Overview of roundtable discussions – November and December 2021

Roundtable participants told Commissioners of the importance of research that examines data relating to self-harm, in addition to data on suicide, and data that can identify what works well and the factors that lead to good mental health outcomes. Participants noted that there has been considerable progress in collecting and sharing data on self-harm and suicide attempts across Australian states and territories.

The Commissioners heard that groups of experts with decades of research and clinical experience have collaborated, over many years, on large, data-based mental health projects. Roundtable participants referred to a self-harm monitoring report published by the Australian Institute of Health and Welfare, which may be relevant to the Royal Commission’s work.

The Commissioners were told about a study of 5,000 participants that includes data on Gulf War veterans. Evidence from the study showed that up to 18% of individuals experience mental health and wellbeing problems within 1 year of entering military service. The trajectories of ex-serving ADF members who died by suicide can be tracked through studies like this one. The Commissioners heard that these large datasets also hold opportunities for further research.

Roundtable participants also suggested that it is important to identify gaps in research, and not just build on existing research, in order to gain a better understanding of these issues in the Australian context. Participants stressed the importance of data linkages with self-harm data from admitted patients, emergency departments and ambulance to improve understanding of self-harm behaviour and the use of services, although there are still challenges in identifying and coding self-harm behaviour. Projects such as the Turning Point’s National Ambulance Surveillance System aim to fill some of the data gaps.

The Commissioners heard that, currently, there is a large data gap when members leave the Australian Defence Force (ADF). Unless members become clients of the Department of Veterans’ Affairs (DVA), very little is known about them. The latest Census has attempted to fill that gap by including a question on ADF service. The data from the Census are not yet available, but roundtable participants believe it will provide a better understanding of ex-serving ADF members once available.

The Commissioners heard that data linkage has enormous potential to provide extensive insight into suicide and self-harm, and that there is much work already being conducted in this field, with a good deal of collaboration and data sharing between agencies. Quantitative analysis of large datasets can identify risk factors specific to military service associated with serving and ex-serving Australian Defence Force (ADF) members. Roundtable participants told the Commissioners that collaboration on data linkages between agencies is critical. Creating these linkages will be complex and costly but necessary. They recommended identifying particular opportunities, such as the high yield, relatively low cost datasets already available, and maximising data usage and data linkage.

Roundtable participants referred to current data projects like the Multi Agency Data Integration Project (MADIP), which includes nationally important datasets such as the Census, Australia Taxation Office data, admitted patient and emergency department data, Medicare, and Pharmaceutical Benefits Scheme (PBS) data. There are further opportunities to include other datasets, such as ambulance and family violence data.

The NIHSI (National Integrated Health Service Information analysis asset) is another large linked dataset, linking across state and territory health data such as admitted patient data, emergency department data, Medicare and PBS. These data may provide insight into the ex-serving ADF member community.

The Commissioners heard that better quality and more consistent data are needed across various datasets, as not all datasets are available across all jurisdictions. A lot of data have been collected at different points in time but bringing it all together is key. For example, non-government organisations often collect data, although not in a consistent manner, according to roundtable participants. However, the Commissioners heard that there is an ongoing goal of improving both quality and access to key datasets nationally. There is work being done in Australia to streamline data linkage and make it a quicker and easier process. Currently in Australia, data linkage takes a long time and is very resource intensive. The National Disability Data Asset is involved in designing a potentially new approach to data linkage.

Participants told the Commissioners that linking data allows exploration and understanding of how an ADF member uses service systems, rather than just individual services. There is information in individual datasets on the use of individual services. However, linking data will provide insight into how service systems as a whole are being used, who is using them and the outcomes.

The Commissioners also heard that the Department of Veterans’ Affairs and ADF may be looking into developing a longitudinal dataset (Data Sharing and Analytics Solution (DSAS)), which is in the initial planning stages, and could help with this data linkage as well as providing essential longitudinal data.

Longitudinal datasets capture information on an ADF member’s journey from induction, through service, transition and post-service. Such a dataset will foster understanding of ADF members’ progression from induction to post-service, how they access and use services and supports, and responses at different points in their career.

The Commissioners heard that individuals could be tracked through their data. This would be independent of their diagnosis and include both ADF members and their families. So if they do present with, for example, post-traumatic stress disorder or suicidality, it would be possible to understand the path they have taken up to that point, including their experiences in the ADF and post-service.

The Commissioners heard that it is important to include families in any research on the suicide of serving and ex-serving Australian Defence Force (ADF) members. As family members can both support ADF members and be a risk factor, roundtable participants said that it is necessary to understand how the family context operates in relation to suicide, self-harm and mental health. It is also important to understand the impact of ADF service on family members.

Linked data allow analysis of how ADF family members are using and accessing services, including but not limited to mental health services, housing services and family violence services. The Commissioners heard that current research into the role of families in the ADF includes the Defence Family Survey, and the Family Wellbeing Study undertaken by the Australian Institute of Family Studies.

Participants said that there is consensus about the capacity to produce high quality research, based on (a) underused existing datasets, (b) increasing opportunities for new research, and (c) translation of research into practice.

Translating research into practice

The Commissioners heard that it is important to establish an interface between research output and clinical care engineering and delivery. Some roundtable participants believe that the lack of interface means research will achieve little more than communication between researchers.

Roundtable participants recommended a drive to develop and use evidence-based models and modelling-informed interventions. An example is the ‘dynamic model’, exploring the population level factors that are likely to drive poor mental health outcomes, including (but not limited to) death by suicide.

The Commissioners heard from roundtable participants that the process of joining the Australian Defence Force (ADF) can be a change in itself that leads to suicidal ideation. Roundtable participants recommended that thinking about transition should start at orientation and be carried through an ADF member’s entire career. This may include strengthening screening at recruitment to determine or predict how a person will adjust to the cultural shift involved in military service and to identify risk factors for individual members.

Stakeholders recommended that the Royal Commission examine the broader context of ADF service, including training, deployment or service, and transition. This may assist in discovering whether suicide rates spike at different times or whether they are higher overall than the national average.

Recruitment

The Commissioners heard that some applicants are attracted to military service because they seek a sense of belonging and perhaps ‘the family they missed out on’. Such applicants may be particularly vulnerable towards the end of their service or if they are forced to leave the ADF involuntarily.

The Commissioners heard that the primary recruitment issues were screening and the financial incentives driving recruiters. Roundtable participants suggested that those incentives might lead recruiters to miss or overlook vulnerabilities that should preclude recruitment, including where an applicant might under-report or not disclose past or present mental health conditions.

Training

Roundtable participants told the Commissioners that basic training in the Australian Defence Force could be seen as subjecting people to ‘abnormal and unreasonable pressures’.

The Commissioners were asked to consider whether the disciplinary processes used in basic training, as well as the management of physical injuries, would be seen as fit for purpose in other modern workplaces. The Commissioners were also asked to take into account that recruits are initiated into a culture that considers asking for help to be a sign of weakness rather than strength, especially when it comes to mental health.

Deployment

The Commissioners heard that experiences on deployment, including repeated deployments to conflict zones, were a potential contributing factor in the suicide of serving and ex-serving Australian Defence Force (ADF) members.

While post-traumatic stress disorder is considered among the most concerning conditions for serving and ex-serving ADF members, roundtable participants stressed that physical injuries (back, knee and joint problems) can also lead to depression and are thus significant risk factors.

The Commissioners were asked to consider that there is a culture of fear in the ADF related to losing one’s position, being withdrawn from operations, and risking future opportunities. Roundtable participants told the Commissioners that this culture can lead to chronic under-reporting or lying about physical and mental conditions.

The Commissioners heard that post-deployment management and transition need greater attention to address the following key points.

• The loss of purpose, community and identity that comes with post-deployment and especially discharge.
• A perceived lack of appreciation or recognition for one’s service, which is manifested as bitterness or anger.
• Focusing on how to support families through this process and giving them the skills needed to support service personnel when they return home.

Transition

Roundtable participants discussed the need for a better, seamless transition from Australian Defence Force (ADF) service to discharge. They particularly noted the delayed or late onset of illness in ex-serving ADF members. The Commissioners heard that a better system of referrals should be developed to address mental health issues, as well as more nuanced support for families. Stakeholders discussed the role and function of the Joint Transition Authority, and other models, including mentoring of ADF members through transition.

Roundtable participants suggested considerations other than suicide deaths that may assist the Royal Commission, including:

• Transition points – there is a need to examine gaps in support, especially for ex-serving ADF members.
• Exploring opportunities for business mentoring programs for serving ADF personnel in preparation for transition.
• How support services for ex-serving ADF members operate alongside other systems.
• The need to provide support both while an ADF member is in service and on separation.

The Commissioners heard that there is much that is not known about the effects of involuntary separation and discharge. Roundtable participants said that data show that there is a very high degree of suicide risk associated with involuntary discharge. They told the Commissioners that a more nuanced understanding of involuntary separation or discharge might mitigate the adverse effects of separation, and further or later risk of suicide.

Health care for serving and ex-serving Australian Defence Force members

The Commissioners heard from stakeholders that serving members of the Australian Defence Force (the ADF) feel discouraged from seeking help because they fear the stigma and consequences of seeking help. It was suggested that this is especially the case if ADF members experience psychological difficulties, and that this stems from ADF command’s approach to mental health issues, whether real or perceived.

The Commissioners were invited to consider whether organisational culture contributes to the distress of people trying to navigate Australian Defence Force and Department of Veterans’ Affairs processes.

Roundtable participants stressed the importance of organisational culture, which should be restorative and just, rather than focused on blame and retribution.

Australian Defence Force culture

Disincentives to seeking help

The Commissioners heard that there is Australian Defence Force (ADF) resistance to support services having direct access to troops, which results in a lower number of referrals than would be expected (compared to other workplaces and organisations). Roundtable participants suggested that ADF members’ concerns about confidentiality may also contribute to the low number of referrals.

The Commissioners heard that mandatory reporting of physical or mental health issues in the ADF may be a disincentive to seeking help. Roundtable participants recommended the development of options for those in need of help that did not result in the end of their career. Participants recommended that ADF members be able to raise issues with their immediate line of command without escalation and removal from service. They could instead be referred to a chaplain or counsellor, and to appropriate support services.

Factors in under-reporting health issues

The Commissioners were asked to consider whether the disciplinary processes used in basic training, as well as the management of physical injuries, would be seen as fit for purpose in other modern workplaces. The Commissioners were also asked to take into account that recruits are initiated into a culture that considers asking for help as a sign of weakness rather than strength, especially when it comes to mental health.

The Commissioners heard that such a culture gives rise to under-reporting and hiding of physical injuries and mental health issues for a number of reasons, including that ADF members want to avoid:

• missing out on deployment
• missing out on postings
• missing out on promotions

being perceived as weak in an institution that values and rewards strength, and in which weakness is not only punished through official sanctions or consequences (such as the three outlined above) but also unofficial repercussions (such as bullying and social ostracisation).

Roundtable participants suggested that this culture developed around 1991-92, when it was decided to reduce the size of the military by attrition. They told the Commissioners that medical classification was used as a means of removing people from service and thus streamlining or thinning the ranks. Roundtable participants suggested that this system of official and unofficial sanctions or consequences for being perceived as weak has resulted in a widespread culture of fear in the ADF.

Mental health

Mental health interventions

The Commissioners heard that, in order for interventions to be more effective and have greater uptake, they need to transcend historically siloed service systems, notably those of the Australian Defence Force (ADF) and the Department of Veterans’ Affairs (DVA). Roundtable participants reported that isolated mental health interventions lack reach, are costly and are more difficult to replicate. An all-in approach to the design, development and implementation of mental health interventions has greater capacity to produce more effective results for all stakeholders.

Roundtable participants invited the Commissioners to consider the US Veterans’ Affairs Reach Out portal, which enables ex-service military personnel to engage with the resources they need in an accessible way. The portal allows ex-service military personnel to rapidly find and interact with matched services and resources.

The Commissioners heard that an evaluation of intensive interventions, like the Way Back Support Service, identified that individuals are at the highest risk of a second attempt in the 3 months after an initial suicide attempt. Researchers learned that a more intensive model of care in the aftermath of a suicide attempt is needed. Moreover, who provides care and their level of training are critical for effective intervention. The Commissioners heard that people with lived experience and non-mental health clinicians may not be well suited to deliver interventions.

Building trust

The Commissioners heard that building trust is central to the effective delivery of initiatives across agencies. Roundtable participants said that developing trust begins with building mutual understanding and that interventions must connect issues at individual, interpersonal and systems levels. Building trust facilitates coordinated research and more coordinated care. Enhancing trust across the ADF, Department of Defence and DVA is fundamental to systemic change.

Roundtable participants told the Commissioners that many ex-serving ADF members have little trust in those agencies, in circumstances where claims can take a minimum of 2 years to process. The Commissioners heard that distrust of ADF and DVA should not be underestimated.

Suicide and suicidality

The Commissioners heard from stakeholders that social isolation and difficulty returning to civilian life are risk factors for suicide and suicidality. Specific risk factors for women include sexualised violence during their Australian Defence Force (ADF) service and experience of domestic violence.

The Commissioners were asked to consider the following:

• Moral injury as a serious risk factor.
• Suicidal ideation increases once people join the ADF and the reasons for this need to be examined.
• Understanding suicide as a behavioural response to pain that requires compassionate and supportive responses, including a well-equipped public health system.
• Risk formulation in health care – understanding what has happened to bring a person to the point of suicidal behaviour, understanding how various factors have played a part in the intended behaviour or suicidality, and understanding what can be done to prevent this happening in the future. Formalised assessment is still needed but a shift away from a risk stratification approach may be required.
• The need to develop responses to, and understanding of, suicidal behaviour that can be understood by laypeople, such as governments and families.
• Perception of causal factors: there is anecdotal evidence that serving and ex-serving ADF members who have experienced suicidal crises perceive the causal factors differently from the families of those members.
• Terminology: roundtable participants recommended using ‘self-harm’ rather than ‘suicide attempt’ because it is difficult to determine a person’s intent, especially where individuals may not be aware of their intent, or where an individual’s intent fluctuates.
• Breaking down myths and de-stigmatising suicidal ideation – including asking people what they need: this was referred to as a befriending relationship.

The Commissioners heard that improved data are needed on suicide attempts through the use of surveys, data from emergency departments and data from ambulance services.

Participants said there is a significant body of knowledge on suicidology internationally. Efforts are needed to focus on what is known and how it can be applied more effectively to support individuals. For example, developing sound practice, service pathways, engagement and outreach based on that body of knowledge.

Suicide prevention

The Commissioners heard from roundtable participants that some key issues for the Royal Commission to consider include:

• What puts serving and ex-serving Australian Defence Force (ADF) members at heightened risk? How can those risk factors be mitigated? How can protective factors be leveraged?
• What are the appropriate points of intervention: proximal or distal factors?
• Access to support for a broad range of people who will need different types of intervention.
• The importance of alcohol as a factor, given the widespread acceptance of alcohol consumption in broader Australian society.
• Suicide prevention approaches that balance evidence of lived experiences with scientific evidence, and take into account the complexity of suicide prevention.
• The need to ask serving and ex-serving ADF members, and people with lived experiences, about what success looks and feels like when it comes to suicide prevention.
• The need to embed peer networks throughout the ADF – peers with lived experience.

The Commissioners heard that roundtable participants are collaborating to examine how chronic pain affects serving and ex-serving ADF members, and the implications of this for health care provision and suicide prevention.

The Commissioners heard that chronic pain is a major issue in the general Australian community:

• 3.4 million Australians are living with chronic pain conditions
• chronic pain results in substantial costs, including $73 billion in health costs.

Roundtable participants told the Commissioners that there is a strong link between chronic pain and suicide. According to research by the Australian Institute for Health and Welfare (AIHW), suicide is 18% more likely among people living with chronic pain than in the general community.

The Commissioners heard that multidisciplinary care is essential for the effective management of chronic pain.

The Commissioners heard that chronic pain disproportionately affects both serving and ex-serving ADF personnel. The AIHW research indicates that almost 20% of ex-serving ADF members have their ability to function limited by chronic pain, notably musculoskeletal pain.

Pain management is a key issue for serving and ex-serving ADF members, particularly because they can be reluctant to seek treatment. For example, serving ADF members may be reluctant to use opioid medication if it means they cannot be deployed.

The Commissioners heard that chronic pain among serving and ex-serving ADF members is an invisible condition but is instrumental in what happens to them, particularly in relation to suicidality.

Legislative reform

The Commissioners heard that legislative reform is needed to harmonise the three Acts governing compensation and claims:

• Veterans’ Entitlements Act 1986
• Military Rehabilitation and Compensation Act 2004
• Safety, Rehabilitation and Compensation (Defence-related Claims) Act 1988.

Department of Veterans’ Affairs – claims, compensation and support

The Commissioners heard that delays in claims processing compounds trauma for ex-serving Australian Defence Force (ADF) members. It is therefore essential to reduce the complexity of the claims process, to improve the timeliness of claims processing by the Department of Veterans’ Affairs, and to address the backlog of claims.

Roundtable participants told Commissioners that consideration should be given to assisting ex-serving ADF members with financial management, especially where compensation is awarded as a lump sum, noting that financial hardship can result from poor financial literacy, gambling and other factors.

Roundtable participants recommended oversight and monitoring of the recommendations for reform ultimately made by the Royal Commission, noting there is frustration at the pace or lack of reform arising from previous inquiries. The Commissioners heard that it will be critical to monitor and evaluate the implementation of recommendations, and to allocate resources to implementation.

Stakeholders also noted that they would welcome continuity in the ministerial portfolio for veterans’ affairs. It was suggested that the Prime Minister take on ministerial responsibility, which would give priority and weight to the veterans’ affairs portfolio.

Families

The Commissioners heard that the families of serving and ex-serving Australian Defence Force (ADF) members need support for a range of complex issues, including:

• The impact of ADF service on families, including social isolation, separation for extended periods, relationship breakdown, domestic violence, and drug and alcohol abuse. Stakeholders considered that families bear the burden of ex-serving ADF members’ wellbeing, although it may not always be safe for them to do so.
• ADF interventions for members who perpetrate domestic and family violence.

Support and service infrastructure

The Commissioners heard that there is scope for greater collaboration between government and non-government organisations (NGOs). The Commissioners heard about a range of issues, including how NGOs should be funded and how best to maximise the effectiveness of NGO advocacy and support.

Roundtable participants discussed the merits of establishing a non-government peak body to set principles and standards for service delivery. They consider that such a body would need to accommodate the diversity of the sector, and contribute to improved advocacy and accountability. NGOs should be representative, robust and authoritative.

Stakeholders raised the need for better coordination and integration between government, NGO, private and community based (generalist) services, especially in rural and regional areas.

The Commissioners heard that any reforms need to take into account that younger ex-serving Australian Defence Force (ADF) members seek help in different ways from earlier generations (such as Vietnam veterans). For example, younger ex-serving members tend to seek help and information through their social media networks rather than traditional government and NGO sources.

Roundtable participants discussed the role of professional and volunteer advocates, and whether volunteer advocates should be funded to undertake training.

The Commissioners heard from stakeholders that NGO assistance should be more client specific and focused, including advocacy that meets the needs of women. Roundtable participants suggested that there may be gaps in NGO support for ex-serving female ADF members. They recommended that research be undertaken to explore any gaps in support and determine whether there is any correlation with the suicide deaths of ex-serving women.

Coronial matters

Role of coronial jurisdiction in suicide prevention

The Commissioners heard that the coronial jurisdiction has a legislated role in suicide prevention. This includes examining preventive factors, including access to services and support, information exchange between relevant agencies and individuals, and the effectiveness of responses. In Queensland, there are around 6,000 deaths each year that are reportable to the coroner. Approximately 700 reportable deaths are classified as suicides in Queensland per year.

If findings are made about matters that could have prevented a death, they are referred to the agency or health service that had responsibility for the deceased.

The Commissioners heard that inquests are not often held into suicides. Identifying a death as suicide can be complex, notably in drug overdose cases. Applying legal standards of proof, a coroner needs to consider whether a death is caused by self harm as opposed to an accident.

The Commissioners heard that Queensland is undertaking a systemic review of suicide, modelled on the Domestic Violence Death Review and Advisory Board (DVDRAB), which was established under section 46 of the Coroners Act 2003 (Qld). The role of the DVDRAB is to prevent domestic violence deaths through systemic review and analysis of data and conducting research to identify patterns, trends and risk factors relating to domestic and family violence deaths in Queensland.

Inquests into Australian Defence Force (ADF) member suicides

The Commissioners heard that it may be impracticable to conduct coronial inquests into clusters of ADF member suicides. Clusters of deaths are difficult to identify. Each death is different and is examined in its own context and circumstances. Inquests that examine clusters of deaths are likely to be more unwieldy and resource intensive than inquests that focus on the death of one person.

The Commissioners heard that there is information exchange between Queensland coroners and the Inspector General of the Australian Defence Force.

Support for families

Roundtable participants told the Commissioners that coronial inquests can take up to 2 years, and many resources, to finalise. Coroners send written correspondence to update families on decisions to hold an inquest, to dispense with an inquest or communicate the findings of an inquest, although not all family members may receive this correspondence. Family contact is generally undertaken by police, who may provide information about grief counselling after a death is reported. Clinical staff attached to the coroner are not on call and do not have surge capacity.