Proceedings of the Subcommittee on
Veterans Affairs
Issue 5 - Evidence (April 17 meeting)
OTTAWA, Wednesday, April 17, 2002
The Subcommittee on Veterans Affairs of the Standing Senate Committee on National Security and Defence met this day at 5:30 p.m. to examine and report on the health care provided to veterans of war and of peacekeeping missions; the implementation of the recommendations made in its previous reports on such matters; and the terms of service, post-discharge benefits and health care of members of the regular and reserve forces as well as members of the RCMP and of civilians who have served in close support of uniformed peacekeepers.
Senator Michael A. Meighen (Chairman) in the Chair.
[English]
The Chairman: Honourable senators, this evening we begin our look, in specific terms, at post-traumatic stress disorder.
We are most fortunate to have with us the ombudsman from both the Department of National Defence and the Canadian Forces.
[Translation]
The Chairman: Welcome. I understand that you have some opening remarks, and I am certain that senators will have questions for you thereafter.
I would appreciate if you could introduce your colleagues to us before beginning.
Mr. André Marin, Ombudsman, Department of National Defense: Mr. Chairman, it is a great pleasure for me to be here and I thank you for having invited me to appear in front of this committee.
[English]
With me this evening are Mr. Gareth Jones, the director of the special Ombudsman response team, and the lead investigator in our PTSD investigation; and Brigadier General, retired, Joe Sharpe, who has been doing some work in my office. He was the advisor to the office on PTSD. These were two very important people in the preparation of the report that I will be presenting to you today.
[Translation]
As you are no doubt aware, my mandate requires me to serve to contribute to substantial and long lasting improvements to the welfare of DND/CF members and their families. The mandate does not extend to issues that fall exclusively within the jurisdiction of Veterans Affairs Canada.
However, my office has always had an excellent working relationship with VAC on matters that impact on both the Department of National Defense and Veterans Affairs Canada.
Clearly, how the Department of National Defense and the Canadian Forces tackle the PTSD and the PTSD related issues with current members has an immediate relevance and significant consequences for Veterans Affairs. I understand that Veterans Affairs Canada are dealing with an increasing number of PTSD related cases, and that there is no risk or sign of the flow abating.
In my view, the challenges presented by PTSD are so profound and so widespread for both the Department of National Defense and Canadian Forces and for the Department of Veterans Affairs that immediate, coordinated and firm action is required.
[English]
As time is brief, and our detailed findings are available in the special report on the systemic treatment of CF members with PTSD, I shall not present the report to you in its entirety today. Rather, I should like to provide honourable senators with a brief overview of some of the more significant findings and recommendations, and I am ready to answer any related questions.
Why is PTSD such an important issue today? Although there are no statistics on the number of members and former members who are affected with PTSD, there is clear and convincing evidence that a large number of CF members and veterans may suffer from the injury. At the Edmonton Garrison alone, estimates indicate that up to 1,000 members have or may have PTSD, the majority of whom decline to seek treatment.
The human and financial costs of PTSD are staggering. Families are destroyed. Dedicated, hard-working CF men and women find themselves ostracized and shunted aside. Many millions of dollars are spent on replacing experienced members who, in my view, need never have been lost.
An untold number of soldiers, sailors, and airmen and women suffering from PTSD have left the Canadian Forces, too ashamed to come forward for treatment. Many of those are only now turning to Veterans Affairs Canada for assistance. The report contains 31 carefully crafted recommendations that were based on exhaustive analysis after an in-depth investigative process. The recommendations are designed to be flexible enough to give DND/CF sufficient leeway to implement them according to the needs of the organization.
For example, we recommended that the Canadian Forces initiate a pilot project to locate one of the post- deployment treatment clinics, referred to as an Operational Trauma and Stress Support Centre, off base, to ascertain whether such an arrangement is better suited to the objectives of the OTSSCs.
We based this recommendation on overwhelming evidence from Canadian Forces members. They told us that the fact that the OTSSC was on base not only created a significant impediment for many to come forward to receive treatment, but also that it was seriously detrimental to many members who did attend. As one serving member being treated at an OTSSC told us: ``I feel like walking in with a paper bag on my head.'' A large number of caregivers also expressed their concerns about having the OTSSCs in such clearly visible locations where confidentiality, which is so important to members who have or may have PTSD, is compromised, either in reality or perception.
Running a pilot project would allow DND-CF to conduct a rational comparison of the two approaches.
In other areas, we found that the quantity and quality of non-deployment-related education and training to members about PTSD is inadequate and in some respects grossly inadequate. This has resulted in a widespread culture within the CF that rejects PTSD as a valid medical condition in that those who claim to suffer from it are malingerers, fakers or abusers of the system. As one soldier told us, ``Many people within the CF believe that PTSD stands for People Trying to Screw the Department.''
The problem faced by the Canadian Forces in relation to PTSD is so serious that it is affecting the ability of CF leaders to properly lead. Recent research by the CF shows a lack of trust by members for taking care of those suffering from PTSD. As such, it has the potential to threaten the very combat capability of the Canadian Forces.
One should not be surprised to find out that the problem of recruiting and retention — which is so severe that according to yesterday's report of the Auditor General it could take up to 30 years to stabilize — is aggravated by the PTSD situation. Countless soldiers — and I hasten to add the best ones — are lost to PTSD every year. It is the surest ticket out of the Canadian Forces. This is one cause of the retention problem we can fix today, not in 30 years.
We have made a number of practical recommendations to demystify and de-stigmatize PTSD through education and training. We recommend mandatory training and education about PTSD for all ranks, and training throughout a member's career. We recommend using multi-disciplinary teams to deliver that education, including members or former members who have been diagnosed with the injury. We recommend using the expertise of the OTSSC staff in the education program CF wide.
At this stage action, not words, is needed to fix the PTSD problem. There have been plenty of words. Since March 1994, when the CF first issued a Canadian Forces administrative order designed to deal with PTSD-related issues, there have been many more reports and commitments made to action by DND/CF that have not been met with any more success in implementing change.
Our report found that one of the most important weaknesses demonstrated by the CF in dealing with PTSD is the failure to execute commitments to reform how it deals with affected members. For example, in the area of educating CF leadership, in 1998 the McLelland report into quality of life issues in the CF recommended training of CF leaders on care of the injured, including those suffering from PTSD. In the same year, the Standing Committee on National Defence and Veterans Affairs, SCONDVA, recommended that the McLelland recommendations be implemented as quickly as possible and that other measures be taken to inculcate leaders on the importance of caring leadership. In its response to SCONDVA, DND/CF stated that leadership course content is being changed to ensure that proper training is given with respect to the care of injured personnel.
Although lesson plans have been developed, our report concluded that, despite these commitments and engagements, there has been little or no advance in the quality and quantity of training actually delivered to CF leadership about PTSD in 2002. Even today, the Royal Military College does not provide the future generation of CF leaders with any substantive education about PTSD.
There are many more examples of noble statements and worthy undertakings throughout the organization in the time period leading up to today. Progress on implementing change has been sclerotic. Training and education is key to changing attitudes. The lack of deliverables has allowed attitudes and prejudice against those who suffer from PTSD to continue to flourish.
Despite the overwhelming public support we have received since our report was published in February, attitudes continue to question the validity of the injury. Take The Kingston Whig Standard the day after the report was published, where a former senior CF leader is quoted as saying that they never called it a syndrome, they called it being a whiner and told them to go deliver pizzas downtown. They are not career soldiers.
As changes occur at a snail's pace, soldiers and their families suffer. This cannot be allowed to continue. We have made 31 recommendations that address the issues of the prevalence of PTSD, attitudes, education, deployment-related training, taking care of the caregivers and systemic issues. While I acknowledge that there are some excellent initiatives underway, during the investigation we found the effort deployed to deal with PTSD is uncoordinated, inefficient and nowhere near what it should be to make a real difference.
As you know, I undertook to report to the Minister of National Defence, nine months after the release of the report, about putting the recommendations into place. I look forward to reporting publicly how the commitments made by the CF to implement the recommendations have in fact translated into action. So far discussions with the organization have proven to be most fruitful.
I am asking specifically for your support in relation to an important recommendation we have made for the creation of the position of a PTSD coordinator. We recommended this position be created because we realized that there is no one individual who has the authority to deal with PTSD CF wide. There are a multitude of different authorities within the Canadian Forces who have an interest and input into dealing with PTSD, ranging from the operational commands through the personnel, medical training and education systems.
In my view, the key to tackling the issue will not be just the introduction of new policy and procedures, but rather how these policies are implemented and enforced at the unit level; a position reporting to the Chief of the Defence Staff, which will be able to galvanize all the sectors in the military in moving this issue forward. The PTSD coordinator's role will be very much like the mortar around the bricks ensuring that the CF's PTSD initiatives are held together and translated from paper to reality.
The complainant in the case we investigated was abandoned and ostracized, and stigmatized by the way he was treated. He was not alone. Far too many of his fellow CF members had been and continue to be treated like second- class citizens because they suffer from an invisible injury. The CF is needlessly losing excellent officers and non- commissioned members in an era where they are scrambling to retain and recruit new members at huge expense. Now is not the time for more studies or to deal with these issues as public relations problems. Now is not the time to think in ``stovepipes'' by dealing with the issue as the primary responsibility of only one area of DND-CF. PTSD is an all- encompassing injury that crosses all boundaries within DND/CF. It is everyone's responsibility, and now is the time for action.
The Chairman: Thank you for a very interesting presentation which, I am sure, will give rise to a good number of questions.
I should take this opportunity to introduce the deputy chairman of the committee, Senator Jack Wiebe from Saskatchewan. He is a fast study, so he will pick up the few points he missed of your opening remarks.
Senator Wiebe: PTSD has certainly been of great concern to me. In our National Defence Committee I raise the question wherever I possibly can. The question I will ask you is a tough one, but it is one that must be asked.
PTSD is rather new, although the condition has been around since the first conflict in which Canadian soldiers were involved. The only problem is we were unable to identify the condition. Part of the problem with PTSD concerns the terms of engagement. We first started to notice PTSD when soldiers were returning from peacekeeping missions where the terms of engagement were all they could do is observe atrocities, report them, and then stand by and see nothing being done about those atrocities.
I had the opportunity to visit with some of our troops in Bosnia under the NATO terms of engagement in which they could actually, if they saw an atrocity, get involved and do something. In talking to the troops, they felt more like they were doing their job. They were doing what policemen do when they see an atrocity. They were being effective. In other terms of reference, they were not being effective. I could certainly see under the old terms of reference that that would affect someone who believes he is not able to correct a problem.
I have a tough question based on something new. As I walked in the room, you made the statement that PTSD is the surest ticket out of the Armed Forces. Are we sure that some of our Armed Forces personnel are not using PTSD as an excuse to get out of the Armed Forces? When someone finds out that the Armed Forces was not what it was cracked up to be in his mind when he first enlisted, is that person using PTSD as an excuse? I said that it was going to be a tough question.
Mr. Marin: When dealing with a peacekeeping mission, it is inherent that the dynamics are different from those in war. There is no doubt that the helplessness felt by soldiers who cannot intervene in situations, given the fact they are on peacekeeping missions, makes it worse for those soldiers. In some cases, that feeling of helplessness has helped precipitate PTSD.
I also believe that, inherent in your question is the issue of the tools to diagnose PTSD. The medical community has now pretty well defined the criteria to look for in diagnosing PTSD. They are contained in the DSM4.
Are some troops faking it? Are some troops using it to get out of the Canadian Forces? That is dealt with in the Canadian report. The short answer to that is no.
If you think about it, why would anyone in the Canadian Forces, given the amount of stigma associated with it and how you are treated once you have PTSD, use it falsely? To claim PTSD brings such an amount of grief that it is hardly an easy ticket out of the Canadian Forces.
We had an opportunity to consult experts in this area as well people from the civilian communities that deal with PTSD, such as paramedics and police officers. There is broad consensus across every profession that it is a common myth that people claim PTSD to get out of doing work because of the kind of stigma that attaches once you are out with PTSD.
It is estimated by medical experts that those faking PTSD, or those where there is likely cause to believe that someone is faking PTSD, are anywhere between 1 and 3 per cent, which is substantially lower than those who fake other kinds of diseases. There are people who call in sick when it is a beautiful day like today. It is 1 to 3 per cent, a very low percentage.
Senator Wiebe: Does this same percentage apply to police officers, firemen or other first responders?
Mr. Marin: We did not engage in an elaborate comparison. From what we could glean from the experts, it is about the same percentage. We interviewed people who must deal with workplace absenteeism in different professions. It seems to be a consensus.
Senator Wiebe: I have not had an opportunity to read your report. It just arrived on my desk yesterday. It may be that the answer to my next question is in there.
Have you, as ombudsman, had an opportunity to look at a case where responsibility or help has been denied to a soldier where you felt that that soldier was faking it?
Mr. Marin: No, we have not found that. We interviewed hundreds of people who came forward. From what we could see, they were all legitimate cases. People commit suicide or attempt to suicide because of it. Families fall apart because of it. These are not signs of people faking.
I believe that there are still some who believe that members are faking PTSD because the organization has never kept any data on PTSD. See no evil; hear no evil; there is no evil.
It has existed since World War I and possibly before. There have been documented cases since World War I. Nonetheless, the organization has never kept any data on the number of people suffering PTSD or those people seeking treatment. There has never been any data kept on those committing suicide, those leaving the forces, or those in the specialized holding patterns because of PTSD.
The lack of data has been a self-fulfilling prophecy. People conclude that, since there is no data, it is questionable that PTSD exists.
We know from consulting medical experts that roughly 20 per cent of those who come back from operations suffer from PTSD. If you include stress related injuries, it could be as half as high again. However, there is no way empirically to say that, because no data is being kept by the organization.
If, in my presentation, I were and telling this committee that 20 per cent of people coming back from operation suffer from tuberculosis, would we be worried about the 1 to 3 per cent of people faking PTSD? We would not. There would be no question that urgent, immediate action would be required.
The experts tell us that 20 per cent, 30 per cent, or even up to 50 per cent, if you include stress related injury, are suffering from PTSD. It is my submission to the committee that, because of those estimates by the medical community, the issue of whether 1 to 3 per cent of people are faking should not be the main preoccupation. We should be preoccupied with the 27 per cent or 25 per cent coming back from operations who we know are not faking it, and who are suffering.
Senator Wiebe: I do not know whether this is the first Senate committee you have had an opportunity to appear before. You will find some of the questions that we ask our witnesses are difficult ones. They are not necessarily questions that we as individual committee members have a particular concern with, but they are questions that we feel must be asked.
One of the biggest criticisms of the Senate is also one of its biggest advantages. We need not worry about being re- elected, so we can ask all sorts of questions. I have a couple of tough ones for you.
You say 20 per cent to 50 per cent of the people who return from overseas duty have some form or other of PTSD. That means, in my mind, that we are not preparing our troops for what they are going into, or we are not doing a good enough job in selecting which kind of troops we should be sending to those particular missions.
In either case, have you had an opportunity yet to come up with any kind of recommendations for the Armed Forces in regard to how they judge which individual is fit for which kind of duty? If the figures you are giving us are right, then 20 to 50 per cent are pretty high figures.
Mr. Marin: I certainly appreciate your candour. I did not mean to suggest that those were the opinions that you were holding.
It is important, Mr. Chair, if we are to get to the bottom of this, to air all of the arguments and all of the issues. Therefore, I do appreciate your questions. I thank you for giving me the opportunity to respond to them.
I will respond to your question regarding the kinds of recommendations that we have made. We have divided the report into eight parts. On the first page of the report, you will see that Part One deals with the prevalence and then the issues of diagnosis and treatment, which relates to the first question you asked me today. We made several recommendations relating to education and training regarding PTSD, that is, pre-deployment and post-deployment training, education for members of the Canadian Forces, how to identify and be better prepared to deal with PTSD, and issues dealing with administrative responses.
As I indicated in my opening statement, there have been some very worthy initiatives by the organization. One of them has been the setting up of five specialized trauma and stress clinics across Canada. That has been a great initiative and we support it.
The Chairman: Are they on-base?
Mr. Marin: Yes, they are on-base.
The Chairman: You recommend they be off base.
Mr. Marin: Absolutely. It is an important recommendation and one that we are working to employ with the Canadian Forces, but the objection that we are hearing — and I am not suggesting this is the final word of the organization — from those who seem to have difficulty with this recommendation, is that if they are placed off-base, then we will be sending people outside the military family for treatment, thereby ostracising them further.
We believe that there is no choice, now. Going to an operational clinic on base makes you wear the PTSD label in a culture that deems that to be a sign of weakness, faking and malingering. Until the culture catches up, if you want to be serious about treating these people, treat them off base. Virtually all of those suffering from PTSD told us that they would have preferred to have had treatment off base. Of the caregivers, people who provide care to people suffering from PTSD, virtually all of them supported having treatment available off-base.
Look beyond this issue of throwing them outside of the military family, because that is not the case. We are acknowledging that there is a treatment and the only way to receive treatment is to send him or her off base. We are saying that they should at least try it out. Locate one off-base.
We strongly support the clinics, but we are saying, go beyond that and try one off-base to see what kind of response you will receive. We are convinced that you will receive a favourable response.
The second recommendation, of the 31, concerns the PTSD coordinator. Although there have been good initiatives, they lack coordination not enough information is shared between the different initiatives. We are recommending that the PTSD coordinator ensure that there is an exchange of approaches and information, and there would be assurance that any order and initiative promulgated by Ottawa would be implemented in actuality — in operations. We are not seeing that all the time. Those are two key recommendations. Coupled with that, there are recommendations about training and education that are crucial to making the culture evolve.
Senator Atkins: I am curious about the recommendation regarding the coordinator. What rank and occupation would that person occupy? What kind of reporting procedure do you envision? It seems to me that, if the recommendation is accepted, that coordinator must have credibility and clout, especially in consideration of the picture you paint about the doubts and problems in the military vis a vis the respectability of someone who claims to have PTSD. How do you visualise that person?
Mr. Marin: The current problem is that PTSD is a problem that crosses the boundaries of all elements in the Canadian Forces. There can be events such as the Swissair crash that will create serious PTSD problems for members of the navy rescue team on the East Coast, and there are peacekeeping members of the army who return from overseas duty suffering from PTSD. It is also an air force, a reservist and an operational problem involving the Deputy Chief of Defence Staff. It affects the issue of retention recruiting. Therefore, it affects the Vice-Chief of Defence Staff. It affects all the different components. When you are making a decision on PTSD, it must be remembered that it affects all these entities. It affects the air force, the army, the navy and it affects policy in Ottawa. That is the problem.
We recommended the concept of the PTSD coordinator, but we left it as a general recommendation so that the organization can help you flesh it out.
The coordinator would be someone whose authority would cross all the boundaries and would be able to determine action for all of the affected entities. For example, suppose the navy is not implementing an order by the Chief of Defence Staff on how to deal with pre-deployment training on PTSD. That coordinator would have the authority to crack down. The individual would report to the Chief of Defence Staff. In other words, the ultimate authority would lie with the Chief of Defence Staff, via the PTSD coordinator, to enforce and ensure that there is execution of whatever decision is made in Ottawa concerning PTSD.
Senator Atkins: This would be someone in the military.
Mr. Marin: Yes.
Senator Atkins: It would have to be a high-ranking individual.
Mr. Marin: Yes. Colonel would be the right level.
Senator Atkins: This person would have to be seen as having the respectability of the chief of staff.
Mr. Marin: Absolutely.
Senator Atkins: Otherwise, he or she would be whistling in the dark.
Mr. Marin: Currently, the Chief of Defence Staff holds the positions of special advisor on international affairs and on personnel. Personnel issues in international affairs have been flagged as special areas that require close scrutiny. Those could serve as models. We did not want to put the organization in a straitjacket of characteristics. The concept is laid out and it is not unprecedented. This issue merits close scrutiny and attention. You are quite right in saying that the coordinator must have the respect and deference of the Chief of Defence Staff, as well as the rest of the organization.
We need someone to crack the whip. A colonel cannot crack the whip on the general, but the coordinator would be the pipeline to the CDS to ensure that orders are followed. This, of course, applies to all of the entities affected in that the coordinator would be able to take immediate enforcement action.
Senator Atkins: My suspicion is that to accomplish this initiative you may have look at a higher-ranking colonel. That person must be seen to be at the right hand of the chief of staff. Otherwise, I think you would have a hard time accomplishing your goal.
Mr. Marin: I appreciate your view. There may be some who agree with you and some who disagree. I am not a military expert. We have presented the problem to the Minister of Defence and to the Chief of Defence Staff. We presented a compelling argument for the creation of that special function. I trust and hope that the Chief of Defence Staff will be able to identify the right level position, the right candidate, and give this person the terms of reference and the necessary tools to do the job. We will be back to report on the success of the job in nine months.
Senator Atkins: I know a little bit about non-visible disabilities. It is difficult to convince people who do not have them to acknowledge that others have the problems that they do, especially when they appear normal. In some cases, that would be true of those suffering from PTSD.
Is there a medical test that helps diagnose a person with PTSD?
Mr. Marin: I am not a doctor. Since the report came out, I have received submissions by some physicians who claim to be able to do blood tests to determine PTSD. Others claim to be able to cure it in 10 minutes.
Senator Atkins: With some form of medication?
Mr. Marin: I am not a medical expert, so I am unable to answer that question.
From our brief look at the diagnostic tools, there appears to be an understanding of how to detect PTSD. There does not seem to be an issue in respect of the tools to diagnose or detect. Beyond that, I do not think I am suited to answer the question.
Senator Atkins: I am not surprised that it is not on the curriculum in the RMC. It seems to me that for cadets or those with a summer vocation in the military, perhaps there is opportunity for that kind of training.
I agree with you that the assignments that our military has in peacekeeping are conducted under totally different circumstances.
I hope that your recommendations are taken seriously.
Mr. Marin: As I said in my opening, and I want to reinforce this message to the committee, my organization has been engaged in discussions with the Canadian Forces since the completion of the report on February 5. Those discussions have been very fruitful. I have been engaged in one-on-one discussions with the Chief of Defence Staff as well. We are satisfied with the progress thus far. We are not there as of yet, but I have my hopes high that we will be able to report to you and to the public that there has been an acceptance of all these recommendations.
Senator Atkins: In your position as ombudsman, do you consider your role is taken seriously by the military? Do you feel you have a record of achievement in view of the time you have been in the job — that you have been able to accomplish much of what you attempted to accomplish?
Mr. Marin: In over 90 per cent of our interventions, we were able to get the result that we were seeking. I think the office has progressed enormously in its clout with the organization. An interesting phenomenon happens in the military. I thought after the office had been around for some time, almost four years now, after successive promotions, people would climb the ranks in the military and realize that the office, although it is independent from the institution, is, in fact, part of the institution. There is talk about how the Charter is 20 years old and has grown on us. I hope the office is accepted as something that attaches to the military and that people who climb the ranks realize the office has to be dealt with.
Unfortunately, some people are promoted and then they decide that their predecessor ``sold the farm to the ombudsman,'' and they are going to fight the ombudsman. Sometimes a person, who has been around for some time, is promoted and he or she must re-fight the old battles of a year or two years ago. I am hopeful that, as the office continues to intervene on serious issues, when there is a promotion I will be able to say that we are all better off and there is greater cooperation. However, it seems to me, unfortunately, in too many cases, when there is a promotion, we must regain the ground that had been gained before.
All in all, I am pleased with the cooperation we are getting. If I had to give a general assessment, I would say I am quite pleased, and we have come a long way.
Senator Atkins: Am I correct in saying that you do not perceive yourself as being seen by the military as an apologist for the military or a handmaiden of their causes?
Mr. Marin: I do not think anyone has accused me of being an apologist for the military. I do not think we are military critics. We are to maintain strict impartiality. When we approach a claim, we do not presume it is founded or unfounded. We presume nothing. We do not feel compelled to defend the system or to bring it down. I hope that message comes across when we release reports. We try to outline the positive. We are not a negative reporting agency. We are not only there to find fault; we are there to find good things as well. The report states that, and I believe today's opening statement conveys that too.
We try to present the most balanced and impartial view of both the claimant and the organization.
Senator Day: I congratulate you and your group on your report. This will be an important document on this entire subject.
My questions will illustrate my lack of in-depth knowledge of this subject. Please bear with me if some of these questions are answered in the documentation.
If I may go back to basics, I have in the back of my mind that we used to call it a ``syndrome,'' and now you are calling it a ``disorder.'' Was it never called a ``syndrome''?
Mr. Marin: It is a syndrome.
Senator Day: The disorder is what you have when you are diagnosed?
Mr. Marin: I meant syndrome. It is a syndrome. It is considered to be an operational injury. PTSD stands for Post- Traumatic Stress Disorder.
Senator Day: How did it go from being a syndrome to a disorder? What is the difference? I have heard people speak about post-traumatic stress syndrome. Is that the manifestation of the disorder? What is the difference between the two?
Mr. Marin: I am not sure I am qualified to answer that. I have heard both words used interchangeably.
Senator Day: Can we do that?
The Chairman: He says he does not know.
Mr. Marin: I have heard the expressions ``disorder,'' ``syndrome'' and ``injury'' being used.
The Chairman: As far as you are concerned, they are interchangeable.
Mr. Marin: They are, yes.
Senator Day: It is all right for me to use either one.
Mr. Marin: The Surgeon General is here.
Senator Day: If someone could come now or next week and let me know if there is a difference, and if so, what I should be thinking. It might be appropriate, Mr. Chairman, to deal with that simple question now.
The Chairman: Would you mind? Please give us clarification?
Colonel Scott Cameron, Canadian Forces Surgeon General, Department of National Defence: From my perspective, the significance of the nomenclature is different in the medical profession versus the lay community. For us there is a specific difference between the syndrome and disorder, which is not significant to your concerns.
The point is, whether you call it a syndrome, a disorder or an injury, it is a real illness and it has many causes, some of which are the trauma that people suffer on operations. From that perspective, it is an injury, and that is why we are now referring to these things as ``psychological injuries.''
A ``syndrome,'' in medical parlance, is a collection of symptoms and findings that is consistent in a particular group of individuals and defines what we call a ``medical syndrome.'' A ``disorder'' is just what the name suggests: It is a malfunctioning, if you will, of a certain system of the body. In both cases there is something wrong. That is probably the best way for you to look at that definition and not get hung up on the difference.
Where the confusion comes in is that sometimes people will call any sort of medical phenomenon a syndrome. We do not do that. For physicians ``syndrome'' has a specific definition, which is that there is a definition that is reproducible across individuals. The word ``syndrome'' is sometimes misused. ``Disorder'' is probably a better term, simply because it is a more specific term within the profession.
Senator Day: If the disorder is diagnosed early in an individual, is it, from a medical point of view, more quickly corrected? Put aside the other costs and damages that could be caused by someone who has the disorder, and it is not, for whatever reason, diagnosed. From the point of view of a medical recovery, if there is an early diagnosis, is there a speedier recovery?
Mr. Marin: That is certainly my understanding. If it is caught and treated early, that also prevents other types of degenerative circumstances. In the case of Corporal McEachern, which is the case that ended up being investigated, this individual was charged with an offence as a result of incidents where he allegedly drove his SUV through the Edmonton garrison and did a few wheelies and sent the furniture and equipment through the windows. A history of things precipitated that.
In that instance, if the disorder had been caught and treated earlier, we could have prevented many of the things that happened afterwards. Certainly, catching these situations early and treating them is not only good for the individual's well-being, but will prevent an escalation of family problems and other personal problems that may arise as a result of getting PTSD.
Senator Day: I was trying to deal with the medical side of this. I understand what other things may happen if PTSD is not diagnosed and the person continues to live with it.
Your understanding is that early diagnosis leads to a speedier recovery as opposed the situation where there is no diagnosis and the disorder lingers for some time.
Mr. Marin: That is correct.
Senator Day: Is there a history of Armed Forces personnel returning from deployment who have suffered another physical injury? I can think of Major Bruce Henwood, for example, and the injuries that he suffered from the explosion of a land mine. Is there any history of this post-traumatic syndrome being related to other physical injuries or not?
Mr. Marin: There are examples of both. There are cases where it is related to physical injuries.
Senator Day: Would a person who suffered a physical injury be more likely to get PTSD? Does this result from something outside of your own body in most instances, such being close to a burned-out tank? Not everyone who is shot develops the disorder. However, having seen a burned-out tank with a half-charred body in it is what has triggered the syndrome in some instances. Is it a result of an outside-of-the-body experience, a visual trauma that triggers PTSD most often?
Mr. Marin: General Sharpe has done a significant amount of work in this particular area, and I would ask him to respond.
Brigadier General (Retired) Joe Sharpe, Special Advisor to Ombudsman on Post-Traumatic Stress Disorder, Department of National Defence: Honourable senators, I am not a doctor, but I can provide you with some general impressions.
Many of the instances of causality — if I may use that term — for PTSD, come from the sense of helplessness. Indeed, you touched on that earlier. If you are able to actually do something about the situation, there is less probability, anecdotally at least, that it will cause longer-lasting psychological problems.
Quite frankly, Canadians educated, raised and trained as we are in a society that is just and fair and treats people well, become quite vulnerable to the negative things that some other folks see in certain situations. We are not used to seeing children slaughtered beside the road and some other things that happen. Canadians are actually more vulnerable, in all probability, than many others who come from a less value-based society. There is certainly that psychological aspect of vulnerability.
Our anecdotal experience would lead us to conclude that those who feel the pain of others most become most vulnerable. To a certain extent this is external to the individual in many ways.
For example, one psychiatrist told us that, if we wanted to prevent PTSD in our soldiers, then we should recruit sociopaths, because they have no feeling and no sense of involvement. The downside of that is that you probably would not want to send them any place to represent the country. There are many external things that go beyond a simple medical explanation.
Senator Day: We think about the General Dalaire situation and his helplessness in the Rwanda situation, as opposed to the post-physical injury stress and depression that a Major Bruce Henwood would go through because of a loss of two legs. That would be depression, as opposed to post-traumatic stress.
Mr. Sharpe: Dr. Cameron will explain that better than I can. Ultimately, Major Henwood contacted us after the investigation had started. We talked about some of his physical problems. I do not see any connection between the physical and the psychological injury.
PTSD does not tend to be related to fear for your personal safety, at least anecdotally. It appears to be related more to this inability to do what you are trained to do or to stop some of these things that are happening.
Senator Day: Some time ago witnesses from Veterans Affairs told us that they are quite proud of the work that they are doing at Sunnybrook, in Toronto, and at St. Anne, in Montreal, in relation to this disorder.
Mr. Marin, Veterans Affairs is not part of your mandate; is that correct?
Mr. Marin: That is correct, Veterans Affairs is not part of my mandate.
Senator Day: While people are in the Armed Forces they are reluctant to seek care because the mentality is: ``This is the kiss of death and, as soon as I say I have got this, I will get kicked out anyway.'' However, with the expanded definition of ``veteran,'' they will not be under the same macho pressures to stay away from the doctor. As veterans, they will fit within the definition of a veteran for treatment because this is an ongoing problem that they will be able to easily establish and therefore they will qualify for treatment, as I understand it, under the veteran program for an injury, disorder, syndrome or whatever they had prior to leaving the Armed Forces.
Do you have a dialogue with Veterans Affairs? Do they understand the potential major financial medical care problem that could be looming for them?
Mr. Marin: Yes, we have a dialogue with Veterans Affairs regularly. There is a committee looking at this and other quality-of-life related issues, and we have representation there. We are keeping open the lines of communication between Veterans Affairs and our office.
Senator Day: That is quite important. I expect that our committee will follow up on that issue.
The final area in this round that I would like to talk about is in relation to treatment for families of Canadian Forces personnel. When we as a committee visited Armed Forces bases, we learned first of all that in many places it is difficult for Armed Forces personnel to contact specialists. Presumably, in this instance a specialized doctor, probably a psychiatrist, must make the diagnosis. We also learned that it is virtually impossible for their families to have access to medical specialists because the Armed Forces do not provide medical care for families. Family members could also be going through some serious problems.
I understand there are other resources available to families, and that that is being developed. We were pleased to see that. Are you satisfied that there is enough support, from a medical point of view, for Armed Forces personnel and their families? We found the level of care varied significantly in different parts of the country. I believe that at one time medical services were available to families of Armed Forces personnel, but that is no longer the case. When they move into a community they often find that no doctors have spaces available in their practice for them. Are you satisfied there is adequate care available for those who need and want it?
Mr. Sharpe: As to your first point on families, one of the strong recommendations we make in the report deals with education, training and support for families. Families are often the first people to notice these problems because, as people try to hide it, it shows up in anger management problems, family disorders, and so on and so forth. Families are often traumatized by the time the member seeks treatment.
The other point you raise is a very good one. The presence of the military member in an area can dramatically impact the level of service available. If you go to a smaller area, which is where most of our bases are located, they do use up a lot of the specialist services available. I am thinking of Gagetown, for example.
Senator Day: I was thinking of Gagetown as well.
Mr. Sharpe: A concern we had early on was that we were using a community standard to determine what was appropriate care for the military but, as the military moved into the community, it changed the community standard. You had this circuitous argument. There have been some significant advances — I am sure Colonel Cameron will talk about those next week — where standards are being established independent of the local influence that the military may have. The standards will become fairly straightforward across the country. I believe it is in the order of two months from the time of reporting to the OTSSC for diagnosis and treatment, which is a significant improvement over what it has been in the past.
Senator Day: Thank you, gentlemen.
The Chairman: We have time for other questions, if there are others that come to mind.
Senator Wiebe: Canada has always prided itself on doing the best it can to resolve any situation with which it is faced. Sometimes we do very well and sometimes we do not move fast enough. Part of our problem as a country is that we have a tendency to be far too modest about our accomplishments. The reason for that little preamble is, as we are dealing with something that is fairly new, I would like to know how our Canadian Forces are stacking up against the forces in Great Britain, in France and in some of the other peacekeeping nations? How are they dealing with PTSD? Do we have something to learn from what they are doing, or do they have something to learn from us?
Mr. Marin: We looked at other armed forces in other countries. It is not an area where we could see any leader in the field; it is not an area where we are necessarily behind the other Armed Forces. That, to a certain point, is some comfort. We also looked at other paramilitary organizations such as police and ambulance services, and they are far ahead of the Canadian Forces.
If you use other armed forces as a baseline, then we are not ahead; we are not behind; we are about the same. If you compare paramilitary organizations, we are behind. When the police discharge a firearm and cause grievous bodily harm or death, a peer support committee is struck to provide immediate and on-going support to the officer involved. There has been training in this area in police colleges throughout this country for the last 10 to 20 years. The police are way ahead of the military.
Senator Wiebe: I am happy to hear that. Why has our military not learned from the successes of our police and our firefighters?
Mr. Marin: That is a good question. The lack of raw data, as I indicated earlier, has reinforced the knowledge that it is not a real issue in the Canadian Forces. I hope that the report and the results of our in-depth look at this issue will serve to point the way towards realizing that this is a serious problem.
We also recommended that the Canadian Forces should start collecting data affecting former members and current members. We need to piece together the extent of the problem in the most empirical fashion. I would add that the military tends to have a bit of a macho culture in that, if you do not see the injury, then it does not exist. ``You are soldiers and you are tough, so just weather the storm.''
I have heard this comment throughout presentations by the military. Someone in the military will say, ``Well, the police are civilians. We are the military.'' Who have we been relying on in the last 10 to 15 years as the backbone of our peacekeeping missions? We rely on reservists who are taken from all different segments of society. People coming back are suffering from PTSD. In essence, the military culture has worked against the evolution in dealing with PTSD. However, we are hopeful that it will change as a result of this report.
Senator Wiebe: That answer leads to another question. On peacekeeping duties, the Armed Forces try to have a reservist complement in every one of its operations. I stand to be corrected, but I think the maximum is 30 per cent. I think their track record in most cases is only around 7 per cent. Are you saying that the majority of those suffering PTSD are reservists?
Mr. Marin: No, I am not saying that. I am just saying that reservists have been hit by PTSD disproportionally because they do not have the same network of support once they come back to the country. They are not part of the institution in the same way, and they do not enjoy the same level of support. They have been hit very hard by PTSD. I would not know the exact numbers because — we come back to the first point — no numbers are being kept.
Senator Wiebe: Thank you.
The Chairman: Senator Michael Forrestall from Nova Scotia has joined us.
Senator Forrestall: I want to touch on a problem that came across my desk yesterday. A returning veteran reservist who has just done back-to-back tours in the Middle East told me that his job was not held for him. His job was no longer available to him. He worked for a provincial government and he no longer has employment.
What did he do today? He applied to go back to the Middle East.
What provision do we make with respect to the reservists when they return from a tour of duty? Are we offering them help or protection? Is the community there for them?
This was a provincial government. I find it inexplicable that a provincial government would not give a man back his job.
The Chairman: Senator Forrestall, the witness is free to offer his opinion. I do not think that it falls within the scope of our inquiry about PTSD, although it may be a cause.
Senator Forrestall: I am sorry if that is an inappropriate question.
Senator Atkins: He is the ombudsman.
Senator Forrestall: Where would I have such a problem addressed unless I approach an ombudsman? I left another committee to come here because I knew this witness would be here.
Senator Wiebe: Which province was it?
Senator Atkins: Nova Scotia.
Mr. Marin: That is a fair question. You come to me. We will look into it. We spoke at the outset about the impartiality of the office. The key to doing that is that we do not presume that there has been fault or no fault.
Senator Forrestall, I am quite prepared to take this back and have a member of my staff contact you to get particulars so that we may get to the bottom of it but, unfortunately, I do not have an answer for you right now. We will look into it, and get back to you.
We are investigators across Canada. We have an office made up of 60 people. What you have outlined is a typical cases that we would investigate on a daily basis. We investigate 1,300 cases a year.
I will have a member of my staff contact you to follow up on that. We will get to the bottom of it for you.
Senator Wiebe: If I could, Mr. Chair, I would like to save the witnesses a bit of work. Prior to joining the Senate, I was the provincial chair of the Canadian Forces Liaison Council. Every province in Canada, with the exception of Quebec, has signed a memorandum and passed legislation that guarantees a reservist their job when they come back. Nova Scotia is one of the provinces that has signed that agreement.
Senator Forrestall, should contact either the chair of the Canadian Forces Liaison Council for that province or the reservist liaison officer. They will deal with the government accordingly. If that does not work, then go to the ombudsman.
The track record of the Canadian Forces Liaison Council in dealing with the employers who have signed the agreement has been a very good one. It is just a matter of bringing that to the attention of the provincial government and CFLC chair in that province. It could be resolved fairly quickly.
Senator Forrestall: Thank you. I appreciate that. I knew you would have the answer.
Senator Day: You estimated that 20 per cent of returning Armed Forces personnel could potentially have some of the PTSD symptoms and might suffer from the disorder.
We have learned about one of the major problems over the past year. By virtue of the small numbers in the Armed Forces, especially of the trained personnel that we can send abroad and the many different fields of activity that we are involved in, there is a frequency of deployment that is not healthy. Soldiers are deployed too frequently.
You are saying that perhaps 20 per cent of each returning group could be suffering from this disorder. If they are going out two or three times a year, we could have 50 per cent of the Armed Forces suffering to some degree from this disorder. Is that what you are telling us?
Mr. Marin: Potentially, yes. I am telling we do not hold any specific data. Those are estimates by experts in the medical community. There are members of the Canadian Forces who have PTSD who develop full-fledged PTSD and leave, which adds to the retention problem. That is a possible scenario.
Senator Day: Is the Armed Forces conducting exit interviews to find out why some of these people are leaving to determine any relationship to PTSD? You should be able to get that statistic.
Mr. Sharpe: We have come across a significant number of soldiers who have taken their release for other reasons while not acknowledging that they had PTSD and then sought help on the outside. Quite often those people do not self-report as having this problem when they take the release. There may be other releases. In this investigation, we came across the fact that people were released on disciplinary grounds when the issue was PTSD. In other cases, people were released for either an alcohol or drug problem, and the underlying issue was PTSD.
Senator Day: These are significant numbers.
Mr. Sharpe: These are significant numbers.
One of the statistics that I find interesting from an operational perspective is that the Americans have suffered more losses of life in their army from suicides by returning veterans from Vietnam than they lost from casualties on the ground in South-East Asia. The suicides were related to PTSD and other stress related problems. The numbers are very large.
Senator Atkins: By definition, those people that get out of the service are veterans. They go to a private medical facility for assistance. They have a medical record. How does that then apply if they look for assistance through Veterans Affairs? Is there a way in which Veterans Affairs accepts a private medical record?
Mr. Sharpe: Quite frankly, Veterans Affairs have been excellent in dealing with this issue. They have accepted soldiers as PTSD veterans, despite the fact they were denied a medical release from the Canadian Forces. That has happened on a significant number of occasions.
We have found from our investigation that Veterans Affairs is far more flexible and understanding than perhaps the Canadian Forces administrative process of changing release items from voluntary or disciplinary releases to medical releases. Veterans Affairs have been very good in this area.
The Chairman: As the Subcommittee on Veterans Affairs, we are pleased to hear that.
Senator Day: I am trying to get some parameters on this problem. Obviously, you do not diagnose very many people, so you must be estimating that 20 per cent have PTSD. They have not been directly diagnosed with this disorder. Do some of those heal themselves over time, without any treatment?
Mr. Marin: Perhaps temporarily but generally it comes out. For some people it takes a matter of months while, for others, it takes years before symptoms appear.
Senator Day: There are various ways to treat the condition, as you have outlined here. If a member does not go through a treatment program then are they not likely to be able to recover?
Mr. Marin: That is correct.
Senator Day: Once the member is diagnosed and has gone through an eight-week treatment program, or whatever amount of time it takes, does the Armed Forces then have a partial back-to-work program and, if so, how is that working? How are these members of the Armed Forces viewed by their co-workers?
Mr. Sharpe: Without trying to give you an elaborate answer, there is a group within the Canadian Forces called the Service Personnel Holding List where people can, if they unable to deploy and perform proper duties, move onto this list for a period of time while they go through some treatment programs. In some cases they will come off that list and go back to their normal jobs while in other cases they will come off that list and be released because they cannot go back to their normal jobs. Some treatment programs are successful.
One of the problems with PTSD, though, because of the stigma and reluctance to identify oneself as having this problem, is that many people delay acknowledging the problem until it is almost too late to get them back into the workforce. A high percentage of PTSD patients wait several years before they are discovered. In fact, we found many of the soldiers that deployed to Croatia in 1993, which was the subject of another investigation a short while ago, are just now starting to come forward, some seven, eight or nine years later, to seek help. In many cases it is very difficult to bring someone back into the workforce from that stage. If someone comes forward earlier, the return-to-work programs are more effective.
There are also work transition programs, work therapy programs and so on, which I am sure Dr. Cameron will touch on, that are quite successful if the individual has been detected early enough to get help.
We heard from a number of psychiatrists that they believe they are seeing in the order of one out of every three, or possibly four, people suffering from PTSD. They believe they are treating in the order of maybe 25 per cent of the people who have PTSD. The others are taking care of themselves or trying to take care of themselves.
Senator Wiebe: How does the percentage of individuals with PTSD from the military compare with members of the RCMP, the provincial police forces, and with fire fighters? Is there a consistency there or does the type of occupation have differences in terms of the percentage of individuals who come down with PTSD?
Mr. Marin: We did not get numbers for those in the police forces and other professions in the course of our investigation. We did not look at that specific issue.
The Chairman: Is there anything you would like to add about the coordination between Veterans Affairs Canada and National Defence? You noted its importance. We certainly would agree with you and would do whatever we can to foster that. Is there anything you can add on that?
Finally, do you see a role for veterans and veterans' organizations in terms of assisting with the treatment of those suffering from PTSD?
Mr. Sharpe: I will answer your second question first. Is there a role? Absolutely. One of the most effective ways of dealing with PTSD is through the tutoring of someone who has survived operations and is still around to talk about the experience. In fact, that is one of the most positive initiatives that the Department of National Defence has started is using veterans to work with other sufferers in local areas.
In that sense there are a tremendous number of veterans around who are suffering. We may perhaps have called it something different after the First World War and after the Second World War, but in fact it is very similar. That community of veterans is important to the long-term nurturing and care of these people. Quite frankly, I would say that is very positive.
In terms of the coordination between VAC and DND, the only area I comment on is if Veterans Affairs Canada has determined that a soldier is a veteran suffering from PTSD and deserving of a pension for that injury, I am frustrated that the Department of National Defence will often look at that same individual and say that he is not entitled to a medical release. There is a significant benefit to having a medical release in terms of access to training and other things.
That is one area of coordination that is lacking right now. Veterans Affairs Canada is leading in this area. I would certainly hope they continue to lead in that area but I would like to see the Department of National Defence coordinate their release items and so on with the Veterans Affairs. If Veterans Affairs is satisfied that someone is suffering from PTSD, then that should be good enough for the Department of National Defence.
The Chairman: Did you say that the Department of National Defence does not always see that as sufficient for a medical release?
Mr. Sharpe: Absolutely, they do not.
The Chairman: Do they sometimes see that as sufficient for a medical release?
Mr. Sharpe: They examine cases individually as they work their way through the system. Release items can be changed. At this point, that is not happening quickly; and, for the majority of people, it is not happening at all.
Mr. Marin: I share that point of view.
The Chairman: Finally, Mr. Marin, I should like to know if I have this straight: You are to do an assessment nine months after you issued the initial report, which would take us to what, November of this year?
Mr. Marin: Yes.
The Chairman: To whom would that report be submitted?
Mr. Marin: This is a report that I will be submitting to the minister and that I will be making public as well.
When we issue these kinds of reports, there is often a concern about whether it will just land and gather dust somewhere, rather then being acted upon. Within our mandate, there is also the ability provided for us to go back and check whether recommendations are being implemented. We decided in this case to announce that we would be coming back after nine months to deliver a report card on where we are in PTSD. Then, in between, hopefully this will provide the incentive for the organization to work with us to go to the next step. We certainly feel that PTSD is worth that intensive effort. We will be coming back with a nine-month report.
The Chairman: Thank you very much. We will obviously follow that with a great deal of interest. I hope that you realize you can count on the support of this committee in your efforts. We commend you for the work you have done so far. I believe we are all encouraged that your overall analysis is that things are moving positively.
Mr. Marin: That is correct. Hopefully that will continue.
I would like to thank the entire committee for the interest, the vigour and the enthusiasm around this issue. It was a real pleasure to be here, Mr. Chairman.
The Chairman: Thanks to each and every one of you. We appreciated the time you took to be with us.
Honourable senators, we will adjourn the informal part of this meeting, but I would ask that you stay for a brief in camera meeting.
The committee continued in camera.