Hidden Battles

A systemic investigation into the identification of mental health needs and support for Primary Reserve members participating in domestic operations

Mandate

The Office of the Department of National Defence and Canadian Armed Forces Ombudsman was created in 1998 by Order-in-Council to improve transparency in the Department of National Defence and the Canadian Armed Forces, as well as to ensure the fair treatment of concerns raised by the Defence community and their families.

The Office is a direct source of information, referral, and education for the members of the Defence community. Its role is to help individuals access existing channels of assistance or redress when they have a complaint or concern. The Office is also responsible for reviewing and investigating complaints from constituents who believe they have been treated unfairly by the Department of National Defence or the Canadian Armed Forces. In addition, the Ombudsman may investigate and report publicly on matters affecting the welfare of Canadian Armed Forces members, Department of National Defence employees, and others falling within their jurisdiction. The ultimate goal is to contribute to substantial and long-lasting improvements to the Defence community.

Any of the following people may bring a complaint to the Ombudsman when the matter is directly related to the Department of National Defence or the Canadian Armed Forces:

• A current or former member of the Canadian Armed Forces
• A current or former member of the Cadets
• A current or former employee of the Department of National Defence
• A current or former Non-Public Fund employee
• A person applying to become a member of the Canadian Armed Forces
• A member of the immediate family of any of the above-mentioned
• An individual on an exchange or secondment with the Canadian Armed Forces

The Ombudsman is independent of the military Chain of Command and senior civilian management and reports directly to the Minister of National Defence.

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Abbreviation guide

AAG

Arrival Assistance Group

CAF

Canadian Armed Forces

CA

Canadian Army

CFHS

Canadian Forces Health Services

CFMAP

Canadian Forces Members Assistance Program

CJOC

Canadian Joint Operations Command

DAG

Departure Assistance Group

DAGPWD

Defence Advisory Group for Persons with Disabilities

DAOD

Defence Administrative Orders and Directives

DIAG

Defence Indigenous Advisory Group

D Med Pol

Director Medical Policy

DMH

Director of Mental Health

DND

Department of National Defence

DTPAO

Defence Team Pride Advisory Organization

DWAO

Defence Women’s Advisory Organization

EPDS

Enhanced Post-Deployment Screening

GBA Plus

Gender Based Analysis Plus

MRQ

Medical Readiness Questionnaire

PHA

Periodic Health Assessment

PRV

Personnel Readiness Verification

R2MR

Road to Mental Readiness

RCAF

Royal Canadian Air Force

RCN

Royal Canadian Navy

VAC

Veterans Affairs Canada

2SLGBTQI+

Two-Spirit, Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Plus

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Executive summary

The goal of this investigation was to determine how the Department of National Defence and the Canadian Armed Forces (DND/CAF) treated Primary Reserve members comparatively to Regular Force members in the identification of their mental health needs and provision of mental health support before, during, and after domestic operations.^{Footnote 1} Domestic operations are conducted in Canada to support matters such as fires, floods, rescues, and the COVID-19 global pandemic.

Context

"The increasing regularity and intensity of natural disasters, combined with limited provincial and territorial investment in disaster and emergency management resources"^{Footnote 2} means that the CAF’s 28,500 Primary Reserve members^{Footnote 3} will most likely continue to be called to respond to domestic disasters.

While the effects of international operations on members’ mental health have been documented, the effects of domestic operations remain largely unexplored. The CAF provided support to long-term care facilities in Ontario and Québec during the COVID-19 global pandemic through Operation LASER. However, the DND/CAF recognized that this operation had traumatic events that may have caused moral injuries to CAF members.^{Footnote 4} The DND/CAF has also recognized the importance of mental health as a factor in overall health.^{Footnote 5} During our investigation, we heard leaders’ and DND/CAF authorities’ desire to improve the well-being of all CAF members participating in domestic operations, including Primary Reserve members.

Our office has been investigating issues related to the health and wellness of Reserve Force members since 2015.^{Footnote 6} These reports identified gaps related to unclear health care policies and lack of communication for Reserve Force members. However, most recommendations from our office related to the health and wellness of Reserve Force members have yet to be fully implemented.

Findings

This investigation found several inconsistencies and a lack of oversight of processes related to mental health needs identification and access to mental health support. These contributed to the challenges and barriers that Primary Reserve members face in accessing those supports before, during and after domestic operations.

Cultural challenges still exist for Primary Reserve members to fully integrate into the Canadian Armed Forces. There is also a belief within the CAF that domestic operations have lesser impacts on a member’s mental health in comparison to international deployments.^{Footnote 7} These biases, a lack of CAF health care resources, and the often-short lead times to deploy have resulted in leadership waiving certain parts of screenings and assessments before a domestic operation.  

The limitation in the access to CAF mental health care caused by the class of Reserve Service employment occurs before and after a domestic operation. During those two periods, Primary Reserve members may work part-time (Class "A” or "B") and have provincial/territorial health care coverage. However, if their illness or injury was caused or aggravated by the performance of military duty, they are entitled to be evaluated by the CAF to ensure their immediate health care needs are met. Regular Force members have Canadian Forces Health Services (CFHS) coverage and do not need to prove this to access support.^{Footnote 8}

Impact: Without a consistent approach to the identification of mental health needs, domestic operations may take place with Primary Reserve members whose operational readiness has not been assessed. Without a pre-deployment assessment, it is challenging for Primary Reserve members to prove that an ongoing mental health need was caused or aggravated by the performance of duty. As a result, Primary Reserve members entitled to benefits may be denied access. For example, Veterans Affairs Canada (VAC) programs and services may be denied due to the absence of supporting medical and administrative documentation linking the mental health need to the domestic operation.

Impact: When mental health needs remain untreated, members’ overall well-being in areas, such as work, family, social, and financial are affected. This may lead to self-medication, substance abuse or addiction. Due to class of service changes, Primary Reserve members alternate between the CAF and provincial/territorial health care systems, which impacts their continuity of care. This also negatively impacts the CAF’s readiness to respond Canada’s needs. Additionally, many Primary Reserve members, the majority from the Canadian Army Reserves, cannot access the CAF mental health supports that are available to them due to the geographic distance from their local Reserve Force unit.

Impact: Primary Reserve members entitled to mental health supports may not be able to access them. The Primary Reserve members, leadership and some mental health care provider’s lack of awareness of Primary Reserves' entitlements means they are less equipped to support members in times of need. We found that some Primary Reserve members were turned away when trying to book an appointment to be assessed and this resulted in a loss of confidence in the CAF. Primary Reserve members who are denied access to CAF mental health supports, may not have the means to access supports external to the CAF. This could lead to self-medication or not being able to access support until they reach a crisis point. These Primary Reserve members would not benefit from the well documented advantages of early intervention.

Impact: Barriers such as CAF culture, being a Reserve Force member and being equity-deserving group members impede the identification of mental health needs and access to mental health support. Care providers may not understand or relate to the experiences of equity-deserving groups members when offering mental health assessments and may be unable to accommodate their needs and provide culturally appropriate treatment. If mental health needs of members are not assessed and treated properly, it will have a negative impact on their performance. If these members feel unsupported by the CAF, retention may also be impacted jeopardizing the CAF’s support to Canadians in times of crisis at home.

To address these findings and improve the CAF’s operational readiness and performance in domestic operations, this office makes six recommendations:

These recommendations, if implemented, would contribute to the CAF’s efforts to meet the members’ mental health needs, to contribute to retention, and to continue supporting Canadians during domestic emergencies.

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Section I: Introduction

The goal of this investigation was to determine how the DND/CAF treated Primary Reserve members comparatively to Regular Force members in the identification of their mental health needs and provision of mental health support before, during, and after domestic operations. Domestic operations are conducted in Canada to support matters such as fires, floods, rescues and the COVID-19 global pandemic.

The effect of domestic operations, compared to the effects of international operations, on members’ mental health remains largely unexplored. The presumption that only participation in international operations may negatively impact mental health and cause operational stress injuries or morale injuries is a bias. All Canadian Armed Forces (CAF) members can experience mental health injuries related to any type of service, including international and domestic operations, and trauma experienced during training. Due to the nature of their physical and social environments, CAF members are at risk of developing mental health challenges, which can include exposure to trauma/traumatic events during combat and non-combat operations.^{Footnote 10}

For example, in the spring of 2020, CAF members were deployed on Operation LASER to support long-term care facilities in Ontario and Québec. During this domestic operation, they helped vulnerable people in the context of a new, and highly contagious disease. The CAF has recognized that these traumatic events may have caused moral injuries.^{Footnote 11} In this specific instance, newly recruited Primary Reserve members were particularly affected. 

“The young reserve [members] were not emotionally ready for this kind of operation. They were told they would manage road control, but then they were suddenly brought to Montreal to help out [with] the long-term care homes. They worked with people who died [and] they were not prepared for that—they were not even soldier trained … They had to do things that would be very hard for anyone, and they were not prepared. The Chains of Command were not even conscious of this.”—Leadership

Our office also examined health needs concerning Primary Reserve members in three previous reports,^{Footnote 12} which came to similar conclusions: Primary Reserve members may be disadvantaged or may have an increased risk of undetected and untreated mental health needs. Our office’s recommendations related to these systemic issues have yet to be fully implemented.

Furthermore, our office continues to receive individual complaints from members suffering from mental health concerns. These member have faced inconsistent institutional support and guidance, notably from their home unit’s Chain of Command.^{Footnote 13} During our constituent engagements, members raised concerns about difficulty accessing mental health support.^{Footnote 14} Additionally, some CAF leaders felt that they did not have the tools to support members under their command who were struggling with mental health or with managing their own mental health needs.^{Footnote 15} Some leaders were aware that they could engage with CFHS for information in order to support their members, however, others did not know where to go for assistance.

Consequently, in May 2022, the Ombudsman launched a systemic investigation on domestic operations that occurred between 1 April 2017 and 31 March 2022. During the period covered in the scope of this investigation 6,124 Primary Reserve members were deployed in domestic operations across Canada.^{Footnote 16}

The DND/CAF authorities and members we consulted as part of our investigation demonstrated excellent cooperation and professionalism. They also demonstrated their commitment to improving the process of mental health identification and access to mental health support for members on domestic operations.

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Section II: Context

"The Primary Reserve […] consists of predominately part-time professional CAF members, located throughout Canada, who respond with appropriate notice to conduct or contribute to CAF defence and security objectives domestically, on the continent, and internationally."¹⁷ Due to climate change, Primary Reserve members’ participation will likely continue to increase.¹⁸ Evidence from the Standing Committee on National Defence has shown that "the Canadian Armed Forces' involvement in response to natural disasters has broadly doubled every five years since 2010. This does not include the 118 requests for assistance received by the Canadian Armed Forces in response to the pandemic."¹⁹

Primary Reserve members typically perform military duties one night per week and one weekend per month, in addition to their civilian employment or studies. These members are known as Primary Reserve members on Class "A" Reserve Service. Most of Primary Reserve Force members "are employed with designated Reserve units in the Canadian Army (CA), however, there are Royal Canadian Navy (RCN), Royal Canadian Air Force (RCAF), and Special Operations Reserve Force members and units as well."²¹

When Primary Reserve members volunteer to participate in domestic operations, the CAF employs them full-time (generally on Class "C" Reserve Service) along with Regular Force members. When the domestic operation ends, Primary Reserve members return to their Reserve home units and generally revert to part-time reserve service and resume their civilian employment or studies.

Eligibility to health care

Most Primary Reserve members work on short-term periods of service (Class "A" or Class "B" – 180 days or less) for the CAF before and after a domestic operation. As a result, their mental health care coverage falls under the provincial/territorial health care systems.^{Footnote 22} If their illness or injuries are attributable to, or aggravated by the performance of duty, they are entitled to care with Canadian Forces Health Services (CFHS), which is the CAF health care system. If the injury or illness is not related to or aggravated by service, for example a chronic medical condition, the member will receive a health assessment until they can be safely transferred to their provincial/territorial primary care physician. The member will then follow-up with their provincial/territorial primary care physician if they have one.^{Footnote 23}

When Primary Reserve members work on full-time periods of service (Class "B" – over 180 days or Class "C") for the CAF, which may occur during a domestic operation, their health care is provided by CFHS.^{Footnote 24}

Graphic 1: Primary Reserve class of service eligibility to CFHS mental health support before, during, and after a domestic operation^{Footnote 25}

Mental health needs can emerge from a single or a combination of various factors and incidents that happened before, during and/or after a domestic operation. Mental health needs do not discriminate. The World Health Organization website notes that "Most people do not develop a mental health condition despite exposure to a risk factor and many people with no known risk factor still develop a mental health condition."^{Footnote 26}

Since eligibility for mental health support overlaps between two different providers (provincial/territorial and CAF) depending on the Primary Reserve members’ periods of reserve employment, it can create significant challenges in the identification of mental health needs and access to the necessary care.

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Section III: Observation

CFHS is experiencing resourcing shortages, which mirror the challenges faced by provincial/territorial health care systems.

According to the 'Wait times for CAF mental health care' posted on the "Get help with mental health in the CAF" page, members are informed to expect between one hour and four weeks for some of the CAF’s mental health services.^{Footnote 27} However, some of the CAF medical clinics experience much longer wait times.^{Footnote 28}

Graphic 2: Experienced wait times for mental health assessments at CAF clinics from 2018 to 2022^{Footnote 29}

Many interviewed participants explained that CFHS is in a better position than the provincial/territorial health care systems to understand the military context impacting their mental health and potential attribution to service.

The shortage of health care resources has a great impact on the identification of mental health needs and access to mental health support for Primary Reserve members. The Surgeon General noted that due to personnel shortages CFHS have chosen to prioritize Regular Force members over Primary Reserve members in conducting Periodic Health Assessments (PHAs) because Regular Force members are not covered under the provincial/territorial health insurance.

The personnel shortages and lengthy delays have left Primary Reserve members interviewed with the impression that they were forgotten, their issues were not important, and—unless they were in a life-threatening crisis—their needs would not be prioritized. CAF authorities and care providers indicated that the demand for mental health services has increased, however personnel resources have not.

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Section IV: Findings

This section presents the investigation’s findings, supporting evidence, as well as their impact on Primary Reserve members and Canadians.

Identification of mental health needs

The CAF has several processes to identify mental health needs before, during and after domestic operations.^{Footnote 30} These processes include medical screenings and assessments, which take place at various points in the members’ careers. Refer to Appendix IV: CAF tools to identify mental health needs for more details. However, our investigation found inconsistent approaches to these processes before, during and after a domestic operation, which created additional challenges for Primary Reserve members. Numerous processes are available for members to self-identify their mental health needs; however, the onus is on members to be aware of and to identify their needs to access these processes.

Screening processes used to identify mental health needs

The CAF developed screening and assessment processes to follow before, during and after a domestic operation. 

Before a domestic operation: CFHS follows the Defence Administrative Orders and Directives (DAOD) 5009-0, Personnel Readiness. Canadian Joint Operations Command (CJOC) will establish mission specific requirements that are above and beyond those established by Military Personnel Command in DAOD 5009 series. 

The medical screenings or assessments that the CAF usually carries out to identify mental health needs before a domestic deployment are:

• PRV (Personnel Readiness Verification) or DAG (Departure Assistance Group)
  • PHA (Periodic Health Assessment)
  • MRQ (Medical Readiness Questionnaire)

During a domestic operation: At the discretion of the Commander of the Regional Joint Task Force, a letter can be sent to the member’s home unit, informing the Commanding Officer of the exposure to potentially traumatic events and recommending follow up with the member.^{Footnote 31} Of note, the letter does not specify how Commanding Officers should follow-up with members, what to watch for and the right of all members for a CFHS assessment if they believe their health issue is caused or aggravated by the performance of duty.

As the operation comes to an end, members must complete a Post-Deployment Health Questionnaire and Declaration in the presence of a Medical Provider to identify and treat any injuries associated with deployments. Refer to Appendix V: Post-Deployment Health Questionnaire and Declaration.^{Footnote 32} This questionnaire offers the opportunity to raise immediate health concerns; however, it does not offer guidance on symptoms to monitor after the deployment and when to seek help should mental health needs arise once a member returns home.

After a domestic operation, on occasion, an Arrival Assistance Group (AAG) is completed. An AAG is the team assembled to receive incoming members, process their initial paperwork, and prepare them for re-deployment. However, for domestic operations, unlike international operations, no enhanced post-deployment screening is mandated even though screening is directed.^{Footnote 33}

Before, during and after domestic operations—self-assessments. Primary Reserve members can self-identify their mental health needs before, during and after a domestic operation.

Members interviewed mentioned that the Mental Health Continuum Model is effective for self-assessments. Leadership and peers can also use this to help identify and monitor behavioral changes in others.

Graphic 3: Mental Health Continuum

The Mental Health Continuum Model was originally created by the DND and refined through the collaboration with the Calgary Police Service and the Mental Health Commission of Canada.^{Footnote 34}

Primary Reserve members can also self-refer to a health care provider at the Psychosocial Program of their Base/Wing medical clinic^{Footnote 35} or disclose their mental health needs to their Chain of Command, a Chaplain, a peer, or a Sentinel.^{Footnote 36} Members can also contact the Canadian Forces Members Assistance Program (CFMAP) for short-term counselling, including sessions by telephone.^{Footnote 37}

In our questionnaires, most members felt confident approaching CFHS, followed by a Chaplain, and their Chain of Command to identify their mental health needs.

Inconsistent approach to follow processes to identify mental health needs

During a domestic operation, processes to identify mental health needs are identical for both Regular and Primary Reserve members. Any circumstances that result in temporary or permanent physical or psychological harm to a CAF member are to be appropriately reported and documented.^{Footnote 38} Members can also identify their needs with their Chain of Command, Chaplain, and CFHS.

Our investigation found that the most common inconsistencies in following processes occur before and after domestic operations. They are as follows:

• inconsistent use of processes to identify mental health needs;
• inconsistent communication to Primary Reserve members compared to Regular Force members regarding available processes;
• inconsistent self-identification of mental health needs for Primary Reserve members compared to Regular Forces members;
• inconsistent approach to notice mood and behaviour changes by Chain of Command, Chaplain, Sentinel, and peers; and
• inconsistent tracking of mental health assessments.

Inconsistent use of processes to identify mental health needs. Mental health assessments can be waived or are inconsistently applied due to urgent circumstances of a deployment or the unavailability of resources to complete them. For example, PHAs should be used prior to a domestic operation. However, as an interim measure until a PHA can be conducted, MRQs can be considered valid for one year. 

The Standing Operations Orders for Domestic Operations has a provision to make exceptions:

"Operational employment of Reserve Force personnel is normally restricted to those personnel who are verified as meeting the medical and fitness requirements for Class "C" Reserve Force Service. […] In exceptional and urgent circumstances however, the Commander CJOC may decide, in consideration of the risk involved, that the normal verification of medical need not be conducted prior to employment by submitting a waiver through their base Surgeon to CJOC Surgeon for review and recommendation to Commander CJOC."^{Footnote 39}

Usually, CAF authorities waive health assessments due to timing constraints (for example, emergency response to natural disasters). This has a particular impact on Primary Reserve members, who are often deployed for these types of domestic operations. According to CJOC,^{Footnote 40} delegated authorities within their Command make the determination to accept the risk of deploying members who have not completed the full PRV process; however, CJOC still requires a PHA or MRQ.^{Footnote 41} The reality seems to differ as interviewees reported that authorities did not always complete the medical screening process before a domestic operation.

"In the Primary Reserves I did a bunch of domestic operations and there was no screening"—CAF member

The second factor influencing inconsistency involves the availability of resources to conduct mental health assessments. Commanding Officers should conduct an annual PRV screening for their members, according to DAOD 5009-0, Personnel Readiness.^{Footnote 42} While this includes a health assessment, a caveat exists for Primary Reservists: "[Primary Reserve] members on Class "A" Reserve Service may be required to complete medical and dental checklist items if opportunity and resources are available.^{Footnote 43} Specifically to medical readiness for domestic operations, health assessments (PHAs or MRQs) will normally be used by the CAF as members change to Class "C" periods of reserve employment. During interviews, nearly half of participants felt that the existing processes for Primary Reserve members to self-identify were ineffective for reasons such as:

• CFHS’s heavy reliance on members to be aware of and disclose their mental health needs;
• Primary Reserve members using the provincial/territorial health care systems as they have less awareness of available CAF processes;
• eligibility to receive mental health support from the CAF depends on class of reserve service and if the illness or injury is attributable to or aggravated by the performance of duty;
• inconsistent application of waiver and health screening by CAF authorities; and
• limited CAF mental health services due to the increases in demand, shortages of mental health workers in Canada, and long wait times.

Graphic 4: Reported effectiveness of CAF identification tools

Inconsistent communication to Primary Reserve members compared to Regular Force members regarding available processes and supports. CAF's approach to communicate information about existing processes is inconsistent, and the availability of information is limited. The CAF intranet is the primary communication tool for members to learn about mental health supports; however, not all Reserve Force members have access to it.

Inconsistent self-identification of mental health needs comparing Primary Reserve and Regular Forces members. The CAF has made efforts and progress to raise awareness about the importance of mental health with the Road to Mental Readiness (R2MR) and the Mental Health Continuum Model. Primary Reserve members interviewed noted a hesitation to self-identify because they feared the CAF may deny them future reserve employment. Additionally Primary Reserve members serving on a part-time basis are less exposed to the tools available to them than Regular Force members and their ability to self-assess and recognize that they have a mental health need may not come as easily or confidently. Finally, our interviews found that tight training schedules and no decompression time may prevent Primary Reserve members from self-identifying mental health needs.

Graphic 5: Reported effectiveness of self-identification tools

Inconsistent approach to notice mood and behaviour changes by Chain of Command, Chaplain, Sentinel and Peers.

The inconsistent approach to notice mood and behavioural changes emerges mainly from the fact that many Primary Reserve members work part-time before and after domestic operations.

The CAF relies on leadership, and peers to assist with monitoring and identifying behavioral changes in others. Chaplains are trained to observe, detect, support, and refer personnel to mental health resources. Sentinels can also offer these services.^{Footnote 44} If a member exhibits atypical behaviour, others may notice, and either approach the individual to provide support or report it to the Chain of Command or CFHS.^{Footnote 45} This approach is more effective for Regular Force members than Primary Reserve members because they have daily contact with their Chain of Command and their peers. Primary Reserve members, working part-time for the CAF before and after domestic operations, have more infrequent interactions.

Moreover, neither CJOC nor CFHS track Primary Reserve members after a domestic deployment, increasing the difficulty to conduct follow-ups as members are dispersed across Canada. Commanding Officers are responsible for the well-being of those under their command. Regular Force members do not require rigorous tracking because they are indirectly monitored by daily interactions with their Chain of Command and peers.

These individuals are more likely to notice when a Regular Force member has mood or behavioural changes. After a domestic deployment, many Primary Reserve members are on a part-time schedule and do not interact with their Chain of Command and peers daily. This creates difficulties in noticing when someone is not doing well and can result in a higher likelihood that the member’s mental health needs would go unnoticed or underreported. This also highlights the importance of leadership proactively sharing information on mental health resources. Unfortunately, an ongoing mental health need can manifest much later after deployment and may not be identified.^{Footnote 46}

"Most mental health issues appear months, years after the operation. Regular Force members have direct access to CAF systems. For Reserve Force members it is more complicated. They may not be fully aware of resources still available to them." - CJOC authority

Inconsistent tracking of mental health assessments. Our investigation found that approximately 65% of members did not receive a medical screening related to their most recent domestic operation. However, almost half of the participants indicated that they completed their last medical screening within the previous year. Of this group, 38% were Primary Reserve members, and 62% were Regular Force members.

Graphic 6: Members' completed health assessment related to their latest domestic operation

CFHS noted that many reporting systems^{Footnote 47} store information from these assessments; this makes it difficult to track and maintain oversight on the type of medical screening tools used when screening members for domestic operations. The member is responsible for ensuring that their PHA is up to date because the reporting systems do not flag when a health assessment is due. This can result in a greater risk for a member to be overlooked.

As noted above, towards the end of a domestic operation, CJOC orders state that members must complete the Post-Deployment Health Questionnaire and Declaration. However, many members and leadership interviewed noted inconsistencies in the completion of the questionnaire.

Additionally, various individuals within health services authorities (Surgeon General, Director Medical Policy, and Director Health Services Reserves) confirmed through interviews that there is no Lessons Learned framework related to the process of mental health identification or access to mental health supports. A CFHS authority reported that they undergo a continuous review cycle in terms of processes and Standard Operating Procedures. Medical care providers interviewed stated that they informally review processes and track some statistics at the local level related to members seeking support. However, there is no standardized approach for monitoring or reporting to policy holders.

The Director of Mental Health (DMH) reported that they have informal Lessons Learned with respect to suicide and, a large Lessons Learned project on mental health care delivery efficiency was initiated in 2021. This project aims to examine medical access for the Regular and the Reserve Forces, wait times, efficiency of care delivery, the length of consultations by clinicians, inter-disciplinary practices, and the functional relationship between care teams and specialists. The purpose of the project is to determine areas of improvement while aligning with the CFHS person-partnered care approach.^{Footnote 48}  DMH did not confirm a completion date.

In conclusion, although the same screening processes exist to identify mental health needs, Primary Reserve members are disadvantaged when compared to Regular Force members.

Access to mental health supports

Several mental health supports are available to Primary Reserve members before, during, and after a domestic operation. Some of these supports include those provided directly by CFHS at medical clinics and those provided outside of CFHS. Refer to Appendix VI - Mental Health Resources for CAF Members. However, access to these supports is either limited or presents some challenges that make it difficult for the CAF to fully support Primary Reserve members in their mental health well-being.

Mental health supports available before, during, and after a domestic operation

• Within CFHS, the first line of mental health care that members can utilize without the need of a physician’s referral is through Psychosocial Services available at all 33 medical clinics across the country.^{Footnote 49} The secondary line of mental health care within CFHS is available through Mental Health Services which are specialized services that provide multidisciplinary and evidence-based care and require a referral from a physician.^{Footnote 50} Mental health services are offered at 28 out of 33 medical clinics across the country, typically co-located with Bases/Wings.^{Footnote 51}
• All interviewees identified several options outside CFHS where members can seek mental health support. These supports include Chaplain Services, Sentinel Program/peer support, engagement with the member’s Chain of Command, CFMAP, Family Information Line^{Footnote 52}, R2MR training, CAF Mobile Application, and provincial/territorial medical care.^{Footnote 53} While the R2MR training is not mandatory for domestic operations, CJOC and CFHS make the decision to provide it to members on a mission-specific basis.^{Footnote 54}

Inconsistent access to mental health supports

While several mental health supports are available to CAF members, Primary Reserve members face inconsistencies when accessing them.

Lack of clarity on how service attribution is determined can impact a member’s access to mental health services. Most of the supports listed above are accessible to both Regular Force and Primary Reserve members, although eligibility can vary based on the class of reserve employment and service attribution. However, determining service attribution is not always clear to Primary Reserve members and their leadership. D Med Pol indicates that determining service attribution is a case-by-case individualized assessment that can sometimes be straightforward, but other times it may not be.

"There can definitely be more challenging spaces when you get into medical diagnosis or mental health diagnosis that are not clearly linked to an event, so a depression, or anxiety, that often does need further assessment to determine all of the pieces and how that relates to service."—D Med Pol

CFMAP is one of the primary options for mental health support outside CFHS, which offers services for assessment and short-term telephone counselling sessions to both Regular and Reserve Forces. However, Primary Reserve members can only access this resource if their service in the CAF is directly linked to the situation or issue for which they are seeking assistance. This condition notwithstanding, all individuals may receive an initial assessment followed by an appropriate referral. It is incumbent of the CAF member to explain how the performance of their military duty relates to their condition. Despite this, our investigation found that, some Primary Reserve members and care providers believed that Primary Reserve members had no access to CFMAP.^{Footnote 55}

Class of Service changes create challenges for uninterrupted mental health care. Primary Reserve members are at a particular disadvantage as their class of service and eligibility for CFHS support changes before, during and after a domestic operation, and they may have an interruption in mental health care.

Health care providers interviewed noted that Primary Reserve members may need multiple referrals to mental health services as they change class of service. While on deployment, they receive mental health care through the CFHS. However, when the deployment ends, they are referred to a provincial/territorial health care system, which can impact the member’s continuity of care. This also makes it more difficult for medical professionals to recognize or treat issues that were caused or aggravated by the performance of duty. In addition, provincial/territorial medical professionals may not be familiar with the military lifestyle, which may be a barrier in receiving adequate support.^{Footnote 56}

Additionally, the provincial/territorial medical systems do not share information with the CAF medical system. This makes it difficult for CFHS to track a Primary Reserve member’s medical history. Members can request copies of their medical records and provide consent to share their provincial/territorial medical information. However, regardless of a member’s consent, CFMAP cannot share information with CFHS or anyone else; it is intended to be fully confidential.

In conclusion, although different mental health supports are available, Primary Reserve members face additional challenges when their access to support relies on service attribution and when their access is interrupted when navigating between unintegrated medical systems.

Awareness

The CAF uses various means to communicate information on mental health supports; however, the information communicated is not tailored to Primary Reserve members. This creates varying levels of awareness of the mental health supports and recourse mechanisms that Primary Reserve members can use.

The CAF’s approach to communication with members on mental health supports and recourse mechanisms

CAF mental health supports are communicated through various means, including:

• posters and promotional items
• training and briefings
• routine orders
• e-mails
• CAF intranet
• Defence Team – Mental health and wellness webpage
• mobile applications, and
• by word of mouth (through peers, Chaplain Services, Chain of Command, CFHS)

Although resources are available on some CAF webpages and the CAF Mobile Application, the content is not tailored for Primary Reserve members. The CAF intranet is the main communication tool for members to learn about mental health supports. However, many Primary Reserve members, have infrequent or no access to the CAF intranet. Primary Reserve Force members depend more on information communicated by their local Reserve Force Unit, compared to Regular Force members who individually have more frequent and full access to the CAF intranet.

Some members interviewed mentioned a lack of a central, public-facing, registry accessible to all members clearly listing all mental health support options. This makes it difficult for members and leadership to be fully aware of the supports available, particularly for Primary Reserve members. Of note, no interviewee identified the Military Benefits Browser ^{Footnote 57} as a potential resource for guidance on mental health supports. This resource and the CAF Mobile Application are the closest to centralized registries.

Additionally, Military Family Services staff indicated that "awareness of CFMAP and their services was incredibly low." Significantly more Regular Force members interviewed were aware of the CFMAP program compared to Primary Reserve members. This inconsistent level of awareness by Primary Reserve members may impact their ability or willingness to seek assistance for their mental health needs.

Several DND/CAF authorities interviewed confirmed that continuous communication and education is important for members to find mental health support. Medical care providers, on the other hand, noted they rely heavily on the Chain of Command to communicate information regarding those supports to members. Our investigation found that while the Chain of Command has a responsibility to provide mental health guidance and support, some leaders reported they did not feel adequately equipped to support the mental health needs of members.

Lack of information on the CAF’s main recourse mechanisms for mental health services. The CAF’s main recourse mechanisms for mental health services concerns are through the Medical Services Unit Complaint Process and the military redress of grievance process.

Medical Services Unit complaint process

The first line of contact for a health services complaint is at the local level. Members may engage directly with their CAF medical care provider or request a second opinion. "Regarding clinical concerns, health-care providers have a professional duty to seek a second opinion when requested, and resolution should always be at the lowest level, with the member working with the clinical team, Quality/Patient Safety Officer, and Base/Wing surgeon for resolution."^{Footnote 58} Some Medical Service Units use the Patient Care Feedback Tool as the first recourse and a Patient Family Advisory Committee for continuous improvement.

CAF members can submit complaints to the clinic by e-mail, feedback boxes, or a primary care nurse. The clinic forwards the complaint to the Base/Wing Surgeon. The Base/Wing Surgeon assigns the case to a Medical Officer who reviews the complaint and drafts a report. The Base/Wing Surgeon writes a decision letter based on the report and includes findings and recommendations to the patient. Updates to this process are currently under development.^{Footnote 59}

Military Redress of Grievance process

The Queen’s Regulations & Orders, Chapter 7 – Grievances stipulates that an officer or non-commissioned member may submit a grievance where they have been aggrieved by an administrative decision, act, or omission and where no other process for redress exists. The Initial Authority must consider and determine the grievance within four months of its submission. The grievance could then be escalated to the Final Authority, for which the Regulations do not include a service standard for a decision.^{Footnote 60}

Other avenues interviewees identified are the Chain of Command, Chaplains, the Department of National Defence (DND)/CAF Ombudsman, regulatory bodies for professional care providers^{Footnote 61} and letters to members of Parliament.

According to CFHS, the lowest level and most direct recourse mechanism is the Medical Services Unit Complaint Process. However, we found a lack of communication from the CAF about these recourse mechanisms. Neither the CAF intranet nor the CAF internet pages have any guidance on how to file a complaint if members encounter concerns with their mental health services. From our questionnaire, 59% of leaders were unaware of the recourse mechanisms available. The lack of information on recourse mechanisms directly impacts the level of awareness, and members are less likely to file a complaint and have their issue addressed. 

Different levels of awareness of Primary Reserve members' eligibility to mental health supports among all groups

Receiving reliable information on the availability of mental health supports and eligibility to access those supports can help improve Primary Reserve members' mental health.

CAF authorities and care providers interviewed had the greatest awareness of mental health supports in general, and how to access them, compared to members and leadership. This awareness is mostly a result of their direct access to subject matter experts (such as policy holders and medical professionals). However, this suggests that members and more junior leaders may be disadvantaged as they do not have the same direct access to experts and have less experience and exposure to those supports.

Results from our questionnaire show that leadership were more aware of how Regular Force members could access mental health supports than they were for Primary Reserve members.

Graphic 7: Leadership awareness of accessibility of mental health supports for Primary Reserve members and Regular Force members

Leadership, clinic administrative staff, and care providers have limited awareness of Primary Reserve members' eligibility to mental health supports, before and after a domestic operation. Some Primary Reserve members interviewed reported that the CFHS turned them away in times of crisis because some administrative staff and care providers did not fully understand their entitlements to care.

Both CAF authorities and members interviewed had better overall awareness and understanding of the class of reserve service limitations related to the eligibility to mental health supports. However, some leadership, clinic administrative staff, and care providers were unsure about what mental health supports Primary Reserve members were eligible to receive.

Graphic 8: Leadership awareness of eligibility of mental health supports for Primary Reserve members and Regular Force members

Overall, there was a greater awareness of Regular Force members' eligibility for mental health supports by these groups compared to Primary Reserve members' eligibility to those same services.^{Footnote 63} This level of unawareness or uncertainty can lead to the misapplication of policies. Furthermore, a lack of awareness can compromise a leader’s ability to properly direct and guide Primary Reserve members who need mental health support. When Primary Reserve members are not able to receive the support they require, it can have a discouraging effect on their willingness to come forward about a mental health need.

A general lack of awareness exists on the main recourse mechanisms available for concerns related to CAF mental health services.

Graphic 9: Leaderships awareness of recourse mechanisms for mental health services concerns

Medical Services Unit complaint process

Most leaders and members interviewed were not aware of the Medical Services Unit complaint process. Even leaders who were aware (22% of those interviewed), reported facing challenges when engaging with CAF medical clinics. Among the few members who were aware of the process, they believed it to be lengthy and expressed little confidence in the use of those mechanisms.

"There is a local complaint box that is monitored, but it takes months to discuss what came up. You can also get a second opinion or a new provider which is easy to accommodate. But, there are no mechanisms if you are unhappy with the care in general."—CAF Member

Redress of grievance process

Leadership interviewed reported a lack of knowledge about the process to submit a redress of grievance related to medical complaints. Primary Reserve members who assist in submitting grievances do not work on these full-time and may have less expertise compared to Regular Force members. This creates inefficiencies and delays if the process is not followed correctly. Among the 44% of leaders who were aware of the redress of grievance process, some stated that the process was ineffective because it was lengthy and not appropriate to manage mental health complaints requiring immediate resolution.

Most medical care providers and CAF authorities interviewed were aware that a grievance could be submitted for concerns related to mental health decisions and only 33% of members indicated the same awareness.

In conclusion, while the CAF uses various means to communicate information on mental health supports, the information shared does not account for the reality that Primary Reserve members experience. Additionally, the inconsistent level of awareness by leaders and those who have a role to play in facilitating access to mental health supports suggests that the CAF must do more.

Barriers

Many barriers can preclude Primary Reserve members from identifying their mental health needs or accessing mental health supports, such as:

Results from our questionnaire showed that before a domestic operation, there were more Primary Reserve member participants who may have needed mental health support but did not request it, than those who requested support.

Graphic 10: Percentage of member participants who may have needed mental health support, but did not request it before, during, and after a domestic operation

The results from members who participated in our questionnaire show that before a domestic operation, 48% of members may have needed mental health support but did not request it. Of this group, 58% were Reserve Force members and 42% were Regular Force members. During a domestic operation, 53% of members may have needed mental health support but did not request it. Of this group 49% were Reserve Force members and 51% were Regular Force members. After a domestic operation, 37% of CAF member participants may have needed mental health support but did not request it. Of this group, 50% were Reserve Force members, and 50% were Regular Force members.

CAF cultural barrier

During our investigation, members identified CAF culture as the main barrier when identifying a mental health need or accessing mental health supports.^{Footnote 64} They also identified various forms of stigma (self-imposed, social, and structural), including:

• not wanting to be an administrative burden to their Chain of Command, unit, or peers;
• fear of being perceived as weak; and
• cultural influences or social perceptions of military culture and mental health.

Cultural challenges exist for Primary Reserve members to be fully integrated in the CAF.

A Commander noted that this mindset has contributed to the struggles that Reserve Force members face due to the nature of their component. It also causes Primary Reserve members to further self-stigmatize and deprioritize their mental health.

"Sometimes Primary Reserve members have [mental health] issues, and their problems are seen as less than [those of] Regular Force members."—Leadership

CAF cultural bias towards leadership supporting mental health also exists. CAF members interviewed noted a lack of support by some leaders, which prevented them from identifying mental health needs or access mental health supports. Some members who expressed the need for mental health support recounted being criticized in front of their peers, punished with tasks that were unsupportive of their ongoing mental health needs, and denied the ability to access mental health supports.

"I was centered out in public by supervisors in front of my peers because of the state that my mental health was in at the time … and I was essentially punished for it."—CAF member

Although all groups interviewed recognized that mental health stigma has improved over the years, it persists within the organisation.

"It's much better now, there's much less stigma than there was 10 or even 15 years ago, so I think we're improving in that regard, but we can’t ignore or deny the fact that there’s still stigma."—CA authority

Barriers to self-identification of mental health needs

Primary Reserve members, compared to Regular Force members, face more barriers to self-identify their mental health needs because of their part-time employment with the CAF and their civilian employment or studies. Examples provided during interviews included:

• They may have less time to go to a CAF clinic because of the tight Reserve Unit training schedule that needs to be balanced with their civilian job or school schedule.
• They may not want to justify or may be unable to receive time off from their civilian job or studies to get assessed at a CAF clinic.
• The pressures of meeting the Universality of Service requirements contributed to their hesitancy to identify mental health needs.^{Footnote 65} This hesitancy increases with Primary Reserve members because some of them may rely on Class "B" or "C" periods of employment for full-time employment or eligibility for deployments. Leadership added that the fear of losing employment or opportunities to work with the CAF can be intensified when the identification of a mental health need could also put the member’s civilian job at risk.

"When your employment is tied to your health, physical or mental, it's not unusual for people to try to hide it. People don't always disclose what they are going through."—JTF commander

Barriers to CAF identification of mental health needs

Two main barriers to CAF identification of mental health needs of Primary Reserve members arise: the bias towards the type of deployment and the lack of daily interaction with their Chain of Command before and after domestic operations.

Bias towards the type of deployment. A bias exists in the CAF, according to leadership and CAF authorities interviewed, that members need less mental health support because domestic operations are not perceived as being as traumatizing as international operations.

"Historically there hasn't been [a screening form] for domestic operations, because of the short-term nature of them and the nature of the deployment. Fires and floods typically aren't exposing folks to the same traumatizing events as overseas."—CFHS authority

The Surgeon General noted that the personnel resourcing challenges require CFHS to prioritize Regular Force members over Primary Reserve members in conducting Periodic Health Assessments (PHAs) because Regular Force members do not have access to provincial/territorial care. Some CAF authorities, care providers and leadership interviewed during our investigation also noted that some clinics, depending on their resources, have been conducting medical assessments based on priority, such as for deployments and promotions.

Note: Those in non-combat roles can develop a mental health needs as much as those in combat-roles.^{Footnote 66} The roles of first responders are also good examples where mental health needs or illness can emerge.^{Footnote 67} To get a deeper understanding of how the non-combat roles can affect mental health, refer to the case study in Appendix VII: Case study—Mental health impacts for first responders to non-combat humanitarian efforts.

Lack of interaction with Chain of Command and peers. A lack of daily interactions with their Chain of Command and peers before and after a domestic operation could also increase the risk of mental health needs of Primary Reserve members going unnoticed. During interviews, CAF authorities mentioned that the member's Chain of Command and peers are usually in the best position to notice when someone within their unit is not doing well. This is an effective approach for Regular Force members who work daily with their Chain of Command and peers. This is not always the case with Reserve Force units. A commander consulted during this investigation observed that the turnover of personnel at the unit especially after a deployment is high as Primary Reserve members rotate out regularly.

"Because of the way it works, the onus [is] on [the] person to say I have an issue, I have a problem, because we won't see that person enough to make that assessment ourselves."—JTF commander

Barriers to access mental health support

The main barriers to access mental health support emerge from the class of service limitation, geographical limitations, as well as the lack of awareness and understanding of the eligibility criteria by CAF members, leadership, and health care providers.

Class of service reserve employment limitation. The working status of Primary Reserve members, such as Class "A," Class "B" (180 days or less) and Class "B" (over 180 days), and Class "C," determines their eligibility to access CFHS.

When Primary Reserve members are deployed (Class "C") to a domestic operation or employed on Class “B” (over 180 days), they have the same access to CFHS mental health services as Regular Force members.^{Footnote 68}

When Primary Reserve members are with the CAF on Class "A" or Class "B" (180 days or less) periods of employment, they are not entitled to care with CFHS because they are covered under provincial/territorial health care systems. However, if their mental health need is caused or aggravated by the performance of duty (attribution to service), they can have access to CFHS mental health services. "[In 4090-02, Interim Guidance for the Delivery of Health Care to Reserve Force Personnel,] the Surgeon General has provided clear guidance on the delivery of healthcare to Reserve Force personnel, directing that any [Primary] Reserve Force member, who presents to a CAF Health Care Centre will be assessed, […], and if their injury is attributable to their service, care will be provided until such time that they can be safely transitioned to a civilian provider."^{Footnote 69}

However, compared to a physical injury, it is more challenging to prove that a mental health need has been caused or aggravated by the performance of duty without a pre- and post- deployment assessment. If a Primary Reserve member request an assessment, they can face a longer waiting period than Regular Force members. When members are employed on a part-time period of employment, they often concurrently hold civilian employment or attend schooling. This can restrict their ability to access CFHS supports during the weekday. As such, Primary Reserve members are less inclined to access CAF mental health services despite lengthier wait times for provincial/territorial supports.

Geographical limitations. Most Primary Reserve members of the RCN and the RCAF home units are co-located with a Base/Wing, whereas the CA units are more distributed and may not be co-located with a Base/Wing. There are over 200 CA Reserve Force units and sub-units.^{Footnote 70} As a result, it is likely that they would face significant travel distances to access mental health services. This may require time off from their civilian employment or studies and travel.

Graphic 11: Canadian Army Reserve Force unit locations and strength in proximity to CFHS clinics with mental health services^{Footnote 71}

"Geographically, I'm a little bit isolated from my unit and get forgotten. So, if I don't take charge of stuff, it doesn't happen."—CAF member

According to CAF authorities and care providers interviewed, one of the biggest barriers for accessing mental health support before or after a domestic operation is the location of the member's home unit—especially from the CA Reserve Units. After an operation, Primary Reserve members return to their home unit, and return to a Class "A" or "B" period of employment, making their access to mental health services more challenging. The Chief of Reserve Advisory Group confirmed that this was a barrier. Meanwhile, Regular Force members normally return to a Base/Wing where they are more likely to have continuous access to CAF mental health care.

Care providers revealed that the hours of operation of mental health services and in-person services is a barrier for Primary Reserve members as they typically coincide with hours of work for their civilian employment or studies.^{Footnote 72} There are few available resources after hours and on weekends, such as the duty Chaplain, a local civilian hospital or CFMAP.

The geographical location of many CA Reserve Units and the absence of virtual consultation capacity are barriers for Primary Reservists to access CAF mental health supports. 

Lack of awareness and understanding of eligibility criteria. As previously explained, we found in our investigation that CAF members, leaders and care providers have limited awareness of health care eligibility criteria of Primary Reserve members' accessing mental health support before and after a domestic operation.

Primary Reserve members, who work part-time before and after a domestic operation, rely on their Chain of Command to help them access mental health support. Without their guidance, Primary Reserve members may not access the necessary CAF health care support.

Additional barriers faced by primary reserve members from equity-deserving groups

When a member also belongs to an equity-deserving group, the previously detailed barriers that Primary Reserve members face when identifying mental health needs and accessing mental health supports increase.

The following table illustrates the CAF Employment Equity representation in Fiscal Year 2019–2020:^{Footnote 73}

CFHS has not adapted to the realities of equity-deserving group members. For example, the Defence Team Pride Advisory Organization (DTPAO) noted that members reported that the mental health staff's lack of knowledge of the realities of Two-Spirit, Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Plus (2SLGBTQI+) communities has generated harm, including judgments and discrimination, and has broken the trust between the members and CFHS.^{Footnote 74} Likewise, the Defence Indigenous Advisory Group (DIAG) outlined that Indigenous Primary Reserves members may not be aware that they can talk to their advisory group for guidance. Additionally, Indigenous CAF members in remote locations may not have the same tools to identify mental health needs as those located in more populated areas.^{Footnote 75}

The additional barriers that members of equity-deserving groups face are an added challenge that may prevent them from identifying their mental health needs and seeking mental health supports. Refer to Appendix VIII: Gender-based Analysis Plus (GBA Plus) for more information on barriers CAF members from equity-deserving groups face.

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Section V: Recommendations

Some recommendations made in previous reports^{Footnote 76}, have yet to be implemented. For example, the report, Part-Time Soldiers with Full-Time Injuries: A Systemic Review of Canada’s Primary Reserve Force and Operational Stress Injuries, recommended revision and amendment of the Queen’s Regulations and Orders Chapter 34 Medical Services and the Canadian Forces Military Personnel Instruction 20/04 to clarify Primary Reserve Force members entitlements to health care. During our last request for a follow-up in both documents are still under review. This report also recommended the development of a communications plan to improve knowledge and awareness of entitlements. During our spring 2022 follow-up, we reported that the CAF had an approved communications plan that they had not yet publicized. As a result, until the recommendations previously made are implemented, the confusion about entitlements and the impact on Primary Reserve members continue to be witnessed.

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Section VI: Conclusion

This systemic investigation focused on the mental health support for Primary Reserve members participating in domestic operations. The goal of this investigation was to determine how the DND/CAF treated Primary Reserve members comparatively to Regular Force members in the identification of their mental health needs and provision of mental health support before, during, and after domestic operations. We found that the DND/CAF often did not treat Primary Reserve members comparatively to Regular Force members, leaving them disadvantaged in terms of mental health well-being, especially before and after domestic operations.

The investigation uncovered systemic issues and revealed challenges for Primary Reserve members in four principal areas:

• identification of mental health needs
• access to mental health supports
• awareness
• barriers

Most challenges that Primary Reserve members face result from their part-time service employment and the lack of awareness of their entitlement to care for mental health needs caused or aggravated by the performance of duty. This is further compounded by the stigma and bias associated with:

• mental health;
• cultural challenges for Primary Reserve members to be fully integrated within the Canadian Armed Forces; and
• the perception that mental health supports are not as necessary before, during, or after domestic operations.

These persistent factors make it difficult to ensure that all members feel supported in their mental health well-being and are treated fairly and with respect.

Due to the increased number of domestic operations in recent years, the CAF expects the Primary Reserve Force to have a larger presence in future domestic operations.

The CAF has developed initiatives and programs, such as the Total Health and Wellness Strategy, R2MR training, Mental Health Continuum Model, CFMAP, and Sentinel Program and each had some successes. However, much remains to resolve greater systemic issues and have leaders regularly check in with those under their command. The CAF’s ability to provide mental health support to members that is free of bias and discrimination is critical for a resilient and healthy workforce that is employable and deployable. Members who can identify their mental health needs and access mental health support will have an improved overall well-being in areas such as their work, family, social and financial lives. "To respond at all levels to the reality of the current and future operational environments, CAF must shift to operating in a dramatically different way, compared to 30 years ago."^{Footnote 77} Thus, proactive, and supportive leadership is key to ensuring the care of our members so that they can continue supporting Canadians during domestic emergencies.

"How we treat those in uniform, how we fix the culture that surrounds them, and how we created and interpret policy in a fair and inclusive manner will determine how many of them stay within our ranks and how many join them in the future."^{Footnote 78}

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Appendix I: Letter to the Minister of National Defence

29 June 2023

The Honourable Anita Anand, PC, MP
Minister of National Defence
Department of National Defence and

The Canadian Armed Forces

National Defence Headquarters
101 Colonel By Drive,
13th Floor, North Tower
Ottawa, Ontario K1A 0K2

Dear Minister Anand:

Please find enclosed the report, Hidden Battles: A systemic investigation into the identification of mental health needs and support for Primary Reserve members participating in domestic operations.

This report makes six evidence-based recommendations. If accepted and implemented, these recommendations will bring long-lasting, positive change to CAF members. Additionally, our office believes timely implementation will assist the CAF’s efforts to fulfill its commitment made to the Defence community in Strong, Secure, Engaged and the Total Health and Wellness Strategy.

This report is submitted to you pursuant to paragraph 38(1)(b) of the Ministerial Directives in respect to the Ombudsman for the Department of National Defence and the Canadian Armed Forces. As is standard practice, we will be publishing the report no sooner than 28 days from the date of this letter. We would appreciate your response prior to publication so that it may be included in the final report. As in the past, we offered your staff a briefing on the report prior to its publication.

I look forward to your response to our recommendations.

Sincerely,

Gregory A. Lick
Ombudsman

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Appendix II: Glossary

Access

availability, eligibility, and awareness of mental health supports for CAF members and their leadership.

Bias

a subjective opinion, preference, prejudice, or inclination, often formed without reasonable justification, which influences the ability of an individuals or group to evaluate a particular situation objectively or accurately.^{Footnote 79}

Canadian Forces Health Services (CFHS) clinics

the CAF clinics’ role is to provide health services to CAF members and eligible personnel to optimize their health.^{Footnote 80}

Canadian Forces Members Assistance Program (CFMAP)

confidential, voluntary, short-term counselling to help resolve personal or work-related stressors. Additional information can be found in Appendix VI: Mental health resources for members.^{Footnote 81}

Care Provider

an individual or group directly involved with the provision of health or spiritual care to members, whether through policy, medical care, or counselling. This includes personnel within Canadian Forces Health Services (medical officers, mental health nurses, social workers) and Chaplains.

Comparable

able to be likened to another. For the purposes of this investigation:

• Mental health supports are offered to the same consistency prior, during and after domestic deployments.
• The entitlement to access mental health assessment and supports are clear for both Regular Force and Primary Reserve Force members.
• Mental health supports are at similar distance from their location and/or offered via telehealth.
• Mental health supports can be utilized in a timely fashion with similar impact on work, such as needing to take time off work for assessments or treatment.
• The chain of command conducts due diligence in ensuring the health and safety of those under their command and check-ins are completed after domestic operations.
• Both Regular Force and Primary Reserve Force members' health conditions can be linked to service/performance of duty, when applicable. Providing comparable access to entitlements.

Discrimination

an action or a decision that treats a person or a group differently for reasons such as their race, age, or disability.^{Footnote 82}

Domestic deployment

provision of humanitarian aid or participation in a specific mission within Canada, reassigning members from their regular duties.^{Footnote 83}

DND/CAF authorities

are involved in the administration of domestic operations, the provision of support services and programs to members or have advisory role. For example, Canadian Joint Operations Command, Surgeon General, Director of Mental Health, Royal Canadian Chaplain Service (RCChS), and Joint Task Force.

Enhanced Post Deployment Screening (EPDS)

mental health screening tool utilized by CFHS post international deployment to evaluate mental health needs.^{Footnote 84} Additional information can be found in Appendix IV: CAF tools to identify mental health needs.

Equity-deserving groups

groups of people who, because of systemic discrimination, face barriers that prevent them from having the same access to the resources and opportunities that are available to other members of society, and that are necessary for them to attain just outcomes. This includes women, Indigenous people, racialized people, people with disabilities, and people who are part of Two-Spirit, Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Plus (2SLGBTQI+) communities.

Force Generator

subject-matter expert in its environment who oversees CAF soldiers, sailors, aviators in the Regular Force and Primary Reserve units. The group is responsible for their training, career progression, and welfare. Within the CAF, the Force Generators include the Royal Canadian Navy, Canadian Army, Royal Canadian Air Force, Chief Military Personnel, Assistant Deputy Minister (Information Management), Canadian Forces Intelligence Command, and Canadian Special Operations Forces Command.^{Footnote 85}

Force Employer

assigned personnel from the Force Generators performing specific missions and operations. The group employs Force Generators’ personnel to achieve the mission objectives and is responsible for the planning and conduct of operations, as directed by the Chief of Defence Staff while meeting Government of Canada requirements. Within the CAF, Force Employers include Canadian Joint Operations Command, Canadian Special Operations Forces Command, and North American Aerospace Defense Command.^{Footnote 86}

Grievance

complaint submitted by an officer or non-commissioned member who has been aggrieved by any decision, act, or omission in the administration of the affairs of the Canadian Forces as no other redress process under the National Defence Act can resolve it.^{Footnote 87}

Home Unit

the regular organization in which the employee performs their positions’ duties.^{Footnote 88}

Identification of mental health needs:

CAF member self-identification and CAF identification of mental health needs.

• Self-identification: action taken by a CAF member to disclose their mental health needs to the CAF.
• CAF identification: action taken by the CAF to identify the mental health needs of CAF members.

Impact

the effect of untreated mental health needs on a member’s quality of life, willingness to voluntarily support domestic operations, quality of the assistance compromising the Canadian public’s confidence in the CAF, operational readiness, and retention.

Leadership

includes all members (not involved in the administration of a domestic operation or provision of support services and programs) in a position of authority over members who may participate in a domestic operation. This includes Commanding Officers and supervisors within the Chain of Command who volunteered to participate in our investigation.

Lessons learned

the adding of value to an existing body of knowledge, or seeking to correct deficiencies in areas of concepts, policy, doctrine, training, equipment, or organizations, by providing feedback and follow-on action.^{Footnote 89}

Military Benefits Browser

a tool used to guide CAF members in assessing their suitability for various benefits available. It allows CAF members to identify if they are Regular Force or Reserve Force, and if they are ill or injured to narrow down the applicable benefits to which they may be entitled.^{Footnote 90}

Mental Health Continuum Model

a tool to assist CAF personnel and support with monitoring and identifying changes in a member’s health. It is a graphic table that displays various behavioural indicators of a person’s mental health well-being used to conduct a mental health self-assessment. Additional information can be found in Appendix VI: Mental health resources for members.^{Footnote 91}

Mental health needs

are those arising from anyone experiencing challenges with their mental health and well-being, including ongoing mental health needs and the formal or informal supports available. The types of support can range from learning about coping mechanisms, managing emotions and feelings, having access to social and cultural supports, seeing a therapist and or requiring medication.

Mental health supports

available CAF programs, services and resources for mental health.

Operational readiness

preparedness for missions, tasks, or functions for which a unit, formation, weapon system or item of materiel is organized or designed.^{Footnote 92}

Periodic Health Assessment (PHA)

a tool to establish a person’s baseline medical fitness, which builds a historical health profile. Additional information can be found in the Appendix IV: CAF tools to identify mental health needs.^{Footnote 93}

Personnel Readiness Verification (PRV)

on an annual basis, the Commanding Officer of a Regular and Primary Reserve Force units must conduct a PRV screening of their members. This is to assess a member’s readiness for a specific task, posting, or deployment according to physical and mental health, domestic, and qualifications factors.^{Footnote 94} Additional information can be found in the Appendix IV: CAF tools to identify mental health needs.

Primary Reserve Force

a sub-component of the Reserve Force that comprises of members working part-time with the military who also have full-time civilian employment or attend school.^{Footnote 95} Primary Reserve members are employed under different Classes of Reserve Service.^{Footnote 96}

Recourse mechanisms

in the context of this investigation, formal or informal ways to address mental health needs for CAF members (such as medical services unit, redress of grievance process, or alternative dispute resolution).

Regional Joint Task Force

the Regional Joint Task Force headquarters provide operational command and control deployed task forces on CAF operations across Canada. There are six headquarters located in key locations within Canada.^{Footnote 97}

Regular Force

full-time employment with personnel deploying in domestic and/or international operations. Regular Force Members are posted to bases and wings across the country, depending on their trade, career progression, and environment (sea/land/air/special operations).^{Footnote 98}

Road to Mental Readiness (R2MR)

resilience and mental health training integrated into a CAF member’s career (including during deployment cycles) to prepare them for any potential challenges they may encounter due to their service. Additional information can be found in Appendix VI: Mental health resources for members.^{Footnote 99}

Self-awareness

ability of the CAF member to perceive or recognize that they have a mental health illness, injury, or need.

Sentinel Program

The Sentinel program is a peer support network made up of trained and supervised volunteer members of all ranks who are embedded within units. Sentinels are trained to observe, detect, support, and refer personnel to other known mental health resources.^{Footnote 100} Additional information can be found in Appendix VI: Mental health resources for members.

Universality of Service

requirement for CAF members to perform general military duties and common defence and security duties and not just the duties of their military occupation or occupational specification.^{Footnote 101}

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Appendix III: Methodology

This investigation focused on the process for identifying mental health needs and accessing mental health support for Primary Reserve Members on domestic operations, compared to Regular Force members. Our investigation covered domestic operations from 1 April 2017 to 31 March 2022. During this investigation, we set out to understand the following:

• the current policy framework
• how mental health needs are identified
• how mental health services are administered
• the impacts of their policy and process on CAF members
• the organizational impacts of their process

This investigation did not consult:

• DND civilian employees
• Casual employees
• Contractors (except for Canadian Forces Health Services employees)
• Cadets/Junior Canadian Rangers
• Canadian Rangers
• Cadet Organizations Administration and Training Service (COATS)
• Staff of the Non-Public Funds, Canadian Forces
• Family members

Investigative plan:

This investigation used a mixed-method approach, which included qualitative and quantitative data, analysis by multiple investigators, and methodological triangulation.

Documentation research and literature review

• CAF Canada.ca websites  
• CAF Mobile Application
• Canada’s Defence Policy—Strong, Secure, Engaged  
• Canadian Forces General Messages
• Canadian Forces Health Services Instructions
• Canadian Forces Member Assistance Program
• Canadian Forces Military Personnel Instructions  
• Canadian Forces Morale and Welfare Services website  
• Compensation and Benefits Instructions  
• Defence Administrative Orders and Directives
• E-mails, presentations, transcripts, data, and other formal/informal and internal written directives provided by DND/CAF authorities
• Military Human Resources Records Procedures
• National Defence Act
• Queen’s Regulations and Orders for the Canadian Forces
• Related grievances data breakdown from Chief Professional Conduct Culture  
• Reports, guides, and policy manuals  
• Road to Mental Readiness Mobile Application
• Standing Operations Order for Domestic Operations
• Surgeon General Instructions
• Total Health and Wellness Strategy  
• Various Standard Operating Procedures

Ombudsman office

• Complaint files from internal database
• Past studies and reports (Periodic Health Assessments, Operational Stress Injuries, Reserve Force Compensation)
• Ombudsman letters
• Education and Research Products
• Military Benefits Browser

Others

• Canadian Institute for Military and Veterans Health Research Forum
• Canada Health Act
• Parliamentary Publications (Standing Committee’s reports or meetings)
• Mental Health Commission of Canada website

Questionnaires and interviews

All participants of our questionnaire volunteered. While most of the CAF members and leadership interviewed for this investigation volunteered, CAF authorities and care providers did not; however, where possible we used a random selection process. We recognize that the experiences and opinions expressed may not necessarily represent the views of all CAF members.

Questionnaires took place from October to November 2022, and 99 responses were received. We spoke with 69 individuals (current and former CAF members, CAF leadership, care providers and DND/CAF authorities) for the purposes of this investigation.

Constituent consultations

We received responses from 82 current and former CAF members:

• 35 Reserve Force members
• 46 Regular Force members
• 1 former CAF member

We received responses from 17 current CAF leadership. The interviews took place from October to December 2022. We spoke to 26 current and former CAF members and CAF leadership:

• 19 Reserve Force and Regular Force members
• 9 CAF leadership

We consulted members and leadership of different ranks within both the Regular Force and Reserve Force to ensure an accurate representation of constituency experiences. This provided our office with a thorough understanding of mental health concerns for Primary Reserve members participating in domestic operations. Additionally, our office engaged with the Ombudsman Advisory Council members and the Chief of Reserves Advisory Group members for their perspectives on challenges faced by Primary Reserve members participating on domestic operations.

DND/CAF authorities and care provider consultations

The investigative team consulted various subgroups within the following organizations:

• Canadian Forces Health Services
• Canadian Forces Morale and Welfare Services
• Canadian Armed Forces Transition Group
• Canadian Joint Operation Command
• Canadian Special Operations Forces Command
• Conflict Solutions and Services
• Force Generators
• Joint Task Forces
• Royal Canadian Chaplain Services

These DND/CAF authorities and care provider consultations took place concurrently with constituents’ questionnaires and interviews. We spoke with 43 DND/CAF authorities and care providers. We also consulted certain DND/CAF authorities via e-mail for data and policies/instructions.

Additionally, we engaged with Defence Advisory Groups and Organizations^{Footnote 102} to gain their perspective on potential barriers encountered by them or their membership regarding identifying mental health needs or accessing mental health support.

We consulted five Defence Advisory Groups and Organizations:

• Defence Indigenous Advisory Group (DIAG)
• Defence Visible Minority Advisory Group (DVMAG)
• Defence Women’s Advisory Organization (DWAO)
• Defence Advisory Group for Persons with Disabilities (DAGPWD)
• Defence Team Pride Advisory Organization (DTPAO)

Potential bias

We recognize that many biases exist when investigating a topic like mental health. Some of those biases may include selection/sampling bias, cognitive bias, information bias, and interviewer bias. Our investigative team used mitigation strategies to ensure that the information presented is evidence-based. This included:

• employing a mixed method approach systematically in the collection and analysis of qualitative and quantitative data
• acquiring quantitative data from various sources, using multiple investigators to collect and analyze qualitative data, and using interviews to enrich questionnaire data;
• selection and sampling expanded to acquire information from various perspectives on the subject, irrespective of rank, this included various DND/CAF Authorities, care providers (policy, administrative, medical, and pastoral), leadership (from Regular Force and Reserve Force), and members (from Regular Force and Reserve Force);
• employing multiple multi-level revisions and validation measures to test for evidentiary rigour in the collection, analysis, and reporting of information; and
• acquiring multiple bias awareness training for the investigative team.

Note: We heard from a small sample size of members in our investigation. It was more challenging to reach out to Reserve Force members than Regular Force members, which is a difficulty the DND/CAF also face. The issues raised by the Primary Reserve members who participated were echoed by leadership interviewed.

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Appendix IV: CAF tools to identify mental health needs

The CAF identifies the mental health needs of both Primary Reserve and Regular Force members through medical screenings and assessments before, during and after domestic operations.

Periodic Health Assessments (PHA): PHAs are a structured health review for members that are conducted regularly. They are valid for five years for members under 40, and for two years for members 40 and over for all Military Occupational Structure Identifications.^{Footnote 103} Although the member’s unit monitors the status and accommodates requirements to maintain currency,^{Footnote 104} it is the responsibility of the member to ensure that PHAs are current.^{Footnote 105}

Medical Readiness Questionnaire (MRQ): The CAF uses the MRQ to screen medical fitness of Regular Force and Primary Reserve members before a deployment, except for international deployments or remote locations postings. It is valid for one year and used only when a member's PHA is expired, as an interim measure until the CAF can complete a PHA.^{Footnote 106} The CAF considers PHAs more efficient in meeting the operational and health requirements of the CAF.^{Footnote 107} Primary Reserve Members on Class “A” service and their provincial/territorial physicians can also use this tool to assess the member’s medical fitness, including their mental health.^{Footnote 108}

Personnel Readiness Verification (PRV)^{Footnote 109}: This process confirms the readiness of a member for a designated tasking, posting or deployment in terms of qualifications, physical and mental health, and domestic factors. It is a two-tier screening process.

• The first tier is a basic readiness verification that all members must complete.
• The second tier is an enhanced readiness verification related to unique occupation and environment-specific requirements.^{Footnote 110} Part 1 is done before the deployment and includes the Departure Assistance Group (DAG) checklist, which evaluates a variety of items, such as medical, dental, financial, security, and training. Part 2 is done post-deployment, and members also complete the Arrival Assistance Group (AAG) process.

Enhanced Post Deployment Screening (EPDS) tool: Canadian Forces Health Services uses this mental health screening tool following international deployments to evaluate mental health needs. No requirement exists to conduct an EPDS following a domestic operation.

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Appendix V: Post-Deployment Health Questionnaire and Declaration

This is a sample of the Post-Deployment Health Questionnaire and Declaration form referenced in the Standing Operations Order for Domestic Operations.

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Appendix VI: Mental health resources for CAF members

For CAF members, the first step to getting help for a mental health need is to contact their local CAF medical clinic. Members will receive immediate help or will be referred to the proper health service program by a medical doctor. CAF members have daily access to a general duty medical officer at the Base/Wing medical clinic.^{Footnote 111}

Medical clinics provide walk-in services; these include crisis services, such as seeing a physician, social worker or mental health nurse, and psychosocial services. No appointments are required to be seen. Mental health services do require a referral from a physician.

The Defence Team – Mental health and wellness webpage lists resources and information for CAF members and their families to get the care they need. These include:

• LifeSpeak
• Operational Stress Injury Connect (OSI Connect)
• Canadian Forces Morale and Welfare Services, which include:
  • Operational Stress Injury Social Support (OSISS) Family Peer Support Coordinator
  • Military Family Resource Centres (MFRCs)
  • Family Information Line 24/7
  • CAFConnection.ca
  • Strongest Families Institute
• Helping Our Peers by Providing Empathy (HOPE) program

For more details, consult the page 'Additional mental health resources for CAF members and their families.'^{Footnote 112}

Canadian Forces Member Assistance Program (CFMAP): This program is a confidential, voluntary, short-term counselling service (up to a maximum of eight sessions) ^{Footnote 113} for CAF members to resolve issues affecting their well-being and military life. CFMAP is available to both Regular Force and Reserve Force members, their families, and veterans. Additionally, CFMAP can be accessed across Canada by phone or online chat.^{Footnote 114} Non-Regular Force members and their family members may receive full assistance under this program only if the situation/issue for which assistance is sought is directly linked to their service in the CAF.^{Footnote 115} This condition notwithstanding, all individuals may receive an initial assessment followed by an appropriate referral. The assessment process includes client contact within 48 hours and an appointment within five days (or sooner in crisis situations). Eligible members who require follow-up services beyond the scope of this program will be referred to Canadian Forces Health Services (CFHS) with the member’s consent. Individuals not entitled to follow-up care from CFHS will be referred to an appropriate provincial/territorial agency.^{Footnote 116}

Defence Advisory Groups and Organizations: represent the four groups designated under the Employment Equity Act to provide advice and unique perspectives to CAF leadership and DND management. As well, the Defence Team Pride Organization advocates for the employment equity interests of Two-Spirit, Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Plus (2SLGBTQI+) members and employees. The following are Defence Advisory Groups and Organizations:

• Defence Indigenous Advisory Group (DIAG)
• Defence Visible Minority Advisory Group (DVMAG)
• Defence Women’s Advisory Organization (DWAO)
• Defence Advisory Group for Persons with Disabilities (DAGPWD)
• Defence Team Pride Advisory Organization (DTPAO)

Self-help resources

Mental Health in the CAF page: This web page provides information on mental illnesses, disorders, and prevention as well as, information about how CAF members careers can be affected while or after recovering from mental health needs.^{Footnote 117}

Mental Health Continuum Model: The Mental Health Continuum Model is a reliable^{Footnote 118} tool used to assess, interpret, and predict CAF members’ psychological, social, and emotional well-being. Members can also use this tool to self-monitor and self-identify changes in their own mental health.^{Footnote 119} Additionally, the CAF promotes the use of this tool on the Mental Health Services intranet site and on the CAF’s Road to Mental Readiness (R2MR) Mobile Application.

Road to Mental Readiness (R2MR): This program provides CAF members and leaders with mental health training at various stages of their career to prepare them for any potential challenges they may encounter due to their service.^{Footnote 120} It helps members become familiar with mental health well-being. These trainings are group-focussed and offered in-person or virtually.^{Footnote 121}

Military Benefits Browser: A tool used to guide CAF members in assessing their suitability for various benefits available. It allows CAF members to identify if they are Regular Force or Reserve Force, and if they are ill or injured to narrow down the applicable benefits to which they may be entitled.^{Footnote 122}

Peer support resource

Canadian Armed Forces Sentinel Program:^{Footnote 123} The Royal Canadian Chaplain Service developed this program, which expanded into a CAF-wide initiative in 2017. It is embedded within the CAF’s Joint Suicide Prevention Strategy and is aligned with the Total Health and Wellness Strategy. The Program operates on all Bases/Wings that have a Chaplain presence and is open to all military occupations within the Regular Force and the Reserve Force. This program is currently made up of over 9,500 non-professional peer support CAF members who have volunteered to be a support resource.

Other resources

Veterans Affairs Canada: Serving and former CAF can make a disability benefits application for one of the most common ongoing mental health needs related to military service (such as anxiety, depressive or trauma-and-stressor-related disorders). Those who do so can receive immediate mental health coverage, while their disability application is assessed.^{Footnote 124} For the full list of eligibility criteria, visit Veterans Affairs Canada.^{Footnote 125}

Atlas Institute for Veterans and Families: The institute works with Veterans, Families, service providers, and researchers to identify the best possible mental health care and supports.^{Footnote 126}

Canadian Mental Health Association: Each Canadian Mental Health Association branch, region and division operates as its own charitable organization offering a range of community mental health and substance use health programs and services, mostly in the following areas: mental health promotion, suicide prevention, peer support, and youth services and programs.

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Appendix VII: Case study—Mental health impacts for first responders to non-combat humanitarian efforts

This case study demonstrates the benefits of post-deployment screenings for domestic operations.

Canadian Public Safety Personnel (PSP) (such as municipal/provincial police, firefighters, paramedics, Royal Canadian Mounted Police, correctional workers, dispatchers) report frequent and varied exposures to potentially psychologically traumatic events (PPTE).^{Footnote 127} This can also be applied to CAF members as they may face high-stress situations and multiple exposures to PPTEs while on domestic operations. Situations, such as exposure to non-combat traumatic events namely, natural disasters, fires or explosions, captivity, serious injury, harm, or death caused to someone, and life-threatening illness or injuries, can be associated to mental health needs.^{Footnote 128} An example of a domestic operation where the CAF recognized that members were at a greater risk of incurring mental health injuries was Operation LASER.

In the spring of 2020, CAF members were deployed on Operation LASER to support long-term care facilities (LTCF) in Ontario and Québec. During this operation, they faced unique challenges such as working extreme hours for multiple days without breaks, being sequestered when not on duty and isolated away from family. Many worked with vulnerable and ill elderly people in the context of a new, potentially dangerous, and highly contagious disease that caused many deaths, especially in LTCF where living conditions and health care were poor. The CAF recognized that members exposed to traumatic events may have caused them moral injuries.  Although it was not systematically done, an Enhanced Post-Deployment Screening (EPDS) was conducted for some members assisting in the Long-Term Care homes. This was the only time it was used for a domestic operation within the scope of our investigation.^{Footnote 129}

Defence Research and Development Canada (DRDC) studied CAF members deployed to Operation LASER to document risk and resilience factors. Additionally, they studied its effects on mental health and the nature and degree of moral distress and moral injury among members.^{Footnote 134} They found 70%^{Footnote 135} of members reported exposure to at least one morally distressing experience during Operation LASER. DRDC also noted some members whose role was outside the LTCF also reported moral distress associated with the deployment.^{Footnote 136} Within their study, 22% of respondents indicated they needed mental health support following Operation LASER. Of this group, 77% sought formal mental health care and 62% sought informal support.^{Footnote 137}

Another study looked at the contribution of different types of occupational trauma from post-deployment mental health challenges.  They found that exposure to death or the injured contributed to the mental health impacts on CAF members even in those with lower levels of exposure to the dead and injured account for part of the mental health burden.^{Footnote 138} Additionally, mental health needs resulting from operational trauma could impact families when frontline workers return home.

For example, a study conducted with firefighters, found that although family members were a major source of support, they sometimes found it difficult to be honest and open about their work because they were afraid that it would change how their families viewed them^{Footnote 139} and their job. Firefighters also noted that mental health stressors from work are sometimes carried over into their family life and they may treat their family members with less tolerance, irritability, or poor communication. Many acknowledged the increased risk of divorce in the fire service and attributed work issues as a contributing factor. This can also be applied to CAF members, when they return from a domestic operation where they experienced or witnessed traumatic events.^{Footnote 140}

Firefighters were also concerned that taking time off work often compromised their family’s financial stability since sick benefits do not replace the usual firefighter income. Although this is not applicable to Regular CAF members, it can be applied to some Primary Reserve members who, upon their return from a domestic operation, go back to their civilian jobs or studies where they may not have sick benefits.

In conclusion, in an article from the Public Services Health and Safety Association ^{Footnote 141}, it noted that "[t]o promote mental health and prevent mental harm in first responders it is beneficial to have an early detection strategy in place designed to detect cognitive and emotional vulnerabilities."^{Footnote 142} This reinforces the importance of conducting check-ins after all domestic operations even if the operation is deemed to have minimal exposure to traumatic events. In fact, "Improving aspects of pre-deployment training and post-deployment decompression and increasing support from military peers/organization and the spiritual, religious community can minimize negative and maximize positive mental health outcomes."^{Footnote 143}

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Appendix VIII: Gender-based Analysis Plus (GBA Plus)

This investigation applied a Gender-based Analysis Plus (GBA Plus) lens. Our questionnaires and interviews with CAF members and leadership were designed with consideration of GBA Plus perspectives. We also engaged with the Defence Advisory Groups and Organizations for their unique perspectives on challenges that their memberships face. The Canadian Army provided us with the Employment Equity data gathered for Operation LASER.

Demographic breakdown of questionnaire respondents who self-identified

In our questionnaires, 46% of respondents indicated they belonged to an equity-deserving group, 48% did not, and 6% preferred not to disclose. Most respondents were Senior Non-Commissioned Officers (35%) and Junior Non-Commissioned Members (32%). Additionally, (41%) of respondents reported having over 20 years of service in the CAF.

Demographic breakdown of domestic operations

The Canadian Army provided Employment Equity self-identification data for all components involved in Op LASER.^{Footnote 144}  Although Op LASER was the domestic operation with the largest number of deployed personnel, the operation had the lowest rate of members who chose to self-identify (75.5%). The majority of deployed members identified themselves as men (87.3%), 12.7% as women, 3.3% as Indigenous, 14.1% as visible minorities and 0.8% as Persons with Disabilities. 

Additionally, the data provided by the CA underlined common characteristics among domestically deployed members who self-identified between 2017 and 2022. Members' average age was 29 years. Considering all components, members deployed have on average, eight years of service, with a maximum of 45 years of service. Most members self-identified were anglophones, and most ranked as Junior Non-Commissioned members.

Defence Advisory Groups and Organizations consultation

Consultation with the five Defence Advisory Groups and Organizations raised the following barriers for all CAF members, not only for Primary Reservists.

Indigenous members

The Defence Indigenous Advisory Group (DIAG) noted that there is a lack of Indigenous awareness among mental health services, which may impede Indigenous members from identifying their mental health needs. Members may instead be more comfortable speaking to someone with cultural knowledge and may seek spiritual healing.

Indigenous members in remote locations may not have the same tools to identify mental health needs as those located in more populated areas. The DIAG outlined that Indigenous members who are Primary Reserves members may not be aware that they can talk to the DIAG for guidance. If they knew that they are accessible to them, it may increase self-identification.

The DIAG also noted that Canadian Forces Health Services, including its access, is based on an approach to health that is not customized for Indigenous people. There is a need for spiritual health support other than the Chaplains, such as access to Elders. This is key for Indigenous peoples, given the generational trauma from the legacy of residential schools.

Women members

According to the Canadian Mental Health Association, "gender bias has a significant negative effect on medical diagnosis and the quality of health care women receive, leading to substantial delays in diagnosis and misdiagnosis. This includes delays in receiving mental health care."^{Footnote 145}

The Defence Women's Advisory Organization (DWAO) identified a lack of care providers of the same sex. Someone who has experienced military sexual trauma, for example, may not feel comfortable speaking about their experiences with someone of a different sex. In addition, they believe that some Bases/Wings do not have military women care providers.

When military women are unable to access a care provider of the same sex, they are sometimes referred to provincial/territorial care providers who may lack the experience or context of working with military members. Having a care provider who understands a member's concerns as well as the military experience can develop trust and improve the member's well-being.

Two-Spirit, Lesbian, Gay, Bisexual, Transgender, Queer, Intersex Plus (2SLGBTQI+) members

The Defence Team Pride Advisory Organization (DTPAO) noted that members also reported to the DTPAO that the mental health staff's lack of knowledge of the realities of 2SLGBTQI+ communities has generated harm, including judgments and discrimination, and has broken the trust between the members wanting to access CAF health services. Another barrier for accessing mental health supports is that 2SLGBTQI+ members not wanting to appear weak. In addition, the DTPAO indicated that some 2SLGBTQI+ members do not trust Chaplains given past experiences, which includes the disclosure of personal information to the Chain of Command without the members' consent.

In consideration of intersectionality, the Defence Advisory Group for Persons with Disabilities (DAGPWD) also noted a perceived lack of effort by medical units, including social workers and psychologists to reach out to the 2SLGBTQI+ communities and address the fear of stigmatization.

Members with disabilities

The DAGPWD indicated that the CAF system continues to create negative consequences when members self-identify or seek mental health support. Despite being told that there are no negative impacts of coming forward with a mental health concern, the possibility of receiving a medical category may discourage members from identifying a mental health need.

Visible minority members

While we did not receive specific information from the Defence Visible Minorities Advisory Group for this investigation, our consultation with other Defence Advisory Groups and Organizations made it clear that the challenges that equity-deserving groups already face in the workplace and in accessing mental health supports becomes compounded if they are also Primary Reserve members.

In May 2022, our office released a report titled 'Employment Equity and Diversity in the Department of National Defence and the Canadian Armed Forces' that highlighted the historical workplace challenges that each designated group face.

Equity-deserving members who must navigate the challenges of bias, discrimination, racism, and micro-aggressions in the workplace also have to navigate the unique challenges of employment as a Primary Reserve member.

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