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The first part of this monograph places the issue of mental fitness and the military within a wider context of (mental) health and Australian society. It notes, however, aspects of this issue that are particular to military service. These include a growing appreciation of the fact that the military exposes its personnel to trauma and therefore experiences corresponding incidences of psychological injury; and that service in the ADF can lead to significant life disruption when that service comes to an end.

Defining the problem

The public don’t like how our vets are treated; don’t send them to war and then refuse to look after them. (Senator Jacqui Lambie)

…

I have watched these issues chew people apart. (Dan Pronk—army medical doctor, retired)

…

There is stigma involved with sharing with strangers. They say there is no stigma but there is still. It is still a mindset amongst soldiers and officers generally of a person who can’t sort out his own stuff. I have witnessed negative stigma from PTSD. People still whisper and spread stories. There is still not enough education in the public and so not as much empathy for people’s situations. There are not enough services and support available for sufferers of PTSD. A lot of it is about mindset. Think of the soldier’s welfare and what is best for them and their loved ones. You sent them there and when they return their lives are never the same.

As a soldier, you are trained from recruit training to kill or subdue your enemy. To be the best and uphold the traditions of the Anzacs. As men, we are too scared to say we are not good enough or that we need help at times. We would die for each other but we will not talk about our fears to each other because the vulnerability and embarrassment is too much at times. This leads to disempowerment, isolation, confusion and despair where we are helpless. Many choose suicide to end it or live lives of quiet desperation. It affects the community at large. It needs community help. It needs mates helping each other and looking out for each other. It needs education and listening to the veterans. It needs funds for rehabilitation. (Samuel—Appendix A)

In addition to the contemporary popular narrative recorded on these pages, it is useful to consider the scale of this issue and briefly rehearse changing attitudes and from where we have come. The effects of military service on mental fitness are poorly understood. It is known that a career spent in the military has a significant shaping effect on the lives of the men and women who choose this profession. An age-old tension exists between capability and individual welfare—that is, between a commander’s desire to maintain a fighting force and the desire to look after the welfare of individual members of that workforce. Another historical facet of the military and mental health has been the way in which those experiencing the negative psychological effects of war and military service have often been branded as cowardly and malingerers and dealt with as a disciplinary matter. Physical wounds were often revered; however, mental scars often brought with them humiliation and the taint of failure.

Elaborate propaganda and coercion strategies have been employed by governments and militaries to ensure the ranks of their fighting forces remained stocked. Examples include white feather campaigns and instilling shame around being labelled with the administrative term ‘lack of moral fibre’.[1] Public attitudes and prejudices towards military-related psychological injuries have fluctuated. While in the US during World War II there was a growing appreciation that all military personnel were vulnerable, in Australia following the Vietnam War, the public appeared to have reverted to World War I thinking when military-related psychological injuries were thought to be due to a pre-existing condition rather than war trauma.[2]

Prevalence rates of mental ill-health in service personnel and veterans

While there are significant gaps in available statistics, what we do know comes from Defence and DVA-funded research, in particular the ADF Mental Health and Wellbeing Study 2010 and the Middle East Area of Operations (MEAO) Census and Prospective Health Studies 2013.[3]

Lifetime rates for mental disorders in the ADF are considerably higher than the Australian community with over 54 per cent of ADF personnel experiencing a ‘disorder’ in their lifetime.[4]

ADF males report higher rates of PTSD (8.1 per cent) than males in the general community (4.6 per cent). There is no statistical difference in the rate of PTSD between males and females. Trauma histories between ADF males and females do differ however, with ADF males more likely to report accidents and other unexpected traumas, while ADF females were more likely to report interpersonal traumas.[5] The Mental Health Prevalence and Wellbeing Study highlighted that in addition to exposure to traumas from civilian life, ADF personnel are additionally exposed to job-specific trauma. The study also reports that 90 per cent of ADF personnel have experienced at least one traumatic event in their lives, compared with 73 per cent of an age and employment matched Australian community sample.[6]

Contemporary Australia

Mental health and the ADF is part of a much larger context of (mental) health and Australian society. This is a highly complex issue that has proven to be susceptible to hijacking in the past by special interest groups and certain professions. The Defence leadership is taking the issue seriously and understand that it is broader than simply a health issue. As a society-wide issue, prevailing attitudes remain dotted with significant stigma towards those affected. Additionally, the military is a culture that does not acknowledge weakness or inadequacy. The cultural change around destigmatising service-related reduced mental fitness has been slow.

For example, PTSD affects a much wider population than veterans of combat or Defence. First responders are routinely exposed to traumatic circumstances and Indigenous children are thought to have high rates of psychological injury as a result of exposure to trauma.[7] The state and federal police, Department of Foreign Affairs and Trade (DFAT) and aid agency workers are other groups thought to experience abnormally high rates of psychological trauma.[8] A unique feature of military service is that the military is the only organisation that requires its workforce to kill people and destroy property as part of their core business. Because of this, the training for and conduct of military service can result in moral injury, a condition to which other professions are not susceptible (Tom Frame—UNSW professor).

The fallout from unrecognised psychological injuries includes increased incidents of self-harm, alcohol and drug abuse, domestic violence, incarceration, homelessness, early death and suicide (Alan Behm—FearLess CEO). One observation is that ‘homeless, displaced veterans have replaced swagmen of a bygone era and are self-treating with suicide’ (Behm). A feature of debates around the above issues, however, is that little data exists to support claims being made about the prevalence of these kinds of consequences of military service. Defence and DVA are currently attempting to address this shortfall with several joint-funded research projects. A key informant raised doubt about the methodologies employed by some of the research currently underway and the extent to which it can provide an accurate read on these complex problems (source chose to remain anonymous). Another criticism of existing research programs is that they do not adequately account for the so-called ‘healthy soldier effect’ (Behm). Comparisons with the general population do not allow for the fact that defence members are a healthy group of people at recruitment. The accurate interpretation of epidemiological data is critically important and this has not always been done well. Such data has in the past been skewed to shore up existing bureaucratic positions (Behm). For example, the ADF Mental Health and Wellbeing Study 2010 states that the ‘prevalence of mental disorders was similar to the Australian community sample…’, an interpretation of which may be that urgent action on ADF mental health is not required.[9] 

While part of a much larger picture of (mental) health and the community, the mental health of current serving Defence personnel and veterans has some unique aspects. Young men, and an increasing number of women, are recruited and taught to see themselves as contributing to something greater, where their own health and ultimately their own lives become a tool of the government of the day. It is rarely explained in this way; it is assumed in the role these men and women take on. Once defence personnel are taught to put the system before themselves, they are exposed to a work environment that doctors know will make some of them unwell. The training and qualities that make good soldiers can be the very things that put these men and women at greater risk of harm, and leave them less able to seek help when it is needed. This monograph sets about framing this problem and its consequences before presenting some of the views of the experts who set the agendas around these issues.

While serving in a professionally satisfying and high-functioning environment, soldiers (particularly among the Special Forces community) are supported by their peers and feel a strong duty to project an image of strength and not let the team down. Anecdotally, ADF members believe that a diagnosis of mental illness will result in missed promotion windows, missed deployment opportunities and most likely, medical discharge. The stigma of ‘mental illness’, combined with the fact that it can be hidden, means that people are continuing on with untreated psychological injuries and other manifestations of reduced mental fitness. Upon leaving the military, individuals may find themselves in comparatively low-status unsatisfying jobs, and, feeling isolated from support, may then experience the psychological fallout of a career spent witnessing trauma. There is often a delayed onset of symptoms associated with PTSD and co-morbidities.[10] This creates a set of challenges that can include difficulties in linking exposure to trauma with (a delayed onset of) symptoms, both from the veteran’s perspective and in official bureaucratic processes.

With low rates of mental health literacy and an inability to identify when help may be required, the situation may become chronic, with the individual feeling increasingly helpless before the case comes to the attention of the medical community or DVA. Records may be patchy and an already unwell veteran may find themselves having to retell their story numerous times in an adversarial setting where the onus of proof is on them to demonstrate they are deserving. The more tragic of these stories find their way into the media, and their compelling nature and compatibility with sensational but easily digestible media agendas mean the story becomes one of ‘this government sent these men and women to war, they have come back broken and it is now refusing to look after them’. Second order effects of this include industries of Ex-Service Organisations that have sprung up in large numbers to fill a (perceived) gap in care. While these groups are most often started by well-intentioned people motivated by helping other veterans, numerous problems have been identified with the current status of these groups (see section on ESOs).

Other features of this system include traumatised veterans appearing before Senate committees where committee members who are veterans themselves are repeatedly exposed to harrowing stories which may trigger the reliving of their own experiences of trauma. Such inquires pit generalist politicians against bureaucrats well-practised at deflecting attention and criticism with strategies such as ruling lines of inquiry outside of their respective administrative remits.[11] Most senior bureaucrats are not subject matter experts in mental health, meaning the responses they give often do not clarify anything or accurately inform the politicians regarding their concerns. Constant attacks and accusations (both by the media and politicians) have had the effect of making inherently insular cultures of the bureaucracy more defensive. The adversarial nature of the hearings only increases the defensive, ‘bunker down’/‘we’re already doing that’ responses. Linda Reynolds (Government Senator) commented: ‘the behaviour of the popular media makes Defence even more reactive and defensive in the area of veterans’ health’.

An independently planned research strategy, informed by subject matter experts (both academics and clinicians), is vital to properly understanding the situation, and needs to be made a priority. It should include both qualitative and quantitative research designed to assess the needs of veterans in a way that genuinely engages the unique aspects of the culture of this population and informs the design of strategies for prevention, early intervention and treatment. At present, an independent research agenda does not exist separate from bureaucratic control. The only reason for denying the publication or distribution of research should be security concerns. Academic research in the US, Canada and the UK is not subject to the same level of bureaucratic control as it is in Australia (Dr Alexander ‘Sandy’ McFarlane—psychiatrist). When politicians and journalists sense something is amiss, but cannot get straight answers, progress is stifled and the same circularity is perpetuated. A program of independent and best-practice research may be one key element in breaking the circular manner in which this issue is played out at present.

Anyone experiencing reduced mental fitness, including Defence members and veterans, is relatively powerless and while stories of wounded veterans are picked up by the media, it remains the case that Defence and DVA do not really know what to do with serving members and veterans whose health has been adversely affected in this way. While Defence is focused on capability, injured veterans become an issue of secondary concern. While the leadership group of Defence is interested in this issue and has a genuine interest in better outcomes for members of these groups, a top-down approach is not the whole answer. Paula Dabovich (researcher—University of Adelaide) noted that you can have the best policies, but if they are not well-understood or accepted by the target populations, they are essentially a waste of time. A gap in the research exists regarding how soldiers feel about the treatment and services available, and what they actually want. ‘We [the research community] need to listen to what soldiers actually want’ (Dabovich). The claim being made here is not that policymakers should be dictated to by a small disgruntled group, but that research into culturally appropriate service provision is an important but missing component of a well-informed approach to improving the experiences of those who feel that existing services have not been designed with their needs in mind.

As Peter Leahy (Chairman, Soldier On) remarked ‘we’ve got to keep talking about this issue’. Major General Gus Gilmore commented that it is the five per cent of veterans who are not receiving proper health care on whom we need to focus our efforts. Retired Army psychologist, Clint Marlborough, said ‘there is a strong feeling among a number of quarters of these debates that the issue has not been dealt with properly and it is now time to do so’.

Part of this puzzle is the relationship between the federal government’s coordination and state-based service provision. Mirrored in the organisation of the Returned and Services League (RSL), state-based health systems can be fragmented (source chose to remain anonymous) due to the nature of the systems that support them. Some, likewise, regard the federal system as fragmented in that Defence and DVA are separate and not always successful in working seamlessly together (ESOs have arisen to fill the gaps occurring between these organisations). From a political perspective, although the consolidation and coordination of these systems appears to offer efficiency dividends, this would require political will. A key informant in this research believes that part of DVA’s role is to be a de facto health insurer in a system lacking systematic oversight and auditing (anonymous). A lack of coordination between federal, state and private sector health services was noted by the same informant.  

First-hand accounts of personal impacts

In the following quote, the wife of an Afghanistan veteran describes the relationship between the (un)availability of physical rehabilitation services and mental fitness impacts:

I think the ADF medical system needs considerable change overall. It’s backward at best and risk-averse in the extreme. Some of the PTSD issues stem from service personnel being medically downgraded and considered unfit for their role, when the reality is with correct physio and support services there is no reason they can’t continue in their role. I know a considerable number of ADF members who use outside services, and pay for them out of their own pocket, because the services provided by the army medically are inadequate and antiquated. Further overhaul of PT practices within the army and rehabilitation programs need genuine improvement. Having worked on an army base and seen the rehab for physical injuries it is hopelessly inadequate; with people not getting better physically, this is only going to add to mental health issues. (Sara—Appendix A)

The following is a first-hand account of the suicide of colleagues where PTSD is highlighted as a potential contributing factor:

Yes, I have a lot of mates who suffered from PTSD. Some committed suicide but I’m unsure whether it was totally PTSD or that started the downwards spiral and drugs/alcohol, or something else, contributed to, or sped up, the process. I have mates at the moment who are suffering in some form or another and others I suspect, but haven’t spoken to about it. (Charlie—Appendix A)

Here, the effects of poor mental health literacy and the resulting stigma are illustrated, as is an unwillingness to offer support to those who may really need it:

Yes, and I was one of these people who looked upon it negatively as a younger soldier. Having gone through some of the experiences myself I could not see why people who signed up to do just that, could break easily. I never said anything and tended to move away from people who were suffering. These days I don’t believe that, possibly because of some of the guys I used to look up to as a younger soldier who now suffer or/and because of the scale of it within Defence/ex-Defence. (Charlie—Appendix A)

The following is another example of the impacts that war-related trauma can have on the lives of those who experience it:

My boss (Lieutenant) shot and killed a Taliban suicide bomber. [He] now suffers severe PTSD and struggles to live days without seeing him in his life. (David—Appendix A)

After having set the scene with these pages on the scope and unique features of the potential psychological effects of working in the military, the background to the research, planning and reviews in Defence, DVA and the Federal Parliament will now be considered in turn. These institutions have done impressive work around the issue of mental fitness and the military workforce. Care needs to be taken interpreting the above quotes taken from the very small group of veterans who agreed to contribute to this research. Although, as noted, many of the sentiments expressed are reflected in the considered views of the working professionals with whom the researcher spoke.

Transition

A recurrent theme raised during interviews was that of transition back to being a civilian following a career in the military—often referred to as separation. This phase of a military career appears to have significance for debates around mental fitness and the military.

A significant feature of a military career is the reported effect it has on people when it ends. This relates to members from across the ADF, not only combat soldiers. Part of the trauma of military service and war appears to be the loss of the closeness and cooperation that it engenders.[12] It has also been theorised that after living an intense and interdependent lifestyle, the process of returning to the individual modern Western lifestyle can be brutalising to the spirit—feelings of alienation and loneliness are often seen to be associated with leaving a military environment:[13]

The very nature of excellence as a combat soldier requires extremes of commitment and fusion of identity with the collective, yet simultaneously puts them [soldiers] at risk of injury and thereby involuntary discharge. This in turn can precipitate a sudden and unexpected shift in identity, embodied by a change of medical employment category within their units, followed by movement to a rehabilitation environment, change of employment and medical discharge. Research with soldiers who are discharged on medical grounds, confirms the high emotional impact…[14]

Discharge from the ADF is often a significant milestone in the lives of these ‘transitioning’ members. After a career spent inside an all-consuming institution, the process of becoming a civilian again can be traumatic for some. Part of this process of transition is leaving a highly satisfying and professional environment and beginning work in a low status and comparatively low-paid job. Sara, the wife of an Afghanistan veteran said:

…helping ex-ADF members find work (particularly work that makes them feel valued). I have a friend who is a highly-qualified Combat Engineer, who did three trips to Afghanistan, left the army and went back to working at the freezer in Coles where he was before he joined—hardly a recognition of his skills and it hugely devalued him. (Sara—Appendix A)

A number of the veterans’ stories included as case studies in this research raised the issue of employment post-discharge. A senior Defence officer remarked that he had been meeting with a NSW minister to devise a way to give veterans priority pathways into state emergency services employment. Such a strategy was intended to act as a positive for both organisations, as veterans have already self-selected into the army and would have attributes valued in the emergency services, making it beneficial to both individuals and first responder organisations. A note of caution, however, is that the potential for exposure to trauma is actually greater in the emergency service sector than the military, and compared to Defence, the first responder organisations do not have comprehensive health systems for members. Stigma surrounding mental health is also a major problem. Perhaps a transition into other leadership roles would be a better outcome. Defence should prepare Special Operations Command [SOCOMD] operators (and by extension all ADF personnel) for careers after discharge (Dan Pronk). While the emotional distress of alienation and loneliness that may accompany transition can be deeply unsettling for some, the issue of employment was an immediate problem raised by numerous contributors to this research.   

Many people interviewed for this paper felt strongly that Defence should play a more active role in the employment futures of members who are no longer ‘fit’ for active duty. In these cases, Defence could consider options for retaining the significant skills and expertise of its highly developed workforce and implement policies to support members being retained within the workforce in some capacity. Members may be better utilised within another area of the organisation, or allocated to a specialised ‘arm’ of the organisation. Alternatively, consideration may be given to the development of a program that sees the ‘redistribution’ of affected personnel into other supportive work environments, in which personnel feel that they are able to make a valuable contribution with their existing skill set in an effective and well-supported capacity (Kerry Howard—psychologist). (See the following section on the 2nd Commando Regiment for an example of how this approach has been successfully implemented).

A different approach might helpfully be taken to models of career progression and transition where workforce flexibility is achieved through the adoption of a range of solutions that assist in the transition process and leave veterans with the thoroughgoing impression that their futures and a high quality of life will be better served by a productive and functional engagement with the community, rather than a fight for pensions and a life of welfare dependency. For those experiencing chronic debilitating conditions, however, there may be little choice. Others may require their need for social inclusion to be supported in meaningful but less permanent ways.[15]

Soldier On has called for a ‘universal transition program’ for all separating ADF members to ensure that this group has effective access to study and meaningful employment post-discharge.[16]