Commodore Hans Jung
Breaking the Barriers to Mental Health Care
CHRIS MACLEAN
© 2009 FrontLine Defence (Vol 6, No 5)

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“We exist to help you. But I can’t help you if you’re not willing to let us help you.”
 
Appointed to the position of Commander Canadian Forces Health Services Group and Surgeon General this past July, Commodore Jung has defined his mission. His current focus is “to enhance the institutional credibility of the health service.” He has tackled a series of media interviews today, and I have to assume this is the last, as the sunlight is fading fast, but he remains energetic and, clearly, he is determined to get his message out to the public. Cmdre Jung’s concern right now is that media emphasis on difficult cases has been damaging the credibility of the CF Health Services Group.

We likely all can recall personal anecdotes when we, or our friends or relatives were able to persevere under complex health challenges because of confidence in a doctor or in ourselves. From the Commander’s perspective, when community confidence in the health sector’s ability to effectively handle patients’ needs dissipates, “that’s going to actually worsen some of the complex medical issues, psychiatric and otherwise.” In particular, he worries that individuals will not seek help for mental health issues. “Who is going to seek out the care of the various institutions if all you hear are negative stories,” he asks, rhetorically. It is a well-known dilemma that people with mental health illnesses are often self-stigmatized, believing it is somehow shameful or a sign of weakness that they are experiencing this. In too many cases, they may be reluctant to seek care, thinking it confirms that they are not in control. If the institution they must turn to is routinely characterized in the media in a negative way, it will undoubtably create another barrier for people to seek care.

He is aware that damaging the credibility of the health care system is, in turn, reducing the ability to connect with potential patients who may then hesitate too long before seeking help. Jung hopes that if more success stories are reported, more people who may be experiencing ­disturbing symptoms will feel comfortable enough to approach a health care professional with questions.  

“No institution can make everybody happy, no system is perfect, but if all you hear is the negativity… the person who needs care won’t seek it, and that is our greatest obstacle right now.” Jung acknowledges that care provided by the CF Health Services Group has been described as world class, “but our challenge is barrier to care, and that barrier is really based upon what we call self-stigma.”

The stigma of mental health exists in every sector of society, however, the military is taking great pains to break down that stigma. According to Jung, military leadership in the CF is strongly encouraged to destigmatize this condition. “We talk about it in the military quite openly now; there has been a major shift in culture towards stigma, from an organizational ­context.”

The biggest challenge still lies with the individual that needs the care. Self-stigmatization is the most difficult situation to uncover. The person may worry that their peers and leaders will think less of them. They try to conceal their inner pain so no one will find out. Sometimes they think that just talking about it is a sign of weakness. “We need to be able to give them the confidence that we’re here for them. We want to say ‘you can come to us, we’ll treat you, look after you in confidence, and you have really nothing to worry about.’ ”

Jung’s answer is to increase the partnership factor by promoting health care as a collaborative venture. “It is not something that I as a physician do to you; you have to be an active partner in that [process].” That being said, if a soldier is reluctant to discuss his or her situation with a mental health professional – for whatever reason – that relationship of trust is hindered.

“We need to get out there,” affirms Cmdre Jung “the Canadian forces has one of the best health cares systems in Canada, if not the best, and you need to come and see us because without that, your medical condition will not be addressed.” In fact, mental health issues may worsen without timely treatment.


Medical technician, Cpl Sandie Walsh, talks with a patient at Kandahar Airfield, Afghanistan.

“It took me 28 years to get here,” the new Commander of CF Health Services Group answers thoughtfully when asked how he plans on making his mark here. “I’ve been watching [these negative stories and negative impacts] with a certain amount of frustration in that the whole story is not getting out. It’s always focusing on the negativity, but I am making a point to hopefully get the whole story out – or at least the other side of the story – so that people can come to their own judgment with fullness of the fact, and they can have a greater confidence so that if someone needs help, they’ll seek it and we’ll be there for them. And that’s ultimately what we’re talking about because none of us health care people joined the military for reasons other than to provide health care. We’re not conscripted, we ­volunteered for this organization and you know that you don’t get rich by being in the military, so we joined because we wanted to help people, and its frustrating when our ability to do so is somewhat impeded by a negative perception that gets blown out of proportion. Sometimes an individual case is reported in five to seven different newspapers and it’s like a pandemic when it’s actually an isolated case.”

All mental health cases are unique, with multiple and varied complicating factors. “We look after them, but like I said, we can’t help anybody in a one directional manner. The person has to be willing to partner with us fully – to walk together in that treatment. I want to encourage people to say ‘look we’re here for you and if you need help, we’re there for you.’ That’s what I want to do because, at the end of the day our aim is to provide health care.”


From left: Lt Tobi Dwyer, an intensive care unit (ICU) nurse, Captain Jennifer Drew, a nursing officer, and Commander Todd Stein, an American ICU nurse, treat a patient at the Role 3 Multinational Medical Unit in Afghanistan.

Some within the CF health care system feel its full merit is underappreciated. Ironically, that may be due to a lack of press coverage. Jung will apparently be trying to combat both perception problems.

“I want to get out there to tell people, you have a great resource here, and if you need it, we’re here for you. But there is nothing we can do if you don’t come to us. I can’t force you do to something.”

Mental health is such a sensitive subject and, of course, the complexities of the mission in Afghanistan means cases are increasing all the time. Are people coming forward to discuss their concerns about mental health?

A Statistics Canada survey of mental health issues found that, in 2002, over 50% of the military people who needed mental health care waited more than five years before they sought health care. If we consider that the most effective care, is timely intervention, that brings us back to Jung’s priorities of reducing the barriers to care. Jung believes that the stigma associated with admitting to mental health problems was higher back then. But there are other reasons.

Mental and physical health assessments are scheduled for 3-6 months after returning from Afghanistan. “We have now done close to 13,000 assessments of people who have come back from Afghanistan and … over 50% are already in care. So that 5 year delay has now reduced to less than 6 months. That’s powerful evidence that people are actually saying, you know what, I need help and I’m going to seek it out before I am asked. The enhanced post-deployment screening will catch those who didn’t [recognize the symptoms], and that’s the other part.”


Major Daniel Dupuis (right), a nurse at 5e Ambulance de campagne, Canadian Forces Base Valcartier, assists with the transport of a casualty into the Role 3 Multinational Medical Unit (R3 MMU) in Afghanistan.

Another key barrier to mental health care today, says Cmdre Jung, is the “large percent of people who don’t know that they need mental health care.” In many cases, people don’t recognize that they’re sick, therefore, a need had emerged to focus both on reducing possible self-stigma and also on educating people that certain symptoms are not necessarily “normal” responses that will resolve themselves.

Mental health professionals hope to keep the door wide open for people to seek some kind of care or guidance or counselling, and depending on the situation, diagnosis and treatment. “It’s very much of a holistic event,” notes the Commander.

“We actually have an educational program for every level of leadership in the Canadian forces. We teach leaders… how to recognize mental health issues [in themselves and] their subordinates.” The Canadian Military has developed a systemic mental health education campaign that reaches the military population at every level of development.

An important stage of mental health awareness education takes place during the pre-deployment process. Each group ramping up for Afghanistan undergoes pre-deployment screening that includes information related to mental health. Discussed, for instance, are natural reactions vice more complex conditions that may require care.

“We also provide training to the family, notes Cmdre Jung, “so they can understand the potential stressors that the members going through, and the dynamics of being separated from their families.”


LCdr Mercy Yeboah-Ampadu, a social worker at 1 Field Ambulance in Edmonton Alberta, is talking with a patient at the Role 3 Multinational Medical Unit (R3 MMU) in Afghanistan.

Physicians, nurses, medical technicians and padres are among the support group deployed to Afghanistan to provide frontline care. A team of mental health professionals is also on-site – psychiatrists, social workers and a mental health nurse – in case anyone needs more specialized care.
A third location decompression aimed at easing the transition from warzone to living room takes place at the end of a deployment. This stage provides education about the return process, recommends monitoring alcohol use, and underlines the change of family dynamics that has taken place during the deployment. For example, the family has been forced to restructure for six months, and the reintegration process can create some stresses on both sides.

There are numerous, natural “settling in emotions” upon return to Canada. Some are normal and will most likely resolve themselves, however, others may be a cause of concern. After a few months, when life has seemed to stabilize at home, some concerns might potentially come to the surface that would not necessarily be seen the day they returned to Canada. The value of another screening process thus becomes obvious. This takes place approximately 3-6 months after return, and as Commander Jung is quick to point out, “anywhere along that point, if they need treatment, we have the greatest access to mental health services anywhere.”

OSIS, the Operational Stress Injury Social support program sends peer counselors to talk confidentially, encourage and guide them into the health care system if they are somewhat hesitant.

Another support system is the Canadian Forces Member Assistance Plan. This toll free phone line is available to the member, spouse, and family and is operational 24/7.

With so many programs, do at-risk people still fall through cracks? “Nobody has a program as comprehensive as in the Canadian Forces,” says Jung, “but in spite of that, if the member does not come forward and partner, there is nothing we can do.”

In a sad turn of events, Cpl TJ Sterling, one of the soldiers injured in the 2003 blast that killed Cpl Robbie Beerenfenger and Sgt Robert Short, ended his life last month. TJ had returned to duty after major shrapnel wounds had healed, and retired from the Canadian Forces in 2007. One can’t help but wonder if he recognized he was having problems, or if he fell through the cracks, or if he couldn’t find a way to accept the help being offered by friends, family or health care professionals.

The CF Health Services is not responsible for the well-being of retired members. The public health care system takes over at that point, and the Department of Veterans Affairs provides extra services, such as funding for Operational Stress Injury clinics which operate out of provincial facilities.

Based on medical confidentially issues, the Commander of Health Services cannot comment on this case specifically, however, he acknowledges that “suicide is a very complex issue. All suicide should be preventable, in theory,” he muses, “but it happens, and the fact that a tragic case like that has happened does not necessarily automatically mean the system has failed; it may have, I don’t know because he was retired. I have no idea if the civilian system is as robust as we are, however, the causes of suicide are so multifactoral that it’s very difficult to say. The fact is that mental health is often on a double standard, on the one hand, people say there is so much stigma in mental health we need to break that ­barrier down, however, those same people [often] expect perfection. Just as we can’t cure everybody with heart problems, cancer, diabetes, those who are obese and who can’t lose weight, some may die, unfortunately it happens. In the same way, we cannot cure all cases of mental health. Many of them will be much improved, but the sad truth is, based upon current science and evidence, some people with mental health ­illness, unfortunately, will not be cured, no matter how much the health care system and society try to provide. Even with the best of care, we can’t always have 100% success rate.”

The risk of not being identified early or a lack of access to clinics are serious barriers to care. Many groups are doing their best to ensure our retired and serving military members can access the care they require, but it must be emphasized that one of the most difficult aspects of this situation is often in convincing the sick person to admit there is something wrong.


WO Craig Harvey, a medical radiation ­technologist, is reading digital X-rays at the R3 MMU in Afghanistan.

Veterans Affairs Canada
The Department of Veterans Affairs has an initiative to educate family practitioners across Canada on the unique cultural ­circumstances of Veterans with Post Traumatic Stress Disorders (PTSD). They can help explain the combat perspective, the trauma, and the self-sufficiency and self-confidence of the soldier culture, so that a family doctor will recognize the difference and will pay attention to certain factors. There is a cultural transition from the military to the civilian health care system. “Without a doubt,” agrees Commodore, Jung, “but the vast majority of them do very well.”

It is important to understand the ­context of trauma and combat in order to diagnose a patient who has been deployed to a volatile area such as Afghanistan. In addition, the process of treatment must be individually tailored. A rape victim, car accident victim, or soldier will all experience trauma differently, resulting in varying treatment needs. Thus, having a greater awareness of that person’s background is very useful. Several Operational Stress Injury (OSI) clinics, to which individuals can self-refer themselves, have opened across Canada.

OSI Joint Speakers Bureau
Another group that has taken initiative in this matter is the Mental Health & Operational Stress Injury (OSI) Joint Speakers Bureau (JSB), which was established in 2007. Speakers include Veterans, serving CF members, family members and mental health professionals. Intent on increasing mental health and OSI awareness through professional development briefings at the unit level, they are trained to deliver formal mental health and OSI education at CF schools across Canada, and general related information to CF families.

According to the web site, the aim is to “assist the Chain of Command in better preparing sailors, soldiers, airmen and airwomen in building psychological resiliency before and after deployments” and “provide tangible and useful tools for leaders and CF members to assist subordinates and peers who are affected by mental health issues.”


Capt Natasha Singh prepares a prescription at the R3 MMU in Afghanistan.

Psychological Trauma
I asked the Commander if non-combat related psychological trauma raised additional concerns in terms of mental health. This would include instances, as reported by returning Canadian soldiers, of being witness to the repulsive practice of Afghan authorities sodomizing young boys. Canadian forces are under strict orders of non-interference in local matters and soldiers have alleged that their inability to render assistance has created conditions of trauma.

“There is a Board of Inquiry going on [and the National Investigation Service is looking into these claims], it is premature for me to say if it exists, or how extensive, but if people are traumatized by whatever incident, trauma is trauma, suffering is suffering, and we’ll be there to help them along. Whether it’s physical or mental trauma, we look at that individually, so if an individual has personally experienced that and it is very traumatic for them and they need help, we’ll look after them. We haven’t had any evidence of an epidemic of mental health arising out of that.

“It doesn’t matter how you get ill, whether you get injured in Afghanistan or get involved in a motor vehicle accident in Canada, it doesn’t matter, PTSD is PTSD – if you’re suffering, we’ll treat you. The context is different, so we’ll tailor a treatment for that, and treatment exists.

As health care providers, we’re looking at you and your health, how you got it is somewhat irrelevant, and where you got it is irrelevant for us. From our perspective, [if] you need treatment we’ll provide that treatment, we don’t differentiate.

Therapy
Cognitive behavioural therapy is the gold standard for treating PTSD. The therapist and patient talk about the experience – learning how to react and live with those symptoms, and hopefully overcome them. Some researchers are looking at virtual reality, giving patients images of a combat situation similar to what they might have been exposed to. However, thus far, says Cmdre Jung, these new technologies are no better than a good client-therapist trusting relationship. “We are observing but nothing has come out that is clearly superior to what we are doing now.”

The human capacity for resilience may be the reason why more people aren’t suffering from PTSD. By current estimates, “about 6.5% of those exposed to trauma will experience PTSD,” says the surgeon General “the rest are going to come back fine, or even stronger because of the experience. And of those 6.5%, one-third will get better, one-third will improve, and the other third, like any disease, will have chronic disease or may never get better or may get worse over time.”


Wounded Warriors is a charity that supports existing programs that tend to Canadian soldiers wounded overseas. The group has raised more than $400,000 since 2006. Shown here, helping to raise funds are, from left: Paul Tracy, Indy car driver; Roza Parlan, Military Family Resource Center; Arch Wilcox, Honda rep; and 1 Area Support Unit CO LCol T. Bradley.

Most mental health discussions focus on the troops, but the medics are under stress as well. “When our medics come back they have to go through the same education process. They are less misinformed and better able to handle those issues, but we do keep an eye and them. Many of us have deployed, so we look after each other in that sense, but they have to go through the same screening as anybody else.” Medical training provides exposure to sicknesses and significant injuries and therefore “it is not as big of a shock when we see it. We see car accidents and occasional knifings; we don’t get bombs going off, but we do see the life and death issues, so it’s part of our training. If you couldn’t deal with that you couldn’t finish your training. You build up that resilience and ability to distance yourself and not internalize it too much, and it becomes part of your profession.”

Physical Rehabilitation
Amputations are extremely traumatic and life is permanently changed after that. To date, 19 Canadian soldiers have amputated injuries. Not long ago, many would have died because the medical capacity was not as good. “We have trained medics immediately on the ground, helicopters arrive, take them to the hospital in less than an hour, surgery, stabilization, all in less than 24 hours. They do another surgery, stabilize them, and bring them back to Canada. People are surviving that would have died in previous wars including the first Gulf war, however, their life is fundamentally changed.

Unlike the American system, where amputees are sent to the Walter Reed Army Medical Center for rehabilitation, “we recognize that family support and social networking is extremely important.” The CF maintains partnerships with seven civilian recovery and rehabilitation centres located near major bases across Canada. CF Health Services augments those services with its own physio and occupation therapists to ensure a high intensity for rehabilitation with the aim of achieving “the highest level of functioning as fast as possible. And if they are able to come back to military great, and if not, at least they have reached their highest performing level given their disability. We have a tremendous system, and that we don’t do 100% ourselves, we really partner with civilian institutions to give them the best health care.”

Captain Simon Mailloux, who lost his lower left leg below the knee, is putting his rehab to the ultimate test. He is preparing to return to the Afghanistan front. Another individual, a double amputee, is currently undergoing evaluation to see whether or not he can function in Afghanistan.

Times are definitely changing. The fact that these men lost one or two legs is not relevant to medical evaluators. The only consideration is “if a person can do the military jobs that are required for him or her, regardless of the diagnosis.” If they are mentally and physically fit, and they can go.

Wrap Up
“As health care providers, we joined the military to provide health care, and we are ready to provide that care, but it is not something that we as professionals do unto someone. It’s… not something that we can do unilaterally to you – it is something that we have to do in partnership. We’re here for you, come see us, and we’ll do everything in our power to give you what you need. If you don’t give us that opportunity, we can’t deliver, so health care is an activity that the patient and the physician have to do together. It is not, by any means, a ­passive exercise and that’s really what I’m looking at. We’ll observe medical confidentiality, but if you don’t give us the opportunity to help, there is nothing we can do. That’s the bottom line.”

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Chris MacLean is the Editor of FrontLine Defence.
© FrontLine Defence 2009

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