Proceedings of the Subcommittee on Veterans Affairs
Issue 5 - Evidence - May 9, 2012
OTTAWA, Wednesday, May 9, 2012
The Subcommittee on Veterans Affairs of the Standing Senate Committee on National Security and Defence met this day at 12:07 p.m. to study the services and benefits provided to members of the Canadian Forces; to veterans; to members and former members of the Royal Canadian Mounted Police and their families.
Senator Roméo Antonius Dallaire (Chair) in the chair.
[Translation]
The Chair: Ladies and gentlemen, welcome to this meeting of the Subcommittee on Veterans Affairs of the Standing Senate Committee on National Security and Defence.
The subcommittee is continuing to study the transition of members of the Canadian Forces, as veterans, to civilian life. We are examining the programs associated with that transition to determine how effectively and to what degree we are able to meet the needs of these members.
We welcome today representatives from the Department of National Defence and from the Department of Veterans Affairs. I think it is excellent that we are once again hearing from representatives of these two departments at the same time. This is not the first time that this has occurred. Maybe one day someone will get the idea to merge these two departments, but I prefer to leave that issue for another discussion.
We welcome Catherine Campbell, Assistant to the Chief Scientist, Personnel Research and Analysis; Dr. Kerry Sudom, Research and Analysis, also with Military Personnel; and once again, Colonel Bernier, Deputy Surgeon General, whom we thank for agreeing to appear once again.
From the Department of Veterans Affairs, we welcome Dr. David Pedlar, Director of Research, whom we know well; and Anne-Marie Pellerin, Director of Rehabilitation and Case Management.
[English]
Today, we are looking at the fact that we have had studies done on the status of transition of veterans. The three that have been brought to our attention are the Survey on Transition to Civilian Life: Report on Regular Force Veterans, January 4, 2011; Income Study: Regular Force Veteran Report, also from January 2011; and the last study is Canadian Forces Cancer and Mortality Study: Causes of Death, of May 2011. They are not insignificant studies. They have been out there for over a year, some of them nearly a year and a half. We will be most keen to pursue the discussion line with regard to content and action, as well as credibility of these studies in achieving your aim.
Dr. Pedlar, if you please.
David Pedlar, PhD, Director, Research, Veterans Affairs Canada: Thank you very much for the opportunity to speak before your committee today. The Life After Service Studies program of research, or LASS as we call it, was designed to help us better understand the transition from military service to civilian life, and the short- and long-term health effects of military service on later veteran life courses.
These studies are unique. For the first time in Canadian research we have been able to focus on the overall veteran population, not just those who are clients of Veterans Affairs Canada. This larger focus is extremely important given that only 11 per cent of the post-Korean war veterans are currently Veterans Affairs clients.
Therefore, these studies are powerful tools that enable us to advance our knowledge of a new generation of veterans. They will also allow us to answer critical questions about their life after service regarding health, disability, the reach of Veterans Affairs programs and their needs. This approach also allows us to compare veterans with the Canadian population.
Let me also say that this is very much a collaboration. We have worked closely together on all three of these studies for the last three or four years. Statistics Canada is also in collaboration with what you see here. However, I just want to impress upon you how closely we have worked together on these, and the partnerships do not just stop here. We also work closely with the university community on the analyses we are doing with this information.
Of course you will want to know what we have learned. Let me get to the specifics around these studies.
First, as Senator Dallaire mentioned, there were three studies. The first looked at income before and after service. We know income is critical to a good life. It is also a critical factor in health. We looked at this over a 10-year period with about 36,000 releasing members during the period from 1998 to 2007. The second study was a population health survey. It looked at living CF regular force personnel who, again, released during that 10-year period. We looked at health, disability and determinants of health such as income, employment, social supports and other factors.
The third study, led by Canadian Forces Health Services, supplements these studies. It looked at causes of death among CF serving and former personnel; released were part of the picture, and therefore supplement this work.
In order to put this in perspective with brief time, I thought the best way to do it would be to highlight some of the positive features, then talk about some of the challenges and subpopulations that we are learning about that we may want to focus attention on with this information.
As for the encouraging findings, 65 per cent of those who released during that 10-year period reported that they had a relatively easy transition to civilian life. Regarding the question of income, released Canadian Forces members were less likely to experience low income compared to other Canadians. In fact, 50 per cent fewer than other Canadians were below the Statistics Canada low-income measure.
Fewer than 2 per cent experienced persistent low income — that is, low income for longer than three years. Only about 1 per cent had used social assistance or welfare programs in any given year of that 10-year period. Unemployment was about 8 per cent estimated by Statistics Canada, which was comparable to the Canadian population at that time frame. Regarding adjustment to civilian life, about 90 per cent worked after release. The majority were satisfied with their work, and the levels of satisfaction increased as time went on. Note that 72 per cent felt that their military experience helped them in their civilian jobs.
With respect to causes of death, male veterans had a 23 per cent lower overall risk of death from all causes compared to the general Canadian population.
Concerning health services, veterans were more likely to have a regular medical doctor and also to have insurance coverage when compared to the general Canadian population.
Now let us take a moment and talk about some of the challenges. While the findings I just mentioned reported a lower overall rate of premature death, the major exception to this pattern was suicide. Male veterans had a 46 per cent higher risk of death from suicide. This was another study that looked at those who enrolled between 1972 and 2006. With respect to concrete actions over the past decade, VAC and DND have invested much time and resources into building capacity to address mental health problems, including a suicide prevention framework and a suicide prevention action plan, which is being implemented.
With regard to research, we are conducting sophisticated analyses on a dimension of this problem — called suicidal ideation — to better understand the problem and potential solutions. There are also issues of disability that do not result in death. For example, rates of musculoskeletal pain, anxiety disorders and disability are higher in this population than in the Canadian population. For example, arthritis was reported at about twice the rate of the general population, as was back problems.
I want to emphasize that many of these health conditions did not appear on their own. They were concentrated in a group of veterans that had complex states of health who had musculoskeletal problems, mental health conditions and chronic pain, all at the same time. This pattern was found in about 16 per cent of the total population. We are focusing on these health issues in additional analyses to look more closely at this and at programs design to address these issues.
Regarding reach, we learned that we are reaching, for example, many veterans who are medically released. We have contact with them and they are clients. However, there are veterans out there who may need help and they are not VAC clients. For example, 17 per cent of veterans who are not VAC clients reported that they had a difficult adjustment to civilian life, and 13 per cent of non-clients reported that they had a mental health condition. These findings speak to issues about program reach and communication with veterans, and we have been working closely with our colleagues to reach out and identify these at-risk groups.
The final piece I want to talk about is some of the subpopulations. As we get further into this work, even though we know many had a relatively easy transition, our research is pointing to subgroups at risk of difficult adjustment. Certain groups have a disproportionate share of challenges. For example, low income was prevalent among those who were released at young ages, those who were released involuntarily, and those with lower ranks. Similarly, people who had persistent low income — that is, low income for several years — tended to be those who were released as young recruits or who were released for involuntary reasons.
Another point was decline in income after leaving the service, not income level. Female veterans experienced a 30 per cent decline in income after release.
Another group of interest were those who served in the middle, for 10 to 19 years. They also experienced large income declines.
While the majority did report a good transition experience, a sizeable minority — about a quarter — said their transition experience was difficult. We have been looking to find out more about who reports a difficult transition experience. As our work continues, some of the clear ones are the medically released, those who are widowed, separated or divorced. Again, this is the 10- to 19-year group of having military experience where their careers may have been disrupted.
The final point I want to go back to is the 16 per cent. There are subsets of veterans with complex health needs. For example, about 16 per cent of the total population identified with these three issues together: musculoskeletal disorders, mental health conditions and chronic pain. Therefore, we need to ensure our programs provide the support they need — support proportional to the complexity of their needs. Our case management function will play a critical role in addressing these concerns.
In closing, we are conducting further analysis on many fronts. We are completing a release that focuses just on the mental health dimension that we have found from these studies. We are working closely with our partners here, but I also wanted to mention the Canadian Institute for Military and Veteran Health Research, which has been very helpful in helping us connect with university researchers across the country as this sector, so to speak, comes together on issues of military and veteran health.
Those are my opening comments. Thank you.
The Chair: Thank you very much. Ms. Campbell, please go ahead.
[Translation]
Catherine A. Campbell, Assistant to the Chief Scientist, Military Personnel Research and Analysis, National Defence: Good afternoon Mr. Chair and members of the committee. Thank you for inviting me to speak to you today.
[English]
I am here as the Director Research — Personnel and Family Support, the DRPFS. As I am currently transitioning to retirement, however, I no longer hold that position but am employed in an advisory capacity to the chief scientist in my division. I am a veteran myself, having served 27 years in the Canadian Forces and four in the RCMP before returning to DND as a public service employee to work in CF personnel research.
With me today is Dr. Kerry Sudom, the team lead of the Psychosocial Health Dynamics Team in DRPFS, who contributed the DND/CF portion of the research on the Life After Service Studies project; and Colonel Jean-Robert Bernier, the Deputy Surgeon General, whose organization led the CF Cancer and Mortality Study with Veterans Affairs Canada.
[Translation]
As you already know, Veterans Affairs Canada is one of the departments responsible for the study of life after military service. However, DND, the Canadian Forces and, in particular, the Chief of Military Personnel were thrilled to be involved. Helping members transition to civilian life has been a priority for our department for a long time.
This collaboration with Veterans Affairs Canada would be a research opportunity that could provide direction for the policies and programs of the Canadian Forces as well as those of Veterans Affairs Canada to help members of the Canadian Forces reintegrate harmoniously into civilian life and to ensure a smooth transition. This project was considered extremely important.
[English]
In DRPFS, our involvement in the Life After Service Studies consisted of participating in the discussions and decisions involving the research methodology for the study; identifying an appropriate data set and the means for linking DND data on former CF members with data from Veterans Affairs Canada and Statistics Canada; obtaining the necessary privacy and legal reviews and seeking departmental approval for linkage of the data; bringing our knowledge of DND/CF policies and of the CF data set to the interpretation of the research findings; and participating in the drafting and editorial review of the reports. In addition, we were responsible for briefing senior officials on the findings of the research.
[Translation]
Many of the results presented in these two reports are of interest to DND and to the Canadian Forces. For example, the survey found that many people are suffering from chronic health problems that have been diagnosed by a health professional as being related to the individual's military service. The same is true of persons with a disability.
What was very interesting was the number of people who indicated having health problems during their military service but who did not seek care from Veterans Affairs Canada.
The obstacles preventing people from seeking care will need to be the subject of a future study.
[English]
Most individuals agreed that their military experience, education and training helped them in re-establishment, indicating that their experience in the CF has been of benefit to them once they have transitioned to civilian life. However, increasing education about skills transferability may be important for individuals in certain occupations for which no clear corresponding civilian job exists.
[Translation]
National Defence and Veterans Affairs Canada are working together to plan a study covering reservists who have served, which would use the same method as the Survey on Transition to Civilian Life of regular force veterans.
[English]
Findings from the Survey on Transition to Civilian Life will provide us with the means to inform Veterans Affairs Canada and DND/CF programs and services. Additional in-depth analyses of the Survey on Transition to Civilian Life data could identify priorities for health promotion while members are still in the CF, thereby preventing or mitigating health and disability problems post-release.
Both departments will therefore benefit from our continued collaboration on transition research in order to meet the needs of members and veterans throughout their life course.
The Chair: Thank you very much. We will commence the questioning of our witnesses with the deputy chair, Senator Plett.
Senator Plett: I thank all of you for coming out, some of you for the second or third time. We certainly appreciate your attendance here.
I want to touch on a program that was set up back in 2010, I believe. I think the government announced at that time about $2 billion in enhanced allowances and benefits for Canada's ill and injured military personnel. In the same year, our government also announced about $52.5 million for a legacy care program.
I am wondering whether any of you can touch on what a legacy care program is and how it is working.
Colonel Jean-Robert Bernier, Deputy Surgeon General, National Defence: Senator, Colonel Blais, the director of casualty support management, who was here testifying to you earlier, is the individual responsible for the management on the National Defence department side of that. I do not think any of us here would be able to comprehensively answer questions related to that program.
Ms. Campbell: We are here to speak to the research conducted. We are not in a position to speak to any of the policy issues, unfortunately.
Senator Plett: You cannot tell me how the program is working?
Ms. Campbell: I am not aware of how the program is working, sir.
The Chair: Senator Plett, the question is noted by the chair and we will pose it to Colonel Blais.
Senator Plett: Thank you. Let me try another question and see if you can answer this one. What is the percentage of people who have served in Afghanistan who have shown or have been determined to have PTSD, and what is the relationship between people who have served "inside the wire" versus "outside the wire"?
Col. Bernier: Senator, I spoke a little bit about this earlier. The cumulative incidence study that was conducted of people serving in Afghanistan between the years 2001 and 2008 found a total incidence of about 8 per cent in terms of people developing PTSD after about four and a half years of follow-up after their return. These were not just based on reported symptoms that may or may not subsequently develop into a firm diagnosis; these were based on actual medical evaluation of charts and an attribution of hard diagnosis to that specific deployment as opposed to any other thing.
There was a firm judgment that 8 per cent is probably the best number we will get, and it is probably the best number that any of our allies have. That is 8 per cent overall, which includes the whole theatre of operations.
Regarding those who served "outside the wire," 17 per cent, roughly, developed PTSD. Those "inside the wire" were about 13 per cent, with lesser proportions for those serving in Kabul or other locations.
The total number so far who have presented for care, which changes every day, has been just short of 1,500. After applying that 8 per cent to the whole population that deployed during that time period and those who deployed subsequent to 2008, we would expect at least another 1,500 to present with that diagnosis in future.
We expect our mental health care burden in future to be at least maintained. Depending on the speed with which the currently diagnosed individuals retire or are cured, and we have a significant number of cured, medically released or who otherwise leave the service, we expect our current burden to expand significantly over the next few years.
Senator Wallin: I will start, if I could, with a couple of clarifications from Ms. Campbell. On the first page of your remarks, you said, "Of particular interest are those individuals who reported having experienced a health problem during military service, but who did not seek care from VAC." Did you mean after? They would not seek help from VAC while they were serving, would they?
Ms. Campbell: Not as a general rule. What she is asking, Dr. Pedlar, is whether the Canadian Forces members would contact VAC during the time they were in the military if they had some kind of health condition.
Senator Wallin: Your note here is "of particular interest," so I am trying to figure out what the interest is of individuals who experienced a health problem during military service but who did not seek care from VAC.
Ms. Campbell: That refers to our survey where people said that they attributed a certain health condition to military service, and yet later went on to say, "no, I have not contacted Veterans Affairs," presumably after, in most cases.
Senator Wallin: Obviously, in my mind, they would not be doing it before. How in depth is your research? It is referenced a couple of times — 17 per cent of veterans who are not VAC clients. Do you question them about why they have not reached out? I ask you both, and Dr. Pedlar can answer.
Ms. Campbell: I believe the survey we are talking about is the Survey on Transition to Civilian Life, which was a telephone interview conducted by Statistics Canada. I do not believe they had any follow-up questions of that nature.
Kerry Sudom, PhD, Military Personnel Research and Analysis, National Defence: The information we had was based on administrative records; it was whether they were participating in VAC programs or not. We received this information from a database. It was not from a survey.
Senator Wallin: You do not know why they are not.
Ms. Sudom: No, we did not ask them that question.
Senator Wallin: It might be a communications problem or it might be that they chose not to.
Ms. Sudom: Exactly.
Senator Wallin: Dr. Pedlar, I found this research quite interesting and more positive than I would have thought. The folks that had a difficult transition — the group that you are concerned about — are those who are medically released, separated, widowed, divorced or released involuntarily. That is kind of a troubled subset, if I can put it that way. The question is, I guess, in terms of the use of resources at VAC, how much can you concentrate on that group that has all these different inputs? They would be having issues if they were not in the military, right, if they had medical problems or if they had behavioural problems or whatever? How much can you focus on that in terms of the percentage use of resources versus veterans who come home and need some help with home care — walks shovelled or whatever — just the basic support programs?
Mr. Pedlar: One of the things we learned from this is that we want to focus on those who are having challenges, but there is no cookie-cutter approach. I want to make that clear. There is a real spectrum. You want to have a wide spectrum of services to meet the needs of that population. However, this can help to identify people that we did not necessarily think about before as much — that we had not thought about as high risk as much as perhaps we should have, for example, people who do not serve for a long time. That might not have been a group that had naturally come to mind as one that we would have high resource needs. Some of these people may be those who become homeless, for example. This gives us the opportunity to look at things like the transition interview.
We can now look at the transition interview and say, "Are the people who are using the transition interview the ones who are most likely to have a difficult outcome later?" It is similar with career transition services. Those are examples of how we are using that to focus resources.
Senator Wallin: We had this discussion with Colonel Bernier last week about these issues, for example with suicide. In fact, the reasons cited are often similar to those in the civilian world, such as marital problems or poverty problems. It might not be service-related only, although they were in the service. You have to figure out a way, perhaps, to separate that out. Otherwise, you will have resources heavily consumed by a smaller and smaller proportion. What does that then mean for the larger proportion of veterans that are functioning — the 65 per cent that say the transition went well?
Mr. Pedlar: It is a question of integrating these findings into our approach. If I could just make a comment on mental health again, one point I want to reinforce is that in this population that we feel needs a lot of attention, mental health conditions in most cases are not alone. Rather, we see complex health problems that require a different approach than a single physical problem or a single mental health problem requires. How we mobilize resources to address that complexity is another key challenge.
Senator Wallin: Can I seek one more point of clarification? Do you feel you have the balance right in terms of the percentage or the amount of resources you are dedicating to these small but very needy groups that have complex problems, versus your overall veteran population, which, by and large, seems to be adjusting fairly well?
Anne-Marie Pellerin, Director, Rehabilitation and Case Management, Veterans Affairs Canada: I can perhaps shed some light on that. The committee is probably familiar with the Integrated Personnel Support Centres. That is where Veterans Affairs has invested as a department in terms of our effort to reach those who are both medically releasing and, through DND supports and information, those who are non-medically releasing. We have a pretty high rate of return in capturing those who are medically releasing and in need into our Veterans Affairs programming. With the non-medically releasing, it is often a bit more of a challenge to capture that population. Often they are releasing and may not have a need for Veterans Affairs services. We are trying, with that transition interview, to educate not only the releasing member but also the family, because often a family member may think later on when a situation manifests itself that they might recall certain benefits and programming available through the department.
In addition to the transition interview, we have just introduced a new risk assessment tool. It helps our staff to measure a little more precisely indicators that a client may be at risk and, if so, to ensure that the veteran or releasing member is fast-tracked through the department for more intensive case management services.
The Chair: As a supplemental, you touched upon all possible people who have been released from the forces who may have some injury and do not necessarily go to Veterans Affairs Canada. You are using a lot of historic data, so there is a lot of history of context that might also be influencing your numbers. As an example, Veterans Affairs Canada gave no support for decades to anyone who had a hearing problem. People who had a hearing problem did not go to Veterans Affairs because they knew nothing would be done for them. Those scenarios existed and probably still exist. Even though they were serving, they did not get the help they required from Veterans Affairs. One, I think, was communications, and the other one was simply not feeling that they could go there.
My point in raising this dimension is the fact that the historic data that you have goes so far back. How does it handle the era where we have been now at war? To what extent does that really cover troops that now have more combat time than even World War II vets, under more complex scenarios? What are you doing to move that side of the study?
Mr. Pedlar: The study covers a 10-year period, so the mortality study we mentioned earlier is a long period. It is a historical study; it goes back to 1972. This study is relatively more recent and we are particularly interested in knowing more about this new generation of veterans who have had higher operational tempo and more deployment and greater exposure to risks. I think that this 10-year period is actually a good one as a baseline to move forward on.
Senator Day: Thank you all for being here. I would like to make a positive comment at the front end that I am glad that you are looking at reservists now, because that is an area that this committee has dealt with. We felt that they might have been overlooked. It is more difficult for you, I am sure, once they go back to reserve mode and are living in diverse communities, but I think it is worth following up, and there will be some unique findings there, I suspect.
The other point I wanted to make, you mentioned the University of Manitoba has a cooperative university research project. I would like to know what, if any, relationship your research project has with Sainte-Anne-de-Bellevue because we have been led to believe that, particularly from operational stress disorder, that is a centre of excellence. Is that only in treating or is it also in research? If it is in research, how do you work with them?
Mr. Pedlar: I am functionally responsible for research in the department, so I am functionally responsible for the activities in the OSI network as well as at Ste-Anne's Hospital. Together the OSI clinic network and Ste-Anne's Hospital has been more, I guess you could say, a clinical focus of our research capacity as it has developed because it is these parts of the organization that see people and treat them.
Therefore, because of the population that Ste-Anne's Hospital has, it is focused more on things like dementia and Alzheimer disease, chronic pain and clinical issues inside a long-term care setting. Similarly, we have a capacity across the operational stress injury network that I have been involved in developing in the last five or six years as well. Again, that focuses more on how to support questions that are directly relevant to clinical questions in the care of mental health.
Senator Day: Other universities, like Queen's University has recently established a centre. Do you work collaboratively with Queen's, for example?
Mr. Pedlar: We have been engaged since practically day one with the Institute for Military and Veteran Health. If I could go a little above that, the way I describe it is that over the last five or six years a sector has come together. The Canadian Institutes of Health Research has shown more interest in veterans and is more engaged. The Institute for Military and Veteran Health came on the scene a few years ago, and we have been engaged in that and their forums every year as strong supporters. That is helping to bring the universities to the table so we are not alone in this challenge. We are working together as a sector that collaborates.
Senator Day: Thank you. Dr. Sudom, you are listed in our background information as a scientist as opposed to a medical doctor.
Ms. Sudom: Yes.
Senator Day: In what area have you a scientific background?
Ms. Sudom: In psychology.
Senator Day: Were you involved in any of the gathering of information for any of these studies or analysis of — presumably the analysis, yes, but it is the gathering of the information and how that was done. Who would be involved in that, who would oversee that?
Ms. Sudom: I was involved from the start in the development of the survey itself, so development of the measures that were used in the survey, the research protocol that is being used. Statistics Canada was contracted to actually carry out the telephone survey and then I was involved in the analysis, the writing and reporting of the results.
Senator Day: I am glad to hear that. I think the gathering of this information in order to have an objective analysis is very important, but I am worried about some of the comments here of self-diagnosis and the person who reported that you have taken the statistic on as someone who has said, "Yes, this is an injury I received when I was in the armed forces." However, they will say that because they know that is where they can get their compensation. They will not say it came from something else.
What did you do to separate that or to ensure that the information you are gathering is reliable information?
Ms. Sudom: We do recognize that it is subjective information, and we have noted in limitations of the study that it is based on self-reporting and their perception. The attribution to military service was higher for certain conditions like PTSD, musculoskeletal conditions, that you might expect would be attributed to military service, as opposed to other conditions such as diabetes. We do recognize that it is a subjective measure, and that it would have to be linked to actual service use in order to determine the accuracy of their statements.
Senator Day: In both of your reports a lot of your comments suggest that "we will" be doing this: We will follow up on these subsets and we are hoping to implement programs. This analysis has been going on for quite a while. Have you got some programs that you can hold out as successes that are actually implemented and being worked on between the Department of National Defence and Veterans Affairs? Anyone?
Ms. Campbell: We have a few studies we are working on now. We do not have results from them right now. We have some folks who are looking at gender differences that show up in the data. In terms of the physical and mental health determinants we have, we are hoping to be able to do a study on rural and urban differences in the data, and we are working with VAC on looking at the main predictors of a difficult adjustment to civilian life.
Senator Day: Is this just all background information that someone else uses, or do you have any programs that are actually out there helping the soldiers and the retired soldiers now, based on the work you have done?
Mr. Pedlar: I could give three quick examples. It is not so much that they are new programs; it is how we target our programs that could have an immediate impact. I gave two examples earlier, one is on transition interviews. Now we could look to see whether the people who are using transition interviews — not everyone does — are the ones who are most likely to have negative outcomes. We are able to work with our colleagues on both sides to try to make sure the transition interviews get to the people who are most likely to use them, and same with the transition services. We wondered a couple of years ago, we noticed that the numbers of people using those programs were not as high as we had expected. What do you do with something like that? You say maybe it is not needed. However, when you have information like this you can say —
The Chair: That is a very positive position to take. There is another option to that.
Mr. Pedlar: It is probably needed, but it may not be getting to the people who should be using it. We decided with that one that that was the case.
The third example would be this work we have done on suicide prevention and suicide, which does not always work one before the other. Sometimes they go beside each other. The focus on mortality, which focused on suicide, was going at the same time, parallel, to an enormous amount of work that we worked jointly on on suicide prevention, which we have been implementing. We have a suicide action plan, and now we also know that suicide rates are higher in released members. Therefore the work we did there, program and research working closely together, was time and energy well spent.
The Chair: I would like to follow up in regard to the actual programs — from the data that you have — that you are actually moving down. We have heard about three that are in various stages of implementation. Well done. However, with this amount of effort gathering data, there must be a whole series of efforts that are going down. I wonder if you might be able to tell us what the other areas of study are and what sort of milestones you will be working on as deductions of this effort. It has been out there for over a year and a half, and surely we can get a better feel for how you will move forward with the data versus simply analyzing the data to date. Would that be suitable?
Ms. Campbell: I am not sure whether you are asking about policies and programs that might —
The Chair: I am asking about what will happen to this data. Are you producing more analysis? I will give you an example. Has this stuff been peer-reviewed by other outside agencies and validated?
Ms. Campbell: Absolutely, it has.
The Chair: Good. From that, you have a solid basis to articulate either new policies or new programs to meet these requirements. Do you have a listing of that in the plan of action?
Ms. Campbell: We pass the research on to the senior leaders, and we actually make recommendations for changes to policies and programs that they might want to consider. After that, unfortunately, we are not necessarily aware of what actions have taken place. I cannot actually speak to the policies and programs that might have been changed as a result of the findings.
The Chair: You have no guidance for future research then?
Ms. Campbell: We know where the future research needs to happen, and we are conducting future research.
The Chair: Good.
Ms. Campbell: It is in the program right now. I think I mentioned a few areas that we are already working on. There is so much data that there is an awful lot of follow-on research from it.
The Chair: If we could get a feel for that, that would be most appreciated.
Senator Andreychuk, welcome.
Senator Andreychuk: I am not a regular member of this committee. Just maybe for my own information, you are zeroing in on transition, and that is what you have been asked to talk about today. It seems to me that what you are trying to do is to provide enough information for the policy-makers on what veterans — in the broad definition — might need. Is this then complemented with research you already have or will do on people entering the service? In other words, I think you have to know that Canadians may come with diverse problems, mental, emotional and physical. We come with genetic propensities to a lot of these things. Do we do a critical analysis of people coming in and their needs? Do we do critical analysis and monitoring during a placement in a theatre or in the services directly before we get to what they are like when they come out? I think the predictors are there in us during our lives, and this is one phase of it.
How do you put it in perspective?
Ms. Campbell: Yes, we do. Of course, on the medical side, they do a great deal of research, both for applicants and military members, on mental and physical health. From the perspective of the psychosocial research that we conduct, we have selection tests that give us some information. We are starting to use personality tests as well. Then, through the entire career of the military member, we have research conducted to find out about their attitudes on a number of things, about family issues and about the human dimensions of operations. We have the whole range of research for the whole career of the military individual, and now, of course, we are trying to hand off to Veterans Affairs so that we have this smooth transition. In most areas, we have research.
Mr. Pedlar: Just a couple of thoughts on that. In terms of the downstream effects that we would see and things that you may want to impact upstream, hearing loss is a key one. It is our biggest medical pension disability area and one where there would be opportunities for improvement. A second area is musculoskeletal conditions. You hear it said that people who serve are like professional athletes. Like professional athletes, there might be musculoskeletal issues downstream — arthritis, back problems and other issues — that we work closely with the CF and DND on.
Finally, I wanted to mention the collaboration that we have done on mental health over the past decade because it is an issue that I think everyone agrees was not focused on enough. That actually came out of a survey we did in 1999 when we found out just how high the level of mental health conditions were in our clients. Enormous effort has been put into that area as we learn more, through this kind of work, about where we should be putting our resources.
Senator Andreychuk: You say that you are now giving information to the veteran and the families when they leave. I have been involved in a lot of placements of young people and others who have gone into another culture, a dynamic, a dangerous situation, probably not as well equipped as our military are. There are a lot of civilians who work in that. You have a hot debriefing, but then you have a cool debriefing because, when they are coming right out, you can give them information. However, they are targeting to leave what they are experiencing, so a cool debriefing seemed to really be where the information was ingested because you are coming out. You are worrying about where you house is and what you are going to do. You have not seen your children or whatever it is. Months later, all of the other stuff starts to make sense. When are your briefings, and do you do a follow-up informational briefing? How have you determined when the best moment to give all of that is?
Col. Bernier: Senator, if you are speaking about currently serving armed forces members, it starts right from enrolment. The personal selection folks — organizational psychologists — do research on the best characteristics for service members. We now have a prospective program of a recruit health questionnaire to give us a base line to follow up on those individuals through the course of their careers. That was just started a couple of years ago, and there have already been a number of analyses on those. In the enrolment medical, they are screening for pre-existing mental health conditions so that, in combination with that and the personal selection factors, we determine who we can enrol safely and who we cannot.
Then, throughout the course of the entire military career, there is a periodic health assessment that occurs according to evidence-based guidelines and that includes a lot of screening for various addictions and mental health conditions, as well as physical health issues. Around peri-deployment — each deployment overseas — there is a six-phase Road to Mental Readiness program. There are pre-deployment briefings for the families and the individuals before they go. In theatre, there are all of the clinical mental health staff. Then, post-deployment, there is a decompression in a third location, usually Cyprus, for organization operations longer than 60 days, where there are a lot more educational briefings. It serves as one of the phases of the six-phase Road to Mental Readiness. It includes education about mental health conditions, what to expect with reunion with the family, social aspects and the availability of mental health professionals for those individuals who may manifest or have questions at that time.
There is also an aspect of that education for the family before the individual returns to their family.
Then, three to six months post-deployment for these operations, there is an enhanced post-deployment screening, carefully looking at physical symptomatology and mental health, that includes interviews with a mental health professional. We know from some of the recent studies on cumulative incidence and, particularly, the Gagetown study of one of the battle groups that had the highest combat exposure and, thus, the highest rate of PTSD, that there is a latency period for the manifestation of serious mental health conditions in many cases. Many of them will not manifest for one to two years. We are still now having manifestation of post-traumatic stress disorder for operations that occurred two decades ago.
We continue to do health assessments to try to find those individuals proactively up until release. At the point of release, there is a release medical, where we carefully look for anything, and over the last few years we have dramatically enhanced our view of the individual on a continuum from the time of serving to the time of transition to Veterans Affairs rather than having a clean break between the Canadian Forces and Veterans Affairs.
The approach now is to overcome any obstacle to a smooth transition happen, rather than finding a rule or regulation that precludes it, so that the transition is as seamless as possible. We are still working on that, but there has been a major improvement, particularly with the Integrated Personnel Support Centres. The transition occurs seamlessly and the care is well established with Veterans Affairs and the provincial health system before the individual is released.
In addition to all of that, there is a huge research effort. There is much applied research within the Canadian Forces. There is the Director General of Military Personnel research on the medical side. There is the Surgeon General's health research program and various other research programs within Defence Research and Development. The Canadian Institute for Military and Veteran Health Research is a consortium of 22 universities. One of them, Queen's University, has established a chair in mental health stigma. On its own, the University of Alberta has established a chair in military and veteran rehabilitation, which includes mental health rehabilitation.
We have two computer-assisted rehabilitation environments with state-of-the-art virtual reality exposure therapy for both physical and mental health issues. In fact, they are here in Ottawa today. This includes the Israelis, the Americans and the Dutch. In everything we do we collaborate with allies to share knowledge and information and establish evidence-based scientific standards on everything.
The NATO Health, Medicine and Protection research committee has multiple research task groups. I am the chair of that committee and also the mentor for one particular research task on military suicide. There are many others on mental health related topics, including medically unexplained physical symptoms, mental health training and others. There is closer collaboration between the American, British and Canadian allies. There is a second phase of the CF Cancer and Mortality Study to look at morbidity due to cancer, specifically. From that, there will be multiple subgroup analyses done for specific exposures related to high-risk populations like Gulf War veterans, the incident of engineers being exposed at Camp Doha, various cancer clusters that we found in specific occupations in the armed forces over the years, and CF firefighters. There is an extensive both basic and Canadian Forces applied research effort.
The Chair: Thank you. Is the three- and six-month post-deployment evaluation for all members, regular and reservists, obligatory? When they miss a dental appointment, they are charged. Is it obligatory that they go to these sessions? That includes the individual augmentees that come from all over the place and not necessarily from formed units.
Col. Bernier: Yes, senator, it is obligatory. It is mandated by policy, but the medical corps does not have the chain of command authority to enforce it, and the burden for its enforcement is on the chain of commands. We have imperfect compliance with that. There are some individuals who feel completely fine, so they find ways of avoiding presentation for care. There are sometimes also administrative obstacles whereby individuals are posted to another unit very soon afterwards, which makes it difficult for the chain of command to enforce it or for the subsequent chain of command to find out. The chain of command emphasizes the requirement repeatedly, and our numbers are getting better. However, it is mandatory by policy for people to present for that three- to six-month evaluation.
[Translation]
The Chair: Unfortunately, the people who are not going are the ones who need it the most. In this regard, the chain of command has not done its job. I hope that you will continue your efforts with the chain of command.
[English]
Senator Wallin: On this, in the last two to three years that we have been pursuing this question I have found that you folks are bending over backwards to give people the option to seek help and care. I know that my own father did not want to ask Veterans Affairs for a hearing aid or to have his walk shovelled because he did not think he deserved it or was owed it. It was the daughters who said, "It is there for you to use and you should benefit from it."
There is some suggestion that the younger veteran is a little more demanding and the expectation is there. What is your gut feeling about why people will not use the service? Is it because they have a psychological issue they are in denial about it? It is almost impossible to avoid it.
Col. Bernier: We have found that the greatest obstacle is self-imposed stigma or self-imposed perception that their symptoms or feelings are abnormal. Some people have the self-imposed macho attitude that they do not need or should not be pursuing care, or they do not recognize that their behaviour or feelings are abnormal.
We must be careful not to medicalize normal reactions to high-stress situations. In most cases, those will sort themselves out naturally. It is individuals with feelings or behaviours that are beyond normal and can benefit from assistance who may fall through the cracks.
Senator Wallin: That is my uncertainty about all of this. We do not want to tell people that they must have some of this so we need to label them. If they are fine, they are fine, and if they are not fine in six months, let us deal with it then, but let us not make them unfine to fit our schedule.
Mr. Pedlar: I do not want to lose the point that the Life After Service Studies show that we have a very good catchment of people with higher needs. We were able to look at different kinds of clients and non-clients. For the most part, the people who are clients had many more problems and were much worse off. In many regards, the non-clients were no different than other Canadians. That told us that we are doing a pretty good job.
On the issue of outreach, we want to go as far as we can. This helps us to go further. We want to ensure that we identify everyone who can use our service.
We have also noted in work that we have done on mental health in the past that there have been particular issues around coming forward for mental health services, not only with veterans but in the Canadian population. This involves processes of coming to the conclusion that you have a mental health problem around symptom recognition as well as willingness to come forward, which can sometimes take years. I am sure you are already aware of this information.
The Chair: The follow-up comes from Senator Andreychuk's question about the hot wash-up and the cold wash-up post-retirement. We talked about those who have been in operational missions, and they are getting those three months or six months, but for the individual going through the joint support unit who is retiring and is right there in the throes of retirement, whether they realize they are injured or not, they get a briefing and detail and so on. Is there another one subsequently down the road to see whether they have actually covered all the bases that needed to be covered in order to be successful in their transition?
Ms. Pellerin: There is not in terms of a formal protocol in terms of a subsequent follow-up, but, as I mentioned earlier, there are, within the transition interview, questions and the risk analysis that we do subsequently. If there is indication that there is need for follow-up, then we endeavour to get the client's forwarding information so that we can follow up and/or refer the releasing member to community-based services to re-engage with Veterans Affairs at a subsequent point. There is not a structured follow-up post-release.
Senator Day: I have in front of me the first page of the Ottawa Citizen for May 2, and the article is "Mental health treatment at CFB Petawawa in `crisis,' report says." The article describes a system that is poorly funded, devoid of forward planning, scrambling to provide even basic care and leaving mentally ill, often suicidal soldiers waiting four month or longer before they can meet with a psychologist or psychiatrist. It also goes on to say that 40 to 60 service personnel were diagnosed with PTSD and were being served and helped out of the National Defence Health Services Centre on Smythe Road, and that is being closed. This was a report that was prepared for the commanding officer at CFB Petawawa. Is that the kind of report that you receive, and would you be aware of this and what action has been taken?
Col. Bernier: On the 40 to 60 patients, it is 43 who were being served here. We have two major challenges. We have no budget limit in hiring enough clinicians. The problem is that in a competitive market in Canada for mental health professionals, it is difficult to attract them. Even with a private contract through a company called Calion that can exceed public service rates, we still cannot hire and attract enough of them to serve in certain locations. We have various innovative means of trying to do that. The other is that the public service hiring process is not rapid. Since they have so many options, the mental health clinicians, by the time we get through our internal government process to offer them a position, have been offered several others and they have moved on elsewhere. There are various ways, for example, posting in additional mental health professionals who are in uniform to isolated locations. Again, there, we also have a shortage. We are not up to full strength.
Senator Day: Smythe Road is not an isolated location.
Col. Bernier: At Smythe Road, there are two psychologists there who were providing services to Petawawa patients who were having to drive down to Ottawa to get their care. That was a temporary measure because we could not attract them. Since then, we have been able to establish an arrangement whereby those two psychologists will now serve those patients in their hometown, in Petawawa. It is critical that they remain close to the social support of their unit and their families. Overall, it is actually going to be an improvement as far as those individuals' access, without having to travel to Ottawa. It is not a closure; it is a relocation to where they should have been from the start.
As for the internal report, that was solicited by our mental health leadership. We conduct a regular series of site assistance visits to try to identify the concerns of each mental health clinic across the country. As part of a visit to the Operational and Trauma Stress Support Centre in Petawawa, the civilian clinicians were asked to put together all of their concerns. It was not a report; it was an internal document for the visiting mental health staff to look at what the list of concerns was.
Senator Day: Do you accept their terminology that health care at Petawawa is in crisis?
Col. Bernier: No, from the perspective of what is considered acceptable mental health care by Canadian standards.
Senator Day: Is it true or is it not true that 15 of 25 mental health care personnel have been laid off? They have their layoff notices?
Col. Bernier: That is unrelated to hands-on clinical care at the coalface. That is at our headquarters, the epidemiological assessment people. No, we currently have about 378 coalface mental health clinician staff, direct clinical support. We are authorized to go up to about 450. There is no obstacle. The money is there. The only obstacles, as I said, to hiring more are those two — the bureaucracy, the administrative requirements to satisfactory the Government of Canada's requirements for hiring, and the shortage in the market for mental health professionals.
Mental health care does not necessarily exclusively require a psychiatrist. Most mental health care in Canada is provided by primary care physicians. Any of our patients who have acute, immediate problems are seen immediately, so they have access to psychiatrists or psychologists. The problem is those individuals who need ongoing care, evaluation and follow-up in the long term. We do have wait-lists, in certain bases more than others, depending on the region of the country, before they can get the psychiatric or psychological assessment. In the meantime, they are getting primary care. In some cases, they are getting psychological group support and are being monitored. At any point, there is an off-ramp to get them into urgent care if they become acutely suicidal or if they have any other acute requirements.
Senator Day: I would love to follow up on this more. Would it be possible for you to make that report available to us?
Col. Bernier: Yes, sir.
Senator Day: I can make this newspaper article available to anyone.
The Chair: Most of us have seen it.
Are you saying you are hiring more psychologists now?
Col. Bernier: We are authorized to hire up to 450.
The Chair: In uniform?
Col. Bernier: No. A certain number are in uniform. The vast majority are civilian. We are currently short 54 civilians and 16 military to reach those numbers.
The Chair: Thank you.
As my last point, ladies and gentlemen, we touched on reserves but we did not get much data. I wonder if you could give to the clerk a better feel for your actual time frame and scope of the work on reserves. They have served just like the others, yet they are being handled afterwards. I really do not know why that is, but we would like to know how you will be handling the reserve side of the house.
With that said, one last point is that at the American Psychiatric Association's conference in Philadelphia over the last couple of days, Canada's program on operational stress injury was held as the example to be applied in the United States and, they hope, in other countries. Well done to all of you who have been involved in moving that yardstick, as they have considered it to be exemplary and also helpful in saving lives. One psychiatrist said that.
The session is closed. Thank you very much.
(The committee adjourned.)