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Personnel

Soldier at twilight

DND photo IS2004-2026a

Operational Stress Injury Social Support: A Canadian Innovation in Professional Peer Support

by J. Don Richardson, Kathy Darte, Stéphane Grenier, Allan English, and Joe Sharpe

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Introduction

The Operational Stress Injury Social Support (OSISS) program was created in May 2001 to meet an important need. The increasing incidence of military members suffering debilitating stress-related injuries as a result of their tours of duty became more widely known to Canadians and within the Canadian military community during and after the Croatia Board of Inquiry (BOI) conducted in 1999-2000.1 A graphic example that brought home to the board members the impact of this devastating injury, as well as illustrating the lack of available support at that time, occurred when a member of the board who had served in Croatia recognized a homeless man on the streets of Ottawa as a fellow soldier who had served in that country. The once-proud soldier had been medically released from the Canadian Forces (CF) and was suffering such serious mental health problems that he was reduced to begging for a living. The board member intervened, and the soldier was able to improve upon his situation. The reality that a fellow soldier was able to help him recover his life, when both the military and the system designed to care for injured veterans had effectively abandoned him, demonstrated to all board members the enormous potential of peer support.

Not long after the Croatia BOI, the Ombudsman for National Defence and the Canadian Forces launched an investigation into the way the CF was dealing with members suffering from post-traumatic stress disorder (PTSD). The investigation was triggered by the circumstances of one specific soldier who was effectively abandoned by his unit, and by the CF in general, when he suffered a severe stress breakdown as a result of his operational experiences. Almost from the moment his situation became public, peers came forward to support him and to work with him. The Ombudsman’s investigation observed how effective this intervention was, and concluded that peer support was an excellent method of assisting injured members. The report produced at the end of the investigation strongly supported the peer support concept that was emerging from within the military under the leadership of then-Major Stéphane Grenier.2 Subsequent research has confirmed the value of peer support, as it has been found that almost 25 percent of those suffering from an Operational Stress Injury (OSI) do not seek professional help, and those that eventually do seek help, due to the stigma associated with OSIs, can delay doing so for up to seven years. In these cases, peer support programs have connected with OSI sufferers, and have assisted them in getting much-needed help more rapidly.3

Exhausted soldiers

DND photo KA2005-R105-0013d

How OSISS Serves the CF, Veterans, and their Families

Aside from the significant human cost – both to those injured and to their families – of operational stress injuries, and the negative impact upon recruiting, the CF also suffers a serious financial loss as a result of this type of injury. The cost of recruiting, selecting, training, and operationally preparing members of the CF to the point that they can be deployed is staggering. For example, an Ombudsman’s report on the subject in 2002 estimated this cost at $315,000 for an infantry soldier.4 Experience indicates that early identification and treatment of an OSI can significantly improve a member’s chances of returning to duty in either his/her original trade, or in another trade that will benefit from someone with operational experience. For every member that is retained – and, by some estimates, peer support results in hundreds being kept on strength, the CF saves hundreds of thousands of dollars in personnel replacement costs. However, these financial savings, while important, are less significant than the effect that the program has had upon enhancing the respect for the dignity of all persons, the first principle in the Statement of Defence Ethics’ hierarchy of general principles.5 One of Canada’s best-known soldiers, and an OSI sufferer himself, Senator Romeo Dallaire, believes that, along with these other benefits, the OSISS program is saving a significant number of lives. He was quoted as saying that “...[peer support] interventions are saving us a suicide a day.”6

The OSISS program comprises a partnership involving two federal government departments – the Department of National Defence and Veterans Affairs Canada. The program’s design includes a multidisciplinary management team, with training conducted by certified mental health professional staff members at such sites as Ste. Anne’s Centre in Ste. Anne de Bellevue, Quebec, and the Veterans Affairs Canada National OSI Centre, Montreal, Quebec. It also includes pre-hiring medical screening and annual health follow-ups, placing a strong emphasis upon the OSISS program boundaries and self care. The management team includes a wide array of experts, advisors, and mental health specialists, including a psychiatrist, nurses, social workers, and former or active CF members. This team, using a participative leadership style, has thus far served the program well.

The individuals hired specifically for this program – Peer and Family Support Coordinators – each have an operational stress injury, such as PTSD. They are deemed by their psychiatrist and/or psychologist to be at a stage in their “own recovery” and rehabilitation to take on this type of work as their day-to-day employment. Peer Support Coordinators are hired to assist CF members, and veterans and Family Support Coordinators are hired to assist their families. The activities of the Coordinators employed within this program are supervised by the OSISS management team.

The role of OSISS Support Coordinators is to increase the level of social support to serving and retired military members, as well as to their families, who have experienced symptoms consistent with operational stress injuries by complementing existing services available from the Department of National Defence, Veterans Affairs Canada, and the local community; to empower CF members and veterans by assisting them in reducing OSI symptoms, improving their functional status and occupational performance; and ultimately, to improve the quality of life for the CF member, the veteran, and their families. The main activities of both the OSISS Family and Peer Support Coordinator consist of ‘one-on-one’ assistance, group work, recruiting and managing volunteers, and outreach activities (See Table 1).

Role of Peer Support Coordinators
Peer Support Coordinator Family Peer Support Coordinator

Focus on military members and veterans

Provide ‘one-on-one’ assistance: listen, assess, and refer

Organize and conduct peer support groups

Select, train, and manage volunteers

Provide program outreach briefings

Focus on families of military members and veterans with an OSI

Provide ‘one-on-one’ assistance: reach out, inform, and connect

Organize and conduct psycho-education groups

Select, train, and manage volunteers

Provide program outreach briefings

Prior to commencing their work, Peer and Family Support Coordinators must attend mandatory training. The curriculum development and the majority of training is provided by Veterans Affairs Canada staff, and it includes psychiatrists, psychologists, clinical nurse specialists, and social workers at the only remaining veterans’ hospital in Canada – Ste. Anne’s Hospital in Montréal, Quebec. The Peer and Family Support Training Course material includes knowledge and skills development in peer support, such as helping to improve relationships, learning methods of conflict resolution, learning to understand and respect boundaries, learning how to actively listen, problem solving, crisis management, suicide intervention, volunteer management and group work, as well as emphasizing the importance of self care. Coordinators also receive information on programs, services, and policies, plus information concerning the many agencies and services they may need to work with and perhaps refer individuals to – not only in government, but often within their local communities. The program also provides ongoing professional development to these individuals through quarterly workshops.

One requirement for individuals working within this program is to remain active with their own mental health therapy. These individuals are also linked to mental health professionals in their local community, and thus, they have a daily contact if they need any form of support, guidance, advice, or direction concerning their work, as well as for their own health and well-being.

Upon completion of the training course, the Coordinators then focus their energies upon getting a support network started. As the network is developing, the Support Coordinator will provide initial assistance to the widest extent possible to all individuals who seek the services of OSISS. This support will then be offered until such time as the Support Coordinators have recruited enough peers in the network to begin developing a formal program consisting of even more trained Peer Support Volunteers.

Exhausted soldier

DND photo AR2007-A043-0042

While respecting strict guidelines and principles of volunteerism, OSISS provides a unique opportunity to veterans, CF members, and families affected by an OSI to help others. This not only allows OSISS to reach a greater number of individuals than the limited number of Peer Support Coordinators could reach on their own, but it also plays a large role in re-establishing the self-confidence and self-worth in most CF members and veterans who volunteer for the program. The importance of the OSISS program has been confirmed because the Peer Support Network it provides was found to be the only common and continuous formal social support capability available to a CF member and/or retiree suffering from OSI experiences in his/her recovery and/or transition from regular military service to retirement.7

The success of OSISS is due in part to the fact that it has ensured a comprehensive screening and training of both the paid Support Coordinators and the Volunteers. Furthermore, the formal structure of two governmental organizations – Veterans Affairs Canada and National Defence – can provide the ongoing support that is vital for a successful program.

Canadian troops in a front line trench, France 1915

NAC PA1326

Battle stress is an old problem. Canadian troops in a front line trench, France 1915

The support OSISS management has received from clinicians has also been instrumental in the success of the program. Clinicians are involved in the decision-making process, as well as in the training and continuing education of all OSISS employees. Mental health staff members collaborate in many ways in the operation of the program. They are involved in hiring Support Coordinators; they sit on management boards and disciplinary committees; and they serve as educators. As OSISS management identifies systemic gaps or shortfalls in the program, collaborating clinicians are brought together to discuss potential solutions. This commitment to cooperation with clinicians has been a cornerstone of the program and often is cited as one of its strengths.

One of the benefits of the support provided by OSISS is that it crosses organizational and institutional divides. As a joint partnership initiative between National Defence and Veterans Affairs, OSISS is mandated to support and care for both serving military members and veterans, as well as for the families of those who suffer from OSIs. Therefore, Support Coordinators can provide a constant link in the continuum of care for the Canadian Forces members and their families before, during, and after release from the military. For example, when the OSISS program was first created, and the new Peer Support Coordinators were trained and started working with military members and veterans across Canada, the clinicians assessing and treating operational stress injuries started having contact with them, often through their patients. It became increasingly common for patients to mention, during their appointment with their doctor or social worker, that they had started attending the peer support group organized in their local community by the OSISS Peer Support Coordinator, or that they had had coffee with the Coordinator and had found it helpful to talk to someone who had been through similar experiences. Or perhaps the patient had attended a briefing on PTSD, and a Coordinator had been one of the speakers, and had talked about personal experiences struggling to put his or her life back together. In other, more serious cases, an OSISS worker could be directly involved in providing critical crisis support to a suffering member. While, to some, the activities of Coordinators might seem inconsequential, they nevertheless had an important impact on improving the quality of life of many OSI sufferers.

Painting Sergeant P.J. Ford by Charles Comfort, Canadian War Museum collection

CWM 12282

Sergeant P.J. Ford, by Charles Comfort, evocatively captures the strain of battle as experienced during the Italian campaign.

Challenges to OSISS

A recurring challenge to the OSISS program is based upon dissatisfaction in certain quarters with the term ‘operational stress’ and the word ‘injury’ in the phrase ‘operational stress injury.’ Expressions of dissatisfaction with the term ‘operational stress’ are most frequent and most sustained from some health professionals, who see the term as imprecise and not reflecting the current terminology their professions use to designate those possessing the symptoms of OSI. This is an old problem, and, as discussed in an earlier Canadian Military Journal article, the names for the diagnoses of the symptoms now associated with OSI have varied considerably over the past 300 years.8

One of the earliest uses of the term ‘operational stress’ in its modern context was by a Royal Air Force medical officer, Donald D. Reid, who was a prolific author on the subject of psychological disorders in Bomber Command aircrew during the Second World War. His 1947 article, “Some Measures of the Effect of Operational Stress on Bomber Crews,” took into account the fact that not all stress observed in bomber crews was actually caused by combat operations. Medical studies conducted during the war indicated that being on standby, or the cancellation of missions at the last minute, could generate almost as much stress as flying on actual combat missions. The experience of one ‘freshman’ pilot in Bomber Command, who ‘scrubbed’ (aborted) 17 times before his first trip, was cited in official reports as an example of this phenomenon. When he finally got to fly on operations, he quit after three trips because he had endured as much stress before he actually got airborne against a real target as someone who had gone on many operations.9 This effect had been observed in early 1940 by flying personnel Medical Officers (MOs) in Fighter and Coastal Commands, who noted that being on standby could generate 25 percent to 80 percent as much stress as actual combat flying, and created so much fatigue that there were “...several cases of pilots falling asleep in the air.”10

More recently, the term ‘operational stress’ has been recognized in US joint doctrine and Health Service Support doctrine as the “...expected and predictable emotional, intellectual, physical, and/or behavioral reactions of Service members who have been exposed to stressful events in war or military operations other than war.”11 Furthermore, the US Marine Corps has been using the term in its Operational Stress Control and Readiness Program since at least 2003.12

These uses of the term ‘operational stress’ indicate a conscious choice to employ a term that encompasses wider meanings than specific medical diagnoses, and they are also examples of how ‘military medicine’ serves the needs of the military profession. Unlike medicine practised in the civilian sector, which tends to put the well-being of the patient first, military medicine adopts a different first principle. Practitioners of military medicine have an obligation to conserve human resources for military purposes. This implies a return of military personnel to duty as soon as possible, even if this entails likely death or injury for the individual.13 This different nature of medical practice for uniformed physicians is addressed in CF doctrine.

Pilots experiencing flight stress

CF photo PL15626

Flying stress. Pilots from 417 Fighter Squadron after flying a mission with the Desert Air Force, Libya, 21 February 1943.

The defining document for Canada’s profession of arms, the Canadian Forces Leadership Institute’s Duty with Honour, recognizes that the military profession in Canada also includes individuals, such as doctors or lawyers, who are members of other professions. However, while they wear a uniform, they are considered to be members of the military profession. Duty with Honour acknowledges that having dual professional responsibilities can be challenging. Nonetheless, as military professionals, they must “...understand and conform to operational objectives and direction unless these are clearly unlawful.”14

One manner in which medical professionals have conformed to operational objectives is in the naming of war-related psychological disorders. There is a significant body of literature on how the labelling process is an important step in the creation and management of mental health in military organizations.15 Whether American soldiers referring to those diagnosed with a “psychoneurosis” as “psycho,” or Canadian soldiers referring to No. 1 Neuropsychiatric Hospital as “No. 1 Nuts,” military organizations have had to face the reality that soldiers will stigmatize those with OSI symptoms if they are labelled as having a mental illness. This stigmatization deters sufferers from seeking treatment, reduces the effectiveness of treatment for those who seek it, and, in the end, it generates unnecessary personnel losses. Therefore, medical professionals in uniform, when faced with the necessity of labelling psychological disorders, have an obligation to select those labels that serve the goals of the CF over those that serve narrower clinical interests. In the past, military organizations have used terms like ‘battle exhaustion’ and ‘combat fatigue’ in an effort to lessen the stigmatization of a diagnostic label. Like these terms, OSI is not a clinically accurate term, but its purpose is to serve the profession of arms.

Besides the terminology issue, as with any new program, there were also challenges to the OSISS concept itself. During the Croatia BOI, it became evident that there was a significant difference in the way the majority of mental health professionals in the CF medical community viewed operational stress injuries, as well as the manner by which the chain of command approached the problem. While there were clearly exceptions, by and large the medical community viewed this injury as a medical condition that should be treated by mental health professionals. The accepted view was that those who were not medical professionals should not be involved in the care of those suffering stress injuries, particularly those who were diagnosed themselves with mental health problems. Accordingly, during the development of the program, there was strong resistance from some segments of the medical professional community, although much of that resistance has disappeared in the face of the positive outcomes that have been observed. Nonetheless, there remains an ongoing challenge from some elements of the medical community with respect to the involvement of peers in the overall process of dealing with OSIs.

Similarly, some in the profession of arms also were doubtful about new attempts to deal effectively with OSIs. At the time of the Croatia BOI, many in the chain of command were largely unconvinced that OSI was a real injury, and believed that those showing symptoms of OSI were either weak to begin with, or were faking the injury to receive benefits. This attitude was reinforced by public commentary from retired military commanders that cast doubt on the validity of the condition. The attitude within the chain of command changed rapidly as evidence to the contrary mounted, but a follow-on Ombudsman’s report found that, while most senior levels in the chain of command, and most soldiers at the peer level accepted the reality of this injury, a strong belief remained at intermediate leadership levels, both commissioned and non-commissioned, that this injury reflected poorly on their personal leadership. Therefore, the presence of outside peer support individuals was not welcomed.16

As a result, OSISS continues to encounter some resistance from both communities – some in the medical community, who believe that OSI is a medical problem best dealt with by medical professionals, and some in chain of command, who view it as a potential negative reflection on the quality of their leadership.

Repatriation Ceremony

The unlimited liability of military service.

The unlimited liability of military service.

International Interest and Future Directions

Viewed as a groundbreaking program in the area of providing effective and structured peer support to OSI sufferers, there has been increasing interest in the OSISS program internationally. As an indication of this interest, OSISS staff members have been invited to make presentations at the following gatherings: the Australasian Society for Traumatic Stress Studies Conference, the European Conference on Traumatic Stress, the NATO HFM Symposium on Human Dimensions in Military Operations, and the IVth World Congress on Traumatic Stress in Argentina. OSISS staff members have also presented in the United States on numerous occasions - for example, to the International Society for Traumatic Stress Studies (ISTSS) and to US Veterans Affairs and US Department of Defense-sponsored conferences, including the Uniformed Services Social Work Conference and the Seamless Transition Conference. OSISS staffers have also contributed a chapter on the OSISS program to an American book dealing with stress injuries in combatants.17

Conclusion

Social support is a critical element in decreasing stigma, and it is crucial to the recovery of veterans and military members suffering from psychological trauma. The benefit of trained peer support is the peer’s ability to automatically identify with the suffering member, to convey interpersonal acceptance, to display resourcefulness, and to establish a special credibility in the eyes of the veteran, the serving member, and their families. The partnership between the Canadian Forces and Veterans Affairs Canada has started to erode the walls between National Defence and Veterans Affairs that impeded the recovery of OSI sufferers, and it has assisted CF members in their transition from actively serving to civilian life. The ongoing collaboration between clinicians working with patients with operational stress disorders and the national peer support program has been successful in decreasing the stigma of OSIs and in providing the treatment and support that those suffering from operational stress injuries require. An important measure of the success of the OSISS program is the overwhelmingly positive reception it has received from experts in the mental health field from around the world. While there are still challenges to be met, this innovative Canadian program promises to make an important contribution in conserving human resources for the CF and in improving the quality of life for CF members, veterans, and their families.

The authors would like to acknowledge the ongoing efforts of the staff of the Ste. Anne’s Centre for their support of the OSISS program.

CMJ Logo

J. Don Richardson, MD, FRCPC, is the consultant psychiatrist for the Parkwood Operational Stress Injury Clinic in London, Ontario and an Adjunct Professor in the Department of Psychiatry at University of Western Ontario. He is also the Veterans Affairs Canada medical advisor for the OSISS program.

Kathy Darte, MN, is the Veterans Affairs Canada Manager of the OSISS program.

Lieutenant-Colonel Stéphane Grenier is a serving CF officer and the originator of the OSISS program.

Doctor Allan English teaches in the History Department at Queen’s University.

Brigadier-General (ret’d) Joe Sharpe continues to work with DND and the CF in a number of areas, and maintains an ongoing interest in OSI issues. The authors are all members of the OSISS Advisory Committee.

Notes

  1. Department of National Defence (DND), Croatia Board of Inquiry – Provisional Report, 15 December1999. Note that the Board’s Report was on the DND website for some time after its release. It was removed for a number of years, and only recently have selected parts of the Board’s work been made available on the DND website, at <http://www.forces.gc.ca/boi/engraph/ home_e.asp>. Accessed 11 April 2008. References here are to a copy of the Report in the authors’ possession.
  2. DND, “Systemic Treatment of CF Members with PTSD Complainant: Christian McEachern,” Ombudsman’s Report (February 2002), at <http://www.ombudsman.forces.gc.ca/rep-rap/sr-rs/pts-ssp/index-eng.asp>. Accessed 11 April 2008.
  3. Statistics Canada, “Canadian Community Health Survey Cycle 1.2 – Mental Health and Well-being (Canadian Forces Supplement),” (Ottawa: Statistics Canada. 2002); D. Fikretoglu, S. Guay, et al., “PTSD, Suicidality, and Treatment Delay in a Nationally Representative, Military Sample,” a paper presented at the 22nd Annual Meeting of the International Society for Traumatic Stress Studies, Hollywood, California, 2006.
  4. DND, “Follow-up Report Review of DND/CF Actions on Operational Stress Injuries,” Ombudsman’s Report (December 2002), p. 65, at <http://www.ombudsman.forces.gc.ca/rep-rap/sr-rs/fr-rs/rep-rap-01-eng.asp#introduction>. Accessed 11 April 2008.
  5. DND, The Fundamentals of Canadian Defence Ethics (Ottawa: Defence Ethics Program, January 2002), pp. 9-11, at <http://www.dnd.ca/ethics/expectations/fundamentals_e.asp>. Accessed 11 April 2008.
  6. Charlie Fidelman, “Dallaire Admits Fear of Going over the Edge,” in Montreal Gazette, 3 June 2006.
  7. DND and Veterans Affairs Canada, “Interdepartmental Evaluation of the OSISS Peer Support Network,” (Ottawa: Chief of Review Services, January 2005), at <http://www.dnd.ca/crs/pdfs/osiss_e.pdf>. Accessed 11 Apr 2008.
  8. Allan English, “Leadership and Operational Stress in the Canadian Forces,” Canadian Military Journal, Vol. 1, No. 3, Autumn 2000, pp. 33-38.
  9. A description of Royal Air Force studies of flying personnel and the policies that resulted can be found in Allan English, The Cream of the Crop: Canadian Aircrew 1939-1945 (Montreal and Kingston, ON: McGill-Queen’s University Press, 1996).
  10. H.W. Corner, “Flying Duties at a Fighter Squadron,” Flying Personnel Research Committee Report 122, dated 24 March 1940, in PRO AIR 57, pp. 1-2.
  11. See JP 1-02, DOD Dictionary of Military and Associated Terms, dated 12 April 2001, as amended through 31 August 2005, p. 95, at <http://www.dtic.mil/doctrine/jel/doddict/data/c/01040.html>; JP 4-02, Doctrine for Health Service Support in Joint Operations, dated 30 July 2001, at <http://www.dtic.mil/doctrine/jel/new_pubs/jp4_02.pdf>. Accessed 11 April 2008.
  12. Assistant Commandant of the Marine Corps, Operational Stress Control and Readiness Program (OSCAR), US MARADMIN Number: 428/03, Washington, DC: US Marine Corps, dated 15 September 2003, at <http://www.marines.mil/news/messages/Pages/Archive/OPERATIONAL%20 STRESS%20CONTROL%20AND%20READINESS%20PROGRAM%20(OSCAR).aspx>. Accessed 11 April 2008.
  13. The issue of ‘military medicine’ in a Canadian context was discussed in a panel on “The Mission and Medical Ethics: Is There a Conflict?” in Proceedings in the Conference on Ethics in Canadian Defence (Ottawa: Public Works and Government Services Canada, 1999), at <http://www.dnd.ca/ ethics/archives/documents/conf1999_e.pdf>. Accessed 11 April 2008. See also Desmond Morton, “Military Medicine and State Medicine: Historical Notes on the Canadian Army Medical Corps in the First World War 1914-1919,” in David C. Naylor, (ed.), Canadian Health Care and the State (Montreal and Kingston, ON: McGill-Queen’s University Press, 1992), p. 55.
  14. DND, Duty with Honour: The Profession of Arms in Canada (Kingston, ON: Canadian Forces Leadership Institute, 2003), pp. 1, 52.
  15. The issue of labelling psychological disorders in military personnel is discussed in Allan English, “Leadership and Operational Stress in the Canadian Forces.” See also T. Bogacz, “War Neurosis and Cultural Change in England 1914-22: The Work of the War Office Committee of Enquiry into ‘Shell-Shock,’” in Journal of Contemporary History No. 24 (1989), pp. 227-56; Chris Feudtner, “Minds the Dead Have Ravished: Shell Shock, History, and the Ecology of Disease Systems,” in History of Science No. 31 (December 1993), pp. 377-420.
  16. DND, “Follow-up Report Review of DND/CF Actions on Operational Stress Injuries.”
  17. S. Grenier, K. Darte, A. Heber, and J. D. Richardson, “The Operational Stress Injury Social Support Program: A Peer Support Program in Collaboration between the Canadian Forces and Veterans Affairs Canada,” in Charles R. Figley and William P. Nash, (eds.), For Those Who Bore the Battle: Combat Stress Injury Theory, Research, and Management (New York: Routledge Psychosocial Stress Book Series, 2006).

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