:
I was up here in March. I recognize some faces and see some new faces. As I think I stated in March, you're going to hear it in a soldier's language. I don't beat around the bush. I shoot from the gut. I have nothing to prove to anybody.
Ladies and gentlemen, you are looking at an individual who has suffered with the dreaded affliction known as PTSD, post-traumatic stress disorder. I have been suffering with this mental disorder for the past 36 years of my life of 62 years. For the past four years, I have been under the care of medical professionals after being diagnosed with the disease in April 2006.
PTSD is a dreaded disease that one can be suffering with while looking completely normal to anyone who does not know what the veteran is fighting with on a daily basis. In other words, we all look normal. You walk in and see me and think, “There's nothing wrong with that guy. He's normal.” Well, I'm not normal, not mentally anyways.
One of the biggest factors that we constantly endure is the knowledge that once a veteran is diagnosed and the word gets out, then we are looked at as an enigma and are treated with distrust, not to be put into an area of responsibility. Basically we are treated like one with leprosy.
To try to cope and hide the fact that there was something wrong with me, I put on a phony act and tried my hardest to socialize, but in the end it all came crashing down, which damn near destroyed me. Many veterans cannot handle this daily battle with oneself and completely withdraw into a world of depression and what we refer to as “bunkering in”. That is, a veteran goes into his basement or his little room, and he stays there and will not come out. He becomes completely reclusive, not wanting to socialize or be bothered by anyone. There is a complete social breakdown.
As for me, I have been suffering from massive headaches, nightmares on a regular basis, bouts of anger to the point that I have scared individuals, frustration in not knowing what was going on with me, anxiety over having to carry out the simplest tasks, and an unwillingness to fully trust anyone close to me--i.e., at work or at home. I was always on guard, keeping my shield up at all times, constantly vigilant as to what was going on around me. I had social misbehaviour and run-ins with authority. These things are common in men suffering from PTSD. I use the word men because I have never worked with women with PTSD.
These conditions manifested themselves directly when I returned from Cyprus in December 1974, after a United Nations tour with the Canadian Airborne Regiment. After my first marriage broke up in 1982--I had been married for 10 years--my parting wife stated to me that she still loved me but did not know me anymore. Another statement she made was, “You are not the same man I married since coming home from Cyprus in 1974, and at times you actually scare me, as I do not know what to expect from you.” This is another one of the things that we have to face--the family support system, and loss of that system.
After returning from Somalia in 1993, I remarried, hoping beyond hope that I could find normalcy with the woman who I now love. This too fell to the wayside, leaving me in a daily battle with my conditions, which I call the roller-coaster ride of emotions: up one minute and down the next.
Presently, I am still suffering through many of these conditions, even though I am seeing a psychologist on a regular basis. Because of the constant struggle to find meaning in life while suffering from the black dog of depression--that is what I call it--my physical being has taken a beating faster than what I or the medical professionals predicted.
I may be wrong in making this assessment, but I blame the never-ending cycle of emotional ups and downs caused by PTSD for my failing health. To try to find some meaning in all of this, and to make a commitment to myself--in others words, for a get-out-of-the-house project--I volunteered to join the OSISS, occupational stress injury support service, as a peer helper. It is this experience with OSISS, of which I am no longer a member, plus taking on a workload of veterans on my own that I now draw upon.
I did my best, giving 100%-plus to help my fellow veterans until I went through what we call the burnout phase, something all peer helpers like me will go through, because you get too involved with the man that you're working with and you get burned out.
It was during these episodes of burnout that I suffered severe depression and a deep bunkering in period. As you can imagine, this took its toll not only on me but also on my relationship with my loving wife, which was already at the breaking point. It was during these black dog times that I completely cut myself off from the outside world, missing important medical appointments and basically cutting back on my duties to help my fellow veterans.
This part really upset me, as I consider it my duty to keep in contact with them. That's the old thing about soldiering. You help your buddies, and in return they help you. When you can't do that anymore, then it falls on your shoulders: you've let them down. We've all gone through it.
These episodes would last for weeks to months at a time. While I have suffered through these horrible times in my life, my loving wife has constantly stood by my side, even though I would spend days in my bunker, not washing, shaving, or changing my clothes, and only going upstairs to eat every now and again. She has endured quite a lot over my illness through the years, and has even threatened to leave me on a few occasions. I would not blame her in the least if she did, as I think she would be better off without me.
As time passed and my condition worsened, she kept cutting back on her hours at work so she could be with me more and more as she was concerned that I was going to kill myself. When she could not cope anymore at work, she decided to quit her job to be with me at all times. Even though this was a great boon to me, it cost us dearly financially, but we manage. This is more stress put upon us. Besides all this, I have not been able to sexually satisfy her for over 10 years. You can imagine what stress this has put on our relationship.
I see my life as one of constant pain and suffering. My life as I knew it is in ruins, and at times I feel that there is no sense in carrying on under these relentless circumstances. I have to admit and I say without malice that PTSD has taken a great toll on me and on hundreds of other veterans.
This is what I have experienced over the past four years.
First, PTSD will ruin the veteran's family and social life until they turn to addictions such as alcohol and prescribed or illicit drugs, gambling to the point where they are no longer in control of their finances, or dangerous sexual overactivity that may turn to prostitution. Or they might become workaholics. By carrying out these manifestations, they ruin any chance of getting self-respect or battling the effects of PTSD.
Also, I must state that when someone is suffering from one or more of these addictions, it makes the diagnosis of PTSD more difficult, as the person must first be treated for these addictions. This period of assessment is very stressful to the member, as it will more than likely ruin his marriage, if he is married, or any relationship that he is in. With the loss of family support, which is critical for the veteran's recovery process, he will more than likely end up as a recluse or come to the point of attempting suicide.
If he can maintain family support, which is hard and stressful not only to the veteran but to the family as well, then he has a much better chance of living with the effects of PTSD. On the other hand, if a member is single, then the battle is waged on a different scale--that is to say, it is harder on him to seek help and he will probably turn to other means such as addictions. If he is not fortunate enough to get medical help immediately, he will normally self-destruct.
Because of the constant mistrust by veterans towards authority and the banishment they feel by the system in place, they will rebuke any help and form themselves into splinter groups to seek advice and help from one another. This is what I refer to as a speeding car going down a one-way street--a very dangerous street at that. Instead of gaining help from one another, all they are doing is putting their lives in jeopardy by not seeking proper medical assistance. Meeting in one's basement or a garage does not solve anything, especially when they do most of their discussions over a couple of cases of beer or illegal tobacco. All they end up achieving is more anger, frustration, mistrust, and the threat of oncoming deep depression. I have personally witnessed these occasions twice, and must admit that it totally shocked the hell out of me.
I have personally attended two group sessions held by my psychologist, which have helped me considerably to further understand the effects and causes of PTSD. These, as well as one-on-one sessions, have taught me how to cope during times of undue stress and anxiety, and have taught me the triggers that set me off. These sessions have considerably helped numerous fellow veterans to try to live a normal life. I will not go as far as to state that they are a magic cure, because they are not designed as such, but they will further benefit the veteran in their daily battles with PTSD and help them put trust in one another. The veteran can only get out of the program what they are willing to put into it. In other words, what I've put into it is what I receive. If I don't want to meet the psychologist halfway, he will not meet me. Then it's a waste of time for both individuals.
Many veterans have been refused help from the medical system because many doctors and psychologists refuse to take us on as patients. They do not know how to treat us, nor do they understand the effects PTSD can cause on the human body. Training is also a big issue. By their refusal, veterans feel even more isolated and mistrustful toward the system. This is one of the main causes of mistrust. If I go looking for help and I can't find it, I don't trust anybody. Then we go to the splinter groups. It's like you're on a speeding car going down a fast hill with a brick wall in front of you. There's no way out of it.
One other major factor that we all suffer from is trying to be understood and properly cared for by a respectful system. That can have very serious effects on the veteran if not found in time. Without proper medical facilities and care, we are basically doomed.
Suicide is on the rise, and I again refer to my own personal experience in stating this. During the last group session I put forward a question to my fellow veterans in attendance. When I asked how many in the group had contemplated suicide, seven out of eight put up their hands. When I asked how many had plans to carry it through, four put up their hands. When I asked how many had tried, three put up their hands. I was one of the three. I have personally suffered through five suicides plus numerous attempts. This has taken its toll on me, as can be well imagined.
Before closing I would like to state that PTSD—and this is coming from a veteran—cannot be cured, but it can be controlled if caught in the early stages. I was not lucky enough to be properly treated at an early stage, even though I requested help back in 1985 and the early 1990s. I knew in 1985 that there was something wrong with me, and my biggest fear was that I was going crazy. That is the first thing a veteran will think when he starts misbehaving and becoming a social outcast. He thinks, “I'm going nuts. I'm the only one out there suffering.”
When I went to the base surgeon in CFB Shearwater in 1985 and explained my concerns about loss of control and nightmares, the medical doctor stated that it was all in my head and that over time I would heal myself.
Well, here I sit, and I am far from being healed.
Signed, Mr. William D. Maguire.
I'd like to thank the committee for the opportunity to be here today. Mr. Cann and I represent Whelan Psychological Services. We're a private practice of psychologists working primarily with military-related OSIs in Nova Scotia.
By way of background, I served in the Canadian Forces from 1977 to 1985. For the past 15 years I've worked as a clinical psychologist, first as director of addictions services for the navy in Halifax. For the past five years I've been in full-time private practice, working primarily with serving and retired military and RCMP.
My remarks today will focus not so much on departments but on the current system of care in effect for veterans.
Our clinic was established in 2005, as an eight-week intervention program in response to a joint RFP by DND and Veterans Affairs, an initiative that was never used. Our work began with referrals of veterans from other civilian providers and family physicians, and self-referrals through the OSISS network. Many of these crisis cases, unknown to the military or Veterans Affairs at the time, were referred by civilians because of addiction or depression problems, and were often assessed and diagnosed by us for the first time.
Recently the situation has improved, in that more referrals to the practice have been previously diagnosed with an OSI by the military. After leaving, they are often referred to us. We tend to have more complicated cases referred to us, which, as Mr. Maguire said, involve a variety of other conditions.
Of the 400 military and RCMP clients referred to our practice over the past five years, approximately 70% are experiencing chronic problems with addiction and post-traumatic stress, which is often further complicated by chronic pain from physical injury, suicidal preoccupation, or anger control problems. Some of these clients, particularly younger veterans and serving members, can do exceptionally well and end treatment successfully. However, in general, the prognosis for successful treatment is guarded, and relapse is the more frequent outcome.
Consistent with the research, veterans with PTSD, and particularly with chronic addiction problems, usually do not respond to treatment as usual for treatment of post-traumatic stress. They often have multiple chronic and comorbid conditions that are difficult to manage on an outpatient basis. They cycle between stability and crisis. Many do not have medical or psychiatric support in the civilian community after they leave their organizations. Suicidal risk is an ongoing concern.
Despite earlier identification and treatment of OSIs by the military, from a continuity of care perspective, there appear to be major gaps in the system. Veterans under medical care in the military often become deeply distressed upon leaving the military, and they go underground, sometimes for years. They're often unemployed, isolated, and pessimistic about any change or possibility of change. Some require hospitalization for attempts of suicide or psychosis; others require close clinical monitoring. In our records, four have died prematurely because of PTSD-related problems.
As outlined in Senator Kirby's 2006 report, “Out of the Shadows”, there are formidable challenges facing the delivery of mental health services across Canada, as we know. In particular, he said,
The...“clash” between mental health services and addiction services has created substantial problems for clients, particularly those with concurrent disorders.
When it comes to managing mental health problems among veterans, then, the question is whether this Canadian average is the expected standard of care.
In our region, services for veterans rely heavily on a collection of approved mental health providers and public health services, when available, such as physicians or psychiatric support, and they may have limited or no expertise in managing veterans' concerns. Under this system there are no mechanisms in place to determine expertise beyond professional credentialling. As well, there are no opportunities for these providers to communicate or coordinate their efforts when a veteran has two or more independent providers.
In contrast, the Canadian Forces in Halifax seem to be working towards a collaborative model in treating military OSIs, including staff cross-pollination and efforts at interdisciplinary cooperation. This model could be considered for application in other jurisdictions. Our attempt to replicate this within a small private practice setting has been very challenging.
The problems faced by veterans are complex and multi-faceted. The solutions will likely require fundamental shifts in organizational cultures, systems of communication, and professional attitude, which must change from one of “experts know best” to one in which client and family needs are identified, valued, and actively managed.
In terms of established evidence in the trauma field, we know that the gold standard involves cognitive behavioural therapy, often in staged approaches that can last one to three years, on average.
In brief, prior to engaging in any treatment of a military-related or an RCMP-related traumatic stress reaction, stabilization is imperative. That includes problems with suicidality. This often means medication management, fostering a stable home environment, managing addiction problems, and reducing overall stressors.
For many of our clients, it is extremely challenging to move past this first stage of treatment. Loss of employment structure and military identity, family dissolution, unmanaged pain, active addiction, problems attaining medical supports, and a persistent preoccupation with pension application and appeal processes results in a perpetual state of instability. As a result, some of these clients may never get to a point of second-phase treatment, which is when they would actively address the specific OSI.
During this time, of course, these clients become even more disillusioned and angry and depressed, which can turn into a chronic state of traumatic reaction.
Mr. Cann is going to complete our remarks.
:
My name's Steve Cann. As well as working at Whelan Psychological, I'm also a contracted clinical supervisor at the addiction treatment program in Stadacona, Halifax. Prior to this, I was a district psychologist, and prior to that I was a case management officer for Correctional Service of Canada.
My comments pertain to two issues: case management and addiction interventions. Before addressing these points, I'll provide a snapshot of our experience as private providers working with these issues with veterans.
In our experience, there are approved services for veterans and there are many others that are necessary but not approved. Efforts to effectively help veterans often mean moving into multiple roles, to the point where our clinical roles become seriously distorted. For example, we are often asked by veterans to act in advocacy roles for them, such as helping them to complete pension applications or referring to civilian physicians or psychiatrists.
There have been instances where we have had to move into the case management role, which can be a source of confusion and conflict. While we are acutely aware of our roles as primary support for our veterans, we are not viewed as being part of any system. We are treated as a resource to be used in a very restricted manner.
There has been much discussion in the past several years about a client-centred approach to veteran treatment. In our experience, a client-centred model of care places the identified client and his family in the centre of a hub surrounded by a collaborative team, all of whom have shared an understanding of the complexity of the issues, have clearly defined roles, a shared commitment to client goals and to the team process, and, importantly, a strong oversight to ensure commitment to these goals. The client and the family form an integral component of this team and are continually involved.
However, what seems to exist can be best described as a “service eligibility” model where each service--psychotherapy, medications--represents a discrete hub with one provider and one veteran working in isolation from two or three other independent hubs involving the same veteran. In this model, there is no opportunity for interaction among the providers and there is no coordinating oversight. Case managers who coordinate client care and have the authority to refer directly to treatment providers are essential for a client-centred approach to function effectively.
As a provider, we find our responsibilities confused by the role adopted by the case managers of Veterans Affairs. In our experience, they do not manage the case. Case management through the department appears to be one of authorizing or denying funding for the recommended interventions based on an insurers list of approved services. Changing the role to one where the case manager is clearly identified as the case leader and coordinator, in consultation with providers in the community, a team approach, would be a big step toward a collaborative model.
Other federal organizations have case managers who act in this role--for example, parole officers through my old job with Correctional Service of Canada. However, a major obstacle to this change in role is that VAC case managers are not permitted to refer or to direct clients to services. These decisions are currently made by outside providers, who may have little or no expertise in the likely outcomes of combat trauma.
Our clinic deals primarily with veterans who are referred for PTSD and addiction. The model of treatment employed at the clinic is an integrative PTSD addiction model, which has shown in our preliminary research to have positive outcomes. Integrated treatment is treating multiple issues and problems simultaneously, such as PTSD, addiction, and depression.
Integrated treatment has been recommended for coexisting disorders for a number of years. Treated alone, the risk is that one disorder can exacerbate the other. For example, the veteran being treated for PTSD becomes overwhelmed emotionally, triggering a relapse to heavy alcohol use, which places him at high risk for self-harm.
In conclusion, as treatment providers we would offer the following suggestions under systems of care: a truly collaborative, client-centred approach be enacted where the veteran and the expert providers collaborate on a team to achieve client goals; teams have a qualified case manager with the knowledge base and the authority to act; and mechanisms be established to ensure continuity of care when serving members who have been treated for OSI are released, thereby helping them avoid treatment relapse.
Under treatment options, we make the following recommendations: first, adoption and implementation of integrative treatment models of care for veterans with coexisting mental health problems; second, decisions about treatment modalities, individual/group medications, or family therapy should not be based on whether it exists on an approved list, but rather it should be made by a collaborative team, based on the evidence and client outcomes; third, in-patient capacity should be sought in local regions for veterans with coexisting mental health disorders to reduce the financial costs and family disruption that occurs when veterans are required to travel to available centres in other areas of Canada, such as Ontario.
Thank you very much.
Basically, we have chosen to leave as much time as possible for questions, so we won't make opening remarks.
Steph and I started this journey about ten years ago as majors. I'm the clinical lead and he's been on the non-clinical side for all the changes that have occurred in DND.
My understanding was that this committee was particularly interested in suicide and suicide prevention, so what I'll try to do--cut me off whenever I've run out of time--is give you a brief overview of the Canadian Forces suicide prevention, including the expert panel we had last year, just in terms of the broad interdisciplinary approach we have within our own organization.
Veterans Affairs colleagues were at this meeting, and they have modified...and they have their own program as well, which is somewhat different. It will become evident, as I speak, that it's very difficult to compare both organizations. We're a large organization; we have 6,000 people in the Canadian Forces health services; we run large clinics; Stadacona has 50 mental health professionals working in this very model. It's a very different thing to try to compare.
The first slide looks at our suicide rates, which are male suicides that are tracked. Contrary to what the media says, we have been tracking very carefully since 1996. I'll speak at the end about how we're tracking them even more closely. We haven't had an increase of serving members since the Afghan conflict began. Nobody can predict the future, but those are the stats we have for now.
In September 2009, the Surgeon General convened, asked us to put together, an expert panel on suicide prevention. The goals were to review what the CF is doing now, evaluate our approach against the scientific literature and the practice of our allies, and recommend opportunities to strengthen the program.
The reason for this was not that we are having the crisis that the U.S. is experiencing with a very high rate, but that suicide and suicide prevention is a major public health issue in this country. It behooves us, as the CF, to have the best practices in place that we can. We're not “happy” that our rate is below civilian society--the loss of every soldier is a loss to us--and if we can do anything to reduce that number, to prevent it, that's our goal.
Very briefly, I'll give you the range of people. We have our CF folks. With our team we have deployment health and epidemiology folks. We have psychiatrists represented, and social workers, primary care physicians, mental health nurses, as well as some of our educators.
We have external consultants. We have our colleagues Dr. Thompson and Dr. Ross from Veterans Affairs. Professor Links is a very important person. He's probably the most renowned suicide expert in Canada, as the chair in suicide studies at St. Michael's Hospital in Toronto. Colonel Ritchie is the advisor to the Surgeon General, so a big player in the U.S.; Lieutenant Colonel Bell, likewise. Andrew Cohn travelled all the way from Australia. Australia does some very interesting things--similar force, similar history, and they don't have all the big hospitals that the U.S. has. It's the same idea of where do we put our high-risk patients; the Australians have a similar thing. We have colleagues from the U.K., Neil Greenberg and Nicola Fear.
The name of a Dutch colleague is not appearing on the slide. I apologize for that....
Oh, there she is: Lieutenant-Colonel Horstman.
A voice: We can't forget the Dutch.
LCol Rakesh Jetly: Yes, we can't forget the Dutch.
The key message from the panel, as I mentioned, is that it's an important public health problem. In terms of the three cornerstones for our suicide prevention program, really what we could put, for an effective mental health program, is excellence in mental health care. When people come, we have to have evidence-based practice. We have to have team-based practice. We have the professionals there.
Within our clinics across the country, we have close to 400 mental health professionals. We're funded up to 440. We're watching the wait-list, we're watching the times, so that when people get ready, they're available, as well as the contract professionals out there.
My colleague here is instrumental in the second of the two, which is effective leadership. Leadership needs to set the tone. Leadership funds mental health care and keeps it as a priority even when we stop the conflict in Afghanistan.
A leader is a gatekeeper. A tough job for a leader is whether I pat a guy on the back, kick him in the butt, or tell him to get help. I think the point was very well taken that being a good leader means knowing your people and knowing when they change. Many, many of the programs, which you can specifically ask Lieutenant-Colonel Grenier about, are aimed at that.
The other part, again, is about aware and engaged members. Members have responsibility. We are educating members to understand mental illness, to understand they're not going crazy and they have something that would benefit from help. They can understand, when they're 40-something years old and dragging ass, that it might be a depression, not just getting old.
These are the three pillars. All three need to be up and standing in order to have effective suicide prevention or an effective mental health program.
JAMA, the Journal of the American Medical Association, published a very comprehensive suicide prevention campaign. Dr. Mann is actually leading the U.S. DOD. I think they are probably going to spend $150 million studying what we did with $50,000, in our Canadian way.
I'll go to the next slide and expand on some of these points. I'll show you how we have actually adopted it, from a suicide point of view.
Up to 90% of those committing suicide—depending on the study you read, it will be from 75% to 95%—have mental health problems, especially depression. Now, PTSD does elevate the risk, and of all the anxiety disorders, PTSD is the highest risk factor.
Then there's usually a stressful life event. Stressful life events can trigger suicidal thoughts. I think this is really important. Quite often we'll see both things happening. As an organization, as a society, it's looking after both sides that's important.
The illness in most cases, plus the stressful life event—which to the rest of us may not seem stressful, but if you're ill, the financial stressors or family stressors can be quite big—lead to suicidal thoughts, intents, plans, and actions. Your last witness talked about putting his hand up, asking who has thought about it, who has actually tried it. These are all lumped into that ideation.
These are really important factors that I've highlighted in the next box: impulsivity, hopelessness, pessimism, and emotional dysregulation. Emotional dysregulation is part of an illness.
Steph and I quite often talk about hope. We champion a few different kinds of things, that outside-of-the-box thinking within our organization about occupational transfer or keeping people within the organization--this kind of thing. A lot of it is that we don't have the science but we've argued we should give them some hope.
These are really important. When we hear people talking about hopelessness, that's when we worry, and that's when we tell our clinicians and our leaders to worry.
With respect to access to lethal means, again, it's what's out there: gun control, different kinds of devices, looking at how pharmacies are packaging drugs. These kinds of things become an issue. It's not always something we can control, but certainly within our organization we do what we can in order to not give people lethal amounts of medication, for example. How we manage our weapons is certainly an issue as well.
Imitation is very controversial, considering we had a really sad suicide in Ottawa lately. There is literature that says talking about suicide too much in the media can be a bad thing, a contagion. We all know about Kurt Cobain and things like that.
People like me don't say hush it, drive it into the ground and don't talk about it, but responsible media reporting presents it in a responsible way. It's dangerous to romanticize it, which Shakespeare did very well, or to rationalize the suicide. “Well, what could the guy have done? He killed himself.” If it's reported in a balanced way, it says this unfortunate thing occurred and there was help available if only the person had gotten help.
So with respect to imitation, some of the suicides I've specifically looked into, where a colleague has killed himself shortly before by the same means.... We worry about the clusters of suicides that occur in universities, for example, for that reason.
The Canadian Forces has limited control over a lot of the access to lethal means. We can't get Home Hardware to stop selling rope, for example. These kinds of things are impractical. The imitation is also difficult because they occur elsewhere. We can certainly look at clusters, if they occur within our own organization, and we can engage media at a certain level, if that is one of our next steps.
We go from where do we get a suicidal ideation, a thought, to the act. All of these factors mediate between them. Basically, then, all of these are potential targets for suicide prevention. So we can look in the box. There are education and awareness programs for primary care providers, members, gatekeepers. Gatekeepers are leaders. One thing we've done is we've gone away from having the mental health professional, the doc, always standing in front of people telling them what they should do. We have people who are peers, who have been trained, who also deliver the message, saying, “I went for help; it helped me too.” The credibility of people who have the experience, who have the time in, the operators, and engaging them in our education programs have been very effective.
There was a question about screening and assessment. We do screen. Like all of our allies, we screen three to six months after deployment. We're asking specific questions about PTSD, depression. On our periodic health exams and your annual medical exam, when you have it—I just had mine recently and looked at the latest questions—we're asking about drinking behaviours. We're asking about that. Unlike our allies, with our screening it's not just the pen and paper. We actually sit and have a professional talk with the person for about 40 minutes as well. So we're screening for PTSD, depression, physical health issues, drinking behaviours, and we've added MTBI since about late 2008, since hours of expert panel on MTBI. So we're doing it, and we know it doesn't end there. You're catching a lot of people there, but there will be people afterwards, so the ongoing initiatives are going on there.
We've split from the Mann model to really realize the advantage that the Canadian Forces has, which Ford doesn't have and Chrysler doesn't have. We have a lot of control over the environment of people. We are the Canadian Forces. People work for us. We provide their health care. We set the tone within the environment. We can decide to work people hard, to rotate people, to rest them. So we've split the work-related stressful life events and other stressful life events. We can't always control what happens at home, but we can certainly have influence over the kind of work environment that we create for our soldiers.
That whole group, which is sort of added onto Dr. Mann's model, is the leadership and organizational factors, in which we have the luxury of actually training our leaders, stepping out in front of them. General Dallaire is certainly an example, as is our Chief of the Defence Staff, standing up talking about the “Be the Difference” campaign, where mental health, the health of folks, is everybody's business. Maybe with mental illness the Surgeon General and his people can do their part, but when it comes to the health of soldiers, leadership has a responsibility of knowing its people and getting them to health because they are our most valuable resource.
So leadership policies and programs can mitigate work stress.
There's also selection, resiliency training, risk factor modification: selecting the right people, enhancing their resilience, decreasing their risk factors. The idea here is let's make sure people are ready for their deployment. Let's train them well. Screen them ahead of time. If they're not, let's have a backup plan. We have had mental health professionals, including in psychiatry, in theatre since 2006.
So making sure people are well is there. We have our “Road to Mental Readiness” five-phase package that's going on throughout the deployment cycle, where people are getting trained a few months prior to going. They have consolidation training during their last exercise in Wainwright or in Fort Irwin.
They're learning the skills from sports psychology. They're learning the breathing, the self-talk, all of these skills. When they go into theatre and they're having trouble, their leaders are taught to ask, “What have you tried? Have you tried the skills?” If not, backup is there as mental health professionals. We're identifying the guys who are having difficulties in theatre, and they can have an appointment by the time they return home. So the continuity we have around the deployment cycle is there.
In terms of barriers to care, most suicide victims have mental illness, but less than half are in care. That's what we're finding as we're investigating our suicides. This is where the non-clinical side comes in. It has to be okay to go for mental care. Leadership has to encourage it. The courageous thing is to step forward and say you're having trouble.
That's a huge issue. We can have the best program in the world--remember our three pillars--but if we don't have leadership that's engaged and keeps the stigma down, then we're not going to get the members into care.
On the delivery of effective care, Dr. Whelan is absolutely right in the sense that we have been in such a hurry to set up phenomenal treatment programs that the actual quality assurance, making sure that what we're doing is working, has sometimes not been emphasized. The next step is to set up the outcome measures. We have little pockets of outcomes. We have satisfaction surveys; we have all that. But in developing a program, we need to look at reducing symptoms across the board. Our next step is to ensure that our programs are giving us effective mental health care for suicidal members.
I think part of the issue there is that we can focus on the person when he is on the bridge about to jump, or we can go back, and through effective leadership and education, and try to stop it before it gets to that point. That's what our targets are.
We talked about mass education, increased suicide awareness, and a mental health program. We have cradle-to-grave mental health education. We give people education at the recruit level. At the junior leader level, they're learning to look after not only themselves but also their subordinates. The officers are getting similar training. I just lectured about 50 or 60 captains in Kingston. People are getting it. It's a matter of training and education.
Psychotherapy and pharmacotherapy are team-based. They have access to clinicians, and there are no co-payments or limits, so members are getting access to evidence-based best practices.
I've just signed off on a new follow-up policy. If a patient doesn't show up, sometimes the CF tends to take a punitive approach. They will write a letter to the soldier's commanding officer, saying it costs this much money and he didn't show up. As soon as this policy gets published, it will be different. If you're a mental health professional and your patient doesn't show up, and you had an hour booked, before you do your paperwork, you call that patient up. You say you missed him, you ask if everything's okay, and you make another appointment. This will be standardized across the country. What the dentists do and the physiotherapists do may be different, but every mental health professional in our organization is going to take that approach.
With respect to media engagement, organizations like the CDC have guidelines for responsible and ethical reporting. One of our hopes is to meet with them at the higher level. CF members tend to be front-page news, even though there are 4,000 or 5,000 suicides in our country a year. We'd like for them not to bury it or hide it, but we'd like to point out that there's a balanced way of reporting. There are guidelines developed not by us but by organizations like the Centers for Disease Control.
Leadership has a great effect on the mitigation of work stress. A fellow is having trouble with finances. You can reprimand him and charge him, or you can give him Friday afternoon off to go see his bank manager to try to get things sorted out. That's the idea, the little things that leaders can do to keep things from becoming big.
Colonel Grenier can tell you all the initiatives we've done over the last ten years in terms of barriers to care.
Finally, you have to understand that not all suicides are preventable. We'll do our best. We'll do our absolute best. The way we've set this up is that the ancillary benefit of such a program will actually be improving the overall mental health of the Canadian Forces. That's our aim.
The last thing that we've been doing has been since April 1...and I just want to tell you the interest within our organization. In September last year we had our panel. Within a month we presented to the chief of military personnel. Two weeks after that, he sort of said, “Hey, this is good”, and he took us to the Chief of the Defence Staff. In his private office we presented it to him again. By February, Armed Forces Council was interested, and in February they endorsed the entire thing, all 61 recommendations.
As of April 1, the Surgeon General was directed, and now we're doing these investigations of every single suicide that occurs within the regular force where a team flies out. I've done two of them. A mental health professional and general duty medical officer will go into the unit, not wait for a board of inquiry of six to eight months, and speak to the members, speak to the treating people, review the person's medical files, speak to the MPs, speak to the chain of command, speak to the spouse, speak to the mother, and find out if we can learn something from this, if we could have done as an organization something different.
Within a month, a report is written, and the Surgeon General has the recommendations. Anything within health services that we can do to change, that we can modify, he can initiate that immediately. If it's something beyond health services then he will have to channel it to the chief of military personnel or the CDS, if necessary.
I'll stop there because I know we're running out of time. Let's get the questions going.
:
Those are excellent questions. You might need to remind me of them, but I'll do the last one first.
Again, we've come way ahead. Nothing's perfect, but we have come way ahead in this area. It starts way back, but one thing we do have for members with chronic illness, physical or psychological, is the joint personnel support units that have been created on every base. So the people who need extra attention administratively, medically, and those kinds of things, belong to these units, which are on every base.
There will be a transition, so a person getting a release message will not be released from the Canadian Forces for at least six months. And “case manger” is the most badly defined term ever, because every clinic will have a different definition of case manager. But our CF case managers are all nurses, and one of their main jobs is absolutely to hook the person up with services after they leave. Again, it's a huge country and people have the right to move wherever they want. If I had my druthers, all of our members would release around large centres, for obvious reasons.
When they do know where they're to be released from the forces, we take care of details right down to telling them, “Make sure you apply for civilian health care.” We don't have OHIP cards, right? We tell them to make sure they apply for a health card. We also ask them if they have a family doctor. If not, we try to set up the person with a family doctor. If we know where they're communicating from, our mental health professionals will try to hook them up with a professional in their region. If it happens to be in a region where there is a VAC OSI—and there are a number of them now—we will make arrangements for them to transition there. They might even be seen there while they're still serving.
So we make those connections with the professionals. Maybe we'll pay by Blue Cross or something like that prior to their release.
So it's now light years ahead of where it was. We're not tossing out people and hoping that VAC.... They can apply for their pensions early. One of the first things I do when I see a patient soon after diagnosing him, even if he is nowhere close to release, is to ask, “Have you put your paperwork in to VAC?” It's much easier to go through the process while they're still with us than somebody having to find them 10 years later.
So as much as possible, we have that transition. It's not rushed, but slow. And they can start their post-secondary education or college while still serving. Within the last six months of this September, they can start in school and still come to our clinic to get care.
As for the families of the members, we are governed by the Canada Health Act. My family doesn't get care on the base either. And when we move, we had to find pediatricians and doctors for our own kids, as well.
We are allowed to provide care in support of the member. Within mental health, we stretch that as far as we can stretch it. So it doesn't mean the member has to be in the room. The member could be overseas. If the spouse walks into our psychosocial services unit and says to our social worker, “I'm having a hard time”, we will help the spouse right there.
When we're treating people and talking about PTSD, part of our standardized assessment across the country is to have the spouse come in within the first or second session. Keep in mind, it's within the member's confidentiality. He or she has to allow the spouse to come in. So very early on, we'll engage the spouse in the process and the education we provide, telling them what's going on.
We run regular educational groups for the spouses. We run couples groups for a week in Halifax. We'll fly people in, for example, to get some education about the illness, coping, anger, stress, families, raising children, and those kinds of things.
So as much as possible, we do provide help. It's not going to be a U.S. TRICARE service. For example, if a spouse suffers from depression, I can't write a prescription for an anti-depressant. We're held back in that sort of way.