Under Fatigue: Assessing the Delivery of Care for Operational Stress Injuries that Canadian Forces Members Need and Deserve, Mr. Pierre Daigle commends the CAF for significant improvements over the past decade, and is quoted as saying “I was pleased to see that care and treatment for Canadian Armed Forces members suffering from an operational stress injury has improved since 2008 and is far superior to that which existed in 2002.”

The Rx2000 reform provided the foundation for our current system. It arose from the 1999 Chief Review Services’ evaluation of the CF Medical Services which noted significant concerns in many areas of health services, and was informed by findings from the Croatia Board of Inquiry, the Lowell Thomas Report, and the McLellan Report on Care of the Injured. The CAF mental health system was further enhanced since 2006 by such measures as the expert panels on mental health-related issues, the Road to Mental Readiness (R2MR) program, expanded mental health research efforts, telemental health, virtual reality exposure capabilities, and others.

The CF H Svcs Gp now has a comprehensive mental health system that consists of strategic, operational and tactical programs and services. The Directorate of Mental Health provides national coordination, strategic assessment and oversight whereas operational delivery of clinical services is carried out through 1 and 4 Health Services Groups. Our mental health system is based on high-quality health surveillance and research to better understand the risks and needs of our population, understand how to improve its health, and improve treatment of illness. We focus on prevention through education and strive to deliver the best possible care. These programs and services essentially cover three components:

1. UNDERSTAND: Health surveillance and mental health research
2. EDUCATE: Mental health education and training
3. CARE: Clinical programs and services

This continuum illustrates changes in mood, sense of humour, sleep, energy level and social interaction to indicate where people are in the continuum of mental health. Everyone would ideally be in the green zone but normal stressors can move people into the yellow or orange zone. The R2MR program teaches people how to best manage these normal changes and to recognize when they need help.

*The MHCM provides a guideline to identify signs that may indicate further assessment from a qualified medical / mental health professional is required.

R2MR encompasses the entire package of resilience and mental health training that is embedded throughout CAF members’ careers, including the deployment cycle. It is designed to ensure that the most appropriate training is provided to prepare CAF members mentally for the challenges they may encounter. All CAF personnel are now provided mental health education during Basic Training, throughout leadership courses as they progress during their careers, and at key points before and after they deploy on military operations. The R2MR model provides insight into the varying levels of mental health issues and offers guidance on the appropriate support depending on the severity of the condition.

The goal of R2MR training is to improve well-being and short-term performance, while mitigating any negative long-term mental health problems for both CAF personnel and their families. This is accomplished by teaching early identification of signs and symptoms of mental illness; the importance of peer and leadership support; appropriate leader actions; barriers to seeking mental health care (including stigma); and available mental health resources. Resilience skills, including tactical breathing, mental rehearsal, goal-setting, and self-talk, are also taught, mentored and cued to improve the ability of CAF members and their families to manage both operational and non-operational stresses.

The CF H Svcs Gp’s Directorate of Force Health Protection also provides the Strengthening the Forces health promotion program. This important program provides awareness and prevention education and skill development in areas such as suicide intervention, anger and stress management, healthy relationships, family violence, and addictions.

The education of CAF personnel and their families is not the sole responsibility of the CF H Svcs Gp and must therefore be well coordinated among all relevant CAF elements. R2MR is the foundational mental health education program, but harmonization and coordination of all mental health education and training is conducted by the Mental Health Education Advisory Committee, which is chaired by the Director of Mental Health. Members include representatives from all environments and training centres, the Chaplain branch, the Directorate of Military Family Services, the Directorate of Military Personnel Operational Research and Analysis, and Defence Research and Development Canada.

The goal of R2MR training is to improve well-being and short-term performance, while mitigating any negative long-term mental health problems for both CAF personnel and their families. This is accomplished by teaching early identification of signs and symptoms of mental illness; the importance of peer and leadership support; appropriate leader actions; barriers to seeking mental health care (including stigma); and available mental health resources. Resilience skills, including tactical breathing, mental rehearsal, goal-setting, and self-talk, are also taught, mentored and cued to improve the ability of CAF members and their families to manage both operational and non-operational stresses.

The CF H Svcs Gp’s Directorate of Force Health Protection also provides the Strengthening the Forces health promotion program. This important program provides awareness and prevention education and skill development in areas such as suicide intervention, anger and stress management, healthy relationships, family violence, and addictions.

The education of CAF personnel and their families is not the sole responsibility of the CF H Svcs Gp and must therefore be well coordinated among all relevant CAF elements. R2MR is the foundational mental health education program, but harmonization and coordination of all mental health education and training is conducted by the Mental Health Education Advisory Committee, which is chaired by the Director of Mental Health. Members include representatives from all environments and training centres, the Chaplain branch, the Directorate of Military Family Services, the Directorate of Military Personnel Operational Research and Analysis, and Defence Research and Development Canada.

Care

Tactical-level clinical programs and services are delivered through 19 CF Health Services Centres and 16 Detachments at bases across Canada and in Europe. These Centres vary in size depending on the supported formation, base, wing, station or unit. The smallest clinics provide only psychosocial services, while the larger ones offer a variety of programs to meet all mental health needs of CAF members.

Mental health care is guided by evidence-based best practices and is delivered through multidisciplinary teams that include primary care clinicians, mental health nurses, psychiatrists, psychologists, social workers, occupational therapists, addictions counsellors and mental health chaplains. Current staff levels and the target of 447 established positions represents the highest ratio of providers to service members in NATO. In addition, there are over 2,000 civilian health care providers on the Blue Cross™ provider list who offer varying levels of care to our members across Canada.

The CF H Svcs Gp offers comprehensive treatment to CAF personnel, including unlimited psychotherapy and access to medication as required. When in-patient care is necessary, the CF H Svcs Gp has long-standing relationships with civilian health care facilities. Integration with the civilian health care system is essential to continuity of care for those referred to external providers, as well as to collaborate in shared research efforts.

As in the civilian community, a great deal of mental health care is delivered to CAF members by primary care clinicians. The CF H Svcs Gp is structured on a primary care delivery model in which all personnel receive care through a multidisciplinary health care team in a Care Delivery Unit (CDU). The CDU team works collaboratively with patients to assess their needs and to provide and coordinate care in support of complete wellness. In many cases, the first point of contact for CAF personnel who are experiencing mental health difficulties is their primary care team, which will either provide the required assistance or refer the member to the most appropriate care provider.

CAF personnel undergoing periodic health assessments and deployment-related medical screenings in primary care are also routinely asked questions pertaining to operational stress reactions, depression, addictions, suicide and other mental health conditions. These routine screening questions support the earliest possible identification of emerging concerns, while providing an opportunity for all CAF members to have a discussion with their care provider about mental health and well-being.

Psychosocial Services

Psychosocial Services provide first-line mental health care that CAF members may access directly without a physician’s referral. They are closely integrated with the CDU. Services include individual, couple, and family counselling to military personnel and their families; crisis management; addictions awareness; administrative support for processes such as compassionate and contingency cost moves; and deployment-related screenings. They are available at all CF Health Services Centres.

Mental Health Services

Mental Health Services are specialized services structured to provide multidisciplinary, evidence-based care, and require a referral from a physician. These secondary programs are provided by larger centres with regional support responsibilities. Delivery of mental health services is organized around a grouping of programs:

• General Mental Health Program: The General Mental Health Program provides assessment and individual and group treatment for those suffering from mental illnesses, such as depression, anxiety or PTSD, that are not attributable to deployed operations.
• Addictions Treatment Program: The Addictions Treatment Program provides assessment and treatment of individuals experiencing dependence or problem usage with alcohol, drugs or other compulsive behaviours. If in-patient treatment is required, it is provided by community resources external to CF H Svcs Gp. Service members are offered a one-year follow-up after treatment. Wherever addictions treatment services are not available within the CF H Svcs Gp, CAF members are referred to the appropriate civilian resource.

Dr. Fiona McGregor, Past President of the Canadian Psychiatric Association (CPA) stated: “The CAF is right to take pride in its mental health program which has been recognized by its NATO allies and civilian organizations.”

Operational Trauma and Stress Support Centres

Operational Trauma and Stress Support Centre (OTSSC) programs are specialized mental health services with regional support responsibilities that ensure comprehensive and consistent assessment and treatment of patients with operational stress injuries using evidence-based best practices. The seven OTSSCs are located in Edmonton, Esquimalt, Gagetown, Halifax, Ottawa, Petawawa and Valcartier. They also conduct educational outreach and research in addition to their primary mandate for assessment and treatment.

After attending an American Psychiatric Association conference, Senator Romeo Dallaire, Chair of the Senate Committee on Veterans Affairs, noted that: “… Canada’s program on operational stress injury was held as the example to be applied in the United States and, they hope, in other countries.”

In addition to in-garrison mental health care, each deployment is provided mental health support ranging from a medic and a General Duty Military Officer, to a mental health specialist team. CAF members have the opportunity to consult with mental health clinicians in-theatre as well as during the transition from the theatre of operations to home. Members deployed to high-stress operations longer than 90 days participate in a Third Location Decompression (TLD) program, where they are encouraged to speak to a mental health professional and raise any concerns they may have. All CAF personnel returning from international operations of 60 or more days undergo the Enhanced Post-Deployment Screening (EPDS) process between three and six months after their return to Canada. This screening tool assists us in highlighting any difficulties returning members may have with mental health or simply with adjusting to life in garrison and within their family unit. It also assists us in connecting them with the appropriate resources. The chain of command plays a critical role in this process by ensuring that all deployed personnel complete their EPDS, in order to support an early identification of reintegration challenges and mental health issues.

Individuals are continually encouraged to seek help throughout the deployment cycle. One half of those who require mental health follow-up have already sought some level of care on their own by the time they complete the EPDS. In order to further reduce barriers to care, referrals can be made directly from theatre or TLD to the member’s local CF Health Services Centre in order to ensure a smooth transition and continuity of care.

Coping with psychosocial and mental health problems can be challenging for CAF members and their families for many reasons and in many ways. CF H Svcs Gp does not have the mandate to provide care directly to family members of CAF personnel. It is recognized, however, that families play a crucial role in a member’s mental health. We can therefore provide mental health services to families when it is a necessary component of the member’s treatment or care. The mental health system provides member-focused family care because there is considerable evidence and professional consensus that family involvement in the treatment process can improve outcomes.

Two successive presidents of the Canadian Psychiatric Association were hosted in November 2012 at Petawawa Health Services Centre by mental health staff. “We were very pleased to have the opportunity to experience the realities of the Canadian Armed Forces and its medical system. Both myself and past-president, Dr. Fiona McGregor, were impressed with what we saw.” said Dr. Suzane Renaud, President of the CPA. “We recognize the sacrifices that soldiers make and are pleased to see a comprehensive mental health system in place to support them. In particular, the CAF mental health system offers a truly interdisciplinary approach to care with mental health practitioners, such as primary care clinicians, psychiatrists, social workers, mental health nurses, addictions counsellors and chaplains, working as a team to treat patients. As well, the CF H Svcs Gp’s electronic records system and its accredited status through Accreditation Canada are truly impressive.”