Respect the dignity of all persons through improving resilience and health of Canadian Armed Forces Members

Introduction

If assenting to the opinion of a crisis in mental health (MH) amongst copious Canadian Armed Forces (CAF) personnel, the development of enhanced and more accessible services must be a consideration. Accompanying the struggles with MH, there is a ‘stigma’ associated with this injury/illness which directly impacts the willingness to seek support or professional medical services. The impact has resulted in much foregoing aid and treatment with some perceiving isolation as directly affecting their ability to feel respected and perform their duties with dignity.

Previous statistical reporting in 2014/15, Veterans Affairs Canada (VAC) stated 10,695 members were clinically diagnosed with PTSD. In 2016-17 those numbers grew to 18,826, and by 2020-21, those numbers swelled to 30,939, translating to a 189% gain (Government of Canada, 2022). Under The Canadian Armed Forces Ethos Trusted to Serve, “it is the responsibility of the CAF to ensure all members are treated with respect and humanity at all times and in all places”.

This paper will examine how the CAF can provide support to health and resilience by implementing initiatives 15-17 of Strong, Secure, Engaged (SSE). Furthermore, this paper will explore what role a Senior Appointed CPO1/CWO is expected to trumpet in commitment to Military Ethos as a steward of the Profession of Arms, vis-à-vis promoting dignity as it pertains to MH. To arrive at a correlation between loss of dignity and MH, this paper will explore published materials, followed by what a CPO1/CWO can do at the institutional level. Furthermore champion alternative medical approaches, and introduce the direct link between the CAF Ethos, and risks to the foundation for inclusion when an atmosphere of stigma continues association with MH.

SSE – MH ANXIETIES IN THE CAF

Care and support for military members suffering from Mental Health (MH) is both a moral responsibility for the CAF, but also practical when viewed from a colder business lens. VAC defines MH as “a state of psychological well-being characterized by continuing personal growth, a sense of purpose in life, and ability to focus, prioritize and plan effectively, self-acceptance and positive relations with others” (Government of Canada, 2022). Essentially, how an individual thinks and acts in response to daily life, its challenges, and interactions with others. Sitting within an audience from recruits to senior leaders, specific character traits are itemized; toughness, strength, reliability, loyalty, and teamwork. It is no secret the CAF values these qualities, and places significant resources to educate, train, and entrench these into everyday actions and attitudes. Anxiety, fear, avoidance, and depression are viewed as clinical, commonly not tolerated, and more importantly, not expected when visualizing a “good soldier”. This is the very stigma “good soldiers” carry, and I hypothesize why the battle is not entirely with the struggles of MH and the state of psychological well-being, but in reshaping the way we accept it, treat it, and de-stigmatize it.

In 2012, Pierre Daigle produced a report for the Government of Canada (GoC) Standing Committee on behalf of the National Defence and CAF Ombudsman in which they conclude three areas of concern about the care of members diagnosed with Post-Traumatic Stress Disorder (PTSD) or Operational Stress Injury (OSI). Each is a well-known and accepted mental health condition by clinicians and the GoC. First, stigma towards those suffering from PTSD/OSI remained prevalent. Second, a discrepancy between what was stated at the strategic level and what was happening at the unit and clinic level was detrimental. Third, the continued shortage of MH professionals was impeding the delivery and sustainability of care (Daigle, 2012). In a detailed, and research-oriented report, the over-arching conclusion to be understood is this; the mandate to deliver care for CAF members suffering from MH has dramatically improved since the initial report of 2002, and follow-up in 2008, due to the passionate professional caregiving being dedicated to patients. However, the execution is impacted by a lack of structured, systemic performance measurement tools and potential failure without a critical mass of qualified experience professional practitioners bridging the capability-capacity gap on the ground. Enter into the conversation Strong, Secure, Engaged: Canada’s Defence Policy.

SSE

After almost two years of consultation, review, draft, and editing, the GoC released a new Defence Policy entitled Strong, Secure, Engaged: Canada’s Defence Policy in June 2017. This document intends to provide direction on future Defence policies spanning the subsequent 20 years. Two years removed from release, the Defence spending has exceeded or kept pace with the policy. However, it has been identified that expenditures on equipment and infrastructure have lagged behind projections, but the spending trends remain positive and on track to meet or exceed the projected 1.4% of GDP utilized as a benchmark (Perry, 2019). Amongst skeptics, and critics both in print and on social media, this contention may be in dispute, nevertheless, Defence officials indicate the discrepancy lies with actual spending and the policy. Primarily, contingencies are not being used, project efficiencies, industry not delivering on schedule, and project delays internal to government (Perry, 2019). While not shy of ambitious, contained within the policy beginning on page 106, are summaries of new initiatives. Specific to the spirit of this paper, items 15 through 17 focus on Supporting Health and Resilience. These will be explored further within this paper.

Augment the CAF Health System and Growth – Item 15 SSE Annex D

The discussion or debate for faults in the system warrants their own paper, therefore let’s drill down to ‘augment’. Augment, adding to, or increasing is a strategy in need of exploration. To step beyond traditional MH practices an evolution requires alternatives to current therapies. What can we imagine that will result in an improvement in MH and happiness? When I think of healing, my mind envisions dogs.

“There is no psychiatrist in the world like a puppy licking your face.”

– Ben Williams

Most are familiar with dogs being utilized within a military construct both in guarding facilities, and more modern practices of demolition detection, but have you considered Service/Therapy dogs and PTSD care? The Americans and Disabilities Act (ADA) defines a service animal as, “Any dog that is individually trained to do work or perform tasks for the benefit of an individual with a disability, including a physical, sensory, psychiatric…” (Sherbert, 2012). Stipulated within the article, a therapy dog is further defined and the service it provides as “a dog that, with a handler, visits individuals or groups to provide some relief…used one-on-one as part of a treatment program…often referred to as animal-assisted therapy” (Sherbert, 2012). In 2007 the US Army, under orders of the Acting Surgeon General, Major-General Gale Polock, directed animal-assisted therapy expanded to include the deployment of therapy canines into Iraq and Afghanistan (Ritchie & Robinette, 2012). The anticipation from clinicians supporting co-locating canines into a theatre of operations was based on the ability to provide stress relief unequaled to human-only contact. It is not uncommon to find healthcare professionals acknowledging the potential mental health improvement by introducing people/animal interactions, as it is well documented that the simple act of petting a dog can significantly lower a person’s blood pressure (Chumley, 2012).

This should not be considered a breakthrough as the US military promoted the use of dogs in a therapeutic setting as early as 1919 at St-Elizabeth’s Hospital in Washington, DC (Chumley, 2012). This bonding experiment in a controlled clinical setting foreshadowed the progress, and creative thinking we see today. Subsequent confirmation of successful deployment of canines into an operational theatre occurred in Iraq and Afghanistan. Both the 212^th and 254^th Medical detachments employed therapy dogs, to study the relationship between canines and MH within soldiers. Participation in this therapy termed Animal-Assisted Therapy (AAT) resulted in positive data supporting the program in tracking mood state, job satisfaction, stress levels, and resiliency (Chumley, 2012). Initially employed within a prevention team, the concentration of this program focused on visiting soldiers in their respective Area of Operations (AOR) and paired the canine with a clinician. The presence of the dogs was recognized as facilitating the therapist to appear more approachable and assisted with the rhythm of communication (Dougherty, Fike, & Najera, Occupational Therapists as Dog Handlers: The Collective Experience with Animal-Assisted Therapy in Iraq, 2012). It was noted that soldiers appeared to let their guard down, and share concerns. Once exposed to the dogs, soldiers would transition from states of anger and stress suddenly smiling, and open to the therapeutic process (Dougherty, Fike, & Najera, Occupational Therapists as Dog Handlers: The Collective Experience with Animal-Assisted Therapy in Iraq, 2012). Furthermore, interactions were not limited to soldiers enlisted into clinical trials involving canines, but open to daily visitors who would drop in proclaiming the need for a hug from the dog, and admit it all was well and this was simply the process of assisting with resilience.

Sometimes there is no substitute for a puppy licking your face!

Removing Barriers – Item 17 SSE Annex D

Statistics Canada, in collaboration with the CAF, VAC, and the University of Manitoba conducted a supplemental survey of CAF members who participated in their study collated in 2002. This group reported that more than 4 in 10 (44%) said they had experienced symptoms consistent with depression or an anxiety disorder, with 25% reporting symptoms of both. Furthermore, and far more alarming in my opinion, is the results indicated an increase of those first reporting MH struggles in veterans no longer in service of the CAF at 48% for females and 38% for males compared with 38% for women and 31% of men who were still enlisted (Government of Canada, 2019). Is the “stigma” associated with MH contributing to current CAF members coming forward, and does it rob them of their dignity? To answer this, we must introduce the “stigma” associated with MH.

In a military context, stigma is defined as a “brand” or “mark of infamy” (Acosta, et al., 2014). This “marked identity” signifies that the individual in question is not normal and beyond the parameters of acceptable within a team dynamic or military community. Essentially, beyond the institutions’ traditional visualization of a “good soldier”. To be clear, we must acknowledge that this stigma can result in the service member perceiving or internalizing this branding about themselves, and how they are viewed by others without direct outside messaging. What cannot be disputed, is the immediate impact on self-worth, or personal dignity, which is associated with the stigma surrounding MH, and the barrier this generates.

Researchers have identified three types of stigma. They include (American Psychiatric Association, 2020):

1. Public stigma - involves the negative or discriminatory attitudes that others have about mental illness;
2. Self-stigma – refers to the negative attitudes, including internalized shame, that people with mental illness have about their condition; and
3. Institutional stigma – more systemic, involving policies of the government and private organizations that intentionally or unintentionally limit opportunities for people with mental illness. Examples include lower funding for MH or fewer MH services.

Suffice it to say, all three categories can apply to CAF personnel currently receiving MH services, members awaiting assistance, or those avoiding due to attached ‘stigma’. This will be further explored within this paper.

Supporting Health and Resilience - Leading the Institution

“The Profession of Arms can only maintain its credibility and trust with the Government and Canadians by respecting the dignity of all persons” (Department of National Defence, 2017). Dignity is a word that has several meanings, but for this paper, let’s apply it to the CAF Military Ethos. A new doctrinal publication released in 2022 entitled, ‘CAF Ethos: Trusted to Serve’ will guide members in the CAF on conduct and performance both off and on duty, at all times. Regardless of rank, position, or appointment, all personnel is called upon to participate and play an active role in reshaping the culture within the military and embody the CAF Ethos. Foundationally based on The Constitution Acts of 1867 to 1982, the CAF Ethos contains three ethical principles. The first principle relative to this paper is ‘Respect the Dignity of All Persons’. Bolded within this publication is “Everyone must be treated with respect and humanity at all times and in all places. Everyone deserves to serve in a safe, inclusive environment. As military professionals, we must respect the dignity of all persons at all times” (Department of National Defence, 2022). An ethos for the CAF is a set of values that it claims as its own. An all-encompassing concept incorporating ethics. In constructing the CAF ethos, consideration must have been based on a foundation of strong values and disciplined behavior which is for the common good; it is the opposite of an individual way of thinking, embodying a communal atmosphere. In conflict rests the potential of loss of personal dignity as a result of the stigma associated with those suffering poor MH.

While there is scope to argue that the catalyst for change and improvement for support of health services was at its peak post-Afghanistan, it is clear the need continues to exist, and the CAF needs to capitalize on the momentum of SSE and future spending.

Supporting improvement to the resilience and health of CAF members published in SSE will be analyzed through the lens of the effectiveness dimension ‘Military Ethos’ as detailed within the CAF Effective model, in collaboration with the recently published CAF Ethos, ‘The Canadian Armed Forces Ethos – Trusted to Serve’. Contained within SSE and itemized to “improve the resilience and health of its members, the Canadian Armed Forces will (Department of National Defence, 2017):

15. Augment the Canadian Armed Forces Health System to ensure it meets the unique needs of our personnel with efficient and effective care, anywhere they serve in Canada or abroad. This includes growing the Medical Service Branch by 200 personnel.
16. Implement a joint National Defence and Veterans’ Affairs Suicide Prevention Strategy that hires additional mental health professionals and implements a joint framework focused on preventing suicide across the entire military and Veteran community.
17. Remove barriers to care, including creating an environment free from stigma where military members are encouraged to raise health concerns of any nature and seek appropriate help when they need it” (Department of National Defence, 2017).

While initiative 16 is associated with suicide, and the continued progress to understand, prevent and support those impacted within the CAF can be categorized as vital, this paper will focus on initiatives 15, and 17.

Analysis of Supporting Health and Resilience – Assessment of SSE Initiatives 15 and 17

The exercise of analyzing each initiative identified for this paper alongside the four internal integration points exposes that the SSE initiatives encompass both merits and flaws. However, as a starting point, and guide to future capabilities or resources, the model is an excellent foundation to build upon.

Beginning with SSE initiative 15, ‘Augment the CAF Health System…efficient and effective care…’, the CAF Ethos has identified that “everyone must be treated with respect and humanity at all times and in all places” (Department of National Defence, 2022). To achieve the ability in providing professional medical services, both in Canada and abroad, it is vital to growing the medical branch. As it pertains to CAF personnel, and ongoing stressors on the medical system in support for members with MH, it is common knowledge that current resources are taxed, and the ability to provide adequate support varies from region to region.

The current COVID pandemic highlights a flaw in SSE specific to numbers within the medical field. An article published online by Global News cites CAF’s struggles with medical staff shortages provided information to the public. It states, that the CAF is prepared to employ approximately 2,500 medical personnel, of which around 460 would be positions dedicated to doctors and nurses. However, the CAF “has less than 50% of the required physicians available to conduct routine activities or operationally deploy with only 75% of nurses and 65 % of medical technicians” (The Canadian Press, 2022). Furthermore, Defence Department spokesman Daniel Le Bouthillier states when interviewed for this article that “throughout the pandemic, the CAF strength has decreased to the point where it can only fill 60% of its mandated tasks,” while confirming that the CAF has struggled with recruiting and retaining doctors to meet its needs (The Canadian Press, 2022). In this author’s experience, retention and recruitment are not restricted to medical services. As it pertains to retention and growth in the medical system and SSE initiative 15, the current pandemic will only neutralize this ability within the CAF. The bi-product is the direct ability to ensure all members are afforded the dignity mandated within our ethos while seeking medical services for MH.

SSE initiative 17, ‘Remove barriers to care ...creating an environment free from stigma” may continue to challenge all levels of leadership, but it is the responsibility of senior leaders to provide stewardship. A rudimentary introduction to stigma previously discussed provided the basic understanding that ‘stigma’, regardless of the magnitude, may contribute to harm. If there is any success in removing barriers to care, addressing the ‘stigma’ associated with MH is paramount. Following the CAF Effective Model, as it pertains to Military Ethos, senior leaders must promote a positive personal example, and reinforce the institution with a combination of aligning the CAF’s culture with the values and ideals of military ethos (Department of National Defence, 2005). It is therefore directly linked to SSE initiative 17 for all senior leaders to talk openly about the ‘stigma’ connected to MH, educate themselves and others as to programs, demonstrate compassion, and encourage equality for all serving members, healthy or injured.

THE ROLE OF THE CPO1/CWO CORPS

To assist SA CPO1/CWOs, various doctrinal and institutional publications are available to reference and guide actions. One such publication available is Leadership in the Canadian Forces Conceptual Foundations. According to this resource (Department of National Defence, 2005), there are four dimensions of leading the institution under the Military Ethos Effectiveness Dimension:

1. Clarify responsibilities, enforce accountabilities;
2. Develop and maintain professional identity, align culture with ethos, preserve CF heritage;
3. Exemplify and reinforce the military ethos, develop and maintain the military justice system; and
4. Establish an ethical culture.

Produced as an aid, contents within the table clarify the responsibilities and differences between the functions of leading people in the CAF and leading the CAF as an institution. “With respect to the military ethos, the Officer-NCM leadership team has a joint responsibility for continuing and extending the professional socialization…” (Department of National Defence, 2005). The question remains, as a SA CPO1/CWO, how can their role influence SSE initiatives? One resource often overlooked, is the direct contact with the most senior Officers of the CAF and the role of leadership team. Those members holding appointments at the tip of the spear are partners of change. Accepted as one of the responsibilities of SA CPO1/CWO is leading the institution. Those entrusted, and selected are charged with exhausting all prospects in a visionary role, to anticipate future needs, both realistic and imaginatively, to create support and direction at the strategic level (Department of National Defence, 2007). Unpacking this statement, key elements jump off the page; anticipate needs, realistic and imaginary. To achieve this, those with influence must master the ability to forecast and plan. These are complementary in that forecasting will identify opportunities, whereas planning assists in the creation of establishing concrete attainable goals with a roadmap to success. As a junior leader, it was instilled upon me to make adjustments before they are needed. Simply put, anticipate future problems before they become real-time problems. Entrusted with the highest level of influence, the CPO1/CWO is key to promoting and leading change. Finally, dignity is deeply embedded in the CAF ethos. It is the first published of three ethical principles. Protection for those injured or ill, and combatting the stigma of MH are necessary to ensure members are not stripped of their dignity. A robust advocacy campaign, interconnected with support from SSE for the expansion of MH resources, is beyond the scope of governance for tactical leaders.

Applying knowledge gained by familiarization with the Leader Framework, published within Leadership in Canadian Forces, Leading the Institution, specifically the five elements and sixteen attributes will assist SA CPO1/CWOs. As institutional leaders, it is imperative to master all five elements and sixteen attributes, however, let’s focus on ‘Professional Ideology’. Specifically, “an internalized ethos whose values and belief guide the application of that knowledge” (Department of National Defence, 2007). SA CPO1/CWOs inherit the moral and appointed duty to embody, promote and influence a professional, approved CAF ethos. This must be accomplished both directly and indirectly up, down, and across all levels of positional influence. To begin, education is a tool with broad opportunities. Those in SA positions must champion current and future programs, but the opportunity to include personal context is typically welcomed. To cite private experience, regardless of the policy or attribute disseminated by those in positional power, when the message is linked to personal involvements I found the ability to receive more inviting. Using education as a platform, a SA CPO1/CWO can shape the message to challenge inaccurate information, contest stereotypes that contribute to stigma, and promote inclusion in step with CAF ethos. Face-to-face interaction is key to reaching the masses, not limited to, but including providing public platforms for those who have had a mental illness, members currently struggling with MH, and professionals with the ability to address programs/support services.

The CAF competency dictionary for CPO1/CWO plainly outlines the duty to promote an ethical climate. Moreover, endorse integrity in organizational practices, programs, and policies. Influencing behavior can be achieved through observed actions in daily interactions, and relevant activities, empowering those members struggling with the dignity traditionally accompanied by team cohesion. One potential result could include openly opposing stigmas associated with MH being targeted as a direct threat to CAF ethos, thus upholding the commitment to an ethical climate.

As SA CPO1/CWOs, the positional power entrusted enables the ability of initiatives to continue moving forward. Intertwined with positional power, the network available to those at the highest appointments afford the ability to personally influence others who are instrumental in directing change. Quite simply, no position within the CWO Corps that appoints and fosters the power to develop new policies, support current doctrine, directly influence morale and attack systemic barriers to care and support of CAF members than that of a SA CPO1/CWO.

CONCLUSION

I believe there are various reasons why SSE, as it pertains to improving the resilience and health of CAF members will continue to be a wicked problem. First, recruitment and retention of medical professionals were lagging before 2020 and the global COVID pandemic. The inability to increase the Medical Services Branch identified in SSE, will become a limiting factor on recruitment, and contribute to the erosion of current medical services. As discussed, it is not an enthusiasm problem, but capacity. Secondly, the idea of psychological weakness and institutional acceptance of what defines a “good soldier” as opposed to traditional military culture. While the CAF Ethos, and Trusted to Serve, will provide a foundation for all levels of leadership, there is still apprehension surrounding the invisible wounds of MH, in comparison to those physical injuries observable by the eye. The correlation between stigmas associated with MH, and the direct impact on personal dignity are in conflict with the CAF Ethos.

As it pertains to SSE, the need to anticipate needs, realistic and imaginary are fused to the duties associated with SA CPO1/CWOs. Forecast, and planning are attributes that require training, cultivation, and dissemination. Entrusted with this appointment, those selected must utilize the platform, key partners at institutional levels, and the CAF audience to acceptable influence behaviors. Nevertheless, it is my opinion, those selected into SA positions have the necessary tools, training, and character to navigate the future needs of the CAF.

As discussed, the relationship between stigma and dignity is a marriage in need of annulment. As conferred within this paper, one such lever with access, education, and board selection are SA CPO1/CWOs. In concert with the bestowed positional power, CAF ethos, and SSE, the roadmap is available. After all, it is the obligation of the CAF to ensure all members are treated with respect and humanity at all times and in all places.

Bibliography

American Psychiatric Association. (2020, August). American Psychiatric Association - Psychiatry.org. Retrieved from Patients and Families - Stigma, Prejudice & Discrimination Again People with Mental Illness: www.psychiatry.org/patients-families/stigma-and-discrimination

Chumley, P. (2012). Historical Perspectives of the Human-Animal Bond Within the Department of Defense. Army Medical Department Journal, 18-20.

Daigle, P. (2012). FORTITUDE UNDER FATIGUE: Assessing the delivery of care for operational stress injuries that Canadian Forces Members need and Deserve. Ottawa: Ombudsman National Defence and Candian Forces.

Department of National Defence. (2005). Leadership in the Canadian Forces, Conceptual Foundations. Kingston: Canadian Defence Academy and Canadian Forces Leadership Institute.

Department of National Defence. (2007). Leadership in the Canadian Forces, Leading the Institution. Kingston: Canadian Defence Academy and Canadian forces Leadership Institute.

Department of National Defence. (2017). Strong Secure Engaged, Canada's Defence Policy. Ottawa: Minister of National Defence.

Department of National Defence. (2022). The Canadian Armed Forces Ethos Trusted to Serve. Ottawa: Department of National Defence.

Dougherty, D., Fike, L., & Najera, C. (2012). Occupational Therapists as Dog Handlers: The Collective Experience with Animal-Assisted Therapy in Iraq. The United States Army Medical Department Journal April-Jun, 51-54.

Government of Canada. (2019, 04 23). Statistics Canada. Retrieved from The Daily: www.150.statcan.gc.ca

Government of Canada. (2022, 04 07). Veterans Affairs Canada. Retrieved from Welcome to Veterans Affairs Canada: www.veterans.gc.ca/eng/about-vac/news-media/facts-figures/7-0

Perry, D. (2019, May). Canadian Global Affairs Institue. Retrieved from Strong, Secure, Engaged: A Two-Year Review: www.cgai.ca/strong_secure_engaged_a_two_year_review

Ritchie, E. C., & Robinette, A. J. (2012). The Early Years. The United States Army Medical Department Journal, 5-7.

Sherbert, J. (2012). Dogs and Human Health/Mental Health: From the Pleasure of Their Company to the Benefits of Their Assistance. The United States Army Medical Department Journal, 21-29.

The Canadian Press. (2022, 01 12). Global News. Retrieved from Global News - COVID: Canadian military struggling with medical staff shortage as provinces seek help: globalnews.ca/news/8505749/military-staff-shortage-covid-provinces/