Good morning, everybody. I call the meeting to order.
Welcome to the 14th meeting of the Standing Committee on Public Safety and National Security.
We are continuing our study on operational stress injuries and post-traumatic stress disorder in public safety officers and first responders. We welcome our guests and witnesses.
Colleagues, I just want to mention that at noon we will be joined by another witness, Dr. Paul Frewen. Because we have only three witnesses today as opposed to our usual four, I suggest we plan on ending the meeting 15 minutes early, at about 12:45. Then we would ask the subcommittee on agenda and procedure to stay for about 15 minutes to go over the witness list for the next few sessions, get that done, and still be out by one o'clock today.
Is that agreed as a kind of working plan? If it turns out that you want more time with the witnesses, absolutely we will do that, but I think we probably should have sufficient time.
Dr. Zul Merali will be our first witness to speak. Each witness has about 10 minutes, so we'll have 20 minutes for presentations, members will ask questions, and then Dr. Frewen will come in after that.
Dr. Merali, welcome. I appreciate your taking the time, and I look forward to your enlightening us.
It's a real honour to be presenting and discussing this issue with you. Rather than making a major formal presentation, I'm going to leave some room for a dialogue, because I know that over the course of your deliberations you have had a lot of presentations that tell you about the scourge of depression and PTSD affecting people of all stripes, including first responders and people in uniform as well as first nations populations. I'm sure you have been well briefed on the immense suffering of their comrades, their families, and their friends, but I'm here today to tell you why I believe the situation is not getting better.
I hear a lot of unsettling statistics about how, as the population returns from Afghanistan, there is going to be a higher rate of PTSD, that the cost of medical marijuana is projected to increase to something like $30 million, and that the rates of suicide are not decreasing and if anything are on the rise.
I would like to share my views on how we could collectively try to correct the course trajectory of these kinds of statistics. I think my plea would be that we need to take research and innovation much more seriously than we have to date, because if we do business the same way as we have always been doing, we cannot expect different outcomes. The different outcomes are really going to come through research and innovation.
Let's do a bit of a reality check. We are successfully treating only about a third of the people suffering from depression and post-traumatic stress disorder—only a third. Another third are really not responding too well, so they are not ready to go back to work. The last third will not respond no matter what you do. It doesn't matter what treatment regimes we have.
Our treatments are taking far too long to kick in and, when they do kick in, they're not very enduring. Why? It's because the way we diagnose and treat medical conditions leaves a lot to be desired. There's much need for improvement.
Let us first talk about the treatments, or I'd say lack of adequate treatments.
As I said, we only bring about a third of people into remission, and the other two-thirds are doing poorly. Even in the third who are showing a positive response, many will relapse within the first year. If you had a situation like this for heart disease or for diabetes, we would not accept it. Why do we accept this for mental illness? It really boggles my mind. We need to move ahead on this front.
One of the problems is that we continue to diagnose mental illnesses by symptoms. People ask you how you feel, and then you may describe your symptoms, and there's a checklist that people go through. Then they say, “You pass the threshold, we give you this diagnosis.”
However, you all know and we all know that there is a huge amount of variability in the symptoms that people express, either symptoms that affect people or the symptoms that affected people want to communicate to you and talk to you about. There's a lot of variability. There can be a variety of emotional symptoms, for example, including depression, worry, intense feelings of guilt, and emotionality. There are intrusive thoughts of various kinds, including memories and sleep disturbances. As well, there are a variety of physical symptoms: neurological, respiratory, musculoskeletal, and cardiovascular.
The symptoms may manifest themselves within months of a traumatic event or years after a traumatic event. They may appear after a single episode of stressure or they may appear after a protracted series of traumatic experiences, as with multiple combat situations.
The point I'm trying to make is that there's a huge amount of variability in the factors that precipitate things such as depression and post-traumatic stress disorder, and the ways in which people express those symptoms are variable.
Then we have these diagnostic scales that are entirely based on the symptoms. We have no blood tests. We have no brain scans. These are the kinds of tests that we have come to expect for heart disease, cancer, and other things, but not for mental illness. We don't have those. As a result, two people can have extremely different symptom expressions, yet they'll both be given the same diagnosis and they'll both possibly end up getting the same kind of treatment. No wonder our treatments don't work well.
Why are we in this predicament? Why is this so different from other medical conditions? After all, this is a medical condition. I think we have to begin to focus a bit more on biology, because our diagnostics right now are agnostic of biology. It's all based on symptoms. Also, we need to develop biomarkers through blood tests and brain scans.
In terms of technology, I think we are at a stage where there have been huge advancements in terms of both genetics and, for example, imaging. We recently invested a huge amount of resources into creating a brain imaging centre at The Royal. The reason we did it is that we wanted to provide a platform that could help us peer into the living brain.
How can you treat an organ that you can't see? You take your car to a mechanic because you know that he knows how the car works. He can see it, he can open your engine, and he can feel it. You can't do that to the brain. Your brain is locked away in the vault of your skull. There is no easy way to get to it. You can't get to it, you can't feel it, you can't pulse it, and you can't see a lump as you can for a cancer. You need to peer inside the living brain to see what is happening. You need to do a sort of non-invasive biopsy of the living brain so that you know what's going on.
In the case of mental illness, we know it's brain based. We need to peer in. It's not just a matter of looking into the brain for abnormalities that are anatomical. I don't think there will be anatomical abnormalities. What is happening is that some circuits within the brain are starting to malfunction. What we need to find out is which ones are the rogue circuits. Where is it that certain symptoms are expressing themselves? How can we use the technologies we have, and other means, to better diagnose—to diagnose early and diagnose precisely, and to know what is causing the illness so that we can specifically treat it in a personalized way, as we do for other illnesses?
For example, if you have a cancer, they'll do a scan. They'll tell you the regions in your body where they see growths. Then they'll do a biopsy and identify the cell type. Then they'll do a spectrum analysis on the cell and say what chemotherapy they think is very specific for that cell type, and that's what they'll put you on. This is all evidence based.
It's my dream that this is where we will get to in terms of mental illnesses. We need to become much more precise and individualized, because we have seen that “one size fits all” does not work. We cannot keep doing the same things over and over again and expect better outcomes. We may throw all the resources we want at these treatments, but we know what the success rates are. Why don't we invest in something that's going to change that?
I thought I'd come here not to tell you a pretty story, but rather to lay out the facts as they are, to tell you what some of the difficulties are in how we do business, to tell you about the lack of effectiveness in the treatments we're using, and to give you a bit of a solution as to how we can begin to find our way out of this pit-hole that we're in right now.
Really, I think investment in research and innovation will be our ticket to what we're looking for, a better quality of life for those who are suffering in silence. We can throw as much compensation at people as we want, and it will only keep on increasing if we don't stem the problem. We need to be able to figure out what goes awry so that we can begin not only to have customized treatments but also, further upstream, to prevent people from getting ill and getting into these situations.
I thought I'd stop at that and open up the floor to see what questions you might have on this front, because I think it is really a call for help.
Thank you. I'm Dr. Alice Aiken. I'm the scientific director of the Canadian Institute for Miliary and Veteran Health Research and a professor at Queen's University.
I'm going to talk to you today about a model that I think works well and could potentially work to meet your needs, and that's the model we follow. I had the advantage of being at an earlier meeting held in Regina and talking about this very issue. The was there as well.
I would really urge the committee to think beyond just post-traumatic stress disorder and encompass all mental health. The issue is that if you only focus on post-traumatic stress disorder, we're going to have a lot of people getting that diagnosis who don't have the problem, and, as we just heard from my esteemed colleague, we're already struggling with finding the correct treatments. It's not going to help if everybody is getting the wrong diagnosis in the first place, so I really urge you to think beyond just post-traumatic stress disorder to mental health more broadly.
One of the facts that supports this is our focus is in military and veteran health research. We know from very good epidemiological data that there are many influences on mental health disorders beyond simply our own biology. There are societal, cultural, and experiential influences on mental health, and one of the best examples of that was a very large-scale study done out of the U.K. on returning combat veterans with mental health issues. The number one diagnosis in the U.S. is post-traumatic stress disorder; in Canada it's a major depressive disorder; in the U.K. it's binge drinking. All three are related diagnoses, but there are obviously differences in culture that might explain those.
I just want you to keep that in mind: that perhaps just to focus on PTSD is not ideal.
As I mentioned, about seven years ago we started the Canadian Institute for Military and Veteran Health Research, and respecting what Minister Oliphant said, we started out with no money and we did it because it was the right thing to do and a good idea. I'm extraordinarily biased, because I am a veteran and I'm married to a veteran, so I thought it was extremely important.
We started this institute at arm's-length from, but in consultation with, National Defence and Veterans Affairs. They recognized that they needed independent arm's-length research to inform their health policies, practices, and programs as they moved forward. Both National Defence and Veterans Affairs recognized that. Their link-in was to the academic community. I would hope that we perceive in this country that a lot of our best and brightest researchers exist in our academic institutions and that it would be where government should be able to turn for these answers.
We actually do operationalize a fairly large standing offer now on behalf of National Defence and Veterans Affairs for their research ideas that they want to put out to the research community. We are a network of 41 Canadian universities and over 1,000 researchers dedicated to researching the health needs of military personnel, veterans, and their families. Public Works has actually cited the way we do business with National Defence and Veterans Affairs as the way government and academia should be working together, so we're pretty proud of that.
The other thing that we did not do from the beginning is we did not limit the research areas. We really wanted to focus on the population, which I think is very similar to your mandate. Your mandate is public safety personnel, meaning first responders, corrections, 911 operators—public safety personnel in a broad sense. We focus on military, veterans, and families.
The vast majority of the research is being done in mental health, but we also do research in physical health, novel health and technologies, and occupational health. There are different areas of research, and what's been really remarkable is we're now seeing overlap among a lot of the areas of research. For example, some of the technology allows for children of military families who are moving around the country to still be treated by the same psychologist through social media and through technology. Those are really neat overlapping areas of research.
I think it's incumbent upon our government—and I say this not as a researcher but as a taxpayer—to ensure that policy or programming decisions are based on evidence, and it's out there. It exists. It's just not always harnessed and used to the best of our abilities. I believe the academic community is here to help with that.
I'll stop there. I'm happy to answer any questions, but my orientation is just to say we've done it. We're happy to help any other group that wants to set up similar organizations for public safety, but I'm going to agree 100% with Dr. Merali that it needs to start with the research. To focus on one area of treatment or to fund treatment programs blindly doesn't solve the problem. We need to go back to research, and some of it in very basic science and new diagnostic methods.
We've always had first responders as part of what we talk about with CIMVHR and at our conference we always have presentations on first responder research as well. It's definitely something that's in our sights and always has been. In fact, a lot of the researchers doing research on military and veterans populations are also doing research on first responder populations. It's the same people that we see doing the work, because they are experts in their area of research and they can focus in on a particular population.
Where we ran into a bit of a hiccup, though, was on the more political side of things. First responders don't see themselves as military and veterans, and military and veterans don't see themselves as first responders. They understand there is an overlap, but they don't see it as exactly parallel.
Have we built a mechanism that works extremely well? Yes, we really have. We've networked the universities and we have the research being done. For example, three years after we started, research on post-traumatic stress in Canadian veterans had increased by 400% over any other period of time since World War II. We know we're having that kind of effect by focusing on a specific population, and we've built a very effective mechanism.
However, what I realized at the meeting in January is that there are a lot of stakeholder groups for public safety who probably need a say in how a research institute moves forward for them. We're happy to share. If an institute were to start, we'd be happy to share whatever we have. If the public safety department decided they wanted their own, they could use our governance structure, our conference, our journal. Anything like that we're happy to share.
I did get the impression—Monsieur Picard will correct me if I'm wrong—that the groups there felt they needed their own institute focused on this, as we were focused on military and veterans health.
Thank you both for being here and giving us your expert opinions. Thank you also for the work that you're doing.
I want to thank my colleagues on this committee for taking on this issue and giving it serious attention and public prominence as well.
For me this is all too real. I served for seven years in a war zone. During that time, over a very short horizon, I had two colleagues who committed suicide. One of them was a serving U.S. service person who went on home leave and killed himself with his service weapon. The other was a civilian PSD, personal security detail, who killed himself in theatre, again with his service weapon. Neither of the two men was directly involved in front-line combat, but neither of them, obviously, had received adequate treatment, and they had the most severe response to the condition that we know of.
I want to begin by asking a question that might be blatantly obvious, but may drill down a bit into the clinical ramifications. The fact that we're talking here, and that this is now out in the open as something to be talked about, has given us the opportunity to give it the attention, the planning, and the resources that it deserves. Again, it's stating the obvious, but is there not also a clinical component to getting past the stigma?
Dr. Merali, in your writing you compared this to the stigma that existed with respect to cancer. We're now breaking down the walls of stigma.
What can we do as parliamentarians? What can we all do as human beings to make sure that this continues to be something that is not stigmatized and is increasingly talked about? Very concretely, what might be the therapeutic benefits of bringing this phenomenon out into the open and tackling it nationally, and increasingly, internationally?
Good morning. Thank you for your presentation.
My comments will follow on the question my colleague Mr. O'Toole asked. This is something that is of great personal interest.
Dr. Merali, you spoke about treatment after a PTSD diagnosis. You said that a third of people who go into treatment are successfully treated, that a third has limited success and that the remaining third has no success at all.
You also said that technology and research made it possible to better predict who would respond the best to a treatment, and it's important to note that this varies from person to person.
Are there pre-existing conditions, such as trauma, that exacerbate this disorder in certain individuals? It would be good if the research or the discoveries that have been made could be used to determine basically which individuals have such conditions. If that was the case, perhaps we could raise awareness about this.
Could you speak more about that?
My question is also for Dr. Aiken.
Thank you for having me. Indeed, I did share the website, and my presentation will pertain directly to it.
Thanks very much. I'm going to share my screen now. You can see it in a moment.
What I'm going to be describing to you is a therapy that we've developed that combines an Internet-based approach with making use of mindfulness meditation and other types of meditation that I feel would be a good intervention for post-traumatic stress in first responders as well as other populations.
I was able to hear some of the earlier presentations which had to do not only with treatment but also preparation for an individual who can be expected to witness and respond to traumatic life events. I heard the terms “preparation” and “self-training”. I feel this type of approach, which is Internet-based and very much an intervention in which people are training themselves, would fit very well with that interest. As such, it should be a feasible intervention to provide in a large capacity.
We should think about the treatment of trauma and stressor-related disorders as involving two primary objectives.
The first is to work through the trauma. This typically involves some dialogue with a therapist in which a person is reviewing what has happened to him or her in different formats, essentially trying to understand what happened to them. It could be verbally or through writing or art, etc. That reflection leads to an increased capacity to not become distressed, for example, by being reminded of what has happened to them.
The other component, which may be talked about less, is the component of self-regulation, which essentially is helping a person cope better with the difficult emotions that come with diagnoses such as PTSD. I think you've certainly heard of the current evidence-based treatments. We have some effective treatments, typically cognitive behavioural approaches to psychotherapy, but there are certainly limitations to the current approaches. Indeed, not so many participants get fully well. For example, only about half show a response rate that leads to a loss of the diagnosis of PTSD in randomized controlled trials, and there's also a lot of dropout.
The literature is starting to turn to both Internet-based treatments and alternative approaches to cognitive behavioural therapy, such as mindfulness-based therapy. Indeed, at the University of Western Ontario, we've been the first to essentially put these two together with an Internet-based approach to mindfulness-based therapy.
Very briefly, assessment of the web-based interventions have been published, especially in the areas of treatments for depression and anxiety disorders, and more recently PTSD as well, and the findings are quite striking. Relative to the same types of treatments administered in the typical way—in face-to-face psychotherapy, for example—the effect sizes, the outcomes for the Internet-based approach are often just as strong and just as good as those obtained in the face-to-face approach. That surprised many, but it has actually been documented extensively now.
This is also the case in PTSD trials, for example, in college student samples, community samples, and combat veteran samples. To my knowledge, we don't have a study yet on an Internet-based approach for first responder groups, but based on the literature, similar kinds of outcomes can be expected.
Mindfulness-based interventions so far have not been delivered in an Internet-based approach, but there are several reasons that we would think mindfulness-based practices should be helpful in the treatment of post-traumatic stress disorder and dissociative disorders.
For one, they tend to improve attention and concentration, can improve the ability to focus on the present and away from ruminations around past trauma as well as future-based anxiety, and can alter cognitive style and help a person become less judgmental and more compassionate towards themselves. They can directly reduce physiological arousal and associated emotions of anxiety, irritability, and anger. They can lower anhedonia—the emotional numbing, the inability to experience positive emotions such as joy—and so increase positive emotions, increase a person's experience of social connectedness, and restore existential concerns towards improved well-being.
There are good ideas. There have been several research projects that have also shown persons with post-traumatic stress disorder are lower on what are called mindfulness traits. For example, they are less likely to notice changes in the body, such as whether their breathing slows down or speeds up. They are less able to put feelings to words and less able to find words to describe their feelings. They are less able to stay in the present. Their minds wander. They are easily distracted. Further, they are less able to accept their feelings without judgment.
These are areas that a PTSD treatment should target, and a mindfulness-based treatment targets such things.
We have recently shown that the relationship between trauma exposure and PTSD symptoms is significantly mediated with these types of mindfulness-based personality traits. If we can affect these traits, then we can affect the PTSD symptoms.
Improvements in attention and improvements in emotion are expected outcomes for mindfulness-based therapy, and there have been several studies that have shown positive results for mindfulness-based therapy, including our own study.
If I have a moment, I'll be able to describe a bit more about the specific treatment using mindfulness and metta-based trauma therapy, which is an Internet-based approach. It involves teaching meditation as well as various mindfulness-based principles and ethics.
We teach six therapeutic principles. The first is about how a person can stay present. The second increases awareness of both mind and body. The third helps a person understand how to let go of difficult forms of distress. The fourth refers to metta, which has to do with loving kindness and self-compassion. The fifth has to do with recentring and decentring, and the sixth with acceptance and change.
I have a couple of slides to show you how we do this. In general, we try to teach a person greater control. PTSD and trauma lead to a sense of inability to control the controls beyond oneself. We're trying to put the control back into a person's hands. We use the acronym PALM to refer to the first four principles of presence, awareness, letting go, and metta.
Presence is the first. This has to do with helping people understand they are in the present and not the past. This has to do with the flashbacks and the re-experiencing and recognizing the influence of the past traumas on their responses in the present.
To assist with the awareness, we're trying to teach people to become more aware of their senses, their body, and their emotions, and to try to label and understand their experiences.
With the letting go, we're trying to help them to be able to let go of the distress as well as teach non-attachment to harmful impulses and desires that can develop from a significant trauma history, such as substance abuse or alcoholism.
We also help with the capacity for metta, for being kind and compassionate to oneself and others.
With the the recentring, people can desire a feeling, but they are feeling too far from it. We're trying to reverse that and bring people back to their sense of self and bring them back to their emotions. At other times we're teaching that if a person is feeling something too much, then the person needs to get outside of that. We're trying to teach a person to be able to develop that experiential distance so as to have the capacity to reflect, decentre, and then wait it out, as the distress will eventually subside.
I'm not sure about my timing, but what I would like to suggest in comparison with—
In comparison with the decentring, we want to contrast that with avoidance. We'll be rejecting the present. With dissociation, we leave the present.
Finally, that last principle is acceptance and change. It really is a sort of balance that typically the trauma survivor is trying to avoid. We talk about this as if it's like a blanket. We try to sweep it under the rug, for example, but it's really a see-through blanket, so we can't do so. Really, the only way to move forward following a trauma is this right balance between acceptance and change.
How are we doing these? Essentially, the website involves a journaling activity as well as various guided meditations.
What I'd also like to suggest, beyond just the website, are various technologies that are being researched, including here at the University of Western Ontario. Persons may have heard of the terms “neurofeedback” and other forms of biofeedback, such as heart-rate variability. The practice of meditation is going to have an effect on the brain and the body, and that's essentially indirect; the practice of biofeedback and neurofeedback is to learn what's actually happening in the body through physiological signals such as heart-rate variability and through the EEG. We can teach a person to directly modulate brain rhythms, cardiac rhythms, respiration, etc., as they're going to be doing naturally in meditation, but the biofeedback can be an additional aid to the person.
In response to both, I think these interventions indeed could be a mental preparation for the difficult types of workspaces we're finding trauma and PTSD to come from. This could be done up front and throughout and encouraged as a well-being practice.
I'm sensitive also to the point around language. Indeed, it might be the same sorts of things, but we can call it mental training or cognitive preparation. A focus on mind and cognition and mental training more than the emotional fluffy stuff can sit well and be more acceptable. That would be the up-front preparation.
We have seen an openness to these types of practices as well. Both men and women in different types of jobs have experienced the trauma, they've struggled, and these types of interventions do more and more make sense to people.
Also, speaking to that as well, the technology focus that I was leaning toward at the end there can also aid the person who might be a little more sceptical of meditation and mindfulness. If you show them their EEG, if you show them their heart rate, if you show them how to regulate their condition, it really puts the power and the control back into their own hands, as opposed to being reliant on a medical model only.
In this particular Internet-based intervention—MMTT, I'll call it for short—all of them are inspired and validated interventions. The journaling activity is part of a cognitive behaviour therapy standard approach, the automatic thought record. It is to take those six principles that I described and apply them to everyday stressors that the individual is experiencing, using those concepts and applying them to regulate themselves to be able to manage their distress, reflect, and respond in a more adaptive way. That is part of typical approaches, but we're using the mindfulness language and specifically making use of it and applying it to that journaling activity. However, the journaling activity, broadly speaking, is a well-validated and researched intervention.
We also include a specific practice that we developed here at Western whereby we can determine the level of concentration experienced during the meditation. It's a self-report methodology, but we're validating it against various experimental methodologies, including collecting EEG, and we're able to predict, for example, the brain state from the self-report, and whether the person was concentrating or distracted during the meditation. As they sit quietly and attend, for example, to their breath, their mind will wander, and it may wander towards the trauma and intrusive memory, but in terms of the degree to which it does so, we can provide some prompts, some cues, to bring them back to the breath, back to the target of their attention.
Finally, the different guided meditations that we include have all been used in various formats, most especially the well-researched mindfulness-based stress reduction and mindfulness-based cognitive therapy. Each of the interventions available through the website has been well researched in different domains with various populations, including PTSD, but also, as you say, various anxiety disorders, depressive disorders, dissociative disorders, substance abuse disorders, which PTSD is typically comorbid with.