Note: Where available, the PDF/Word icon below is provided to view the complete and fully formatted document
Foreign Affairs, Defence and Trade References Committee
Mental health of returned Australian Defence Force personnel

McGUIRE, Dr Annabel Leslie, Private capacity

CHAIR: Welcome. Is there anything you would like to add to the capacity in which you are appearing today?

Dr McGuire : I am appearing essentially as an individual today. I was going to explain how I came to be here and why I think I have an opinion to offer in my opening statement.

CHAIR: All right; after you make a brief opening statement, we will go to questions.

Dr McGuire : I thought I would give you my professional background first. I did a PhD through the Australian National University and I looked at the expertise in military tactical decision making. My first job after my PhD was back to the Chief of Army doing an evaluation of their formal military decision-making processes, so at the end of that I spoke reasonably good military.

A job opened at the Centre for Australian Military and Veterans’ Health for a postdoctoral research fellow, and I won that position. I finished when the centre closed at the end of last year as the acting director and director of research at the centre. I was the chief investigator on the Timor family study, which looked at the consequences of deployment for families. I was the investigator on the Bougainville, East Timor and Solomon Islands studies. I was the project manager for the review of PTSD treatment programs for the Department of Veterans' Affairs. I wrote the first working draft of the questionnaire for the MEAO census study. I am currently an adviser to the Defence Health Foundation's scientific advisory board, I am on the board of Legacy in Brisbane and I am a scientific advisor for the University of Otago veterans' research theme.

From a personal perspective, I am the wife of a person who finished his military career as a senior military officer; he is no longer in the military. He served for 26 years. In that capacity, at various times I played a welfare role as the wife of a senior military officer. He deployed to Cambodia, Timor, Iraq and Banda Aceh, so I know how to hold my breath for a very long time. I am here because for the first time in a very long time I am not running any studies being funded by defence or DVA, I am not working for a university and I am not earning any money through this system, so it is one of those rare times when I can offer an opinion without an agenda. That is why I wrote and made comments to the committee.

Senator LAMBIE: Dr McGuire, what is your biggest point of contention? What have you noticed that you find quite disturbing?

Dr McGuire : For me personally, as a researcher, it was that I would do a lot of work that I felt quite passionate about, but there was rarely the opportunity to have a discussion with the departments about what that research meant and what implications it might have for policy. We would present a report, which would be tabled in the appropriate ways, but when you are doing that kind of research and you run the focus groups and you talk to the participants, there are always things that do not make it into a formal report. I would have loved the opportunity to work with the departments to get the most out of it.

I also think that when you conduct large and expensive research, if you cannot see tangible outcomes that come from it and if these are not visible to the people who participate in the studies, then you are not going to get people to participate in the studies again. So you end up with a disenfranchised ex-service community that does not want to fill out another study because they cannot see where it is going and what it is doing. I would always like to see that better connection—and a very overt connection—between the work that was done and the outcomes that were made. I also sometimes think that when we, as academics, design studies with the departments it would be better if we and the program managers at both Defence and DVA worked together initially, before it went out to tender, to make sure that we are asking the right questions, because sometimes we ask questions without necessarily looking at getting to the point where we are getting the right answers.

Senator LAMBIE: How many of your recommendations from the 2012 studies have been adopted?

Dr McGuire : I was not allowed to make recommendations for the 2012 Timor study.

Senator LAMBIE: So you just wrote the report with no recommendations.

Dr McGuire : I wrote the report and I tried to give some sense of where I would go and what I would do next, but they encouraged me not to have recommendations in the report, so I did not. By the same token, I think one of the big things that sometimes gets lost in things like this is that there are a lot of military families—and I am one of them—that are doing very well. I do not think that we should ever imagine that everybody that ever served or deployed in the military is broken. I would personally like to see more work done in the space before people get broken so that wives and families understand the difference between what is a normal adjustment period upon return from deployment and what is not, because you cannot walk out of a war zone and back into Brisbane's sunny streets and feel exactly the same way two days later. But reacting then is not being ill or having a mental illness. It might be a problem in six months time, but immediately post deployment that is normal adjustment.

Senator LAMBIE: How much did the taxpayer pay you to do this report, such as it is, without recommendations?

Dr McGuire : The study was funded at just over $2 million.

Senator LAMBIE: And there are no recommendations with that report. Do you know why they would not ask for recommendations with your report? Why would we pay nearly $2 million for a report that does not come with recommendations?

Dr McGuire : I do not know how to answer that.

CHAIR: What was the tender document?

Dr McGuire : It went to tender. The tender document was to look at the health consequences for families of a military member who served in Timor compared with somebody who did not serve in Timor. At the time we were doing that study it was very difficult to unpack the people. People who had served in Timor had also served in Iraq and Afghanistan, and there was a group of people who had not served on any deployments or had not served in Timor, and that was a little conflated.

CHAIR: There was a tender document that went out?

Dr McGuire : Yes, there was a tender document.

CHAIR: There was a description of the study?

Dr McGuire : It was to answer those questions and to look at what the risk and protective factors were.

CHAIR: What were the outcomes sought by the tender? The tender would have stipulated some outcomes, would it not?

Dr McGuire : It was to write a report that addressed those two questions, which we did. The report found that there was no difference between Timor deployment and non-Timor deployment on physical, mental or psychological health outcomes for families, remembering that you have deployed groups in both, so there were probably sample size issues. It saw that about 10 per cent of children of deployed families were showing extended signs of distress, which is close to Australian norms, and about 20 per cent were showing some signs of distress. There was a correlation between more deployments and poor outcomes for partners, in terms of psychological health and particularly PTSD, and there was a correlation between more deployments and poor outcomes for children.

CHAIR: Is this report published?

Dr McGuire : It is available on the DVA website.

CHAIR: What purpose is it used for? Is it used to inform public policy?

Dr McGuire : It was to inform the department about what was the state of health of families.

Senator LAMBIE: How many veterans' families did you include in this survey?

Dr McGuire : We had 4,000 current or past ADF members and 1,300 partners participate in a quantitative survey. We also ran focus group questionnaires, and about 900 couples participated in that. One of the issues we had was that participation for the partners had to be with the permission of the ADF member, because of privacy legislation. We could not actually go directly to partners and ask them; we had to go through the ADF service member.

Senator LAMBIE: Do you believe that most of your business would be taken away if all of the war veterans were guaranteed access to the health benefits of a gold card?

Dr McGuire : No, because I think there are still issues around looking at and monitoring what are best treatments, evaluating the outcomes of treatments and ensuring that we continue to monitor and improve what can happen. Every piece of research I have done shows that there is a strong correlation between working and health, so I am always a little nervous about having a straight compensation system. Equally, I know that the Australian Longitudinal Study on Women's Health looked at World War II widows who had a gold card, and it found that they did not use more medical services than other widows of the same age, but they did feel better about it.

Senator LAMBIE: Would that slow the suicide rate down? If they felt better about themselves, they could get those services and they did not have to fight a bureaucratic system, do you believe that would help the current suicide group?

Dr McGuire : I think you also have to be prepared to ask for help. One of the consistent findings across all of the research that I have done is that the people who find it hardest to ask for help are the people who are more likely to need it. There is a strong correlation between high symptoms of PTSD and perceiving more barriers to care. I think that you have to very careful in how you offer that care. It has to be an 'any door, right door' policy that comes together with compensation, rather than just straight compensation.

Senator LAMBIE: Do you think they will not ask for help because they have no trust in Veterans' Affairs?

Dr McGuire : I do not think it is a problem that sits just with Veterans' Affairs; I think it sits across a whole range of things. If you are not feeling well, everything seems hard. The sicker that you feel, the harder everything seems—so, yes, I think an easier and less bureaucratic system would be better, but I do not think that it would be a solution to everything.

Senator LAMBIE: With $2 million, what recommendations would you like to bring forward now? If you were putting recommendations into place, could you please tell the inquiry what those recommendations would be?

Dr McGuire : Military members are within a family unit; it operates as a unit. When one member is not doing well, be it the partner or the military member, that has consequences for all of the family. There needs to be better education of military partners about what is normal and what is not normal, and when that changes. So, when you first return from deployment and you are tired and cranky and you start at the backfiring of a car and have a bit of a panic attack, if it is within a couple of weeks of return, maybe that is a lifesaving reaction. If it is six months later, maybe there is a problem. I think having education available to families so that they do not panic at the first sign of distress and so that they know which door to go through to ask for help would be a great thing. I think that there is work to be done.

There are things that happen relatively easily for the people who are really ill, because there are actions for them. For the people that can get a little bit of help at the right time, that can tip them to the balance of having a better outcome; if they get no help at that time, that can tip them towards having a poorer outcome. I think some work could be done around education and low-level support. With some of the work that VVCS does in that area, where a family member can access VVCS—if their partner has eligible service—to ask for support, I think that is fantastic. It is exactly that kind of thing that makes a difference. I do not think that enough people know that that option exists. As recently as last week, I spoke to a senior still-serving military member and said, 'But don't you know that your guys could go to VVCS?' 'Doesn't that have to be through Defence?' 'No, it does not. They can access that themselves.' So I think there are some big holes in how we educate and how we get the military members—serving and not serving—and their families to understand what support is available to them.

Senator FAWCETT: You made the comment about eligible service. Given that there are a whole range of triggers that can cause PTSD or other mental health issues and they compound and people hide them and go on deployments regardless, would it be a better situation where people did not perceive there was that barrier but any family member of a serving serviceman could reach out to a social worker or a psychologist and seek in the first instance advice and support if they have concerns rather than perceiving there is this barrier of eligibility?

Dr McGuire : I absolutely agree with that, and I think there are enough things that happen with service whether you have deployed or not, and certainly there is evidence in the data that deployment is not the only thing in the military that is likely to cause you mental or physical health injuries. I think you need access to your support when you need it or when you have a question about do I have a problem, is this normal behaviour, should I worry—then, yes, I think eligibility creates its own problems.

Senator LAMBIE: Are you telling me that Defence is failing to get the message through to give you the options that you can take if you want to take them?

Dr McGuire : I think it is both things. I think it is Defence, the department, and the preparedness to listen. People have to be willing to hear the message and hear what it is. I cannot tell you how many conferences or think tanks or whatever I have been to where somebody said, 'We really need this service' and somebody across the other side says, 'We do that.' There are a lot of things that are out there and available—it is how you access them at the right time and in the right place.

Senator FAWCETT: You say in the submission that the majority of people know that services exist and know where to get the help but choose not to access those services.

Dr McGuire : Some people know where to get help. One of the really interesting things that we consistently find in our study is that the people who are showing fewer symptoms particularly of psychological distress say that they know where to get help, they know what is available to them and if they felt they needed help they would go. The people who are showing signs of psychological distress are worried about the impact it would have on their career, they do not know whether they would ask for it, they worry it would be too expensive and all sorts of other things. So the worse you are doing, the harder it is to ask for help, which means the more support you need from the hierarchy, your mates, your friends saying, 'Come on, mate, I think we should go and see VVCS, let me set you up an appointment, or 'How about going to the Mates for Mates drop-in centre?' There are any number of things. It has to be that holistic education not just for the people who need it. One of the things that the UK do a lot of education on is looking after each other, taking a friend along and saying, 'I don't think this is quite right, let's get it checked out.'

Senator FAWCETT: I guess the reason for the question is that there are a number of elements that have to be joined up for this to work—first, the services have to be provided; second, people have to know about them; and, third, they have to be prepared to access them, which means admitting the fact that they have a problem, whatever vehicle that then takes, whether it is a friend who takes you. It is important for this inquiry to get a good sense for do we have enough programs that are not accessed enough, do we have a lack of suitable programs—that is one question—and the second question is are they advertised well enough, do people know how to access them, and the third question is are there barriers—and you have identified some and every inquiry has identified the reluctance to identify because of impact on postings or deployments or promotions or other things. For our recommendations—and we will have recommendations—we need to know where to target the effort. That is why I am interested to understand whether we have enough programs, do people know where to get them, is it really the hurdle or barrier to identification that we need to be addressing as a priority.

Dr McGuire : I think it is the barriers to identification that I would address first. There are a lot of programs out there run at a government level, by a funded independent level, by people running their own businesses.

There are a number of programs where there is not validation or check of their efficacy or what they are doing. There are a number that we keep getting. The point was made before about having collaborative efforts between ESOs. I certainly know that at Legacy they are trying to look at ways for ex-service organisations to collaborate together, rather than compete, because we have people trying to do the same thing and compete for the same dollar.

But people want their story and their version of their story and their needs to be heard, and they might feel that one organisation does not do that so they set up their own. And I think that is the difference between the needs of the individual and the need to contribute and do good—rather than necessarily the need for service. I am not sure that you could actually ever pull apart those three aspects, because they go together.

Senator FAWCETT: Sure. There are some really interesting findings here about the fact that non-commissioned officers and other ranks were significantly more likely to have sought help than officers. It surprised me a little bit to see that finding. But did you glean any feedback as to what kinds of things would make people more likely to report? For example, we have had some discussion over the last number of witnesses about whether Defence could find a way to work with an individual and say: 'Look, if you want to redeploy but you are prepared to identify, we will help you and provide support. So it is not going to finish your career. You will be able to redeploy.' Because they are doing it anyway; they are just choosing not to report and they are deploying. Do you think that kind of measure would be enough to encourage people to seek help early? Or do you think it would not make a difference?

Dr McGuire : I think cultural change takes a long time, so I think it would take time for it to make a difference. With the policy change, they now deploy people who are using effectively treatments for depression. I would much rather deploy with somebody or have an airline pilot who was actively treating his depression fly my plane than somebody who was not being treated. I think that Defence could do a much better job. If they had the support of the person who had undergone treatment and deployed again, and they could say, 'See, we helped this person and now they are deploying'. I think we keep the success stories quiet. I think if you could show consistently and demonstrate—and I know examples where that has happened. If you made that part of the discussion and the lexicon—'So-and-so did it; you can do it'—then you would get this gradual shift.

Senator FAWCETT: With those case examples, were they anxiety or depression or were they PTSD?

Dr McGuire : I am not 100 per cent sure.

Senator FAWCETT: Sure.

CHAIR: In amongst all of this, where does the Privacy Act fit in—if people do not want to self-identify, and other people can see a problem? I mean, where does the Privacy Act come in? Does that actually compound the situation?

Dr McGuire : When I talked about the Privacy Act, I was talking about it in terms of the study and how I could access partners to participate in the study. I am not sure how the Privacy Act influences directing people to care or supporting them to get health care. Certainly I do not think you can make somebody do it.

CHAIR: Okay, thank you. Senator Fawcett.

Senator FAWCETT: My last line of questioning is around families. We have heard again and again that families are a crucial element to supporting the service man or woman to move through whatever they are facing. I have two questions for you. How can we better inform families about the support that is available to them? How can we change? Things like that eligibility—what can we change structurally to make the support better? And, lastly: are there areas of actual support for families that you have heard, seen or experienced that are lacking?

Dr McGuire : The first thing is, if you want to better inform families, you have to inform families directly and not through the serving member. You have to provide that information to them directly. At the moment, the channel for information flows through the serving member, and it is their choice whether they take it back to their family or put it in the bin. Anecdotally, a lot of people just do not want to tell their partners that kind of information.

Some information goes out to families if they are a registered family member on the personnel register. There are mechanisms for some information to go out to them. There is very limited support for families in and of themselves. It is the duty of care. The mechanism of injury is through the veteran. The support that is available directly to family members is, except in the case of vvcs, quite low and varies a lot. It depends a lot—particularly around deployment—on the welfare officers and the people in charge of that unit when it is deploying. Some people do a great job and other people do not. Again, there is that example of what is a great job and what you should be doing and what you get better results for.

Senator FAWCETT: The DCO used to have staff who reached out to families. We have heard a lot of stories about that service contracting or being resource constrained. If major bases, like Enoggera, had social workers available to proactively work with unit welfare officers to reach out to families, is that a model you think could help?

Dr McGuire : When I was first married there were more 'family liaison officers', they were called at the time. It comes down to what you keep hearing: that individuals do a great job. I think that model could help. Having more people and resources to help families when they need it would be beneficial.

Senator FAWCETT: We talked a lot about families and the burden they share, both partners and children, if somebody has PTSD. We see a number of marriage or relationship breakdowns. A family may have been damaged over 15 years. The marriage breaks down. The currently serving or ex-service member moves away. Do you have any evidence from the work you have done that there are families now who are, essentially, cut adrift from any support mechanisms because they are no longer related to a serving or ex-serving member but are still suffering the consequences?

Dr McGuire : Anecdotally, yes, but not from the studies. The study we designed did everything it could to get ex-partners to participate. We got less than a handful, which made them very identifiable so we did not look at any of the results. To my knowledge, there is not a great deal available if you are no longer the partner.

Senator WHISH-WILSON: I am interested in how important the issue of privacy was in your study. We have heard a lot of evidence directly from vets themselves, mostly young vets, around the stigma and not wanting to talk to anyone about problems they may be having. When you did your study did you find that you got the information you wanted? I am trying to work out how much of this is hidden from statistics, from studies like yours.

Dr McGuire : We did a lot of extensive phone follow-up to make sure that we got as many people to participate as we did. We called mobile numbers because mobile numbers are more likely to stay with the person. Their last known address may have little bearing on their current address. When we explained that we would not give personal information to either department about them, we would get them to participate. On the other side of the coin, I think the people who are travelling worst do not have time to participate in that kind of study and they have very little faith in what a university researcher is going to find. I do not think you get the extremes participating.

Senator WHISH-WILSON: We also heard from a younger veteran, yesterday, who had quite severe symptoms a decade after he left the service. He was still working in a military environment and refused to acknowledge he had up problem—up to the point where it nearly killed him. We have been hearing that often 10 or 15 years down the track vets can develop these problems. With studies like yours or the bigger studies like the Mental Health Prevalence and Wellbeing Study, that is often used and quoted in the media, are you confident they are capturing the silent problem that is taking time to emerge?

Dr McGuire : I think they are a snapshot in time. The US Millennium Cohort Study was originally funded for 21 years. It started before the first deployment to Iraq or Afghanistan. They are following people and adding new people to their study all the time. They are getting a lot more of a sense through that kind of work of the progression of illness.

In my personal opinion, I think you see the emergence of mental health problems at key points of change in your life. So when you leave the military and you lose your comradeship, your mateship and your normal work support mechanisms, that is one of the points where you might see symptoms of mental health or poor mental health emerge. When your marriage breaks down, it is another point where you might look around and think, 'Maybe I'm doing as well as I thought I was; something is wrong here.' When you change jobs and when you retire, these are all points that give you pause for thought to evaluate your life and give you that space to look and see, and to notice, because you are not able to mask what is happening to with work and other things. Yes, I think you see mental health emerge, apparently, for the first time, or the first seeking of support for it, at key points of transition in life.

Senator WHISH-WILSON: Would many of the people you surveyed had done multiple deployments at that stage?

Dr McGuire : Yes.

Senator WHISH-WILSON: So that would have been captured in the—

Dr McGuire : Yes. We also had a group of partners participate—I think it was around 100—whose military member was on deployment at the time. Funnily enough, the only difference that they reported was fewer arguments. That was the only difference we could find between partners of people who were currently on deployment and partners of people who were not on deployment. Obviously, you have to be with somebody to argue with them.

Senator WHISH-WILSON: In terms of the Mental Health Prevalence and Wellbeing Study, not only have we heard politicians but we have heard some fairly senior bureaucrats in DVA quote that study and say that incidences of mental health of PTSD are not any different in Defence communities, or are not much different to incidences in the civilian population. Do you accept that that is simplistic? Or do you think that is an accurate assessment?

Dr McGuire : I think that is an over simplistic view of it. One of the common numbers that you hear quoted is that there is eight per cent across the Defence Force. Where you measure across the Defence Force—and I have seen the numbers—I have no doubt that the numbers, as they studied them, were absolutely true. But, as you would have also heard, the experience of deployment is quite different. Some people deploy and do not make it into country because they are in a supporting location. Some people will never leave the base and go on patrol. Other people will actually be in combat. I think you have different rates of likely mental health problems depending on which group you belong to. Eight per cent is probably accurate across everyone, but if you started to look at ex-serving members who had a combat role and left military service with less than MEC class 1, then I think the rates of mental health in that smaller group would be much higher.

CHAIR: Are those stats publicly available?

Dr McGuire : Yes.

CHAIR: So people who actually go on patrol or are in the SAS, are those injury rates—

Dr McGuire : Not in the SAS. We were never allowed to look at SAS unpacked separately because of particular concerns around the SAS. If you look at the MEAO census study and you unpack some of the things—again, it was only a snapshot in time and we were not that far from the deployment—the highest rates of reported PTSD were in ex-serving military members.

Senator LAMBIE: How do you get a true account though if they are not going to come forward and tell you they have PTSD because they know their careers are on the line, albeit the PTSD does not hit them until further on in life? How do you actually get an accurate account for that?

Dr McGuire : I think you monitor over time. With the idea of a snapshot study—and this was one of the points I was trying to make in the report—if you do one-off studies, they are not going to be a panacea for all the problems. It is about monitoring over time. With DVA, if you actually track their statistics—which I have done—you can look at the increasing number of accepted claims for PTSD over time. You can compare the number of Vietnam veterans with accepted PTSD claims with the number of people who deployed to Vietnam, and with Iraq, Afghanistan, Timor and Solomon Islands, and you kind of unpack their own data.

Senator LAMBIE: What about depression rising out of chronic pain or abuse-related PTSD? Do you do studies on that?

Dr McGuire : No, I have not done any work on that.

Senator WHISH-WILSON: This is probably an unusual question: given your understanding of this issue, are you able to comment on whether there are any differences in resilience of mental health in Defence populations over time—between generations?

Dr McGuire : I do not have the data to comment on it in that sense. Do I think that the work that Defence and DVA do—the very fact of talking about mental health and that there are places to go to seek help and support will help improve things overtime? Yes, I do. But I do not have any data for that.

CHAIR: Thank you very much, Dr McGuire, for your evidence and for coming here today.

Dr McGuire : Thank you.