Mental Health Treatment Benefits for Family Members, in their Own Right, for Conditions related to Military Service - January 19, 2021

Executive Summary

On January 29, 2020, Veterans Affairs Canada (VAC) introduced a new guideline to clarify the intent of its policy on family member access to funding for mental health services.  In some cases, this resulted in limiting mental health services previously provided to family members.^{Footnote 1} There was also a lack of transparency with respect to how these significant changes in interpretation were implemented. The lack of clear communication caused confusion and frustration among some Veterans and their families, especially since some family members only found out about the changes during their mental health appointments.

The January 2020 restrictive guideline reinforced the Office of the Veterans Ombudsman’s (OVO) 2016 recommendation that VAC provide funding for mental health treatment for family members in their own right; i.e., not based solely on the needs of the Veteran. This recommendation was not implemented, and the January 2020 guideline exacerbated the situation. In February 2020, the OVO urgently requested that the January 2020 guideline be reversed, and at the same time initiated an investigation into the need for access to mental health treatment benefits for families in their own right, as a result of the unique and challenging conditions of military service.

On May 6, 2020, the guideline (January 2020) was revised, but it was not reversed. The OVO maintains that this guideline continues to be too narrow and that families should receive better access to the mental health supports that they need. VAC’s current interpretation of the guideline reinforces that: 

• the treatment has to have a positive impact on the Veteran’s mental health;
• the treatment must be a part of the Veteran’s treatment or rehabilitation plan;
• the need for family access to the services must be established by the professional treating the Veteran; and, 
• family members can only access one health professional or service at a time. 

Further, it states that it limits all mental health services to 25 sessions per family member in a one-year period. 

This report examines whether access to mental health treatment benefits should be provided to the families of CAF Veterans in their own right, as a result of the unique and challenging conditions of military service.^{Footnote 2} 

In the OVO’s assessment, when a family member suffers from an illness or injury related to the unique conditions and challenges of military service, they should have access to mental health treatment, independent of the Veteran’s treatment or rehabilitation plan. Current research indicates that military service affects the health and well-being of both Veterans and their family members for a number of reasons, including frequent postings and deployments as well as the inherent risk of military service. Therefore, the family member’s request for mental health care should be considered regardless of whether the Veteran is engaging in mental health treatment or not. 

The report concludes with the following recommendations:

• Considering the unique impact of military service on the mental health and well-being of both Veterans and their family members as a result of frequent postings, long and multiple absences, and the inherent risk of military service resulting in illness, injury or death,  the Government ensure that family members, including former spouses, survivors and dependent children, have access to federal Government funded mental health treatment in their own right when the mental health illness is related to conditions of military service experienced by the family member, independent of the Veteran’s treatment plan and regardless of whether the Veteran is engaging in treatment. 
• That VAC conduct and publish a Gender Based Analysis+ of the accessibility to mental health treatment benefits and services to family members, including spouses, former spouses, survivors and dependent children, to determine if there are barriers which make it difficult for certain groups to access the mental health care they need.
• That VAC continue to demonstrate flexibility to address the urgent mental health needs of family members. Further, we encourage VAC to explore expanding and obtaining additional authorities to minimize the significant financial costs of obtaining mental health treatment for family members that some Veterans and their families experience. This may include expanding access to treatment sessions for family members.

Introduction

On January 29, 2020, Veterans Affairs Canada (VAC) introduced a new guideline to clarify the intent of its policy on family member access to funding for mental health services. In some cases, this change limited mental health services previously provided to family members.^{Footnote 3}

Prior to the January 2020 change, family members could access funding for families/couples counselling, psycho-education, and/or individual mental health treatment if it was part of the CAF Veteran’s treatment or rehabilitation plans to help the Veteran achieve their own goals. As a result of the January 2020 guideline, the funding was reduced to cover only family/couples counselling and/or psycho-education to the extent that it contributed to the treatment or rehabilitation plans of the Veteran, and for a limited duration of up to 25 sessions in a one-year period from the date of authorization. Family members would no longer have access to individual mental health treatment. With this tighter interpretation, family members, including spouses and dependent children, who need mental health treatment (for conditions related to their spouse’s/parent’s military service) would have to do without; pay out of their own pocket if they had insufficient or no access to private health insurance; or seek mental health family services offered by provincial, territorial or community programs, where resources in many locations are often limited, have long waiting lists which delays access, or are inadequate to address these families’ needs. 

There was also a lack of transparency with how these significant changes in policy interpretation regarding family member access to needed mental health treatment were implemented. Some family members found out about the changes during their mental health appointments. As the following quotes from complaints to the Office of the Veterans Ombudsman (OVO) show, this lack of communication and the restriction in access to mental health treatment caused confusion and frustration among some Veterans and their families. 

Reported Impacts of the January 2020 Guideline

The OVO became aware of the policy interpretation changes when Veterans or family members began to voice their concerns and relate the difficulties they were facing as a result of the change.^{Footnote 4} 

This spouse questions the removal of needed support:

"Last week, my therapist sent me an email saying Blue Cross was no longer covering my much-needed sessions. I called my husband and asked him to contact his VAC case worker. She told him the policy was changed as of the beginning of February and that I was entitled to no more than 25 sessions of service for life…

If spouses are the main support structure for the Veteran as VAC keeps saying, then why are they trying to destroy the pillars of support? I am not a mental health professional and I shouldn't be expected to do this alone!! Cutting these services to spouses is yet another jab at the Veterans suffering! We are not asking for charity we are asking for me to get the help I need to support a man who has given up too much already in the service of his country!"

A Veteran and mother describes the impact of this loss of treatment to her children:

“As a disabled vet I’ve gone through a lot but I really need help with my kids. When I came back from the xx I became really sick but it took a long time to get help. My children, both under 12, had to take care of me… They have been through a lot and, as a result, my youngest has trouble being by herself... the help she has been getting is now going to be taken away. She has panic attacks and other episodes. Taking her therapy away… is causing me distress, which is having a chain reaction that is become increasingly difficult. I’ve made such good progress but I feel like one step forward two back is going to be my new normal.  She really needs her therapy I can’t afford it.”

A spouse describes the impact of the termination of mental health therapy provided to her and her children in dealing with her Veteran spouse’s traumatic brain injury and PTSD: 

“When my children are functioning physically and mentally then my spouse can function … When he sees his children upset and having episodes due to his PTSD, then he unravels, and we take steps backwards. Both children have been making progress with trying to understand what is wrong with their father. Before therapy, my children suffered and could not handle my husband’s episodes – they would either freeze or severely shake. It is not uncommon for me to find my kids hiding in their closets when he is having issues. When he realizes this, he goes backwards and feels horrible, often suicidal, thinking his kids do not deserve this. I barely survive; I walk on eggshells, and try to smooth things over. This is not fair to take away these kinds of services from our children. I will try to manage and deal with him the best I can, my kids should not be cut off from support. They did not ask for this, they did not ask for a broken father, all they often want is a dad who is not sick, a normal dad. How do you give this to them? They seek counselling to help them understand via age appropriate methods and skills, that are beyond my scope as a mother.”

A spouse provides her thoughts on the termination of her mental health therapy:

“My husband’s tours in Afghanistan changed him forever… he is short tempered, distrustful of others... you get the gist… I think this policy change that’s coming will be a detriment to the service persons healing... as now the extra guilt of knowing you’re the cause of someone else hurting so much… and now any help they were getting is being pulled out from under their feet. It’s going to be a disaster all around.”

Actions taken by the OVO

In 2016, the OVO recommended that VAC provide funding for mental health treatment for family members in their own right and not based on the needs of the Veteran. ^{Footnote 5} That recommendation was not actioned. The new January 2020 guideline further restricted family member access to VAC-funded mental health treatment.  Annex A provides a review of the OVO’s previous analysis and recommendations related to mental health treatment for family members in their own right.

In a letter to the Minister of Veterans Affairs and Associate Minister of National Defence, dated February 24, 2020, the OVO requested that the revised January 2020 guideline be reversed as a matter of urgency. At the same time, the OVO initiated an investigation into family members’ need for access to mental health treatment benefits in their own right, as a result of the unique conditions and challenges of military service. ^{Footnote 6} If the mental health condition is a result of service-related conditions, then there is an obligation for the Government of Canada to provide the necessary care to support the family member regardless of the Veteran’s treatment or rehabilitation plan.

On May 6, 2020, the January 2020 guideline was revised but it was not reversed. It now extends some funding for mental health treatment to individual family members, but it is the OVO’s assessment that the interpretation continues to be too narrow to ensure that families receive the mental health support they need.  It is restrictive in the following ways:^{Footnote 7}

• The treatment has to have a positive impact on the Veteran’s mental health and be part of either the Veteran’s treatment or rehabilitation plan; 
• The need to include family members must be established by the Veteran’s treating health professional;
• It states that it limits all mental health services combined to 25 sessions per family member, in a one-year period; and
• The family cannot access multiple health professionals or services at the same time; i.e., group therapy and individual treatment.

Despite the confusion with regards to the changing guidelines, the OVO’s assessment is that when a family member suffers from an illness or injury arising from the unique conditions and challenges of military service, they should have access to mental health treatment in their own right and independent of the Veteran’s treatment or rehabilitation plans, regardless of whether the Veteran is engaging in treatment or not.

Purpose

The purpose of this report is to examine whether access to mental health treatment benefits should be provided to the families of CAF Veterans, in their own right, and as a result of the unique and challenging conditions of military service, reinforcing the OVO’s 2016 recommendation.^{Footnote 8} 

Approach – Fairness

The OVO investigates issues of fairness using a model with three components: Fair Treatment, Fair Process, and Fair Outcome.

Fair Treatment is about how VAC relates with Veterans. It includes being honest and forthright when communicating and providing clear, easy-to-understand information and properly counselling Veterans and their family members on available programs and services. Fair Process is about how decisions are made by VAC. It includes informing the Veteran of the decision-making criteria, timely decisions, and meaningful reasons for the decision. Fair Outcome is about whether the ultimate decision or result is fair for the Veteran or family member. It includes assessing whether: decisions are based on relevant information; decisions are the result of fair and reasonable legislation, regulations and policies; and decisions are equitable.

Systemic investigations, such as this report, also assess the fairness of programs and services against: intended outcomes for and needs of Veterans and their families; benefits, services and programs available in other jurisdictions; and whether the benefits, programs and services are properly resourced to achieve the expected outcomes. The provision of mental health care to family members is an issue of fair outcomes in that service-related needs are not being met by current programs. The increasing number of Veterans and family members who have approached the OVO regarding the challenges experienced in accessing the mental health care they require indicates a systemic issue. Specifically, there is a failure to ensure that the family members of Veterans have access to the treatment they need, as a result of mental health conditions arising from the unique conditions and challenges of military service.

The Impact of the Unique Conditions and Challenges of Military Service on Families Well-being

There is a growing body of Canadian research focused on the effects of military service on families. The results of this research are consistent with the 2013 National Defence and Canadian Forces Ombudsman’s report: On the Homefront: Assessing the Well-being of Canada’s Military Families in the New Millennium.^{Footnote 9} This report concludes that there are unique stressors that Canadian military families experience: mobility due to frequent relocations and postings, separation due to deployments and training, and risk of illness, injury or death inherent in military service. This triad of factors, when combined, creates a distinct and unique lifestyle experienced by military families, with some military family members experiencing negative impacts to their well-being throughout their life-course. 

The Canadian Forces Morale and Welfare Services (CFMWS) Support Our Troops organization was established in 2007 to meet the unique needs and special challenges faced by members of the CAF community as a result of military service. Its website identifies relocation, absence and risk as factors which uniquely impact military families’ well-being with the following results:

• Children of deployed military members in high profile, high-risk locations experience physical and mental health issues — including stress and anxiety.
• Recurring absences can negatively impact parent-child relationships, sometimes with long-term or permanent consequences.
• Academic performance can suffer for military children facing frequent relocation.
• A parent returning home ill or injured, or not returning at all, can be devastating for even the strongest of families.
• Frequent moves are a source of anxiety for military families, as they must continually adapt to new cities, communities, and schools.
• Repeatedly finding new employment, healthcare providers and childcare services is challenging.
• Peers and friends are continually left behind and military families must rebuild their social networks in a new community.^{Footnote 10} 

Impact of Frequent Relocation on Families

Military families are required to relocate frequently to meet the operational needs of the CAF. They move three to four times more often than civilian families.^{Footnote 11} In a 2018 survey, 34% of CAF Regular Force member respondents reported that they had relocated at least four times due to military postings.^{Footnote 12} Relocations challenge military families and impact financial security, intimate partner relationships, health care for non-military family members, spousal employment, childcare and education. Frequent relocation also affects children’s participation in school, academic progress, and access to educational accommodations for those with identified disabilities or special learning needs.^{Footnote 13} While the vast majority of families are resilient and manage these challenges successfully, a small percentage (10%) still struggle.^{Footnote 14} These struggling families, for whom the effects can be lifelong, may require support. 

Impact of Frequent Absences on Families

Since the end of the Cold War, the considerable change to the nature, intensity, and frequency of CAF operations has significantly affected the military family. The CAF has been engaged in operations almost continuously since the 1990s, with operations ranging from domestic, peace support to war fighting.^{Footnote 15} Lengthy separations from family are common and the risk of injury, physical and mental illness, disability, or death has increased.^{Footnote 16} The effect of military service on military families is not new. It was highlighted in a 2004 Veterans Affairs Canada – Canadian Forces Advisory (VAC-CFAC) Council Report:

“Military life exacts a high price from members’ spouses and children including separations, “living the mission”, and its hazards each day through real-time media reports; disrupted family roles; separation from established support networks; interrupted or abandoned spousal careers, and family relationships impaired by a members’ physical or psychological injuries. These strains can lead to a higher than average number of marital breakdowns, increased suicide rates among children and physical or mental breakdowns. Spouses and children can experience secondary trauma when they are exposed to the suffering of a family member who has operational stress injuries.”^{Footnote 17} 

CAF members regularly spend upward of a quarter of their time separated from their families due to both training and deployment.^{Footnote 18} Seventy per cent (70%) of CAF military spouses have experienced the deployment of their military partner at least once, while 21% have experienced five or more deployments.^{Footnote 19} While military families are widely regarded as strong and resilient, many family members who were interviewed for the DND/CF Ombudsman’s 2013 report expressed concern that their children were “paying a price” for the CAF parent’s service.^{Footnote 20}  

Effect of Military Service on Children

A 2017 Canadian Pediatric Society paper documents the stresses on military children of frequent geographical moves and isolation from extended family support systems, long periods of separation, and deployments to high-risk areas of the world.^{Footnote 21} The paper states that children and youth in military families, when compared to their civilian counterparts, experience more unusual developmental pressures and stressors placed on them due to the unique demands of military life. The paper documented the following mental health and behavioural concerns:

• Changes in behaviour, both externalizing and internalizing, and changes in school performance are consistently reported during parental deployments;
• Higher levels of mental health disorders, sadness and worry are prevalent for most age groups; 
• Depressive symptoms are reported in approximately one in every four children experiencing the deployment of a parent; and
• Adolescents from military families are more likely than civilian peers to report depressive symptoms and suicidal ideation.^{Footnote 22} 

A 2011 Defence Research and Development Canada study also documents that military parental absences have various effects on their children including higher levels of internalizing behaviour; greater depression and anxiety; a decrease in academic performance; experiencing intense feelings of sadness, loneliness, abandonment and anger; as well as acting out and the manifestation of externalizing behaviours.^{Footnote 23}  

Effects of a Veteran’s Illness and Injury on Families

Current data suggests that approximately 9,000 Regular and Reserve Force members leave the CAF each year, approximately 2,500 of whom release for medical reasons.^{Footnote 24} The VAC 2016 Life After Service Study (LASS) found 28% of medically-released Veterans indicated their partners had difficulty with their release, and 17% reported their children had difficulty with their release.^{Footnote 25} In military families, spouses of military members are often the primary caregivers, and providing this care can have a negative impact on their own health, well-being and careers. Moreover, an increasing body of research shows that caring for military personnel with psychological illnesses can be particularly exhausting for caregivers and increase the risk of their own psychological distress due to the military member’s increased reliance on them for physical and emotional support.^{Footnote 26} Key research findings include:

• A 2008 literature review on the impact of Veterans’ operational stress injuries (OSI)^{Footnote 27} on family members found that OSIs can adversely impact them in a number of ways, including: increased mental health problems in spouses; increased caregiver burden for spouses; problems in marital adjustment; increased divorce rates; increased physical and verbal aggression against partners; and adverse impacts on children’s behavioural and psychological adjustment.^{Footnote 28} 
• A 2017 study by Skomorovsky et al. found that spouses of military members or Veterans with more severe physical and mental health conditions experienced higher levels of psychological distress and tension in their spousal relationship, in part due to the burden they experience as caregivers. The study suggested that such findings emphasize the importance of not only ensuring support services are available for ill or injured Veterans, but also for the spouses providing them with care.^{Footnote 29} 
• A 2015 review of research on military and Veteran families concluded that families were particularly important for Veterans suffering from service-related conditions, and that families are critical to the well-being of Veterans.^{Footnote 30} 
• A similar finding was recorded in the 2016 OVO Report, Transitioning Successfully: A Qualitative Study. The survey results and follow-up interviews with Veterans identified support from their spouse as a key contributor to their successful transition.^{Footnote 31} 
• The 2016 Mental Health and Well-Being of Military Veterans during Military to Civilian Transition study found that the family is often the ground zero for transition challenges. Families act as caregivers and primary supports and are the first to become aware of developing problems. Strong and supported families are key to successful transition.^{Footnote 32} 

The above-noted studies clearly show that the unique conditions and challenges of military service affect the mental health of some families of Veterans and that the spouse has an important role in supporting the military to civilian transition of ill and injured CAF members. Therefore, if the family member’s mental health condition is a result of service-related conditions, the OVO concludes that there is an obligation for the Government of Canada to provide access to the necessary care and treatment to support them. Currently, however, access to mental health treatment from VAC to Veteran family members is limited to only support what is needed to help the Veteran. 

Mental Health Support and Programs for Family Members Available From VAC 

The families of Veterans receive substantially more support today than when the New Veterans Charter (NVC)^{Footnote 33} / Veterans Wellbeing Act (VWA) came into effect in 2006. The table at Annex B provides a description of current VAC programs and services related to mental health support available from VAC to family members. 

Recently, VAC has improved access to education, health promotion and short-term support resources for family members. Some of these improvements include:  

• Increasing the number of the VAC Assistance Services sessions from 6 up to 20 hours of short-term support from a mental health professional, per issue;
• Expanding access to all Military Family Resource Centres to medically-released Veterans and their families under the Veteran Family Program.  This program predominantly focuses on providing transitional services and resources, including providing family members with education and referrals within the community;
• Partnering with the Royal Ottawa Mental Health Centre to develop an online tool called OSI Connect.  This tool provides OSI clinic patients and their family members and caregivers with psycho-education regarding operational stress injuries and self-management strategies; 
• Partnering with the Mental Health Commission of Canada to develop and provide Mental Health First Aid courses across the country for Veterans and their families;
• Partnering with Health Canada and introducing LifeSpeak, an online mental and physical health information and support resource to Veterans and their families; and
• Partnering with St. Elizabeth Health Care to develop an online caregiver support tool, called Caregiver Zone.

It would be beneficial for VAC to evaluate the effectiveness and uptake of these new programs or program enhancements to determine to what extent the service-related health needs of family members are being addressed. Despite these improvements, one significant gap in mental health support to families remains: “current initiatives do not provide treatment benefits specifically for CAF Veterans’ family members in their own right.^{Footnote 34}”

VAC’s current mental health policy on Program of Choice 12 (POC 12), which became effective on April 1, 2019, provides guidance on the range of mental health services and benefits available to family members from VAC:

• The policy authorizes the provision of mental health treatment benefits to family members to the extent that the treatment is required to achieve the treatment or rehabilitation outcomes that have been established for the Veteran and must be established in the Veteran’s treatment or rehabilitation plans.^{Footnote 35}
• The policy also states that for families that have mental health needs unrelated to the Veterans’ career loss or health problem for which the treatment or rehabilitation plan has been approved, information can be provided about local community resources.^{Footnote 36}

The “Guideline for Funding Mental Health Services Involving Veterans Family Members(s),” introduced in January 2020 and revised in May 2020, reinforces the POC 12 Policy on providing mental health benefits involving Veterans family members.^{Footnote 37} The key messages related to the revised guideline state that:

• “Family members may be involved in mental health services if this treatment will have a positive impact on the Veteran’s mental health.”
• The need for mental health services must be established by the Veteran’s treating health professional in the Veteran’s treatment or rehabilitation goals.
• There is a “limit to a maximum of 25 sessions for all services” per family member within each one-year period.
• The guideline limits family members to accessing only one health professional or mental health service at a time; e.g., they cannot access group therapy and individual sessions at the same time.
• Funding for family members to access mental health treatment in their own right as a result of the unique challenges of military service is not provided.  The exception is where a Veteran’s survivor, spouse or common-law partner has been determined eligible for their own vocational assistance plan and related services through the Rehabilitation Services and Vocational Assistance Program.
• Any family member who is experiencing mental health issues of their own can be referred to the VAC Assistance Service for support from a mental health professional and community referrals for mental health treatment if required.
• Mental health supports are not available for separated or divorced spouses for the military experience/impact or relationship with the children.

The POC 12 policy and its revised guideline essentially states that if the mental health need of the family member is tied to the goals of the Veteran’s treatment or rehabilitation plan, funding for the family members’ treatment can be approved. If the mental health treatment need is not tied to the Veteran’s treatment or rehabilitation plan but the illness or injury is related to the unique and challenging conditions of service, family members struggle to access timely provincial public mental health services, have to do without, or pay out of their own pocket if they do not have access to, or insufficient, private health insurance. Most private insurance programs have annual limits, with coverage typically ranging from $400 to $1,500 annually – which may only cover two to eight treatment sessions. Mental health services may also be lumped in with other services, such as massage and physiotherapy, further reducing funds available. Many Veterans and their families have access to the Public Service Health Care Plan which provides support for mental health treatment. Annex B provides more detail on this insurance plan.

The Canada Health Act does not specify that the universal health-care system must include basic mental health care provided by addiction counselors, psychologists, social workers, and specialized peer support workers. A report from the Canadian Mental Health Association states that evidence-based psychological services, delivered by psychologists and other related professionals, are not typically publicly funded; and when funded, there are long wait times, making them unavailable when most needed. In Ontario, for example, in 2016, 12,000 youth were reported to be waiting up to 18 months for services.^{Footnote 38} Paying for these services provides a significant financial barrier for some families and may limit the number of treatment sessions that can be afforded.^{Footnote 39}

While there are 31,151 Veterans in receipt of a VAC disability benefit for a psychiatric condition,^{Footnote 40} only a small number of Veterans’ family members access mental health benefits under POC 12:

• In 2018, 1,454 family members accessed individual counselling, and 787 family members accessed family/couples counselling.
• In 2019, 1,575 family members accessed individual counselling, and 930 family members accessed family/couples counselling.^{Footnote 41}

This low number of family members accessing mental health treatment raises the question: is this the result of a restrictive policy and are family needs being met?

VAC provides Veterans and family members with access to the VAC Assistance Service, which includes 24/7 access to crisis and suicide prevention and intervention, as well as a referral to a local clinician for short-term counselling. While this is the only mental health support program provided to family members in their own right, its participation rate is low; i.e., only 471 individuals in the 2017-2018 fiscal year and 578 in the 2018-2019 fiscal year.^{Footnote 42} The VAC Assistance Service is not mental health treatment; it provides solution-focused support for short-term or immediate issues. This service is an important element in providing short-term counselling for a defined issue as well as crisis intervention, but it is unable to provide mental health diagnosis or address the long-term mental health needs of family members of Veterans.

A family member’s need for mental health support for conditions arising from military service should be considered independent of the Veteran’s treatment or rehabilitation plan and regardless of whether the Veteran is actively participating in the rehabilitation program. Some of the benefits of having access to treatment for family members in their own right include:

• Empowering spouses/partners to seek the treatment on their own terms, and without needing the Veteran to agree (and in some case coordinate) for them to have access to the required care.
• Potentially spurring on the Veteran to seek treatment resulting in improved mental health outcomes for the entire family.
• Facilitating trust and promoting full disclosure of personal information, experiences and health habits. While it may be preferred for families to work together when addressing health issues, doing so is not always a realistic option.
• Ensuring all family members, including survivors, former spouses and dependent children, have access to the services and supports they need will improve health and family outcomes and will ensure a successful military to civilian transition for the entire family.

Authority for the Provision of Mental Health Treatment for Families of Veterans

At the core of VAC’s mandate is the responsibility to support the well-being of Veterans and their families. However, the phrase “Veterans and their families” causes confusion and frustration with respect to the policy and interpretation guidance related to providing access to mental health care.  VAC has not defined a specific outcome related to the support and care required for CAF Veteran family members. Though the VAC 2020-2021 Departmental Plan includes “families” as well as “Veterans” for care and support, families are not eligible “in their own right.”^{Footnote 43} This lack of clear and defined outcomes for the care and support of families will continue to cause frustration and confusion among Veterans’ families.

A VAC 2009 evaluation of the NVC highlights the challenge associated with the lack of clear and defined outcomes for the care and support of CAF Veterans’ family members. While VAC confirmed that the regulations, policy and expected results all identify support for families as an important component of the NVC,^{Footnote 44} the evaluation revealed that staff across the Department were confused regarding VAC’s role in meeting the needs of families.

One of the difficulties identified in the report is that family members are not entitled to direct support from VAC as a matter-of-right.  For example, while a Veteran’s mental health condition has a negative impact on family members and family functioning, VAC is unable to provide support to the family unless the Veteran is in undergoing treatment or in the rehabilitation program. The evaluation stated that this is a significant problem when a Veteran with severe mental health conditions refuses to apply for the rehabilitation program. The report also noted the disparity in availability and accessibility of non-VAC resources stating that “while there are some family services offered by other federal, provincial or community programs, resources in many locations are often limited and inadequate to address these families’ needs which are directly related to Veterans’ re-establishment.”^{Footnote 45}

Finally, while the evaluation report noted that the introduction of the NVC provided improved services and support to survivors, spouses and dependents, it found a disconnect between the expected results and the legislative authority causing staff confusion regarding VAC’s role in meeting the needs of families. Specifically, VAC does not have the current legislative authority to provide treatment to family members in their own right.^{Footnote 46}

Ten years after this evaluation, the new guideline introduced in May 2020 does not resolve the issue, but rather exacerbates the barrier to CAF Veterans’ families accessing mental health treatment benefits. Despite research demonstrating that family members of serving CAF members and Veterans are at an increased risk of developing a variety of mental health injuries or illnesses related to military service, VAC’s policies and guidelines continue to fail family members as they do not directly address the mental health treatment needs of family members in their own right.

Gender Based Analysis+ (GBA+) – Considerations

There is much diversity in the CAF Veteran family community; however, it is unclear if the service-related needs of all the community were considered and addressed when developing the mental health policy and guideline for Veteran family members. Unique factors that need to be considered include:

• There are almost 600,000 CAF Veterans (302,000 Regular Force and 269,000 Reserve Force), of whom more than 400,000 have partners.^{Footnote 47}
• 74% of Veterans are married and 37% have children under 18.^{Footnote 48}
• 87% of military spouses are female.^{Footnote 49}
• VAC clients include 60,000 Veteran survivors and most of whom are female.^{Footnote 50}
• 21-27% of military families report that they do not have a primary care physician for themselves or their children compared to 15% of the general Canadian population.^{Footnote 51}
• Veterans and their families live in urban and rural areas throughout the country.

As these numbers demonstrate, the barriers and gaps associated with access to mental health treatment for service-related conditions disproportionately impact women. Moreover, the requirement to obtain mental health treatment through their man spouse or ex-spouse (the Veteran), reinforces patriarchal norms and power imbalances where men are in control of the resources available to support women and children while women have had to sacrifice their career for the careers of their man partner. While removing the identified barriers would disproportionately benefit women spouses and ex-spouses with service-related mental health needs, it is also worthwhile noting that man spouses and partners of Veterans in same-sex relationships who require support would also benefit.

Children who are unlikely to have independent access to financial resources, are at risk of not receiving the care they need if the only way to access mental health care is contingent on the Veteran participating in mental health treatment or the Veteran identifying this need on their treatment plan. Delaying access to evidence-informed care can have a lasting negative impact on children’s health and well-being. Given the lack of access to primary care physicians experienced by military families, it would be important to determine what kind of access military and Veteran families have to community mental health supports.

The geographic location of Veterans and their families along with the availability and types of services for both treatment and for online pyscho-education programs, especially in rural areas, must be assessed. While there are some mental health family services offered by federal, provincial, territorial or community programs, resources in many locations are often limited, with long waiting lists delaying access, and are sometimes inadequate to address these families’ needs. A Canadian Mental Health Association report documents that low-income communities experience higher rates of mental illness and have a greater need for mental health services, yet research shows that there are inequities in the provision of psychiatric services and that our universal health-care coverage tends to support “regular psychiatric treatment for individuals with high socioeconomic status and comparatively milder psychiatric disorders than it supports care for disadvantaged groups or those with severe and chronic mental illness.”^{Footnote 52} Additionally, access to broadband Internet is not always widely available in rural locations to facilitate access to online mental health services. Further, even in circumstances where it is available, accessing Internet may be cost prohibitive to lower income families.^{Footnote 53}

Veterans who release at lower ranks report having more difficulty during transition.^{Footnote 54} These Veterans are also more likely to have a lower income after release.  Further, if they are receiving support from VAC, they are more likely to be receiving the minimum amount of the Income Replacement Benefit (IRB). As a result, their lower family income may mean that their spouse and children are unable to pay for additional out-of-pocket expenses related to accessing adequate mental health treatment in their communities, including when the need is related to service. Thus, the impact of VAC’s policy is potentially worse for lower-income family members with service-related mental health issues, than for those of a Veteran who released at a higher rank.

Undergoing a comprehensive a GBA+ analysis at the onset of policy development would be the first step to ensure that adequate benefits are in place for all Veterans and their families, that benefits are sufficient to meet their needs, and that benefits are easily accessible by all those who need them.

Conclusion

Research on the effects of military service on family members in the Canadian context is relatively new. Current research indicates that the unique conditions of military service has an impact on the mental health and well-being of both Veterans and their family members as a result of frequent postings, long and multiple absences, and the inherent risk of military service resulting in illness, injury or death. Therefore, when a family member suffers from an illness or injury that is related to these unique conditions and challenges, the Government of Canada has an obligation to ensure that family members have access to the care they need. Their eligibility for services should be based on their need for treatment and not on the Veteran’s needs or how the treatment will impact the Veteran. It is essential that family members be able to access timely, evidence-informed mental health care. This results in unfair outcomes for family members who cannot access timely, evidence-informed mental health care.

Recommendations

It is unfair for family members to be denied access to mental health treatment for illness or injury related to the unique conditions and challenges of military service. The Office of the Veterans Ombudsman makes the following recommendations to address this unfairness:

• Considering the unique impact of military service on the mental health and well-being of both Veterans and their family members as a result of frequent postings, long and multiple absences, and the inherent risk of military service resulting in illness, injury or death, the Government ensure that family members, including former spouses, survivors and dependent children, have access to federal Government funded mental health treatment in their own right when the mental health illness is related to conditions of military service experienced by the family member, independent of the Veteran’s treatment plan and regardless of whether the Veteran is engaging in treatment.
• That VAC conduct and publish a Gender Based Analysis+ of the accessibility to mental health treatment benefits and services to family members, including spouses, former spouses, survivors and dependent children, to determine if there are barriers which make it difficult for certain groups to access the care they need.
• That VAC continue to demonstrate flexibility to address the urgent mental health needs of family members. Further, we encourage VAC to explore expanding and obtaining additional authorities to minimize the significant financial costs of obtaining mental health treatment for family members that some Veterans and their families experience. This may include expanding access to treatment sessions for family members.

Annex A

Previous OVO Recommendations Related to Mental Health Treatment for Family Members in their Own Right

In 2016, as part of its work on transition, the Office of the Veterans Ombudsman (OVO) published a comprehensive report on the role of families and the challenges they face during transition: Support to Military Families in Transition: A Review.^{Footnote 1} The review included a scan of current CAF and VAC policies related to the families of medically-releasing CAF members and interviews with key stakeholders. It also included a detailed review of the recommendations and government responses to the following reports, all of which identified challenges faced by families in transition from military to civilian life:

• Improving the New Veterans Charter: The Report, Office of the Veterans Ombudsman (OVO), June 2013;^{Footnote 2}
• On the Homefront: Assessing the Well-being of Canada's Military Families in the New Millennium, DND/CF Ombudsman Special Report, November 2013;^{Footnote 3}
• Caring for Canada's Ill and Injured Military Personnel, House of Commons Standing Committee on National Defence, June 2014;^{Footnote 4}; and
• The New Veterans Charter: Moving Forward, House of Commons Standing Committee on Veterans Affairs (ACVA), June 2014.^{Footnote 5}

These four reports were consistent in their findings and concluded that if the Veteran has difficulty making the transition to civilian life, it affects the entire family; conversely, if the family faces challenges during the transition, it can affect the health and well-being of the transitioning member. Specific findings included:

• Caregiver support provided to an ill or injured transitioning member is frequently assumed by a spouse, parent or other relative. Caregivers may be ill-prepared and ill-equipped to take on the care of a loved one who suffers from complex medical conditions.
• Living with a transitioning member who suffers from an Operational Stress Injury (OSI) can put significant stress on the family. Due to stigma, families often face these stressful situations alone. 
• A family that moves to a different location after the medical release of a CAF member, especially one who suffers from a severe illness or injury, can face challenges because of lack of community services, unfamiliarity with available community services, loss of continuity of the family’s primary and specialist medical care, and loss of spousal employment.
• Families living in CAF Residential Housing Units and who must move out after the medical release of a CAF member may find it particularly difficult to adapt to life in the civilian housing community.
• Spouses may be unaware of the various services and programs available to help their transition.

All four of the reports further highlighted that though the burden on family members is high, they do not receive the same level of support as the Veterans themselves. In particular, the reports noted a lack of counselling for families in their own right, and a lack of continuity of health care services as members and their families transition to civilian life. This lack of support impedes both the Veteran’s and the family’s transition. Some of the challenges outlined in the reports related to the current services and support provided to the families of transitioning members include: 

• Insufficient counselling, education and support to help families cope with and care for a transitioning member who suffers from a mental health problem(s). 
• Insufficient assistance to families to help them find a family doctor, specialist care, childcare and other community supports, especially for the families who will [or have] relocated to a new community, following the medical release of the CAF member.
• Inadequate follow-up with families of seriously ill or injured Veterans to confirm if their needs are being met. 

The OVO review concluded that while improvements have been made regarding support for families, challenges still remain. It states specifically that beyond the increase in the number of VAC Assistance Service sessions, current initiatives do not provide treatment benefits specifically for family members in their own right independent of the Veteran’s treatment or rehabilitation plans, and regardless of whether the Veteran is engaging in treatment or not.^{Footnote 6}

In a 2016 blog, the OVO highlighted the importance of the conclusions of its report Support to Military Families in Transition: A Review.^{Footnote 7} The OVO also stated that the well-being of the Veteran is inextricably linked to the well-being of the family and, similarly, the impact of a member’s illness or injury is experienced by the whole family. Highlighting recent research, the OVO documented that caring for the most seriously injured Veterans can take both a physical and emotional toll on family members and that they may require more support as a result of the care they provide. Specific findings included: 

• Informal caregivers to modern-day veterans tend to be younger, employed and likely have children but they can also be adult children, parents, other family members or even non-relatives.^{Footnote 8} 
• Caregivers support the most seriously ill and injured Veterans by doing basic functional tasks such as bathing and managing medications. They also assist by coordinating and arranging care, advocating, coordinating household tasks, and helping to cope with stressful situations and other emotional and behavioural challenges.^{Footnote 9}  The presence of an informal caregiver can improve the care recipient’s well-being and recovery and reduce medical costs by enabling home-based or community living for the disabled.^{Footnote 10} 
• In addition to strained family relationships, caregivers may experience worse health outcomes and more workplace problems than non-caregivers, as well as higher levels of burden, distress, stress, physical and mental health problems (such as anxiety and depression) and lower levels of life satisfaction.^{Footnote 11} 

In conclusion, the OVO recommended that VAC provide mental health treatment benefits to families in their own right.^{Footnote 12}

Annex B

VAC’s Mental Health Support for Family MembersFootnote 1
Support	Eligibility	Description	Details	Gaps and Barriers
VAC Mental Health Policy on Program of Choice 12 (POC 12)Footnote 2	Family members of Veteran CAF and RCMP members including spouse, common-law partner, dependent child, orphan, mother, or fatherFootnote 3 may be provided mental health support when the Veteran’s treatment or rehabilitation plan has established that doing so will achieve a positive outcome for the Veteran.	Mental health support for families is provided and all of the services must be focused on achieving positive outcomes for the Veteran as it contributes to their treatment or rehabilitation goals, and for a limited duration of 25 sessions over a one-year period. Where exceptional circumstances exist, consideration may be given on a case-by-case basis to extend coverage beyond the 25 sessions.	If families have needs for mental health services that are unrelated to the approved rehabilitation or treatment plan of the Veteran, they are to be addressed through local community resources.	Does not provide funding access to long-term, evidence-based mental health counseling or treatment benefits to family members in their own right, independent to the treatment or rehabilitation needs of the Veteran. For mental health treatment benefits not approved beyond the 25 sessions, the family has to pay out of their own pocket for access to private mental health services if they do not have private health insurance. Alternatively, family members are subjected to lengthy waiting lists for temporary provincial mental health treatment. Access to mental health treatment benefits is not available for separated or divorced spouses regardless of how long they were together, the military experience, or relationship with the children. Survivors do not have access to the mental health treatment benefits under POC 12.
Rehabilitation Services and Vocational Assistance Program for Survivors or Spouses/Common-law Partners of Diminished Earning Capacity (DEC) CAF VeteransFootnote 4	Spouses or common-law partners of Veterans who cannot benefit from vocational rehabilitation due to Diminished Earning Capacity. Survivors of members or Veterans who died on or after April 1, 2006, as a result of a service-related injury or disease, or a non-service related injury or disease that was aggravated by service.	The types of rehabilitation services available are psycho-social and/or vocational rehabilitation.	Psycho-social services would include support to restore eligible participants’ independent functioning and to facilitate their social adjustment through psychological or social interventions; e.g., psychological counselling, life skills, and family relationship or couples counseling. Family and/or couples counselling is available to support the goals of the vocational plan.	Survivors of Veterans who died before April 1, 2006, as a result of service-related injury or disease, or a non-service related injury or disease that was aggravated by service, are not eligible for these services Survivors and spouses are only eligible for mental health treatment benefits if they are participating in the vocational training.
OSI ClinicsFootnote 5	Family members including spouse or common-law partners or children to the extent that they are required to achieve the treatment or rehabilitation outcomes that have been established for the Veteran.	OSI Clinics’ support to family members includes couple and family assessments, counselling for partners, and family therapy.	The need to include family members in a Veteran’s treatment plan must be established by the Veteran's treating health professional or be identified in the VAC Rehabilitation Plan.	Family members are not eligible for services at an OSI clinic unless the Veteran is receiving treatment at the clinic. Then, even if family members are eligible, only limited services are available.Footnote 6
VAC Assistance ServiceFootnote 7	Spouses, and dependents under age 21 or up to age 25, if they are full-time students, can access for any issue of their own.  Caregivers including friends, extended family members and children over 21 who are not full-time students, or full-time students up to age 25, are eligible if their issue is related to the care of the Veteran or former RCMP member and where the objective is to better support the individual.  Separated spouses if separated for less than 1 year. Ex-spouses for issues related to the children of the Veteran.	This is a confidential, short-term counselling service provided by mental health professionals for all Veterans and their families as well as primary caregivers who have personal concerns such as: problems at work or at home; personal or emotional difficulties; family or marital problems; or anything that affects one's well-being.  Bereavement services have also been added through the VAC Assistance Service. The bereavement services include assessment, counselling (short-, medium- and long-term) and case management. They  assist families, Veterans of the CAF and the RCMP, and caregivers who are affected by a service-related death.Footnote 8	The service is available 24 hours a day, 365 days a year by calling 1-800-268-7708, and is offered free of charge. It is the primary provision of support to family members in their own right. This service specializes in short-term and immediate crisis counseling as well as facilitating referrals to community providers for other issues.  Longer-term mental bereavement services can be accessed on request through the VAC Assistance Service toll-free line. Since December 1, 2014, the number of counselling sessions has been increased from 8 to a maximum of 20 sessions, per issue, when needed.	While the VAC Assistance Service can provide immediate support, it is unable to assess or diagnose an individual or provide any type of longer-term or specialized treatment. Family members do not have a choice in type of mental health clinician they receive counselling from (such as a psychologist, social worker or psychotherapist). 20 hours of support may not be adequate for some psychological difficulties that require long-term support.
Operational Stress Injury Social Support (OSISS)Footnote 9	CAF members, Veterans and family members.	The OSISS program is a  non-clinical peer support network for CAF members, Veterans and their families. It provides personal and group support, and conducts outreach, referral and advocacy activities on behalf of their peers. Joint program with the CAF.Footnote 10	The family peer support component consists of family members who have had the experience of living with a CAF member or Veteran with an OSI, who provide support to other families going through a similar experience.	OSISS is only available to CAF members, Veterans, and their families who are suffering from an OSI.  Services are not available to caregivers of Veterans who are not their family members. Peer support only; not considered mental health treatment.
Group Health Insurance (Public Service Health Care Plan)Footnote 11	Former CAF members who are eligible for VAC rehabilitation services. Former CAF members who released on or after April 1, 2006, and have been approved for the SISIP Long Term Disability program. Survivors of CAF members or Veterans who died after April 1, 2006, as a result of a service-related injury or illness, and are not already receiving the Public Service Health Care Plan through the Department of National Defence.	The PSHCP provides coverage for a wide variety of health-related products and services. Participants are responsible for paying monthly premiums. Participation is voluntary. Once eligible, Veterans can maintain the PSHCP coverage for life.Footnote 12  The plan reimburses 80 percent of the cost for most eligible expenses including: prescription medicines; vision care; some regulated medical practitioners; dental treatments as a result of accidental injury; other services and supplies, out-of-province referrals or expenses; and hospital accommodation charges depending on the coverage selected.Footnote 13	The PSHCP provides up to $2,000 per calendar year, per family member, for mental health treatment services from a registered psychologist, reimbursed at a rate of 80%.Footnote 14 While the maximum service fee varies by province, $2,000 may not provide sufficient coverage for a family member to address significant mental health issues. For example, the Ontario Psychology Association (2015) recommends that its members charge a maximum hourly fee of $225 for consultation and counselling.Footnote 15 This maximum rate could translate into just nine sessions per year with an out-of-pocket expense of approximately $380, as only 80% is covered by the PSHCP.  This cost is a significant financial barrier for some families and may limit the number of treatment sessions the family can afford to attend.	Accessibility to this service may be a concern if the client cannot afford to pay the monthly PSHCP premiums or the service fee at the end of the session (and submit for reimbursement) as there is no direct billing option available. Eligible spouses and dependents of a Veteran can only obtain health care coverage through PSHCP if the Veteran is eligible, and directly enrolls them in the plan.  Reimbursement requires that the family member has a current prescription for psychological services which may pose a barrier as many Veteran family members do not have a family physician.
Veteran Family ProgramFootnote 16	Medically-released CAF Veterans and their families.	Veteran Family Program offers access to the 32 Military Family Resource Centres across the country.	This program focuses on providing transitional services and resources, including providing family members with referrals within the community and education.Footnote 17	This program is only available to medically-released CAF Veterans and their families.
Operational Stress Injury Connect (OSI Connect)Footnote 18	OSI patients and their families.	OSI Connect is a free mental health learning and self-management mobile app developed to help OSI patients and their families understand the nature of OSIs and provide help through the OSI Clinic Network.	Provides information on post-traumatic stress and triggers, depression, anger, sleep problems, substance abuse, and stress management. There are assessments, videos and information, including how to get an OSI clinic appointment.Footnote 19	Access relies on having the appropriate technology (device). Access relies on internet service being reliable and available in rural communities. Provides information only; not mental health treatment. Not tailored to specific needs of individual family members.
Mental Health First Aid (MHFA) for VeteransFootnote 20	CAF Veterans and former RCMP members, family members, relatives, health professionals, providers of Veteran services and volunteers.	Based on the principles of physical first aid, this two-day session helps participants learn how to recognize a mental health problem and how to respond appropriately to a mental health crisis until the crisis is resolved or professional help can be obtained.Footnote 21	MHFA is tailored to address the needs of Veterans and the people who care for them.  Offered at no cost to the Veteran community.	Available throughout the country, but often difficult to access and find where the courses are being offered. Considered psycho-education not mental health treatment.
LifeSpeakFootnote 22	CAF Veterans and their families. Former RCMP members and their families.	VAC contracted Health Canada to provide an online mental and physical health information and support resource to Veterans and their families. Provided as part of the VAC Assistance Service, free of charge and available 24/7.	Offers education on a variety of topics including mental health. Educational videos are about 5-8 minutes in length and are facilitated by subject matter experts in English and French. Includes videos, podcasts, transcripts, printable tip sheets and action plans all accessible via computers, smartphones and tablets. Offers ‘Caregiver Zone e-learning program,’ which empowers informal caregivers to protect, improve and sustain their own health and well-being throughout their caring journey. Access relies on having the appropriate technology (device).	Access relies on internet service being reliable and available in rural communities. Considered psycho-education not mental health treatment.
PTSD CoachFootnote 23	CAF Veterans and their families. Former RCMP members and their families.	The PTSD Coach Canada is a mobile app that provides information and helps individuals manage symptoms that can occur after trauma.	Features of the app include: Information on PTSD and about treatments that are effective, Tools for screening and tracking symptoms, and Convenient, easy-to-use tools to help manage stress symptoms Information on crisis support and how to get help	Access relies on having the appropriate technology (device). Access relies on internet service being reliable and available in rural communities. Considered psycho-education not mental health treatment.
The Caregiver ZoneFootnote 24	For family members caring for ill or injured Veterans (CAF and RCMP).	The Caregiver Zone is a free online resource that provides videos and other resources, on a wide range of topics.	This online resource offers: Reference library: a large collection of articles, education, videos, and tools, on a range of caregiving topics Community of Sharing: a safe and positive community to share stories, experiences, and caregiving wisdom with other caregivers Caregiver Coach Support: expert and resourceful health care professionals who provide personalized guidance and advice Resources: a list of helpful services, organizations and resources	Access relies on having the appropriate technology (device). Access relies on internet service being reliable and available in rural communities. Considered psycho-education not mental health treatment.