Report: S. Bailey (CANADA)
Canadian Forces Health Services
Road To Mental Readiness Programme
In 2007, the Canadian Armed Forces established a working group to consider new and innovative approaches to mental health training and education in the CAF, and was given the task of developing, delivering and evaluating mental health education across the spectrum of Canadian Forces audiences, including Canadian Forces members’ families.
The Canadian Armed Forces (CAF), like other militaries, recognizes that mental fitness and well-being are key contributors to operational readiness. When the findings of the CAF Supplement to the 2002 Statistics Canada Community Health Survey indicated that a significant portion (84-96%) of military members who met criteria for a disorder but did not use services indicated that they did not need services, it was clear that more could be done to help CAF personnel recognize distress in themselves and others, and encourage them to seek consultation if required.
A working group was established in 2007 to consider new and innovative approaches to mental health training and education in the CAF, and was given the task of developing, delivering and evaluating mental health education across the spectrum of Canadian Forces audiences, including Canadian Forces members’ families.The group, consisting of mental health clinicians working in partnership with military leaders and operational personnel, as well as military veterans with operational stress injuries (OSIs) and families, consulted with experts in adult education, the Canadian Mental Health Association (CMHA), and military allies such as the United States Marine Corps (USMC).
Research conducted by Megan Thompson and Donald McCreary at Defence Research and Development Canada (DRDC) was instrumental in developing an educational strategy to change attitudes toward mental health in the CAF (Thompson & McCreary, 2006). Drs Thompson and McCreary highlighted the importance of addressing beliefs and feelings underlying the attitudes to be changed; the role of persuasion, interaction, and professional credibility on the process of attitude change; and the combined role of evidence-based information and vivid personal accounts from credible speakers with operational experience. In addition, while an educational program could begin to have some impact on individual attitudes and behaviours, larger cultural change within the organization would require leadership support and policy change in order to be sustained.
R2MR program development was also informed by a set of guiding principles, developed by Dr Mark Zamorski, that are consistent with similar guidance from leading experts in military mental health training (Castro, C. A., & Adler, A. B. ,2009), and the NATO Implementation Principles for Mental Health Training (Van den Berge, 2011). The guiding principles recognized that any military mental health training must be integrated into the organizational culture, be based on clear requirements and needs, and built in a developmental fashion to progressively add concepts and skills over time. For the training to be well received and useful, it must also be experiential and action focused, using tangible skills to build flexible and adaptive coping with real-world application. Training content would need to be strengths-based, building on existing skills and abilities, while creating the positive expectancy that most people can manage most demands placed on them.
One of the key changes to mental health education delivery was the decision to pair trained mental health clinicians with military operators to co-facilitate the sessions. Thompson and McCreary identified that audiences would be more likely to change their attitudes toward mental health if the messages were delivered by credible, persuasive speakers who had operational experience similar to that of their target audience. The mental health clinician as co-facilitator also brings their experience of providing treatment to CAF personnel affected by mental health problems, and can credibly deliver the theoretical and practical knowledge of mental health issues in the areas of etiology, prevention, intervention, and resources. Both the clinician and the operator are also appropriately trained and must demonstrate that they can effectively deliver an interactive and engaging program to the intended audience.
Initially focused on mental health education at the basic training and primary leadership levels, the CAF implemented curriculum in 2008 that was focused on increasing mental health literacy, decreasing stigma and other barriers to care, and enhancing well-being and performance. One of the foundational elements of the program was the Mental Health Continuum Model (MHCM), developed in collaboration with the USMC. Using the Mental Health Continuum as an anchor, CAF personnel are provided with mental health education that normalizes mental health fluctuations, creates an expectation of recovery and wellness, and highlights actions that individuals can take to maintain or regain their mental fitness.
One of the key messages is that mental health and mental illness are merely two points on a continuum. Health, be it physical or mental, is a dynamic changing state that can deteriorate or improve given the right set of circumstances. Many CAF members have physical and mental health concerns that, if identified and treated early, have the potential to be temporary and reversible. The mental health continuum provides insight into the varying levels of mental health issues and offers guidance on the appropriate support depending on the severity of the condition. The arrow acknowledges movement in both directions, creating an expectancy of return to full health and functioning, and encouraging earlier access to care. Furthermore, as many CAF personnel suffer from mental health issues that are not operationally related, this training focuses not only on operational stress but also on non-operationally related stress and mental health problems. Non-OSI mental health problems cause similar functional deficits and have similar prognoses as many OSIs, and for that reason, they have the same implications with respect to readiness, operational effectiveness, force sustainability and overall well-being.
In order to help CAF personnel recognize symptoms of stress and distress in themselves and others, the MHCM was developed using common behaviours rather than diagnostic criteria (see below). The benefit of using observable behaviours is two-fold: it increases mental health literacy and awareness, while distinguishing common and reversible distress from more persistent conditions. Given the stated preference of many CAF personnel to manage their own mental health conditions, the MHCM helps to distinguish between early distress that can often be self-managed, and more persistent symptoms that would require professional assistance. This approach has enhanced the ability of CAF personnel to self-monitor, recognize their own early indicators of distress, and take action to regain a healthier level on functioning.
In addition to earlier recognition, the R2MR program focuses on stigma and other barriers to care, and includes time for interactive discussion aimed at challenging some of those barriers as well as increasing awareness of the broad range of resources available to CAF personnel. Thompson and McCreary had highlighted the importance of using two-sided messages, thereby acknowledging and then refuting negative attitudes, which can be more effective in promoting changes for complex attitudes such as mental health and OSIs. Over the past seven years, there has been a noticeable trend toward earlier care seeking, and the mental health continuum has provided a framework to better determine when someone should consider seeking care beyond self-management.
As the program has expanded, it has grown to include sessions for leaders across the organization, further embedding the knowledge within the CAF and reinforcing that health and well-being are a shared responsibility between the individual, their chain of command, and CF Health Services. Leaders at all levels have a key role in sustaining the mental readiness of service personnel under their command, and the program provides leaders with information and practical strategies for dealing with stress and the provision of psychological support. The goal is to enhance personal and unit effectiveness in modern military operations, whether at home or on deployment.
More recently, the R2MR program has incorporated detailed information about the stress response and its potential impact on performance and decision making. The explanatory approach, advocated by both Zamorski and Van den Berge, highlights misunderstood reactions and provides a scientific explanation for why individuals should apply strategies to better manage their response to stress. Some of the leadership training also highlights the role of leaders in reappraising stressful situations, reinforcing the knowledge that overcoming the impact of stress often leads to increased confidence, new skills and strengths, and a renewed sense of purpose in life.
Building on the outcomes of a similar program implemented by the US Navy Seals, the CAF has adopted four primary skills or countermeasures (goal setting, self-talk, mental rehearsal, and visualization) that have been proven to be effective in managing physiological responses to stress and enhancing performance. Curriculum for certain occupations includes a fifth skill, attention control, which is aimed at helping them to effectively direct their attention to appropriate cues for the duration of a task while screening out irrelevant external and internal stimuli. While the same skills are taught in both the career and deployment training, they are tailored and adapted to the rank, task, occupation, environment or mission. Minimizing the number of skills keeps it simple, thereby increasing the likelihood that participants will recall and practice applying the skills. Repetition of the skills reinforces learning while demonstrating that the skills can be applied to a wide range in situations in both military employment as well as day-to-day life. This is particularly relevant, as we know that daily hassles and psychosocial stressors can have as much or even greater impact on our mental health as acute adverse events.
While the explanation of why the skills are important and how they work can lead to better audience engagement, program evaluation conducted in collaboration with DRDC has demonstrated that repetitive application and practice of the skills in the training environment is essential for retention and effectiveness. This information has reinforced the importance of instructor training, standardization and quality control of content, and fidelity checklists for each curriculum package. While much of the research that informed early program development had mentioned these factors, recent evaluation outcomes have underscored some of the challenges of ensuring that the program isdelivered in the way it was designed and intended. Ongoing research continues to confirm that there are many details to be considered when implementing a nationally standardized education program if the training content is to be effectively applied in both the short and long term.
Efforts are underway to ensure that the R2MR mental health education program meets the unique requirements of all CAF elements and occupations, with specific attention to high-risk occupations such as Search and Rescue Technicians, Special Operations personnel, and the Health Services clinicians who provide medical care. This work will further embed the key skills and knowledge in the specialized training for these occupations while ensuring that it is adapted to better manage the distinct demands of such employment. Recent trials of unit-level training, whereby unit personnel are trained to deliver the program within their own sections, has also demonstrated tremendous effectiveness and will continue to be assessed for wider implementation across the organization. Additional tailoring and application of the skills will also be facilitated with the release of mobile applications for each of the skills taught during the R2MR training, as well as a Mental Health Continuum app that will allow individuals to monitor their own health behaviours and determine where additional attention or resources may be required. It is anticipated that such mobile applications will provide CAF personnel with the opportunity to customize each of the skills and apply what they have learned to a variety of potentially stressful demands in their lives.
As with any training program of this scope, ongoing research and validation will continue to inform development and delivery, in order to maintain the most scientifically current and relevant programming.
LtCol Suzanne Bailey, MSM, CD, MSW, RSW
Source: Medical International Forum (2/2015)