Clock is ticking on healing the moral injury of our veterans

By Dean Yates

A single paragraph in last year’s interim report by the Royal Commission into Defence and Veteran Suicide said officials would check on former soldiers who reported suicide plans and attempts during landmark research in 2015. What the royal commission didn’t say was that mental health experts – some of the best in Australia -- had estimated 505 veterans from the cohort they studied had tried to kill themselves.

That’s right. 505.

The Department of Veterans Affairs refused to do anything.

The Australian War Memorial says 46 personnel were killed in Afghanistan in 20 years of war, our deadliest conflict since Vietnam. By comparison, at least 1,600 soldiers and veterans died by suicide between 1997 and 2020, official data shows.

“I had repeated conversations with DVA about the need to follow up those people and to find out whether their health needs are being met,” Professor Alexander (Sandy) McFarlane told the commission in December 2021. “That request has never been acceded to.”

The study was one of nearly 10 reports under the Transition and Wellbeing Research Programme carried out for DVA by the Centre for Traumatic Stress Studies (CTSS) at the University of Adelaide.

Nearly 20 CTSS experts analysed data from a mental health assessment of veterans who left service from 2010-2014. Many had deployed to Iraq and Afghanistan. Diagnostic telephone interviews with 1,049 of the veterans were conducted in 2015 using World Health Organization criteria. Those results were weighted against the entire cohort of 24,932 who left service from 2010-2014. The research found psychological distress was driving soldiers out of the military as well as a “strong association” between service and the development of anxiety disorders.

McFarlane is a global authority on PTSD in military and civilian disaster contexts. He was also director of the CTSS until it was forced to close at the end of 2019 when DVA and the Australian Defence Force – it’s two main financial backers for a decade – halted funding.

The final Transition and Wellbeing report hadn’t even been published.

McFarlane had worked closely with the ADF and DVA for three decades. He never got a straight answer on why the financial taps were turned off.

The willful neglect of our veterans and first responders is one of the most scandalous things I’ve seen in 30 years as a journalist – and I covered the Iraq War. I got to know dozens of brave men and women who served our country and community during my three admissions to the Ward 17 psych unit in Melbourne from 2016-2018. I’ve stayed in touch with many. Every single one said abandonment by their organisations and then DVA/workers’ comp hell has been worse than the occupational trauma that gave them PTSD. All those soldiers, coppers, paramedics, and firefighters knew what they were getting into. What they never signed up for was betrayal, the crushing of their identity, the powerlessness. The system doesn’t just fail them, it punishes them and their families.

If those damaged souls and tens of thousands like them are ever to heal, this nightmare needs to be acknowledged, those responsible held accountable, the system changed so it doesn’t happen again, and restitution made.

It starts by making use of world-class independent research like that done by the now defunct CTSS. It also means recognising and understanding the moral dimension of trauma among service personnel and veterans. The moral injury of their experiences.

Moral injury is a wound to the soul, a condition that shatters someone’s sense of self. It has similarities to PTSD but is a distinct affliction that can occur in any occupation/walk of life. All that’s needed is for someone’s idea of what’s right to be violated strongly enough.

There are two types of moral injury:

1/ Perpetrating, failing to prevent, bearing witness to, or learning about acts that deeply transgress one’s moral or ethical values.

2/ Betrayal of what’s right by someone who holds authority in a high-stakes situation – think of DVA’s many documented failures.

Moral injury’s signature symptoms are guilt, shame and rage. Moral injury and PTSD can co-exist and it’s possible to have one and not the other. PTSD is a mental illness under the DSM-5. Moral injury is not. But moral injury has deep psychological and spiritual consequences. It causes functional impairment, ruins relationships, and can lead to suicide.

I’m in awe of the work done by journalists such as Nick McKenzie and Chris Masters in reporting on Australia’s special forces who committed war crimes in Afghanistan. This has been investigative journalism at its finest. At the same time, my heart goes out to the vast majority of soldiers and veterans who have served Australia with honour in war, peacekeeping duties or been deployed at home. (I’ve heard Nick, and I’m sure Chris has done this as well, repeatedly refer to the moral courage of those special forces soldiers who blew the whistle on these atrocities in Afghanistan or testified to what happened)

Soldiers are trained to deal with battlefield danger. They want to believe missions are noble. Few are emotionally equipped to deal with the horror of war, civilian casualties, the rampant corruption of local warlords and politicians. They aren’t schooled in what to do when they realise their mission is based on lies (Iraq) or the objective dissolves after a few years (Afghanistan). The East Timor intervention (1999) was honourable, but what soldiers encountered there was evil. Where do you even begin to deal with the immorality of the Vietnam War? I met a young veteran in Ward 17 who within a few weeks of arriving in Iraq was asking himself: “What the fuck am I doing here?” Another veteran had been a peacekeeper in Somalia in the early 1990s, a symbol of failed international peacekeeping operations and immortalised by the movie Black Hawk Down.

The CTSS research showed how much our veterans are suffering. It was also the only study in the world to have used gold standard diagnostic questioning and cover an entire veteran population. Prominent experts outside CTSS involved in the effort included Professor David Forbes, director at the Phoenix Australia Centre for Posttraumatic Mental Health in Melbourne, Professor Richard Bryant at the University of New South Wales, Professor Ian Hickie at Sydney University and Malcolm Sim at Monash University.

The first report, released in April 2018, showed:

-- 46.6 percent of the veterans were estimated to have had a mental health disorder in their first year out of the military. This was way above an estimated 20 percent of Australians who had a mental illness in the 12 months prior to being interviewed for the 2007 National Survey of Mental Health and Wellbeing.

-- 21.7 percent experienced suicidal ideation, plans or attempts in the last 12 months. Nearly 29 percent felt life was not worth living. CTSS estimated 505 veterans discharged from 2010-2014 had tried to kill themselves in the 12-month period after they left service. Veterans under 30 had a suicide rate 2.2 times that of men in the same age group in the general population.

-- Nearly 10 percent were estimated to have bipolar disorder.

-- Nearly 25 percent were estimated to have met the criteria for PTSD in their lifetime.

I found this alarming data buried in the DVA website while doing research for my memoir Line in the Sand. In 2020, I wrote about this for Crikey and alerted politicians from Labor, the Greens and various independents. I later learned DVA had insisted CTSS make no recommendations in its final report. I also discovered the Morrison government in 2019 had quietly shut down a $6 million project (The Centenary of ANZAC Centre) to find new and more effective ways to treat PTSD and other mental illness among veterans. Compare that to the $500 million upgrade to the Australian War Memorial and the $550 million that Guardian columnist Paul Daley estimated coalition governments spent commemorating the 100th anniversary of World War 1. A total of $1.1 billion!

Meanwhile, Ward 17 is a rarity. Australia once had a network of repatriation hospitals, but they were either closed decades ago, incorporated into public hospitals, or taken over by private operators. Veterans can get a bed at scores of private psychiatric hospitals but there are often waiting lists and such wards treat folks with a range of mental disorders. When in crisis, vets have no option but to go to overcrowded, noisy public hospital emergency departments.

The Royal Commission into Defence and Veteran Suicide interim report in August 2022 was damning. It said the veteran’s system was so complicated it was adversely affecting the mental health of some veterans and could be a contributing factor to suicidality. Negative engagement with DVA staff regarding claims and entitlements was pervasive among submissions to the commission. Some submissions referred to dealing with DVA as “administrative violence”.

The minister for veterans' affairs, Labor’s Matt Keogh, said some of the report’s 13 recommendations were already being addressed such as increased staffing to tackle the claims backlog. Inexplicably, Keogh said he still had confidence in the DVA leadership. At the very least, people should have been sacked.

The interim report did an excellent job giving a voice to veterans and their loved ones. They could share their heartbreaking stories.

It’s a good start.

But the 312-page report barely mentioned the ground-breaking CTSS research. McFarlane was not quoted in the main text. He spent days speaking to commission staff. It’s as if no one understands the ramifications of the research, even though McFarlane tried to make it clear.

“We found that the rates of psychiatric disorder in those who had left (from 2010 to 2014) was -- and listen to this carefully -- 46.4 per cent,” he told the commission in December 2021.

“I think we should have been profoundly concerned about the adequacy of care of those 46 percent of people we found with psychiatric disorders who had transitioned, and what plans were in place to improve the quality of their care. DVA took no steps of that nature.”

“We had a body of international experts who could have assisted DVA in how to better interrogate that (CTSS) data, and also to make recommendations about how to better understand the treatment needs and the causes of some of the phenomena we were finding … No discussion of that type ever occurred and we were specifically told not to make those sorts of recommendations.”

My goodness, the royal commission needs to investigate why DVA was so wilfully derelict, so cruel. It needs to investigate how many lives were needlessly lost and who is responsible. It must also remember that a good claims system is only as good as ongoing independent monitoring of veteran mental health and data collection as well as concerted efforts to find better treatments, all done in an accountable and transparent manner.

The media also needs to dial down its obsession with China and focus on this story. The scandalous abandonment of our veterans is as bad as Robodebt.

The awesome painting is by Marcus ‘Woody’ Woodlock. Acrylic on canvas. Anonymous field near Pachendale, France post WW1. A farmer is trying to work the land without disturbing its history below.